112,99 €
Mehr erfahren.
- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
The most comprehensive textbook on the theory, research, and practice of child and adolescent therapy
Child and Adolescent Therapy: Science and Art is a unique textbook that introduces readers to all the major theoretical orientations (CBT, family systems, etc.) and applies them to the common diagnostic categories (anxiety, disruptive behavior, etc.). Rather than championing one therapeutic approach above the others, it identifies the strengths and applicability of each, with an emphasis on matching strategies to client needs and preferences. The central theme is the integration of outcome research and clinical reasoning to choose techniques and personalize counseling for each client. The vast literature on therapy outcomes is distilled into user-friendly summaries with clear conclusions and implications for treatment planning.
The book models the thought processes of expert clinicians as they integrate theoretical principles, research findings, and observations of clients in real time to conceptualize cases, make clinical decisions, and decide what to say next. Theoretical concepts, empirically supported treatments, and best practices are translated into numerous examples of therapist statements and conversations between counselor and client. Unlike edited books with chapters by different authors, this work is an integrated whole, with connections between chapters, a building block approach to learning, and unifying themes developed throughout the book.
The Third Edition has been thoroughly updated to reflect current research and clinical advances. It features new material on:
- The Internal Family Systems therapeutic model
- Modular psychotherapies
- Transdiagnostic approaches
- Head-to-head comparisons between empirically supported therapies
This textbook offers a thorough and practical introduction for graduate students in psychology, counseling, and social work. It also serves as a valuable resource for practicing mental health professionals who want to fill gaps in their knowledge, catch up with the outcome research, and learn new techniques. Purchasers get access to a companion website where they can download therapy handouts; instructors can also download teaching materials such as questions for discussion and exam questions.
Sie lesen das E-Book in den Legimi-Apps auf:
Seitenzahl: 1609
Veröffentlichungsjahr: 2025
Ähnliche
Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
Preface
Acknowledgments
Abbreviations Used in Multiple Chapters
Introduction: Integrating Science and Art in Therapy
About the Companion Website
PART I:
THE TOOLS OF THE THERAPIST
1 Therapy Fundamentals
The Therapeutic Orientation Toward Clients
Getting Started
Basic Child Therapy Skills
Overcoming Obstacles to Client Engagement
Motivational Interviewing
Simple Therapeutic Interventions
Therapeutic Collaborations
Termination
Summary
2 Behavior Therapy
Learning Theory
Assessment and Case Formulation
Change Processes
Outcome Research
The Therapist's Style
Exposure
Contingency Contracting
Relaxation Training
Social Skills Training
Summary
3 Cognitive Therapy
Cognitive Theory
Assessment and Case Formulation
Change Processes
Outcome Research
The Therapist's Style
Self‐Monitoring
Self‐Instruction
Self‐Reinforcement
Socratic Questioning
Cognitive Restructuring
Tests of Evidence
Personal Experiments
Using Spectrums to Develop Moderation
Summary
4 Mindfulness‐Based Cognitive‐Behavioral Therapies
Mindfulness and Psychotherapy
Assessment and Case Formulation
Change Processes
Outcome Research
The Therapist's Style
Mindfulness Training Exercises
Dialectical Behavior Therapy Implementation
Acceptance and Commitment Therapy Implementation
Summary
5 Psychodynamic Therapy
Psychoanalytic Theory
Assessment and Case Formulation
Change Processes
Outcome Research
The Therapist's Style
Facilitating the Expression of Material
Interpretation and Insight
Dynamic Psychoeducation
Corrective Emotional Experience
Summary
6 Constructivism
Postmodernism and the Social Construction of Reality
Assessment and Case Formulation
Change Processes
Outcome Research
The Therapist's Style
Solution‐Focused Techniques
Narrative Therapy Techniques
Summary
7 Family Systems Therapy
Systems Theory
Assessment and Case Formulation
Change Processes
Outcome Research
The Therapist's Style
Combining Family and Individual Modalities
Facilitating Communication
Systemic Insight
Reframing
Treating Enmeshment and Disengagement
Therapist Directives
Treating Positive Feedback Loops
Summary
8 Atheoretical and Transtheoretical Techniques
Miscellaneous Techniques
Parent Counseling
Balance Between Extremes
Psychoeducation
Values in Psychotherapy
Incorporating Experiences into New Structures of Meaning
Overcoming Fear of Failure
Summary
PART II:
THE NEEDS OF CLIENTS
9 Cultural Factors in Therapy
The Role of Culture in Psychotherapy
Assessment
Treatment Planning
The Therapist's Style
Connecting the Cultures of Therapy and Client
Managing Conflicts Between Client Cultures and the Predominant Culture
Addressing Prejudice and Discrimination
Bringing Spirituality into Therapy
Summary
10 Disruptive Behavior in Children
Diagnoses Treated in This Chapter
Clinical Presentation and Etiology
Assessment
Treatment Planning
Behavioral‐Systemic Parent Training
Collaborative Problem‐Solving
Individual CBT With the Child
Psychodynamic Therapy
Summary
11 Disruptive Behavior in Adolescents
Diagnoses Treated in This Chapter
Clinical Presentation and Etiology
Assessment
Treatment Planning
Behavioral‐Systemic Therapy
Psychodynamic Therapy
Parent Counseling
Summary
12 Aggression and Violence
Diagnoses Treated in This Chapter
Clinical Presentation and Etiology
Assessment
Treatment Planning
Addressing Decisions About Fighting
Violent and Peaceful Foundations of Self‐Esteem
Bullying
Cognitive‐Behavioral Therapy
Psychodynamic Therapy
Systems‐Oriented Intervention
Summary
13 Anxiety
Diagnoses Treated in This Chapter
Clinical Presentation and Etiology
Assessment
Treatment Planning
Cognitive‐Behavioral Therapy
Psychodynamic Therapy
Parent–Child Work
Summary
14 Depression
Diagnoses Treated in This Chapter
Clinical Presentation and Etiology
Assessment
Treatment Planning
Special Topic: Suicide Risk
Cognitive‐Behavioral Therapy
Psychodynamic Therapy
Systemic Intervention
Summary
15 Stress and Trauma
Diagnoses Treated in This Chapter
Clinical Presentation and Etiology
Assessment
Treatment Planning
Cognitive Behavioral Therapy
Coaching Clients in Coping
Psychodynamic Therapy
Constructivist Therapy
Systems‐Oriented Intervention
Therapy for Parental Divorce
Therapy for Bereavement
Therapy for Sexual Abuse
Summary
Afterword: The Therapist’s Experience
References
Index
End User License Agreement
List of Tables
Chapter 1
Table 1.1 Eric's Therapy Prescription
Table 1.2 Examples of Therapy Goals
Table 1.3 A Simple Therapeutic Plan
Table 1.4 Types of Work With Parents
Chapter 2
Table 2.1 Mechanisms Through Which Consequences Influence Behavior
Table 2.2 Four Stages of Behavioral Skills Training
Chapter 3
Table 3.1 Questions for Assessing Client Cognitions
Table 3.2 Examples of Common Cognitive Distortions
Table 3.3 Vance's Daily Thought Record
Table 3.4 Socratic Questions
Table 3.5 Questions for Assessing Client Cognitions
Table 3.6 Example of a Test of Evidence
Chapter 4
Table 4.1 Distress Tolerance Techniques
Chapter 5
Table 5.1 Common Defense Mechanisms
Chapter 6
Table 6.1 Questions for Constructing the Externalization Metaphor
Chapter 8
Table 8.1 Problems and Frameworks of Meaning Into Which They Can Fit
Chapter 9
Table 9.1 Components of Culturally Competent Practice
Table 9.2 Questions for Cultural Assessment
Chapter 10
Table 10.1 Sequence of Parent–Child Interaction in Disruptive Behavior Diso...
Table 10.2 Principles of Parent Training Programs
Table 10.3 Guidelines for Effective Commands
Table 10.4 The Time‐Out Procedure
Table 10.5 The Problem‐Solving Procedure
Table 10.6 Key Concepts in Treatment of Disruptive Behavior Disorders
Chapter 11
Table 11.1 Motivational Versus Capability‐Related Factors in Conduct Distur...
Table 11.2 Characteristics of Effective Rules and Consequences
Table 11.3 Example Point System
Chapter 12
Table 12.1 Negative Consequences of Winning Fights
Table 12.2 Sequence of Violence Prevention Strategies
Table 12.3 Ambiguous Situations
Table 12.4 Plausible Attributions for Table 12.3's Ambiguous Situations
Table 12.5 Fair and Unfair Behavior in Conflicts
Table 12.6 Translating Criticisms of Personality into Criticisms of Behavio...
Chapter 13
Table 13.1 The Four Dimensions of Anxiety
Table 13.2 When to Use Different Cognitive‐Behavioral Techniques for Anxiet...
Chapter 14
Table 14.1 Four Dimensions of Depression
Table 14.2 Differences Between Depressive and Coping Cognitions
Table 14.3 Terriana's Pleasant Activities Schedule
List of Illustrations
Chapter 1
Figure 1.1 Common therapeutic sequences.
Chapter 2
Figure 2.1 Example of a behavior chart.
Figure 2.2 Example of a daily behavior chart for teachers.
Chapter 3
Figure 3.1 The ABCs of emotion.
Figure 3.2 Hierarchical structure of cognitions in reaction to events.
Figure 3.3 Example of a diagram used in cognitive restructuring.
Chapter 6
Figure 6.1 Felicia's first story.
Figure 6.2 Example of a story written at the conclusion of therapy.
Figure 6.3 Example of a graduation diploma.
Chapter 7
Figure 7.1 A four‐person system.
Figure 7.2 Nicolle's genogram.
Figure 7.3 Diagram of a positive feedback loop.
Chapter 8
Figure 8.1 Dimensions of functioning.
Figure 8.2 Balancing the needs of self and others.
Figure 8.3 Distress as a temporary part of a positive whole.
Figure 8.4 Short‐term failures within a process of long‐term success....
Chapter 11
Figure 11.1 Jack's rules and consequences.
Figure 11.2 A simple behavior contract.
Chapter 14
Figure 14.1 Example of a suicide prevention contract.
Figure 14.2 Example of a responsibility pie.
Guide
Cover Page
Title Page
Copyright Page
Preface
Acknowledgments
Abbreviations Used in Multiple Chapters
Introduction: Integrating Science and Art in Therapy
About the Companion Website
Table of Contents
Begin Reading
Afterword
References
Index
WILEY END USER LICENSE AGREEMENT
Pages
iii
iv
xi
xii
xiii
xv
xvii
xviii
xix
xx
xxi
xxii
xxiii
xxv
1
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
376
377
378
379
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
426
427
428
429
430
431
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448
449
450
451
453
454
455
456
457
458
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
477
478
479
480
481
482
483
484
485
486
487
488
489
490
491
492
493
494
495
496
497
498
499
500
501
502
503
504
505
506
507
508
509
510
511
512
513
514
515
516
517
518
519
520
521
522
523
524
525
526
527
528
529
530
531
532
533
534
535
536
537
538
539
540
541
542
543
544
545
546
547
548
549
550
551
552
553
554
555
556
557
558
559
560
561
562
563
564
565
566
567
568
569
570
571
572
573
574
575
576
577
578
579
580
581
582
583
584
585
586
587
588
589
590
591
592
593
595
596
597
598
599
600
601
602
603
604
605
606
607
Child and Adolescent Therapy
Science and Art
Third Edition
Jeremy P. Shapiro
This edition first published 2025© 2025 John Wiley & Sons, Inc.
All rights reserved, including rights for text and data mining and training of artificial intelligence technologies or similar technologies.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per‐copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750‐8400, fax (978) 750‐4470, or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748‐6011, fax (201) 748‐6008, or online at http://www.wiley.com/go/permission.
The manufacturer’s authorized representative according to the EU General Product Safety Regulation is Wiley‐VCH GmbH, Boschstr. 12, 69469 Weinheim, Germany, e‐mail: [email protected].
Trademarks: Wiley and the Wiley logo are trademarks or registered trademarks of John Wiley & Sons, Inc. and/or its affiliates in the United States and other countries and may not be used without written permission. All other trademarks are the property of their respective owners. John Wiley & Sons, Inc. is not associated with any product or vendor mentioned in this book.
Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
For general information on our other products and services or for technical support, please contact our Customer Care Department within the United States at (800) 762‐2974, outside the United States at (317) 572‐3993 or fax (317) 572‐4002.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic formats. For more information about Wiley products, visit our web site at www.wiley.com.
Library of Congress Cataloging‐in‐Publication DataNames: Shapiro, Jeremy P., author.Title: Child and adolescent therapy : science and art / Jeremy P. Shapiro.Description: Third edition. | Hoboken, NJ : Wiley, 2025. | Includes bibliographical references and index.Identifiers: LCCN 2024039539 (print) | LCCN 2024039540 (ebook) | ISBN 9781394230716 (hardback) | ISBN 9781394230747 (adobe pdf) | ISBN 9781394230730 (epub)Subjects: MESH: Psychotherapy–methods | Mental Disorders–therapy | Treatment Outcome | Child | AdolescentClassification: LCC RJ504 (print) | LCC RJ504 (ebook) | NLM WS 350.2 | DDC 616.89/140835–dc23/eng/20241101LC record available at https://lccn.loc.gov/2024039539LC ebook record available at https://lccn.loc.gov/2024039540
Cover Design: WileyCover Image: © Triff/Shutterstock
Preface: The Therapist’s Challenge
The purpose of this book is to equip readers with the knowledge and skills to provide effective psychotherapy to children and adolescents. I aim to provide an understanding of the major theoretical approaches, knowledge about the findings of outcome research, training in a variety of therapeutic techniques, and lots of good words to say to young people and their parents. This is an academic text and a how‐to book in which intellectual rigor and practical application are viewed as equally important, complementary objectives. The goal is to articulate the knowledge base and thought processes of skilled therapists making scientifically and clinically well‐informed decisions about what to do when. Thus, the book is about theory, etiology, change agents, technique, meta‐analysis—and what to say to the kid.
When our field was young at the beginning of the 20th century, psychotherapy was called “the talking cure,” and this description is still accurate. Therapy is not alone in its purposeful use of conversation, and people have sought help by talking to trusted relatives, friends, and clergy for far longer than counseling has existed. But therapy is also a professional service, and to justify the remuneration we receive, counselors should be able to provide forms of help that laypeople cannot reliably offer. There needs to be something different about our talk.
Psychotherapy fulfills a distinctive and rather remarkable function in our society. When something goes wrong with our cars, we go to automobile mechanics to fix them. When something goes wrong with our bodies, we go to physicians for treatment. When something goes wrong with our emotions or behavior, society recognizes psychotherapists as the people to call for help with these central aspects of self.
The trust that parents and children demonstrate by coming to us for help imposes an important responsibility. They are generally willing, just moments after meeting a stranger, to disclose important, painful, and, perhaps, embarrassing aspects of their lives, sometimes revealing things they have never told anyone before. They do this because the stranger sitting in front of them has a license indicating her commitment and ability to respond helpfully to this type of disclosure. It is an honor and a privilege to work with children and families on the most personal aspects of their lives, and, to be worthy of this trust, we must do our best not to let our clients down.
Language is the main tool of the therapy trade. Although play and artistic activities sometimes supplement verbal communication with children, and our talk often refers to actions, for the most part the work of therapy consists of a search for good words. Physicians have their laboratory tests, radiological devices, medicines, and surgical instruments—we have our words. At first, this might be an intimidating thought, because we are up against a lot. The causes of mental health problems include genetic vulnerabilities, neurobiological dysfunction, poverty, racism, family discord, trauma, maladaptive learning histories, and so forth. By the time a child becomes a therapy client, factors like these may have operated in his life day after day, month after month, for years. Confronted with forces like these, words might not seem like much.
When I was a graduate student in my first clinical placement, a client with severe problems resisted my invitation to therapy on the grounds that, “I don't see how talking about it will help.” I did not have an adequate response. In fact, I was frightened that the young man might be right, and talking about his unhappy life would do nothing to make it better.
I panicked prematurely. As discussed in the outcome research sections of the chapters to follow, psychotherapy is usually an effective means of treating emotional and behavioral problems. During the past 100 years or so, clinicians and researchers have developed a number of methods that, for most clients, are at least moderately helpful. In a sense, this book represents a long, detailed response to my fear that therapy (i.e., mere talk) might be too weak and vague an activity to overcome the causes of mental health problems. The therapist’s challenge is a daunting one, but most of the time it can be met. Talking about problems—in certain, specific ways—really can help. The chapters that follow describe these ways.
The website associated with this book includes a number of forms and handouts that therapists can use with clients. The forms can be printed out as they are, or you can modify the documents to customize them for particular clients. The web address is http://www.wiley.com/college/shapiro.
Acknowledgments
A number of people made important contributions to this book. My coauthors for the first edition, Robert Friedberg and Karen Bardenstein, provided a great deal of fine material that remains in this third edition, and I greatly appreciate their clinical knowledge and acumen. I thank Shira Wiesen, Nora Feeny, Rebekah Dorman, Karen Tucker, Tim Gesing, Sarah Dickman, and Rebecca Lord for specific suggestions that I incorporated into the text. I am particularly indebted to Amy Murrell, who spent hours on the phone with me explaining the fine points of Acceptance and Commitment Therapy with children. My editor and copy editors at John Wiley & Sons, Darren Lalonde, Janaki Kumudam Gothandaraman, and Shakila Suresh provided valuable help with the writing process. I also thank Katherine McRaven for her meticulous work in helping me prepare the manuscript.
On a more personal level, I want to express deep gratitude and appreciation to my wife, Nancy Winkelman, who provided endless patience and support during the long process of writing the book. I also want to honor the memory of my parents, Felicia and Jack, who were the source of my energy for learning and thinking that culminated in this book.
Abbreviations Used in Multiple Chapters
ACT:
Acceptance and Commitment Therapy
AHDH:
Attention Deficit Hyperactivity Disorder
APA:
American Psychological Association
CBCL:
Child Behavior Checklist
CBT:
Cognitive‐Behavioral Therapy
DBT:
Dialectical Behavior Therapy
DSM‐5‐TR:
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Training Revision
EBP:
Evidence‐Based Psychotherapy
ES:
Effect Size
HPA Axis:
Hypothalamic‐Pituitary‐Adrenal Axis
IFS:
Internal Family Systems
JCCAP:
Journal of Clinical Child and Adolescent Psychology
ODD:
Oppositional Defiant Disorder
PTSD:
Posttraumatic Stress Disorder
RCT:
Randomized Controlled Trial
TAU:
Treatment as Usual
Introduction: Integrating Science and Art in Therapy
The purpose of this Introduction is to explain how to use this book as a guide for conducting psychotherapy with children and adolescents. To fulfill this purpose, a larger issue must be addressed: The relationship between books about therapy and therapy as it is practiced in the “real world.” This relationship is not simple; there are discrepancies between the two.
I want to minimize these discrepancies, but they cannot be reduced to zero, because for textbooks to be useful to readers, they must be simpler and more coherent than the realities they describe. (This is true in all fields, not just ours.) If you understand the differences between this book and the reality of psychotherapy, you will not be misled by the ways I have simplified and or ganized the presentation for the sake of accessibility.
Our field is organized mostly in terms of theoretical orientations: behavioral, psychodynamic, and so forth. The way to learn how to do therapy is to learn these treatment approaches, and that is how Part I of this book, The Tools of the Therapist, is organized. The major approaches each have their own chapter, and they are presented as distinct, separate, and self‐contained. However, this method of presentation is a teaching strategy more than a reflection of how therapists actually work. Some practitioners adhere to a single theoretical orientation, but most are eclectic, drawing on techniques from multiple theories (Tasca et al., 2015; Thoma & Cecero, 2009). Eclecticism would make no sense if one or two therapeutic approaches stood head and shoulders above the rest, but as discussed ahead, this is not the case.
For ease of communication, this book has many sentences taking the form, “Cognitive therapists do this,” and “Solution‐focused counselors believe that,” as if these terms referred to different groups of people. To some extent they do, but mostly these terms refer to clinicians using particular strategies at certain points in time. In other words, one can be a systems‐oriented therapist at the beginning of a session, a behaviorist in the middle, and a narrative therapist at the end; there is no contradiction in this. Theoretical orientations can be like hats we put on and take off at different points in our sessions, hopefully determined by client needs and therapeutic opportunities. Also, therapeutic approaches can be blended by working multiple change processes at the same time. Nonetheless, Part I does not present the major theories this way but, for ease of comprehension, describes them in their pure forms, unmixed with other theories.
Theoretical orientations are the primary colors of psychotherapy. Just as painters mix a few primary colors to create every possible hue, clinicians mix treatment approaches to create the variety of technique combinations we provide to clients. Part I of this book presents these therapeutic primary colors, and in Part II we do some mixing, matching, and blending.
Part II, The Needs of Clients, is organized mostly in terms of diagnostic categories—another simplification. Many medical diagnoses are objective and definite, with clear boundaries between them, and they usually provide information about etiology—factors causing or maintaining disorders—which is what we really want to know. However, this is generally not the case in the mental health field. When our diagnoses are examined empirically, the boundaries between them turn out to be poorly defined, in that many clients have symptoms of multiple diagnoses, there is much heterogeneity within diagnoses, and clients can have the same symptoms for different reasons, so diagnosis provides little information about etiology (Essau & de la Torre‐Luque, 2019; Kotov et al., 2017). Nonetheless, we need shorthand terms to convey information quickly, if roughly, and diagnoses fulfill this function.
The Power and Limitations of Outcome Research
One central goal of this book is to help readers combine knowledge of research findings with clinical reasoning to plan therapy and, on a micro level, decide what to say next. But first, it is worth asking why the development of this difficult skill is even necessary—wouldn’t it be more reliable simply to use outcome research to plan therapy with each client?
In general, scientific research is the most reliable known method of producing knowledge about the natural world, which includes human beings, our problems, and ways to alleviate them. Nonetheless, therapy outcome research, in its current stage of development, has some major limitations as a basis for treatment planning. We need to understand the weaknesses of the outcome research literature to make good use of its strengths. There are some things it can tell us, and some it cannot.
The first task of outcome research was to answer the question of whether, overall, psychotherapy is helpful to people with mental health problems. The answer to this question might seem obvious now, but during most of our field's history, it was not, and there was real controversy about whether our endeavor had any value at all. Eventually, researchers worked out the methodological problems that needed to be overcome to demonstrate conclusively that, on the whole, the answer to this question is yes—therapy “works.”
More accurately, the answer is mostly yes. To summarize a huge body of research in one sentence, it would be fair to say that, for most diagnoses and both children and adults, in most outcome studies the treatment that works best is associated with improvement in approximately 75% of clients, with waitlist and no‐treatment control groups showing improvement in about one‐third of their cases, just because some people with mental health problems get better with the passage of time (Roth & Fonagy, 2006; Wampold & Imel, 2015). This difference between three‐quarters and one‐third means therapy is definitely valuable, overall.
But what about the approximately one‐quarter of clients who got the winning intervention but did not show improvement? They do not change the conclusion of the research, but to clinicians, they are a big deal, an unsolved problem, and a significant part of our practices. These clients cannot be sent home with the statement so often found at the end of journal articles: “Future research is needed….”
Also, the 75% are not all fully recovered—far from it. The amount of benefit varies widely, and many clients who achieve some improvement still have serious difficulties after therapy is completed (Cohen, Delgadillo, & DeRubeis, 2021; Ng, Schleider, Horn, & Weisz, 2021). For these reasons, knowing the best treatment for most members of a diagnostic group (a research question) does not necessarily tell us the best treatment for the client sitting in front of us (a clinical question).
What Works for Whom?
There have been great hopes and what seemed like reasonable expectations that outcome research could guide clinical practice by answering Gordon Paul's (1967) classic question: What works for whom? Our field has addressed this question by identifying therapies that, in multiple studies, have achieved more improvement for clients than what was found in control groups. These interventions are called Evidence‐Based Psychotherapies (EBPs). The thousands of studies conducted since 1967 have identified many EBPs and have definitely begun to answer Paul's question—but the answers are far from complete.
Research has found that, overall, and with some notable exceptions, the major therapeutic approaches are similar in effectiveness (Prochaska & Norcross, 2018; Wampold & Imel, 2015). This book will focus on the exceptions, but that does not negate the rough equivalence.
Even when an outcome study finds one therapy superior to another, there is always substantial overlap in the outcomes of the two groups. It is generally the case that a significant minority of the clients who got the winning therapy did not get better, and a majority of the clients who got the losing therapy did improve (e.g., 75% improved in one group and 60% in the other). Significant group effects do not guarantee that the client sitting in front of you would get the maximum benefit from the therapy that was effective for most young people in the studies. If your client differs from the study samples in some way, it is possible she would respond better to interventions that were less effective for the groups as a whole. Therefore, knowledge about outcome research should be the beginning, not the end, of treatment planning.
Another general finding is that, again with exceptions, most therapeutic strategies that are effective with one disorder are also effective with many others, at least within the broad categories of emotional versus behavioral disturbances. As examples, Dialectical Behavior Therapy, Acceptance and Commitment Therapy, and cognitive‐behavioral training in psychosocial skills have all been shown to reduce the symptoms of just about every diagnosis with which they have been tested. This does not mean these interventions help everyone (as discussed, about 75%); it means there is not a strong relationship between diagnosis and the type of therapy most likely to help. It may be more important to identify the etiological processes causing or maintaining disturbances, because therapeutic techniques usually target these processes.
The original vision of a research‐based answer to Paul's (1967) question was, in essence, a grid. The idea was that, once the necessary outcome research was done, diagnoses could be listed in rows, EBPs could be listed in columns, and there would be one or a few intersections for each, indicating what works for whom. If such a grid existed, assessment could consist simply of diagnosis and treatment planning could be accomplished by reading along the appropriate row until an EBP for that disorder is reached.
Things have not worked out this way, for the reasons described: Diagnostic groups are actually heterogeneous, client problems cross‐cut diagnoses to a substantial degree, EBPs do not work for nearly all the clients in any diagnostic group, and many EBPs are effective treatments for many diagnoses. The reality is much more complicated and messy than a grid.
That is why this book is so long! (It is one of the reasons, anyway.) The material on treatment planning certainly starts with diagnosis and outcome research, which are our foundation, and then discusses clinical observations, etiologies, change processes, and client preferences, all of which must be woven together to produce our best guesses about what would work for whom. It sounds harder than it is, although it is certainly not easy.
While the major therapeutic approaches generally have similar overall or average effects, they also have widely varying individual effects on clients (Cohen et al., 2021). As an illustration, let's say a very small study provided two kinds of therapy to two groups of three clients each, and in both groups, there were identical reductions in depression scores of 0, 5, and 10 points. Both treatments produced the same average reduction of five points, and yet different individuals had very different responses to the same interventions. This is a valid illustration in that practically all studies include clients who recover completely, improve somewhat, show no change, and deteriorate during therapy.
It would be extremely useful to know how clients would respond to different interventions in advance, without trying techniques to see what happens. In statistics, variables that predict different responses to the same treatment are called moderator variables. (This term has nothing to do with “moderation” in the usual sense.) For example, if a treatment were helpful to girls but not boys, gender would be the moderator variable. Efforts to answer the question of what works for whom consist, in large part, of a search for moderators.
Unfortunately, thus far, this search has not found much. The Journal of Clinical Child and Adolescent Psychology (JCCAP) devoted a special issue to research on moderator variables. In their introduction, Mullarkey and Schleider (2021) provided an honest assessment of this research by stating that, while significant results have been obtained here and there, no reliable moderators of outcome for any disorder have been identified. They came to the “sobering” conclusion that a large body of research has not yet provided a basis for personalizing therapy for young clients. As discussed previously, even diagnosis is not much of a moderator.
Researchers are well aware that they have a long way to go before fulfilling their promise to clinicians, and they are working on new tools to produce more useful guidance. The new information technologies of machine learning and artificial intelligence are being applied to the goal of personalizing therapy (Aafjes‐van Doorn, Kamsteeg, Bate, and Aafjes 2020; Schwartz et al., 2021). However, as of now, no new method has provided a clinically useful tool, and the achievement of this goal might be many years in the future (Cohen et al., 2021; Ng et al., 2021).
This is why clinical reasoning is a vital aspect of therapy planning and will remain so until the data that outperform it finally arrive. In the meantime, research and clinical reasoning should be viewed as complementary, not opposing, tools for planning. This complementarity is based on the reality that research is about groups, while clinical judgment is about individuals.
Modular Treatments
Research itself is beginning to incorporate some room for clinical judgment in its development of modular treatments. John Weisz and colleagues (Chorpita & Weisz, 2009; Weisz & Bearman, 2020; Venturo‐Conerly, Fitzpatrick, & Weisz, 2023) have been leaders in this new approach to child therapy, as have Hofmann, Hayes, and Lorscheid (2021) in work with adults. The key is to break both interventions and diagnoses down into smaller units. Therapies are broken down into techniques or modules. Diagnoses are broken down into the smaller unit of problems. Decisions about which modules to use and when to use them are made by therapists on the basis of clinical judgment.
The Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH; Chorpita & Weisz, 2009) is a menu of empirically validated cognitive‐behavioral techniques from which clinicians choose to create individualized treatment packages. In studies by Weisz et al. (2012, 2013), MATCH produced better outcomes than treatment as usual both posttreatment and at two‐year follow‐up, with effect sizes about twice as large as those usually found in comparisons of manualized, validated therapies to treatment as usual.
The FIRST program (Weisz & Bearman, 2020) is a similar, transdiagnostic menu of empirically validated, cognitive‐behavioral techniques that fit into the categories of Feeling calm, Increasing motivation, Repairing thoughts, Solving problems, and Trying the opposite. In a series of studies using pre/posttreatment, within‐client designs, FIRST produced strongly positive results, with effect sizes much larger than those typical in outcome studies (Cho, Bearman, Woo, Weisz, & Hawley, 2021; Weisz, Bearman, Santucci, & Jensen‐Doss, 2017).
MATCH and FIRST both involve clinical judgment, in that therapists choose techniques from menus. However, their scope of clinical reasoning is limited—the menus are not broad—in that they include only cognitive‐behavioral techniques. This is not because only these techniques have been empirically validated.
Integrating Outcome Research and Clinical Reasoning
Outcome research is not difficult to define: Generally, it involves measuring client functioning before and after a treatment and then comparing the difference to change in a control group over the same period of time. (Chapter 2 provides more explanation of research methods.)
Clinical reasoning is harder to define. Unless a therapist simply chooses an EBP on the basis of a client's diagnosis, almost anything he thinks about while deciding what to do is clinical reasoning. Empirical findings should be included whenever possible, but this can occur in a more wide‐ranging, flexible way than moving directly from diagnosis to outcome study to treatment plan. Also, clinical judgment extends beyond scientific findings to include past clinical experience, theory, personal experience, and intuition.
Because scientific research has a level of reliability that no one's intuition, experience, or reasoning can approach, we can be confident that empirical findings mean what it seems like they mean. (This is called “internal validity.”) On the other hand, a counselor in a room with a youth has a different kind of advantage: She knows her observations are directly relevant to her client (“external validity”). Outcome studies are not necessarily relevant to her client because he might differ from the samples in outcome studies in important ways, even if his diagnosis is the same. Outcome research and clinical reasoning involve different kinds of information, and the differences are complementary, so the combination is optimal.
This book's emphasis on the integration of outcome research and clinical reasoning is consistent with the consensus of the psychotherapy field. The Practice Directorate Guidelines of the American Psychological Association (APA, 2023) define evidence‐based practice as the integration of, (1) the best available research with, (2) clinical expertise in the context of, (3) patient characteristics, culture, and preferences. Other mental health professional associations have similar guidelines.
Much clinical reasoning is about which outcome studies are most relevant to a client's needs and strengths, particularly in the common situation in which multiple interventions have been found to be effective with the client's diagnosis (Cohen et al., 2021; Ng et al., 2021). Also, non‐clinical research in areas like social, cognitive, developmental, and positive psychology, and in the social sciences in general, provide innumerable insights into patterns and processes in clients' lives, and these insights can help us plan therapy.
Most of the time, clinical considerations should just fill in the details of research‐based frameworks and guide the implementation of EBPs. There are also times, however, when clinical considerations should outweigh research findings (APA, 2023).
Clinical reasoning sometimes generates units of intervention much smaller than the strategies studied in outcome research. These consist of therapist statements, ranging from one sentence to a couple paragraphs in length, that address a client issue much smaller than a disorder or even a symptom. These micro‐interventions will probably never be evaluated in an outcome study because their scale is too small—some are just good lines to use in certain situations—so clinical judgment is their only possible basis of implementation. These little bits of therapy can be useful because, when they hit a nail on the head, their value becomes apparent even without a supportive study.
One big difference between outcome research and clinical reasoning is the role played by etiology. In outcome studies, client samples are generally defined by diagnosis, and diagnosis is defined by symptom patterns, not etiology (American Psychiatric Association, 2022). In contrast, clinicians frequently wonder why clients show their patterns of emotion and behavior. Counselor responses are based largely on their hypotheses about etiology, because this is what theories of psychotherapy are largely about (Hofmann, Hayes and Lorscheid, 2021; Mullarkey & Schleider, 2021). For example, if a child was depressed because he was unable to make friends, the therapist would probably provide social skills training, while if a popular youth was depressed because of self‐critical thoughts, the counselor would probably respond with cognitive therapy.
Treatment planning can involve a three‐part sequence. Therapists: (1) discern patterns, (2) try to figure out what is causing or maintaining those patterns, and (3) choose techniques to address those etiological factors.
Different theories provide different patterns to look for and different links between etiologies and interventions. In a sense, we are looking for something broken that we know how to fix. This (not diagnosis) is the most important purpose of assessment.
In the past, partisans of the different theoretical orientations argued vehemently that their approach was superior to the others, and this sometimes happens today, although less frequently. Over time, our field is moving toward a consensus that the different theories describe different psychological processes, etiologies, and change agents, which vary in their degree of relevance to different clients. The existence of one etiology or change process is not an argument against the existence of other etiologies or change processes. For example, the existence of operant conditioning is not an argument against the existence of unconscious defenses, and evidence for the efficacy of reinforcement is not evidence against the efficacy of insight. If so, arguing about whether behavioral, mindfulness‐based, or psychodynamic therapy is best makes as much sense as arguing about whether orthopedics, cardiology, or neurology is best—that is, it makes no sense at all. The different approaches to medicine and therapy target different processes and systems, and they all offer value to patients suffering from dysfunction in the processes and systems they treat.
Guidelines for personalized, assessment‐based therapy planning can be complicated and sophisticated, with many checklists and flowcharts (e.g., Hofmann et al., 2021). On the other hand, in the midst of clinical work, these decisions often seem straightforward. Some children and families show the etiological patterns of particular theories so clearly that the appropriate therapeutic response seems obvious. I would describe my experience of this process as like responding to clients in the language with which they address me. When they present patterns described by family systems theory, I respond with systemic techniques; when they present patterns described by cognitive theory, I respond with those strategies, and so forth.
While researchers strive to be rigorous, clinicians are more concerned about being pragmatic. Of course we should be thoughtful about which techniques we try, but if our first attempts are unsuccessful, we can make use of a wonderful freedom: If one thing does not work, we can try something else!
About the Companion Website
Child and Adolescent Therapy: Science and Art is accompanied by a companion website.
www.wiley.com/go/shapiro/childandadolescenttherapy3e
The website includes:
PowerPoints
PART ITHE TOOLS OF THE THERAPIST
1Therapy Fundamentals
Objectives
This chapter explains:
The orientation toward clients at the foundation of therapy
.
Therapeutic language, including some specific words and phrases to use
.
What can and cannot be kept confidential from the youth's parents
.
Assessment interviewing
.
Two active listening techniques: reflection of feeling and reflection of meaning
.
The Internal Family Systems model
.
How clients can envision and mentally rehearse planned responses to problem situations
.
How to use play and art in child therapy
.
Motivational Interviewing: an intervention for overcoming resistance and building motivation to change
.
Simple, directive therapeutic interventions
.
Case Study
Simplicity
Brent, a 5‐year‐old African American boy, was having trouble in kindergarten. The teacher reported that his academic skills and peer relationships were age‐appropriate, but there had been repeated incidents of disobedience toward the teacher, accompanied by tantrums. Brent was not physically aggressive, but he screamed and cried, and it sometimes took 10–15 minutes to bring him under control. His behavior was generally pleasant and appropriate in between these outbursts, which had occurred two or three times per week during the several months since school began.
Brent lived with his mother, an older sister, and his maternal grandparents, who provided much day‐to‐day childcare. The caregivers reported that Brent saw his father once a month or so and seemed sad at the end of the visits. The caregivers said there were no problems with Brent's behavior at home, and they described him as a happy, energetic, cooperative child.
The therapist's impression of Brent was consistent with his caregivers' description. In both play and conversation, his behavior was organized and compliant. His play with puppets depicted exciting activities and interactions, with no unusual themes of distress or defiance. Because Brent had exhibited no problems prior to starting school, the counselor made a diagnosis of Adjustment Disorder with Mixed Disturbance of Emotions and Conduct
.
While most of the chapters in this book are organized around specific theories of psychotherapy or categories of disturbance, in this chapter, we begin with basic therapeutic principles and procedures that crosscut theoretical orientations and apply to most diagnoses. Research has produced a great deal of evidence that such shared or common factors of therapy are central to its effectiveness (Cuijpers, Reijnders, & Huibers, spiepr NONBREAK2019; Wampold, spiepr NONBREAK2015).
The Therapeutic Orientation Toward Clients
While the activity of psychotherapy is based largely on theory and technique, there is a certain attitude that lies at the foundation of our endeavor. This attitude orients us to our job, organizes our efforts, and guides the interpersonal tone of our behavior with children and families. The idea behind the therapeutic orientation is so simple that it might sound like a cliché, but its ramifications are important to consider. The moment‐to‐moment behavior of therapists should convey that they are there to help the client with her problems and her life. This is the role of therapists as established by professional ethics and licensing regulations.
Although this point seems obvious, it is worth making because parents and children sometimes fear their therapists are not there to help. Youth sometimes think that being brought to counseling is a serious form of getting in trouble (an impression that is not always inaccurate). Children and parents sometimes think therapists are there to evaluate and judge them—to identify and point out their failures and inadequacies. This fear seems particularly common in low‐income and ethnic minority families who feel intimidated by encounters with “the system” (Fisher, 2021; Sue, Sue, Neville, & Smith, 2022). Therapists should be alert to the possibility of these concerns so they can address them either with explicit explanations of their role or by making sure to convey a help‐focused agenda in their way of interacting with families. We can say something like, “I'm here to be a coach, not a judge.”
When the therapeutic orientation is translated into behavior, the therapist models an attitude toward life that is adaptive and constructive. She does not hesitate to discuss any issue or experience, no matter how awkward or upsetting. The counselor's stance does not change whether the youth reveals things about himself he considers wonderful or things he considers shameful; the therapist's unvarying intention is to understand and help.
The issue of counselors making judgments about clients has two aspects. The therapeutic attitude is based on unconditional acceptance, respect, and caring about the client as a person. However, this attitude does not include unconditional approval of all client behaviors. On the contrary, in many cases, our efforts to assist clients necessarily involve helping them change maladaptive behaviors. This two‐part attitude can be explained to children using words like the following:
“I like you; I just don't like what you did. In fact, I like you too much to want you to go on doing what you did.”
The idea of unconditional respect for clients generally makes sense to therapists when they read about it in a book, but in the midst of real clinical work with difficult clients, maintaining this attitude can be difficult. Our commitment to a humanistic, forgiving view of people is sometimes tested by contact with child and parent behaviors that are obnoxious, mean‐spirited, and cruel. I do not know of research on sustaining the therapeutic orientation under these conditions, so I will offer some personal, experience‐based reflections.
The therapeutic attitude seems based on an awareness of certain truths about human life. People, especially children, usually do not choose the situations in which they find themselves. They do not choose the family environments, neighborhoods, and schools that influence their development, nor do they choose the genetic endowments and neurobiologically based temperaments that, operating from within, strongly influence their experience and behavior. Within these constraints, people try to do the best they can for themselves, seeking happiness where opportunities present themselves and avoiding pain when dangers occur.
People become therapy clients when their efforts to feel better are disrupted by neurobiological dysregulation, environments that are harmful or poorly matched to their needs, traumatic events, and unrealistic thinking. As a result, clients stumble, grope, and flail in their efforts to be happy, sometimes leaving painful experiences for other people in their wake. But clients do not wake up in the morning and decide to make themselves and others miserable—these are unchosen outcomes. Even when people do poorly, they are generally doing the best they can in a world perceived as confusing and painful.
Therapists' initial, natural response to obnoxious or purposely hurtful behavior is often emotional distancing, perhaps even revulsion. However, I have found that the most effective response to this therapeutic challenge is not distancing but attending more closely to the parent or child, because increased awareness of the other person's experience usually counteracts anger and disrespect. Looking closely into a person's face, feeling the rhythm of her speech and movements, and sensing the emotions behind her behavior strengthen our appreciation of that person's humanity. When your therapeutic attitude toward a client is threatened, I would suggest trying to imagine what his life feels like to him, moment to moment, as he wakes up in the morning, goes about his day, and encounters you in this strange context called therapy. If you do this, I predict your respect and compassion will be rescued, not by abstract moral principles, but by the little things people do and say that express something intimately human and reveal their struggle and suffering.
The Therapist's Interpersonal Style
The theoretical orientations described in the chapters to follow differ somewhat in their recommendations for the counselor's style of interacting with clients. Nonetheless, there are some basic principles that crosscut the different therapeutic approaches, and we will begin with these.
One of the most robust findings in psychotherapy research with both youth and adults is that the quality of the therapist‐client alliance predicts continuation in therapy (versus dropout) and improvement in client functioning (Cirasola & Midgley, 2023). The magnitude of this effect is generally small but significant, and it has been demonstrated across a wide range of theoretical approaches and diagnostic groups (Karver, De Nadai, Monahan, & Shirk, 2018; Murphy & Hutton, 2018). In other words, the therapist‐client relationship is one significant factor in outcome, but we need much more to achieve major benefits for clients.
The next question is, what can therapists do to engender positive relationships with clients? A review by Wampold and Flückiger (2023) identified two main components of strong alliances in clients: (1) feeling accepted, understood, and cared about by the counselor, and (2) perceiving the clinician to be highly knowledgeable and skillful. Thus, research indicates that therapists should combine the qualities of professional expertise and empathic warmth—science and heart—in their interpersonal style with clients.
Research indicates that therapists should combine the qualities of professional expertise and empathic warmth— science and heart—in their interpersonal style with clients.
Social psychology research has found that people like others more when the person mirrors their nonverbal behavior and interacts with a similar tone of voice, energy level, and rhythm (Chartrand & Lakin, 2013; Chartrand & van Baaren, 2009). When two people interact in an engaged, harmonious way, their styles tend to converge and become more similar over time. This phenomenon occurs in psychotherapy: Therapists whose moment‐to‐moment fluctuations in physiological arousal mirror those of their clients are rated as more empathic by those clients (Marci, Ham, Moran, & Orr, 2007). We can capitalize on this phenomenon by tuning into our clients' styles and allowing ourselves to fall into their rhythms (Ogden, 2016). We cannot be chameleons, but we can adjust our style to somewhere in between our baseline and the client's style, which enables us to connect while remaining anchored in our usual way of interacting. This would mean being soft and gentle with a shy, anxious child and being rougher, jauntier, and more casual with a rebellious adolescent.
This kind of close, nonverbal mirroring might be difficult in a teletherapy situation. Nonetheless, Meininger et al. (2022) found that young clients who switched from in‐person to remote therapy following the outbreak of Covid generally did not report a decrease in their satisfaction with treatment.
Although the early influence of psychoanalysis once popularized a neutral, observant style for therapists, research indicates that most clients do not connect well with reserved, distant counselors. Instead, treatment alliances are strongest when the client perceives the therapist as a real person who is fully engaged, present, and authentic in the relationship (Geller, Greenberg, & Watson, 2011), and when the client believes the therapist likes and cares about him (Karver, De Nadai, Monahan, & Shirk, 2019). I have heard young clients complain about past therapists who “sat there and waited for me to say something,” and who “stared at me and didn't talk.”
Depictions of therapists in the media typically portray a manner that Foster Wallace (1996) described as “somewhere between bland and deep.” However, research does not support this interpersonal style: A meta‐analytic review by Peluso and Freund (2018) found that high levels of therapist emotional expression were associated with more improvement in client functioning. Our baseline manner should be calm and kind but, depending on the content and situation, there are also times when it is effective to be playful and humorous, or earnest and intense, or even moved and passionate, in the way we speak to clients.
The traditional, analytic style excluded therapist self‐disclosure, but there are problems with this exclusion. Clients sometimes ask us questions. Himelstein (2013) noted that many youths are put off by the analytic response of asking why the client desires this information; this type of answer might seem evasive. In my experience, it is better to answer the questions I feel comfortable answering (almost all of them) and to respond to questions that seem too personal by saying I do not want to answer for this reason. If the question seems to have emotional meaning for the client, it seems more effective to inquire about this after giving an answer.
Research supports the value of therapist self‐disclosure, within limits. In studies of adults, counselor self‐disclosure is associated with positive client outcomes (Henretty Currier, Berman, & Levitt, 2014; Hill, Knox, & Pinto‐Coelho, 2018). Self‐disclosure can help clients feel comfortable by showing that therapists have feelings too and are not ashamed to express them. Modeling emotional self‐expression can help clients learn how to talk about feelings. Youth seem to appreciate accounts of the therapist facing and coping with problems similar to their own when the therapist was young. Of course, counselors should self‐disclose only to achieve some therapeutic benefit for the client, not to fulfill a personal need of their own.
The therapist‐client alliance seems to develop best when a certain balance is achieved, and the therapist's manner is warm and caring but without an emotional intensity that would change the relationship from a professional to a personal one. Therapists should be cheerleaders for their clients, rooting for them to make progress against their problems. Our faces should light up when we hear reports of progress and should express concern when setbacks occur. However, there should be boundaries around our reactions, which should never be so intense that clients come to worry about upsetting us or letting us down.
Empathy is more important than sympathy in psychotherapy, but when people reveal suffering, there is a place for both. If these words convey your feelings, there is no reason not to say, “I am so sorry that happened to you,” or “I am sorry you are hurting so badly.”
Therapy Language
Therapists' talk should consist of ordinary language and speaking styles. Counselors should avoid technical jargon, intellectualized language, and an overtly “touchy‐feely” style. Youth generally like therapists who talk like regular people, not “shrinks.”
