Introduction to Abnormal Child and Adolescent Psychology. Robert Weis
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The therapist must communicate that she values the client and will support the client’s decisions. Rogers believed that clients whose therapists provided them with these three conditions would experience the greatest benefits from treatment (Rogers, 1961).
The Therapeutic Alliance
An essential ingredient of successful treatment is the therapeutic alliance or collaborative relationship between the client and the therapist. The therapeutic alliance has both an emotional and cognitive component. With respect to emotion, the client and therapist must experience a positive emotional connection based on trust and support. With respect to cognition, the client and therapist must agree on the goals of therapy and the steps that are needed for reaching those goals. Building these emotional bonds and agreeing on the course of therapy are primary tasks early in treatment (Karver, De Nadai, Monahan, & Shirk, 2018).
The therapeutic alliance is important because it predicts children’s success in psychotherapy. Children who experience a greater connection with their therapists, and agree on the goals of treatment, show greater involvement in therapy, report a higher willingness to change their behavior, and display more openness during their sessions. Similarly, parents who build close relationships with their child’s therapist are more likely to attend sessions with their child and follow through on recommendations to help their children. In contrast, a weak alliance predicts poor participation in therapy, an uncooperative or confrontational approach to treatment, and high likelihood of dropout (Norcross & Lambert, 2020).
Few practitioners dispute the importance of the common factors of therapy and the need for a strong alliance. However, most clinicians regard these elements as necessary, but not sufficient, to bring about change. Consequently, they supplement these common factors and alliance-building techniques with specific strategies and tactics consistent with their theories of human development and the origins of psychopathology. The specific therapeutic methods they use depend on the system of psychotherapy they practice, the presenting problem of the client, and the family’s goals and resources (Karver et al., 2018).
Review
Psychotherapy is a professional relationship between at least two people with the goal of alleviating distress or impairment and promoting growth and competence. This goal is achieved by altering the way the client thinks, feels, or acts in the context of the relationship.
Rogers identified three factors that lead to change in therapy: (1) empathy, (2) congruence, and (3) unconditional positive regard.
The therapeutic alliance describes the collaborative relationship between the clinician and the client. The quality of the relationship predicts change in therapy.
What Are the Major Systems of Psychotherapy?
There are hundreds of systems or “schools” of psychotherapy. They can be loosely categorized in terms of the level at which they approach clients’ presenting problems. These levels include the child’s (1) immediate symptoms and overt actions, (2) patterns of thinking, (3) interpersonal relationships, (4) family structure and functioning, and (5) awareness of oneself (Prochaska & Norcross, 2019).
Behavior Therapy
Behavior therapy focuses primarily on the client’s overt actions. Behavior therapy has its origins in the work of Joseph Wolpe (1958), Hans Eysenck (1959), and B. F. Skinner (1974). Behavior therapists address clients’ problems at the symptom level. Behavior therapists do not assume that underlying personality traits or unconscious conflicts influence behavior. Instead, behavior is determined by environmental contingencies—that is, conditions in the person’s surroundings that elicit, reinforce, or punish their actions. The goal of behavior therapy is usually to alter these environmental contingencies to increase the likelihood that clients will engage in more adaptive patterns of action.
Recall that behavior therapists typically perform a functional analysis of their clients’ problematic behavior in order to determine situations that elicit the behavior (antecedents) or conditions that reinforce it over time (consequences). Then, behavior therapists work with clients to find ways to avoid these environmental triggers or alter the consequences of the behavior that maintain it (Miltenberger, Miller, & Zerger, 2015).
Recall that Anna’s most problematic behavior is her tendency to binge and purge. A behavior therapist would carefully note the frequency of Anna’s bingeing. Then, the therapist would try to identify situations that often precede a binge. For example, Anna might report that she tends to binge after school, when she is feeling lonely, and when she is hungry. The therapist would also try to determine how Anna’s bingeing is maintained over time. Anna might report feeling less lonely and hungry immediately after bingeing; thus, bingeing is negatively reinforced by the withdrawal of these unpleasant feelings (Fishman, 2018a).
Over the course of treatment, a behavior therapist might teach Anna to monitor her binge eating, its antecedents, and its consequences. Then, the therapist might help Anna avoid antecedents that trigger binges. For example, the therapist might help Anna eat more regular, balanced meals to avoid feelings of intense hunger. Similarly, the therapist might help Anna identify ways to avoid the loneliness and boredom that often elicit her binges. The therapist might encourage Anna to become more involved in after-school activities or teach her to develop more satisfying peer relationships. Alternatively, the therapist might help Anna identify coping strategies, like relaxation techniques or exercise, to manage negative emotions. By altering environmental factors that elicit or reinforce her binges, Anna should be able to decrease their frequency.
Cognitive Therapy
Cognitive therapy focuses primarily on the client’s patterns of thinking about herself, others, and the future. One cognitive therapist, Aaron Beck (1976), argued that people experience psychological distress and impairment when they engage in systematic errors in thinking called cognitive biases and cognitive distortions. A cognitive bias occurs when someone selectively attends to negative aspects of her life rather than looking at situations in a more balanced, realistic way. For example, a girl with social anxiety who is giving a class presentation might focus exclusively on her classmates’ laughs or snickers rather than on her teacher’s nods of approval. Similarly, a boy with depression might attend to the fact that only one classmate sits with him during lunch instead of feeling supported by his friend who chose to spend time with him.
From Science to Practice: Cognitive Therapy With Children
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Cognitive therapists teach children that the way we think affects how we feel. If we can change the way we think about a situation, we will likely feel better. A therapist might use the cartoon of the elephant and the mouse to teach this concept to a young child with anxiety.
Therapist: How is the elephant feeling?
Child: He’s scared.
Therapist: Why?
Child: He thinks the mouse will hurt him.
Therapist: Will the mouse really hurt him?
Child: No. The mouse is so little.
Therapist: If the elephant had a different thought like, “Look at that cute little mouse,” would he feel differently?
Child: Yes. Maybe he’d be happy and want to play with the mouse.
Therapist: So the way we think about situations affects how we feel.
Child: Yes, just like the elephant.
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