Psychosocial Interventions

Essential Concepts

Psychosocial interventions include the full range of nonpharmacologic treatments that engage the child, adolescent, and family in the process of adaptive change.
The type of psychosocial intervention recommended depends on the presenting symptoms and evidence for the type of intervention that works best for the child’s specific difficulty.
Use goals and objectives for treatment to remain focused and to ensure ongoing assessment of effectiveness or needed modifications.
In working with children and adolescents, both the parents or guardians and the identified patient need to be engaged in the therapeutic process.

Whenever two people meet there are really six people present. There is each man as he sees himself, each man as the other person sees him, and each man as he really is.

—William James

General Principles and Clinical Considerations

Psychotherapeutic interventions are indicated for the majority of psychiatric disorders in children and adolescents. For psychotherapy to be effective with youth, the parents or guardians need to be engaged—to be educated about their child’s problems and share a vision with the therapist regarding the goals of treatment and the therapeutic interventions. In fact, family therapy or working with the parents to help them learn and utilize more effective parenting skills may be the modality of choice for some difficulties.

A key to effective psychosocial treatment is to choose the types of intervention that are most helpful for the problem at hand. This requires familiarity with the range of levels of care, as well as a wide variety of therapeutic techniques and their indications.

Practical Aspects of Psychotherapeutic Applications

Ideally, the mental health service delivery system provides an integrated continuum of care at a variety of levels of intensity and utilizing individualized modalities specific to the child’s particular needs. The child and family can easily access appropriate services as the clinical situation warrants.

Although the ideal continuum of services may not be available, children live in systems (family, school, etc.), and it is incumbent upon the child and adolescent psychiatrist to assess and help the child and family access needed services. Child and adolescent psychiatric disorders cannot be successfully treated unless the family dynamics and the system environment are considered. Often, the therapist coordinates with the school, child, family, social service agency, pediatrician, juvenile court personnel and/or any other significant providers in the child’s life.

Choosing appropriate modalities of treatment is informed by a thorough psychiatric evaluation. An appreciation of the child’s level of physical, cognitive, and emotional development is required to set appropriate goals and tailor effective interventions. All therapeutic interventions focus on helping the child and family gain skills required for more adaptive and healthy development and coping, and enhancing his or her overall level of functioning. Table 25.1 summarizes the types of psychosocial treatments that are indicated for various types of difficulties.

Individual Psychotherapies

While there are many forms of psychotherapy, all of them follow a basic psychotherapeutic process, which has been well described in a 1982 publication by the Group for the Advancement of Psychiatry Committee on Child Psychiatry. Table 25.2 outlines this five-stage process.

The Psychotherapeutic Process

Establishing a working relationship, or engagement period, is the first stage of any psychotherapy. This process begins with the very first encounter. In transference, your patient unconsciously

reenacts a past relationship and transfers it to the present relationship with you. Be aware that transference reactions will occur with the child as well as with his or her parents or guardians. Transference may be positive or negative (or, most commonly, a bit of both). Try to identify and work with transference early on. Retaining children and families in treatment is perhaps the biggest challenge—about 50% of children who begin treatment drop out before the therapy is successfully completed. This may be most common with the most severely ill youth and families, where the patient and his or her family (or both) may have a basic difficulty with engagement and trust. Maintaining a collaborative relationship with the guardians is integral to treatment integrity for the child.

Table 25.1. Essentials of Psychosocial Treatments for Children and Adolescents

Type of Treatment Used	Indications	Modalities Used
Hospitalization	Acute safety issues (to self or others) Functionally incapacitating psychiatric symptoms Lack of stabilization in less intensive treatment	Pharmacotherapy Individual psychotherapy Milieu therapy/behavioral therapy Group therapy Family therapy Education assessment or maintneance
Residential treatment	Chronic and severe behavioral and emotional problems that cannot be adequately addressed in outpatient setting	Same
Partial hospitalization or day treatment	Patient is safe to live at home, foster home, or group home but requires intensive therapeutic supports	May or may not include a school program Pharmacotherapy Individual psychotherapy Family involvement Group therapy
In-home behavioral treatment	Patient is safe to live at home, but entire family requires intensive supports to maintain home safety and foster the child’s appropriate and healthy development	In-home behavioral plans Psychoeducation about parenting, child development In-home therapy of child and family Pharmacotherapy as appropriate
Wrap-around services	Child with complex mental health and psychosocial needs To avoid need for institutional care	In-home services are component Integration with social services to ensure entitlements and housing Crisis intervention teams Respite services Coordinated community services
Psychotherapy
Individual therapy	Youth who has difficulty forming positive relationships with adults or who is in crisis Verbal youngsters who are struggling to deal with recurrent maladaptive relationship issues or traumatic events Verbal youngsters who are working through relationship and personality development issues Circumscribed problems of recent onset Depressed, anxious, or conduct-disordered youth Behavior or developmentally disordered youth	Supportive therapy Psychodynamically oriented therapy Psychoanalysis Time-limited therapy CBT, ITP, and other EBPs Behavior therapy
Group therapy	Single stressor, single psychiatric disorder, or focus of difficulty	Social and coping skills groups Problem solving and anger management Mutual support and insights
Family therapy	Family with poor communication and structure Resistant families with rigid coping and relating Family that does not understand the nature of the child’s difficulties and how to be helpful Family with child who has learned negative behaviors Parents who do not have skills in behavior management of their children	Structural family therapy Strategic family therapy Psychoeducational family therapy Behavior therapy Parent Management Training (PMT)
CBT, cognitive behavioral therapy (there is trauma-focused CBT, as well as specific CBT techniques for depression, anxiety disorders, and obsessive-compulsive disorder); ITP, interpersonal therapy; EBPs, evidence-based psychotherapies.

Table 25.2. The Stages of the Psychotherapeutic Process

Stage of Psychotherapy	Tasks of the Stage
Establishing the working relationship	Engaging with the child and parents Identifying any transference or countertransference problems Developing trust in treatment relationship
Analysis of the problem and its cause	Examination of the child’s life Assist the patient in developing a problem list Assist the parents in developing a problem list Integrate the problem list for next stage
Developing an explanation of the problem	Describe the possible reasons for the identified problems Outline the work needed to be done Define the rules for the working relationship (appointment times, billing, cancellations, etc.) Agree on a treatment plan
Establishing and implementing the formula for change and selected formula for change	Implement the treatment plan (prescription for change) Readjust formula for change as indicated If there is now progress, review and adjust initial problem list
Termination	Review the reasons for entering treatment Summarize what was helpful and not helpful in solving presenting problems Consolidate therapeutic gains with praise Address any loss issues Review any needed follow-up Review indications for return to treatment
From Group for the Advancement of Psychiatry (GAP) Committee on Child Psychiatry. The Process of Child Therapy. New York: Brunner, Mazel, 1982, with permission.