Child and Adolescent Therapy: Science and Art / Edition 1 available in Hardcover
Child and Adolescent Therapy: Science and Art equips today's therapists with the current theory, research, and techniques of psychotherapy with these special client groups. With coverage of major theories alongside their associated therapeutic interventions and techniques, this comprehensive resource brings both academic rigor and on-the-ground experience to bear on such approaches as: Behavior therapy, Constructivism-solution-oriented and narrative therapy, Cognitive therapy, Family systems therapy, Psychodynamic therapy, Atheoretical and transtheoretical techniques.
Along with different approaches, the text discusses outcome research and other clinical considerations that guide practitioners in creating the best possible treatment plans for individual clients. The overall tone of this handbook is informal and approachable-like the voice of an effective therapist-with frequent specific examples of what to say, who to say it to, and when to say it.
Bringing the science and art of therapy together in an innovative and up-to-date guide, Child and Adolescent Therapy offers an invaluable resource for both clinicians in training and skilled practitioners looking for new ideas and techniques.
About the Author
JEREMY P. SHAPIRO, PHD, is a Clinical Child Psychologist and an Adjunct Faculty Member of the Psychology Department and Mandel School of Applied Social Sciences at Case Western Reserve University.
Read an Excerpt
Child and Adolescent Therapy
By Jeremy P. Shapiro
John Wiley & SonsISBN: 0-471-38637-5
Chapter OneTherapy Fundamentals
This chapter explains:
The attitude or mind-set toward clients that is at the foundation of therapy.
Therapeutic language, including some specific words and phrases that come in handy in counseling.
What to do in the first meeting with children and parents.
Strategies for achieving buy-in from youth who do not want therapy.
What can and cannot be kept confidential from the youth's parents.
Two client-centered therapy techniques: reflection of feeling and reflection of meaning.
Techniques for helping clients open up, including therapeutic books and games.
How to use play and art in child therapy.
Collaboration with professionals in other child-serving systems.
When and how to terminate therapy.
Brent, a 5-year-old African American boy, was having trouble in kindergarten. The teacher reported that his academic skills and peer relationships were age-appropriate, but there had been repeated incidents of disobedience toward the teacher, accompanied by tantrums. Brent was not physically aggressive, but he screamed and cried, and it sometimes took 10 to 15 minutes to bring him under control. His behavior was generally pleasant and appropriate in between these outbursts, which had occurred two or three times per week during the several months since school began. Brent lived with his mother, who was a single parent and registered nurse, an older sister, and his maternal grandparents, who provided much day-to-day childcare. The caregivers reported that Brent saw his father once a month or so and seemed sad at the end of the visits. The caregivers said there were no problems with Brent's behavior at home, and they described him as a happy, energetic, cooperative child. The therapist's impression of Brent was consistent with his caregivers' description. In both play and conversation, his behavior was organized and compliant. His play with puppets depicted exciting activities and interactions, with no unusual themes of distress or defiance. He loved playing catch with a foam ball the therapist had in his office. Because Brent had exhibited no problems prior to starting school, the counselor made a diagnosis of Adjustment Disorder with Mixed Disturbance of Emotions and Conduct.
While most of the chapters in this book are organized around specific theories of psychotherapy and categories of mental health disturbance, in this chapter we begin with basic therapeutic principles and procedures that cross-cut theoretical orientations and apply to most diagnoses. Research has produced a great deal of evidence that such shared or common factors of therapy are central to its effectiveness (Ahn & Wampold, 2001; Baskin, Tierney, Minami, & Wampold, 2003; Grissom, 1996).
This chapter may make therapy sound simple-and, in a way, it is. In another way, therapy is quite complicated, as the next 14 chapters will make clear. We will begin at the beginning and build an understanding of therapy from the ground up.
The Therapeutic Orientation toward Clients
While the activity of psychotherapy is based largely on theory and technique, there is a certain attitude that lies at the foundation of our endeavor. This attitude orients us to our job, organizes our efforts, and governs the interpersonal tone of our behavior with children and families. The idea behind the therapeutic orientation is so simple that it might sound like a cliche, but its ramifications are important to consider. The moment-to-moment behavior of therapists should convey that they are there to help the client with her problems and her life. This is the role of therapists as established by licensure and relevant laws.
Although this point seems obvious, it is worth making because parents and children sometimes fear their therapists are not there to help. Youth sometimes think that being brought to counseling represents a serious form of getting in trouble, and they may think the therapist's job is to punish them or to forcibly bring their behavior under control. Children and parents sometimes think that therapists are there to evaluate and judge them-to identify and point out their failures and inadequacies. This fear seems particularly common in low-income and ethnic minority families who feel intimidated by encounters with "the system" (S. Sue, 1998; Sue & Sue, 2002). Therapists should be alert to the possibility of these concerns in clients so they can counteract them either with explicit explanations of their role or by making sure to convey a help-focused agenda in their way of interacting with families. If families seem more concerned about your approval or disapproval than about benefiting from counseling, it may be useful to say something like: "Remember-You don't work for me; I work for you."
When counselors translate this attitude into behavior, they create an interpersonal environment that is therapeutic for clients. During the time they are together, the clinician is devoted solely to the child's welfare, with no needs of his own involved in the relationship other than professional needs for remuneration and meaningful work.
The therapist models an attitude toward life that is adaptive and constructive. She does not hesitate to discuss any issue or experience, no matter how awkward or upsetting. The counselor's stance toward the client does not change whether the child reveals things about himself he considers wonderful or things he considers shameful; the therapist's unvarying desire is to understand and help.
The issue of counselors making judgments about clients has two aspects. The therapeutic attitude is based on unconditional acceptance, respect, and caring about the client as a person. However, this attitude does not include unconditional approval of all client behaviors. On the contrary-in many cases, our effort to assist clients necessarily involves helping them to change undesirable behaviors. This two-part attitude can be explained to children using words like the following:
"I like you; I just don't like what you did. In fact, I like you too much to want you to go on doing what you did."
The idea of unconditional respect for clients generally makes sense to therapists when they read about it in a book but, in the midst of real clinical work with difficult clients, maintaining this attitude is not always easy. Our commitment to a humanistic, forgiving view of people is sometimes tested by contact with child and parent behaviors that are obnoxious, mean-spirited, and cruel. No one knows how to increase the resilience of the therapeutic attitude, but we try to provide some guidance by offering personal, experience-based reflections.
The therapeutic attitude seems based on an awareness of fundamental characteristics of human life. People, especially children, do not choose the situations in which they find themselves. They do not choose the family environments, neighborhoods, or schools that influence their development. People also do not choose the genetic endowments, physical constitutions, and neurophysiologically based temperaments that, operating from within, strongly influence their experience and behavior. Within these constraints, people try to do the best they can for themselves in the world, seeking happiness where opportunities present themselves and avoiding pain when dangers seem apparent. People become therapy clients when their efforts to adapt are disrupted by neurophysiological dysregulation, environments that are harmful or poorly matched to their needs, unrealistic thinking, and painful emotional states. As a result, clients often flail, grope, and fail in their efforts to be happy, sometimes leaving painful experiences for other people in their wake. But clients do not wake up in the morning and decide to spend the day making themselves and others miserable-these are unchosen outcomes.
Therapists' initial, natural response to obnoxious or purposely hurtful behavior is often emotional distancing, perhaps even revulsion. However, we find that the most effective response to this therapeutic challenge is, not distancing, but attending more closely to the parent or child, because increased awareness of the other person's experience usually counteracts anger and disrespect. Looking closely into a person's face, feeling the rhythm of her speech and movements, and perceiving the emotions, thoughts, and pain behind her behavior usually strengthen our appreciation of that person's humanity. When there is a threat to your therapeutic orientation, we suggest trying to imagine what life feels like, moment to moment, for the parent or child as she wakes up in the morning, goes about her day, and goes to sleep at night. If you try this, we predict that your respect and concern will be rescued, not by abstract humanistic principles, but by the little things people say and do that express something intimately human.
The Therapist's Interpersonal Style
The theoretical orientations described in the chapters to follow differ somewhat in their recommendations for the counselor's style of interacting with clients. Nonetheless, we will offer some initial suggestions that may apply across the various approaches. There has been a good deal of research on client responses to different styles of therapist behavior, although these studies have generally focused on adult clients. We make use of this indirectly applicable research and our own clinical experience with youth in formulating our suggestions.
One of the most robust findings in psychotherapy research is that the quality of the therapist-client alliance predicts continuation in therapy (versus dropout) and improvement in client functioning (Horvath & Bedi, 2002; Karver, Handelsman, Fields, & Bickman, 2005; Martin, Garske, & Davis, 2000; and see Shirk & Karver, 2003, for a meta-analysis of studies of child and adolescent therapy). This association has been found across different theoretical orientations and diagnostic groups.
The next question is: What can therapists do to engender positive relationships with clients? Our response to this question draws on the efforts of a task force of the American Psychological Association that reviewed research on the therapist-client relationship (Steering Committee, 2002). Therapist empathy seems to be the single most important factor in the development of the treatment alliance (Bohart, Elliott, Greenberg, & Watson, 2002). In addition, research indicates that most clients respond best to counselors who are friendly, kind, and warm (Najavits & Strupp, 1994). A review of studies by Orlinsky, Grave, and Parks (1994) also identified client perceptions of therapist credibility and professional skill as important to the therapeutic relationship. Thus, research indicates that therapists should try to combine the behavioral qualities of professional expertise and empathic warmth-science and heart-in their interpersonal style with clients.
Perhaps because of the early influence of psychoanalysis, the traditional way for therapists to behave with clients has been a neutral, observant style in which the therapist does not initiate topics of conversation but waits to hear what the client brings up. However, most nonanalytic approaches have not recommended this style, and research on therapeutic relationships indicates that most clients do not connect well with reserved, distant counselors. Instead, treatment alliances are strongest when the client perceives the therapist as a real person who is authentic in the relationship (Klein, Golden, Michels, & Chisholm-Stockard, 2002), and when the client believes the therapist likes and cares about him (Farber & Lane, 2002). In our clinical experience, we have heard young clients complain about past therapists who "sat there and waited for me to say something," and who "stared at me and didn't talk." Therefore, we suggest that counselors allow themselves to be natural and emotionally present in the context of a professional but genuine person-to-person relationship.
The therapist-client alliance seems to develop best when counselor behavior toward the client is friendly and caring, but without an emotional intensity that would change the relationship from a professional to a personal one. Therapists should be cheerleaders for their clients, rooting for them to make progress against their problems. Our faces should light up when we hear reports of success and should express concern when setbacks occur. However, there should be boundaries on the expression of these natural reactions, which should not be so intense that clients come to worry about letting us down.
Clients sometimes ask therapists questions about themselves, with the most common one probably being, "Do you have kids?" The traditional, psychodynamic view has been that such questions reflect emotional issues and that answering these questions interferes with exploring the concerns beneath them. Accordingly, the recommendation has been to respond to personal questions with other questions, such as, "What do you think?" However, many client inquiries seem to reflect nothing other than ordinary curiosity, and a sphinx-like refusal to give straight answers may frustrate clients. We suggest that counselors respond to appropriate questions by providing ordinary information. Therapists who think the client's question might express an underlying concern can investigate this possibility after the question has been answered.
Counselors should probably not employ the same behavioral style with every client but should tailor the details of their interpersonal behavior to accommodate each youth. Therapists cannot be chameleons but, when they are sensitive to client preferences and moods, counselors can adjust their behavior to provide what clients need at the moment. For example, it makes sense to be warm and soft when clients are distressed and hurting. In contrast, tough adolescents generally do best when their counselors have a strong, direct style. Youth who do well in school may admire your professional stature and want to hear about your academic background. Youngsters who rebel against authority need firm limits, but they also feel most comfortable with therapists who, rather than being formal and proper, present themselves as casual, approachable people who like to have fun, too.
Therapists' talk should consist of ordinary language and tones of voice. We would caution against adopting a stereotypically therapeutic speaking style because this may come across as affected to clients. Counselors should avoid technical jargon, intellectualized language, and a "touchy-feely" style. Youth generally like therapists who talk like regular people, not "shrinks."
The phrases "It sounds like ..." and "It seems like ..." are convenient and useful as long as they are not overused. Statements beginning with the pronoun "I"-such as "I think that ...," and "I wonder if ..."-have a straightforward quality. For example:
"I think you would like to do well in school, but you don't know how to go about doing that."
"I can see that you're mad at yourself for losing your temper with him."
Much therapy talk involves words for feelings. Most preschool children know basic emotion words like "sad," "mad," "scared," "fun," and "happy." Most elementary school children know words like "nervous," "disappointed," "excited," "upset," and "bored." Adolescents can usually talk about still subtler varieties of emotion.
Discussion of emotional issues need not consist entirely of words for feelings. Talking about motives, goals, meanings, and reactions also builds self-awareness and clarifies issues. Clinicians talk about what clients want and do not want, what they hope for and fear, and what they like, love, dislike, and hate. As other examples:
"You love the teddy bear your aunt brought you, and it was horrible when Debbie spilled grape juice on it."
"You really had your hopes up, and it was disappointing when she said no."
Ambivalence can be described as "mixed feelings" or "having two different feelings about the same thing at the same time." Motivational conflict can be discussed by referring to "parts of you" that want different things. Even more simply, counselors can portray the co-occurrence of conflicting emotions by using the word "and" to connect them in the same sentence and by using a tone of voice implying that such co-occurrence is possible and natural. For instance:
"You're scared to go, and you're excited to go."
"You want to tell me what happened, and you don't want to tell me what happened."
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Table of Contents
|Preface: The Therapist's Challenge||xi|
|Part I||The Tools of the Therapist|
|The Therapeutic Orientation toward Clients||4|
|Basic Child Therapy Skills||15|
|Helping Clients Open Up||21|
|Collaborating with Other Child-Serving Systems||34|
|Assessment and Case Formulation||47|
|The Therapist's Style||55|
|Social Skills Training||66|
|Assessment and Case Formulation||76|
|The Therapist's Style||83|
|Tests of Evidence||95|
|Naming Cognitive Distortions||97|
|Assessment and Case Formulation||113|
|The Therapist's Style||123|
|Facilitating the Expression of Material||123|
|Interpretation and Insight||124|
|Corrective Emotional Experience||131|
|5||Constructivism: Solution-Oriented and Narrative Therapy||135|
|Postmodernism and the Social Construction of Reality||136|
|Assessment and Case Formulation||141|
|The Therapist's Style||149|
|Solution-Oriented Therapy Techniques||150|
|Narrative Therapy Techniques||158|
|6||Family Systems Therapy||167|
|Assessment and Case Formulation||176|
|The Therapist's Style||186|
|Combining Family and Individual Modalities||187|
|Treating Enmeshment and Disengagement||195|
|Treating Negative Feedback Loops||198|
|Treating Positive Feedback Loops||199|
|Extended Family and Multigenerational Therapy||202|
|7||Atheoretical and Transtheoretical Techniques||205|
|Providing Information and Direction to Clients||212|
|Meeting the Client Halfway||222|
|Incorporating Experiences into New Structures of Meaning||228|
|Part II||The Needs of Clients|
|8||Outcome Research and Clinical Reasoning in Treatment Planning||245|
|The Controversy: How Should Counselors Plan Therapy?||245|
|The Case for Outcome Research||246|
|What the Research Says||249|
|Mediators and Moderators of Treatment Effects||255|
|The Limitations of Outcome Research||257|
|What the Research Does Not Say||259|
|Bridging the Gap between Research and Practice||263|
|When to Consider Techniques without Strong Empirical Support||272|
|9||Cultural Factors in Therapy||277|
|The Role of Culture in Psychotherapy||278|
|Assessment and Case Formulation||289|
|The Therapist's Style||295|
|Connecting the Cultures of Therapy and Client||296|
|Conflicts between Client Cultures and the Predominant Culture||299|
|Addressing Prejudice and Discrimination||300|
|Culturally Specific Adaptations of Therapeutic Approaches||301|
|Bringing Spirituality into Therapy||302|
|10||Disruptive Behavior Disorders in Children||307|
|Diagnoses Treated in This Chapter||308|
|Clinical Presentation and Etiology||308|
|Behavioral-Systemic Parent Training||319|
|The Collaborative Problem Solving Approach||331|
|Cognitive-Behavioral Therapy with the Child||334|
|11||Disruptive Behavior Disorders in Adolescents||341|
|Diagnoses Treated in This Chapter||342|
|Clinical Presentation and Etiology||342|
|12||Aggression and Violence||375|
|Diagnoses Treated in This Chapter||376|
|Clinical Presentation and Etiology||376|
|Interventions Addressing Attitudes, Values, and Motivation||386|
|Diagnoses Treated in This Chapter||408|
|Clinical Presentation and Etiology||409|
|Family Therapy and Parent Counseling||438|
|Diagnoses Treated in This Chapter||444|
|Clinical Presentation and Etiology||445|
|Special Topic: Suicide Risk||456|
|Family Therapy and Parent Counseling||472|
|15||Stress and Trauma||477|
|Diagnoses Treated in This Chapter||478|
|Clinical Presentation and Etiology||478|
|Coping with Stress and Trauma||483|
|Therapy for Parental Divorce||500|
|Therapy for Bereavement||504|
|Therapy for Sexual Abuse||506|
|Afterword: The Therapist's Experience||515|
What People are Saying About This
"This book is by far the most comprehensive and useful child therapy text. Amazingly well-written, it is both supremely helpful for new clinical graduate students and an outstanding, sophisticated review for clinicians and researchers. The second edition of this book is even more useful than the original text! The first edition filled a key gap by providing a broad array of useful and evidence based information to new child clinicians learning to conduct therapy with kids and teens. Because of its currency and clinical sophistication, it is also suited to busy practitioners who are looking for practical ways to integrate new, clinically relevant evidence and ideas. The writing engages the reader with a crisp style and clear real-world examples showing a deep understanding of evidenced based work with youth. The revised edition adds new material on mindfulness-based cognitive-behavioral therapies and motivational interviewing, and it weaves recent neuroscience research into discussions of clinical topics. To a unique degree, this book articulates the thought process of an experienced therapist as he or she integrates outcome research and clinical considerations to plan treatment strategy and decide what to do and say in work with clients. We use this textbook in our didactic practicum with new clinical graduate students at the University of North Carolina, and each fall, the students and I enjoy reading the combination of a broad perspective, specific techniques and logistical implementation ideas, as well as up to date references. Child and Adolescent Therapy: Science and Art is a helpful and detailed yet fun read for new and seasoned clinicians!"—Jen Kogos Youngstrom, PhD, Professor of Clinical Psychology, Director of Child and Family Services and Assessment Clinic The University of North Carolina at Chapel Hill
"This book combines clear, insightful explanations of the major theoretical orientations, rigorous summaries of outcome research, and the clinical wisdom of an experienced therapist in a unique synthesis that shows readers how to plan treatment and decide what to say when with clients. My graduate students loved the first edition of this book—there’s nothing like it. The broad array of theoretical approaches that are covered helps to develop a comprehensive understanding of intervention approaches and provides a very solid foundation in child and adolescent therapy. This new edition has added an excellent chapter on mindfulness-based therapies and has infused a sophisticated neuroscience framework throughout the book. I highly recommend this text to mental health professionals working with young people and to graduate students beginning their work in child and adolescent therapy."—Sandra W. Russ, Distinguished University Professor Case Western Reserve University
"As a researcher, clinician, and instructor in a school psychology graduate program, I appreciate books that offer breadth of content but also sufficient depth in evidence-based practices in order to best prepare future youth mental health professionals. After switching from other texts that were either overly broad and historical or too narrow, I adopted the first edition of this book as the required text for my introductory course in counseling and psychotherapeutic interventions. My graduate students and I have given this book the highest praise. We appreciate the clear, insightful explanations of theory and research and the detailed, vivid instructions for implementation that make the process of therapy come alive. Unlike edited books with chapters by different authors, this text presents psychotherapy as an integrated whole. The chapters cross-reference each other frequently to identify connections and contrasts among the major theories and to show how elements of different approaches can be woven together in customized therapy for each client. My students are particularly thankful for the numerous vignettes and example scripts that illustrate best practices and provide detailed demonstrations of effective therapy."—Shannon Suldo, Professor, University of South Florida
"This book is essential for courses covering child and family therapy. It is comprehensive, well-written, engaging, well-organized, and informative. When I used the first edition, my students told me they looked forward to reading each week's assignment and that this is the book they return to again and again throughout their career as a resource for the most up-to-date information on interventions for various disorders. The author not only provides background information about the theory and evidence base behind interventions but also practical illustrations for how to implement interventions effectively and stylistic suggestions that demonstrate the art of conducting therapy. This book is a wonderful addition to any therapist's library, whether a therapist in training or an experienced therapist who wants to stay current."—Amy Przeworski, Ph.D. Assistant Professor Case Western Reserve University