Building a Positive Therapeutic Relationship with the Child or Adolescent and Parent

Building a Positive Therapeutic Relationship with the Child or Adolescent and Parent

Ruth C. Brown, Kimberly M. Parker, Bryce D. McLeod, and Michael A. Southam-Gerow


Although there is debate about the relative importance and influence of the therapeutic relationship in psychological treatments for children and adolescents, few assert that the relationship is not important. Evidence-based treatments assume that a strong therapeutic relationship with the child and parent is critical. Further, workgroups and task forces have underscored that the therapeutic relationship is a key component of evidence-based practice (e.g., Castonguay and Beutler 2005; Norcross 2011).

The therapeutic relationship is also believed to play an instrumental role in cognitive behavioral therapy (CBT) for children with anxiety and depressive disorders. For one, a strong therapeutic relationship is believed to promote positive outcomes by increasing child engagement in the skill-building tasks that are a hallmark of CBT. A strong therapeutic relationship is also believed to facilitate child engagement in the emotionally challenging tasks of CBT, such as exposure tasks. Considered a key component of CBT for child anxiety, exposure tasks are challenging and emotionally demanding. Children who feel a strong connection to their therapist may be more willing to engage in exposure tasks and thus experience greater symptom improvement (Chu and Kendall 2004).

The ability to form a strong therapeutic relationship with a child and parent depends in part on a therapist’s ability to tailor treatment to the unique needs of the client. This requires a thorough understanding of the core CBT interventions and of how to adapt the delivery of these interventions to fit the personal, developmental, and cultural needs of particular clients. It also requires an understanding of how to help children and parents agree on the tasks and goals of treatment. Ultimately, treatment success depends on the therapist’s ability to convince the child and parent that the different elements of a CBT program are important and that participating in treatment will lead to symptom reduction.

In this chapter we describe competencies that are relevant for building and maintaining a positive therapeutic relationship with child or adolescent clients and their parent(s). Specifically, we will focus on four aspects of the therapeutic relationship by (i) describing key competencies that contribute to therapists fostering positive therapeutic relationships; (ii) discussing how those competencies are specifically applied in treating anxiety and depression in children/adolescents; (iii) outlining how those competencies are adjusted for clients of different developmental levels (e.g., younger children vs. adolescents) and different cultural background; and (iv) delineating obstacles to building a positive therapeutic relationship and outlining methods for overcoming those obstacles.

Key Features of Competencies

Sburlati, Schiering, Lyneham, and Rapee (2011) identified four broad competencies associated with building a positive therapeutic relationship: (i) building alliance with children; (ii) building alliance with parents; (iii) instillation of hope and optimism for change; and (iv) engaging children in developmentally appropriate activities. In this chapter we discuss each of these competencies, beginning with alliance-building behaviors. Before we dive into these issues, it is important to note that cultural and diversity issues must be carefully considered when building a therapeutic relationship. A number of factors relevant to the therapeutic relationship can be influenced by a client’s cultural background. Such factors may be the degree of formality of the therapeutic relationship, expectations for treatment, and treatment goals (e.g., expression of distress). Thus a key part of building a therapeutic relationship with a parent and a child is understanding how their cultural values may impact the process and the outcome of therapy. This information should be used in turn to inform efforts to build and maintain the alliance.

Alliance building

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.

Instilling hope and optimism for change

Parents and children who come to treatment with low expectations about its potential advantages can benefit from a sense of hope. Thus, early in treatment therapists must ascertain what expectations parents and children have for treatment. This work can occur when they discuss the treatment’s tasks and goals. Any sign of unrealistic treatment expectancies indicates the need to instill a sense of hope for change. Providing psycho-education about the therapy process, the typical timeline for treatment, and the expected outcomes can instill hope and generate a set of realistic expectancies. To help maintain hope, therapists should foster the development of client self-efficacy regarding his/her ability to successfully accomplish the tasks and goals of treatment. And, to foster this development, therapists can highlight accomplishments and normalize “set-backs” by reminding clients that change is not a linear process.

Competence in Treating Anxiety Disorders and Depression

Although the competencies described up to this point apply to working with children who suffer from anxiety or depressive disorders (or both), there are some disorder-specific suggestions to consider.


Some children with anxiety are inhibited. A few issues arise from this state of affairs. First, these children may be slow to form an alliance; in fact interacting with the therapist may be an exposure task for inhibited children. Second, with inhibited children, therapists may struggle to gauge the quality and progress of the alliance, which makes it important to regularly assess that alliance from the child’s and the parent’s perspectives.

Exposure tasks are a key ingredient of CBT for anxiety. These tasks are challenging and emotionally demanding for children. A strong alliance may facilitate client involvement in exposure tasks. Existing evidence suggests that exposure tasks do not have a negative impact on the alliance, particularly in the context of an established positive alliance (Kendall et al. 2009). It is therefore important to establish a strong alliance with a child before starting on the exposure tasks, so as to maximize child involvement. Providing encouragement and praise during exposure tasks can help maintain the alliance and build client self-efficacy.

Children with anxiety disorders are likely to have parents who suffer from anxiety too. Anxious parents may inadvertently interfere with treatment by negatively reinforcing escape behaviors or by “rescuing” their children from challenging tasks. Therefore the therapist must help parents understand how their behavior impacts treatment progress. In the context of a supportive parent–therapist alliance, parents may feel more comfortable to express concerns or difficulty in watching their children face distressing situations. Therapists may also find the need to provide the parents with strategies for coping with their own anxiety, or they may recommend that the parents seek their own treatment.


Children with depression tend to be irritable. An irritable client can punish help-giving behaviors and can be a tough challenge for a therapist aiming to form an alliance. Indeed, clients with depression provide lower levels of reinforcement in response to alliance-building behaviors. Therapists thus need to be vigilant and maintain their alliance-building efforts despite the lack of reinforcement from the child.

Children’s irritability can make reinforcement difficult for their parents as well (Dietz et al. 2008). Parents of depressed children may therefore need increased support to appropriately reinforce the tasks and skills the child is acquiring in treatment. Feedback to parents will be easier to give and better received in the context of a supportive parent–therapist alliance.

The therapist should also be aware that parents of depressed children may suffer from depression and other psychiatric disorders themselves. Depressed parents may be difficult to engage in treatment. If parental psychopathology interferes with treatment progress, it may be necessary to refer a parent to treatment. Indeed recent studies have shown that the treatment of parental depression can lead to improvements in the child’s depression (Wickramaratne et al. 2011).

Jan 18, 2017 | Posted by in PSYCHOLOGY | Comments Off on Building a Positive Therapeutic Relationship with the Child or Adolescent and Parent
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