It is important to build a positive alliance early in treatment and to maintain a strong alliance throughout treatment. The alliance is often conceptualized as being comprised of three related but distinct dimensions: bond, tasks, and goals. Bond refers to the affective aspects of the client–therapist relationship. Tasks constitute agreement and participation in the activities of therapy. Goals represent the agreement between the client and the therapist on the desired outcome of treatment. A challenge for child therapists is building and maintaining a strong alliance with both the child and the parent. And, of course, the therapist should carefully consider the client’s cultural background, as this can influence a number of factors relevant to forming the alliance (the therapist’s stance, the target of treatment, and so on).
Alliance building with children
Children rarely refer themselves for therapy, so their motivation to participate in therapeutic activities can vary. A key task of a therapist is to engage children in treatment and to keep them motivated throughout treatment. With children the alliance-building process often starts with forming a strong affective bond and working to achieve agreement on the goals and tasks of therapy.
The affective bond is one of the most important components of the alliance with children who derive motivation to participate in therapeutic tasks from a positive relationship with the therapist. It is therefore important to establish with a child a relationship marked by warmth and openness, and to do so early in treatment. Interventions traditionally associated with client-centered psychotherapy can facilitate alliance building. Rapport-building behaviors that elicit information, provide emotional understanding and support, and explore the child’s subjective feelings help foster an affective bond (Karver, Handelsman, Fields, and Bickman 2008). Therapists’ use of collaborative language (e.g., we, us, let’s) can also help build the bond by helping to establish therapy as a collaborative effort (Creed and Kendall 2005). Attending to and tracking client affect (e.g., fear, disappointment) and the use of validating statements help clients feel understood and supported. In all, client-centered interventions such as these help form an affective bond and ensure that the child will present him-/herself to treatment ready to engage in the hard work ahead.
As children get older, agreement on the tasks and goals of treatment becomes increasingly important. Young children do not have the cognitive capacity to understand long-term goals, so the affective aspect of the alliance is more important for young children (Shirk and Saiz 1992). However, adolescents have an increased need for autonomy, so it is essential that they have a say in establishing the goals and tasks of treatment. Of course, treatment goals and tasks should be presented in developmentally appropriate terms. Young children may find the simplest explanation suitable (e.g., “Today we are going to learn how to talk back to your anxiety”), whereas adolescents may benefit from a more detailed rationale of the treatment strategies to be used (e.g., “Today we are going to talk about two kinds of thoughts: anxious thoughts and coping thoughts because it is important to understand how our thoughts can influence our feelings”). Collaborative approaches that allow the child to have input into the selection of goals and tasks help to strengthen the alliance. Indeed, children who feel like they have some say in establishing treatment goals and tasks are more motivated and willing to engage in treatment (Meyer et al. 2002). Therapists must be aware that parents and children may have different goals for treatment. Parents often initiate treatment and have treatment goals that the child client may not share. The therapist must therefore work to resolve discrepancies or to identify common goals by following ethical and professional standards.
Alliance building with the parents
The therapist must build and maintain a strong alliance with the parents. Parents play a critical role in child psychotherapy. While it is important to establish a strong affective bond with them, it may be more important that both parties – therapist and parents – agree on the tasks and goals ahead. As many parents give consent and provide transportation for their children, failure to agree on the goals and tasks of treatment can result in premature termination. Taking the time to understand the parent’s treatment goals, drawing a clear connection between tasks and goals, and setting realistic treatment expectations can help form a strong alliance with a parent. It is also important to check in with the parents throughout treatment, to ensure that no problems related to tasks and goals arise.
Parents play various roles in treatment. In some cases they may be asked to take responsibility for homework activities that give a child the opportunity to practice skills. In other cases parents may be asked to alter behaviors that contribute to the development and/or maintenance of a child’s symptoms. Parents may not expect to participate in treatment without understanding why their participation will help achieve treatment goals. It is therefore important to clearly explain why a parent is being asked to participate in treatment, and also to detail how his or her participation will help achieve treatment goals.
