Academic journal article American Journal of Psychotherapy

The Supporting Alliance in Child and Adolescent Treatment: Enhancing Collaboration among Therapists, Parents, and Teachers

Academic journal article American Journal of Psychotherapy

The Supporting Alliance in Child and Adolescent Treatment: Enhancing Collaboration among Therapists, Parents, and Teachers

Article excerpt

Research indicates that the therapeutic alliance between therapist and pediatric patient is most effective in the context of a productive supporting alliance-an alliance encompassing the network of relationships among therapists, parents and teachers. In this essay, we develop a model of the supporting alliance, arguing that the child's primary relationships with various parties (therapists, teachers, and parents) imply a set of secondary relationships among those parties (parent-therapist, therapist-teacher, parent-teacher). We review the literature on these secondary relationships, focusing on their nature and discussing the benefits of and obstacles to establishing productive collaborations in each case. We also describe three sorts of pathology that can afflict the supporting alliance as a whole, and discuss the importance of patient autonomy and therapist-patient confidentiality relative to the supporting alliance. Finally, we identify directions for future research and highlight implications for practice.

KEYWORDS: supporting alliance; system of care; collaboration; parent; teacher; therapeutic alliance

ENHANCING THE SUPPORTING ALLIANCE AMONG THERAPISTS, PARENTS AND TEACHER IN CHILD AND ADOLESCENT TREATMENT

This essay begins with the notion that the therapist1 is the ultimate authority in the treatment of a child with a chronic psychiatric, emotional or developmental disorder. There is some truth to this idea: the therapist has formal responsibility for setting key parameters of a child's treatment. He or she may conduct psychodynamic, cognitive-focused or behavioral therapies, and/or select and prescribe psychopharmacological treatment. It is perhaps more revealing, however, to examine how this idea (that the therapist is the ultimate treatment authority) is false.

The following four propositions point to ways in which the therapist is not the ultimate authority in the treatment of a pediatric patient with a mental health disorder. The word "authority" implies both control and expertise. The first two propositions refer to "authority as control"; they are not, we expect, controversial.

1. The vast majority of interpersonal interactions, including many that have consequences for the child's therapy and some that are explicitly therapeutic in nature, are not controlled or managed by the therapist.

2. In the case of psychopharmacology, the pharmacotherapist is responsible for selecting medications, but rarely controls or supervises their delivery.

The third and fourth propositions refer to a different idea of authority: "authority as expertise." These are perhaps more controversial, though in our view they are equally self-evident.

3. The therapist often has comparatively limited contact with the child and little direct access to information about the child's daily life.

4. The therapist's perspective on the appropriate goals of therapy has no clear moral priority over other perspectives, including those of the child, the child's family and the society in which the child lives.

Taken together, these four propositions suggest that the therapist's direct authority over a child's therapy is highly attenuated. Her influence is one among many. She must make decisions with imperfect information and may need to advance her goals for the child's treatment in competition with the goals of others. To increase her authority (control) over the child's treatment, she must act in concert with the various significant others in the child's life; to increase her authority (expertise) over the child's treatment, she must rely on those significant others for information. The logical conclusion of this argument is striking: effective collaboration increases rather than decreases a therapist's authority. But what constitutes effective collaboration?

In this essay, we develop and explore a model for effective collaboration - a model that we call the supporting alliance. …

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