The Role of the Therapist in Therapeutic Change: How Knowledge From Mental Health Can Inform Pediatric Rehabilitation

ABSTRACT

The therapist is a neglected and poorly understood variable in pediatric rehabilitation. Much more attention has been paid to the role of intervention on client change than the role of therapist-related variables. This article synthesizes what is known in the adult and child mental health literature about the role of the therapist, and integrates this with work in pediatric rehabilitation. The article reviews the mental health literature on the therapist as a random variable associated with client outcomes (role of the therapist alone) and the role of three other therapist-related constructs: the therapist-client relationship (therapist and client), treatment implementation (therapist and intervention), and therapy process (therapist, client, and intervention considered holistically). Implications for clinical practice in pediatric rehabilitation include recognition of change as a multi-determined phenomenon involving common therapist-related factors, the therapist's role in creating facilitative conditions for change (through supportive relationships, positive expectancies, and mastery and learning experiences), and the importance of training in collaborative partnership skills. A contextual approach to therapeutic change is advocated, in which psychosocial factors and mechanisms are acknowledged, the therapist is seen as crucial, and the intervention process is seen as the context or vehicle through which changes occur.

KEYWORDS.:

• Alliance
• client change
• collaborative relationship
• family-centered care
• fidelity
• therapy process
• treatment expectancies

ABOUT THE AUTHOR

Gillian King's primary interest is in the psychosocial aspects of pediatric services and child, youth, and parent well-being.

APPENDIX 1: CASE EXAMPLE OF THE CONTEXTUAL MODEL

Jeremy is a 5-year-old boy with cerebral palsy receiving the services of a physical therapist, Liz, along with his mother, Rachel.

During the initial assessment, Liz invests time to find out about Jeremy, his mother, and the family (adopting a holistic, contextual perspective). Liz's intent is to create a setting where Rachel and Jeremy feel comfortable sharing information, knowing that developing a positive therapeutic context and relationship will be essential for mobilizing change in physical therapy. Liz learns about Jeremy's interests and what he would like to do, engaging his mother Rachel in the conversation. Through a stance of positive regard, genuineness, and collaboration, Liz strives to understand the family situation, Rachel's hopes for Jeremy, their goals for therapy, and the types of interventions that align with child and family beliefs, needs, and priorities (building a collaborative partnership).

Picking up on Rachel's hesitancy to be seeking services for her child, Liz adopts a non-judgmental and empathic approach. She invites conversation and asks questions in a respectful manner, recognizing that Rachel is an essential partner in the co-construction of meaningful and manageable therapy goals and plans. Over a few sessions, Rachel becomes more comfortable and engaged in the physical therapy sessions. She offers more opinions, and helps Liz understand what they have tried before at home and in the community, and what seems to work and what does not. Liz asks Rachel what she is looking to get out of physical therapy for her son. The foundation for a therapeutic relationship is set, in which Rachel feels free to express her views, engage in mutual goal setting, and agree or disagree with therapy directions (considering therapist-client-intervention—holistically and contextually; D in Figure 1).

Over time, as a result of their conversations and as Jeremy enters school, family goals shift and therapy tasks are adjusted to fit Jeremy, family preferences and situations, and Jeremy's school life and friendships. In addition to considering Jeremy's needs and the best intervention for him, Liz engages with Rachel to understand present family goals, values, and desired family activities, and offers her own knowledge of appropriate evidence-based interventions and personalized therapy strategies that might make a difference (considering therapist-client-intervention—contextually and over time; D in Figure 1).

Liz recognizes that there are fluctuations over time in her relationship with the family, as well as fluctuations in the importance of therapy in the family's life, the goals that are most important to them, and their sense of success and feeling of hope. She strives to meet the client where they are at on any given day. In each session, Liz reflects on how she herself can best engage with the family, asks what they are thinking and feeling, and fine-tunes the intervention to Rachel's reports of successes and issues. Liz listens carefully when Rachel has concerns about the intervention and together they come up with workable alternatives (considering therapist-client-intervention—as a process; D in Figure 1).

Mindful of key psychosocial aspects of mobilizing change (Figure 2), Liz routinely considers and invests in relationships with both Jeremy and Rachel, and considers how she can best support the family to take the next steps toward their goals (mindful of building a supportive relationship; Figure 2). She pays attention to what the family is learning, how the intervention is working for the family, and what the family thinks of the intervention—whether they buy into it or not (mindful of fostering positive expectancies; Figure 2). She pays attention to their sense of trust and comfort in sharing their thoughts and feelings, their confidence in carrying out co-constructed therapy tasks that are meaningful to the child and family, and, when needed, seeks to enhance their confidence in making desired changes through pacing, in-session practice, and other strategies (mindful of mastery and learning experiences; Figure 2). Above all, Liz sees her role as setting the conditions that will best facilitate and support change for this unique family. She is mindful of how the smaller therapy tasks relate to the larger desired goal of the client.

What is Different?

• Liz realizes the importance of adopting a holistic, contextual, and process-oriented perspective in which she invests in the relationship with the family because she sees its value. She trusts in an unfolding, dynamic, and co-constructed intervention process to meet their needs.

• Liz is comfortable with the complexities of the therapy process. She sees that fostering change is much more than providing a family with an intervention, and that failure to truly understand the client situation and failure to develop a collaborative relationship will be counterproductive in the long run. She believes positive therapeutic context and relationship are key drivers of service delivery.

• Liz explicitly considers how to manage the intervention process as a whole. She recognizes that child and family as active and essential partners in developing the intervention, and takes client thoughts and feelings about the intervention and the intervention process into account.

• Liz is highly mindful and present in her interactions with Rachel and Jeremy. She focuses on the overall therapist-client-intervention, is continually thinking about what is happening in relational terms, and considers how to mobilize change given this gestalt. In other therapy models, person, activity, and context/environment are more likely to be considered separately and/or non-iteratively, and the process of managing change is not as explicit. In this approach there is awareness that many factors influence change in different amounts and at different points over time.