Child and Adolescent Therapy

Science and Art

Jeremy P. Shapiro

• Publisher: Wiley
• Year: 2015
• ISBN:
  9781118722077
• Topic: Architecture
• Subtopic: Architecture General
• Edition: 2

Comprehensive introduction to the theory and practice of therapy

Child and Adolescent Therapy: Science and Art, Second Edition relies on both psychotherapy research and clinical expertise to create a comprehensive guide to evidence-based practice for providers of child and adolescent therapy. It includes explanations of all major theoretical orientations and the techniques associated with each, with application to the major diagnostic categories. This updated Second Edition includes a new chapter on Mindfulness-Based Cognitive-Behavioral Therapies (Dialectical Behavior Therapy and Acceptance and Commitment Therapy), incorporation of recent neuroscience research, instruction in Motivational Interviewing, and guidance in using therapeutic diagrams with young clients.

The book models the thought process of expert therapists by describing how the science and art of therapy can be combined to provide a strong basis for treatment planning and clinical decision-making. Theoretical concepts, empirically supported treatments, and best practices are translated into concrete, detailed form, with numerous examples of therapist verbalizations and conversations between counselor and client. Child and Adolescent Therapy: Science and Art, Second Edition:

• Explains the work of therapists from the ground up, beginning with fundamentals and moving on to advanced theory and technique
• Covers the major theoretical approaches: behavioral, cognitive, mindfulness-based, psychodynamic, constructivist, and family systems
• Guides therapists in planning effective treatment strategies with balanced consideration of outcome research, cultural factors, and individual client characteristics
• Connects treatment planning with the diagnostic characteristics of the major child and adolescent disorders

For both students and skilled clinicians looking for new ideas and techniques, Child and Adolescent Therapy: Science and Art, Second Edition offers a thorough, holistic examination of how best to serve young therapy clients.

Part I

The Tools of the Therapist

Chapter 1
Therapy Fundamentals

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Objectives

This chapter explains:

• The orientation toward clients at the foundation of therapy.
• Therapeutic language, including some specific words and phrases to use with young people.
• What to do in the first meeting with children and parents.
• What can and cannot be kept confidential from the youth's parents.
• Reflection of feeling and reflection of meaning.
• Therapy goals that motivate and organize clients' efforts for improvement.
• How to use play and art in child therapy.
• Motivational interviewing, a strategy for overcoming resistance.
• Simple, directive therapeutic interventions.
• Therapy termination.

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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, 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. 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.

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While most of the chapters in this book are organized around specific theories of psychotherapy or categories of disturbance, in this chapter we begin with basic therapeutic principles and procedures that crosscut 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 (Baskin, Tierney, Minami, & Wampold, 2003; Imel & Wampold, 2008; Wampold, 2010).

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 cliché, 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 professional ethics and licensing regulations.

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 is a serious form of getting in trouble (an impression that is not always inaccurate). 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” (Sue & Sue, 2013). 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 the therapeutic attitude is translated into behavior, 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 efforts to assist clients necessarily involve helping them change maladaptive behaviors. This two-part attitude can be explained to children using words like the following:

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1. “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.”

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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 I will try to provide some guidance by offering personal, experience-based reflections.

The therapeutic attitude seems based on an awareness of certain fundamental truths about human life. People, especially children, usually do not choose the situations in which they find themselves. They do not choose the family environments, neighborhoods, and 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, seeking happiness where opportunities present themselves and avoiding pain when dangers occur. 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 emotions. As a result, clients often stumble, grope, and flail 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. Even when people do poorly, they are generally doing the best they can in a world perceived as confusing and painful.

Therapists' initial, natural response to obnoxious or purposely hurtful behavior is often emotional distancing, perhaps even revulsion. However, I have found 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 sensing the emotions behind her behavior strengthen our appreciation of that person's humanity. When your therapeutic attitude toward a client is threatened, I would suggest trying to imagine what his life feels like to him, moment to moment, as he wakes up in the morning, goes about his day, and encounters you in this strange context called therapy. If you do this, I predict your respect and concern will be rescued, not by abstract humanistic principles, but by the little things people do and say that express something intimately human and reveal their struggle and suffering.

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, there are some basic principles that crosscut the different therapeutic approaches, and we will begin with these.

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, Del Re, Fluckiger, & Symonds, 2011; Marcus, Kashy, & Baldwin, 2009; Norcross, 2010; and see McLeod, 2011 for a meta-analytic review focusing on child and adolescent therapy). This association, which is generally of modest but significant strength, has been found across a variety of theoretical orientations and diagnostic groups.

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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.

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The next question is: What can therapists do to engender positive relationships with clients? Therapist empathy seems to be the single most important factor in the development of the treatment alliance (Bohart, Elliott, Greenberg, & Watson, 2002). Most clients respond best to counselors who come across as friendly, kind, and warm (Najavits & Strupp, 1994). A review of ...