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Therapist perspectives on the

therapeutic alliance with children and
adolescents
a a
Adele Frances Campbell & Janette Graetz Simmonds
a
Psychology Programs, Monash University , Building 6, Wellington
Road, Clayton, Victoria 3800, Australia
Published online: 11 Oct 2011.

To cite this article: Adele Frances Campbell & Janette Graetz Simmonds (2011) Therapist
perspectives on the therapeutic alliance with children and adolescents, Counselling Psychology
Quarterly, 24:3, 195-209, DOI: 10.1080/09515070.2011.620734

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 Counselling Psychology Quarterly
Vol. 24, No. 3, September 2011, 195–209

Therapist perspectives on the therapeutic alliance with children and

adolescents
Adele Frances Campbell and Janette Graetz Simmonds*

Psychology Programs, Monash University, Building 6, Wellington Road, Clayton,

Victoria 3800, Australia
(Received 10 August 2010; final version received 8 August 2011)
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Bordin’s pan-theoretical conceptualisation of the therapeutic alliance

identifies three underlying, interdependent components: bond, task and
goal. In the research reported here, therapists’ perspectives of significant
contributions to the therapeutic alliance with children aged 2–5 years, 6–11
years and adolescents aged 12–17 years were investigated. Sixty three
questionnaires regarding alliance conceptualisation, therapist, parent and
child contributions, alliance barriers and demographic information were
completed. Five therapists were also interviewed about their development
and maintenance of the therapeutic alliance with children. Personal
conceptualisations provided by participants highlighted the collaborative
nature of the therapeutic alliance, with prominent themes emerging of
alliance bond, parental alliance, therapist resources and therapist
self-awareness and well-being. Therapist empathy and cultivation of trust
were valued by therapists as bond contributions. Parental support and
commitment to the therapy was rated as the most significant parental
contribution. Interview accounts highlighted the importance of therapist
understanding, reassurance and support extended to the parents.
Keywords: therapeutic alliance; children; adolescents; therapist
perspectives; empathy; trust

The therapeutic alliance is a much discussed aspect of the therapist–client

relationship and has attracted significant research attention with over 2000 studies
recorded up to 2002 (Kazdin & Whitley, 2006). Green (2006, p. 426) observed that
the term ‘therapeutic alliance’ is ‘an umbrella term for a variety of therapist–client
interaction and relational factors operating in the delivery of treatment’ and there are
numerous other definitions offered in the literature. A number of factors that may
contribute to the development and maintenance of the alliance have been proposed,
including therapist and client aspects, technical factors, process factors, type of
pathology, treatment type and demographic factors. Research has shown varied
findings and conflicting views regarding the aspects influencing the alliance, which
may reflect various theoretical conceptualisations and research methodologies. There
is an empirical evidence of the relationship between therapeutic alliance and
treatment outcomes (Horvath, 2001a; Horvath & Bedi, 2002) and the importance of

*Corresponding author. Email: janette.simmonds@monash.edu

ISSN 0951–5070 print/ISSN 1469–3674 online

ß 2011 Taylor & Francis
http://dx.doi.org/10.1080/09515070.2011.620734
http://www.tandfonline.com
 196 A.F. Campbell and J.G. Simmonds

this relationship for both adults and children is widely recognised (Green, 2006;
Hubble, Duncan, & Miller, 2002; Shirk & Karver, 2003). Hubble et al. (2003) report
that around 30% of client improvement is accounted for in the therapeutic
relationship, emphasising the importance of the alliance in therapeutic change.
Research on the child alliance, however, has not been given the same attention as
with adults, despite it being highly valued by the therapist, parent and child (Kazdin
& Whitley, 2006; Shirk & Karver, 2003).
Freud first conceptualised the notion of therapeutic alliance, believing that the
‘proper rapport’ or ‘effective transference’, and an ‘analytic pact’ were necessary for
the patient to hear the analyst’s interpretations (Byerly, 1993; Freud, 1912, 1937;
Shaughnessy, 1995). His term of ‘effective transference’ was later renamed by
Fenichel as the ‘rational transference’ (Schowalter, 1976; Summers & Barber, 2003).
A positive rational relationship coinciding with irrational aspects of the transference
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was recognised as necessary for analysis. The term ‘therapeutic alliance’, introduced
by Zetzel (1956), was used to describe this concept, and later referred to by Greenson
(1965) as the ‘working alliance’ to include various clinical aspects (Byerly, 1993;
Horvath, 2001b; Novick, 1970). Various models of the alliance emerged, further
developing the concept and reflecting various theoretical backgrounds. Bordin’s
pan-theoretical conceptualisation of the alliance identifies three underlying,
interdependent components: bond, task and goal (Bambling & King, 2001;
Bordin, 1979; Cecero, Fenton, Nich, Frankforter, & Carrol, 2001). ‘Bond’ describes
the system of positive attachments between the client and therapist, including trust,
acceptance and confidence. ‘Task’ includes the interventions that form the
counselling process, seen as relevant by both client and therapist. ‘Goal’ describes
agreed outcomes and priorities (Hougaard, 1994).
The importance of the alliance is broadly recognised as significant in influencing
therapy outcomes (Bambling & King, 2001; Green, 1996, 2006; Horvath, 2001b;
Horvath & Bedi, 2002; Marziali, 1984; Shirk & Karver, 2003; Tryon, Blackwell, &
Hammell, 2007), but the literature reports differing opinions on aspects which may
influence the development of the alliance with children. Fostering an alliance with
children may be more difficult because children rarely refer themselves for treatment,
can be reluctant to enter therapy, infrequently recognise the existence of problems or
agree with adults on therapeutic goals (DiGiuseppe, Linscott, & Jilton, 1996; Green,
2006; Horvath, 2001a; Oetzel, Bolton, & Scherer, 2003; Shirk & Karver, 2003).
Children may have difficulty forming therapeutic relationships as a result of their age
and cognitive capacities (Faw, Hogue, Johnson, Diamond, & Liddle, 2005; Green,
2006; Shirk & Karver, 2003) and because of the nature of possible transferences,
phantasies, psychological issues and stages of ego formation (Mishne, 1983).
Understanding more about the influences contributing to a positive alliance is
therefore essential.
The capacity for empathy is recognised as a significant therapist characteristic in
developing the alliance (Diamond, Liddle, Hogue, & Dakof, 1999; Olden, 1953).
Rothschild (2006, p. 47) describes empathy as ‘a highly integrated process involving
both cognitive and somatic, brain and body’. DiGiuseppe et al. (1996) however,
assert that the goals, and second, the tasks of therapy, with children are the most
important aspects related to outcome, and that research has placed too much
emphasis on the bond.
Training, motivation and experience are believed to enhance skills in alliance
development (Green, 2006; Kazdin, Seigel, & Bass, 1990; Krupnick et al., 1996).
 Counselling Psychology Quarterly 197

McKay, Hibbert, Hoagwood, Rodriquez, and Legerski (2004) emphasise that

training in engaging families represents a first step from clinical research settings into
‘real world’ settings and supports mental health providers in implementing changes
in their practice. Henry, Strupp, Butler, Schacht, and Binder (1993), Horvath (2001a)
and Shirk and Phillips (1991) argue that therapist characteristics rather than training
are significant contributions to the alliance, and that a therapist’s personal
characteristics may be more difficult to modify through training than technical
skills (Shirk & Phillips, 1991). Horvath emphasised the role of the therapist’s
attachment style and temperament on the quality of the alliance.
The parent/therapist alliance in child therapy is seen as a significant underlying
aspect in supporting the development of the alliance with the child (Frederico,
Jackson, & Black, 2005; Kazdin & Whitley, 2006; McKay et al., 2004; Shirk &
Phillips, 1991). Research on parental perceptions of alliance supports and barriers
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indicates that providing information and follow-up phone calls, addressing practical
issues and potential barriers, encourages parental confidence and co-operation
(McKay et al., 2004). McKay et al. propose that further research in the area of
alliance development with children and families, which includes inquiry of child,
family and provider perspectives in accounting for service use, is needed.
This study explored therapists’ perspectives of the therapeutic alliance with
children using a mixed methods design. It incorporated a questionnaire, plus
additional semi-structured interviews with five participants. The questionnaire
sought therapists’ perspectives of valuable components, contributions and potential
barriers to the therapeutic alliance. The interview explored in more depth therapists’
personal perceptions of the aspects influencing alliance development.

Questionnaires
Sample and procedure
Three hundred questionnaires with covering letters were sent to individual
psychotherapists who indicated in publicly available listings that they provided
psychotherapeutic services to children, either in private practice or in organisations
providing services to children. Additionally, a posting on the Australian
Psychological Society (APS) website, in ‘Research Opportunities’, extended an
invitation to participate in the research.

Materials
A purpose-designed survey questionnaire which included open ended questions was
employed. The questionnaire sought therapists’ personal understandings of the
therapeutic alliance, value of alliance components and contributions from the
therapist, child and parents, views on potential alliance barriers and preferred
treatment modalities.

Participants
Fifty-three women and 10 men from metropolitan, regional, rural and remote areas
of Australia, with training in psychology, psychiatry, psychotherapy, social work
and welfare work, returned completed surveys. While 43% of participants worked as
 198 A.F. Campbell and J.G. Simmonds

sole therapists, 55.6% worked in teams with a median size of 6.5 people (Mdn ¼ 6.5).
Thirty-six per cent of respondents reported having fortnightly supervision, 16%
weekly supervision, 16% monthly supervision and 27% accessed supervision as
needed. Thirty-five participants (55.6%) indicated that they had participated in
personal therapy.
Of the participants, 60% worked with children from 2 to 17 years of age, 17.5%
worked with children from 6 to 17 years of age and 17.5% worked exclusively with
adolescents between 12 and 17 years of age. Of the participants, 68% indicated that
their professional work place was the primary therapy space, i.e. their office or
organisation therapy room. Thirty-three per cent of survey participants also
provided therapy in the client’s school, as a secondary workplace. Twenty-six per
cent of participants identified the child’s home as their third most utilised therapeutic
setting.
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Results
Participants were asked to rate, on a scale of one to five, from not important to very
important, the importance of each of the three alliance components of Bordin’s
therapeutic alliance model: goals, tasks and bond. Overall, the bond was rated as
very important by 68% of participants (see Table 1). Therapeutic goals were rated as
being very important by 25% of respondents and tasks were rated as very important
by 19% of participants.
In a broader perspective of alliance contributions which included a rating scale of
one to seven, 65% of participants rated therapist bond as the most important
feature, followed by therapist personal qualities (20.6%). Therapist training,
supervision, experience and goals were also rated highly as important therapist
features
The child’s contribution to the rapport and the child’s attachment style were
rated highly as the most important child aspects influencing the alliance (27% and
20.6%, respectively). Presenting diagnosis was rated by 14.3% of participants as the
third most influential child aspect. Developmental/cognitive and social/emotional
issues, the impact of trauma and the child’s ability to trust, were also rated as
influential child aspects contributing to the development of the therapeutic alliance.
Forty-one per cent of participants reported that parental support, which included
commitment, involvement in and respect for the therapy, was the most important
parental contribution with the younger groups of children. The parents’ relationship
with the child, which included parenting skills and emotional relationship/
availability to the child, was rated by 19% of participants as the most important
parental aspect, followed by parental insight into the child’s problem (14.3%).
Parental emotional stability and stability of home-life were also considered to be
important influential aspects on alliance development.
Participants were asked to identify the most frequently experienced barriers in
alliance development in the three age groups. Issues regarding parental support,
payment, attendance and transport were considered the most important barriers in
alliance development for children in the 2–5 year and 6–11 year age groups. Lack of
motivation, lack of goal focus and perception of problem were rated as most
important adolescent barriers by 41.3% of participants. Adolescents’ fear and
 Counselling Psychology Quarterly 199

Table 1. Therapist, child and parent aspects influencing the therapeutic alliance showing first,
second and third most important aspects (participants ranked aspects in order from 1 to 7).

Percentages

First Second Third

Percentage endorsement by rank order of first, second and third most important aspects
Therapist aspects
Bond 65.1 44.4 39.7
Personal qualities 20.6 33.3 25.4
Training 3.2 4.8 12.7
Child aspects
Rapport 27 22.2 11.1
Attachment issues 20.6 14.3 20.6
Diagnosis/problem 14.3 15.9 19
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Parent aspects
Support/commitment/involvement/respect for therapy 41.3 23.8 20.6
Relationship with child/parenting skills/emotional availability 19 14.3 11.1
Insight re child’s problem and therapy needs 14.3 11.1 4.8

anxiety about participating in the therapy was rated as the most important alliance
difficulty by 17.5% of respondents.
More therapists reported a greater significance of the parental alliance in
supporting the therapeutic alliance with the child for 6–11 year olds (56.9%) than for
2–5 year olds (50.8%). More therapists reported achieving a very strong alliance with
6–11 year olds (58.8%), than with 2–5 year olds (23.8%) and with adolescents (38%).
Similarly, more participants reported feeling very confident in developing the
alliance with 6–11 year olds (51%) than with 2–5 year olds (23.8%) and
adolescents (44%).
Play therapy was reported as the primary treatment modality with children up to
5 years of age and the second most frequently used modality with children between 6
and 11 years of age. Cognitive behavioural therapy (CBT) was the primary treatment
modality for children between 6 and 11 years of age and for adolescents, with client
focussed/strengths based treatments, narrative therapy and motivational approaches
utilised almost equally as secondary treatments for adolescents.

Alliance definition/conceptualisation
Participants’ definitions or conceptualisations of the therapeutic alliance were
analysed using interpretative phenomenological analysis (IPA; Smith, 2003, 2004;
Smith & Eatough, 2006). Participants emphasised the collaborative nature of the
relationship, the importance of common goals and mutual understanding of the
presenting issues. The therapist’s ability to understand the child’s view of the world
was often referred to. Client conditions, including the child developing trust and a
sense of safety and security were frequently included as necessary in facilitating a
purposeful relationship.
 200 A.F. Campbell and J.G. Simmonds

Some definitions included recognition of the relationship of the therapeutic

alliance with outcome, while others highlighted the importance of the therapeutic
alliance in facilitating the therapeutic process, for example, participants wrote
concerning the therapeutic alliance: ‘allows the space and freedom to explore who
they are and wish to be without any feeling of obligation to the counsellor’ and
‘supporting them from behind, communicating confidence that they will move
forward’.
Many definitions expressed the importance of the bond, and related aspects
including rapport, warmth, trust, respect and empathy, with trust being referred to
most frequently. The following conceptualisation emphasised a working relationship
over the bond aspects, and the possibility of change without a very strong alliance,
supporting the views of DiGiuseppe et al. (1996). A participant noted:
. . . building a relationship is not important but building a working relationship is
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essential. Although there is obviously a strong correlation between the alliance and
outcomes this does not mean that a strong alliance is essential to good therapy. With
highly motivated children or with a few problem areas, such as panic attacks, rapid
change is possible without much of an alliance.

Interviews
Method
Five therapists additionally participated in semi-structured interviews, which were
audio-recorded, transcribed and then individually analysed. In accord with IPA
method, notes and comments were made by the interviewer (the first author) for
each interview, and emerging themes were identified, using key phrases. The themes
were summarised and recorded, with the transcription page, line number and short
quote beside it. Themes were then clustered together as master themes and compared
across each interview, so that new super-ordinate themes across all cases were
produced. Final emerging themes were significant to all the participants in the
interviews.

Participants
The five interviewees, one male and four females, were between 50 and 60 years of
age, with 7–17 years experience in therapeutic work with children. Three
psychologists, one family therapist and one therapist with training in bioenergetics
and expressive therapies participated. (The pseudonyms of Pam, Genie, Colin, Meg
and Camille are used for the five participants to maintain anonymity.)

Results
The therapist/parent/carer relationship
The benefits of a positive parent/carer alliance emerged in the accounts, particularly
for children in the younger age groups, up to 11 years old. Parents’ fear or reluctance
to engage with the therapist may have a significant effect on their child’s relationship
with the therapist:
 Counselling Psychology Quarterly 201

. . . if the parents have had experiences where they don’t trust um, anyone, that transfers
to the child so then the child is picking up all the signals and messages from the parents
not to trust, anyone . . . (Colin)
Building the alliance with the parents by helping them feel comfortable, nurturing
their trust, reassuring them of their adequacy as parents and showing respect for
their relationship with their child were remarked on. Pam and Meg found that
having the parents and younger children attend the first sessions together helps
establish the parent’s trust with the therapist, which then transfers to the therapist’s
relationship with the child:
. . .‘if mum is afraid I should be afraid, if mum is anxious I should be anxious’ (child’s
thought) and so, as I soothe mother then as I am able to soothe the child, then as the
mother trusts me the child trusts me.
Meg balanced this with a caution about the difficulties of managing the parent’s
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disclosures about the child, in front of the child, although the opportunity to observe
the child’s attachment style and relationship with the parent is valuable.
Meg also found that working with the parents, teachers and other professionals
enables a more comprehensive assessment and intervention for the child. However,
this creates the possibility of the parents perceiving a confidentiality breach by the
therapist, which undermines their trust. Meg’s experience highlighted for her the
importance of sensitivity with information shared by parents, when working with
teachers and other professionals. Clarifying roles and expectations with parents and
professionals is equally as important.
Besides their trust, parents’ confidence and sense of efficacy in their parenting
skills need to be considered. Meg helps parents build a sense of efficacy through
communicating to them that they are the experts. Genie promotes the parents’
confidence by taking a collaborative team approach with them and providing
positive feedback on what they are doing well: ‘I’m very aware that parents need
encouragement. . .I tell them all the good things that they are obviously doing that
are coming out in their child that I observe’. She engages the parents in activities with
the child to enhance their understanding of the child so that ‘they can learn from the
inside out’. Pam found that encouraging the parent to ‘catch the child being good’
can help form a parental alliance, as well as positively enhance the parent’s view of
the child. Camille found that education on child developmental issues provides
parents and carers with a different understanding of the child, which usually brings a
positive response.
Education, support, encouragement and feedback by therapists encourages
parental confidence as well as the parental therapeutic alliance.

Therapist and client bond

The therapeutic bond was described in various ways by participants, including
phrases such as a humanistic approach, empathic understanding, trust, therapist
authenticity, confidentiality and intuition. Colin described the therapist as being a
‘welcoming blank sheet’ and having ‘an openness and a genuineness that you have to
bring to that first few minutes of the relationship . . . emotionally, intellectually,
physically . . ..’. Genie proposed that being respectful and offering unconditional
positive regard formed the essence of developing the alliance. She expressed that the
humanistic approach; seeing the child’s world through the child’s eyes and ‘ignoring
 202 A.F. Campbell and J.G. Simmonds

diagnostic labels’ put onto the child when the child entered the room, as being
essential for developing the bond. Meg takes each individual child or adolescent ‘as
they come in the door’, deciding which of her skills and resources will be needed.
Gaining the trust of the child emerged as a significant aspect of the alliance
development in both children and adolescents, more particularly in adolescents. Meg
pointed out that adolescents developmentally are seeking identity, separation and
individuation, and in this process they are beginning to think differently about the
adults in their world. The quality of the therapeutic alliance requires a neutral stance
and this can be achieved ‘when they take me out of the category of parent, teacher,
authority figure’ (Genie). Meg reflected this view: ‘I really try to remove myself from
any parental kind of figure . . .’.
The accounts highlighted the ability of adolescents to detect insincerity in the
therapist; ‘I think they have a different kind of a radar and certainly – certainly can
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pick up insincerity’ (Pam). Trust is very much engendered through openness,

genuineness, authenticity and being non-judgemental, ‘who I am, is what I bring to
my work. . ..I don’t think you can pretend, I don’t think you can fake it’ (Meg). Pam
found that ‘honouring the client’s truth’; validating the adolescent client and their
story was crucial – ‘don’t ever negate that might have happened’.
Intuition, being attuned to the client’s feelings and what is needed in the moment,
was considered integral to the therapist’s understanding and empathy. There was a
sense that intuition is a personal quality that the therapist brings into the therapeutic
work they do, that enables them to read in the moment what is needed and to feel
empathically what the client is experiencing. ‘Intuition is really powerful’ (Colin),
though not always clearly understood, ‘. . ..I suppose it’s a bit like reading auras in
that respect, you’ve just got to be open to it, don’t you . . .’. Colin described how
intuition supports the development of the alliance, and includes a sense of empathic
understanding of the client’s pain and a communication of this to the client.
Meg noted that ongoing attuning to the child’s or adolescent’s responses and
levels of comfort, and adjusting to what is happening therapeutically, is a constant
and active process for the therapist, but which needs to be allowed to develop. Meg
remarked: ‘it’s a right brained decision making process, it’s not a logical ‘‘now this,
now this, now this’’’. Genie explained ‘I don’t think you can do this work from a
purely a head position, from left brain, from knowledge. This has to come from deep
within you; it has to be integrated within your person’. From the accounts, there was
an underlying sense that, coupled with experience, the therapists valued a
humanistic, intuitive, creative and ‘right brain’ approach to the development of
the bond.

Finding Fantasia: therapists’ creativity in the use of resources and the therapeutic
environment
Participants described the therapeutic space as being ‘the child’s world’. Pam and
Genie created a special space for their young clients, ‘it’s like a wonderland and so
I just lead them by the hand and they instantly decide what – what appeals to them’
(Pam). Pam finds the therapeutic environment allows children to contain their own
anxiety, allows their curiosity to come out and is a retreat if they are not feeling safe.
 Counselling Psychology Quarterly 203

The child’s curiosity can then expand so that ‘they can become curious about other
things in their life that are more difficult’.
Genie talked about the use of the therapeutic environment in fostering a
collaborative approach to the alliance:
we externalise whatever’s going on for the child into the environment . . . we’re both
focusing on this externalizing . . . of the issue and in that, the child and the therapist
become the alliance, and there’s a lot of power - and strength in that.
The therapeutic environment set up by Genie extends beyond the therapy room
to the quiet surrounds of her rural setting and allows children to leave the outer
world and come into their inner world of emotions and deeper parts of themselves.
‘Sometimes we abandon everything and go down the paddock and pat a sheep and
sometimes. . .the conversation that happens on the way down to the paddock and the
way back, that is the critical connection’. In a similar way, Camille found
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that travelling in a car helped facilitate discussion, which in turn helped nurture the
alliance. Sitting beside the child without direct eye contact, and having the
distractions that occur while travelling in a car created a safe enough environment
for a reluctant child or young person to be willing to engage.
Meg developed the alliance with the child through imagination, play and a rich
array of resources and materials to capture the attention and imagination of her
young clients. She spoke of the need to also experience in herself, through her own
inner child, the joy of the therapeutic surrounds: ‘you’ve got to have a – a sense of
fun and delight’.
Colin found that the school environment tended to offer very limited resources.
Often the therapeutic space is ‘everything from a video store room, to a cupboard
to. . .maybe using a room that some-one has to vacate’. This adds to the difficulties of
developing the alliance with some resistant children, and Colin likened this to finding
the one grain of sand left in Fantasia, from ‘The Neverending Story’ (Ende,
1979/1984). He talked about the creativity needed in finding that one last grain
of sand:
the . . . ‘nothing’ is taking over Fantasia and . . . there’s only one grain of sand left of
Fantasia . . . that’s what it’s like, trying to find that one grain - the one interest or the one
thing that you can build on with the child.
In the absence of the wonderland environment to nurture the alliance, Colin
relied on his own internal resources and joined with the child imaginatively in finding
spaces and activities, creating opportunities for the alliance to develop: ‘you can
create your ‘Fantasia’ I suppose. . . kids of that age are imaginative too’.
The style of therapist creativity, incorporating past experiences of what had
worked, varied between therapists but was found in their imagination, in the
resources they could provide, and in how they could work with limited resources.

‘Therapist know thyself’: therapist self-awareness

There was a shared view that what happens in therapy is a contribution from both
therapist and client, with about 60–70% attributed to what the therapist is feeling
inside at the time. Therapist self-awareness therefore plays a significant role. Being
 204 A.F. Campbell and J.G. Simmonds

present for the client, being empathic, genuine and understanding, requires
therapist’s awareness of their own unresolved childhood issues and the potential
impact on the therapist and/or the client. Put succinctly by Pam, ‘therapist know
thyself’. Genie expressed similar feelings:
unless you’re very familiar with your own fears and your own emotional baggage, your
own woundedness that you bring from childhood, from the less than perfect nurturing
that we all got, um unless you’ve dealt with your own, how could you possibly walk in
the child’s shoes and be empathetic.
Camille’s self-awareness included her reflection on her parenting of her own
children and her growth as a parent through work experience, training and study.
Keeping in mind her own less than perfect parenting of her children helped her work
with the parents and carers.
Meg suggested that therapists’ awareness of their own adolescence can help them
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empathise with and validate the issues of the young person they are working with;
‘your own adolescence, you know, your own experience, you’ve got to kind of be
able to. . .validate, I think, what they’re saying’.
Supervision was agreed on as being fundamentally important to therapist
well-being, in understanding personal issues and identifying stress levels. Meg
expressed it, ‘if you don’t do that (supervision), you run, you’re in danger of . . . being
misdirected in what you do, or even developing an inflated idea of what you can do’.
Genie, who is professionally isolated in the rural environment where she lives, finds
support through regular weekly phone contact with therapists who share a similar
work philosophy and work style.
Pam proposed that if therapists’ adolescent issues have been worked through, if
the therapist is being well supported in ongoing supervision and has received
appropriate training in working with adolescents, energy levels can be maintained
and the work is ‘never’ draining. Colin on the other hand pointed out how much
energy an hour of therapy could demand, especially when exposed to the client’s
anxiety and depression; ‘You’re using a lot of energy with that empathy and that
listening and just being present for them’. Genie noted that when ‘working with
children - the essence is being fully present’. To be fully present and commit so much
energy, Colin believes therapists need to learn how to separate themselves
psychologically from the feelings of the client to some extent. He described this as
a process of responding genuinely with empathy, but with some distance, not
allowing himself to feel too much of the client’s distress ‘ . . . it’s definitely not fake,
it’s a psychological separation so that you do not become too . . . damaged or stressed
from the, you know, empathy response’. Balancing workload with other activities,
monitoring client numbers and resting between clients, also helped participants to
manage their stress levels.

Discussion
The parent/carer therapeutic alliance
The interview participants attended to potential parental alliance barriers by
providing parents with information, advice, reassurance and positive feedback on
their parenting skills. McKay et al. (2004) reported positive parental alliance
outcomes from similar strategies. Providing early feedback on the meaning of the
child’s behaviour and ‘catching their child being good’, described in the interview
 Counselling Psychology Quarterly 205

accounts, may assist the parent’s ‘mentalisation’ of the child’s mind – ‘the ability to
represent the behaviour of self and others in terms of underlying mental states’
(Fonagy & Bateman, 2005, p. 1). Sorensen (2005) described this as the opportunity to
look at things from a different perspective, which relieves parents from feelings of
helplessness, rage and guilt, and allows them to see that they can have a powerful,
intuitive and empathic function. This positive experience for the parents may
strengthen the parents’ trust in the therapist and therefore the alliance, beyond the
practical strategies outlined by McKay et al. (2004).
The therapists’ encouragement of joyful feelings in the child, and educating
parents ‘from the inside out’ in the accounts, can make a substantial clinical
improvement before any intervention work occurs. Regarding child attachment
development and brain neurology, Barish (2004) noted the importance of positive
affect in therapist–child and parent–child relationships. An intersubjective affect
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state develops during the infant’s first year of life, enabling the child to participate in
the emotional state of the other and to experience joyful qualities of social
interaction (Schore, 2003). Barish proposes that problems for some children referred
to therapy may have resulted from intersubjective affective experiences being
impaired in early years. Encouraging joyful feelings in the child, and teaching parents
how to play in therapy sessions, may help to heal the effects of early attachment
disruption in the child, leading to positive outcomes and enhancing the parent’s
confidence in the alliance.

Therapeutic bond
The ability of the client to detect insincerity and trustworthiness in the therapist,
described as young clients ‘having their own radar . . . ’ highlights the importance of
therapist sincerity, honesty and authenticity in developing trust. The literature
supports the views that adolescents respond poorly to insincerity and pretence but
respond well to candor or ‘being real’ (Oetzel et al., 2003). Interview participants
employed a ‘judicious approach’ (Barish, 2004; Oetzel et al., 2003) which included
‘honouring the client’s truth’, ‘validating’ the clients’ feelings and experiences and
being removed from the ‘parental figure’. Participants referred to letting the client
‘tell their story’, which may assist adolescents in identity formation and autonomy
development (Diamond et al., 1999).
Being in touch with the ‘fun and delight’ of the child within themselves, allows
therapists to be responsive to the child’s positive affect. This is significantly the most
important aspect of successful child therapy (Barish, 2004) and is experienced by the
child as ‘being known’. Putting diagnostic labels ‘on shelves’, taking the child or
adolescent as they come, treating each child individually and ‘declinicalising’ the
therapy, are approaches which concur with assertions by Shirk and Phillips (1991)
that children and adolescents are not a homogenous group and should not be treated
with ‘developmental uniformity’ or in a framework resulting from short course,
manualised treatments.
The interview participants’ descriptions of intuition: ‘right brain rather than
logical’ and ‘akin to reading auras’ resonate with Rothschild’s (2006) explanation of
mirror neurones in the human brain. Internal emotional (bodily) feedback from the
mimicking of another person’s facial expressions or bodily behaviours is the
probable mechanism underlying somatic empathy, which may manifest as what is
 206 A.F. Campbell and J.G. Simmonds

known as mind reading, intuition or Extra Sensory Perception (ESP) (Rothschild).

Like Rothschild, participants believe that ‘intuition is really powerful’ and empathy
is an essential personal characteristic of the therapist which may be developed over
time, but which many therapists may also bring into the profession.

Therapist creativity
The interview accounts illustrated the therapists’ creative orientation in establishing
an appropriate therapeutic environment, allowing play and discovery.
The creation of the therapeutic room, likened to a ‘wonderland’ or Enid Blyton
type of ‘magical environment’ was reminiscent of the therapeutic environment
experienced in the well-known account of the treatment of Dibs by Axline (1964).
Similar to Axline’s approach, the child could interact with whatever appealed in the
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environment, externalising deeper, emotional issues onto the activity or medium,

independent of verbal communication. However, not all therapists have this
opportunity and face the task of creating their own ‘Fantasia’ with children in
under-resourced environments. Maintaining the joy of the ‘child within’ also
supported the therapists in establishing and maintaining the alliance, again calling on
their internal resources: imagination, self-awareness and well-being.

Therapist self-awareness and well-being

Therapist self-awareness and well-being is integrated within and underpins all other
themes in the interview accounts. Interview participants emphasised being ‘fully
present’ and recognised that supervision, training and counselling are essential for
therapists to participate optimally in therapy with their clients.
Interview participants acknowledged that while their own childhood or
adolescent issues could be valuable for client empathy, they could also be
counter-productive to the therapeutic process, could undermine the alliance and
could lead to exhaustion in the therapist. Rothschild (2006) describes empathy as the
‘connective tissue’ of good therapy which hones the tools of insight and intuition, but
also points out that the neurological, psychological and somatic mechanisms of
empathy can lead to compassion fatigue or vicarious traumatisation. She discusses
being fully present as a dual awareness, attending to and reconciling both external
and internal sensory information in the therapy. A psychological separation from the
clients’ issues discussed in one account, was possibly achieved by the therapist
consciously separating themselves from the clients’ situation; a process proposed by
Rothschild as a cognitive exercise, which can be learned by therapists and
deliberately practiced in the therapy. From a psychoanalytic perspective, it can
also be seen as the necessity of the therapist being aware of their counter-transference
issues, and taking care to not over-identify with their young clients.

Conclusion
This study focussed on therapists’ perspectives of the aspects which influence the
therapeutic alliance with children, using data gathered by both questionnaire and
interview. Definitions of the therapeutic alliance supplied by participants emphasised
collaboration and bond, with a predominant focus on therapist contributions to the
 Counselling Psychology Quarterly 207

bond. Data from both sources very strongly highlighted the positive contribution
of the bond and bond elements, including empathy and trust, to the
alliance development. Therapist characteristics, training and supervision were also
highly valued. In the interview data, participants also considered that the parents’
commitment and support to the therapy was essential in developing the therapeutic
alliance with the child, and that the quality of the parent/therapist alliance
contributes significantly to the quality of the alliance with the child. Development of
parents’ trust, validation of their parenting abilities, and helping them understand
the emotional experiences of their child, served to develop the alliance with parents,
and supported the relationship between the parent and child. Therapist creativity,
self-awareness and ongoing self-care serve to support the therapists and their
therapeutic relationships with their clients.
This study provides insight into therapists’ perspectives, based on their
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therapeutic experience, of aspects which contribute importantly to the development

and maintenance of the therapeutic alliance with children. This study, like other
studies of their nature, is limited by the self-report methodology employed. Future
research, using IPA and including both therapist and client perspectives in accounts
of alliance contributions, may reveal further interesting themes.

Notes on contributors
Adele Campbell is a graduate of the Counselling Psychology Program at Monash University,
Melbourne, Australia and now works as a psychologist working in an outreach position in
rural Australia. In her previous role she provided specialist assessment and intervention for
children and adolescents with complex attachment and trauma issues.
Present address: West Vic Division of General Practice, 148 Baillie Street, Horsham, Victoria
3400, Australia.
Janette Simmonds is a senior lecturer and coordinator of the Counselling Psychology Program
at Monash University, and a psychotherapist and group analyst.

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