Topic 3: Therapy Basics with Children and Adolescents {by 6/19}

There are two readings due this week:  Moustakas (1959) and Greenspan and Thorndike (2005).  Address the following two discussion points:  (1) Moustakas’ reading was definitely not CBT in nature.  Nevertheless, identify and explain three topics/suggestions from the reading that are not “CBTish” but still appear to have much utility for therapy with youth.  (2) Greenspan and Thorndike stated a few times that therapists should not let their own anxiety interfere with their observation of the child (or parent-child interactions).  What is this comment referring to?  Also, were there any suggestions for the clinical interview that did not “sit well” with you?  Your original post should be posted by the beginning of class 6/19.  Have your two replies no later than 6/21.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

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44 Comments (+add yours?)

  1. Taylor Tagg
    Jun 16, 2014 @ 18:12:28

    1) Moustaka’s reading was centered on “relationship theory” and the importance of building a child’s self-esteem in hopes of overcoming internalizing issues and reaching positive self-development. There were a couple different concepts from the reading, from my personal opinion, that would most likely have therapeutic benefits, although not from a CBT-viewpoint. I liked how the article reinforced the idea of focusing on the “here and now” in sessions and the importance of dealing directly with feelings rather than approaching the child’s problems or symptoms and their causes. By doing so, the therapist becomes a symbol of a new reality for the child. I also found the section of the therapeutic setting to be another important factor in therapy with youth. The setting must aim to make the child feel safe and they must feel a sense of peace and harmony while present. I have a 4 ½ year old client and since I meet with him in the mornings, I am lucky enough to use one of the after school program rooms (geared towards kindergarten through fourth grade children) in the agency. Utilizing this particular environment, I believe, has had an influence on therapeutic gains because I feel as though he feels comfortable and at peace, and the games, toys, etc. are geared towards his specific age. The last concept that I found to have benefits in therapy with youth is the focus on internalizing issues (i.e. anger, anxiety) and working through them in hopes of reaching positive feelings. I have witnessed such therapeutic change with a couple of clients throughout my internship in which there was once feelings of anger, sadness, and low self-esteem, and towards the end of treatment, positive feelings were restored, leaving feelings of happiness, optimism, and high self-esteem.

    2)The comment that Greenspan and Thorndike stated related to not letting therapists’ own anxiety interfere with their observation of the child, I believe, is focused on holding back from intervening with a child’s psychopathology and how he or she presents in session. For example, if I was seeing a client in an initial session who became very angry over something very little, Greenspan and Thorndike would advise me to have the client ride out the anger, and to keep myself from intervening until I have a good picture of the gravity of my client’s psychopathology related to that anger. Not only was this particular suggestion a little unsettling to me (i.e. 30-second stare-down example in reading), but there were a couple others, as well. For example, the authors talked about taking notes and following a structured column list throughout the initial meeting with the child and complete such notes as the interview progresses. Although this may be a suitable method for obtaining information, I feel as though it may also interrupt building rapport, which essentially influences the beginning impressions of the therapeutic relationship. Building a good therapeutic alliance, particularly with children, is pivotal! A couple other suggestions that did not sit well were in regards to offering cookies, candy, etc. to youth clients, restraints and holding clients when upset, and also talking about dreams during initial meetings with youth.

    Reply

    • Ashley
      Jun 17, 2014 @ 10:10:30

      Taylor, I thought you brought up some good concerns in regards to the Greenspan article. I had not thought of the chart as being interruptive to the therapy session but I can see how it could be. It made me reconsider the use of such a tool. This further my thought process to wonder when it is a good time to jot a note down because I know that sometimes things said by others get missed when you are concentrating on writing the last comment down. I also had not considered the idea of the here and now in the Moustakas article. That is a concept we addressed in our group class thus an important one to consider throughout all of therapy.

      Reply

      • Taylor Tagg
        Jun 18, 2014 @ 14:17:46

        Good point, Ashley. Generally, I do not take notes during a therapy session, only throughout a parent-intake do I write things down. While I am in session, I simply try to pinpoint certain themes and phrases that are discussed and make mental notes that I can add to my progress notes.

        Reply

  2. Julianna Aguilar
    Jun 17, 2014 @ 08:16:14

    Though Moustakas’ (1959) understanding of the best therapeutic practices appears to be quite different from CBT, there are still elements that could benefit the CBT therapist in his or her clinical work. First, though “relationship therapy” may not be the model of choice of a CBT clinician, the broad theme is very important for CBT as well. Specifically, Moustakas (1959) notes that, within the therapeutic relationship, it is important for the therapist to convey a sense of warmth, empathy, and trust in the child so that the child knows that the therapist believes in him or her. In CBT, it is very important for the therapist to validate the child’s feelings and model an appropriate and supportive relationship between a child and an adult, especially being that the child may not have this experience in other parts of his or her life. Second, the importance of the setting is beneficial for the CBT therapist to keep in mind. Moustakas (1959) points out that “the playroom becomes the other world of constant peace and harmony…where the child is revered as a precious person” (p. 10). Creating an appropriate setting is already an important part of CBT therapy. However, Moustakas (1959) adds to this element by pointing out the importance, given each child’s unique circumstance, the therapy room may be one of the most safe and comforting parts of his or her life. Third, an important aspect of therapy to take from Moustakas (1959) is considering the negative effect that the parents (or other important adults) can have on their child by labeling them. Moustakas (1959) writes, “parents gradually, often subtly and indirectly, convey to the child that they consider him a person of limited value and potentiality…[The child then] loses touch with his own real feelings, with himself” (p. 28). I would not argue that this situation happens with every child and family, or use such broad phrases as “loses touch with himself” when discussing the issue with parents or children. However, there is a valuable message to CBT therapists in that statement. That is, therapists must be aware and cautious of the impact of directly or indirectly labeling a child and the harmful effect that label can have on the child’s behavior.

    Greenspan and Thorndike (2005) state that therapists should not let their own anxiety or discomfort interfere with their observation of the child or the parent-child interaction. There seems to be a two-fold meaning to this statement. First, the authors appear to be referring to therapists’ inclination to want to support and comfort children when he or she is upset. If the therapist is too soon to jump in, however, he or she cannot observe and experience first-hand the full nature of the child’s psychopathology. Second, there are certain behaviors that may make the therapist uncomfortable (e.g., primitive disorganized behavior, according to the authors). Because we may have difficulty understanding this behavior being that it is different from our own, we can feel uncomfortable. Though the discomfort is our own, therapists tend to pin that anxiety on the child and try to change the structure of the interview to alleviate that anxiety instead of simply observing the behavior.

    When the authors describe the general structure of an interview, there were two parts in particular that did not sit well with me. First, I am very skeptical about the use of physical restraint in therapy sessions with children, regardless of whether the therapist or the parent is doing the restraining. In a practical sense, restraining a child has serious ethical implications. Aside from settings in which restraint is practiced more routinely and necessary for daily safety, the almost inevitable costs of restraining a child do not seem to outweigh the benefits. It is one thing to need to use the most minimal contact possible to defend yourself if a child is acting in a physical and dangerous way toward you, but it is another to restrain the child simply to facilitate better conversation. Similarly, when the authors discussed the possibility of having the parents hold the child, I could not help but think that scenario is likely to damage the therapeutic relationship and therapeutic process in general. If a child is essentially being held down in therapy, he or she is not likely to enjoy the process or find it beneficial. Second, I found the authors’ discussion of dreams a bit troublesome. I understand their argument about using dreams as a vehicle to discuss important topics in the child’s life. However, given that discussing the significance of dreams with adults can be a tricky topic, I worry that this discussion might give children the wrong impression about how to understand and change behavior even if that is not the intent behind the intervention.

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    • Ashley
      Jun 17, 2014 @ 10:18:00

      Julie, you make a great point when you say that parents need to be careful on how they directly or indirectly label a child. In your professional opinion (or anyone elses) do you think that if a child is inappropriately labeled they may conform to that label? For instance, if a parent states (many times) that their child has a “cold heart” is it possible that the child starts to act in a manner that is congruent with this label?

      Reply

      • Julianna Aguilar
        Jun 20, 2014 @ 13:59:02

        Ashley, I definitely think it is possible for the child to start to take on the traits consistent with their parents label of them–whether positive or negative. In a positive light, I see a lot of adolescents perform very well because of their parents’ constant affirmation that they are capable individuals who are able to do their school work, accomplish their goals, etc. Unfortunately, I often see this trend in the other direction as well. As a personal example, I have a 14-year old adolescent who I see at his high school. He is extremely bright in many ways–he plays multiple instruments, currently takes a course at a local community college (as a freshman in high school), and scored above average on nearly all of his psychological testing. However, his mother is convinced that he incapable of organizing and completing school work on his own, and absolutely must have a staff member at the school meet with him every day to make sure he is on track. At this student’s progress meeting mid-year, I reported that he has demonstrated consistently throughout the semester that he was able to track his own progress in school and, furthermore, did not want any help (nor do most kids who are capable of more independence). His mother demanded that he stay with me because “he does not know that he needs help, and the fact that he does not know that he needs help proves how much help he needs.” That argument is a story for another day, but the main point that came out of that meeting, and interactions with his mother in general, was this student being confused and upset about not being able to function academically on his own. Without his mother’s input, he believed he was intelligent and capable. As soon as she said otherwise, he almost immediately lost confidence in himself. Of course, there are always going cases where you do not see this self-fulfilling prophecy for various reasons (e.g., individual characteristics of the child), but I do have to say that I (sadly) see it more often than not.

        Reply

    • Taylor Tagg
      Jun 18, 2014 @ 13:57:12

      Julianna, I liked how you pointed out the issue of “labeling” children. I believe that it is so important for a child’s authority figures (and other important supports) to refrain from labeling a child in negative terms because such terms might stick with the child. Children are constantly learning and part of that learning is forming an identity. If a child is consistently being labeled as a “bad kid”, a “bad listener”, or “always doing things wrong”, then I believe it is very likely that the child will internalize such things about herself which will influence the formation of her identity (i.e. poor self-esteem/self-efficacy, worthlessness, etc.)

      I also liked your “two-fold” approach to what Greenspan and Thorndike were referring to in regards to therapists not letting their own discomfort or anxiety interfere with the observation of the child. I had assumed similar to your first rationale: holding back from intervening with how a child is presenting his or her psychopathology. However, I had not considered the influence of how a child presents (i.e. destructive behaviors, hysterical crying, etc.) and how it would make me feel as a therapist in session. I would like to think that I would be able to simply let a child express his or her feelings, but had not considered how the child expresses such feelings would make me feel.

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    • Rebecca Boisvert
      Jun 20, 2014 @ 16:57:06

      Julianna, I agree with your comment regarding the therapeutic inappropriateness of a parent holding their child in place during therapy. I think that this is wrong on several levels. First, as you mentioned, the child is essentially forced into the therapeutic process, which I think is wrong. Second, the child may not be ready, willing, or able to process the issues that are being forced upon him, and doing so may cause more issues than not. Third, by forcing the child to process, the parents are essentially telling the child that his issues are not his to process, but it is out of his control and the choice as to when and where it will be dealt with is not his to make. Furthermore, the reason why the child needs to be restrained is most likely closely related to the target issue, and he/she is probably acting out because he is not ready to process. Chances are, forcing them to do so will create more issues, rather than solve the problem.

      Reply

  3. Ashley
    Jun 17, 2014 @ 09:49:55

    1) In Moustakas article on “relationship theory” he offers some ideas that are not CBT related but could be useful/taken into consideration. The first point or portion of the article that I found useful was Moustakas description on the therapeutic setting. It is indicated that the therapeutic setting should allow the child to express themselves threw play. During the course of therapy, toys and materials can be used to release tension and demonstrate repressed feelings. Although Moustakas suggests offering toy guns, knives, swords and sand (not something I would bring into the therapeutic setting) I think the overall concept of allowing the child to use the toys “without limits” can give an observer a look into the mind of the child. Many children express their feelings or actions taking against them through play and it would be beneficial to see such play occur. The second part I though beneficial was when Moustakas talks about the therapeutic relationship and what it conveys to the child. Moustakas states, “therapist believe in the child as a person, with potential to grow with ligament thoughts and feelings and worries so that child can fully explore the full intensity, impact and meaning of his feelings.” This statement really stuck with me because throughout my short time in internship i have heard numerous parents say “I just dont know what to do with him/her anymore.” As therapist if we can portray a relationship that allows the child/adolescent to express themselves and give meaning to their worries/fears it will form a strong therapeutic relationship that can impact more positive change. Lastly, I thought the concept of working through internal struggles was an important concept in Moustakas article. By addressing the fears and anxieties and working through them there is an opportunity to change those fears and anxieties into more positive structures (happiness, content, positive self image). This is something I hope to see while in my internship/practicum.

    2) Throughout the Greenspan article, it is stated several times that the therapist should “not let their own anxieties interfere with their observation of the child.” There are several meanings that go into this statement. First, therapist should not become alarmed when everything does not run perfectly. At times therapist become concerned/dwell on the times they do not respond with the appropriate amount of empathy but this is not necessary because assessing the child’s reaction is important none the less. At times therapist act on their anxieties over the child’s response before letting the child handle the situation on their own. It is more important to wait to see what the child does before acting because you can learn from their response even if it was not the perfect situation. Another meaning, is the way the therapeutic process is structured due to therapist anxieties and worries rather than the needs of the child. In some cases the child makes us feel anxious or at a loss of control so we move to a more structured interview. Greenspan suggests asking internal questions such as “is this for the child or for myself.” A structured process might be more to relax our inner anxieties rather than those of the child. Greenspan suggests to remain quiet when we find ourselves becoming anxious or irritated with the child rather than change the structure of things so our own inner voice does not impact the child.

    There were two comments that stuck out to me that didn’t sit will. The first was when Greenspan stated that people talk more before their hour is up because they don’t want to go. I actually think its the opposite. In my personal opinion I think people would talk more at the end of the session because it allows them to say the hard things and “run away” from the comment. If they had stated them in the beginning of the session than therapist would press them on the issue and ask them to dig deeper into their feelings. By stating it at the end of the session it allows them to escape without addressing the issue further. Lastly, I found the ideas around restraints, giving out food (candy and cookies) and discussing dreams to be troublesome. Unless you being threatened I do not think therapist should be restraining their clients. As discussed last week in class, candy/cookies should not be involved because you do not want to a child’s behavior to be the product of an ultimatum and discussing dreams has no real therapeutic value.

    Reply

    • Taylor Tagg
      Jun 18, 2014 @ 14:10:04

      Ashley, I liked how you pointed out the importance of working through the internal struggles that a child experiences and its usefulness in therapy. That was one point that I had addressed, as well. Working through fears and anxieties is so beneficial in helping children process and confront them. More so, certain fears and anxieties may actually be centered in the home environment (and with those involved) and therefore, the child may not be able to discuss such things with his or her family. Therefore, therapy will serve as an outlet for the child to talk about his or her fears and anxieties with someone who listens and understands the child, which will facilitate the therapeutic process of working through such fears and anxieties.

      I also liked your emphasis on asking the important question of “Is this for the child or for myself?” that was presented in the Greenspan and Thorndike article. I completely agree with your thoughts on a structured session being more to relax our own anxieties rather than those of the child. I sometimes feel the internal pressure of making something happen in session and that the only way to make something happen is to plan a structured activity/discussion in order to do so. However, there have been plenty of other times where I had not planned anything particular with clients and they would walk into session with plenty to talk about and from there, certain strategies or interventions were employed. It is hard for us as therapists to simply let a session play out as is because we have goals to meet in order to help our clients, however sometimes it is just as beneficial to take the pressure off and see what the child brings with them to a session that is not so structured.

      Reply

    • Melysa Faria
      Jun 19, 2014 @ 13:52:09

      Ashley, I like the point you made about an alternative reason for why clients may bring up an important topic towards the end of the session rather than the beginning. While Greenspan and Thorndike (2005) stated that this may be due to the client wanting the therapy session to continue longer, you pointed out the possibility that the client may bring up a large issue at the end of a session to avoid processing the issue in detail. I had not even thought much about alternative reasons a client may bring up important issues at the end of a session, but I think depending on the client’s diagnosis and personality, there are likely to be some clients that want the session to go longer and other clients that would prefer to avoid a long discussion about difficult issues. Perhaps clients with personality disorders such as Borderline Personality would attempt to lengthen a session while a client that has difficulty with trusting others or being assertive may bring up a heavier topic towards the end to avoid a deeper evaluation and discussion.

      Reply

    • Rebecca Boisvert
      Jun 20, 2014 @ 17:12:14

      Hey Ash, I wanted to comment on your thoughts about disclosures made at the beginning vs. the end of the session and the client wanting to “run away”. I would agree with this for some clients, but for others, I think that they may enjoy the breakdown/processing part of therapy, and appreciate the help that the therapist can provide. For the clients that I think that you are talking about disclosure may be something that they are not interested in (especially if therapy is mandated, etc), and they may disclose because they feel obligated, but are not interested in the help of the therapist. On the other hand, others may just be really embarrassed and need to disclose, but then get out of there for a period of time before the next session so they can prepare for the processing part of therapy. I actually had a child this week in one of the classrooms that I work who needed to tell me something private about a story he had been writing, but was really embarrassed to tell me face-to-face. So he kept writing his comments on scrap paper and giving them to me to read. After I read them, he was able to discuss the context with me verbally, but it was the private/confession/disclosure part that he found very embarrassing and wasnt able to speak to me directly. It was very interesting because I have had a strong rapport with this child all year long, but then again, this information was important to him, and writing has been his best outlet of expression. So it worked out well.

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  4. Sarah Chelio
    Jun 17, 2014 @ 20:11:36

    1) Although Moustakas’ article was not CBT, it still contains elements that could be useful to a cognitive-behavioral therapist working with youth. First, it states the importance of showing respect for the uniqueness of each child. I think that this aligns with CBT in that each case is different and unique, due to a variety of environmental, psychological, and biological factors. This points at the need to get to know each child as an individual. Second, although past experiences do matter, the reading suggests focusing on the present. This is similar to CBT, which looks at the here-and-now of a child’s emotions. I agree that this is effective because these feelings can be examined and time is not wasted by looking for past problems that may or may not be relevant. Third, I found the section on limit setting to be helpful. I think that in order for treatment to be effective and enjoyable, clear boundaries must be established. Specifically, time limits and rules about respect for property and the therapist should be implemented. At my internship site, the use of timers is common so that the children know how much time they have. They react well to this.

    2) Greenspan and Thorndike talk about how therapists should not let their anxiety disrupt their observations. I believe that what they are referring to here is the need for clinicians to recognize and tolerate discomfort in order to let the child continue with that they were doing or saying in order to show their symptoms. Interruptions could unintentionally hinder this. This seems like it could be difficult at times, because one’s instincts could be to help out a child who is afraid or confused. Greenspan and Thorndike would suggest staying out of it and seeing how the child handles it because that will give them valuable information.

    One thing that did not sit well with me from the article was not asking too many questions. They suggest making declarative statements in order to provide an alternative way of expressing thoughts or feelings, rather than questions. Although I understand the rationale behind doing this with children, I think that doing this at the wrong times would frustrate a child. Saying “you are angry” rather than asking whether or not they are feels like making an assumption. If this is actually not what the child is feeling, they could become frustrated or feel like the therapist does not understand them.

    Reply

    • Angela Vizzo
      Jun 20, 2014 @ 22:55:53

      Sarah, I liked Moustakas’ comment about limit setting as well. It is necessary for children to learn that limits exist and they cannot act however they want, whenever they want, but that they have to follow the rules. By doing this it can model the limit setting for the parents to use at home and teaches the child skills that are necessary in the real world.

      Reply

  5. Paige Hartmann
    Jun 18, 2014 @ 12:29:14

    In Moustakas’(1959) article, although it was not based on CBT principles, there were some elements that were discussed that could be useful to a CBT therapist. Moustaka discusses the importance of the “unique nature” of a child. This would be relevant to a CBT therapist because each client is treated as an individual and treatment is tailored to the specific needs of the client. Moustaka also mentions how it is essential for the child to feel warmth and empathy from the therapist. Within CBT treatment, establishing and building a strong rapport between the child and the therapist is imperative for effective treatment. Lastly, Moustaka emphasizes how relationship therapy deals with the present moment, focusing on the child’s feelings rather than the child’s symptoms and causes. By dealing with the child’s feelings in the moment, the therapist can help the child reconstruct any negative cognitions.

    Greenspan and Thorndike mention a few times that therapist should not let their own anxiety interfere with their observation of the child, in order to avoid interrupting the presentation of the child’s psychopathology. Another example of what Greenspan and Thorndike are referring to is the therapist’s anxiety to help structure the interview for a client, when the therapist feels the interview is not going as planned. However, Greenspan and Thorndike mention that a therapist should be aware of their own anxiety and ask themselves, “Am I taking care of myself or am I taking care of this child?” The therapist should overcome their own anxieties to do what is best for the child. It did not “sit well” with me when the need for physical restraint was discussed. Greenspan and Thorndike explain, “you need to decide, sometimes, if you or the parents should assist the child by holding him if his behavior demands it” (p. 156). I don’t agree with this suggestion, and personally do not think the therapist should be involved with physically restraining a child.

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    • Nafi
      Jun 19, 2014 @ 16:49:27

      Paige, I agree with everything that you said in your response. The restraints on child was also something that did not sit well with me either. There is a level of boundaries that we must maintain with our clients. Are we to expect the child to return to the next session after we restrained them? My thought is that this would impact the therapeutic relationship, especially with older youth.

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    • Sarah Chelio
      Jun 20, 2014 @ 16:20:35

      Paige,

      I agree with your comments on the use of restraints. I do not think it is the therapist’s place to do this, and think it would have consequences on the therapeutic relationship they are trying to form. I think it would decrease the comfort of both the child and the parents. I imagine that often when this happens the parents decide to stop bringing their child to therapy. It is not something I would be comfortable doing, as a counselor.

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    • Rebekah Kiely
      Jun 21, 2014 @ 02:02:49

      Paige,
      I completely agree with your comment on the use of physical restraint. I cannot imagine I would ever be willing to restrain a child; nor can I imagine many parents that would be comfortable with a therapist who does this in the world today. I think the choice to try to restrain a child when the situation appears to be calling for it may also be put the therapist in a dangerous situation. If a child has become so agitated that he/she is bordering on aggression, I don’t believe it is the therapist’s responsibility to try and calm the child down again at this point. What if restraining a child elicits a negative reaction and the child continues past even aggression and just becomes violent? As much as I will always want to do all I can to help my clients, I would never want to put my safety at any significant risk, which I feel this therapist has done by using physical restraint no matter what the actual outcome was.

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  6. Juliana Eells
    Jun 18, 2014 @ 21:39:57

    1) Although Moustakas (1959) was not CBT oriented, there were still several aspects that could still be beneficial for a CBT therapist.
    First, he emphasized the importance of the therapeutic setting and how the child should feel comfortable and be able to express themselves freely. He also discussed specific types of toys and their individual functions and specific emotions or problems that children may use them to express. He emphasized the importance of having all kinds of toys so the child can freely express themselves however they prefer. While these things are not stressed in CBT, I can see how it would be useful to understand how children use different types of toys and to make plenty of options available for the child to use to express him/herself.
    Second, Moustakas emphasized treating the child as a unique person with individual integrity, rather than as an object, and “it”, or a case to be studied. I can absolutely see how this would be supportive and empowering for a child, especially because adults may talk about children in this way often without realizing it. Showing this sort of respect for each individual child could go a long way in developing a positive therapeutic relationship.
    Finally, Moustakas states that in relationship therapy the focus is always on the here-and-now and deals directly with current feelings. This also involves not dealing with the current problems, symptoms, or causes. While CBT may often focus on the here-and-now as well, the symptoms and causes are generally very important to proper diagnosis and successful treatment. I can see how it would be useful to focus more on the immediate feelings rather than more broadly discussing symptoms and problems as young children may have difficulty thinking in more broad terms.

    2) Greenspan & Thorndike (2005) repeatedly emphasize the importance of following the child’s lead, not interfering, and allowing the child to express him/herself freely. They state that you will not observe the child’s full capabilities or the full extent of the pathology if you are too quick to interfere. The child with give the most honest information on their own and interfering with their expression or being too directive will yield less honest or accurate information. So when the therapist feels anxious, they should resist the urge to jump in and begin directing or redirecting the child, and simply continue to observe instead. One thing that did not sit well with me from Greenspan & Thorndike was when discussing the early part of the interview they mentioned “correcting any distortions”. Although they did not elaborate on this point, it seems that this may be too early to begin challenging a client’s thoughts. We typically have learned that a good therapeutic relationship should be developed before you begin challenges.

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    • Jane Jenkins
      Jun 19, 2014 @ 10:34:55

      Juliana,
      I thought the piece about the purpose of the toys was interesting as well. I particularly wondered about the statement that if the kid ruins the toy, they have not identified with it. I’m not sure how I would ever be able to distinguish “not identifying” with the toy versus the fact that the kid is just really frustrated and wants to take it out on something. I can definitely understand how the child could use the toy as a representation of himself, however, and that could lead to important discoveries about the child.

      Reply

      • Juliana Eells
        Jun 21, 2014 @ 08:18:18

        I definitely agree that assigning any single explanation for why a kid would ruin a toy would be too much of a generalization. I’m doing my internship at a therapeutic day school for K-6 kids who very easily get frustrated or act out for so many different reasons. I would definitely say that the context and asking about the child’s intent would be important if they were to ruin or break a toy.

        Reply

  7. Sara Grzejszczak
    Jun 18, 2014 @ 21:40:21

    One thing in Moustakas’ article that was not CBTish but still seemed to have utility in therapy is the limit setting. This is important in no matter what type of therapy is going. Children and even adults need to know where the limits are so that way there is some structure for what is to go on in session and even out of session. Limits in session will also help the child to feel safe, and again have that structure, when things outside of therapy may not be going so well. Another thing that is not a part of CBT but is important is the fact that the therapist should “pay unqualified acceptance, respect, and faith” to the child. While this is not said in CBT terms the idea of accepting the child and his or her issues is important in building rapport with the child and the child’s family. This idea is also important because this idea of unqualified acceptance will allow the child to share anything and everything with the therapist and not have to worry about being judged. Finally, Moustakas’ idea of labeling children could have a negative effect on how other people see the child and in turn the child sees himself. The article mentions that when a child is labeled their parents indirectly and even subtly let the child know that they are of limited value because of the diagnosis and in turn the child will have negative feelings about themselves grow stronger and the child then begins to lose touch with his own feelings.

    The comment that Greenspan and Throndike were referring to was that of the idea that many times when child is becoming unorganized a therapist likes to “fix” it and make their play or ideas more organized. The authors say that the therapist does this because even though they outwardly say it is to help the child the therapist is actually doing it to help themselves become organized in the situation. Greenspan and Thorndike warn against this because by organizing the child’s thoughts or play you will not really see what the child is trying to tell you with their un-organization. The authors suggest to let this type of play go on for a few minutes to see where it leads because it can be a gateway into a lot of good information about the child and the symptoms that the child is having. One suggestion that did not sit well with me was the fact that the authors suggested that the therapist should not ask questions but instead make declarative statements. I understand that by making statements that the therapist is helping the child to put his thoughts and feelings into words but when an interview is going on there needs to be questions so the therapist can start to formulate the case and what is going on and what symptoms the child is having.

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    • Paige Hartmann
      Jun 19, 2014 @ 11:04:27

      Sara,
      I like the point you discussed about the negative impact of labeling a child. How parents treat their child based on the child’s diagnosis can cause the child to have a negative view of himself/herself. It is important for parents to be understanding and supportive of their child to prevent this from happening.

      Reply

  8. Rebecca Boisvert
    Jun 19, 2014 @ 00:41:46

    1. Although Moustakas’ article was not CBT in nature, I thought that several of the child therapy techniques may be beneficial for those who wish to work with children. One suggestion that Moustakas gives is to remember to view the child as an individual who is capable of self-determination, and problem solving challenges with solutions that will best fit his/her own life. I think that this is important because not only does the therapist validate the child’s feelings, but he also allows the child the freedom of figuring out the problem on his/her own, rather than fixing it for them. I think as adults, and definitely as therapists, the tendency is to want to step in and make it all better for the person who is in need, especially if that person is a child. However, by empowering and guiding the child to try to find a solution themselves, the therapist is conveying the message that they trust and believe in their capability to do so on their own. I believe as a therapist, the importance of guiding, rather than fixing may be more important than if the solution was given immediately.
    Another beneficial component of child therapy that Moustakas describes is the importance of a stable, unchanging office/therapy area. Moustakas aptly describes the child’s life outside of therapy as inconsistent and unstable. However, the therapist and the therapy area should remain a consistent aspect of the child’s life which he can rely on for strength and support. This is important for several reasons; one being a strong therapeutic relationship should develop as a result of the reliability that the child feels from therapy. Second and possibly more important is the fact that the child should have reliability and consistency in order to develop successfully.
    Finally, Moustaka’s scripted examples that are given provide several important therapeutic messages, one being that underlying issues are very common in children. Often what presents on the surface (the behavior) is just the consequence of another issue that may be hidden from sight and usually a much larger problem than what can be seen as the behavior. A therapist should take care not to judge too quickly when oftentimes there is an underlying issue which should be addressed in order to treat the overt behavior issue.
    2. The second reading by Greenspan and Thorndike emphasize that the therapist’s desire to structure the session in ways which are to their liking, or which will produce the most clinically significant data may cause them to alter the manner in which the child is playing in order to gain the most therapeutic advantage. Furthermore, the authors state that a therapist may personally experience feelings of anxiety during observation if the child is exhibiting behaviors that are outside the realm of what is considered “typical”. Greenspan and Thorndike provide the example of a therapist who is observing a child who has begun to play in a disorganized manner. His first impulse is to redirect the child, and restructure the play. However, eventually, the therapist decides to allow the child to play freely in order to gain the best therapeutic data.
    There are a few things that don’t sit well with me in the Greenspan and Thorndike article. First, I do not agree with the practice of restraining children who require it for disciplinary reasons or otherwise. It is understood that restraint severely distresses the therapeutic bond formed by the client and therapist, and I think that it should be avoided at all cost. Second, I found the author’s statement about not asking questions during the interview contradictory to what I understand to be beneficial in the therapeutic process. Although the authors were not suggesting that the therapist shouldn’t interact at all, their recommendations were to make related/observational statements instead. While I think that this form of information gathering can be very useful, it can also be leading and suggestive to the client, and it also may cause boredom and frustration if only one form of questioning is used during this part of the interview.

    Reply

    • Paige Hartmann
      Jun 19, 2014 @ 11:12:49

      Becca,
      I liked your discussion of the importance of a stable therapy setting. Providing this consistency to children within therapy is necessary since many of these children face inconsistencies in their every day lives. I agree with you when you said that providing this stable environment will help to build a strong rapport with the child since it is reliable.

      Reply

    • Melysa Faria
      Jun 19, 2014 @ 14:01:47

      Rebecca,
      I agree with your point about Greenspan and Thorndike’s discouragement of using questions during a session with a child. Used with moderation, questions can be very helpful in eliciting information. However, I do think that asking too many questions with children can be overwhelming and the repetition of the same question may lead them to change their answer to what they feel the therapist would like to hear. I feel that observation of the child’s behavior and allowing them to lead the discussion can be highly beneficial in interpreting some things that the child may not be able to express verbally, especially depending on the child’s age. Many of the questions during the initial intake of information should be questions that are asked of caregivers rather than children, since they may not be old enough to understand what the question is asking or they may not know the answers to the questions, so direct observation may provide more information in some cases than asking direct questions.

      Reply

  9. Anthon Rofino
    Jun 19, 2014 @ 09:29:52

    1) Moustakas (1959) presents some ineresting ideas regarding relationship therapy. The first is the focus on the present compared to the past. Where CBT can focus on precipitating factors that led for the need for therapy and tackles these issues, relationship therapy focuses on the here and now of a child, which i think can be very useful. Secondly, the therapy puts the client in the “driver seat” so to speak. The child makes all of the decisions, which the therapist encourages. The therapist engages in the child’s whims and engages the child to think about his/her decisions that best suite their life. This is interesting because it allows the child to make bad decisions, but to learn and grow through them through the therapist, as they may benefit the child in the end. Finally, the therapeutic space should be consistent to contradict the chaotic life of the child. I think this is an important aspect that should be applied to all therapy. The therapeutic space should be a place of consistency and stability for the client.

    2) I think with the statement from Greenspan, it is important that, when doing the initial interview, that no therapeutic techniques be used, and instead, a more observational approach be taken. What this means is, if the child is exhibiting anger or anxiety, it is very natural for a therapist to employ various therapeutic techniques to help the child cope with these feelings and descelate the client. To not do so may cause an anxiety in the therapist because, while they have the tools to help, doing nothing could feel like a disservice to the child. However, the opposite is true. In order to get the best picture of the child in crisis requires the therapist not to intervene as to gauge what is necessary in therapy to work on. If the child is soothed quickly, it could lead to the therapist thinking less work needs to be done on certain aspects. Physical restraints did not “sit well” with me. I say this due to personal experience, as i work one on one with children. In my field, I have been taught that under no circumstances am I allowed to physically restrain a child, even though i have been properly trained to do so, for liability reasons. Even in a setting with a parent involved, if a parent does not like the way you restrained their child, it could lead to legal ramification and without a witness, lead to disaster.

    Reply

    • Larrisa Palmer
      Jun 20, 2014 @ 23:49:59

      Anthon, I agree with the statement from Greenspan that the initial sessions should be used mainly for observation. I realized that has I practice conducting therapy sessions my initial response is to jump into intervention mode because I want to help my client to cope or feel better. Though it may seem appropriate in the moment, I realized that there are several disadvantages of moving too quickly, so I definitely appreciate this reminder.

      Reply

  10. Angela Vizzo
    Jun 19, 2014 @ 09:51:54

    Three suggestions from the Moustakas reading that I found useful are that the child is encouraged to express themselves, talk, and make decisions which allows the child to gain self-esteem; the therapist gives the child undivided attention and conveys to the child that they will never be criticized for what they say or how they feel; and that there are limits set which convey responsibility. All of these points are important in developing a relationship with the child and providing a therapeutic environment.

    This comment refers to the anxiety a therapist may feel by watching the child go through a difficult time, we want to comfort them or stop the behavior but as long as it doesn’t become harmful to the child it is best to observe and see what coping skills the child has and how they deal with it on their own. It can also be anxiety provoking to watch a parent respond to the child inadequately, but this as well provides data on the parenting style. Finally, it is important to observe how the parent responds to different tasks asked of them and see how they handle their own anxieties. All of this information provides details on the environment of the child and the nature of the problem that can then be utilized in treatment. One thing that didn’t sit well with me was approaching the child first upon first meeting them. I understand the rationale for this, it conveys to the child that you are there for them and are their ally, but it still doesn’t feel right and could be misconstrued as disrespectful by the parents, especially if it is your first time meeting them as well.

    Reply

    • Jane Jenkins
      Jun 19, 2014 @ 10:30:37

      Angela, I liked that you recognized that the play environment encourages an unconditional positive regard Rogerian sort of atmosphere for the kids. It is almost as though, if done correctly, they can walk into a whole different world. No matter what they say or do they will be respected and understood. What better way to give kids freedom to express problems they are experiencing?

      Reply

  11. Jane Jenkins
    Jun 19, 2014 @ 10:27:07

    1) The three suggestions that I think are useful for therapy with youth are a) creating an atmosphere that provides a child freedom to talk b) understanding that limits provide the structure for growth to happen c) seeing a behavior all the way through to gain the best understanding of it.
    a) I really appreciate the idea that the play room becomes a special place with an entity all its own, and an intention of making the child feel comfortable and free, not only to play, but to express whatever feelings or behaviors need to be expressed. This seems to be a really pure (for lack of a better word) way to facilitate a child’s expression of difficulties. It seems to meet them where they are at.
    b) Using limits as a vehicle through which to observe how a child regards them, tests them, and grows past a conflict regarding them, was never something I thought about until I read this article. I like how it can be used to create a stronger relationship between the therapist and the child if handled correctly.
    c) Restraining impulses to intervene when a child behaves inappropriately, to witness how they manage their anxiety, frustration, or ability to regulate themselves makes a lot of sense, though I imagining myself just sitting witness to this seems difficult. I agree that breaking up a behavior limits the therapist’s ability to fully understand the child’s conflict though, and it is a skill well worth acquiring.
    2) What Greenspan and Thorndike are referring to when they talk about therapists not letting their anxiety interfere with observations is that we cannot let our own discomfort interfere with how well we observe, or cause us to cut off the child while they are trying to tell us the story. If we are uncomfortable, we may stop listening intently enough to pick up on things. In addition, If we interfere because we have become uncomfortable with a story, we will miss out on important information that the child may have revealed had we let him or her continue. Their idea is “the less you intrude, the more the child will tell you” (p. 148). I can definitely see how this would be true while observing parent-child interactions.

    Reply

  12. Robin Horsefield
    Jun 19, 2014 @ 12:48:13

    The Moustakas chapters had some interesting ideas. The first being the beginning of the first chapter talking about the appreciation that the therapist must have for the “uniqueness” of the child. The author specifies that the therapist must focus on the child in their present state, and this reminded me of the group therapy class last semester where we talked about staying in the “here and now.” The therapist must focus and help the child explore the present feelings before exploring their deeper origin. Another is the discussion about the environment. While unstructured materials are essential, I thought the discussion about the “safe haven” aspect of the room was more important. The child needs to understand that they are safe and free from judgment in the therapy room. When they understand this point, they may then be comfortable enough to confront the negative thoughts that have brought them to therapy. Related to this was the last suggestion regarding the therapist-client relationship. The chapters emphasize the importance of a warm and regarding relationship between the therapist and the child. Only through this relationship can the child explore the “full intensity, impact and meaning of his generalized negative feelings.”

    Working with children can be difficult because as a society we believe in the purity of childhood. We are uncomfortable with pain, loss, or other not-so-nice things that happen to children when they are young. Greenspan and Thorndike list as one of their two main principles that a therapist must be willing to “tolerate his or her own discomfort as well as that of the patient” during sessions. I think that what the authors mean is that therapists need to be able to recognize and put aside when we are feeling uncomfortable about a line of discussion with a child and monitor our responses. The authors give an example that if a therapist moves in too quickly to dispel an anxious thought then the child will not earn to cope for himself. The authors could also be alluding to experiences that the therapist has had for themselves that they may see reflected in a child. For instance if a child talks about the sadness they feel over losing their family pet and the therapist experienced something similar, the therapist must stay present in the session and with the child.
    Greenspan and Thorndike also made some suggestions for conducting a clinical interview that I struggled to accept. The authors made a point of telling the reader to hold back explaining to the child who the therapist is and why the child is there for therapy. I can understand that the therapist may get a sense of the child and their coping strategies, but I don’t know if I could just sit and watch a child who is getting visibly uncomfortable. Another suggestion from the chapter is less of a suggestion and more of a theoretical difference, but at the end, the authors talk about how to interpret statements made by the child. The one that sticks out the most was a girl who talks about things that stick out and the authors suggested that this meant that she was afraid to stick her neck out. This interpretation did not make sense and made me cringe. A final suggestion was discussed for when a child gets too aggressive; the chapter talks a little about how to physically restrain the child. Perhaps this is a personal issue for me, but I do not know how I would respond if I felt that physical restraint was necessary and a parent was not present.

    Reply

    • Larrisa Palmer
      Jun 21, 2014 @ 00:12:11

      Robin, I also would have an issue if I have to physically restrain a client in therapy. I guess it’s based on where you work because I work at a residential program and the clinicians there restrain clients all the time. Having the knowledge of how unpredictable and aggressive a client can get sometimes I’m a bit concern; I think if it’s a life and death situation wherein I’m unable to call for help in the moment, then I would definitely restrain that client.

      Reply

  13. Larrisa Palmer
    Jun 19, 2014 @ 13:05:22

    1. Although Moustakas’ reading was not CBT in nature, there are several important concepts that can be utilized when working with youths. This therapy highlights the present, living experience of the child, where the therapist begins where the child is and focuses on his or her feelings rather than on the past. The therapeutic process is one in which the therapist conveys acceptance, respect and warmth toward the child. The child is encouraged to make his or her own decisions and explore his or her thoughts and feelings. Another important factor in the relationship therapy that can be used with youths is limit setting. Limits define the boundaries of a relationship; provide structure and offer security that allows the child to play in a safe environment.

    2. Greenspan and Thorndlike stated several times that therapists should not let their own anxiety interfere with their observation of the child or parent-child interaction. This comment is referring to the fact that many therapists may become uncomfortable and anxious when a child is exhibiting a particular behavior and may move in too quickly to support the child. For example, if a child is rigid and silent, many therapists may become uncomfortable with this and breaks the silence within a few seconds instead of waiting to see if the child can initiate a conversation on his or her own. One of the disadvantages of move too quickly is that therapists run the risk of not observing the full extent of the child’s psychopathology. Greenspan and Thorndlike are therefore encouraging therapists to tolerate their own discomfort as well as that of the child in order for certain symptoms to manifest fully.
    I do not agree or support the suggestion that was made in regards to physically restraining a child in therapy, if a child has an outburst or is physically aggressive there are less restrictive ways to deescalate the child. Moreover, if the child does not want participate in therapy I think that therapists should not force the child in the moment because he or she may become more non-complaint and associate therapy to a place where they go to get torture.

    Reply

    • Angela Vizzo
      Jun 20, 2014 @ 23:04:51

      Larissa, I agree with you about not restraining the child or forcing them to play when they do not want to. I feel like Moustakas’ idea of letting the child direct the therapy session would be more of the way I would practice. I would not force a child to engage in an activity that they do not want to and on the same lines, I wouldn’t force a child to stay in the room if they wanted to leave either. By doing these things it is very easy to loose the child’s trust and undermine the relationship.

      Reply

  14. Melissa Symolon
    Jun 19, 2014 @ 13:28:59

    Although the reading from Moustakas (1959) is about relationship therapy, there were multiple elements that can apply and be useful in CBT. Much of the article was related to the therapeutic relationship and developing rapport with children. He cites that the therapist should be warm, accepting, empathetic, that structure and boundary setting is important to establish early on, and that the therapist respects the child’s values and what he/she shares during therapy.
    There was a statement on p. 5 of the article that reminded me of the cognitive triad of the person’s environment, their personal dispositional characteristics, and their behavior. Moustakas stated “When the child regards himself as worth while, when he values his contribution to others, he is one the road to the recovery of a self in control, a self in which is growing…” This statement reminded me of the triad because it expresses how one’s self image, their behaviors, and the interactions with the surrounding environment are continuously changing and growing.
    A third point that is useful to cognitive-behavioral therapists is that the setting and toys can be used with young children to recreate and interpret “significant interpersonal situations” (p. 7). As we have talked about in other discussions, CBT is often difficult to do with young children because they have difficulty identifying their thoughts and feelings. Using metaphors and representations during play therapy can be more beneficial to them.

    Greenspan and Thorndike (2005) state that a therapist should not let their own anxiety interfere with their observations of a child. To me, this statement simply means that therapists should remain objective and not project their own feelings and experiences into those of a client. To remain objective, therapists should let children express their feelings and thoughts and not push through the interview because it is uncomfortable for them. They also state that therapists should note when such anxieties when a child brings them up. I think this is to prepare the therapist for the topic to come up again during future sessions and to evaluate their own reactions and skills at facilitating a therapeutic discussion that benefits the client.

    Reply

    • Nafi
      Jun 19, 2014 @ 16:54:33

      Melissa, I agree with your pointed out themes from the Moustakas article. The way which we interact with our clients is very important and can impact the development of a relationship. Also the setting which we do therapy may be welcoming and warm or uninviting for the child. Choosing a setting that is inviting and presents options for the child is also good, especially for younger children.

      Reply

  15. Nafi
    Jun 19, 2014 @ 14:32:27

    The reading by Moustaks was an interesting read as the concepts were not the ones that I am used to reading. One topic that could be a utility for therapy with youth is “the unique nature of the child.” Not often stressed, but the reading describes that the child should always be regarded as a person with individual integrity. Sometimes when working with children, we tend to forget that they are individuals and just as with working with adults we are fostering change and growth. Another useful concept that was pointed out is, focusing on internalizing issues and working through them to reach positive feelings. Feelings such as anger, sadness, low self-esteem and/or anxiety can truly take hold of someone’s life. Many times people come to therapy lacking more effective tools and strategies for managing these emotions. The shift from entering treatment at an all time low and leaving at a higher level of functioning is amazing to see. This is one of our goals as therapist to help our clients reach their highest level of adaptive function and to be able to do this outside of treatment. One final idea that stuck out was, the setting of therapy. This is an important factor for doing therapy with all age groups and populations I believe. We want clients to feel safe in the environment and a free will to express their deepest concerns or thoughts. With children this is important because sometimes the setting of the room can foster in developing rapport and establishing a therapeutic relationship.

    The comment by Greenspan and Thorndike I believe is referring to not jumping to quickly to comfort the child when he/she is upset. The authors suggest that doing this may take away from the therapists’ ability to experience the symptoms first hand and observe the nature of it. Moreover, there are some behaviors that may make us feel uncomfortable because we may not understand the behavior. This makes me think about when working with an anxious individual and we instruct the client o sit with the anxiety and experience the feeling that in the end, nothing will come from it. As therapist we will have to do this as well and in the end, it will contribute to our growth as clinicians. Not every client will be pleasant and nice and that is simply the reality of working with human beings. A suggestion for the clinical interview that did not sit well with me was offering food to youth or holding them when upset. Boundaries is a very important concept overall and should be upheld within therapy and especially with children. For some children, this may be a very vulnerable time and being held by their clinician could go in opposite directions.

    Reply

    • Julianna Aguilar
      Jun 20, 2014 @ 14:13:46

      Nafi, I like how you pointed out the utility of understanding the uniqueness of the child for two reasons. First, when working with children, we have talked a lot about how therapy can be nearly as effective, if not more effective in some cases, to simply work with the parents namely around parenting techniques. By doing so, we may overlook some of the important and unique aspects of the particular child as they change throughout the course of therapy. I think it is important to find a balance of accepting and understanding the child as a unique individual, though also providing the best treatment possible (which sometimes may mean not having the child there). Second, there are a lot of basic parenting techniques that therapists may teach parents (e.g., reward, time-out, etc.). By learning about the uniqueness of the child, the therapist will be able to work with both the child and the parent to adjust these techniques to cater to the child’s unique qualities.

      Reply

    • Rebekah Kiely
      Jun 21, 2014 @ 02:03:48

      Nafi,
      I strongly agree with the statement you made about the importance of boundaries and personally, I believe the leniency the clinician was exhibiting relative to crossing boundaries is especially worrisome with such a young client. I think the offering of food or the way in which the therapist rocked the child is something that will come off as very ‘parental’ and as such may impact the relationship between the therapist and client. I am concerned about the possibility that a child in such a situation would grow too dependent on the therapist and subsequently lead to further issues.

      Reply

  16. Rebekah Kiely
    Jun 19, 2014 @ 14:34:15

    (1) I liked the three topics of freedom to talk, the use of the playroom, and the constant sensitivity to the child. In this therapy the child is encouraged to talk and express himself in order to allow the child to develop a strong sense of self-esteem. I find it intriguing, but I also wonder how such a method will be helpful for cases in which the child is simply shy and his/her personality is that in which talking to people he/she does not know very well is uncomfortable. What if encouraging a child to talk distressing him/her even more? The use of the playroom in this type of therapy is very interesting; Employing the use of toys and the entire room as a whole to gather a picture of the child and allow him/her to express him/herself in play and action and allowing for the release of many feelings we would likely not know about at all in younger children especially I find may be very useful. Finally, the theme of constant sensitivity to the child is implied throughout this entire reading and I believe that no matter the therapeutic orientation a therapist works by being sensitive to the child so as to understand what the child is really trying to communicate whether vocalized or not.

    (2) Greenspan and Thorndike’s comment about therapists own anxiety interfering with their observations of the child refers to the possible level of discomfort a therapist may experience during a session with a child. I believe this refers to the extent to which the therapist’s own behavior can impact the way in which a child presents. In other words, we as therapists, from Greenspan and Thorndike’s perspective want to get a view of our client as they truly are; we want to observe their behaviors and interactions without impacts it with our own behavior or feelings. The ability of a therapist to manage this discomfort during a session with a child can be difficult; personally, I would find it very challenging emotionally if I had to choose to ignore a child presenting with real significant distress and I have to ignore those emotions to attain an accurate observation of the child. The mentions of making contact with a child before making contact with the parents and physical restraint were disconcerting to me. I can’t imagine a child would really react very well if someone they considered to be a total stranger went straight to them without any recognition by their parents, though this will likely depend on the child. I also wonder about the parents reaction to this. Using physical restraint on a child in my opinion I completely disagree with; If I had a client who was becoming unmanageable I would never use any physical restraint myself, I would leave that to the parents if at all possible.

    Reply

    • Sarah Chelio
      Jun 20, 2014 @ 16:25:43

      Rebekah,

      I, too, would find it difficult to ignore my own discomfort and just observe. I think it is an initial reaction to see a struggling child and help. I do understand the article’s rationale behind not doing so, but this would require time for me to get used to. I also agree with your opinion on the use of physical restraints. I do not think that is good for the relationship and it is not something I would feel comfortable with doing.

      Reply

    • Juliana Eells
      Jun 21, 2014 @ 08:31:17

      Rebekah,
      I thought it made sense to follow the child’s lead and let them express themselves freely as Moustakas described, but I also wondered about children who are shy or do not automatically start talking as well. What if a child comes in and just sits there not talking or playing with anything for whatever reason? Sometimes kids will need more direction in such a new situation that might be anxiety provoking for them.

      Reply

  17. Melysa Faria
    Jun 19, 2014 @ 14:51:20

    1. Moustakas (1959) discussion on psychotherapy with children highlighted many important suggestions of how to build and maintain a healthy and trusting therapeutic relationship with children. Although this article does not focus on the use of cognitive-behavioral therapy as the primary therapeutic orientation, it contains many useful concepts regarding the process of constructing and sustaining a therapeutic relationship with children and adolescents.

    One of the first points I felt could be very useful to keep in mind when working with children is Moustakas emphasis on waiting in relation to the child’s discovery and expression of himself/herself. He states “Waiting is a positive force, a commitment of faith actively expressed by the therapist”. Having patience with a new client and allowing them to move at his or her own pace is very helpful in building a strong rapport with a client, especially if the client is a child. Moustakas main point about waiting is that the therapist must allow the child to get to a point where the child feels he is ready to gain more autonomy; this is not a process that can be forced upon someone. However, I think the concept of waiting and having patience can be particularly important when working with children or adolescents that have experienced trauma. In cases such as these, the trust building process may take a longer period of time. Showing the child unconditional acceptance and listening to expressions of experiences or emotions as the child is ready to share them can create a healthy and strong relationship.

    I also agree with Moustakas that having unstructured toys and activities available to the child during sessions can be useful in emotional expression, or even as a coping skill if the child is talking about something difficult (i.e. squeezing a stress ball). However, I do not think structured items like toy guns, knives, swords, and darts are appropriate therapeutic activities. Although this could be a way to take out some anger and aggression, I feel that allowing toys such as these can encourage aggressive behaviors and lead to increased aggression in the future with real guns, knives, and other weapons. When I am working with children, I always keep paper, markers, fidgets (i.e. stress balls) and playing cards with me in order to use these activities if they are needed to allow the child to express themselves in different ways or have some type of coping skill available.

    The last aspect discussed by Moustakas that I found to be very important when working with children, regardless of the type of therapeutic intervention the therapist uses with the child, is limit setting. Setting limits on how long the session lasts and how to use materials appropriately in session can be useful not only to the boundaries of the therapeutic relationship, but it is also good practice for children who have difficulty with boundaries and following rules at home, in school or in the community. Having limits in therapy can be an intervention for impulsivity and help the child work on decreasing defiance. Limits and boundaries used in therapy sessions can be discussed with parents or other professionals working with the child in order to generalize the limits and boundaries the child faces across different areas of their life and create consistency.

    2. Greenspan and Thorndike (2005) state that “during the first phase of the interview, you should be concerned with the child communicating why he is there, how he views you, and how he understands the situation.” If a child senses any type of anxiety that the therapist is experiencing, this may affect what the child shares with the therapist, how the child views the therapist and how the child feels about the situation. This can interfere with the observation process and it could also cause bias on behalf of the therapist due to subjective opinions, past personal experiences and discomfort. In order to create a trusting and open therapeutic relationship, the therapist must be able to view the client and the client’s situation objectively. The article also discusses the importance of allowing the child to organize his or her own themes and see how he or she responds to the new situation. Allow the child to show naturally how they react to a situation rather than jumping in immediately and intervene with any feelings of anger or anxiety the child may have. This will give a more accurate picture of the child’s behaviors.

    The main part of the article that did not sit well with me is something many classmates have mentioned; the use of restraint. While there may be times when restraint is unavoidable (i.e. if the child attempt to harm themselves or someone else), then it may be necessary. However, it must not be something which is used regularly and if a child’s behaviors are severe enough to require restraints then it is likely that the child requires more intense services than an outpatient setting.

    Reply

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Adam M. Volungis, PhD, LMHC

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