Child and Adolescent Social Work Journal

, Volume 26, Issue 1, pp 49–63 | Cite as

What’s the Relationship Got to do with It? Understanding the Therapeutic Relationship in Therapeutic Foster Care

  • Dannia G. Southerland
  • Sarah A. Mustillo
  • Elizabeth M. Z. Farmer
  • Leyla F. Stambaugh
  • Maureen Murray


The therapeutic relationship is increasingly recognized as important to understanding how process variables contribute to treatment outcomes. In this paper, we examine the therapeutic relationship between children with serious emotional and behavioral disorders and their treatment providers in the context of an observational study of Therapeutic Foster Care (TFC). Our findings suggest that the quality of the relationship between the treatment parent and youth in a TFC setting is significantly associated with better emotional and behavioral functioning for the youth. It appears from these findings that the quality of the relationship between the youth and treatment parent in a TFC setting is at least one of the mechanism or process factors that contribute to improved functioning for the youth.


Therapeutic Foster Care Therapeutic relationship Child mental health Evidence based practice on social work Common process factors 



This work was supported by NIMH Grant # MH57448.


  1. Andersen, R. M., & Davidson, P. L. (2007). Improving access to care in america: Individual and contextual indicators. In R. M. Andersen, T. H. Rice & G. F. Kominski (Eds.), Changing the U.S. Health care system: Key issues in health services policy and management (3rd ed.). San Francisco, CA: Jossey-Bass.Google Scholar
  2. Bickman, L. (2005). A common factors approach to improving mental health services. Mental Health Services Research, 7(1), 1–4. doi: 10.1007/s11020-005-1961-7.PubMedCrossRefGoogle Scholar
  3. Bickman, L., de Vides Andrade, A. R., Lambert, E., Doucette, A., Sapyta, J., Boyd, A., et al. (2005). Youth therapeutic alliance in intensive treatment settings. The Journal of Behavioral Health Services & Research, 31(2), 134–148.Google Scholar
  4. Brekke, J. S., Ell, K., & Palinkas, L. A. (2007). Translational science at the national institute of mental health: Can social work take its rightful place? Research on Social Work Practice, 17(1), 123. doi: 10.1177/1049731506293693.CrossRefGoogle Scholar
  5. Burns, B. J., & Hoagwood, K. E. (2002). Community treatment for youth: Evidence-based interventions for severe emotional ad behavioral disorders. New York: Oxford University Press.Google Scholar
  6. Chamberlain, P. (2002). Treatment foster care. In B. J. Burns & K. E. Hoagwood (Eds.), Community treatment for youth: Evidence-based interventions for severe emotional and behavioral disorders (pp. 117–138). New York: Oxford University Press.Google Scholar
  7. Chamberlain, P. (2003). The Oregon multidimensional treatment foster care model: Features, outcomes, and progress in dissemination. Cognitive and Behavioral Practice, 10(4), 303–312. doi: 10.1016/S1077-7229(03)80048-2.CrossRefGoogle Scholar
  8. Drake, R. E., Goldman, H. H., Leff, H. S., Lehman, A. F., Dixon, L., Mueser, K. T., et al. (2001). Implementing evidence-based practices in routine mental health service settings. Psychiatric Services (Washington, D.C.), 52(2), 179–182. doi: 10.1176/ Scholar
  9. Eltz, M. J., Shirk, S. R., & Sarlin, N. (1995). Alliance formation and treatment outcome among maltreated adolescents. Child Abuse & Neglect, 19(4), 419–431.Google Scholar
  10. Epstein, M. H., Harniss, M. K., Pearson, N., & Ryser, G. (1999). The behavioral and emotional rating scale: Test-retest and inter-rater reliability. Journal of Child and Family Studies, 8(3), 319–327. doi: 10.1023/A:1022067329751.CrossRefGoogle Scholar
  11. Epstein, M. H., Kutash, K., & Duchnowski, A. (1998). Outcomes for children and youth with emotional and behavioral disorders and their families: Programs and evaluation best practices. (1998). Austin, TX: PRO-ED, Inc.Google Scholar
  12. Epstein, M. H., Mooney, P., Ryser, G., & Pierce, C. D. (2004). Validity and reliability of the behavioral and emotional rating scale (2nd edition): Youth rating scale. Research on Social Work Practice, 14(5), 358–367. doi: 10.1177/1049731504265832.CrossRefGoogle Scholar
  13. Farmer, E. M., Burns, B. J., Dubs, M. S., & Thompson, S. (2002a). Assessing conformity to standards for treatment foster care. Journal of Emotional and Behavioral Disorders, 10(4), 213–222. doi: 10.1177/10634266020100040301.CrossRefGoogle Scholar
  14. Farmer, E. M., Compton, S. N., Burns, J., & Robertson, E. (2002b). Review of the evidence base for treatment of childhood psychopathology: Externalizing disorders. Journal of Consulting and Clinical Psychology, 70(6), 1267–1302. doi: 10.1037/0022-006X.70.6.1267.PubMedCrossRefGoogle Scholar
  15. Farmer, E. M., Dorsey, S., & Mustillo, S. A. (2004). Intensive home and community interventions. Child and Adolescent Psychiatric Clinics of North America, 13(4), 857–884. doi: 10.1016/j.chc.2004.04.004.PubMedCrossRefGoogle Scholar
  16. Farmer, E. M., Wagner, H., Burns, B. J., & Richards, J. T. (2003). Treatment foster care in a system of care: Sequences and correlates of residential placements. Journal of Child and Family Studies, 12(1), 11–25. doi: 10.1023/A:1021349907744.CrossRefGoogle Scholar
  17. Fisher, P. A., & Chamberlain, P. (2000). Multidimensional treatment foster care: A program for intensive parenting, family support, and skill building. Journal of Emotional and Behavioral Disorders, 8(3), 155–164. doi: 10.1177/106342660000800303.CrossRefGoogle Scholar
  18. Florsheim, P., Shotorbani, S., Guest-Warnick, G., Barratt, T., & Hwang, W.-C. (2000). Role of the working alliance in the treatment of delinquent boys in community-based programs. Journal of Clinical Child Psychology, 29(1), 94–107. doi: 10.1207/S15374424jccp2901_10.PubMedCrossRefGoogle Scholar
  19. Gale, J., Pfefferbaum, B., Suhr, M. A., & Overall, J. E. (1986). The brief psychiatric rating scale for children: A reliability study. Journal of Clinical Child Psychology, 15, 341–345. doi: 10.1207/s15374424jccp1504_9.CrossRefGoogle Scholar
  20. Hahn, R. A., Bilukha, O., Lowy, J., Crosby, A., Fullilove, M. T., Liberman, A., et al. (2005). The effectiveness of therapeutic foster care for the prevention of violence: A systematic review. American Journal of Preventive Medicine, 28(2, Suppl 1), 72–90.PubMedCrossRefGoogle Scholar
  21. Hoagwood, K., Burns, B. J., Kiser, L., Ringeisen, H., & Schoenwald, S. K. (2001). Evidence-based practice in child and adolescent mental health services. Psychiatric Services (Washington, D.C.), 52, 1179–1189. doi: 10.1176/ Scholar
  22. Hogue, A., Dauber, S., Stambaugh, L. F., Cecero, J. J., & Liddle, H. A. (2006). Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems. Journal of Consulting and Clinical Psychology, 74(1), 121–129. doi: 10.1037/0022-006X.74.1.121.PubMedCrossRefGoogle Scholar
  23. Horvath, A. O. (2005). The therapeutic relationship: Research and theory: An introduction to the special issue. Psychotherapy Research, 15(1–2), 3–7. doi: 10.1080/10503300512331339143.CrossRefGoogle Scholar
  24. Horvath, A. O., & Symonds, B. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38(2), 139–149. doi: 10.1037/0022-0167.38.2.139.CrossRefGoogle Scholar
  25. Jensen, P. S., Weersing, R., Hoagwood, K. E., & Goldman, E. (2005). What is the evidence for evidence based treatments: A hard look at our soft underbelly. Mental Health Services Research, 7(1), 53–74. doi: 10.1007/s11020-005-1965-3.PubMedCrossRefGoogle Scholar
  26. Karver, M. S., Handelsman, J. B., Fields, S., & Bickman, L. (2005). A theoretical model of common process factors in youth and family therapy. Mental Health Services Research, 7(1), 35–51. doi: 10.1007/s11020-005-1964-4.PubMedCrossRefGoogle Scholar
  27. Karver, M. S., Handelsman, J. B., Fields, S., & Bickman, L. (2006). Meta-analysis of therapeutic relationship variables in youth and family therapy: The evidence for different relationship variables in the child and adolescent treatment outcome literature. Clinical Psychology Review, 26(1), 50–65. doi: 10.1016/j.cpr.2005.09.001.PubMedCrossRefGoogle Scholar
  28. Kazdin, A. E., Marciano, P. L., & Whitley, M. K. (2005). The therapeutic alliance in cognitive-behavioral treatment of children referred for oppositional, aggressive, and antisocial behavior. Journal of Consulting and Clinical Psychology, 73(4), 726–730. doi: 10.1037/0022-006X.73.4.726.PubMedCrossRefGoogle Scholar
  29. Kazdin, A. E., & Nock, M. K. (2003). Delineating mechanisms of change in child and adolescent therapy: Methodological issues and research recommendations. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 44(8), 1116–1129. doi: 10.1111/1469-7610.00195.PubMedCrossRefGoogle Scholar
  30. Lachar, D., Randle, S. L., Harper, R. A., Scott-Gurnell, K. C., Lewis, K. R., Santos, C. W., et al. (2001). The brief psychiatric rating scale for children (bprs-c): Validity and reliability of an anchored version. Journal of the American Academy of Child and Adolescent Psychiatry, 40(3), 333–340. doi: 10.1097/00004583-200103000-00013.PubMedCrossRefGoogle Scholar
  31. Mustillo, S. A., Dorsey, S., & Farmer, E. M. (2005). Quality of relationships between youth and community service providers: Reliability and validity of the trusting relationship questionnaire. Journal of Child and Family Studies, 14(4), 577–590. doi: 10.1007/s10826-005-7189-8.CrossRefGoogle Scholar
  32. O’Connor, T. G. (2002). Annotation: The ‘effects’ of parenting reconsidered: Findings, challenges, and applications. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 43(5), 555–572. doi: 10.1111/1469-7610.00046.PubMedCrossRefGoogle Scholar
  33. Oswald, D. P., Cohen, R., Best, A. M., Jenson, C. E., & Lyons, J. S. (2001). Child strengths and the level of care for children with emotional and behavioral disorders. Journal of Emotional and Behavioral Disorders, 9(3), 192–200. doi: 10.1177/106342660100900305.CrossRefGoogle Scholar
  34. Prevatt, F. F. (2003). The contribution of parenting practices in a risk and resiliency model of children’s adjustment. The British Journal of Developmental Psychology, 21(4), 469–480. doi: 10.1348/026151003322535174.CrossRefGoogle Scholar
  35. Rauktis, M. E., Vides de Andrade, A. R., Doucette, A., McDonough, L., & Reinhart, S. (2005). Treatment foster care and relationships: Understanding the role of therapeutic alliance between youth and treatment parent. International Journal of Child and Family Welfare, 8(4), 146.Google Scholar
  36. Redding, R. E., Fried, C., & Britner, P. A. (2000). Predictors of placement outcomes in treatment foster care: Implications for foster parent selection and service delivery. Journal of Child and Family Studies, 9(4), 425–447. doi: 10.1023/A:1009418809133.CrossRefGoogle Scholar
  37. Robbins, M. S., Turner, C. W., Alexander, J. F., & Perez, G. A. (2003). Alliance and dropout in family therapy for adolescents with behavior problems: Individual and systemic effects. Journal of Family Psychology, 17(4), 534–544. doi: 10.1037/0893-3200.17.4.534.PubMedCrossRefGoogle Scholar
  38. Rubin, D. B. (1996). Multiple imputation after 18+ years. Journal of the American Statistical Association, 91(434), 473–489.Google Scholar
  39. Schafer, J. L. (1998). Multiple imputation for multivariate missing-data problems: A data analyst’s perspective. Multivariate Behavioral Research, 33(4), 545–571. doi: 10.1207/s15327906mbr3304_5.CrossRefGoogle Scholar
  40. Sheppard, V. B., & Benjamin-Coleman, R. (2001). Determinants of service placements for youth with serious emotional and behavioral disturbances. Community Mental Health Journal, 37(1), 53. doi: 10.1023/A:1026544422274.PubMedCrossRefGoogle Scholar
  41. Shirk, S. R., & Karver, M. (2003). Prediction of treatment outcome from relationship variables in child and adolescent therapy: A meta-analytic review. Journal of Consulting and Clinical Psychology, 71(3), 452–464. doi: 10.1037/0022-006X.71.3.452.PubMedCrossRefGoogle Scholar
  42. Shirk, S. R., & Russell, R. L. (1996). Change processes in child psychotherapy: Revitalizing treatment and research. New York: Guilford Press.Google Scholar
  43. Shirk, S. R., & Saiz, C. C. (1992). Clinical, empirical, and developmental perspectives on the therapeutic relationship in child psychotherapy. Development and Psychopathology, 4(4), 713–728.CrossRefGoogle Scholar
  44. Smith, D. K., Stormshak, E., Chamberlain, P., & Bridges Whaley, R. (2001). Placement disruption in treatment foster care. Journal of Emotional and Behavioral Disorders, 9(3), 200–205. doi: 10.1177/106342660100900306.CrossRefGoogle Scholar
  45. Vance, E. J., Bowen, N. K., Fernandez, G., & Thompson, S. (2002). Risk and protective factors as predictors of outcome in adolescents with psychiatric disorder and aggression. Journal of the American Academy of Child and Adolescent Psychiatry, 41(1), 36–43. doi: 10.1097/00004583-200201000-00009.PubMedCrossRefGoogle Scholar
  46. Vance, E., & Sanchez, H. (1997). The trusting relationship questionnaire (unpublished).Google Scholar
  47. vanDeMark, N. R., Russell, L. A., O’Keefe, M., Finkelstein, N., Noether, C. D., & Gampel, J. C. (2005). Children of mothers with histories of substance abuse, mental illness, and trauma. Journal of Community Psychology, 33(4), 445.CrossRefGoogle Scholar
  48. Walrath, C. M., Mandell, D. S., Holden, E. W., & Santiago, R. L. (2004). Assessing the strengths of children referred for community-based mental health services. Mental Health Services Research, 6(1), 1.PubMedCrossRefGoogle Scholar
  49. Wells, K., Farmer, E. M., Richards, J. T., & Burns, B. J. (2004). The experience of being a treatment foster mother. Qualitative Social Work: Research and Practice, 3(2), 117–138.CrossRefGoogle Scholar
  50. Westermark, P. K., Hansson, K., & Vinnerljung, B. (2007). Foster parents in multidimensional treatment foster care: How do they deal with implementing standardized treatment components? Children and Youth Services Review, 29(4), 442–459.CrossRefGoogle Scholar
  51. Wintersteen, M. B., Mensinger, J. L., & Diamond, G. S. (2005). Do gender and racial differences between patient and therapist affect therapeutic alliance and treatment retention in adolescents? Professional Psychology: Research and Practice, 36(4), 400–408.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Dannia G. Southerland
    • 1
  • Sarah A. Mustillo
    • 2
  • Elizabeth M. Z. Farmer
    • 3
  • Leyla F. Stambaugh
    • 4
  • Maureen Murray
    • 1
  1. 1.Services Effectiveness Research Program, Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamUSA
  2. 2.Sociology DepartmentPurdue UniversityWest LafayetteUSA
  3. 3.Department of Health Policy and AdministrationThe Pennsylvania State UniversityUniversity ParkUSA
  4. 4.RTI InternationalCornwallis RoadUSA

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