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.