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Developing the therapeutic alliance in child

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

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Applied & Preventive Psychology 5:85-100 (1996). Cambridge University Press. Printed in the USA.

Copyright 1996 AAAPP0962-1849/96 $9.00 + .00

Developing the therapeutic alliance in

child-adolescent psychotherapy
R A Y M O N D DIGIUSEPPE, JEAN LINSCOTT, AND ROBIN JILTON
St. John's University

Abstract

The psychotherapy process research on the therapeutic alliance in child and adolescent psychotherapy is alarmingly
scarce. Findings from the adult therapeutic alliance literature and from the few existing studies on child and
adolescent therapeutic alliance are reviewed. Bordin's (1975) model of the working alliance and Prochaska and
DiClemente'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 not
self-referred and (b) frequently come to therapy in a resistant, precentemplative stage of change are presented as the
major obstacles to forming effective alliances with children and adolescents. Traditional child and adolescent
psychotherapies may fail to develop effective alliances due to their primary focus on the development of the bond
and neglect in achieving agreement on the goals and tasks of therapy. Multimodal strategies for building therapeutic
alliances with children and adolescents incorporating techniques from emotional script theory, social problemsolving theory, motivational interviewing, and strategic family systems theories are presented.
Key words: Therapeutic alliance; Psychotherapy; Children; Adolescents.

Outcome and process research in child and adolescent psychotherapy has greatly lagged behind research in adult psychotherapy (Institute of Medicine, 1989; Hoghughi, 1988;
Johnson, Rasbury, & Siegel, 1986; Kazdin, 1988, 1990).
Meta-analytic studies suggest that research on psychotherapies for children and adolescents generally finds effect
sizes of similar magnitudes as do treatments f o r adults
(Casey & Berman, 1985; Weisz, Weiss, Alicke, & Klotz,
1987). However, the bulk of research regarding child and
adolescent psychotherapy is done on populations that have
identifying problems different from those that characterize
actual clinical practice (Koocher & Pedulla, 1977; Silver &
Silver, 1983; Tuma & Pratt, 1982). In fact, research suggests (Weisz, Weiss, & Donenberg, 1992) that outcomes for
samples from clinics are significantly poorer than those in
research studies. There is considerably less assurance that
psychotherapies for children are as effective as they are for
adults. One reason for this state of affairs appears to be the
lack of research and investigation on the therapeutic process
with children and the development of the therapeutic alliance in particular. This article reviews the recent literature

on the therapeutic alliance in child-adolescent psychotherapy

and offers some research strategies and techniques to develop
the therapeutic alliance with children and adolescents.
The adult psychotherapy research literature has placed
particular emphasis on the role of the therapeutic relationship, and the working alliance, as an important variable for
predicting psychotherapeutic change (Greenberg & Pinsof,
1986; Horvath & Greenberg, 1986; Luborsky, Crits-Christoph, Mintz, & Auerbach, 1988; Marmar, Horowitz, Weiss,
& Marziali, 1986). One would expect equal research exploring this topic since most theories of child and adolescent
psychotherapy posit that the therapeutic relationship is crucial to therapy outcome. Kazdin, Siegel, and Bass (1990)
surveyed over 1100 child therapy practitioners. Therapists
were asked to rate the types of variables they believed most
influence treatment. The majority of therapists judged the
therapeutic relationship to be one of the most important
variables determining successful treatment. More than 90%
of the child]adolescent therapists thought the therapeutic
relationship was extremely important in influencing the degree of change in therapy. Correspondingly, most respondents did not rate technical aspects of treatment, such as
specific therapist techniques, duration of treatment, or frequency of sessions, as important to outcome. Of all variables
considered to influence change, the therapeutic relationship
was rated as important far above any other variables.

Address correspondence and reprint requests to: Raymond DiGiuseppe,

Department of Psychology, St. John's University, 8000 Utopia Parkway,
Jamaica, New York 11439.
85

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DiGiuseppe, Linscott, and Jilton

Despite the crucial role that the therapeutic relationship

appears to play in the theoretical and clinical literature, and
despite practitioners' beliefs regarding the importance of the
therapeutic relationship, few practitioners expressed a belief
in the importance of researching the therapeutic relationship
or alliance. In Kazdin, Siegel, and Bass's (1990) survey,
only 58% of the respondents thought it was important to
examine therapeutic processes in research, and only 36%
thought therapists' characteristics (including the therapeutic
alliance) were important as a focus for research.
The crucial role of the therapeutic relationship in mediating psychotherapy outcome, and the faith in the effectiveness of the presently utilized techniques for developing the
therapeutic relationship, seem to be unquestioned assumptions amongst child/adolescent psychotherapists. Particularly striking is the dearth of psychotherapy process research with children and adolescents (Kazdin, Siegel, &
Bass, 1990; Shirk & Saiz, 1992) to validate commonly held
assumptions about techniques implemented to build a therapeutic relationship. A special issue of the Journal of Consulting and Clinical Psychology on psychotherapy process
research (June, 1990) included no articles on process research in child or adolescent psychotherapy. Also, Greenberg and Pinsof's (1986) text on psychotherapeutic process
research has no chapter dedicated to child therapy process
research. No major journal in the field of psychotherapy,
clinical psychology, child or school psychology has addressed a special issue or section on the therapeutic relationship with children and adolescents.
Our review of the literature on the therapeutic process
research with children and adolescents uncovered very few
studies with children and adolescents. Most of the research
has focused on specific child or therapist behaviors in sessions, and most of it is irrelevant to the issue of the therapeutic relationship or how the child experiences therapy (see
Shirk & Saiz, 1992 for a review of the early process literature). Another line of research has been to measure or influence the child's expectation of therapy (Bonner & Everett,
1982; Weinstein, 1988). Although a priori expectations
may influence the relationship and deserve further study,
this research has yet to empirically link prior expectations
about therapy to the therapeutic relationship or alliance.
Wright, Truax, and Mitchel (1972) reported that therapists warmth and empathy could be reliably measured in
child therapy sessions. Siegel (1972) reported that therapists' warmth, genuineness, and positive regard were positively related to children's positive statements about themselves in the middle phase of treatment.
Only one study to date has linked a measure of the therapeutic relationship with outcome. Taylor, Adelman, and
Kaser-Boyd (1986) attempted to assess adolescents' perceptions of the psychotherapy relationship using a scale
developed by Koenigs and Hess for school children (Koenigs & Hess, 1976). The results showed very low correlations
between therapists' and clients' responses. Both therapists
and adolescents rated the establishment of trust as the most

important aspect of the therapeutic relationship, while the

development of the client's autonomous actions was rated
as the least important aspect. Nonetheless, those therapists
who emphasized the development of autonomous actions
rated their clients more favorably on outcome measures, and
those clients who experienced the enhancement of personal
autonomy in therapy showed the highest degree of satisfaction with therapy at termination (Taylor, Adelman, &
Kaser-Boyd, 1984). Limitations of this study include the
limited number of therapists and adolescents surveyed (9
and 24, respectively), the lack of a standardized scale, and
the failure to include parent or teacher ratings of therapy
outcome.

Stages of Change, Referral, and Child Psychotherapy

Prochaska and DiClemente (1988) proposed a model of
the attitudes people have toward changes. Research in the
stages of change model examined numerous types of patients and nonpatients to understand how people think about
change (Prochaska, Norcross, & DiClemente, 1992). The
first stage of change, called the precontemplative stage, reflects no desire to change. In the contemplative stage people
are willing to explore whether change is desirable. In the
action stage people take concrete steps to change. In
the maintenance stage people attempt to consolidate the
changes they have made. It seems that most self-referred
psychotherapy clients seek help in either the contemplative
or action stages. People willingly enter psychotherapy because they wish to explore the possible advantages of
change or want to implement actions to change. Selfreferred clients have reached some insights about their emotions and/or behaviors that have moved them from the precontemplative stage to the contemplative or action stages
before entering therapy.
Most systems of psychotherapies were designed for selfreferred clients in the contemplative or action stages. The
most difficult patients in adult psychotherapy are those who
were forced into therapy against their wishes. Such persons
would be in the precontemplative stage. The field of psychotherapy has always had difficulty with substance abusers, court-mandated referrals, and other clients who attend
therapy at the insistence of others.
We believe that the most crucial characteristic of child
and adolescent psychotherapy, which makes the therapeutic
alliance difficult to establish, is that youth are not selfreferred for treatment (DiGiuseppe, 1988; Kazdin, 1988;
Kendall, 1991; Koocher, 1976; Shirk, 1990; Tuma, 1983)-a characteristic they share with other difficult to treat
groups. The insights that self-referred clients have accomplished, and which are usually assumed to have been
reached by most theories of psychotherapy, are therefore
lacking in children and adolescents.
The insight or awareness that change is desirable may not
be easily achieved. A study of adults entering psychotherapy (Saunders, 1993) indicated, " . . . that seeking professional mental health help is a fairly long and difficult

Therapeutic Alliance

process." Forty-eight percent of adults seeking treatment

required almost a year or more to realize they had a problem.
More than 60% required from a few months to more than a
year to decide that therapy might help after they realized they
had a problem. Thus, adult self-referred patients seem to
have taken considerable time to have reached some important insights about their problem before arriving for therapy.
Children and adolescents are unlikely to have reached these
insights before the first session since the referral is instituted
by others. A. Freud (1965), Meeks, (1971), and Mishne
(1983) have noted that the most prominent factor blocking
children's motivation for treatment is their lack of selfknowledge about their problems and failure to want change.
For child and adolescent psychotherapy to advance and
become more effective, several steps are necessary.
1. Theoreticians, researchers, and practitioners need to
acknowledge that youth are not self-referred for therapy.
2. The effect of forced referral on the agreement on the
goals, and secondarily on the tasks aspect of the therapeutic alliance needs to be explored.
3. Research and theory need to focus on those insights.
and experiences that have moved self-referred clients
from the precontemplative stage of change to the contemplative or action stages. An understanding of the
self-change processes, whereby people realize that
change is desirable, will help us to conceptualize the
problems of forced referred clients in general, and
children and adolescents in particular.
4. We need to develop therapies which are based on the
premise that young people are not motivated for treatment. Therapy techniques must focus on developing
the insights and attitudes toward change that have already been achieved by self-referred clients.
Some areas that might be helpful in achieving these goals
are the social problem-solving literature, the emotional
script construct in the sociology of emotions, and the work
with substance abusers in motivational interviewing.
The voluminous process research in adult psychotherapy
could provide a starting point for considering issues relevant
to the assessment and development of psychotherapeutic
relationships and alliances with children and adolescents.
One of the most influential models of the therapeutic relationship has been Bordin's model (1979). This model of the
therapeutic relationship applies to all psychotherapy orientations. Components of Bordin's therapeutic alliance model
include: (1) agreement on the goals of therapy, (2) agreement on the tasks of therapy, and (3) the development of the
bond (or therapeutic relationship). The goals component of
the therapeutic alliance can be described as the client's and
therapist's formulation and agreement upon what is hoped
to be accomplished in therapy. The tasks component of the
therapeutic alliance is an agreement between the therapist
and the client on the techniques, procedures, or behaviors,
which will be used to accomplish the goals of therapy. The

87

bond component of the therapeutic alliance is described as

the relationship formed between the client and the therapist.
Bordin's formulation of the therapeutic alliance goes beyond just the therapeutic bond and relationship. The model
assumes that an accepting warm bond between the therapist
and the client may not necessarily lead to a contract on the
goals and procedures of therapy. We would define a positive
therapeutic alliance as:
"A contractual, accepting, respectful, and warm relationship between a child~adolescent and a therapist for the
mutual exploration of, or agreement on, ways that the
child~adolescent may change his or her social, emotional
or behavioral functioning for the better, and the mutual
exploration of, or agreement on procedures and tasks
that can accomplish such changes."
The establishment of the therapeutic alliance has been
shown to predict treatment outcome in adults (Greenberg &
Pinsof, 1986; Horvath & Greenberg, 1986; Marmar et al.,
1986). In addition, a meta-analytic review of the therapeutic
alliance research (Horvath & Luborsky, 1993; Horvath &
Symonds, 1991) reached some firm conclusions about the
alliance. The alliance appears to develop by the third or
fourth session. The alliance predicts therapy outcome equally for all theoretical orientations. Clients' ratings of alliance
are more predictive of outcome than either therapists' or
observers' ratings. The alliance is unrelated to diagnosis or
severity of psychopathology. Therapeutic techniques from
different orientations all appear to influence the alliance
equally. Also, agreement on the tasks of therapy appears to
be the most crucial component of tlie alliance for predicting
therapy outcome.
Child and adolescent psychotherapy appears dominated
by the assumption that supportive and reflective therapeutic
techniques alone build the therapeutic relationship and alliance (Axline, 1947; Buxbaum, 1954; Freud, 1964; Moustakas, 1953; Reisman, 1973). The traditional model of therapy is based on the assumption that providing a warm,
accepting relationship with a therapist is a set of conditions
that allows the opportunity for a normal developmental tendency toward growth to take place. This assumption requires reexamination and possible empirical verification.
There is an important distinction here between the therapeutic relationship and the therapeutic alliance. Traditional theories of child and adolescent psychotherapy appear to have
overly focused on the bond as necessary and sufficient to
bring about changes. They have neglected the goals and
tasks aspects of the "alliance and may even be opposed to our
definition that the alliance is a social contract that may be
necessary but not sufficient for change. A strong alliance is
necessary for the therapist and child to implement the techniques or tasks of therapy and is a curative process in and of
itself. We propose that the establishment of a therapeutic
alliance is more difficult with children and adolescents compared to adults, because it is more difficult for the therapist

88

DiGiuseppe, Linscott, and Jilton

and child or adolescent to reach agreement on the goals of

therapy. This occurs because the majority of children are
not self-referred for psychotherapy (DiGiuseppe, 1988;
Koocher, 1976; Tuma, 1983). As a result, children and adolescents may not acknowledge the existence of problems,
and are often unmotivated to change (DiGiuseppe, 1988;
Kendall, 1991, Kazdin, 1988; Tuma, 1983). Without research on the therapeutic relationship and alliance with children and adolescents, therapists are denied access to crucial
information such as knowledge concerning how reliably
therapeutic relationships can be assessed, how long it usually takes to establish an alliance, what factors lead to alliance ruptures, and whether one must establish an alliance
before moving on to other tasks.
Shirk and his colleagues developed a measure of the therapeutic alliance based on B ordin's (1979) multidimensional
theory (Shirk & Saiz, 1992). They constructed items to
reflect three subscales, the child's affective experience of
therapy in a positive bond, negative affective response to
therapy subscales, and collaboration with the tasks of therapy. They reported adequate internal consistency as measured by Cronbach's alpha, and moderate convergence between therapists' and children's versions of the scale. They
found that " . . . the child's affective orientation to therapy
has an important bearing on the child's collaboration with
the therapeutic task. Children who felt more positively towards therapy were more likely to talk about problems and
feelings than children who were more negative" (Shirk &
Saiz, 1992, p. 720).
Shirk and Saiz (1992) proposed a social cognitive model to
explain the difficulty children and adolescents may have in
attaining a therapeutic alliance. The developmental schema
proposed that influence the ability to form an alliance are: (a)
the attachment scheme the child has formed, (b) self-evaluation, (c) the ability to form internal attributions for behavior, and (d) beliefs about the contingency of problem solutions. According to this model children and adolescents have
the best chance to form a positive therapeutic alliance if they
have a scheme for positive attachments with others, can
evaluate their own emotions and behavior, can generate
internal attributions for behavior, and believe that their efforts can result in positive outcomes. Although Shirk and
Saiz (1992) have used Bordin's model to construct a theory
and measure of the therapeutic alliance, they have primarily
focused on the bond and agreement on the tasks aspects of the
alliance. We propose here that agreement on the goals is the
crucial aspect of the alliance that is missing in most children
and adolescents. Although all four aspects proposed by Shirk
& Saiz (1992) appear helpful in attaining the alliance, we
maintain that self-evaluation is most crucial, since self-evaluation may be most related to attaining agreement on the
goals. If children are unable to evaluate themselves and see
themselves as having a problem, they may not participate in
therapy long enough to master the other three social cognitive
variables.
Self-evaluation has been shown to follow a developmen-

tal sequence (Selman, 1980). For example, preschoolers and

elementary school children fail to distinguish between a
wishful scheme of the self and an actual scheme of the self
(Katz & Zigler, 1967; Leahy & Huard, 1976; Stipek, 1984),
and that self-evaluation increases in accuracy with maturation (Stipek, 1984). Older children are more likely to use a
social comparison process in self-evaluation (Ruble, Feldman, & Baggiano, (1976). Although it is normal for children to overrate their competencies and underestimate their
weaknesses (Harter, 1988), this process may be greater in
clinical populations (Vondra, Barnett, & Cicchetti, 1989:
Zimet & Farley, 1986). Many children and adolescents
maybe referred to psychotherapy before they have developed sufficient maturation on this variable to accurately
evaluate their emotional and behavioral problems and, thus,
are unable to see themselves in need of change. The theoretical and clinical question that is central to our approach
is whether children's capacity for self-evaluation can be
strengthened or taught and in this way can help children
understand the need for change and thereby reach agreement on the goals.
Developmental considerations suggest that different aspects of the therapeutic alliance (i.e., bond, goals, or tasks)
may differ in prominence in predicting therapy outcome
across age. For example, it seems plausible that preschool
and early elementary school children's therapeutic alliance
may be influenced solely by the bond. This age group may
have little concern about the implied social contract involved in therapy. Less of the variance in outcome may be
related to agreement on the goals or tasks.
Adolescents, however, appear most concerned with the
agreement on the goals and tasks of therapy since dependence, independence, and self-determination are important
developmental issues for them. Adolescents are sensitive to
having others' goals imposed upon them. They also desire
to choose their own way of doing things. As a result, agreement on the goals and tasks may be more difficult to establish with adolescents than with younger children.
The nature of an adolescent's presenting problem may
also influence which aspects of the therapeutic alliance are
related to outcome and which aspects of the alliance are
easier to establish. Adolescents with internalized disorders
may establish agreement on goals and tasks much more
easily, due to their emotional discomfort, than youth with
externalized disorders. They also may be more willing to
form an alliance since they may have less of a problem with
authority figures and may wish to reduce the emotional
discomfort associated with internalizing disorders. Oppositional and conduct disorder children do not appear to benefit from traditional therapeutic techniques (Weisz, Weiss,
Alicke, & Klotz, 1987) because they are unmotivated for
change and are unwilling to enter any contract for change
with the therapist (Sherwood, 1990).
We are uncertain about children approximately between
the ages of 8 and 11 years. Our clinical experience suggests
great variability in their ability to benefit from the suggested

Therapeutic Alliance

procedures focused on attaining agreement of the goals.

Perhaps some children in this age group have not developed
sufficiently to improve self-evaluation skills and form a
social contract for help and may require a different approach
that focuses on a curative relationship. Others in this age
group appear willing to adopt the goals provided by therapists in an uncritical way.
We propose that different techniques may be required to
establish an effective therapeutic alliance with children and
adolescents depending on developmental stage and type of
problem. In the child/adolescent therapy literature most authors recommend the same reflective; supportive strategies
as the only way to build rapport with all types of clients
(Axline, 1947; Moustakas, 1959; Reisman, 1973). Strategies to build a therapeutic alliance may need to be prescriptive depending on age, presenting problem, desire for
change, or personality structure. For example, Sherwood
(1990) proposed that adolescents with narcissistic personality structures require a very different stance on the part of
the therapist, to build a relationship, than do adolescents
who are not narcissistic. Sherwood proposed that uncritical
acceptance of the adolescents' desires, but feedback on the
negative consequences and social desirability of actions, is
important with this group of adolescents.
Theoretical Differences in Forming Bond,
Goals, and Tasks
We would like to suggest some strategies for building a
therapeutic alliance with adolescents and preteens. The procedures that follow are suggested for children ages 10 years
and older. The lower age limit for their effectiveness may be
extended to age 8 years but will be determined by the
child's cognitive developmental level.
Building a Bond
As mentioned above, most texts on child and adolescent
psychotherapy recommend similar nondirective, supportive,
reflective strategies to build a therapeutic alliance. Traditional psychodynamic and client-centered approaches utilizing these strategies seem to focus on the development of the
bond, while de-emphasizing agreement on the goals and
tasks of therapy after the initial therapy session. It is possible that such exploratory, insight-oriented, or supportive
strategies will not be effective in establishing agreement on
the goals and tasks of therapy. There is no research evidence
that techniques designed to build the therapeutic bond will
have any impact on the child's or adolescent's acceptance
and understanding of the goals and tasks of psychotherapy.
The possibility exists that children and adolescents will
form a strong bond or attachment to a therapist but still
refuse to engage in any discussion of the problem behavior
(Sherwood, 1990).
Most texts on child-adolescent psychotherapy suggest
(Carek, 1979; Moustakas, 1953; Reisman, 1973; Weiner,
1975) that the use of interpretation and direct intervention

89

are best reserved until after the establishment of the therapeutic relationship. However, no research exists to verify
this often stated advice. Also no research evidence exists to
support the belief that supportive, reflection techniques are
the most effective way to build the therapeutic relationship.
Our clinical experience suggests that while reflection techniques may build a bond with younger children, some older
children, and especially adolescents, respond to this technique with suspicion or disinterest. Some children and adolescents experience the active, directive style of cognitive
behavioral therapy as an indication of the therapist's caring
(DiGiuseppe, 1981; DiGiuseppe & Bernard, 1983; DiGiuseppe, 1989). Actively helping children solve their problems may be an effective strategy for building rapport. It is
possible that attempts to foster a strong therapist-child relationship or bond, prior to, or in place of a clear explanation
of the goals and process of therapy, might be experienced as
manipulative by adolescent clients.
The child/adolescent psychotherapy literature displays
greater emphasis on techniques that build the therapeutic
bond than on techniques that foster agreement on goals or
tasks. Yet, in adult psychotherapy, the therapeutic relationship in and of itself, is not sufficient for successful treatment
outcome (Bordin, 1975; Marmar, Horowitz, Weiss, & Marziali, 1986). Research on the adult therapeutic alliance demonstrates that of the three components, the agreement on
tasks of therapy is the best predictor of treatment outcome
(Horvath & Greenberg, 1986). The primacy of the therapeutic bond in mediating a positive therapeutic outcome may be
overemphasized for children and adolescents.
Formulating Goals
To reach agreement on the goals of therapy, the initial
goals that motivated the referral must be explained to the
youngster. Adolescents often lack a clear picture concerning
why they are in therapy, since they are referred by their
parents and schools. Frequently the parents and/or therapist
may have treatment goals that differ from, or are in strong
opposition to, the child's goals. There is, therefore, a greater
likelihood that adolescents, as opposed to adults in therapy,
could disagree with their therapists on the goals of therapy
(Johnson, Rasbury, & Siegel, 1986).
The incompatibility of client-therapist goals may be
most problematic for traditional psychodynamic therapy.
Clear specification and explanation of goals are avoided in
many forms of child/adolescent psychotherapy because
goals in therapy are often determined by others, and therefore may be conflictual for the child/adolescent (HareMustin, Marecek, Kaplan, & Liss-Levinson, 1979;
Koocher, 1976; Weinberger, 1972). Many child/adolescent
therapists do not ask children to construct goals in therapy,
or they may suggest a vague or nonspecific goal such
as deeper self-understanding (Carek, 1979; Freud, 1964;
Tuma, 1983). Children in the concrete operations stage of
development tend to view causes of behavior as external,
situational, and singular, as opposed to resulting from inner

90

DiGiuseppe, Linscott, and Jilton

psychological constructs (Shirk, 1988). Given such cognitive limitations on their insight or self-understanding, it is
perhaps unrealistic to expect young children and adolescents to comprehend the goals of therapy as insight (Jurkovic & Ulrici, 1982; Nannis, 1988; Nuffietd, 1988; Shirk,
1988). Thus, there is a high probability that the techniques
of traditional child/adolescent therapy do not foster clear
agreement on goals.
In behavioral and family-oriented approaches to treatment, the child or adolescent is more likely to be aware of the
goals the therapist is working toward, since the goals are
more likely to be discussed. This does not ensure that the
child or adolescent client is in agreement with the goals,
because in both types of therapies the goals and tasks of
therapy are often chosen by either the parents or the therapist. The conceptual distinction between the roles of the
client and the customer reflect family systems theory's
awareness of such possible goal conflict (Haley, 1976;
Minuchin, 1974). Perhaps in behavioral and family therapies, in which the therapists' efforts are aimed less directly at
the child/adolescent and more directly at the larger parent]child or family systems, the therapeutic alliance formed
with the child/adolescent is less important to the success of
therapy than the therapeutic alliance established with the
parents.
Cognitive approaches to therapy suggest that goals be
discussed clearly and openly with the client and that the
child/adolescent's conceptualization of the target behavior
is important to explore. DiGiuseppe (DiGiuseppe & Bernard 1983; DiGiuseppe 1988; 1989) suggested that agreement on goals can often be achieved by an initial phase of
therapy that focuses on teaching alternative thinking and
consequential thinking skills about emotions. Helping the
children to explore the consequences of their behaviors and
emotions and alternative ways of feeling and behaving, can
help formulate the goals of therapy.

Understanding Tasks
There is little socialization of children and adolescents to
the activities expected in therapy, or on how these activities
are related to the goals of their therapy. Adults in our society have seen movies that portray the process of psychotherapy, or have friends who have participated in psychotherapy. The ideas of introspection, relaying dreams, and
expression of feelings as part of the process to attain treatment goals, are more familiar to adults entering psychotherapy. Adults also may hold implicit personality theories
that include experiences of what is necessary for change,
and therefore have some expectations as to what types of
activities will lead to behavior or emotional change. Children and adolescents are less likely to have any expectations
concerning the tasks of psychotherapy. Children and adolescents may lack any previous experiences to prepare them for
therapy. They may not understand that the behaviors the
therapist and the child engage in during their sessions are
related to accomplishing the goals of therapy. Children will

therefore be less likely to agree with and understand the

tasks of therapy than will adults.

The Importance of Understanding Therapy

Holmes and Urie (1975) demonstrated the beneficial effects of preparing children for psychotherapy. When children were given advanced explanations about the process of
therapy, and the opportunity to discuss these areas with the
therapist, premature termination was less likely (Holmes &
Urie, 1975). Remaining in therapy long enough for sufficient participation to occur is likely to increase the probability that the child or adolescent will benefit from psychotherapy (Holmes & Urie, 1975). Weithorn (1980) argued for
continued child participation in treatment decisions to enhance the child's motivation to achieve treatment goals.
One might conclude that the therapist's continued assistance
in focusing the child on the goals and tasks of therapy would
be beneficial.
Many articles on child and adolescent therapy attest to the
importance of developing a treatment contract with children
during the initial session(s) of therapy. Forming the treatment contract may include a discussion of goals and tasks
(Brooks, 1985; Johnson, Rasbury, & Siegel, 1986; Koocher,
1976; Tuma, 1983). It is unclear in many of these articles,
however, whether the discussion of goals and tasks is limited to the initial session(s) or continued throughout the
course of treatment. Setting clear goals for each session is a
crucial component of cognitive behavior therapies with
adults (Walen, DiGiuseppe, & Dryden, 1992). The same
strategy is recommended in cognitive behavior therapies
with children (Kendall, 1991; Linscott & DiGiuseppe,
1994). Traditional psychodynamic-oriented therapists appear to discuss goals only in the initial session and avoid
setting agendas for each session. Rather they leave the decision as to what will be done in the session to the needs of the
child or adolescent (Axline, 1947; Freud, 1964; Moustakas,
1953; Reisman, 1973).
Child/adolescent therapists need to provide a clearer explanation about how their techniques are designed to influence each element of the therapeutic alliance: goals, tasks,
and bond. It is also important that research evaluate whether
techniques actually influence the alliance and whether the
alliance is predictive of treatment outcome.

Treatment Manuals
Luborsky and DeRubis (1984) argued for the importance
of treatment manuals in psychotherapy research and the use
of such manuals are now standard practice in therapy outcome research. Manuals allow for clear specification of the
particular treatment method employed and of the exact techniques involved in performing the treatment. Shaffer (1984)
has called for the development of child treatment manuals in
accordance with trends in adult psychotherapy research.
Without treatment manuals it is difficult for child/adolescent
researchers and clinicians to know which specific treatment
methods have been subjected to research, and which tech-

Therapeutic Alliance

niques have been validated. Although there has been some

attempt to have child/adolescent therapists manualize their
treatments (Kendall et al., 1989; LeCroy, 1994) few treatment manuals exist for therapies with children and adolescents. A recent special section of Psychotherapy (1993,
Volume 30, Number 4) on psychotherapy treatment
manuals failed to include any article on child/adolescent
treatment. The type of specificity that is found in therapy
manuals is generally lacking in most texts on child-adolescent psychotherapy.
Although cognitive-behavior therapies appear to focus
more on the goals and tasks of therapy in each session and
throughout the session with children and adolescents, there
is no theory to describe when the therapist needs to spend
more time on building the alliance. Therapy manuals and
texts usually do not include specific steps to monitor either
the therapeutic alliance or continued discussion of the goals
and tasks of therapy when agreement on these aspects of the
alliance has not been reached.
Goal conflict. Many authors recognize the potential difficulty in goal setting and the frequent discrepancies between
parents and youngsters on the goals of therapy (Brooks,
1985; Koocher, 1976; Margolin, 1982; Johnson, Rasbury &
Siegel, 1986; Reisman, 1973; Weithorn, 1983; Weinberger,
1972). However, authors usually fail to provide strategies
for therapists to resolve such discrepancies. Some therapists
might not consider a concrete goal and may choose a goal
based on their own theoretical orientation. Others may
choose the parents' goals as targets for treatment, because
the parents are paying and must bring the youngster to
treatment. Ideally the therapist attempts to have the youngster and the parents reach a mutual decision concerning the
goals of therapy (Robin & Foster, 1989). Consensus on
strategies to resolve this issue are rarely discussed in the
literature and need further attention. When the child or adolescent disagrees with the parents' goals, however, the therapist must decide whose goals, the parents' or adolescent's,
will in fact serve the youngster's and family's best interests.
If the parents' goals are chosen, the therapist may need to
develop incentives for the adolescent to accomplish the parents' goals. If the parents' goals are not in the adolescent's
best interests, the therapist may need to recontract with the
parents to explore more appropriate goals for therapy. Research is lacking to assess which strategies are most effective in reaching agreement on the goals. Research on the
effectiveness of strategies to resolve goal conflict is needed
for this common problem in child/adolescent therapy.

Research on the Therapeutic Alliance with Adolescents

We recently developed a downward extension of Horvath's working alliance scale for children ages 11-18 years,
called the Adolescent Working Alliance Inventory (AWAIt;
1 Request for a revised version of the Adolescent Working Alliance
Inventory should be sent to the first author at Department of Psychology, St.
John's University, 8000 Utopia Parkway, Jamaica, New York, 11439.

91

Linscott, DiGiuseppe, & Jilton, 1993), which attempts to

measure the therapeutic alliance as conceptualized by Bordin
(1979) and defined above. Horvath's original items were
rewritten to lower the reading level for a younger audience.
To assess therapists' impressions of the alliance we used
Horvath's original therapists' form of the working alliance
inventory. Ninety adolescents and their therapists were administered the respective scales cross-sectionally in therapy.
The results indicated that the total scale score, agreement on
the goals scale, agreement on the tasks, and therapeutic bond
subscales all demonstrated adequate intemal consistency (oL
> .90). The factor analysis of the adult working alliance
measure yielded one general factor and three separate factors
for goals, tasks, and bonds. The adolescent sample yielded
one large first factor, labeled a general alliance factor. Three
other factors were present, but they did not represent any
consistent content area and accounted for small amounts of
the variance. Thus, the alliance for adolescents may be more
of a one-factor phenomenon. Younger patients may fail to
discriminate between the different aspects of the relationship. Support for this notion comes from our clinical experience with the AWAI, which indicates that failure to establish
one aspect of the alliance results in failure to establish it
entirely.
There were only moderate correlations between therapists' ratings of the alliance and the AWAI (averaging .40).
Although this correlation appears substantial, it is low considering it represents two people's impressions of the same
relationship in the same sessions. This result suggests that
therapists may not accurately judge the alliance they have
established with adolescents. Finally, therapists' ratings of
their therapeutic activities performed in therapy predicted
the alliance. Therapists' rating of more frequent use of silence, questions about feelings, and transference interpretations negatively predicted alliance (R -- -.47). This suggests that some therapeutic strategies may not be as efficient
as others at establishing the alliance. Although this research
represents an initial attempt to assess the therapy alliance in
adolescents more data are needed.

Strategies To Develop The Alliance

Emotional Scripts and Social Problem-Solving Skills

Humans have beliefs about the type and strength of emotions they are supposed to feel and beliefs about which
emotions are helpful or hurtful to themselves or to others.
Sociology of emotions provides some clues concerning the
cultural nature of these expectations and information on
when people may be motivated to change their emotions
(Abelson, 1981; deSousa, 1980; Fehr, & Russell, 1984;
Sabini & Silver, 1982; Tomkins, 1979; see Kemper, 1991
and Russell, 1991 for a review). Hochschild (1979) proposed a concept called emotional deviance, which represents a person's perception that the emotion experienced
differs from a socially prescribed, appropriate emotion.

92

DiGiuseppe, Linscott, and Jilton

Thoits (1985, 1989) proposed that people are motivated to

change their behavior, physiological reactions, situation, or
emotions when they experience emotional deviance. According to this theory, the recognition that one's emotional
reactions are inappropriate or socially unacceptable to a
situation is the primary motivation for emotional change.
Script theory maintains that individuals learn the scripts of
their culture and family. Individuals may have learned culturally unacceptable scripts, or failed to learn acceptable
scripts, or learned too few scripts because of deviant socialization though their family, clan, or subgroup. Children and
adolescents may arrive for therapy without having learned
that their emotional scripts are inappropriate, or they may
not have learned that there are alternative emotional scripts
to substitute for the dysfunctional ones they experience. We
have found the concept of emotional scripts helpful in building the agreement on the goals aspect of the therapeutic
alliance with children and adolescents.
The social problem-solving approach to adjustment is a
cognitive-behavioral therapy that asserts that maladaptive
behavior occurs because of a lack of problem-solving skills
(Spivack, Platt, & Shure, 1976). According to this view the
most important skills are alternative solution thinking and
consequential thinking. Alternative solution thinking is the
ability to generate possible behaviors to a situation before
deciding on a response. Consequential thinking is the skill
of evaluating one's behaviors before emitting them. Although most of the research in social problem solving has
focused on the generation of alternative behaviors and consequences of behaviors, DiGiuseppe (1981; 1989; 1995;
DiGiuseppe & Bernard, 1986; DiGiuseppe, Tafrate, &
Eckhardt, 1994) has suggested social problem-solving skills
can be applied to emotional scripts as well. Specifically,
children' and adolescents' lack of motivation in therapy
may occur because they fail to recognize and have not
learned the negative consequences or social unacceptability
of their disturbed emotional scripts. They may also fail to
conceptualize alternative emotional scripts to substitute for
their disturbed emotion. They may not recognize that the
consequences of an alternative script could be more beneficial to them than existing scripts.
Perhaps it is the processes of evaluating one's emotional
scripts and realizing that they are dysfunctional, and conceptualizing that a different emotional script is possible, that
moves one from the precontemplative stage of change to the
action stage. Adults may have more sophisticated and numerous schema for emotional scripts than they can possibly
experience in any situation. This may also help motivate
cooperation in therapy because adults are more likely to
conceptualize alternatives. Our clinical experience suggests
that children and adolescents have difficulty conceptualizing alternative emotional reactions. Change often seems impossible to them. The following case vignette is an example
of how these two elements interfered with agreement on the
goals and tasks of therapy.

Joe, a 10-year-old boy, was referred because of his angry

outbursts. During one session he reported being punished
by his parents because he hit his brother. Because we
were working on anger control we analyzed his beliefs in
this situation. In previous sessions, I had taught Joe how
thoughts influence feelings and how he could change his
feelings by challenging his thoughts. Joe was angry at his
brother for breaking his bicycle and independently identified his dysfunctional beliefs. "My brother should not
have broken my bike; I can't stand not having my bike."
He was unresponsive to my challenge of his irrational
beliefs, and responded: "What's the matter with you, you
want me to be happy about it?"
Joe knew that by challenging his beliefs I was attempting
to change his anger. If he were not angry, he could conceptualize only one alternative--happy. That alternative seemed
"crazy." Because Joe perceived no acceptable alternative
emotional scripts, he was not prepared to engage in tasks
designed to change his anger either to a less intense form of
anger or an alternative, more adaptive emotional script. To
Joe, his anger was the only appropriate emotion. Until Joe's
evaluations about his anger could be changed, and a viable
alternative emotional reaction considered, the goals and task
of therapy were unacceptable.
Several hypotheses relevant to the treatment of children
and adolescents follow from emotional script and social
problem-solving theories. First, children and adolescents
may have failed to recognize that their emotions are regarded as deviant in their culture or-have led to dysfunctional consequences. As a result, they fail to experience emotional deviance and do not wish to change. Second, children
and adolescents may not have learned from their families
the emotional scripts that guide the emotional reactions proscribed by the mainstream culture. Third, they may be surprised when they respond emotionally with a script proscribed by their family and these emotional reactions are
perceived as deviant by other adults. As a result they may
believe their emotional reactions are "invalidated" by the
adult world. Some support of the role of consequential
thinking in developing agreement on the goals of therapy
comes from the work of Prochaska et al. (1994). They
showed that for a sample of more than 3800 people with 12
different problem behaviors, the negative consequences of
changing their problems outweighed the pros of change for
people in the precontemplative stage of change. The opposite was true of peQple in the action stage of change. More
evidence is needed to ascertain whether changes in alternatives and consequences of behavior can lead to changes in
the therapeutic alliance.
Emotions that are disturbed and that may appear obviously unpleasant to therapists may be ambivalently or positively evaluated by young clients. If either of these is the
case, children and adolescents will not want to change their
emotions. The following clinical hypotheses follow from

Therapeutic Alliance

script theory and social problem-solving models for clients

who are unwilling to change:
Tasks designed to change emotions will be ineffective
if the child or adolescent maintains positive, neutral, or
ambivalent evaluations about his/her emotion and is
not committed to emotional change.
Children and adolescents have valuative cognitions
about their disturbed emotions. They may like them,
admire them, hate themselves for having them, or become resigned to them.
The evaluations children and adolescents have about
their emotions are multiple and sometimes inconsistent.
Children and adolescents will have expectancies o1:
which emotions people in their situation are supposed
to experience dependent on the emotional scripts they
have learned.
Children and adolescents who cling to affective states
that they label as negative may do so because they have
difficulty construing alternative, more functional emotions.
Children and adolescents will not feel an emotion that
they cannot conceptualize as an acceptable response to
a situation. If people do not possess a script for an
emotional reaction, they will not contract with a therapist to work at experiencing an emotional change.
Children and adolescents may need to be taught alternative emotional scripts before they agree on the goal of
change. The more emotional scripts the person is taught
the more likely they will be able to choose one that they
believe is appropriate to their subculture.

The Motivational Syllogism. After exploring the consequences of a youngster's emotional scripts and presenting
acceptable alternatives, the therapist can use these insights to
increase the child's or adolescent's motivation for change.
We call this technique the Motivational Syllogism. First, the
therapist Socratically explores the consequences that follow
whenever the client experiences the target emotion. Once the
child/adolescent agrees that it is in her/his best interest to
change her/his emotion, one moves to the second step of
helping clients generate alternative scripts. This step can
often be achieved by having the child or adolescent recall the
successful reactions of others whom they respect. This activity helps to generate a model for an alternative script. Youngsters from very dysfunctional families may have few such
models. The therapists may have to suggest models from the
general culture, the literature, folklore, or film of the client's
culture. After a model is chosen for an alternative script, it is
important to review the consequences of the model's behavior following the script. Next, the youngsters are asked to
imagine that they react in the same manner as the script and
imagine that the consequences happen to them. In this way
the youngsters can provide information on how they believe
the script may not be socially or personally acceptable to a

93

person in their situation. This process is repeated until the

client accepts the alternative emotional script. Third, the
therapist should explain the tasks that will be used to change
the target emotion or behavior to that of the new script. Once
the therapist and youngster have successfully accomplished
these steps, the therapist can continue with the treatment of
the child's or adolescent's anger. The therapist is free to
implement any strategy s/he and the client mutually agree
upon. The strategy suggested above may help motivate the
client to continue with therapy.
Before embarking on any therapeutic task the therapist
should review the Motivational Syllogism.
The first premise is: "My present emotional reaction is
dysfunctional."
The second premise is: "There is an alternative script
which is more functional for me."
The third premise is: "I can control which emotional
reaction I have to the activating event."
The conclusion is: "I need to examine ways in which I
can change my emotional reaction."
It is often helpful to quickly review the Motivational
Syllogism at the initiation of a discussion on a new anger
arousing event and at the beginning of each session. In this
way the child/adolescent is reminded of the previous points
that s/he and the therapist agreed upon earlier in therapy and
of the reason for the therapeutic task. Whenever a youngster
reports a new problem the therapist might respond by reviewing the Motivational Syllogism. By reviewing these
steps, it is hoped that the client is motivated to keep working
at anger control. The review can also be considered a restatement of the therapeutic alliance.
Disturbed yet desired emotions. Ellis (1983) suggested
that clients may "resist" the tasks of therapy because they
still believe that their emotions, which cause them so much
trouble, are actually desirable in some way. An alternative
therapeutic strategy is to discuss with clients their rationale
for believing that although the emotion in question is painful, it is beneficial in some way. Some clients claim that
the painful emotions they experience are desirable because
they motivate or cue them to behave in a certain way.
These clients may hold a false, unverified hypothesis, that
their disturbed emotions are necessary to maintain desired
behaviors or social status. For example, many angry adolescents we see maintain that they must get angry to show
others they will not be pushed around. They believe that
failure to display anger will result in increased attacks
from other adolescents. Such anti-empirical beliefs need to
be challenged before they will consider alternative emotional scripts. Therapists can proceed as they would in disputing any anti-empirical statement that is dysfunctional to
clients. The discussion could focus on furthering empirical
evidence for clients' hypotheses that disturbed emotions

DiGiuseppe, Linscott, and Jilton

94

have provided the motivation for functional behavior. Reviewing the consequences of clients' behaviors when they
experience disturbed emotions will usually bring up much
disconfirming evidence. Youngsters can be shown models
of others who behave in the desired manner but who do
not experience the disturbed emotions in question. These
models will help clients believe that less disturbed emotions can lead to desired adaptive behavior. Clients who
give up the ideas that maintain the emotion will be much
more willing to dispute the irrational ideas that generate
the emotion.

Motivational Interviewing
Treatment programs designed to work with clients with addictive behaviors may provide some insights into working
with youngsters who have not consented to change. Miller
and Rollnick (1991) developed an intervention program designed to build an alliance with clients with addictive behavior and maximize their motivation for change during the
initial sessions. The program, called "motivational interviewing," incorporates Prochaska and DiClemente's (1988)
model of change, and draws on principles of social, cognitive, and motivational psychology (i.e., Kanfer, 1987; Miller & Brown, 1991). Miller and Rollnick (1991) conceptualized addicts as receiving treatment in Prochaska &
DiClemente's precontemplative stage of change and as,
therefore, ambivalent about change. It follows, then, that the
therapist's task is to help move these clients toward the
contemplation of change and then to the action stage. Miller
and Rollnick contended that motivation for change is a
state, as opposed to a character trait, The will to change is,
therefore, dependent upon context. This is an important conceptual distinction, because it defines the therapist's task as
helping alter the client's interpersonal context in ways that
increase the probability for change.
If it is accepted that motivation is a context-dependent
state rather than a stable personality attribute, then the principles of motivational interviewing, which have found success with highly "resistant" clients (Miller & Rollnick,
1991), may be applied to other populations who are generally unmotivated for change. Specifically, children and adolescents who are not self-referred for treatment may contemplate positive changes if the motivational interviewing
approach is employed as a means of building the agreement
on the goals/tasks of the alliance. With this in mind, we will
summarize some of the general principles of motivational
interviewing and suggest how they might be applied with
adolescent clients.
Working with precontemplators. Miller and Rollnick
(1991) found that certain strategies in the initial phase of
therapy tend to either evoke resistance or circumvent it. The
key to successfully handling the patient's ambivalence begins with an assessment of his/her degree of motivation,
according to the stages of change model. Motivation is defined by this model as "the probability that a person will

enter into, continue and adhere to a specific change strategy." Therapists' interventions must be tailored to the client's current stage of motivation for change, and any attempt to work with the patient is likely to fail if the aims of
later stages are approached too early. For instance, jumping
to interventions aimed at action before the patient has resolved to change is likely to elicit resistance. Therapists are
often tempted to press the client for participation in tasks
beyond the client's present stage of change. Such action
may trigger psychological reactance as clients assert their
freedom against coercion.
The primary tasks of early therapy are to build an alliance
and motivate the client toward change. Therapists can accomplish this by raising doubts in clients' minds about the
undesirability of change. To do so, the therapist needs to
increase the client's perception of risks and problems regarding current behavior. More specifically, how to best
accomplish this may depend on the kind of precontemplator
the therapist is dealing with. Proschaska and DiClemente
(1986) described four types of precontemplation, which he
summarizes as the "four Rs": reluctance, rebellion, resignation, and rationalization.

Reluctant precontemplators simply do not want to change.

They may be unaware of the problematic nature of their
situation. Proschaska and DiClemente (1986) suggested that providing feedback in a sensitive empathetic
manner can be sufficient to motivate this group for help.
Many preadolescents fit in this category.

Rebellious precontemplators are invested in making their

own decisions, and are resistant to advice and direction
from others. These clients may appear hostile, argumentative, and oppositional to change. Clinical experience suggests that adolescents may be most likely to fit
the rebellious profile--presumably because a primary
focus of adolescence is the establishment of independence. Providing choices seems to be a successful
strategy for working with this type of precontemplator.
Carefully planned paradoxical interventions may also
be used with success.

Resigned precontemplators are remarkable for their lack

of investment and energy, and resignation to their
plight. Proschaska and DiClemente (1986) described
these clients as people who are overwhelmed, feel out
of control, and have given up hope for change. He
suggested that instilling hope and exploring barriers to
change are the most productive strategies for working
with this group. Such resignation may occur because
people fail to conceptualize alternative scripts for
change. Children and adolescents with primary or comorbid depression often fit this pattern.

Rationalizing precontemplators have a storehouse of reasons why the problem is not a problem, or why it may be
a problem for others but not for them. Interviews with

Therapeutic Alliance

this type of client may begin to feel like debate sessions.

They are distinguished from rebellious clients in that
their resistance is more intellectual than emotional. Discussion of the problem can sometimes lead to strengthening their side of the argument, so Proschaska and
DiClemente (1986) advised empathy and reflective listening as the best strategies for these clients. He also
advocated double-sided reflection (i.e., explicitly reviewing both sides of the argument for the client without
taking sides).

Building the alliance through motivational interviewing. With adults, research shows that the quality of the
therapeutic alliance tends to stabilize by the third or fourth
sessions and is predictive of retention and outcome (Horvath
& Luborsky, 1993). Although these results have not been
duplicated with adolescents, there is little reason to believe
that the results are different. Our preliminary results with the
AWAI suggest this is the case. The job of the therapist is to
raise the client's doubt about the undesirability of change by
increasing the client's perception of risks and problems related to current behavior and having them focus on the
advantages of alternatives. Early strategies of motivational
interviewing emphasize techniques for building such a positive relationship. These strategies include:
1. Providing an explanation of the s~ucture of the therapy, including a description of the roles of the therapist
and client and the goals of the therapist.
2. Asking open-ended questions or Socratic questioning
that allow the client to do most of the talking.
3. Reflective listening to open-ended questions is an important ingredient of motivational interviewing, and,
according to Miller and Rollnick, constitutes a substantial portion of therapists' responses during the early phase of therapy. Therapists should selectively reflect the clients' answers to emphasize and reinforce
any aspects that reflect movement toward change. For
instance, self-motivational statements that express a
desire to change, negatives about the target behavior,
or advantages of alternatives should be reflected, so
that the clients hear their own statements twice.
4. Affirming and complimenting clients for their efforts
and expressing understanding for their problems.
5. Therapists should express empathy, avoid argumentation, support self-efficacy, and roll with resistance as
much as possible. By the latter, it is meant that the
therapist should treat the client's resistance as natural
and understandable and avoid attempts to impose new
views or goals. Instead, the therapist should involve
the client actively in the process of problem solving.
6. It is important to get clients to present the arguments
for change. To this end, Miller and Rollnick emphasized the importance of eliciting self-motivational
statements. Self-motivational statements include rec-

95

ognition of a problem, expression of concern about

problems, intention to change, and optimism about
change. Eliciting such statements can be accomplished
in several ways. Therapists can offer verbal and nonverbal reinforcement of spontaneously offered selfmotivational statements, followed by questions that
encourage elaboration on the motivational topic. Clients can also be asked to describe the extremes of their
concerns, such as imagining the worst consequences
that could ensue if they don't change, and to envision
a changed future and talk about how things might be
after change.
7. The clarification of goals is an important facet of increasing clients' motivation for change, according to
the model. These goals should be the client's own, and
should be realistic and obtainable. An exploration of
the individual's values can be a preliminary step toward setting goals and can also help the client discover ways in which the problem behavior is inconsistent
with, or undermines, these values. The exploration of
goals is important to alliance building, but it is also a
strategy that allows for a discrepancy to be elucidated
between the client's own goals, the present problem
behavior, and the goals of the referring agent.
While exploring goals, it is helpful for the therapist to
summarize and link material that has been discussed, especially the client's self-motivational statements. This strategy
often includes helping clients express their ambivalence. It
can even be helpful to have clients discuss the positive as
well as the negative aspects of their present behavior and
draw up a balance sheet to allow them to see the full picture
of their ambivalence. Table 1 summarizes some of the do's
and don'ts of working with resistant clients.
Miller and Rollnick suggested therapists should avoid
asking a series of questions to which the client can give
short, unelaborated answers, and should also avoid confronting clients by defining their problems for them or labeling them. This usually leads to the client's denial or minimization of the problem. Similarly, therapists should avoid
blaming clients for their difficulties, or focusing on conceres different from those that the client first presents. Finally, the therapist will work most effectively with resistance if he or she relinquishes the role of expert advisor to a
passive recipient, and instead helps clients to explore and
resolve ambivalence for themselves.
The principles of motivational interviewing seem relevant to psychotherapy with children and adolescents. Research is needed to ascertain which motivational interviewing strategies may be more or less effective with clients of
different ages. Adolescents are likely to be rebellious precontemplators because they are in a stage of development
that centers around the establishment of independence.
Younger children may be reluctant precontemplators who
have never considered their situation.

96

DiGiuseppe, Linscott, and Jilton

Table 1. Do's and Don'ts of Working with Treatment Resistant Clients

Do

Don't

Express empathy.
Support self-efficacy.
Roll with resistance.
Stay with the client's concerns.
Explore the consequence of the clients behaviorand emotions.
Explore the alternativeemotionalreactions the client could experience.
Explore acceptablemodelswho displaymore adaptivebehaviorand emotions.
Explore the possibleconsequences of alternative reactions.
Collaborativelyexplore the resistance.

Dealing with Ambivalence

Another group who has addressed the issue of dealing with
unmotivated clients is Milton Erickson and the strategic
family therapists, including Haley, Maddanes, and the Mental Research Institute (MRI) group. Consistent in the work
of these therapists are the notions that resistant clients may
be ambivalent and struggling with two parts of themselves.
One side that would like to change, and another side that
feels attached to the status quo for a variety of reasons.
Because of psychological reactance--the client's natural
desire to reassert his/her freedom--if the therapist pushes
for change the individual will move to align with the static
side of the ambivalence. However, if the therapist does not
take sides, or even aligns with the change-resistant side of
the person, the person will be more likely to begin to argue
for change. Paradoxical directives take advantage of this
psychological phenomenon. In general, techniques that
work with resistant clients will be ones that give clients the
opportunity to make choices and participate in decision
making. Perhaps the mechanism of paradox is that the client
is given permission to experience the target behavior and in
so doing evaluates the advantages and disadvantages for the
first time.
Therapy with unmotivated adolescents is not qualitatively
different from that of other resistant clients, although some
special considerations may be in order. Tober (1991)
pointed out that the progress of adolescents in treatment
may be hindered by a sense of low self-esteem and low selfefficacy. These may result from the realistic perception that
their views and desires are often not considered in decisions
that affect them. Secondly, they may have negative reactions to authority figures because of expectations of disapproval and punishment. In working with adolescents, then,
it is helpful to use the sessions to empower the young person
by enhancing their sense of choice and self-esteem. Finally,
the problematic behaviors for which they were referred often fall within the norms of a peer subculture. Rather than
fall into the trap of arguing against these norms, the therapist must focus on the unique circumstances and selfidentified problems of the client, and acknowledge the ado-

Argue with the client.

Get into the question/short answer trap.
Tell client what their problem is.
Blame clients.
Move beyond the client's stage of change.
Assume the referral agents view is the child's view of the problem.
Institute a task without explaining its goals and activities.
Remain silent and wait for the client to talk.
Take the role of expert.

lescent's conflict that his/her behavior is censured by some

and approved by others.
The following strategies serve to illustrate the principles
used by strategic therapists to work with unmotivated clients:
Getting the problem mentioned by the client first (e.g., by
asking for other people's perceptions of the situation).
Eliciting the client's spontaneous expression of concern
about the problem, and then focusing on this immediately.
Dealing with the client's resistance by reinforcing the
expression of concern about the problem, but ignoring
the expressions of denial.
Exploring whether the client has other concerns about the
problem.
Summarizing the concerns, emphasizing the negative
side first, and de-emphasizing the positive.
Strengthening the client's perception of the problem (i.e.,
identifying the conflict about the problem and strengthening the perception of this conflict). The decisional
balance sheet is good for this.
Building up motivation for change, while expressing empathy and concern.
Eliciting expression of desire to change, while bolstering
self-esteem and self-efficacy (throughout the whole
process).
Developing a strategy for change and taking an active
helping role as mediator, arranging social supports,
counseling parents, etc. Suggestions should be concrete, obtainable, etc.
Fostering the notion that clients are responsible for their
behavior and choices.

Attachment and the Alliance

A question that we have pondered concerning our technique is "what develops the therapeutic bond?" Many thera-

Therapeutic Alliance

pists believe that one must develop a bond before engaging

in therapy techniques. A common notion is that children
form working models of their relationships with attachment
figures, which reflect their relationship with caregivers
(Bowlby, 1973). The warm, accepting, genuine reflections
of therapists change the clients scheme of attachment objects. Accepting, reflective attitudes of therapists work to
change such schemes. Although this may in fact be the case,
building agreement on goals and tasks may also lead to a
positive bond and a similar change in the attachment
scheme. Perhaps therapists' seeking children's agreement
on the goals demonstrates respect for them that they have
not previously experienced. Therapists' attempts to help clients assess their best interests communicates a concern that
may not have been previously experienced. We are now
collecting data on the use of a revised version of our AWAI
with adolescents across therapy sessions. The one lesson we
have learned from the analysis of 10 cases is that the alliance appears to be established early, and that therapists can
do very different things and still develop a good alliance.
The proposals offered here are but one way to build an
alliance. The field has suffered from proposals concerning
the "right" way to do things. We remain convinced that
there are numerous paths to a successful alliance and.
Summary
We make the point that child and adolescent psychotherapy
differs significantly from adult psychotherapy because the
client is not self-referred. Most, if not all child and adolescent clients, enter in the precontemplative stage of change.
As a result child and adolescent psychotherapy is much like
therapy with other groups who are resistant to treatment. It
is suggested that the tripartite model of the therapeutic alliance maybe helpful in conceptualizing the difficulties encountered in child/adolescent psychotherapy. Youngsters
are much less likely to reach agreement on the goals and
tasks of therapy than adult psychotherapy clients. The traditional approaches to child and adolescent psychotherapy
appear designed to build the therapeutic bond and may not
address significant attention to reaching agreement on the

97

goals and tasks of therapy. It is suggested that the problem

for child/adolescent psychotherapy is to address the difficulty of failure to reach agreement on the goals and tasks of
therapy. Three approaches to this problem have been suggested: a combination of emotional script theory and social
problem-solving skills training, motivational interviewing,
and strategies for overcoming resistance from strategic therapy. The first strategy focuses on the content of what children and adolescents may or may not think about their
emotions and behavior, and teaching them the skills to evaluate the consequences of emotional scripts and the teaching
of new scripts. The second strategy, motivational interviewing, focuses on differentiating the responses of the client
based on a topology of precontemplators. These strategies
appear to shape a negative evaluation of the target behavior
through Socratic interviewing and selective verbal reinforcement of comments suggesting the desirability of
change. The third strategy, strategic therapy techniques focus more on the reactance of the clients helping the clients
evaluate the desirability for change themselves, not as a
submission to authority. These three models are not mutually exclusive and in fact, seem to share much. It appears to
us that approaches to deal with resistance and reach agreement on goals involves strategies that focus the client on
evaluating the consequences of the target behavior and the
consequences of alternatives. This appears to be a common
mechanism for the three strategies suggested here. Research
is needed to confirm that such problem-solving cognitions
are the mechanism of change.
Clinically, combinations of all three strategies may be
used by therapists to help form an alliance with children and
adolescents. Therapists need to quickly assess the nature of
the clients' lack of motivation and determine which strategy
is most appropriate.
Research is needed on the effectiveness of different techniques in the development of the therapeutic alliance. It is
suggested that treatment manuals based on these three approaches be constructed and tested to assess the success of
these concepts in building the therapeutic alliance in children and adolescents. It is hoped that these suggestions will
lead to more effective therapy outcomes.

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