Developing the Therapeutic Alliance in Child-Adolescent Psychotherapy

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    Developing the therapeutic alliance in child—adolescent psychotherapy

    Article in Applied and Preventive Psychology · March 1996Impact Factor: 2.27 · DOI: 10.1016/S0962-1849(96)80002-3

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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 .Copyright © 1996 AA APP 0962-1849/96 9.00 + .00

    Developing the therapeutic alliance inchild adolescent psychotherapy

    R AY M O N D D I G I U S E P P E , J E A N L I N S C O T T, A ND R O B I N J I LT O N

    St. John's University

    Abstract

    The psych othera py process research on the therapeutic alliance in child and adolesc ent psyc hothe rapy is alarminglyscarce. Findings fro m the adult therapeutic alliance literature a nd from the few existing studies o n child andadolescent therapeutic alliance are reviewed. Bor din' s (1975) model of the working alliance and Procha ska andDiClemente'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 notself-referred and (b) frequently com e to therapy in a resistant, prec entem plative s tage of chan ge are presented as themaj or obstacles to forming effective alliances with children and adolescents. Traditional child and adolescen tpsychotherapies may fail to develop effective alliances due to their primary focus on the developme nt of the bondand neglect in achiev ing agreem ent on the goals and tasks of therapy. Multimodal strategies for building therapeuticalliances with children and adolescents incorpora ting techniques from emotion al script theory, social proble m-solving theor y, motivationa l interviewing, and strategic family sys tems theories are presented.

    Key words Therapeutic alliance; Psych othera py; Children; Adolescents.

    Outcome and process research in chi ld and adolescent psy-chotherapy has great ly lagged behind research in adul t psy-

    chothera py (Inst itute of Medicine, 1989; Hogh ughi , 1988;Johnson, Rasbury, & Siegel , 1986; Kazdin, 1988, 1990).Meta-analyt ic s tudies suggest that research on psycho-therapies for chi ldren and adolescents general ly f inds effects izes of s imilar magn itudes as do t reatments fo r adul ts(Casey & Berman, 1985; Weisz, Weiss , Alicke, & Klotz,1987). Howe ver, the bulk of research regarding chi ld andadolescent psychotherapy is done on populat ions that haveident ifying problems different f rom those that character izeactual c l inical pract ice (Koocher & Pedulla , 1977; Si lver &Silver, 1983; Tu ma & Prat t , 1982). In fact , research sug-gests (Weisz, Weiss , & Donenberg, 1992) that outcomes forsamples from cl inics are s ignif icant ly poorer than those inresearch s tudies . There is considerably less assurance thatpsychotherapies for chi ldren are as effect ive as they are foradul ts . O ne reason for this s tate of affairs appears to be thelack of research and invest igat ion on the therapeut ic proce sswith chi ldren and the develop men t of the therapeut ic al l i -ance in part icular. This ar t ic le reviews the recent l i terature

    Address correspondence and reprint requests to: Raym ond DiGiuseppe,Department of Psychology, St. John's University, 8000 Utopia Parkway,Jamaica, New Yo rk 11439.

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    on the therapeutic al l iance in chi ld-ad olesce nt psyc hotherapyand offers some research s trategies and techniques to deve lop

    the therapeutic alliance with children and adolescents.The adul t psychotherapy research l i terature has placed

    part icular emphasis on the role of the therapeut ic relat ion-ship, and the working al l iance, as an important variable forpredict ing psychotherapeut ic change (Greenberg & Pinsof ,1986; Horvath & Greenberg, 1986; Luborsky, Cri ts-Chris-toph, Mintz, & Auerbach, 1988; Marmar, Horowitz , Weiss ,& Marzial i , 1986). One would expec t equal research explor-ing this topic s ince most theories of chi ld and adolescentpsychotherapy posi t that the therapeut ic relat ionship is cru-cial to therapy outcome. Kazdin, Siegel , and Bass (1990)surveyed over 1100 chi ld therapy pract i t ioners . Therapistswere as ked to rate the types of variables they bel ieved m ostinf luence t reatment . The majori ty of therapis ts judge d thetherapeut ic relat ionship to be one of the most importantvariables determining successful t reatment . More than 90%of the chi ld]ad olescent therapists th ought the therapeut icrelat ionship was extremely important in inf luencing the de-gree of chang e in therapy. Correspo ndingly, mo st respon-dents did not rate technical aspects of treatment , such asspecif ic therapis t techniques, durat ion of t reatment , or f re-quen cy of sessions, as important to outcome. Of al l var iablesconsidered to inf luence change, the therapeut ic relat ionshipwas rated as important far above any other variables .

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    86 DiGiuseppe Linscott and Jilton

    Despi te the c ruc ia l ro le tha t the therapeut ic re la t ionsh ipappears to p lay in the theore t ica l and c l in ica l l i te ra ture , anddespi te prac t i t ioners ' be l ie fs regard ing the im por tance o f thetherapeut ic re la t ionsh ip , few p rac t i tioners expressed a be l ie fin the impor tance o f research ing the therapeut ic re la tionsh ipor a l l i ance . In Kazdin , S iege l , and Bass ' s (1990) survey,

    only 58% of the respondents thought i t was impor tan t toexamine therapeut ic processes in research , and only 36%thought therap is t s ' charac te r is t ics ( inc lud ing the therapeut ica l l iance) were im por tan t as a focu s for research .

    The c ruc ia l ro le of the therapeut ic re la t ionsh ip in m edia t -ing psychotherapy outcome, and the fa i th in the e ffec t ive-ness o f the presen t ly u t i l i zed techniques for deve loping thetherapeut ic re la t ionsh ip , seem to be unques t ioned assump-t ions amongs t ch i ld /adolescent psychotherap is t s . Par t ic -u la r ly s t r ik ing i s the dear th of psychotherapy process re -search wi th ch i ldren and adolescents (Kazdin , S iege l , &Bass , 1990; Shi rk & Sa iz , 1992) to va l ida te com mo nly he ldassumpt ions abo ut techniques implem ented to bu i ld a thera-peut ic re la tionsh ip . A spec ia l i s sue o f theJournal of Con-sulting and Clinical Psychologyo n p s y c h o t h e r a p y p r o c e s sresearch ( June , 1990) inc ludedno ar t ic les on process re -search in ch i ld or adolescent psychotherapy. Also , Green-berg and P inso f ' s (1986) tex t on psychotherap eut ic processresearch hasno chapter ded ica ted to ch i ld therapy processresearch . No m ajor journa l in the f ie ld of psychotherapy ,c l in ica l psych ology , ch i ld or school psyc holog y has ad-dressed a spec ia l i ssue o r sec t ion on the therapeut ic re la t ion-sh ip wi th ch i ldren and adolescents .

    Our rev iew of the l i t e ra ture on the therapeut ic processresearch wi th ch i ldren and adolescents uncovered very few

    studies wi th ch i ldren and adolescents . M ost o f the researchhas foc used on spec i f ic ch i ld or therap is t behaviors in ses -s ions, and m os t o f i t is i r re levant to the i s sue of the therapeu-t ic re la t ionsh ip or how the ch i ld exper iences therapy ( seeShi rk & Sa iz , 1992 fo r a rev iew of the ear ly process l i te ra -ture). Ano ther l ine of research has b een to m easure o r in flu-ence the ch i ld ' s expec ta t ion of therapy (Bonner & Evere t t ,1982; Weins te in , 1988) . Al thougha priori expec ta t ionsmay inf luence the re la t ionsh ip and deserve fur ther s tudy,th i s research has ye t to empir ica l ly l ink pr ior expec ta t ionsabout therapy to the therapeu t ic re la tionsh ip or a l l iance .

    Wright , Truax , and Mi tche l (1972) repor ted tha t thera-p i s t s w a r m t h a n d e m p a t h y c o u l d b e r e l i a b l y m e a s u r e d i nchi ld therapy sess ions . S iege l (1972) repor ted tha t thera-p is t s ' warmth , genuineness , and pos i t ive regard were pos-i t ive ly re la ted to ch i ldren ' s p os i t ive s ta tements about them -se lves in the middle pha se o f trea tment .

    Only on e s tudy to da te has l inked a measure o f the thera-peut ic re la t ionsh ip wi th ou tcome. Taylor, Adelman, andK a s e r- B o y d ( 1 9 8 6 ) a t te m p t e d t o a s se s s a d o l e s c e n t s ' p e r -cep t ions of the psych otherap y re la t ionsh ip us ing a sca led e v e l o p e d b y K o e n i g s a n d H e s s f o r s c h o o l c h il d r e n ( K o e n -igs & Hess , 1976) . The resu l t s showed v ery low cor re la t ionsbe tween therap is t s ' and c l ien ts ' responses . Both therap is t sand ado lescents ra ted the es tab l i shmen t of t rus t as the mo s t

    impor tan t aspec t o f the therapeut ic re la t ionsh ip , whi le thedeve lopm ent of the c l ien t ' s au tonom ous ac t ions was ra tedas the leas t imp or tan t aspec t . Nonethe less , those therap is t sw h o e m p h a s i z e d t h e d e v e l o p m e n t o f a u t o n o m o u s a c t i o n sra ted the i r c l ien ts more favo rab ly on outco me measures , andt h o s e c l ie n t s w h o e x p e r i e n c e d t he e n h a n c e m e n t o f p e r s o n a l

    au tono my in therapy show ed the h ighes t degree of sa t is fac-t ion wi th therapy a t t e rmina t ion (Taylor, Adelman, &Ka ser- Bo yd , 1984). L imi ta t ions of th i s study inc lude thel imi ted number of therap is t s and adolescents surveyed (9and 24 , respec t ive ly) , the lack o f a s tandard ized sca le , andthe fa i lu re to inc lude paren t o r t eacher ra t ings of therapyo u t c o m e .

    Stages of Change Referral and Child PsychotherapyP r o c h a s k a a n d D i C l e m e n t e ( 1 9 8 8 ) p r o p o s e d a m o d e l o f

    the a t t i tudes people have toward changes . Research in thes t a g e s o f c h a n g e m o d e l e x a m i n e d n u m e r o u s t y p e s o f p a -t ien ts and nonpat ien ts to unders tand how peop le th ink aboutchange (Prochaska , Norcross , & DiClemente , 1992) . Thef i rs t s tage o f change , ca l led the p recontem pla t ive s tage , re -f lec ts no des i re to change . In the contem pla t ive s tage peopleare wi l l ing to explore whether change i s des i rab le . In theac t ion s tage people take concre te s teps to change . Inthe main tenance s tage people a t tempt to consol ida te thechanges they have made . I t seems tha t mos t se l f - re fe r redpsycho therapy c l ien ts seek he lp in e i ther the contem pla t iveor ac t ion s tages. Peop le wi l l ing ly en te r psycho therapy be-cause they wish to explore the poss ib le advantages ofchange or want to implement ac t ions to change . Se l f -re fe r red c l ien ts have reached some ins igh ts about the i r emo-

    t io n s a n d / o r b e h a v i o r s th a t h a v e m o v e d t h e m f r o m t h e p r e -contempla t ive s tage to the contempla t ive or ac t ion s tagesbefore en te r ing therapy.

    Most sys tem s of psychotherap ies were des igned fo r se l f-re fe r red c l ien ts in the contem pla t ive or ac t ion s tages . Themos t d i ff icu l t pa t ien ts in adul t psychotherap y a re those w howere forc ed in to therapy aga ins t the i r wishes . Such personswould be in the precontempla t ive s tage . The f ie ld of psy-chotherapy has a lways had d i ff icu l ty wi th subs tance abus-ers , cour t -mandated re fe r ra l s , and o ther c l ien ts who a t tendtherapy a t the ins i s tence of o thers .

    We be l ieve tha t the mos t c ruc ia l charac te r i s t ic o f ch i ldand adolescent psychothe rapy, which makes the therapeut ic

    al l iance diff icult to establish, is that youth are not self-re fe r red for t rea tment (DiGiusepp e , 1988; Ka zdin , 1988;Kendal l , 1991; Koocher, 1976; Shi rk , 1990; Tuma, 1983)- -a characteris t ic they share with other diff icult to t reatgroups . The ins igh ts tha t se l f - re fe r red c l ien ts have accom -pl i shed , and which a re usua l ly assumed to have beenreached by mos t theor ies of psychotherapy, a re thereforelack ing in ch i ldren and adolescents .

    The ins igh t o r awareness tha t change i s des irab le may n otbe eas i ly ach ieved . A s tudy of adul t s en te r ing psycho-therapy (Saunders, 1993) ind ica ted , . . . tha t seek ing pro-fess iona l menta l hea l th he lp i s a fa i r ly long and d i ff icu l t

    https://www.researchgate.net/publication/18148809_Reliability_of_process_ratings_of_psychotherapy_with_children?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/232561753_Applicants'_experience_of_the_process_of_seeking_therapy?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/18148809_Reliability_of_process_ratings_of_psychotherapy_with_children?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/232561753_Applicants'_experience_of_the_process_of_seeking_therapy?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==

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    Therapeu t ic Al l i ance 87

    p r o c e s s . F o r t y - e i g h t p e r c e n t o f a du l ts s e e k i n g t r e a t m e n tr e q u i re d a l m o s t a y e a r o r m o r e t o r e a l i z e t h e y h a d a p r o b l e m .M o r e t h a n 6 0 % r e q u i r e d f r o m a f e w m o n t h s t o m o r e t h a n ay e a r t o d e c i d e t h a t t h e r a p y m i g h t h e l p a f t e r t h e y r e a l i z e d t h e yhad a p rob lem . Thus , adu l t se l f - re fe r red pa t i en t s seem toh a v e t a k e n c o n s i d e r a b l e t i m e t o h a v e r e a c h e d s o m e i m p o r-

    tan t ins igh t s abou t the i r p rob lem before a r r iv ing fo r the rapy.C h i l d r en a n d a d o l e s c e n t s a r e u n l i k e l y t o h a v e r e a c h e d t h e s eins igh t s be fore the f i r s t sess ion s ince the re fe r ra l i s ins t i tu tedby o thers . A . Freud (1965) , M eeks , (1971) , and Mish ne( 1 9 83 ) h a v e n o t e d t h a t t h e m o s t p r o m i n e n t f a c t o r b l o c k i n gc h i l d r e n ' s m o t i v a t i o n f o r t r e a t m e n t i s t h e i r l a c k o f s e l f -k n o w l e d g e a b o u t t h e ir p r o b l e m s a n d f a i l ur e t o w a n t c h a n g e .

    F o r c h i l d a n d a d o l e s c e n t p s y c h o t h e r a p y t o a d v a n c e a n db e c o m e m o r e e f f e c t i v e , s e v e ra l s t e p s a r e n e c e s s a r y.

    1 . Theore t i c ians , r esea rchers , and p rac t i t ioners need toacknowledge tha t you th a re no t se l f - re fe r red fo r the rapy.

    2 . T h e e f f e c t o f f o r c e d r e f e r ra l o n t h e a g r e e m e n t o n t h egoa l s , and second ar i ly on the t a sks aspec t o f the the ra -peu t ic a l l i ance needs to be exp lored .

    3 . Research and theory need to focus on those ins igh t s .a n d e x p e r i e n c e s t h a t h a v e m o v e d s e l f - r e fe r r e d c li e n tsf r o m t h e p r e c o n t e m p l a t i v e s t a g e o f c h a n g e t o t h e c o n -templa t ive o r ac t ion s tages . An unders tand ing o f thes e l f - c h a n g e p r o c e s s e s , w h e r e b y p e o p l e r e a l i z e t h a tchange i s des i rab le , wi l l he lp us to concep tua l i ze thep r o b l e m s o f f o r c e d r e f e r r e d c l i e n t s i n g e n e r a l , a n dch i ld ren and ado lescen t s in pa r t i cu la r.

    4 . We n e e d t o d e v e l o p t h e r a p ie s w h i c h a r e b a s e d o n t h ep r e m i s e t h a t y o u n g p e o p l e a r e n o t m o t i v a t e d f o r t re a t -

    m e n t . T h e r a p y t e c h n i q u e s m u s t f o c u s o n d e v e l o p i n gthe ins igh t s and a t t i tudes toward change tha t have a l -r e a d y b e e n a c h i e v e d b y s e l f - re f e r r e d c l ie n t s.

    Some a reas tha t migh t be he lp fu l in ach iev ing these goa l sa re the soc ia l p rob lem-so lv ing l i t e ra tu re , the emot iona lsc r ip t cons t ruc t in the soc io logy of emot ions , and the workwi th subs tance abusers in mot iva t iona l in te rv iewing .

    T h e v o l u m i n o u s p r o c e s s r e s e a r c h i n a d u lt p s y c h o t h e r a p ycould p rov ide a s t a r t ing po in t fo r cons ider ing i s sues re levan tt o t h e a s s e s s m e n t a n d d e v e l o p m e n t o f p s y c h o t h e r a p e u t i cre la t ionsh ips and a l l i ances wi th ch i ld ren and ado lescen t s .One o f the mo s t in f luen t ia l mode ls o f the the rapeu t ic re la -

    t i on s h i p h a s b e e n B o r d i n ' s m o d e l ( 1 9 7 9 ). T h i s m o d e l o f t h etherapeu t ic re la t ionsh ip app l ies to a l l psycho therapy or ien-t a ti o n s. C o m p o n e n t s o f B o r d i n ' s t h e r a p e u t i c a l l ia n c e m o d e linc lude : (1 ) agre em ent on the goa l s o f the rapy, (2 ) agree -m e n t o n t h e t a s ks o f t h e r a p y, a n d ( 3 ) t h e d e v e l o p m e n t o f t h ebond (o r the rapeu t ic re la t ionsh ip) . The goa l s component o fthe the rapeu t ic a l l i ance can be desc r ibed as the c l i en t ' s andt h e r a p i s t ' s f o r m u l a t i o n a n d a g r e e m e n t u p o n w h a t i s h o p e dt o b e a c c o m p l i s h e d i n t h e r a p y. T h e t a s k s c o m p o n e n t o f t h etherapeu t ic a l l i ance i s an agreement be tween the the rap i s tand the c l i en t on the t echn iques , p rocedures , o r behav iors ,which wi l l be used to accompl i sh the goa l s o f the rapy. The

    b o n d c o m p o n e n t o f t h e t h e r a p e u ti c a l l i a n c e i s d e s c r i be d a sthe re la t ionsh ip fo rmed be tween the c l i en t and the the rap i s t .B o r d i n ' s f o r m u l a t i o n o f t h e t h e r a p e u t i c a l l i a n c e g o e s b e -y o n d j u s t t h e t h e r a p e u t ic b o n d a n d r e l a t io n s h i p. T h e m o d e la s s u m e s t h a t a n a c c e p ti n g w a r m b o n d b e t w e e n t h e t h e r a p is tand the c l i en t may no t necessa r i ly l ead to a con t rac t on the

    g o a l s a n d p r o c e d u r e s o f t h e r a p y. We w o u l d d e f i n e a p o s i t iv etherapeu t ic a l l i ance as :

    A cont rac tua l , accep t ing , r espec t fu l , and war m re la t ion-sh ip be twee n a ch i ld~adolescen t and a the rap i s t fo r themutua l exp lora t ion o f , o r agreement on , ways tha t thech i ld~adolescen t may change h i s o r he r soc ia l , emot iona lor behav iora l func t ion ing fo r the be t t e r, and the mutua lexp lora t ion o f , o r agreeme nt on p roce dures and t askstha t can accompl i sh such changes .

    T h e e s t a b l i s h m e n t o f t h e t h e r a p e u ti c a l l i a n c e h a s b e e ns h o w n t o p r e d i c t t r e a t m e n t o u t c o m e i n a d u l t s ( G r e e n b e rg &Pinsof , 1986 ; Ho rva th & Gree nberg , 1986; M arm ar e t a l .,1986). In add i t ion , a me ta -ana ly t i c rev iew o f the the rapeu t ica l l i a n c e r e s e a r c h ( H o r v a t h & L u b o r s k y, 1 9 9 3 ; H o r v a t h &S y m o n d s , 1 9 9 1 ) r e a c h e d s o m e f i r m c o n c l u s i o n s a b o u t t h ea l l i ance . The a l l i ance appears to deve lop by the th i rd o rfour th sess ion . The a l l i ance p red ic t s the rapy ou tcome equa l -ly fo r a l l theore t i ca l o r ien ta t ions . C l ien t s ' r a t ings o f a l l i ancea r e m o r e p r e d i c t i v e o f o u t c o m e t h a n e i t h e r t h e r a p i s t s ' o robservers ' r a t ings . The a l l i ance i s unre la ted to d iagnos i s o rs e v e r i t y o f p s y c h o p a t h o l o g y. T h e r a p e u t i c t e c h n i q u e s f r o mdi ffe ren t o r ien ta t ions a l l appear to in f luence the a l l i ancee q u a l ly. A l s o , a g r e e m e n t o n t h e t a s k s o f t h e r a p y a p p e a r s t o

    b e t h e m o s t c r u c i a l c o m p o n e n t o f t li e a l l ia n c e f o r p r e d i c t i ngt h e r a p y o u t c o m e .

    C h i l d a n d a d o l e s c e n t p s y c h o t h e r a p y a p p e a r s d o m i n a t e dby the assumpt ion tha t suppor t ive and re f l ec t ive the rapeu t ictechn iques a lone bu i ld the the rapeu t ic re la t ionsh ip and a l l i -ance (Axl ine , 1947; Buxba um , 1954; Freud , 1964; M ous-takas , 1953; R e i sm an , 1973). T he t rad i t iona l mode l o f the r-a p y i s b a s e d o n t h e a s s u m p t i o n t h a t p r o v i d i n g a w a r m ,accep t ing re la t ionsh ip w i th a the rap i s t i s a se t o f cond i t ionstha t a l lows the oppor tun i ty fo r a normal deve lopmenta l t en-d e n c y t o w a r d g r o w t h t o t a k e p l a c e . T h i s a s s u m p t i o n r e -qu i res reexamina t ion and poss ib le empi r ica l ve r i f i ca t ion .There i s an impor tan t d i s t inc tion here be twe en the the rapeu-t i c re la t ionsh ip and the the rape u t ic a l l i ance . Trad i t iona l the -o r i e s o f c h il d a n d a d o l e s c e n t p s y c h o t h e r a p y a p p e a r t o h a v eover ly focused on the bond as necessa ry and suff i c ien t tob r i n g a b o u t c h a n g e s . T h e y h a v e n e g l e c t e d t h e g o a l s a n dtasks aspec t s o f the a ll iance and ma y even be oppo sed to ourdef in i t ion tha t the a l l i ance i s a soc ia l con t rac t tha t may benecess a ry bu t no t su ff i c ien t fo r change . A s t rong a l l i ance i snecessa ry fo r the the rap i s t and ch i ld to implement the t ech-n iques o r t a sks o f the rapy and i s a cura t ive p rocess in and o fi t se l f . We propose tha t the es tab l i shment o f a the rapeu t ica l l i ance i s mo re d i ff i cu l t wi th ch i ld ren and ado lesce n t s com -pared to adu l t s, bec ause i t i s more d i ff i cu lt fo r the the rap i s t

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    and chi ld or adolescent to reach agreement on the goals oftherapy. This occurs because the majori ty of chi ldren arenot self-referred for psychotherapy (DiGiuseppe, 1988;Koocher, 1976; Tuma, 1983). As a result, children and ado-lescents may not acknowledge the exis tence of problems,and are of ten unmotivated to change (DiGiuseppe, 1988;

    Kendall, 1991, Kazdin, 1988; Tuma, 1983). Without re-search on the therapeut ic relat ionship and al l iance w ith chi l -dren and adolescents , therapis ts are denied access to crucialinformation such as knowledge concerning how rel iablytherapeut ic relat ionships can be assessed, how long i t usu-ally takes to establish an alliance, what factors lead to alli-ance ruptures , and whether one must establ ish an al l iancebefore moving on to other tasks.

    Shirk and his col leagues developed a measure of the ther-apeut ic al l iance based on B ordin 's (1979) mult idimen sionaltheory (Shirk & Saiz, 1992). They constructed items toref lect three subscales , the chi ld 's affect ive experience oftherapy in a posi t ive bond, negat ive affect ive response totherapy subscales , and col laborat ion with the tasks of thera-py. They reported adequate internal consis tency as mea-sured by C ronbach ' s a lpha , and modera te convergence be-tween therap ists ' and chi ldre n 's versions of the scale . Theyfound that . . . the chi ld 's affect ive or ientat ion to therapyhas an important bearing on the chi ld 's col laborat ion withthe therapeut ic task. Children who fel t more posi t ively to-wards therapy were more l ikely to ta lk about problems andfeel ings than chi ldren who were more negat ive (Shirk &Saiz, 1992, p. 720).

    Shirk and Saiz (1992) propo sed a social cognit ive mode l toexplain the diff icul ty chi ldren and adolescents may have in

    at taining a therapeut ic al l iance. The developmental schemaproposed that inf luence the abi l i ty to form an al l iance are: (a)the at tachment scheme the chi ld has formed, (b) self-eval-uat ion, (c) the abi li ty to form internal a t tr ibut ions for behav -ior, and (d) bel iefs about the cont ingency of problem solu-t ions. Accordin g to this model chi ldren and adolescents havethe best chance to form a posi t ive therapeut ic al l iance i f theyhave a scheme for posi t ive at tachments with others , canevaluate their own emotions and behavior, can generateinternal a t t r ibut ions for behavior, and bel ieve that their ef-for ts can resul t in posi t ive outcomes. Although Shirk andSaiz (1992) have used Bordin 's model to construct a theoryand measure of the therapeut ic al l iance, they have prima ri ly

    focused on the bond and agreem ent on the tasks aspects of theal l iance. We propo se here that agreem ent on the goals is thecrucial aspect of the al l iance that is missing in mo st chi ldrenand adolescents . Although al l four aspects propo sed by Shirk& Saiz (1992) appear helpful in at ta ining the al l iance, wemaintain that self-evaluat ion is most crucial , s ince self-eval-uat ion may be most related to at ta ining agreement on thegoals . I f chi ldren are unable to evaluate themse lves and seethemselves as having a problem , they may not part ic ipate intherapy long eno ugh to ma ster the other three social cognit ivevariables.

    Self-evaluat ion has been shown to fol low a developmen-

    tal sequence (Selman, 1980). For example, preschoolers andelementary school chi ldren fai l to dis t inguish between awishful scheme of the self and an actual scheme of the self(Katz & Zigler, 1967; Leahy & Huard, 1976; Stipek, 1984), and that self-evaluat ion increases in accuracy with matura-tion (Stipek, 1984). Older children are more likely to use a

    social comparison process in self-evaluat ion (Ruble, Feld-man, & Baggiano, (1976). Although i t is normal for chi l -dren to overrate their competencies and underest imate theirweaknesses (Harter, 1988), this process may be greater inclinical populations (Vondra, Barnett, & Cicchetti, 1989:Zimet & Farley, 1986). Many chi ldren and adolescentsmaybe re fe r red to psycho therapy before they have deve l -oped suff icient maturat ion on this variable to accuratelyevaluate their emotiona l and behavioral proble ms and, thus,are unable to see themselves in need of change. The theoret-ical and cl inical quest ion that is central to our approachis whether chi ldren 's capaci ty for self-evaluat ion can bestrengthened or taught and in this way can help chi ldrenunderstand the need for change and thereby reach agree-ment on the goals .

    Developmental considerat ions suggest that different as-pects of the therapeut ic al l iance ( i .e ., bond, goals , or tasks)may differ in prominence in predict ing therapy outcomeacross age. For example, i t seems plausible that preschooland early elementary school chi ldren 's therapeut ic al l iancemay be inf luenced solely by the bond. This age group mayhave l i t t le concern about the implied social contract in-volved in therapy. Less of the variance in outcome may berelated to agreement on the goals or tasks.

    Adolescents , however, appear most concerned with the

    agreement on the goa l s and t asks o f the rapy s ince depen-dence, independence, and self-determinat ion are importantdevelopm ental issues for them. Ado lescents are sensi t ive tohaving others ' goals imposed upon them. They also desireto choose their own w ay of doing things. As a resul t , agree-ment on the goals and tasks may b e more diff icul t to estab-l ish with adolescents than with younger chi ldren.

    The na tu re o f an ado lescen t ' s p resen t ing p rob lem mayalso inf luence which aspects of the therapeut ic al l iance arerelated to outcome and which aspects of the al l iance areeasier to establ ish. Adolescents with internal ized disordersmay establ ish agreement on goals and tasks much moreeasi ly, due to their emotional discomfort , than youth with

    external ized disorders . They also may be more wil l ing toform an al l iance s ince they may have less of a problem w ithauthori ty f igures and may wish to reduce the emotionaldiscomfort associated with internal izing disorders . Opposi-t ional and conduct disorder chi ldren do not appear to ben-ef i t f rom tradi t ional therapeut ic techniques (Weisz, Weiss ,Alicke, & Klotz, 1987) because they are unmotivated forchange and are unwil l ing to enter any contract for changewith the therapist (Sherwood, 1990).

    We are uncertain about chi ldren approxima tely betweenthe ages of 8 and 11 years . Our cl inical experience suggestsgreat var iabi l i ty in their abi l i ty to benefi t f rom the sugge sted

    https://www.researchgate.net/publication/17551530_Self-Image_Disparity_A_Developmental_Approach?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/232546890_The_first_stage_of_treatment_with_the_conduct_disordered_adolescent_Overcoming_narcissistic_resitance?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/232546890_The_first_stage_of_treatment_with_the_conduct_disordered_adolescent_Overcoming_narcissistic_resitance?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/17551530_Self-Image_Disparity_A_Developmental_Approach?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==

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    Therapeut ic l l i ance 89

    procedures focused on a t ta in ing agreement of the goa ls .Perhaps som e ch i ldren in th is age group have not deve lop edsuff ic ien t ly to im prov e se l f -eva lua t ion sk i l ls and form asoc ia l cont rac t for he lp and m ay requi re a d i ffe ren t approachtha t focuses on a cura t ive re la t ionsh ip . Others in th i s agegroup appear wi l l ing to adopt the goa ls p rovided by thera-

    pists in an uncri t ical way.W e propo se tha t d i ffe ren t t echniques ma y be requi red to

    es tab l ish an e ffec t ive therapeut ic a l l i ance wi th ch i ldren andadolescents depending on deve lopmenta l s tage and type ofproblem. In the ch i ld /ad olescen t therapy l i t e ra ture mos t au-thors recommend the same re f lec t ive ; suppor t ive s t ra teg iesas the on ly way to bu i ld rappor t wi th a l l types of c l ien ts(Axline, 1947; Moustakas, 1959; Reisman, 1973). Strate-g ies to bu i ld a therapeut ic a l l iance m ay ne ed to be prescr ip-t ive depending on age , p resen t ing problem, des i re forchange , o r persona l i ty s t ruc ture . For example , Sherwood(1990) proposed tha t adolescents wi th narc i ss i s t ic person-a l i ty s t ruc tures requi re a v ery d i ffe ren t s tance on the par t o fthe therapist , to build a relat ionship, than do adolescentswho are no t narc iss i s tic . Sherw ood prop osed tha t uncr i t ica lacceptance of the adolescents ' des i res , bu t feedback on thenega t ive con sequenc es and soc ia l des i rab i l i ty of ac t ions , i simpor tan t wi th th i s g roup of adolescents .

    T h e o r e t i c a l D i ff e r e n c e s i n F o r m i n g B o n d ,Goals , and Tasks

    We would l ike to sugges t some s t ra teg ies for bu i ld ing atherapeut ic a l li ance wi th adolescents and pre teens . Th e pro-cedures tha t fo l low are sugges ted fo r ch i ldren ages 10 years

    and o lder. The low er age l imi t fo r the i r e ffec t iveness may beextended to age 8 years bu t wi l l be de te rmined by thechi ld ' s cogni t ive deve lopmenta l l eve l .

    B u i l d i n g a B o n dA s m e n t i o n e d a b o v e , m o s t t e x ts o n c h i l d a n d a d o l e s c e n t

    p s y c h o t h e r a p y r e c o m m e n d s i m il a r n o n d i r e c t iv e , s u p p o r t iv e ,reflect iv e strategies to build a therap eutic al l iance. Tradi-t iona l psyc hody nam ic and c l ien t -cen te red approaches u t i l i z -ing these s t ra teg ies seem to focus on the deve lopm ent of theb o n d , w h i l e d e - e m p h a s i z i n g a g r e e m e n t o n t h e g o a l s a n dtasks of therap y a f te r the in i t ia l therapy sess ion . I t i s pos-s ib le tha t such explora tory, ins igh t -or ien ted , o r suppor t ive

    s t rateg ies wi l l no t be e ffec t ive in es tab l ish ing agreem ent onthe goa ls and tasks of therapy. There i s no research ev idencetha t t echniques des igned to bu i ld the therapeut ic bond wi l lh a v e a n y i m p a c t o n t h e c h i l d ' s o r a d o l e s c e n t ' s a c c e p t a n c eand unders tanding o f the goa ls and tasks of psychotherap y.The poss ib i l i ty ex is t s tha t ch i ldren and adolescents wi l lform a s t rong bond or a t tachment to a therap is t bu t s t i l lre fuse to engage in any d iscuss ion of the problem behavior(Sherwood, 1990) .

    M o s t t e x t s o n c h i l d - a d o l e s c e n t p s y c h o t h e r a p y s u g g e s t(Carek, 1979; Moustakas, 1953; Reisman, 1973; Weiner,1975) tha t the use of in te rpre ta t ion and d i rec t in te rvent ion

    are bes t reserved un t i l a f te r the es tab l i shment of the thera-peut ic re la t ionsh ip . However, no research ex is t s to ver i fyth is o f ten s ta ted advice . Also n o research ev ide nce ex is t s tosuppor t the b e l ie f tha t suppor t ive , re f lec t ion techniques a rethe mos t e ffec t ive way to bu i ld the therapeut ic re la t ionsh ip .Our c l in ica l exper ien ce sugges ts tha t whi le re f lec t ion tech-

    n iques may bu i ld a bond w i th young er ch i ldren , some o lderch i ldren , and espec ia l ly adolescents , respond to th i s t ech-n ique wi th susp ic ion or d i s in teres t . Some ch i ldren and ado-lescents exper ience the ac t ive , d i rec t ive s ty le of cogni t ivebehaviora l therapy as an ind ica t ion o f the therap is t ' s ca r ing(DiGiuseppe , 1981; DiGiusep pe Bernard , 1983; Di -Giuseppe , 1989) . Act ive ly he lp ing ch i ldren so lve the i r p rob-lems m ay b e an e ffec t ive s t ra tegy for bu i ld ing rappor t . I t i sposs ib le tha t a t tempts to fos te r a s t rong therap is t -ch i ld re la -t ionsh ip or bond , p r ior to , o r in p lace of a c lear explana t ionof the goa ls and process o f therapy, might be exper ien ced asmanipula t ive b y ad olescent c l ien ts .

    The ch i ld /adolescent psychotherapy l i t e ra ture d i sp laysgrea te r emphas is on techniques tha t bu i ld the therapeut icbond than on techniques tha t fos te r agreement on goa ls o rtasks . Y et , in adul t psy chotherap y, the therapeut ic re la t ion-ship in and of i tself , isn o t suff ic ien t for success fu l t rea tmentoutcom e (Bord in , 1975; Marm ar, Horo wi tz , Weiss , Mar-zial i , 1986). Research on the adult therapeutic al l iance dem-ons t ra tes tha t o f the th ree components , the agreement ontasks of therapy i s the bes t p red ic tor o f t rea tment ou tco me(Horva th Greenb erg , 1986) . The pr imacy of the therapeu-t ic bond in media t ing a pos i t ive therapeut ic ou tco me ma y beoveremphas ized for ch i ldren and adolescents .

    F o r m u l a t i n g G o a l sTo reach agreement on the goa ls o f therapy, the in i t i a l

    goa ls tha t mot iva ted the re fe r ra l mus t be expla ined to theyoungs te r. Adolescents o f ten lack a c lear p ic ture concern ingwhy they a re in therapy, s ince they a re re fe r red by the i rparen ts and schools . Frequent ly the paren ts and /or therap is tma y hav e t rea tment goa ls tha t d i ffe r f rom, or a re in s t rongoppos i t ion to , the ch i ld ' s goa ls . There i s , therefore , a g rea te rl ike l ihood tha t adolescents , as opposed to adul t s in therapy,could d i sagree w i th the i r therap is ts on the goa ls o f therapy(Johnson , Rasbury, S iege l , 1986) .

    T h e i n c o m p a t i b i l i t y o f c l i e n t - t h e r a p i s t g o a l s m a y b emost p roblemat ic for t rad i t iona l psychodynamic therapy.Clear spec i f ica t ion and exp lana t ion of goa ls a re av oided inm a n y f o r m s o f c h i l d / a d o l e s c e n t p s y c h o t h e r a p y b e c a u s egoals in therapy a re of ten de te rmined by o thers , and there-f o r e m a y b e c o n f l i c t u a l f o r t h e c h i l d / a d o l e s c e n t ( H a r e -Must in , Marecek , Kaplan , L iss -L evin son , 1979;Koocher, 1976; Weinberger, 1972) . Many ch i ld /adolescenttherap is ts do no t ask ch i ldren to cons t ruc t goa ls in therapy,or they may sugges t a vague or nonspec i f ic goa l suchas deeper self-understanding (Carek, 1979; Freud, 1964;Tuma, 1983) . Chi ldren in the concre te opera t ions s tage ofdeve lo pm ent tend to v iew causes o f beha vior as ex te rna l ,s i tua t iona l, and s ingular, as op posed to resu l t ing f ro m inn er

    https://www.researchgate.net/publication/238321529_Principles_of_Psychotherapy_with_Children?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/232546890_The_first_stage_of_treatment_with_the_conduct_disordered_adolescent_Overcoming_narcissistic_resitance?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/232546890_The_first_stage_of_treatment_with_the_conduct_disordered_adolescent_Overcoming_narcissistic_resitance?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/238321529_Principles_of_Psychotherapy_with_Children?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==

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    90 DiGiuseppe Linscott and Jilton

    psychological constructs (Shirk, 1988). Given such cogni-tive limitations on their insight or self-understanding, it isperhaps unreal is t ic to expect young chi ldren and adoles-cents to comprehend the goals of therapy as insight (Jurko-vic Ulrici, 1982; Nann is, 1988; Nuffietd, 1988; Shirk,1988). Thus, there is a high probability that the techniques

    of t radi t ional chi ld/adolescent therapy do not foster c learagreement on goals .

    In behavioral and family-oriented approaches to t reat-ment , the chi ld or adolescent is mo re l ikely to be aware of thegoals the therapist is working toward, s ince the goals aremore l ikely to be discussed. This does not ensure that thechi ld or adolescent c l ient is in agreement with the goals ,because in both types of therapies the goals and tasks oftherapy are of ten chosen by ei ther the parents or the thera-pis t . The conceptual dis t inct ion between the roles of thecl ient and the customer ref lect family systems theory 'sawareness of such possible goal confl ic t (Haley, 1976;Minuchin, 1974). P erhaps in behavioral and famil y thera-pies , in which the therapists ' effor ts are aime d less direct ly atthe chi ld/adolescent and more direct ly at the larger par-ent]chi ld or family systems, the therapeut ic al l iance formedwith the chi ld/adolescent is less important to the success oftherapy than the therapeut ic al l iance establ ished with theparents.

    Cognit ive approaches to therapy suggest that goals bediscussed clear ly and openly with the cl ient and that thechi ld/adolescent 's conceptual izat ion of the target behavioris important to explore. DiGiu seppe (DiGiu seppe Ber-nard 1983; DiG iuse ppe 1988; 1989) suggeste d that agree-ment on goals can often be achieved by an ini t ia l phase of

    therapy that focuses on teaching al ternat ive thinking andconsequential thinking ski l ls about emotions. Helping thechi ldren to explore the consequences of their behaviors andemotions and al ternat ive ways of feel ing and behaving, canhelp formulate the goals of therapy.

    Understanding TasksThere is l it t le social ization o f chi ldren and adolescents to

    the act ivi t ies expected in therap y, or on ho w these act ivi t iesare related to the goals of their therapy. Adults in ou r soci-ety have seen movies that portray the process of psycho-therapy, or have fr iends who have part ic ipated in psycho-therapy. The ideas of introspect ion, relaying dreams, and

    expression of feel ings as part of the pro cess to at ta in t reat-ment goals , are more famil iar to adul ts enter ing psycho-therapy. Adults a lso may hold implici t personal i ty theoriesthat include experiences of what is necessary for change,and therefore have some expectat ions as to what types ofact ivi t ies wil l lead to behavior or emotional change. Chil-dren and adolescents are less l ikely to have any expectat ionsconcerning the tasks of psychotherap y. Children and adoles-cents may lack any previous experiences to prepare them fortherapy. They may not understand that the behaviors thetherapist and the chi ld engage in during their sessions arerelated to accomplishing the goals o f therapy. Children wil l

    therefore be less l ikely to agree with and understand thetasks of therapy than wil l adul ts .

    The Importance of Understanding TherapyHolmes and Urie (1975) demonstrated the beneficial ef-

    fects of preparing chi ldren for psychotherapy. When chi l -

    dren were given advance d explanat ions about the process oftherapy, and the opportuni ty to discuss these areas with thetherapist , premature terminat ion was less l ikely (HolmesUrie, 1975). Remaining in therapy long enough for suff i -cient part ic ipat ion to occur is l ikely to increase the proba-bi l i ty that the chi ld or adolescent wil l benefi t f rom psy cho-therapy (Ho lme s Urie, 1975). Weithorn (1980) argued forcont inued chi ld part ic ipat ion in t reatment decis ions to en-hance the chi ld 's motivat ion to achieve t reatment goals .One migh t conclude that the therapist ' s cont inued assis tancein focusing the chi ld on the goals and tasks of therapy wouldbe beneficial.

    Many ar t icles on chi ld and adolescent therapy at test to theimportance o f developing a t reatment contract with chi ldrenduring the initial session(s) of therapy. Forming the treat-ment contract may include a discussion of goals and tasks(Broo ks, 1985; Johnso n, Rasb ury, Siegel, 1986; Koo cher ,1976; Tuma, 1983). It is unclear in many of these articles,however, whether the discussion of goals and tasks is l im-i ted to the ini t ia l session(s) or cont inued throughout thecourse of t reatment . Set t ing clear goals for each session is acrucial component of cognit ive behavior therapies withadults (Walen, DiGiusep pe, Dryden, 1992). The samestrategy is recommended in cognit ive behavior therapieswith chi ldren (Kendal l , 1991; Linscot t DiGiusepp e,

    1994). Tradi t ional psychodynamic-oriented therapists ap-pear to discuss goals only in the ini t ia l session and avoidset t ing agendas for each session. Rather they leave the deci-s ion as to what wil l be done in the session to the needs o f thechild or adolescent (Axline, 1947; Freud, 1964; Moustakas,1953; Reisman, 1973).

    Child/adolescent therapis ts need to provide a clearer ex-planat ion about how their techniques are designed to inf lu-ence each element of the therapeut ic al l iance: goals , tasks,and bond. I t is a lso important that research evaluate whethertechniques actual ly inf luence the al l iance and whether theal l iance is predict ive of t reatment outcome.

    Treatment ManualsLuborsky and DeRubis (1984) argued for the importance

    of t reatment manuals in psychotherapy research and the useof such manuals are now standard pract ice in therapy out-com e research. Manuals al low for clear specif icat ion of thepart icular t reatment method em ploye d and of the exact tech-niques invo lved in performing the t reatment .Shaffer (1984) has cal led for the develo pmen t of child t reatment manuals inaccordance with t rends in adul t psychotherapy research.Without t reatment manu als i t is diff icul t for chi ld/adolescentresearchers and cl inicians to know which specif ic t reatmentmethods have been subjected to research, and which tech-

    https://www.researchgate.net/publication/232495723_Causal_reasoning_and_children's_comprehension_of_therapeutic_interpretations?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/21996765_Effects_of_preparing_children_for_psychotherapy?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/16812628_Notes_on_Psychotherapy_Research_among_Children_and_Adolescents?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/232495723_Causal_reasoning_and_children's_comprehension_of_therapeutic_interpretations?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/21996765_Effects_of_preparing_children_for_psychotherapy?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/16812628_Notes_on_Psychotherapy_Research_among_Children_and_Adolescents?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==

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    Therapeutic Alliance 91

    n i q u e s h a v e b e e n v a l id a t e d . A l th o u g h t h e r e h a s b e e n s o m eat tempt to have ch i ld /adolescent therap is t s manual ize the i rt rea tments (Kendal l e t a l . , 1989; LeCroy, 1994) few t rea t -m e n t m a n u a l s e x i s t f o r t h e r a p i e s w i t h c h i l d r e n a n d a d o -lescents . A recent spec ia l sec t ion ofPsychotherapy (1993 ,Vo l u m e 3 0 , N u m b e r 4 ) o n p s y c h o t h e r a p y t r e a t m e n t

    manuals fa i led to inc lude any a r t ic le on ch i ld /adolescentt rea tment . The type of spec i f ic i ty tha t i s found in therapym a n u a l s i s g e n e r a l l y l a c k i n g i n m o s t t e x t s o n c h i l d - a d o -l e s c en t p s y c h o t h e r a p y.

    A l t h o u g h c o g n i t i v e - b e h a v i o r t h e r a p i e s a p p e a r t o f o c u sm o r e o n t h e g o a l s a n d t a sk s o f t h e r a p y in e a c h s e s si o n a n dthroughout the sess ion wi th ch i ldren and adolescents , therei s no theory to descr ibe when the therap is t needs to spendm o r e t i m e o n b u i l d i n g t h e a l l i a n c e . T h e r a p y m a n u a l s a n dtex ts usua l ly do not inc lude spec i f ic s teps to moni tor e i therthe therapeut ic a l l iance or con t inued d iscuss ion o f the goa lsa n d t a sk s o f t h e r a p y w h e n a g r e e m e n t o n t h e s e a s p e c ts o f th ea l l iance has no t been reached .

    Goal conflict. Ma ny au thors recogn ize the po ten t ia l d i ff i -cu l ty in goa l se t t ing and the f requ ent d i sc repanc ies be twee np a r e n t s a n d y o u n g s t e r s o n t h e g o a l s o f t h e r a p y ( B r o o k s ,1985; Kooc her, 1976; Margol in , 1982; Johnso n , RasburySiege l , 1986; Reisman, 1973; Wei thorn , 1983; Weinberger,1972) . However, au thors usua l ly fa i l to provide s t ra teg iesfor therap is ts to reso lve such d isc repanc ies . Som e therap is tsm i g h t n o t c o n s i d e r a c o n c r e t e g o a l a n d m a y c h o o s e a g o a lbased on the i r own theore t ica l o r ien ta t ion . Others maychoose the paren ts ' goa ls as ta rge ts for t rea tment , becauset h e p a r en t s a r e p a y i n g a n d m u s t b r i n g t h e y o u n g s t e r tot rea tment . Idea l ly the therap is t a t tempts to have the y oung -

    s te r and the paren ts reach a mutua l dec is ion concern ing theg o a l s o f t h e r a p y ( R o b i n F o s t e r, 1 9 8 9 ). C o n s e n s u s o ns t ra teg ies to reso lve th i s i s sue a re ra re ly d i scussed in thel i te ra ture and need fu r ther a t ten t ion . Whe n the ch i ld o r ado-lescent d i sagrees wi th the paren ts ' go a ls , howev er, the ther-ap is t mu s t dec ide who se goa ls , the paren ts ' o r adolescent ' s ,wi l l in fac t se rve the youn gs te r ' s an d fam i ly ' s bes t in te res ts .I f th e p a r e n t s ' g o a l s a r e c h o s e n , t h e t h e r a p is t m a y n e e d t odeve lop incent ives for the adolescent to accom pl i sh the par-en ts ' goa ls . I f the paren ts ' goa ls a re no t in the adolescent ' sbes t in te res ts , the therap is t ma y nee d to recont rac t wi th theparen ts to explore more appropr ia te goa ls for therapy. Re-search i s l ack ing to assess which s t ra teg ies a re mos t e ffec-

    t i v e i n r e a c h i n g a g r e e m e n t o n t h e g o a l s . R e s e a r c h o n t h eeffec t iveness of s t ra teg ies to reso lve g oa l conf l ic t is need edf o r t h is c o m m o n p r o b l e m i n c h i l d / a d o l e s c e n t th e r a p y.

    Research on the Therapeutic Alliance with AdolescentsWe r e c e n t l y d e v e l o p e d a d o w n w a r d e x t e n s i o n o f H o r-

    v a t h ' s w o r k i n g a l l ia n c e s c a l e f o r c h i l d re n a g e s 11 - 1 8 y e a r s ,c a l le d t h e A d o l e s c e n t Wo r k i n g A l l i a n c e I n v e n t o r y ( AW A I t ;

    1 R e q u e s t f o r a r e v i s e d v e r s i o n o f t h e A d o l e s c e n t W o r k i n g A l l i a n c eI n v e n t o r y s h o u l d b e s e n t t o t h e f i rs t a u t h o r a t D e p a r t m e n t o f P s y c h o l o g y, S t .J o h n s U n i v e r s i t y, 8 0 0 0 U t o p i a P a r k w a y, J a m a i c a , N e w Yo r k , 11 4 3 9 .

    Linscot t , DiGius eppe , J i l ton , 1993) , which a t tempts tomeasu re the therapeut ic a ll i ance as conce ptua l ized by Bord in(1979) and def ined above . Horva th ' s o r ig ina l i t ems wererewr i t ten to lower the read ing leve l for a you nge r audienceTo assess therap is t s ' im press ions of the a ll i ance we usedHo rva th ' s o r ig ina l therap is t s ' fo rm o f the work ing a l l i ance

    inventory. Nine ty adolescents and the i r therap is t s were ad-minis te red the resp ec t ive sca les c ross -sec t iona l ly in therapy.The resu l t s ind ica ted tha t the to ta l sca le score , agreem ent onthe goa ls sca le , agreemen t on the tasks , and therapeut ic bondsubsca les a l l demo ns t ra ted adeq uate in tem al con s is tency (oL> .90) . The fac tor ana lys i s o f the adul t work ing a l l i ancemeasu re y ie lded one gen era l fac tor and three separa te fac torsfor goa ls , t asks , and bonds . The adolescent sample y ie ldedone la rge f i r st fac tor, l abe led a g enera l a l l i ance fac tor. Thre eother fac tors were presen t , bu t they d id no t represen t anycons is ten t conten t a rea and accounted for smal l amounts othe var iance . Thus , the a l l iance for adolescents may be m oreo f a o n e - f a c t o r p h e n o m e n o n . Y o u n g e r p a t i en t s m a y f a il t od iscr imina te be tween the d i ffe ren t aspec ts o f the re la t ion-sh ip. Sup por t for th is no t ion com es f rom o ur c l in ica l exper i -ence w i th the AWA I, w hich ind ica tes tha t fa i lu re to es tab l i shone aspec t o f the a l l i ance resu l t s in fa i lu re to es tab l i sh i tent irely.

    T h e r e w e r e o n l y m o d e r a t e c o r r e l a t i o n s b e t w e e n t h e r a -p is t s ' r a t ings of the a l li ance and the AW AI (averag ing .40) .Al thoug h th i s cor re la t ion appears subs tan tia l, i t is low con-s ider ing i t represen ts two peo ple ' s imp ress ions of the samere la t ionsh ip in the same sess ions . This resu l t sugges ts tha ttherap is ts ma y not accu ra te ly judge the a l l iance they havees tab l i shed wi th adolescents . F ina l ly, therap is t s ' r a t ings of

    the i r therapeut ic ac t iv i t i es per formed in therapy pred ic tedthe a l l i ance . Therap is t s ' r a t ing of more f requent use of s i -lence , ques t ions ab out fee l ings , and t ransference in te rpre ta -t ions nega t ive ly pred ic ted a l l i ance (R - - - .4 7) . T his sug-ges t s tha t some therapeu t ic s t ra teg ies m ay no t be as e ff ic ienas o thers a t es tab l i sh ing the a l l iance . Al thou gh th i s researchrepresen ts an in i t i a l a t tempt to assess the the rapy a l l i ance inadolescents more da ta a re needed .

    S t ra t e g ie s To D e v e l o p T h e A l l i an c e

    Emotional Scripts and Social Problem Solving SkillsH u m a n s h a v e b e l i e f s ab o u t t h e t y p e a n d s t r e n g th o f e m o -

    t ions they a resupposed to fee l and be l ie fs about whichemot ions a re he lpfu l o r hur t fu l to themselves or to o thers .S o c i o l o g y o f e m o t i o n s p r o v i d e s s o m e c l u e s c o n c e r n i n g t h ecul tura l na ture of these expec ta t ions and informat ion onw h e n p e o p l e m a y b e m o t i v a t e d t o c h a n g e t h e i r e m o t i o n s(Ab elson, 1981; deSo usa, 1980; Fehr, Russel l , 1984;Sabin i S i lver, 1982; Tom kins , 1979; see Kem per, 1991and Russel l , 1991 for a review).H o c h s c h i l d ( 1 9 7 9 ) pro-posed a concept ca l led emot iona l dev iance , which repre-sen ts a person ' s percept ion tha t the emot ion exper ienceddi ffe rs f rom a soc ia l ly prescr ibed , appropr ia te emot ion .

    https://www.researchgate.net/publication/233893874_Emotion_Work_Feeling_Rules_and_Social_Structure?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/233893874_Emotion_Work_Feeling_Rules_and_Social_Structure?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==

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    9 2 DiGiuseppe Linscott and Jilton

    Thoi t s (1985 , 1989) proposed tha t people a re mot iva ted tochange the i r behavior, phys io logica l reac t ions , s i tua tion , o re m o t i o n s w h e n t h e y e x p e r i e n c e e m o t i o n a l d e v i an c e . A c -cord ing to th i s theory, the recogni t ion tha t one ' s emot iona lreac t ions a re inapprop r ia te or soc ia l ly unacceptab le to as i tua t ion i s the pr imary mot iva t ion for emot iona l change .

    Scr ip t theory m ain ta ins tha t ind iv idua ls l ea rn the sc r ip t s o fthe i r cu l ture and fam i ly. Ind iv idua ls ma y hav e learned cu l -tu ra l ly unacceptab le sc r ip t s , o r fa i led to learn acceptab lescr ip t s , o r l ea rned too few scr ip t s because of dev ian t soc ia l -iza t ion though the i r fami ly, c lan , o r subgroup . Chi ldren andadolescents may ar r ive for therapy wi thout hav ing learnedtha t the i r emot iona l sc r ip t s a re inappropr ia te , o r they maynot have learned tha t there a re a l te rna t ive emot iona l sc r ip t sto subs t i tu te for the dysfunc t iona l ones they ex per ience . Wehave fou nd the con cept o f emot ion a l sc r ip t s he lpfu l in bu i ld-ing the agreeme nt on the goa ls aspec t o f the therapeut ica l l iance wi th ch i ldren and adolescents .

    The soc ia l p roblem-solv ing approach to ad jus tment i s acogni t ive-behaviora l therapy tha t asser t s tha t maladapt iveb e h a v i o r o c c u r s b e c a u s e o f a l a c k o f p r o b l e m - s o l v i n g s k i l ls(Spivack , P la t t, & Shure , 1976) . Accord ing to th i s v iew themost impor tan t sk i l l s a re a l te rna t ive so lu t ion th ink ing andconsequ ent ia l th ink ing . A l te rna t ive so lu t ion th ink ing i s theabi l i ty to genera te poss ib le behaviors to a s i tua t ion beforedec id ing on a response . Consequent ia l th ink ing i s the sk i l lo f eva lua ting one ' s behav iors before emi t ting them. Al -though most o f the research in soc ia l p roblem so lv ing hasfocused on the ge nera t ion of a l te rna t ive behaviors and con -sequences of behaviors , DiGiuseppe (1981; 1989; 1995;DiGiuseppe & Bernard , 1986; DiGiuseppe , Taf ra te , &

    Eckhard t , 1994) has sugges ted soc ia l p roblem-so lv ing sk i ll scan be appl ied to emot iona l sc r ip t s as wel l . Spec i f ica l ly,ch i ldren ' and ad olescents ' l ack of mot iva t ion in therapym a y o c c u r b e c a u s e t h e y f a i l t o r e c o g n i z e a n d h a v e n o tlearned the nega t ive consequen ces or soc ia l unacceptab i l i tyof the i r d i s turbed emot iona l sc r ip t s . They may a l so fa i l toconcep tua l ize a l te rna tive emo t iona l sc r ip t s to subs t i tu te fo rthe i r d i s turbed emot ion . They may not recognize tha t theconseque nces of an a l te rna t ive sc r ip t could be m ore benef i -cial to them than exist ing scripts .

    Perhaps i t is the processes of eva lua ting on e ' s em ot iona lscr ip t s and rea l iz ing tha t they a re dysfunc t iona l , and con-ceptua l iz ing tha t a d i ffe ren t emot iona l sc r ip t is poss ib le , tha tm o v e s o n e f r o m t h e p r e c o n t e m p l a t i v e s ta g e o f c h a n g e t o t h eac t ion s tage . Adul t s may have more sophis t ica ted and nu-merous schem a for emot iona l sc r ip t s than they can poss ib lyexper ien ce in any s i tua t ion . This m ay a l so he lp m ot iva tecoopera t ion in therapy because adul t s a re more l ike ly toconcep tua l ize a l te rna t ives . Our c l in ica l exp er ience sugges tstha t ch i ldren and adolescents have d i ff icu l ty conceptua l iz -ing a l te rna t ive emot iona l reac t ions . Change of ten seems im -poss ib le to them. Th e fo l lowing case v igne t te i s an exam pleo f h o w t h e s e t w o e l e m e n t s i n t e r fe r e d w i th a g r e e m e n t o n t h egoa ls and tasks of therapy.

    Joe , a 10-year-o ld boy, was re fe r red because o f h is angryoutburs ts . Dur ing on e sess ion he repor ted be ing punishedby h is paren ts because he h i t h i s b ro ther. Because wewere w ork ing on an ger cont ro l we ana ly zed h is be l ie fs inth i s s i tua t ion . In prev iou s sess ions , I had taught Joe h owthoughts in f luence fee l ings and how he could change h is

    fee l ings by ch a l lenging h is thoughts . Joe was angry a t h i sbro ther for b reak ing h is b icyc le and ind epende nt ly iden ti -f ied h i s dysfunc t iona l be l ie fs. M y bro ther should no th a v e b r o k e n m y b i k e; I c a n ' t s t an d n o t h a v i n g m y b i k e .He w as unrespons ive to my cha l lenge of h i s ir ra t iona lbe l ie fs , and responded : W hat ' s the mat te r wi th you , youw a n t m e t o b e h a p p y a b o u t i t ?

    Joe kne w tha t by cha l lenging h is be l ie fs I was a t tempt ingto change h is anger. I f he w ere no t angry, he could concep -t u a li z e o n l y o n e a l t e r n a t i v e - - h a p p y. T h a t a l t e rn a t iv e s e e m e dcrazy . Becau se Joe perce ived no acceptab le a l te rna t ive

    emot iona l sc r ip t s , he was no t p repared to engage in tasksdes igned to chan ge h is anger e i ther to a less in tense form o fanger or an a l te rna t ive , more adap t ive emot iona l sc r ip t . ToJoe , h i s anger was the on lyappropriate emot ion . Unt i l Joe ' seva lua t ions about h i s anger could be changed , and a v iab lea l te rna tive emo t iona l reac t ion cons idered , the goa ls an d taskof therapy were un acceptab le .

    Severa l hypotheses re levant to the t rea tment of ch i ldrenand adolescents fo l low f rom emot iona l sc r ip t and soc ia lproblem-solv ing theor ies . F i r s t , ch i ld ren and adolescentsmay have fa i led to recognize tha t the i r emot ions a re re -garded as devian t in the i r cu l ture or-have led to dysfunc t ion-a l consequences . A s a resu l t , they fa i l to expe r ience emo-

    t iona l dev iance and d o not wish to change . Se cond, ch i ldrenand adolescents may not have learned f rom the i r fami l iesthe emot ion a l sc r ip ts tha t gu ide the emo t iona l reac t ions pro-scr ibed by the mains t ream cul ture . Thi rd , they may be sur-pr i sed when they respond emot iona l ly wi th a sc r ip t p ro-scr ibed by the i r fami ly and these emot iona l reac t ions a reperce ived as devian t by o ther adul t s . As a resu l t they maybel ieve the i r emo t iona l reac t ions a re inva l ida ted by theadul t wor ld . Some suppor t o f the ro le of consequent ia lth ink ing in deve loping agreement on the goa ls o f therapyc o m e s f r o m t h e w o r k o f P r o c h a s k a e t a l . ( 1 9 9 4 ) . T h e yshow ed tha t for a sample of mo re than 3800 peo ple wi th 12di ffe ren t p roblem behaviors , the nega t ive consequences ofc h a n g i ng t h e ir p r o b l e m s o u t w e i g h e d t h e p r o s o f c h a n g e f o rp e o p l e i n t h e p r e c o n t e m p l a t iv e s t a g e o f c h a n g e . T h e o p p o -s i te was t rue of peQple in the ac t ion s tage of change . Mo reevidenc e i s neede d to ascer ta in w hether changes in a l te rna-t ives and consequences o f beha vior can lead to changes inthe therapeutic al l iance.

    Emot ions tha t a re d i s turbed and tha t may appear obvi -ous ly unpleasant to therap is t s may be ambiva len t ly or pos-i t ive ly eva lua ted by young c l ien ts . I f e i ther o f these i s thecase , ch i ldren and adolescents wi l l no t want to change the i remot ions . The fo l lowing c l in ica l hypotheses fo l low f rom

    https://www.researchgate.net/publication/238407353_Self-Labeling_Processes_in_Mental_Illness_The_Role_of_Emotional_Deviance?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/238407353_Self-Labeling_Processes_in_Mental_Illness_The_Role_of_Emotional_Deviance?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==

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    Therapeutic Alliance 93

    s c r i pt t h e o r y a n d s o c i a l p r o b l e m - s o l v i n g m o d e l s f o r c l ie n t swho a re unwi l l ing to change :

    • Ta s k s d e s i g n e d t o c h a n g e e m o t i o n s w i l l b e i n e ff e c t i v ei f the ch i ld o r ado lescen t main ta ins pos i t ive , neu t ra l , o ra m b i v a l e n t e v a l u a t i o n s a b o u t h i s / h e r e m o t i o n a n d i s

    n o t c o m m i t t e d t o e m o t i o n a l c h a n g e .• Chi ld ren and ado les cen t s hav e va lua t ive cogn i t ions

    a b o u t t h e i r d i s t u r b e d e m o t i o n s . T h e y m a y l i k e t h e m ,a d m i r e t h e m , h a t e t h e m s e l v e s f o r h a v i n g t h e m , o r b e -c o m e r e s i g n e d t o t h e m .

    • T h e e v a l u a t i o n s c h i l d r e n a n d a d o l e s c e n t s h a v e a b o u tthe i r emot ions a re mul t ip le and somet imes incons i s ten t .

    • Chi ld ren and ado le scen t s wi l l have exp ec tanc ie s o1:which emot ions peop le in the i r s i tua t ion a resupposedt o e x p e r i e n c e d e p e n d e n t o n t h e e m o t i o n a l s c r i pt s t h e yhave l ea rned .

    • Chi ld ren and ado lescen t s who c l ing to a ffec t ive s t a test h a t t h ey l a b e l a s n e g a t i v e m a y d o s o b e c a u s e t h e y h a v ed i ff i cu l ty cons t ru ing a l t e rna t ive , more func t iona l emo-t ions.

    • Chi ld ren and ado lescen t s wi l l no t f ee l an emot ion tha tt h e y c a n n o t c o n c e p t u a l i z e a s a n a c c e p t a b l e r e s p o n s e t oa s i tua tion . I f peop le do no t possess a sc r ip t fo r anemot iona l r eac t ion , they wi l l no t con t rac t wi th a the ra -p i s t to w o r k a t e x p e r i e n c i n g a n e m o t i o n a l c h a n g e .

    • Chi ld ren and ado lescen t s m ay need to be t augh t a lt e rna-t ive emot iona l sc r ip t s be fore they agree on the goa l o fchange . The m ore emo t iona l sc r ip t s the pe rson i s t augh tthe more l ike ly they wi l l be ab le to choos e one tha t theybe l ieve i s appropr ia te to the i r subcu l tu re .

    The Motivational SyllogismAfte r exp lor ing the conse-q u e n c e s o f a y o u n g s t e r ' s e m o t i o n a l s c r i p t s a n d p r e s e n t i n gaccep tab le a l t e rna t ives , the the rap i s t can use these ins igh t s toi n c r e a s e t h e c h i l d ' s o r a d o l e s c e n t ' s m o t i v a t i o n f o r c h a n g e .W e ca l l th is t echn ique the M ot iva t iona l Sy l log i sm . F i r st , thetherap i s t Socra t i ca l ly exp lores the consequences tha t fo l loww h e n e v e r t h e c l i e n t e x p e r i e n c e s t h e t a rg e t e m o t i o n . O n c e t h ech i ld /ado lescen t agrees tha t i t i s in he r /h i s bes t in te res t toc h a n g e h e r / h i s e m o t i o n , o n e m o v e s t o t h e s e c o n d s t e p o fhe lp ing c l i en t s genera te a l t e rna t ive sc r ip t s . Th i s s t ep canof ten be ach ieve d by hav ing the ch i ld o r ado lesce n t reca l l thes u c c e s s f ul r e a c t i o n s o f o t h e r s w h o m t h e y r e s p e c t . T h is a c t i v -i ty he lps to genera te a mo de l fo r an a l t e rna t ive sc r ip t . Young-s t e r s f r o m v e r y d y s f u n c t i o n a l f a m i l i e s m a y h a v e f e w s u c hm o d e l s . T h e t h e r a p i s ts m a y h a v e t o s u g g e s t m o d e l s f r o m t h egenera l cu l tu re , the l i t e ra tu re , fo lk lo re , o r f i lm of the c l i en t ' scu l tu re . Af te r a m ode l i s chosen fo r an a l t e rna t ive sc r ip t , i t i si m p o r t a n t to r e v i e w t h e c o n s e q u e n c e s o f t h e m o d e l ' s b e h a v -io r fo l lowing the sc r ip t . Nex t , the youngs te r s a re asked toi m a g i n e t h a t t h e y r e a c t i n th e s a m e m a n n e r a s t h e s c r i p t a n di m a g i n e t h a t t h e c o n s e q u e n c e s h a p p e n t o t h e m . I n t h i s w a yt h e y o u n g s t e r s c a n p r o v i d e i n f o r m a t i o n o n h o w t h e y b e l i e v et h e s c r i p t m a y n o t b e s o c i a l l y o r p e r s o n a l l y a c c e p t a b l e t o a

    person in the i r s i tua t ion . Th is p rocess i s r epea ted un t i l thec l i en t accep t s the a l t e rna t ive emot iona l sc r ip t . Th i rd , thetherap i s t shou ld exp la in the t a sks tha t wi l l be used to chang ethe t a rge t emot ion o r beh av ior to tha t o f the new sc r ipt . Oncet h e t h e r a p is t a n d y o u n g s t e r h a v e s u c c e s s f u l ly a c c o m p l i s h e dthese s t eps , the the rap i s t can con t inue wi th the t r ea tment o f

    the ch i ld ' s o r ado lescen t ' s anger. The the rap i s t i s f ree toi m p l e m e n t a n y s t r a t e g y s / h e a n d t h e c l i e n t m u t u a l l y a g r e eu p o n . T h e s t r a te g y s u g g e s t e d a b o v e m a y h e l p m o t i v a t e t h ec l i en t to con t inue wi th the rapy.

    B e f o r e e m b a r k i n g o n a n y t h e r a p e u t i c t a s k t h e t h e r a p i s ts h o u l d r e v i e w t h e M o t i v a t i o n a l S y l l o g i s m .

    The f i r s t p rem ise is : M y presen t emo t iona l r eac t ion i sdys func t iona l .

    The second prem ise is : The re i s an a l t e rna t ive sc r ip tw h i c h i s m o r e f u n c t io n a l f o r m e .

    T h e t h i rd p r e m i s e i s: I c a n c o n t r ol w h i c h e m o t i o n a l

    reac t ion I have to the ac t iva t ing even t .

    T h e c o n c l u s i o n is : I n e e d to e x a m i n e w a y s i n w h i c h Ic a n c h a n g e m y e m o t i o n a l r e a c t i o n .

    I t i s o f t en he lp fu l to qu ick ly rev iew the Mot iva t iona lSy l log i sm a t the in i t i a t ion o f a d i scuss ion on a new angera rous ing even t and a t the beg inn ing o f each sess ion . In th i sw a y t h e c h i l d / a d o l e s c e n t i s r e m i n d e d o f t h e p r e v i o u s p o in t stha t s /he an d the the rap i s t agreed upon ea r l i e r in the rapy ando f t h e r e a s o n f o r t h e t h e r a p e u ti c t a s k . W h e n e v e r a y o u n g s t e rr e p o r t s a n e w p r o b l e m t h e t h e r a p i s t m i g h t r e s p o n d b y r e -v i e w i n g t h e M o t i v a t i o n a l S y l l o g i s m . B y r e v i e w i n g t h e s e

    s teps , it i s hope d tha t the c l i en t is mo t iva ted to keep work in ga t a n g e r c o n t r o l . T h e r e v i e w c a n a l s o b e c o n s i d e r e d a r e -s ta tement o f the the rapeu t ic a l l i ance .

    Disturbed yet desired emotionsEl l i s (1983) sugges tedt h a t c l i en t s m a y r e s i s t t h e ta s k s o f t h e r a p y b e c a u s e t h e ys ti ll b e l i e v e t h a t t h e ir e m o t i o n s , w h i c h c a u s e t h e m s o m u c ht roub le , a re ac tua l ly des i rab le in some way. An a l t e rna t ivetherapeu t ic s t ra tegy i s to d i scuss w i th c l i en t s the i r r a t iona lefor be l i ev ing tha t a l though the emot ion in ques t ion i s pa in -fu l , i t i s benef ic ia l in some way. Some c l i en t s c la im tha tt h e p a i n f ul e m o t i o n s t h e y e x p e r i e n c e a r e d e s i r ab l e b e c a u s et h e y m o t i v a t e o r c u e t h e m t o b e h a v e i n a c e r t a i n w a y.These c l i en t s may ho ld a fa l se , unver i f i ed hypothes i s , tha tthe i r d i s tu rbed emot ions a re necessa ry to main ta in des i redb e h a v i o r s o r s o c i a l s t a t u s . F o r e x a m p l e , m a n y a n g r y a d o -l e s c e n ts w e s e e m a i n t a i n t h at t h e y m u s t g e t a n g r y t o s h o wothers they wi l l no t be pushed a round . They be l i eve tha tfa i lu re to d i sp lay anger wi l l r e su l t in inc reased a t t acksf rom o ther ado lescen t s . Such an t i -empi r ica l be l i e f s need tob e c h a l l e n g e d b e f o r e t h e y w i l l c o n s i d e r a l t e r n a t i v e e m o -t iona l sc r ip t s . Therap i s t s can p roceed as they would in d i s -pu t ing any an t i -empi r ica l s t a tement tha t i s dys func t iona l toc l i en t s . The d i scuss ion cou ld focus on fu r the r ing empi r ica le v i d e n c e f o r c l i e n t s ' h y p o t h e s e s t h a t d i s t u r b e d e m o t i o n s

    https://www.researchgate.net/publication/232452151_Rational-emotive_therapy_RET_approaches_to_overcoming_resistance_I_Common_forms_of_resistance?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==https://www.researchgate.net/publication/232452151_Rational-emotive_therapy_RET_approaches_to_overcoming_resistance_I_Common_forms_of_resistance?el=1_x_8&enrichId=rgreq-2eb5c5d5-1433-4d54-8294-f82ff82da13b&enrichSource=Y292ZXJQYWdlOzIyMzE2ODU2MztBUzoyMTMxNDIxOTQ5MjE0NzJAMTQyNzgyODQ2NzEyOA==

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    94 DiGiuseppe Linscott and Jilton

    have provided the motivat ion for functional behavior. Re-viewing the consequences of cl ients ' behaviors when theyexperience disturbed emotions wil l usually bring up muchdisconfirming evidence. Youngsters can be shown modelsof others who behave in the desired manner but who donot experience the disturbed emotions in quest ion. These

    models will help clients believe that less disturbed emo-tions can lead to desired adaptive behavior. Clients whogive up the ideas that maintain the emotion wil l be muchmore willing to dispute the irrational ideas that generatethe emotion.

    Motivational InterviewingTreatment programs designed to w ork with cl ients with ad-dictive behaviors may provide some insights into workingwith youngsters who have not consented to change. Millerand Rollnick (1991) developed an intervention program de-signed to build an alliance with clients with addictive be-havior and maxim ize their motivat ion for change during theinitial sessions. The program, called motiva tional inter-viewing, incorporates Prochaska and DiClemen te 's (1988)model o f change, and draws on principles o f social , cogni-tive, and motivational psychology (i.e., Kanfer, 1987; Mil-ler & Brown, 1991). Miller and Rollnick (1991) concep-tualized addicts as receiving treatment in Prochaska &DiClemente 's precontemplat ive stage of change and as,therefore, ambivalent ab out change. It follows, then, that thetherapist 's task is to help move these clients toward thecontem plation of change and then to the action stage. Millerand Rollnick contended that motivat ion for change is astate as opposed to a charactertrait The will to change is,

    therefore, dependent upon context . This is an important con-ceptual distinction, because it defines the therapist 's task ashelping alter the client's interpersonal context in ways thatincrease the probability for change.

    If i t is accepted that motivat ion is a context-dependentstate rather than a stable persona lity attribute, then the p rin-ciples of motivational interviewing, which have found suc-cess with highly resistant clients (Miller & Rollnick,1991), may be applied to other populations who are gener-ally unmotivated for change. S pecifically, children and ado-lescents who are not self-referred for t reatment may con-template positive changes if the motivational interviewingapproach is employed as a means of building the agreemen ton the goals/tasks of the alliance. With this in mind, we willsummarize some of the general principles of motivat ionalinterviewing and suggest how they might be applied withadolescent clients.

    Working with precontemplators. Miller and Rollnick(1991) found that certain strategies in the initial phase oftherapy tend to either evok e resistance or circum vent it. Thekey to successfully handling the patient's ambivalence be-gins with an assessment of his/her degree of motivat ion,according to the stages of change model. Motivation is de-fined by this mod el as the probability that a person will

    enter into, continue and adhere to a specific change strate-gy. Therap ists' interventions must be tailored to the cli-ent 's current s tage of motivat ion for change, and any at-temp t to work w ith the patient is likely to fail if the aims o flater stages are approache d too early. For instance, jump ingto interventions aimed at action before the patient has re-

    solved to chan ge is likely to elicit resistance. Therapists areoften tempted to press the client for participation in tasksbeyond the cl ient 's present s tage of change. Such act ionmay trigger psychological reactance as clients assert theirfreedom against coercion.

    The pr imary tasks of early therapy are to build an allianceand motivate the client toward change. Therapists can ac-complish this by raising doubts in clients' minds about theundesirability of change. To do so, the therapist needs toincrease the client's perception of risks and problems re-garding current behavior. More specifically, how to bestaccomplish this may depend o n the kind of precontemplatorthe therapist is dealing with. Proschaska and DiClemente(1986) described four types of precontemplat ion, which h esumma rizes as the fou r Rs : reluctance, rebellion, resigna-tion, and rationalization.

    Reluctant precontemplators s imply do not want to change.They m ay be unaware of the problematic nature of theirsituation. Proschaska and DiClemente (1986) sug-gested that providing feedb ack in a sensitive empatheticman ner can be sufficient to motiva te this group fo r help.Many preadolescents fit in this category.

    Rebellious precontemplators are invested in m aking theirow n decisions, and are resistant to advice and directionfrom others. These clients may appear hostile, argu-mentative, and oppositional to change. Clinical experi-ence suggests that adolescents may b e most likely to fitthe rebell ious profi le--presumably because a primaryfocus of adolescence is the establishment o f indepen-dence. Providing choices seems to be a successfulstrategy for working with this type o f precontemplator.Carefully planned paradoxical interventions m ay alsobe used with success.

    Resigned precontemplators are remarkable for their lackof investment and energy, and resignation to theirplight. Proschaska and DiClemente (1986) described

    these cl ients as people who are overwhelmed, feel outof control , and have given up hope for change. Hesuggested that instilling hope and exploring barriers tochange are the most productive strategies for workingwith this group. Such resignation ma y occu r becausepeople fail to conceptualize alternative scripts forchange. Children and adolescents with primary or co-morbid depression often fit this pattern.

    Rationalizing precontemplators have a s torehouse of rea-sons why the problem is not a problem, or why i t may b ea problem for others but not for them. Interviews with

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    Therapeutic Alliance 95

    th i s type o f c l ien t ma y beg in to fee l l ike deba te sess ions .They a re d i s t ingu ished f rom rebe l l ious c l i en t s in tha tthe i r r es i s t ance i s mo re in te l l ec tua l than emot iona l . D is -c u s s i o n o f t h e p r o b l e m c a n s o m e t i m e s l e a d t o s t r e n gt h -en ing the i r s ide o f the a rgume nt , so Proscha ska andD i C l e m e n t e ( 1 9 86 ) a d v i s e d e m p a t h y a n d r e f l e c t iv e l is -

    t en ing as the bes t s t ra teg ies fo r these c l i en t s . He a l soadvoca ted double - s ided re f l ec t ion ( i . e . , exp l ic i t ly re -v iew ing bo th s ides o f the a rgum ent fo r the c l ien t wi thou ttak ing s ides ) .

    Building the alliance through motivational interviewing. With adu l t s , r e sea rch show s tha t the qua l i ty o f thetherapeu t ic a l l i ance t ends to s t ab i l i ze by the th i rd o r four ths e s s io n s a n d i s p r e d i c t i v e o f r e t e n ti o n a n d o u t c o m e ( H o r v a t h

    Luborsky, 1993) . Al though these resu l t s have no t beendupl ica ted wi th ado lescen t s , the re i s l i t t l e r eason to be l i evetha t the resu l t s a re d i ffe ren t . Our p re l im inary resu l t s wi th theAW AI sugges t th i s i s the case . The job o f the the rap i s t i s tora i se the c l i en t ' s doub t abo u t the undes i rab i l ity o f change b yincreas ing the c l i en t ' s pe rce p t ion o f ri sks and p rob lem s re -l a t e d t o c u r r e n t b e h a v i o r a n d h a v i n g t h e m f o c u s o n t h eadvan tage s o f a l te rna t ives . Ear ly s t ra teg ies o f mot iv a t iona li n t e r v ie w i n g e m p h a s i z e t e c h n i q u e s f o r b u i l d in g s u c h a p o s i -t ive re la tionsh ip . T hese s t ra teg ies inc lude :

    1 . P rov id ing an exp lana t ion o f