Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairments in social communication, with repetitive patterns of behavior, interests, and/or activities (American Psychiatric Association, 2013). There is a subgroup of adults with ASD often being termed as high functioning ASD (HF-ASD), who have normal or above average intellectual abilities and have the capacity to use language in a superficially normal way (Tebartz van Elst et al., 2013). The prevalence of adults with HF-ASD has been reported to fall between 0.7% and 1.9% (White et al., 2011), and approximately half of all adults with autism develop lifelong psychiatric disorders, including anxiety and depression (Hofvander et al., 2009).

The Sociocultural Impact on Chinese Families of Children with ASD

For adults with HF-ASD, assistance from their family members can help with maintaining a fair degree of psychosocial functioning (Kamio et al., 2013). However, in a Chinese cultural context, values that emphasize familial obligation may greatly reduce the help-seeking behaviors of parents raising their autistic children and thereby increase their burden of care and parenting stress (Lin, 2014). In Chinese societies, there is a cultural expectation for the parents to be responsible for child-rearing, such that the parents are expected to raise their autistic child to the best of their ability in spite of the difficulties that are being encountered (Huang & Zhou, 2022). Chinese parents tend to sacrifice their own good and adjust themselves for the sake of the best of their autistic children (Huang & Zhou, 2022). Social lives of Chinese families of children with ASD are therefore often adversely affected due to the highly demanding parenting duties, thus hampering the family’s overall quality of life (Wang et al., 2011).

In addition, stigmatization of autism in Chinese societies also reduces the social support network for families with a child with ASD, which could impact family relationships (Ma et al., 2020). In China, parents of children with ASD have been found to suffer from a higher level of social stigma and to self-isolate more than their Western counterparts (Zheng & Zheng, 2015). A recent meta-analysis reported that Asian parents were often blamed for poor parenting due to their autistic children’s socially inappropriate behaviors, and many of them faced rejection from extended family members for having a child with ASD (Shorey et al., 2020). Chinese parents tend to cope with these rejections by social withdrawal in order to maintain face (Lai et al., 2015). Internalized stigma was prevalent in these parents, and this internalized stigma was found to mediate the associations between family functioning and parental depression (Zhou et al., 2018), suggesting the importance of devising a family-based intervention to help reduce social isolation, promote self-understanding, and enhance family relationships for Chinese families of individuals with ASD.

Impacts of the Pandemic on Chinese Families of Children with ASD

In China, the COVID-19 pandemic and the various lockdowns have affected the mental health of families with members with ASD (Huang et al., 2021). Given the heightened psychological distress found among adults dealing with ASD during the pandemic due to the discontinuation of support and the rise in social rejection (Mosquera et al., 2021), it is no surprise that the family relationships of adults with ASD in China have been strained amid such high stress.

The need to expand knowledge of clinical services grounded in a family systems approach for people with ASD has been observed since well before the dawn of the pandemic (Cridland et al., 2014). In our study, we therefore investigated an initiative using a process-oriented multifamily therapy (MFT) to work with families of adults with HF-ASD in Hong Kong, in which the adults with HF-ASD participated in our MFT with their parents. Our primary aim was to explore the feasibility of adopting a family group psychotherapy with Hong Kong Chinese adults with HF-ASD and their parents in two treatment delivery formats—face-to-face and online—during the pandemic. We also sought to explore the potential therapeutic process factors of MFT that might be deemed helpful by the families participating in our study.

Family Psychotherapy for Individuals with ASD

Most psychosocial interventions in aid of the ASD population, in view of their impairments in social communication and the need for predictability, take the form of psychoeducation and social skills training (Chorpita & Daleiden, 2009). Recently, greater attention has been paid to the bidirectional association between family accommodations and mental health conditions of people with ASD (Feldman et al., 2019), suggesting a need for family systems intervention.

Multifamily Therapy for Families of Adults with HF-ASD

Multifamily therapy (MFT) is a family-based intervention that has received increased attention in Chinese contexts in the past decade (Ma et al., 2018). As a systemic approach, MFT adopts ‘an interactional framework that counteracts the potential for overemphasizing individual blame’, such that the ‘problematic behavior’ of an individual was conceptualized in the context of relationships existing in different systems and sub-systems of which the person and the family are part (Asen, Dawson & McHugh, 2001; p.2). MFT remains distinct from other group psychotherapy methods in that they facilitate changes in families by creating an experience of communality, affording opportunities for participants to learn from each other’s strengths, generating multiple possibilities, and mobilizing multiple resources (Lemmens et al., 2009).

The MFT models across the world share some common treatment goals, such as reducing stigma, expanding the family’s social-support network, relieving caregiver stress, and strengthening family support for the persons with mental illnesses (Asen & Scholz, 2010). For the sake of providing a general picture of MFT model in this article, we generally divided the MFT models into two types, of which one is process oriented and the other one is psychoeducation oriented. However, one should note that there are no clear lines between the process and psychoeducation MFT models. Instead, most of the MFT models are an integration of the two (e.g., the Maudsley MFT model, Simic et al., 2021).

Process-oriented MFT, marked by the integration of family therapy and group therapy (Asen et al., 2001), emphasizes spontaneous observational learning, direct exchange, and mutual support among family members. The therapeutic processes in a process-oriented MFT are facilitated by intensifying interactions and experiential learning between the family members, from which self-understanding of the individuals can be strengthened and new insights into the ‘problems’ faced by the families can be stimulated (Asen & Scholz, 2010). Process-oriented MFT emphasizes that all responsibilities for taking care of the member with mental illness rests with their family members. The MFT therapists attempt to decentralize themselves in the therapeutic process and encourage the families to help each other.

Unlike the process-oriented MFTs, the psychoeducational model is developed using a family psychoeducation framework that combines education about the biology of mental illness, crisis management, effective family communication strategies, family support, and training in problem-solving (McFarlane, 2002). The group process within a psychoeducational approach is guided by a structured problem-solving format and the families can learn to cope with the challenges of the mental illness. While there is a strong evidence base that psychoeducational MFT can reduce symptom relapses for individuals with mental illness (McFarlane, 2002), its impact on decreasing negative family interactions has been inconclusive (Fristad et al., 2003).

The application of MFT for families with individuals with ASD has received little attention in the literature. To our knowledge, the only MFT intervention developed for families of adults with ASD, known as “Working Together”, adopted a psychoeducational framework to guide its design and primarily aimed at improving the outcomes for the adults with ASD, such as increasing the work engagement of the adults with ASD (Smith DaWalt et al., 2021). Even so, this model adopts a parallel group design such that the autistic adults and their parents join the MFT separately to discuss some specific topics. Though the parents receive training on taking a facilitating role to support their adult child, there is no room in this MFT model for the adults with ASD and their parents to exchange their views explicitly on their daily challenges nor to practice new ways of developing family interactions in the MFT.

Given family therapy’s promising effects on families of adults with HF-ASD in Hong Kong (Ma et al., 2020), we believe that a process-oriented MFT could definitely benefit family relationships within the population. Further investigations of the unique therapeutic factors of MFT for specific clients (Gelin et al., 2018) and MFT’s application in an online setting (Lo et al., 2022) are therefore warranted.

Factors of MFT Processes for People with ASD

A recent review of mental health interventions for people with ASD has revealed common factors of such treatment processes, including treatment engagement, therapeutic alliance, and treatment satisfaction, which might contribute to positive therapy-induced changes experienced by persons with ASD (Albaum et al., 2022).

Treatment Engagement

MFT has been characterized as an effective treatment modality for engaging clients with mental illness (e.g., Gopalan et al., 2011). MFT’s nonstigmatizing group setting and its emphasis on participants’ ability to build mutually supportive relationships are considered to be essential factors contributing to effective engagement with families (Gopalan et al., 2011). However, autistic individuals were found to be two to three times more likely to drop out of psychotherapy than individuals with other mental health diagnoses (Malhotra et al., 2004). While we may easily attribute the treatment disengagement to the client’s characteristics, such as impairments in social communication, a previous study pinpointed that the key perceived barriers to psychological treatment were the therapist’s lack of knowledge of autism and the therapist’s inability or unwillingness to tailor the treatment to support the needs of those on the autism spectrum (Adams & Young, 2021). These barriers suggest that understanding the autistic individuals’ worldview and addressing their psychological needs by accommodating the treatment content within the MFT could lead to successful involvement for treating autistic individuals.

Such treatment engagement for people with ASD has usually been measured in terms of their attendance of treatment, completion of homework, and in-session involvement as rated by the therapist. It has been suggested, however, that a greater understanding of the engagement process (Albaum et al., 2022) and the facilitating factors leading to treatment involvement (Adams & Young, 2021) as experienced by people with ASD is needed.

Therapeutic Alliance

Therapeutic alliance, or the collaborative relationship between client and therapist, has been identified as a common factor in individual psychotherapy and single-family therapy (Thompson et al., 2007), and as predictive of better treatment outcomes of adult psychotherapy for the non-ASD population (Flückiger et al., 2018). However, research into therapeutic alliance with autistic individuals remains sparse and mostly focuses on children (e.g., Kerns et al., 2018). One study examined the alliance outcome relation in a mindfulness-based treatment for autistic adults and suggested that a stronger alliance predicts an improved depressive mood in autistic adults at a post-treatment stage (Brewe et al., 2021). This finding suggests that the alliance should be explored as an important component in a treatment process for adults with ASD, thus mirroring the non-ASD literature. The study also found that the ASD symptom severity and the depression symptoms of autistic adults were negatively associated with the alliance formation (Brewe et al., 2021). Hence, adults with high-functioning ASD may be less affected by the ASD core symptoms in developing collaborative relationships with others in a group psychotherapy than those at the low-functioning end. Apart from the client characteristics, the therapist’s acceptance of the client is another crucial factor determining the strength of alliance formation and the degree to which individuals with ASD feel supported and safe enough to reveal their inner worlds during therapy (Stoddart, 1999).

Despite the significant role that a therapeutic alliance can play in different psychotherapy approaches, the extant research on the alliance in MFT is scant. Gelin and her colleagues (2015) proposed that the therapeutic alliance in MFT can be conceptualized at three levels: the therapist–family alliance, the cross-family alliance, and the intrafamilial alliance. Among them, the cross-family alliance, characterized by group cohesion and communality, has been treated as the unique process-related factor distinguishing MFT from other treatment modalities, chiefly due to its central role in promoting group dynamics and generating multiple perspectives on the presenting problems of the family (Gelin et al., 2015). There is a lack of definition of cross-family alliance in exiting literature. Building on the three-component framework of therapeutic alliance proposed by Bordin (1979), a cross-family alliance in an MFT is defined in our study as the collaborative relationship between the participating families, such that their active participation, their affective bonding with one another and their agreement on the same treatment goal determine the strength and quality of this collaborative relationship. Such a cross-family alliance in MFT stimulates social exchange between families, which may help families of people with ASD in China by reducing the influence of parenting stress (Lu et al., 2018) and promoting parental self-efficacy and the family’s quality of life (Feng et al., 2022). Research on the specific contributions of a cross-familial alliance to changes in MFT is therefore critical (Cook-Darzens et al., 2018).

Treatment Satisfaction

Treatment satisfaction, generally defined as the perceived helpfulness of an intervention and one’s enjoyment in said intervention, is a commonly studied factor of psychosocial treatments for individuals with ASD, one often used to indicate an intervention’s acceptability (Albaum et al., 2022).

The quality of the relationship with the therapist was found to be the strongest predictor of the overall satisfaction in psychotherapy for adults with ASD, similar to those with other mental health diagnoses such as depression (Lipinski et al., 2019). Despite their difficulties in self-expression and communicating their own thoughts and emotions, adults with autistic conditions self-reported to have a strong desire for engaging in meaningful social interactions (Strunz et al., 2016), and a positive social interaction is found to be associated with increased life satisfaction of these individuals (Schmidt et al., 2015). A previous study showed that positive social experience, such as social acceptance, has a positive impact on the self-concept of people with autism (Weiss et al., 2003). Successful social experiences within a psychotherapy intervention may therefore create a healthy and experience-rich interpersonal context that improves the self-understanding of the autistic individual (Huang et al., 2017).

The MFT literature has reported a high level of treatment satisfaction across families of members with psychiatric (Gelin et al., 2018) and nonpsychiatric conditions (Cook-Darzens et al., 2018). Although Smith DaWalt et al. (2021) developed MFT for adults with ASD, they did not examine users’ satisfaction with the intervention. The unknown acceptability of MFT among families of adults with ASD thus warrants investigation.

Online Family Psychotherapy

Although online psychotherapy for families has received increased attention due to its cost-effectiveness (Collie et al., 2002), studies have also demonstrated that conversations in online settings do not achieve a significantly different emotional understanding compared with what face-to-face conversations achieve (Mallen et al., 2003). Added to that, no significant difference was found in the development of therapeutic alliances in online versus face-to-face psychotherapy (Simpson & Reid, 2014).

Despite the growing trend of utilizing technology in psychotherapy, most of the discussion has focused on online psychotherapy for individuals, with limited study focused on online psychotherapy for families. A recent meta-narrative review additionally revealed that online family psychotherapy is associated with good user satisfaction and affords treatment outcomes similar to those of face-to-face psychotherapy (Helps & Le Coyte Grinney, 2021). While most of the therapists recognized the unique benefit of online psychotherapy in connecting family members who are physically separated from one another (McCoy, Hjelmstad, & Stinson, 2013), how the added complexity of managing multiple participants at a distance impacts the family therapy process is also a concern. Wrape and McGinn (2019) have recommended strategies to address some practical concerns to translate face-to-face family therapy to an online setting. For instance, when escalation occurred during the online session where physical blockage of problematic interactions by the therapist is not possible, the therapist is advised to address this distraction collaboratively by opening a problem-solving discussion with the family members (Wrape & McGinn, 2019). The process of joining individual family members may also be impeded in an online session, which could affect the alliance formation. In this case, the therapist is advised to schedule an in-office visit at the initial stage of family therapy and solicit more verbal feedback regularly in the online session in order to understand the in-session experience of family participants (Wrape & McGinn, 2019).

Present Study

We sought to answer three research questions in the present study:

RQ1: To what extent are treatment engagement, cross-family therapeutic alliance, and treatment satisfaction in MFT positively associated with enhanced family relationships and increased self-understanding among adults with HF-ASD and their parents?

RQ2: To what extent do participants’ experiences differ between online and face-to-face MFTs in terms of treatment engagement, cross-family therapeutic alliance, and treatment satisfaction?

RQ3: From the perspective of participating family members, what are the perceived helpful experiences in the treatment process of MFT? Are there any differences in the helpful experience between online and face-to-face MFTs?

In relation to those questions, we hypothesized that the three factors in the examined MFT would be positively associated with enhanced family relationships and self-understanding for adults with HF-ASD and their parents. We also hypothesized that there would be no difference between MFT conducted online and that conducted face-to-face.