Psychiatry Residency, Yale University School of Medicine, New Haven, CT, USA
Received date: September 01, 2015 Accepted date: September 12, 2015 Published date: September 20, 2015
Citation: Lubit R (2015) Building and Maintaining an Alliance with a Child Patient. Int J Sch Cog Psychol 2:145. doi:10.4172/2469-9837.1000145
Copyright: © 2015 Lubit R. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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As a child psychiatrist I have often witnessed child therapists interacting with children in ways that undermine the therapy or even hurt the child. The key problem is that therapists tend to forget what it was like to be a child and therefore neither appreciate how certain behaviors will be experienced by the child, nor what the child needs to be able to trust the therapist and build a therapeutic relationship. Building and maintaining a therapeutic connection with a child is often a difficult task. The first challenge is that children rarely choose to go to therapy; it is generally imposed on them by their parents. A second issue is that therapists often feels obligated not simply to the child but to the parents, who the child may well be upset with and who may be treating the child in problematic ways. The challenge escalates when the therapist does not want to hear, and certainly does not want to believe, that the parents are mistreating the child. Under all of these pressures, it is easy for a therapist to fail to empathize with the child, and even to fall into invalidating the child. Doing this, will not only doom the therapy, but may hurt the child. Therapeutic success depends above all else on empathy and connection. With empathy and connection, children will benefit from sessions, regardless of the theoretical orientation of the therapist. Without them the therapist may hurt the child. Having left childhood behind long ago, I found the following ideas very helpful as guidelines for building and maintaining an alliance with a child in therapy
Child Patient; Worse; Betrayal
Building and maintaining a therapeutic relationship with a child is a delicate art, and you must be careful not to behave in a way that would jeopardize that relationship . Children are very sensitive, and once your relationship with a child is damaged, it is unlikely to be fully repaired. To build and maintain a therapeutic relationship, therapists need to understand how children experience the world and their interactions with adults.
Children’s therapists generally understand that children are not simply miniature adults. Their thinking patterns and ability to deal with abstractions are limited in preteen years [2,3]. These are not, however, the most crucial differences with adults. During the interval between childhood and becoming a therapist, many therapists forget what life was actually like to be a child, including what it felt like to be small in a world run by much bigger people, most of whom have limited interest in what you say. Children frequently experience adults discounting their complaints, and believing the word of almost any adult over theirs. To make matters worse, children are often unable to escape a situation that is painful or destructive to them. While an adult may find it impractical to leave a difficult home or job, the adult at least has a choice. There is a huge difference between an adult choosing to stay in a painful situation because it is impractical to leave, and a child being powerless to.
Failing to remember what it felt like to be a child, children’s therapists do not appreciate the powerful impact children’s lack of both power and credibility in the eyes of adults have on children’s ability to forge relationships with therapists. Moreover, most therapists never knew what it was like to be seriously mistreated by an adult. Compounding the problem, therapists are motivated to not believe a child’s complaints of mistreatment, because it would compel the therapist to take actions that would be difficult for them, and might jeopardize the parents’ willingness to keep the child in therapy. Due to these factors, therapists often behave in ways that invalidates the child, and communicates their lack of faith in the child’s statements. Doing so undermines the therapy, and can be emotionally destructive to the child .
There are important guiding principles to follow to maximize the chance that you can create and maintain a therapeutic relationship with a child. At the beginning of therapy you need to explain to the child your responsibility to them and to their parents. This includes discussing the boundaries of confidentiality. The type of information the therapist will relay to parents and the situations under which the therapist will share information with parents need to be explained. How to deal with privacy concerning self-destructive behavior is a thorny issue. You are not obligated to tell patients that their confidentiality ends if their safety is at issue, as long as you do not lead them to believe that their communications are totally private. Making a point of saying that they lose confidentiality if they report thoughts of self-harm may lead the child to remain silent on the issue, preventing you from knowing what is going on and impeding them from getting needed help. Children do not have full confidentiality for any topic, and parents may not accept a situation in which they hear nothing. The best avenue to take is let the child know you will share very general statements, such as the child is able to talk comfortably in therapy, the child feels stressed about school, the child is dealing with sadness and anxiety, the child seems engaged and is using therapy well, or is not. Rather than bluntly saying to the child that if they reports suicidal thoughts you will tell the parents, you should say to the child that if their safety is in danger you will work with them to protect and help them, and that you hope the child could share with their parents so they can help too.
It is essential that children’s therapists learn active listening skills, and stay much more engaged and involved with a child than is necessary with an adult . While an adult may have the discipline and understanding to work with a therapist who shows little expression, children do not, and will assume the therapist is disinterested. A therapist scribbling on their pad while trying to maintain a neutral expression will almost invariably be interpreted as a therapist that does not care. A child will trust their own impressions over the statement of a therapist; no matter how much the therapist insists they are listening, the child will not believe it, and in fact will lose trust in the therapist, because the child will believe the therapist is lying. It is vital to not only listen, but to look like you are listening, using both body language and facial expressions. Be engaged in listening through eye contact. Express concern or interest, even if it only amounts to an affirmative sound. If for some reason you become distracted, admit it. If you are having a bad day, admit it. If you cannot maintain active listening and involvement with all of your patients, then decrease the number of patients you see. You are hired to help the child to the best of your ability, which means being emotionally available. Accepting money for incompetent therapy is theft.
When interacting with a child, smile. Be warm and kind, and they will open up to you. An adult will speak about themselves to a therapist because they know the therapist is there to help. A child needs a friend to talk to, or the therapy will be useless. While when working with an adult you should avoid speaking about yourself, this is not the case with a child. It can be extremely helpful to note similarities between the two of you. Perhaps you both enjoy a certain sport, or you both love to draw. Maybe you both hate broccoli. Sharing something about yourself makes you more real to the child and helps the child to connect with you. The child will feel they are with a real person they can connect to rather than a stranger with a notepad, and will therefore be more open about their thoughts and feelings. They will trust you; you must do whatever is in your power to keep that trust. Do not break promises. Breaking promises will not only destroy the relationship, but will tell the child that breaking promises is acceptable behavior. A child is not likely to understand the excuses a therapist may make, such as they thought they could keep the promise, or they intended to keep the promise but the situation changed, or you felt it was best to break it. The excuses will be trivial to the child. What they will remember is that they were betrayed, and that going forward, neither this nor any therapist can be trusted.
Accepting and validating the child’s feelings is key both to maintaining the relationship and helping patients . Simply validating the feelings of someone who is upset can provide significant relief. Focusing attention on finding a solution, before validating the person’s feelings, can be experienced as a lack of care concerning their feelings. The child needs to hear that you understand what they are going through, and not simply that you can make their life better in the future. If the child feels that you do not care, you will invariably damage the relationship. Validation requires accepting the child’s emotional experience and belief as reasonable given their position, and making comments that show the child that you understand, or are at least trying to understand. They need to see that you do not deride them or see them as disturbed for seeing the world the way they currently do. Only after the child sees that you understand what they are experiencing can you help them see their situation as less overwhelming and hopeless.
It is easy, and common, to fall into making comments that are invalidating or patronizing, including “I know how you feel”, “it could be worse”, and “you need to calm down”, or pointing out how the situation has a positive side. Do not say to a child you know how the child feels. You can echo the child’s words and see if you are correct. You can ask if the child is saying something or expressing a certain reaction, but don’t tell the child you know. While an adult is likely to speak up and correct you, a child will be less likely to speak up and will simply withdraw; having been taught it is rude or useless to challenge an adult’s belief. Furthermore, telling a child how the child feels, as opposed to listening in order to find out, can make the child feel as though you are attempting to impose emotions on them . This can undermine the child’s ability to read and deal with their feelings and foster feelings of inadequacy and insecurity. It is perfectly legitimate to admit that you don’t know how they feel. Instead of informing them of how they feel, offer them the chance to tell you. Telling a child their problems could be worse creates feelings of guilt, and a spiraling feedback loop of shame and insecurity. The result of such treatment is further emotional damage to a likely already traumatized child. It will encourage the child to withhold emotion from the therapist, for fear of such a reaction. Therapists tend to make these statements in order to help themselves feel better when they feel helpless. The line between validation and invalidation can be very subtle. For instance, when a child is going through a rough period it is far better to say “how are you doing today”, rather than “how are you doing”. The first conveys an understanding that the child is going through a very difficult time. The second can easily be seen as invalidating, since it suggests that you think the person might now be fine .
Validating the child is a crucial first step in dealing with a problem. Stopping at this point, however, will doom the therapy if the child is dealing with problems for which they need adult assistance. Children have a right to their parents’ help. However, if the parents are the problem, the child will appropriately look to the therapist for help. To fail to render concrete assistance, which the child has a right to expect some adult to give, indicates to the child that you, and adults in general, do not care. Either way, the child will cut their ties to you, and you will become a negative role model for the child. Perhaps the most difficult position you will be in is if a child from a divorced home asks you to contact the court to help the child live with the other parent. The first reaction of therapists tends to be to stay clear of the fray and keep their heads low. The common justifications for doing nothing is that someone else will act, or that the court already decided who the better parent is, and that intervening will destroy the therapy. In reality, if a child wants concrete help, and you say that your job is simply to listen, you will lose what relationship you had with the child. The child will no longer trust you and will be further injured by yet another betrayal, yet another experience with an adult who does not care enough to actually do something. Moreover, you are teaching the child that the world does not really care, and that it is appropriate to sit by when others are being mistreated. These are horrible behaviors to model for a child. Decent parents will do whatever is necessary to protect their child if they find out that someone is mistreating the child. When a parent is the source of the abuse, the child has no one to turn to other than you. Even if the child is not being abused, even if the issue is simply that the child is upset by limited contact with the preferred parent, it is important to speak up. Being kept away from a primary attachment figure causes children marked stress and harm, even if the other parent treats the child reasonably. As courts do not appreciate this, it is up to you to inform the court.
There is another issue. Failing to speak up makes a powerful statement. If the child is in therapy, the court will assume that the therapist will speak up if something is wrong. A therapist not speaking up sends a powerful message to the court that all is well. The job of a therapist is to help a child get to a point where the child is safe and happy. If there are elements in the environment which prevent this, the therapist must do whatever is necessary to change this. In any case, what kind of human being is unwilling to help a child in need?
It is invasive and ultimately destructive to push a child to speak about private, painful material the child is not ready to speak about. If you attempt to probe into a child’s thoughts before you have established a solid relationship, the child will either instantly withdraw, or be overwhelmed and avoid returning. Pushing a child to speak about memories they are not prepared to is a surefire recipe for creating a sullen, withdrawn child. The therapy will become an ordeal, a trial the child will dread. This is the exact opposite of what you are trying to accomplish. While you can invite the child to share such material, and explain to the child that doing so will be helpful to the therapy, under almost no circumstances should you pressure the child to do so. A rare exception is if you feel a child is being hurt and needs protection. Pressuring a child to speak about memories and feelings they does not agree to share is experienced as invasive and violates the nature of the relationship. Forcing secrets from a child that the child is not ready to share will irreparably damage your relationship, as well as likely traumatize the child and damage the child’s ability to work with therapists in the future. Be patient. Don’t hurry the conversation, or put words in the child’s mouth, or push for answers. Let the conversation unfold at its own pace. Keep in mind that while an adult has the ability to walk out the door, a child cannot. This distinction is a key and fundamental difference between working with children and working with adults, and all the more reason for you to be respectful of a child’s boundaries.
When a child unearths painful memories, you need to be prepared for a considerable amount of repressed anger. You need to be able to tolerate a child’s anger. In tolerating the child’s anger you show the child that anger does not need to escalate and does not need to destroy either the relationship or the people involved. This is especially vital for abused children, who have been conditioned to associate anger with violence, either emotional or physical. If the child accuses you of being unfair or unreasonable or wrong or hurting them, do not instantly go on the defensive and try to justify what you did. Be very wary of making excuses for yourself or others, including parents. Bad behavior or mistakes by yourself or others should be labeled as such. Rather than deflecting the child’s feelings, therapists should validate the child’s feelings. For many, if not almost all children, validating their feelings are the most crucial aspect of therapy. Children are unsure of their feelings, and unsure of the validity of their feelings. Only by becoming aware of feelings does it become possible to gain control of them. Similarly, it is necessary to be aware of anger before it can be channeled. Telling a child they should not be angry will only serve to bury the feeling, make the child uncomfortable with themselves, and lead the child to distrust their feelings, which can lead to long-term consequences. For instance, people who distrust their feelings often stay in destructive situations.
If the connection with a child is not working, rather than holding onto the patient, the therapist must communicate to the parents that the therapy is not benefiting the child and a new therapist should be sought. No therapist wants to give up a client, which means losing a source of income. No therapist wants to admit that he or she could not connect with a child. Nevertheless, as a therapist you owe it to the child to ensure they get the best treatment possible for them, even if that means releasing them into another’s care. Keep in mind that while an adult can walk out the door and not come back, a child cannot. The therapist must therefore be more active in questioning whether the therapy is useful and optimal for the child.
Building and maintaining a therapeutic relationship with a child is difficult. Many therapists unknowingly act in ways which interfere with the therapeutic relationship and threaten the therapy. In working with children it is crucial to appreciate the very limited power they have in the world, and their frequent experiences with adults who do not believe them. You have to be more of a real person to a child, showing interest and feeling. While an adult may be able to deal with limited feedback, a child cannot, and must see that you are interested in what they have to say. You must validate the child’s experience and avoid comments that are invalidating. Once you have done this, you need to be willing to take concrete action if the child needs you to. Sitting by when a child is not being treated well, or simply when a child is being kept away from the parent the child wants to be with, is both unethical and ultimately destructive to the therapy. Saying nothing when a living situation causes a child distress will hurt the child, make you a negative role model and almost inevitably lead the child to emotionally abandon the therapy. There is no neutral position in a custody case. Saying nothing sends a message that everything is fine. Finally, pressuring a child to speak about memories and feelings they are not ready to, before you have built an adequate relationship, before you have dealt with the child’s resistance to sharing what is going on, will be experienced as invasive and will damage the therapy.