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Raymond A Digiuseppe
St. John's University
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Applied & Preventive Psychology 5:85-100 (1996). Cambridge University Press. Printed in the USA.
Abstract
The psychotherapy process research on the therapeutic alliance in child and adolescent psychotherapy is alarmingly
scarce. Findings from the adult therapeutic alliance literature and from the few existing studies on child and
adolescent therapeutic alliance are reviewed. Bordin's (1975) model of the working alliance and Prochaska and
DiClemente's (1988) stages of change model are employed to evaluate existing strategies for building alliances
with child and adolescent clients and to develop proposed strategies. The facts that (a) children are most often not
self-referred and (b) frequently come to therapy in a resistant, precentemplative stage of change are presented as the
major obstacles to forming effective alliances with children and adolescents. Traditional child and adolescent
psychotherapies may fail to develop effective alliances due to their primary focus on the development of the bond
and neglect in achieving agreement on the goals and tasks of therapy. Multimodal strategies for building therapeutic
alliances with children and adolescents incorporating techniques from emotional script theory, social problemsolving theory, motivational interviewing, and strategic family systems theories are presented.
Key words: Therapeutic alliance; Psychotherapy; Children; Adolescents.
Outcome and process research in child and adolescent psychotherapy has greatly lagged behind research in adult psychotherapy (Institute of Medicine, 1989; Hoghughi, 1988;
Johnson, Rasbury, & Siegel, 1986; Kazdin, 1988, 1990).
Meta-analytic studies suggest that research on psychotherapies for children and adolescents generally finds effect
sizes of similar magnitudes as do treatments f o r adults
(Casey & Berman, 1985; Weisz, Weiss, Alicke, & Klotz,
1987). However, the bulk of research regarding child and
adolescent psychotherapy is done on populations that have
identifying problems different from those that characterize
actual clinical practice (Koocher & Pedulla, 1977; Silver &
Silver, 1983; Tuma & Pratt, 1982). In fact, research suggests (Weisz, Weiss, & Donenberg, 1992) that outcomes for
samples from clinics are significantly poorer than those in
research studies. There is considerably less assurance that
psychotherapies for children are as effective as they are for
adults. One reason for this state of affairs appears to be the
lack of research and investigation on the therapeutic process
with children and the development of the therapeutic alliance in particular. This article reviews the recent literature
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are best reserved until after the establishment of the therapeutic relationship. However, no research exists to verify
this often stated advice. Also no research evidence exists to
support the belief that supportive, reflection techniques are
the most effective way to build the therapeutic relationship.
Our clinical experience suggests that while reflection techniques may build a bond with younger children, some older
children, and especially adolescents, respond to this technique with suspicion or disinterest. Some children and adolescents experience the active, directive style of cognitive
behavioral therapy as an indication of the therapist's caring
(DiGiuseppe, 1981; DiGiuseppe & Bernard, 1983; DiGiuseppe, 1989). Actively helping children solve their problems may be an effective strategy for building rapport. It is
possible that attempts to foster a strong therapist-child relationship or bond, prior to, or in place of a clear explanation
of the goals and process of therapy, might be experienced as
manipulative by adolescent clients.
The child/adolescent psychotherapy literature displays
greater emphasis on techniques that build the therapeutic
bond than on techniques that foster agreement on goals or
tasks. Yet, in adult psychotherapy, the therapeutic relationship in and of itself, is not sufficient for successful treatment
outcome (Bordin, 1975; Marmar, Horowitz, Weiss, & Marziali, 1986). Research on the adult therapeutic alliance demonstrates that of the three components, the agreement on
tasks of therapy is the best predictor of treatment outcome
(Horvath & Greenberg, 1986). The primacy of the therapeutic bond in mediating a positive therapeutic outcome may be
overemphasized for children and adolescents.
Formulating Goals
To reach agreement on the goals of therapy, the initial
goals that motivated the referral must be explained to the
youngster. Adolescents often lack a clear picture concerning
why they are in therapy, since they are referred by their
parents and schools. Frequently the parents and/or therapist
may have treatment goals that differ from, or are in strong
opposition to, the child's goals. There is, therefore, a greater
likelihood that adolescents, as opposed to adults in therapy,
could disagree with their therapists on the goals of therapy
(Johnson, Rasbury, & Siegel, 1986).
The incompatibility of client-therapist goals may be
most problematic for traditional psychodynamic therapy.
Clear specification and explanation of goals are avoided in
many forms of child/adolescent psychotherapy because
goals in therapy are often determined by others, and therefore may be conflictual for the child/adolescent (HareMustin, Marecek, Kaplan, & Liss-Levinson, 1979;
Koocher, 1976; Weinberger, 1972). Many child/adolescent
therapists do not ask children to construct goals in therapy,
or they may suggest a vague or nonspecific goal such
as deeper self-understanding (Carek, 1979; Freud, 1964;
Tuma, 1983). Children in the concrete operations stage of
development tend to view causes of behavior as external,
situational, and singular, as opposed to resulting from inner
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psychological constructs (Shirk, 1988). Given such cognitive limitations on their insight or self-understanding, it is
perhaps unrealistic to expect young children and adolescents to comprehend the goals of therapy as insight (Jurkovic & Ulrici, 1982; Nannis, 1988; Nuffietd, 1988; Shirk,
1988). Thus, there is a high probability that the techniques
of traditional child/adolescent therapy do not foster clear
agreement on goals.
In behavioral and family-oriented approaches to treatment, the child or adolescent is more likely to be aware of the
goals the therapist is working toward, since the goals are
more likely to be discussed. This does not ensure that the
child or adolescent client is in agreement with the goals,
because in both types of therapies the goals and tasks of
therapy are often chosen by either the parents or the therapist. The conceptual distinction between the roles of the
client and the customer reflect family systems theory's
awareness of such possible goal conflict (Haley, 1976;
Minuchin, 1974). Perhaps in behavioral and family therapies, in which the therapists' efforts are aimed less directly at
the child/adolescent and more directly at the larger parent]child or family systems, the therapeutic alliance formed
with the child/adolescent is less important to the success of
therapy than the therapeutic alliance established with the
parents.
Cognitive approaches to therapy suggest that goals be
discussed clearly and openly with the client and that the
child/adolescent's conceptualization of the target behavior
is important to explore. DiGiuseppe (DiGiuseppe & Bernard 1983; DiGiuseppe 1988; 1989) suggested that agreement on goals can often be achieved by an initial phase of
therapy that focuses on teaching alternative thinking and
consequential thinking skills about emotions. Helping the
children to explore the consequences of their behaviors and
emotions and alternative ways of feeling and behaving, can
help formulate the goals of therapy.
Understanding Tasks
There is little socialization of children and adolescents to
the activities expected in therapy, or on how these activities
are related to the goals of their therapy. Adults in our society have seen movies that portray the process of psychotherapy, or have friends who have participated in psychotherapy. The ideas of introspection, relaying dreams, and
expression of feelings as part of the process to attain treatment goals, are more familiar to adults entering psychotherapy. Adults also may hold implicit personality theories
that include experiences of what is necessary for change,
and therefore have some expectations as to what types of
activities will lead to behavior or emotional change. Children and adolescents are less likely to have any expectations
concerning the tasks of psychotherapy. Children and adolescents may lack any previous experiences to prepare them for
therapy. They may not understand that the behaviors the
therapist and the child engage in during their sessions are
related to accomplishing the goals of therapy. Children will
Treatment Manuals
Luborsky and DeRubis (1984) argued for the importance
of treatment manuals in psychotherapy research and the use
of such manuals are now standard practice in therapy outcome research. Manuals allow for clear specification of the
particular treatment method employed and of the exact techniques involved in performing the treatment. Shaffer (1984)
has called for the development of child treatment manuals in
accordance with trends in adult psychotherapy research.
Without treatment manuals it is difficult for child/adolescent
researchers and clinicians to know which specific treatment
methods have been subjected to research, and which tech-
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The Motivational Syllogism. After exploring the consequences of a youngster's emotional scripts and presenting
acceptable alternatives, the therapist can use these insights to
increase the child's or adolescent's motivation for change.
We call this technique the Motivational Syllogism. First, the
therapist Socratically explores the consequences that follow
whenever the client experiences the target emotion. Once the
child/adolescent agrees that it is in her/his best interest to
change her/his emotion, one moves to the second step of
helping clients generate alternative scripts. This step can
often be achieved by having the child or adolescent recall the
successful reactions of others whom they respect. This activity helps to generate a model for an alternative script. Youngsters from very dysfunctional families may have few such
models. The therapists may have to suggest models from the
general culture, the literature, folklore, or film of the client's
culture. After a model is chosen for an alternative script, it is
important to review the consequences of the model's behavior following the script. Next, the youngsters are asked to
imagine that they react in the same manner as the script and
imagine that the consequences happen to them. In this way
the youngsters can provide information on how they believe
the script may not be socially or personally acceptable to a
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have provided the motivation for functional behavior. Reviewing the consequences of clients' behaviors when they
experience disturbed emotions will usually bring up much
disconfirming evidence. Youngsters can be shown models
of others who behave in the desired manner but who do
not experience the disturbed emotions in question. These
models will help clients believe that less disturbed emotions can lead to desired adaptive behavior. Clients who
give up the ideas that maintain the emotion will be much
more willing to dispute the irrational ideas that generate
the emotion.
Motivational Interviewing
Treatment programs designed to work with clients with addictive behaviors may provide some insights into working
with youngsters who have not consented to change. Miller
and Rollnick (1991) developed an intervention program designed to build an alliance with clients with addictive behavior and maximize their motivation for change during the
initial sessions. The program, called "motivational interviewing," incorporates Prochaska and DiClemente's (1988)
model of change, and draws on principles of social, cognitive, and motivational psychology (i.e., Kanfer, 1987; Miller & Brown, 1991). Miller and Rollnick (1991) conceptualized addicts as receiving treatment in Prochaska &
DiClemente's precontemplative stage of change and as,
therefore, ambivalent about change. It follows, then, that the
therapist's task is to help move these clients toward the
contemplation of change and then to the action stage. Miller
and Rollnick contended that motivation for change is a
state, as opposed to a character trait, The will to change is,
therefore, dependent upon context. This is an important conceptual distinction, because it defines the therapist's task as
helping alter the client's interpersonal context in ways that
increase the probability for change.
If it is accepted that motivation is a context-dependent
state rather than a stable personality attribute, then the principles of motivational interviewing, which have found success with highly "resistant" clients (Miller & Rollnick,
1991), may be applied to other populations who are generally unmotivated for change. Specifically, children and adolescents who are not self-referred for treatment may contemplate positive changes if the motivational interviewing
approach is employed as a means of building the agreement
on the goals/tasks of the alliance. With this in mind, we will
summarize some of the general principles of motivational
interviewing and suggest how they might be applied with
adolescent clients.
Working with precontemplators. Miller and Rollnick
(1991) found that certain strategies in the initial phase of
therapy tend to either evoke resistance or circumvent it. The
key to successfully handling the patient's ambivalence begins with an assessment of his/her degree of motivation,
according to the stages of change model. Motivation is defined by this model as "the probability that a person will
enter into, continue and adhere to a specific change strategy." Therapists' interventions must be tailored to the client's current stage of motivation for change, and any attempt to work with the patient is likely to fail if the aims of
later stages are approached too early. For instance, jumping
to interventions aimed at action before the patient has resolved to change is likely to elicit resistance. Therapists are
often tempted to press the client for participation in tasks
beyond the client's present stage of change. Such action
may trigger psychological reactance as clients assert their
freedom against coercion.
The primary tasks of early therapy are to build an alliance
and motivate the client toward change. Therapists can accomplish this by raising doubts in clients' minds about the
undesirability of change. To do so, the therapist needs to
increase the client's perception of risks and problems regarding current behavior. More specifically, how to best
accomplish this may depend on the kind of precontemplator
the therapist is dealing with. Proschaska and DiClemente
(1986) described four types of precontemplation, which he
summarizes as the "four Rs": reluctance, rebellion, resignation, and rationalization.
Rationalizing precontemplators have a storehouse of reasons why the problem is not a problem, or why it may be
a problem for others but not for them. Interviews with
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Building the alliance through motivational interviewing. With adults, research shows that the quality of the
therapeutic alliance tends to stabilize by the third or fourth
sessions and is predictive of retention and outcome (Horvath
& Luborsky, 1993). Although these results have not been
duplicated with adolescents, there is little reason to believe
that the results are different. Our preliminary results with the
AWAI suggest this is the case. The job of the therapist is to
raise the client's doubt about the undesirability of change by
increasing the client's perception of risks and problems related to current behavior and having them focus on the
advantages of alternatives. Early strategies of motivational
interviewing emphasize techniques for building such a positive relationship. These strategies include:
1. Providing an explanation of the s~ucture of the therapy, including a description of the roles of the therapist
and client and the goals of the therapist.
2. Asking open-ended questions or Socratic questioning
that allow the client to do most of the talking.
3. Reflective listening to open-ended questions is an important ingredient of motivational interviewing, and,
according to Miller and Rollnick, constitutes a substantial portion of therapists' responses during the early phase of therapy. Therapists should selectively reflect the clients' answers to emphasize and reinforce
any aspects that reflect movement toward change. For
instance, self-motivational statements that express a
desire to change, negatives about the target behavior,
or advantages of alternatives should be reflected, so
that the clients hear their own statements twice.
4. Affirming and complimenting clients for their efforts
and expressing understanding for their problems.
5. Therapists should express empathy, avoid argumentation, support self-efficacy, and roll with resistance as
much as possible. By the latter, it is meant that the
therapist should treat the client's resistance as natural
and understandable and avoid attempts to impose new
views or goals. Instead, the therapist should involve
the client actively in the process of problem solving.
6. It is important to get clients to present the arguments
for change. To this end, Miller and Rollnick emphasized the importance of eliciting self-motivational
statements. Self-motivational statements include rec-
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Don't
Express empathy.
Support self-efficacy.
Roll with resistance.
Stay with the client's concerns.
Explore the consequence of the clients behaviorand emotions.
Explore the alternativeemotionalreactions the client could experience.
Explore acceptablemodelswho displaymore adaptivebehaviorand emotions.
Explore the possibleconsequences of alternative reactions.
Collaborativelyexplore the resistance.
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