▪ Psychotherapies

▪ Psychotherapies

The origins of psychotherapy can be traced to diverse sources. Freud attempted to understand the horse phobia of a child (Little Hans) in light of his own theories of development and the unconscious. Early behaviorists noted the important role of learning in fear and fear conditions (e.g., the case described by Mary Jones in 1923). Over time, the field of psychotherapy as it applies to children and adolescents has expanded dramatically. During this period, the predominant mode of scientific inquiry has shifted from the focus on the single clinical case to research methods using groups of children in clinical trials. Modern approaches pay considerable attention to issues of study method and design, use of standard measures, manualization to ensure replicability, and so forth (see Weersing & Dirks, 2007).


An important and immediate issue is the question of whether psychotherapy works. The first review of psychotherapy, now more than 5 decades old, raised important questions about the effectiveness of psychotherapy (i.e., over rates of improvement noted in untreated children and adolescents). This result corresponded, in many ways, to an influential review questioning the efficacy of psychotherapy in adults. Both sets of findings were the source of much debate. Thoughtful consideration of these early efforts identified several important limitations of the then available research. These included nonrandom assignment to treatment, lack of attention to independent evaluations, the need for careful control and comparison groups, and so forth. Recognition of these limitations led to the development of more effective clinical trial research.

A substantive body of research is now available, and it has become possible to conduct meta-analytic reviews in which the results of carefully selected studies can be pooled and analyzed. Results can then be summarized in terms of overall effect size. Typically, a statistic such as the statistic proposed by Cohen’s d quickly conveys how different a treatment group is from a comparison in terms of units of standard deviation. For example, a d of 0.2 would usually be termed a small effect size, and a d of 0.8 would be viewed as large.

In the first review of this kind in psychotherapy for children, Casey and Berman (1985) noted a reasonably good effect size (0.71). Subsequent work has generally confirmed that medium to large effect sizes are frequently observed, similar to those reported in adults. Subsequent research has also addressed issues that may moderate treatment outcome (e.g., variables in child, family, and environment). Interestingly, the nature of the child or adolescent’s difficulties does not appear to straightforwardly related to the degree of improvement. Children and
adolescents with internalizing-type problems (depression, anxiety) are just as likely to profit from intervention as are those with externalizing difficulties (conduct disorder, attentional problems). If appropriate controls are used, adolescent girls are more likely to improve, and behavioral interventions appear to be generally more effective than more traditional psychodynamic approaches. On the other hand, some treatments, such as interpersonal therapy (IPT) for adolescents with depression and multisystemic therapy (MST) for youth with conduct problems, do not easily fit into this simplistic dichotomy. Clearly, some treatment approaches, such as family or group therapy, may also include both more behavioral and more psychodynamic elements (Kazdin & Weiss, 2003).

The movement toward evidence-based treatment has factored heavily in attempts to evaluate psychotherapies. To qualify as evidence based, a treatment must have been shown to work in two independent, carefully designed, controlled studies with random assignment to treatment and comparison to either a placebo or comparison treatment group. (Some argue that well-controlled single cases studies could also qualify if these were sufficiently numerous.) The term probably efficacious has been used when the study design is less stringent (e.g., through comparison of treated cases to a wait list control). Using these guidelines, a series of psychosocial treatments can be regarded as well established for conduct disorder, enuresis, and phobias; the evidence for anxiety and depressive disorders suggests that treatments for patients with these disorders are probably efficacious. Behavioral treatments have been much more numerous, and accordingly, they are more likely to be identified as evidence based than more traditional psychodynamic ones. In the current climate of concern about health care reform and use of potentially scarce resources, it is not surprising that issues of evidence-based treatments have become the focus of much debate. Even when the efficacy of a specific treatment model has been established, typically in a highly research-oriented setting, important questions of the effectiveness of the treatment in real-world settings must also be addressed. The typical university setting for clinical trials offers many advantages in terms of access (e.g. extensive logistical support, the potential for careful training and monitoring treatment methods over time). If conducted as part of a research project, participation may be free or participants may even be paid for being involved. Unfortunately, only a few studies have actually addressed the issue of treatment effectiveness in more usual treatment settings. In one review, Weisz and others (1992) found a handful of studies of clinic treatment as usual and noted that the mean effect size was near zero. Various attempts have been made to address this problem (e.g., through enhanced service coordination), but results have been disappointing. Thus, there is a major gap between what can be done in research settings and what actually happens in the community.

Attempts have been made, particularly in the areas of depression and anxiety disorders, to address these issues, and initial results are encouraging. Studies have also examined combined treatments (e.g., medication and cognitive behavior therapy [CBT]) suggesting a modest benefit of adding CBT to drug treatment. Other efforts have focused on the effectiveness of work with parents, notably in the area of parent management training (PMT), in which studies evaluating both clinical use and cost effectiveness of this approach have appeared with initial positive results (e.g., in reducing number of arrests). Given the public health and social policy significance of youth conduct problems, these results are particularly encouraging, and the approach has been adapted for other populations, including for substance abuse.

Clearly, psychotherapy can work for children and adolescents. The question of how it works remains an important topic for research and active area of debate. The question is a difficult one to answer for many reasons. Even a highly structured treatment will include multiple components, any of which, or any combination of which, may be most relevant to particular problems. For example, in work on anxiety using CBT, is it the explicit teaching of relaxation that is more important or the education, or is it the exposure to the anxiety-provoking situation or the combination? Further problems arise given our limited understanding of the pathophysiology. Only a few studies have attempted to understand treatment processes. It will be important for future work in this area to develop more relevant measures, that is, beyond the typical child and parent report and observation scales, to more direct measures of behavior or physiology.


Insight-oriented or psychodynamic psychotherapy is the oldest of the psychotherapies and has its origins in the attempt beginning the 19th century to understand mental activity, the interplay of mind and brain, and symptoms and conditions that could be related to these processes. Sigmund Freud’s contribution remains substantial, and modern methods owe a considerable intellectual debt to him (e.g., of the conscious and unconscious mind and the importance of developmental issues in understanding symptoms; see Chapter 1). Freud’s case of “Little Hans” provides one of the first reports of attempts to engage in psychotherapy with children. Because of Freud’s emphasis on the importance of early experience in the analysis of adults, he and his students had a strong developmental orientation. Several of his early trainees, including his daughter Anna, began direct work with children. From early on, this work noted the importance of an awareness of development, the role of parents, and the special complexities of work with children (e.g., the role of education, the place of play activities). In England, Melanie Klein developed the model of play analysis as the analog of free association in adult psychoanalysis and emphasized interpretation with a focus on core issues. In contrast, Anna Freud, who moved to England with her family shortly before World War II and who had been trained as a teacher, emphasized the “educative” functions of child therapy as well as interpretation. The war in Europe, and increased interest in mental health issues after the war, contributed to an influx of European-trained psychiatrists and analysts in the United States. Their ideas influenced a generation of therapists and had an impact on the approaches to treatment used in child guidance clinics, congregate care programs, and similar settings.

Goals of psychodynamic psychotherapy often involve changing patterns of thought, feeling, or behavior that are partly, or even fully, not in the individual’s consciousness. This process also relies on the importance of the relationship with the therapist attempting to help the patient. The notion of transference arises in the regard and refers to the tendency of people to treat the therapist in ways they believe they have been treated. In addition, there is a significant “real” relationship with the therapist that may also further the psychotherapeutic process; this is particularly the case in work with children. Usually, the therapist attempts to understand the patient’s difficulties in light of his or her early history and experiences as well as in the context of the direct observations and interaction with the patient.

Freud elaborated a complex theory of psychological functioning (see Chapter 1), and at different points in his professional life, he emphasized different features, but his theory was always strongly developmental. He highlighted the interplay of biological factors and psychological ones in both normal development and psychopathology. He emphasized the importance of sexual development and believed that the surface (conscious behaviors, thoughts, and feelings reported by people) could be studied scientifically and was multiply determined and that aspects of unconscious or not fully conscious issues could be inferred based on observation and discussion with the patient. His theory also emphasized the importance of conflict (external or internal) in the formation of difficulties and of various “drives” (sexual or aggressive) that the individual must cope with. As a practical matter, his therapy took the form of talking, or with children, playing, to clarify the nature of conflicts and developmental arrests and distortions (i.e., in the various ways, maladaptive and adaptive, that the individual dealt with these). One of the goals was to make conscious operations or response patterns that would otherwise remain unconscious and continue to be acted out or acted upon in some way. This was done as the therapist gathered data over time and could make interpretations. Freud also viewed the tendency of the patient to relieve past relationships within the therapy (transference) as important and noted that the therapist could similarly have feelings about the patient (countertransference) that also provided information.

Freud’s theory evolved over time but had a tremendous influence on the development of models of the mind and mental illness in the 20th century. Many aspects of Freud’s views have been incorporated into other aspects of psychology and many of his concepts have influenced educational practices and child care. Over time, a myriad of other models and approaches have appeared. For example, one group, the ego psychologists, developed a strong interest in understanding the working of the ego. Many members of this group were interested in children’s
development and child psychotherapy. Another group developed in response, or counterresponse, to some of Freud’s notions about female development and female sexuality. Another school of psychoanalytic thought, object relations theory, has emphasized the centrality of internal representations both of the self and others in typical development and psychopathology. This school has been very much concerned theoretically with the earliest development of the mind and clinically with some of the more challenging patients (e.g., those with borderline personality disorders) and emphasizes issues such as early modulation of aggression and the ability to tolerate affect and develop relationships with parents and others.

Regardless of the specific theoretical orientation of the therapist, psychodynamic psychotherapy is centrally concerned with the therapist-patient relationship both as a lens for viewing the past and understanding how the past colors the present. The therapist also looks at patterns in the patient’s relationships and daily life to clarify these issues. In addition, the patient has, to some degree, a “real relationship” with the therapist. For therapists working with children, this “real relationship” is often very much present and provides, at least in theory, a greater potential for learning from new experiences. Accordingly, there is great emphasis on how the therapist conducts him- or herself with the child (or adult) patient. The therapist also models a reflective and thoughtful stance encouraging examination, to the extent possible, of repetitive, maladaptive behaviors. This attitude of respect and concern also has the benefit of encouraging the treatment alliance, which is the commitment of the patient to seek greater self-understanding even in the face of anxiety or unpleasant feelings. The countertransference feelings that the patient elicits in the therapist also provide the therapist with important information that can guide treatment.

Many different aspects of treatment can enter into psychodynamic psychotherapy in engaging in psychotherapy with children and adolescents, including work with the parents or family, some degree of education, use of medications, and other modalities. Goals of individual psychodynamic therapy include developing a reasonably full understanding of all the various influences in the child’s or adolescent’s life and how past experience and patterns of adaptation continue to be expressed in the present (e.g., as symptoms or problem behaviors). This treatment approach is most typically indicated when present difficulties appear to be related to past problems and when intrapsychic conflict and maladaptive solutions (defense mechanisms) can be identified. In some situations (e.g., in relation to current traumatic events or specific life stresses/transitions), psychodynamic therapy can also be helpful. Contraindications for psychodynamic therapy include difficulties that limit capacities for self-reflection and self observation or cognitive capacities (e.g., in terms of language or symbolic thinking). Because such therapy is typically time consuming, it often is not undertaken if a less intensive approach is available. In this regard, however, it is important to note that in contrast to other forms of psychotherapy, the goals of intensive psychodynamic psychotherapy are not limited solely to symptom reduction or elimination. Rather, the goals have to do with helping the individual child or adolescent (or adult for that matter) assume a more normative developmental path with increased capacities for self-regulation, improved relations with others, and an enhanced ability to take appropriate pleasure in school or work activities.

The opening phase of psychodynamic therapy is usually concerned both with fostering the treatment and engagement of the child as well as clarifying aspects of diagnosis and interpersonal dynamics. Depending on the age of the child, the therapist might meet with the parents or, in the case of adolescents, the child first. For younger children, initial visits with the parents can provide important historical information but also let the parents establish a sense of trust in the therapist that can then be conveyed to the child. For adolescents, issues of autonomy, confidentiality, and trust may have special importance. If the therapist meets with the parents first, there is an opportunity to provide some guidance on how to introduce the topic to the child. For younger children, parents may initially join for some portion of the visit with the therapist, although the goal is usually to help the child meet individually with the therapist as quickly as is reasonable. Meeting with the parents early on also helps clarify some aspects of the therapeutic relationship with them (i.e., in general, the therapist strives to maintain confidentiality for the child and typically refrains from conveying information from sessions to the parents, with certain very specific exceptions related, for example, to thoughts of suicide
or aggression; see Chapter 24). Children, particularly younger children, may chose to make use of play materials, toys, games, and other activities. For some adolescents, the use of such activities (e.g., cards or chess) may also provide a structure within which the patient can be more comfortable talking “on the side” with the therapist.

Negotiating the complexities of working with the child and meeting periodically with the parents can be challenging. It is important for the therapist to be aware of these complexities and cope as effectively as possible. In some situations, often in child guidance clinics, parents are seen by a colleague for counseling. Even in such cases, however, parents quite rightly want periodic updates and reports of progress.

The therapist strives to foster the therapeutic alliance in several ways. This includes a respectful, supportive, nonjudgmental stance; insistence on confidentiality; and active engagement with the child or adolescent. To this end, the physical location should be appropriate to the needs of the child with appropriate materials for children and adolescents of different levels. For younger children, this includes a set of play materials that can be relatively simple along with drawing and other creative materials and, for older children and adolescents, a selection of games of various types. Some children may bring special materials to therapy sessions or a therapist may supply a specific material in light of a child’s needs. At some point, the issue of limit setting will arise. This may initially occur as the child becomes more aggressive or destructive of materials or if the child has difficulty ending a session at the specified time. Setting ground rules and use of routines (e.g., relative to cleaning up materials at the end of each session or storing play materials or activities in a special place) can be helpful.

An evaluation for intensive psychodynamic therapy (i.e., two or more sessions per week) may come either after other treatments have been tried or, occasionally, as an initial option. Typically, the evaluation includes a series of meetings with the child or adolescent and parents during which the therapist tries to formulate an initial diagnostic impression and treatment plan with a specific focus on the issue of whether the child and parents can be helped by the treatment modality. A meeting with the parents, perhaps including the child or adolescent, is held at the conclusion of the evaluation to present an overview of the therapist’s perspectives on the difficulties and recommendations for further treatment. Depending on the situation, even more intensive work might be recommended. In classical psychoanalytic treatment, sessions typically occur four or five times weekly. Specific goals are organized around the individual’s needs, but there are some important overarching goals, including the desire to help the patient have greater insight, develop new ways to cope with unpleasant feelings and problematic behaviors, and so forth.

The initial or opening phase has to do with obtaining important information on the child or adolescent and his or her difficulties as well as modeling a new approach for the child in attempting to understand these difficulties. This comes about through both implicit processes (modeling, empathizing) as well as more explicit ones (e.g., interpretation). Interpretation consists of helping the child or adolescent understand, with the therapist’s help, a new way to understand his or her thoughts, feelings, or impulses. For younger children, the integrative process begins though ongoing commentary of the therapist to the child’s play or about the child’s behavior or language. The therapist may draw the child’s or adolescent’s attention to something by wondering about or questioning something with the overarching goal of helping the child become more consciously aware of defense patterns, impulses, or maladaptive ways of coping. The opening phase of treatment typically lasts for weeks to several months.

After a treatment alliance has been established, the middle phase of the treatment concentrates on helping the child develop new defenses and give up old ones. This period, usually the longest phase of treatment, can last from months to even years. By this time, the child or adolescent is actively engaged in treatment as reflected in his or her ability to make use of the therapist’s consistency and nonjudgmental approach. Often, play during this time becomes richer and, with older children and adolescents, some activity may alternate or gradually be replaced by talking. Difficulties in the treatment take the focus of resistance (e.g., the child may actively resist coming to sessions or be silent and “bored” during session or, in some cases, the child may be overly compliant but relatively unengaged and passively resistant). The expected moments of resistance or difficulty in therapy, expressed by a sudden shift in topic,
feeling, behavior, or withdrawal, can be important clues for the therapist regarding the child’s inner experience. It is during the middle phase of treatment that the transference relationship develops most vividly. Thus, the patient will tend to experience the therapist in very specific and unique ways, reflecting previous experiences, particularly with the parents. Important differences from the adult transference relationship exist because the child continues to live with the parents and has a child-adult relationship with the therapist, and the therapist also exists as a new and real person to the child. As a result, the transference relationship in child patients may be less deep and complex than that observed in adult patients. The transference relationship is only one part of the therapeutic process; increased capacity for self-reflection and mastery is also important.

Work with children and adolescents is more immediate and intense than work with adults in intensive psychotherapy or psychoanalysis. The degree to which interpretation and developmental assistance or intervention help is another important difference (i.e., children and adolescents have more opportunities for development and learning in the context of the ongoing treatment). In intensive, psychodynamic therapy even the child’s or adolescent’s narrative of an external event has the potential for fruitful work (e.g., relative to the patient’s growing ability, with increased cognitive maturity, of seeing more than one side of a situation). The therapist continually must balance all of these factors to help the patient achieve a fuller understanding of her or his own mind and its working. A considerable literature exists on this topic; these interventions can include clarification, defense interpretations (pointing out the operation of some specific defensive process), and reconstructions (an explanation that uses the past to explain current experience). Fostering normative developmental processes is also important.

During the middle phase of treatment, the work with parents includes understanding the parent’s fears and beliefs about treatment, their hopes for their child in the future, and their fantasies and unrealistic expectations (e.g., that the child will be rescued). In some situations, the parents can see the therapist as a rival or as the authority figure. As much as possible, the therapist should attempt to form an alliance supporting the parents’ positive striving as parents. In some situations, parental referral for individual or marital psychotherapy may be appropriate.

The termination phase of treatment involves both the decision to terminate and the process during which treatment is ended. The decision to end treatment can come from the child, therapist, or parents. Ideally, all agree on the appropriateness of setting an ending date. Sometimes a decision will be made unilaterally because of external factors (e.g., a family move). At other times, it may stem from a unilateral decision (e.g., by a parent who feels threatened or ambivalent about the treatment). The final phase of treatment provides an opportunity for a review and reworking of many of the themes and issues raised earlier in the treatment. The child’s or adolescent’s fantasies and expectations about termination become important. The therapist should consider various factors in considering termination, including the gains made and the child or adolescent’s ability to maintain these gains and the degree to which developmental process have been facilitated. Termination awakens issues of separation and loss for both patient and therapist alike. For the patient, the resolution of much less real transference relationship and giving up the very real therapeutic relationship are typically colored by earlier experiences of separation or loss. In this context, regression may occur, and symptoms not seen for some time may reemerge. Such situations provide the child or adolescent with an opportunity to face and discuss these issues and consolidate the insight and self-awareness that hopefully have emerged over treatment. The child or adolescent’s ability to internalize some of the therapist’s “observing ego” functions is a hallmark of a successful treatment and facilitates longer term development. As much as possible, the child or adolescent patient should be actively involved in the process of termination. The termination phase will be colored by the patient’s life experience and can include fear, anger, aggression, or depression. Depending on the situation, the frequency of visits may be gradually reduced or a set frequency may be maintained until the final session. For child and adolescent patients, natural times for ending are frequent (e.g., around the end of school or beginning of a new school or at a prolonged holiday time); it is important that the therapist not, however, choose a date of convenience if this entails giving
the patient insufficient time for dealing with her or his reactions to termination. Depending on the situation, a follow-up plan may be put into place; in any event, the door should be left open for the patient to return if the need arises.

In contrast to other treatments, notably CBT (see below), the quality and quantity of research are limited, and in many respects, psychoanalysis and related psychodynamic psychotherapies face major challenges for the future given the absence of this research. This is unfortunate and, in some respects, paradoxical given the origins of psychodynamic treatment in developmental theory and observation. Challenges for research include the diversity of theoretical approaches, the continued reliance on case reports rather than controlled trials, and the dearth of well-done research studies. Fortunately, some work has appeared based on metaanalyses suggesting important gains associated with treatment (see Ritvo & Ritvo, 2007) with reasonably good effect sizes for general psychiatric difficulties, specific targeted problems, and overall functioning at follow-up. Several ongoing research projects, including a large series of carefully conducted studies based at the Anna Freud Center, have shown similarly impressive results. In this series of studies, differences between who did and did not respond to treatment were noted (e.g., children whose symptoms were more severe or whose development were uneven, particularly if they started treatment at younger ages, did well, but those with disorders such as autism did not). Increasingly, studies are being done prospectively. Such work will clarify important issues of treatment dose, efficacy, and patient subject selection. Recent research on psychodynamic therapy has also used some of the method effectively with other treatments (e.g., manualized treatments, carefully selected subject populations, and so forth; Muratori et al., 2003).


CBT is the most frequently used evidence-based treatment at present. The term refers to a number of interventions designed to address both cognitive and behavioral issues that impact mental health problems (see Boettcher & Piacentini, 2007). This set of techniques has its origin in learning principles and has had a very strong research basis. As a method, it has grown considerably over the past decade; this reflects its various advantages. In addition to being strongly data based, these techniques are readily learned; are useful for focused, short-term treatment; and are both patient and clinician friendly. CBT has been used in a wide range of disorders, including anxiety disorders, eating disorders, habit and tic disorders, posttraumatic stress disorder (PTSD), conduct disorders, depression, and attention-deficit/hyperactivity disorder (ADHD). It has also been used in targeting social skills and maladaptive behaviors (including anxiety and depression) in individuals with autism and related disorders.

The behavioral foundations of CBT rest strongly in learning theory and the large body of work on behavioral treatments. This work emphasizes the central role of changing behavior with the latter being examined within a broad context, including both antecedences and consequences. This perspective helps clarify what elicits and maintains the behavior and allows for intervention aimed to disrupt some aspect of this process. It is important to understand factors that maintain the behavior, not just those that initially seem to cause it. This approach draws on aspects of both classical and operant conditioning. The work in the 1920s by Mary Cover Jones in demonstrating the learning of fear responses in children was widely applied in the understanding of phobias in general. In phobias, continued avoidance behavior helps to maintain the phobia by preventing exposure to the fear-inducing situation and thus prevents extinction of the fear response. Aspects of classical conditioning can also be used to understand emotional reactions other than fear as well as other mental health problems, including substance abuse and some psychosomatic disorders. As might be expected, treatments based on this model aim to encourage extinction of the learned behavior. Other techniques (e.g., exposure or response prevention) can be used as well. Operant conditioning is similarly based on analysis of antecedents and consequences. In contrast to classical conditioning, operant conditioning can explain acquisition of new behaviors (i.e., not just ones paired with a specific stimulus). This work, based on the work of learning theorists such as Skinner, understands
acquisition of new behaviors through reinforcement (e.g., an association of a behavior with a positive outcome). Removal of the reinforcement would, over time, result in a decrease in the behavior. Within this model, rewards or punishments will increase or decrease the frequency of the target behavior (a process called shaping). Different schedules of reinforcement can have different effects in learning (e.g., periodic or variable reinforcement can be even more effective for long-term learning, but continuous reinforcement may be more effective as a behavior is learned). Aspects of operant conditioning have been well studied and widely used (e.g., in the treatment of children with autism in applied behavior analysis; see Chapter 4) along with PMT for children with behavior or conduct problems as well as for many other conditions. Extinction occurs when reinforcement is no longer provided (e.g., to reduce or totally eliminate a behavior). This process may be initially associated with higher levels of the behavior of interest (the so-called “extinction burst”) before rates of the behavior decrease. Some of the common techniques derived from operant condition principles are listed in Table 22.1.

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Aug 1, 2016 | Posted by in PSYCHIATRY | Comments Off on ▪ Psychotherapies
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