Children who have had adverse childhood experiences (ACEs) face a higher risk of developing mental health disorders later in life. ACEs refer to events such as witnessing or experiencing physical or sexual abuse, violence, parental separation, neglect, or living in a dysfunctional household before the age of 18 (Gomez et al., 2017). Mental health disorders include depressive disorders (Chapman et al., 2004), anxiety, suicidal tendencies (Bruffaerts et al., 2010), and alcohol-use disorders and their comorbidity (Pirkola et al., 2005).

In Singapore, 63.9% of the population reported experiencing at least one adverse childhood experience (ACE) in their lifetime. These experiences are strongly related with an increased risk of developing mental health disorders (Subramaniam et al., 2020). Studies in Singapore indicate that having at least one ACE is strongly associated with drug (Gomez et al., 2017) and substance use (Oei et al., 2021). These findings are consistent with the Western psychological literature, which links ACEs to a higher risk of mental health disorders later in life. Thus, to mitigate the deleterious effects of ACEs, it is important for children with ACEs to receive appropriate treatment, such as psychotherapy. Additionally, it is essential to examine factors that increase the efficacy of such treatments — one key factor being the quality of the therapeutic alliance (TA) (Martin, Garske & Davis, 2020; Baier, Kline & Feeny, 2020).

Therapeutic alliance
In the case of child and adolescent psychotherapy, TA is defined as “a contractual, accepting, respectful, and warm relationship between a child/adolescent and a therapist for the mutual exploration of, or agreement on, ways that the child/adolescent may change his or her social, emotional or behavioral functioning for the better, and the mutual exploration of, or agreement on procedures and tasks that can accomplish such changes” (DiGiuseppe et al., 1996, p. 87).

TA has been consistently found to be moderately related to treatment outcomes of mental health conditions regardless of other variables (Martin et al., 2000). Among both adults and youths, a weak TA is associated with higher treatment dropout rates (Shart, Primavera & Diener, 2010; Gergov et al., 2021), whereas a strong TA is consistently associated with positive outcomes regardless of treatment modality (Baier et al., 2020). A poor TA can improve over time, provided the therapist is aware of the rupture and actively works to repair it (Hersoug, Høglend, Havik, von der Lippe & Monsen, 2009).

While many studies show that TA contributes to better treatment outcomes (DiGiuseppe, Linscott & Jilton, 1996; Horvath & Luborsky, 1993; Stubbe, 2018), most of the findings are in the context of adult psychotherapy. In comparison, there is a paucity of research on TA in child psychotherapy, and even less research on factors that enhance TA for children with trauma-related experiences (Zorzella, Muller & Cribbie, 2015). To improve treatment outcomes for children with ACEs, it is critical to conduct more research on how to strengthen TA in this population.

Certain client characteristics unrelated to health can influence functioning and, in turn, help to strengthen TA. These characteristics may include fixed traits such as age, gender, and socioeconomic status, as well as variable factors such as experiences, habits, and personality (Majnemar, 2011).

In general clinical populations, certain client characteristics have been found to correlate with the quality of TA. Positive correlations include clients’ psychological mindedness and motivation for change (Castonguay, Constantino & Holtforth, 2006), while negative correlations include interpersonal difficulties (Gaston et al., 1988; Constantino, Castonguay & Schut, 2002; Paivio & Bahr, 1998). Demographic characteristics such as gender and age have not consistently predicted TA quality; the sole exception is education (Constantino et al., 2002). Therefore, these demographic variables will not be evaluated in this study.

Psychological mindedness
Psychological mindedness is defined as an awareness and psychological understanding of their own and others’ emotions and behaviors (Rai et al., 2015). It reflects a general ability to analyze conflicts and to engage in problem-solving behaviors (Piper et al., 1998), which may contribute to a stronger TA (Piper et al., 1994; Piper et al., 1998). Conversely, low psychological mindedness has been associated with weaker TA (Constantino et al., 2002).

Motivation for change
Another client characteristic that can improve treatment outcomes is motivation, defined as “an intrinsic psychological force that encourages the individual to attempt to master skills that are at least moderately challenging to them” (Majnemer, 2011, p. 1). Clients with higher levels of motivation are more collaborative and more likely to engage in therapy tasks (Bachelor et al., 2007). Treatment motivation is characterized by the client’s determination to engage in treatment, which includes being cooperative and open during sessions, and limiting resistant or rejecting behaviors (Drieschner, Lammers & van der Staak, 2004). These expectations align with the components of TA (e.g., engaging in therapy tasks); thus, a high level of motivation for change is likely to improve TA.

Interpersonal difficulties
In brief psychotherapy, the client’s interpersonal functioning and level of defensiveness are two important determinants of the strength of TA (Gaston et al., 1988). Traits such as hostility, coldness, social anxiety, and non-assertiveness have been found to be negatively correlated with aspects of the alliance in the early stages of therapy (Paivio & Bahr, 1998). Defensiveness is manifested in noncompliance, irritability, and paranoia (Beutler, Moleiro & Talebi, 2002). As defensiveness interferes with learning (Bohart, 2000), defensive clients are less open to feedback and less motivated to work toward change (Gaston et al., 1988). Hence, clients must have the capability to form and sustain trusting relationships; otherwise, they may struggle to relate to others (Gaston et al., 1988) and be unable to build a strong TA.

This exploratory qualitative study examines the variable characteristics of child clients that local practitioners perceive as crucial for strengthening TA and their potential to enhance treatment outcomes.