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Joel Pomerantz December 22nd, 2004 04:23 PM

dealing with "internalizing" in children
Does anyone have any advice on how to engage a child (12 yr. old) who is a classic "internalizer", in cognitive therapy (or any therapy!) - He doesn't really see a need to change anything (won't admit that his negative self view is impacting his performance through lack of self-efficacy etc. and isn't really willing to open up and discuss feelings...) the student has a mild learning disability and a long history of sub-average achievement. Thank you so much for this invaluable resource!!

JustBen December 22nd, 2004 04:53 PM

Re: dealing with "internalizing" in children
That's a tough one. If he doesn't think that he needs to change anything, then he obviously doesn't want to be in therapy. Of course, someone does or else he wouldn't be there. Instead of questioning him directly about his problems - which places you in the role of hostile interragator - maybe you could begin the discussion by asking about the referral source.

For example, you may ask:
Why do you think X wanted you to come and see me?
Where might X get such an idea?
What do you think X thinks about this?

If he still denies doing or saying anything that might have caused X to refer, you might ask, "So if X really just sent you here without any good reason, then you must think X is just a bad person?"

Either way he chooses to answer this question, he's opened a door. If he denies that X is a bad person, then you can ask, "Well, if X isn't a bad person and has your best interests at heart, then he/she must've had some reason for wanting you to come and see me. What would you guess that is?" If, on the other hand, he agrees that X is a bad person, then you can begin gathering evidence for and against that belief.

I don't know, though. This could be terrible advice. It's just what popped into my head. Good luck.

Joel Pomerantz December 22nd, 2004 09:24 PM

Re: dealing with "internalizing" in children
Thank you! that sounds like a great approach... not very different from the approach that I have used in the past with "externalizers" i.e. wouldn't you like to get (refferal source) to stop nagging you / get off your back etc... I'm glad that I still have a week of winter break to mull it over:-)

Joop Meijers December 23rd, 2004 04:01 AM

Re: dealing with "internalizing" in children
According to Bordin's by now classic and generally adopted conditions for a working alliance between therapist and client there are three necessary components:
1. strong bond between client and therapist
2. agreed upon goals
3. agreed upon tasks

Since none of the conditions seems to exist I wonder if the child ought to be your client or the adult that apparently referred the child to you.
Very often ( and research supports this) it is better, more effective to work with the parents or caregivers of the child then with the child itself.
So maybe also in this case it may be worthwhile to reconsider wether to work with the child or the adult.

dr. Joop Meijers

Micah Perkins December 24th, 2004 04:35 PM

Re: dealing with "internalizing" in children
It does sound like a difficult case. I agree with a lot of what Ben said. Possibly asking the child "if your mother (or whoever referred him) were here what would she say?", "what do you think that your mother would want you to work on?" "How do you feel about your mother bringing you here?" If you start getting an emotion out of him (which I am guessing will be anger) then you have your foot in the door. "What about ____ makes you feel angry?" "When you think about ____ what are some of the ideas that go through your mind?"
But.... on the other hand, if he still doesnt give anything then you could either 1. Tell him something like "if I were failing all of my classes, I think I would be feeling pretty mad or sad. Are you feeling this way?" He replies "no". "Well, then we are obligated to spend this hour together for the next few weeks, what would you like to do during our time."
Even if several of the first sessions are just spent playing games, you are building rapport with him and he may start to discuss how he is feeling about things.
Or...2. You could ask whoever brought him (mother, father, whoever) to come in on the session. In the presence of the kid, ask mom why she brought him here, etc. You may start seeing some emotion out of him then, and may be able to start working on some issues.

In the end, my initial thought is that this kid is used to failing and has subsequently "cut" himself off and has disconnected from things so that he will not be hurt. He probably sees you as just another person to tell him what to do and to remind him how he is such a failure. I think reestablishing a connection (by building rapport with him, and working on his relationship with his parents- who are probably adding to his feelings of being a failure) are key, In addition to working on his self defeating beliefs. What may also be helpful is to focus on things he is doing well (what has he succeeded at, how did he feel, what did he do, what were his thoughts, etc.) By using a more 'balanced approach' between 'problem talk' and 'solution talk' (as my solution focused therapy friends would say) it may help him overcome his belief that he is a failure at EVERYTHING and that he will ALWAYS fail.

Just some guesses,Hope this helps, good luck


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