Read an Excerpt
Child and Adolescent Therapy
By Jeremy P. Shapiro John Wiley & Sons
ISBN: 0-471-38637-5
Chapter One
Therapy Fundamentals
OBJECTIVES
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.
Case Study
Simplicity
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.
Therapy Language
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."
(Continues...)
Excerpted from Child and Adolescent Therapy by Jeremy P. Shapiro Excerpted by permission.
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