Introduction to Psychotherapy with Children & Families

PSY 4930Melissa Stern

October, 17th, 2006

PLEASE NOTE!!!

THE FINAL EXAM WILL BE HELD IN CLASS ON DECEMBER 5th!!!!

We will not be having lecture that day, just the final exam

Second Note

We will be having lecture after the second exam. Part of it will be a guest speaker so please plan on staying the

whole time!

Learning Objectives• What is child psychotherapy and how does it differ

from other treatments?• Who is a good candidate for child/adolescent

psychotherapy?• How does child psychotherapy differ from adult

psychotherapy?• What are the factors in child psychotherapy that bring

about behavioral and personality change?• What are the primary stages in the psychotherapy

process and what are the issues dealt with at each stage?

Learning Objectives• What kind of ethical dilemmas does one

confront when engaging in child psychotherapy?• What empirical support is there for the

effectiveness of child psychotherapy?• What are the “Myths of Psychotherapy”• How does and understanding of these “Myths”

lead to better research?

Approaches to Child Treatment: Overview

• Approaches to the treatment of behavioral or psychological problems in children:– behavioral (operant, classical conditioning)

– cognitive-behavioral – psychopharmacological– family therapies – group therapies– residential treatments– And others . . .

Characteristics of “Psychotherapy”• Most treatments discussed could be viewed as "psychotherapy" in the most general sense

• Psychotherapy is commonly thought of as an interpersonal process, involving a verbal and/or nonverbal interchange between a patient who exhibits psychological problems and a professional who wishes to be of help

• These approaches are usually based on a “Medical Model” of psychology

Characteristics of Psychotherapy• Within this context the therapist attempts to:– gain an understanding of the patient's problems

– utilize the nature of the relationship and various therapeutic techniques

– to facilitate constructive personality and behavior change.

• Psychoanalytic and Interpersonal approaches would fall into this category

Children versus Adults in Psychotherapy

• Some argue that the basic principles involved in child treatment are similar to those involved in the treatment of adults

• The major difference between working with adults and children is the need to alter therapy techniques to accommodate the child's level of cognitive and emotional development– 5 y/o with PTSD

Children versus Adults in Psychotherapy

Important child differences that impact treatment:– conceptually more concrete – linguistically less competent – less introspective– less likely to see themselves as displaying difficulties

– less likely to see the value of talking about problems

– often less motivated to participate in ongoing treatment and

– less likely to share common treatment goals with the therapist

Children versus Adults in Psychotherapy

• Two most important issues to consider in psychological treatment of children:

1. Level of cognitive development

2. Level of dependence on the parents

Level of Cognitive Development• Greater emphasis be placed on non‑verbal communication and interactions

• Child psychotherapy is often carried out within the context of play activities rather than involving the level of verbal discourse characterizing adult or even adolescent psychotherapy

• Play is often considered a major vehicle for change in child psychotherapy

Level of Cognitive Development

• As the age of the child increases there is typically a corresponding increase in the degree to which verbal interchanges predominate during therapy sessions

• Even with older children, however, the use of games, which serve as a medium for therapeutic interaction and expression, is common

• Can often be a useful buffer in therapy sessions – Playing checkers while talking

Level of Dependence on Others• Therapist deals with persons (e.g., parents, caregivers, teachers) other than the patient more than when working with adult patients

• Children seldom refer themselves for treatment

• Referral may reflect:– the child's need for treatmentOR

– the parents level of tolerance for what is essentially normal, although possibly problematic, child behavior

Level of Dependence on Others

• Intervention efforts may be focused on:– the child's problematic behavior

AND/OR– factors such as parenting stress, parenting skills, or perceived lack of competence in the parenting role which may contribute to strain on the parent-child relationship

Level of Dependence on Others• Parents may also influence the outcome of child treatment

• With adults, continuing in therapy is related to variables such as:– the patient's relationship with the therapist

– current levels of patient distress– whether the patient feels that therapeutic gains are being made

• With children, whether the child stays in treatment often has as much to do with parental as with child factors

Level of Dependence on Others• Parental/family factors affecting child treatment:– parent schedules – the degree to which parent's view the child's therapy as having credibility (“all they do is play”)

– the nature of the parent's relationship with the child's therapist

– the extent to which the child's problem behavior is changing as quickly as the parent expects

• Child therapists must work with other members of the family (particularly parents) to a much greater degree and in different ways than is usually required in adult-oriented treatment

The Complexity of Child Treatment• Child psychopathology is often related to factors operative within the family– ongoing parental conflict – maladaptive communication – interaction patterns existing within the family

• Thus, it is frequently necessary to deal with other family members in order to effect therapeutic changes in the child

Basic Principles of Psychotherapy

• Many of the basic principles of psychotherapy are the same for adults and children

• Factors to consider in the application of principles: – the child’s immaturity – dependent status of the child

Elements of Change

• Two common goals in child treatment:– resolution of the presenting problem that resulted in the child being referred

– bringing about general personality change to reduce the likelihood of the child developing problems in the future.

• How are such changes made? What brings about such changes?

Elements of Change• Tuma (1989) has suggested that therapeutic changes are attributable to;– General Factors- certain aspects of the therapy relationship

– Specific Factors - various therapy "techniques", that may be employed within the context of the therapy relationship

General Factors in Psychotherapy• General factors that bring about change include:

– “opportunity for catharsis”

– “attention from the therapist”

– “reinforcement effects”

– “expectancy effects”

“Therapist Offered Conditions”

• Tuma gives special consideration to several "therapist offered conditions" described by Rogers (1942; 1951)

• Change in therapy is enhanced, not just by undivided attention of the therapist, but through the therapist communicating:– empathy– non-judgmental warmth – genuineness

Therapist Offered Conditions• Empathy - therapist communications that he/she cares for the child and is able to understand the problems from the child's perspective

• Genuineness - openness, honesty, and authenticity which allows the child to believe that the therapist can be trusted

• Therapist warmth - therapist communicates an atmosphere of non‑judgmental acceptance, helps child feel secure in dealing with even sensitive and anxiety arousing topics

• Communications can be verbal or non-verbal

Therapist Offered Conditions• Numerous research studies linking these variables with positive therapy outcome (e.g., see Truax & Mitchell, 1971

• Empathy, genuineness and warmth are necessary (although not sufficient) conditions for therapeutic change

• Therapist’s low on the conditions, not only have patients who do not get better – they often have patients that get worse!

Specific Factors in Psychotherapy• Specific factors that contribute to change include therapist communications such as:

– questions - designed to elicit information or encourage the child to continue talking

– exclamations - used to facilitate further discussion or to communicate the importance a particular topic

– confrontations - which encourage the child to deal with some therapy‑related issue

Specific Factors in Psychotherapy• clarifications - help the child understand the significance of certain behaviors– descriptions of the patient's behavior– repetition of the child's statements, to get the child to elaborate on what he/she is doing (e.g., " It looks like you spanked that doll really hard ")

• clarifications can also help the child understand and label feelings of which he or she may be unaware– similar to the technique of "reflection of feeling"

Specific Factors in Psychotherapy• Reflection of feeling - therapist comments on the child's feeling state, as reflected in his/her behavior– saying “that made you really mad", in response to the child clinching his/her fist and becoming flushed while talking about getting blamed for something done by a younger sibling

• reflective statements are useful in helping the child develop verbal labels for feelings, thus making them less confusing and overwhelming to the child (Freedheim & Russ, 1992)

Interpretation in Child Therapy• interpretation (of the child's play or verbal statements) - comments regarding the relationships between thoughts, feelings and behaviors or the posing of tentative hypotheses regarding the "meaning" of certain behaviors

• used to increase the child's understanding of the causes of his/her behavior

• may deal with material close to consciousness to those that are designed to bring unconscious material to awareness

• It must be noted that with interpretations, proper timing is essential

Paving the Way for Interpretations• Questions, clarifications, exclamations, and confrontations prepare the way for the interpretive process

• Early comments by the therapist are centered on empathic and accepting verbalizations

• Later, as certain areas are pursued, questions and clarifications are used to gain an understanding of the child's feelings and attitudes

• Then confrontations are used, and, finally, when the child appears ready to accept them, interpretations are offered

The Role of Interpretations• Interpretations help the child develop cognitive insight in to the nature of his or her difficulties so that problem behavior becomes more understandable

• As this occurs it is possible for the child to engage in a "working through" process in which conflicts and problems areas are dealt with in a more direct fashion

“Working Through”

• First, the child develops a better awareness of his/her feelings as well as insight into the causes of problem behaviors

• Then, “working through" allows the child to develop more adaptive ways of relating and behaving through learning alternative problems solving strategies and methods of coping

Psychotherapy: The Big Picture

• None of the general or specific factors considered here are, in and of themselves, sufficient to accomplish the goals of psychotherapy

• Constructive personality and behavioral change results from the combined effects of these variables

Stages of Psychotherapy: From

Referral to Termination• Only rarely does a child request

treatment• In most cases the child is referred by some adult:– Parents– Teachers– Pediatricians – Juvenile Courts – Youth and Family Service agencies

• Referral for treatment is almost always based on an adult's perception of the child's behavior as abnormal

Reasons for Referral1. Parents have little tolerance for child behaviors that are seen as normal by most other parents and child experts– view certain normal behaviors as troublesome enough to warrant their seeking help in dealing with them (Goodness of fit issue)

– may suggest the need for parents to be involved in treatment as well as the child or perhaps instead of the child

Reasons for Referral2. Child displays genuine adjustment problems– due to the child's intrinsic emotional make‑up, some type of trauma or other life experiences

– due to disturbed home and social environments

– may display emotional problems and act out secondary to learning disabilities

– may display psychological problems secondary to some physical condition

Assessment for Psychotherapy• As always, thorough assessment is necessary to determine the nature of the child's problems and the proper approach to treatment

• Though clinicians may differ in the approach taken, most would agree that assessment is a necessary prerequisite for treatment

• Assessment is directed toward determining:– whether the child displays evidence of psychopathology

– factors that contribute to this pathology– whether the problem is amenable to psychotherapy or must be dealt with in some other way

Assessment for Psychotherapy• Assessment may provide information about potential goals and information to guide the nature of treatment.

• The assessment process often begins with a parental interview

• Clinician obtains information regarding– the specific nature of the child's problem behaviors

– the duration of these problems– any precipitating events– the situations in which the problem behaviors occur

– how these problems are responded to by others– previous attempts to deal with the child's difficulties

Assessment for Psychotherapy• Other information gathered:

– child's developmental history – medical history – school performance – peer and family relationships – other factors that might impact on the child and family and contribute to the child's problems

– parent's expectations regarding child behavior

– disciplinary methods used, – degree to which parent variables seem to contribute to the child's difficulties

– child’s perception of problem (depending on age)

Assessment for Psychotherapy• The interview process may be sufficient to make a clinical decision regarding treatment or it may suggest the need for psychological testing or other assessment methods to more clearly delineate the nature of the child's problems

• A major assessment‑related question is whether the child is likely to benefit from individual psychotherapy or whether some alternative approach to treatment would be more appropriate

Assessment for Psychotherapy• Other possibilities might include medication, behavioral interventions, family therapy, or various forms of environmental manipulation

• Children can display a range of problems that result in distress and elicit the concern of parents– Only some of these difficulties are amenable to child psychotherapy

Assessment for Psychotherapy• For example, children with behavioral problems often come from chaotic homes and social environments that may contribute to their behavior– modification of the child's environment is a more appropriate treatment approach than psychotherapy

• For example, with children with autism, the need for treatment is not in doubt– appropriateness of treating these children with psychotherapy must be questioned due to their deficits in communication

Assessment for Psychotherapy• Reisman argues; "Since professional psychotherapy is often a lengthy and demanding process . . . it should be offered only when it is appropriate and after serious consideration is given to viable alternatives"

• Regarding problems that are amenable to child psychotherapy he states; "Psychotherapy seems to be a more appropriate treatment in dealing with the comparatively mild to moderate problems of childhood”

The Setting for Psychotherapy• Unlike therapy with adults, the setting for child psychotherapy is often a playroom, especially for very young children– It is believed children can communicate more effectively through play

– play is seen by many clinicians as an important vehicle for patient‑therapist interaction

• With older children and adolescents the setting may be an office with various games and/or play materials rather than a playroom

The Structure of Psychotherapy• The structure is defined by the physical setting, and also by the frequency and duration of therapy sessions

• Most common for sessions to be 45 ‑ 50 minutes long and to be scheduled once per week

• This information is discussed with the child to provide a relevant structure regarding the extent and nature of the therapeutic involvement

• As Dare (1977) has suggested, the regularity of therapy contact, along with punctuality, suggests to the child that the psychotherapist views the treatment as important

The Initial Stage of Psychotherapy• Early sessions usually involve providing the child and the parent with:– general information regarding the nature of psychotherapy

– developing agreed-upon goals for treatment, and

– discussing the role of the therapist, the patient, and the parents in working toward these goals

• Issues such as the confidentiality of information provided by the child in therapy and any limits on confidentiality are also considered at this point.

The Initial Stage of Psychotherapy• The initial stage of therapy also involves a continuation of the assessment process

• More detailed information is gathered concerning – the nature of the child's difficulties– important areas of conflict– defense mechanisms– adaptive and maladaptive methods of coping– factors which appear to contribute to problem behaviors

• clinician develops a conceptual framework for understanding the child's problems which can serve to direct the therapy process

The Initial Stage of Psychotherapy• Development of a patient‑therapist (and, with younger children the parent‑therapist) relationship– therapists with a client‑centered orientation typically place the greatest emphasis on the patient‑therapist relationship

– developing adequate rapport with the patient (and parents) is viewed as necessary by most therapists regardless of orientation

– without such a relationship even the most skilled therapist is likely to be ineffective

The Initial Stage of Psychotherapy• During this stage, additional structuring of the treatment process may include setting limits on the child’s behavior within therapy sessions (with some children, you never have to address limits, but with kids with conduct problems, you may need to set limits early on)

• Therapy is a place where patients can express themselves freely

• Most therapists are accepting of a range of behaviors exhibited by the child patient

• However, certain behaviors are unacceptable and demand a response from the therapist

Setting Limits in Therapy• For example, most therapists would agree that limits should be set against hitting or other physically aggressive behavior

• Most therapists would prohibit the child from behaving in a manner that might result in him/her harming him or herself

• Most would not allow the child to destroy materials in the playroom

• Less serious situations that might require limit setting could include:– the child insisting on multiple trips to the bathroom

– inappropriate demonstration of physical affection

Dealing with Limits in Child Therapy

• Setting limits may involve simple statements that certain behaviors are unacceptable to physical restraint in extreme cases

• Usually relatively few limits are needed and therapists only invoke them when necessary– e.g., a child is not routinely told that he/she cannot hit the therapist or tear up play materials if these behaviors have not come up as a problem

– Limit setting is most often a response to specific inappropriate behaviors rather than the strict laying down of the rules

Limits in Child Therapy• Limit setting is done in a way that the therapist conveys continued acceptance of the child, while at the same time conveying the unacceptability of certain behaviors

• Limit setting is therapeutic because:– it provides lessons in self control– provides the child with a sense of security– provides a sense of reassurance for the child that certain behaviors cannot occur and that certain, possible threatening, fantasies cannot be carried out in behavior

Limits in Child Therapy• Limit setting is a good example of why stages of therapy cannot be separated in more concrete manner

• While providing guidelines for acceptable in‑therapy behavior often occurs during the early stages of therapy, it may also be necessary and appropriate to deal with the issue of limits at any stage in the treatment process

The Middle Stage of Therapy• While the process of attempting to resolve conflict and of bringing about constructive personality change is something that occurs throughout therapy, this process is most evident during the middle phase of treatment.

• Tuma (1989) has described this phase as the most important in achieving the goals of treatment

• The focus is on the application of treatment methods such as those described earlier

The Middle Stage of Therapy• Treatment methods vary depending on the orientation of the therapist and the nature of the child's problem:

• An analytically oriented therapist may focus on the interpretation of the child's play so the child can develop insight into the meaning of his/her behavior and so that conflicts can be worked through in an emotionally constructive manner.

• A client‑centered therapist may use techniques such as reflection of feeling to clarify the nature of the child's feelings, while attempting to provide a therapy atmosphere which facilitates personal growth

The Middle Stage of Therapy• Activities of the therapist during this phase of treatment involve more that the simple use of interpretations and reflection of feeling

• The extent to which specific treatment methods are used would depend on the nature of the patient‑therapist interactions at a given point in time and the therapist's view as to what needs to be accomplished to move the patient toward treatment goals

• Therapy should involve an active ongoing decision making process on the part of the therapist

The Termination Phase• As treatment progresses and treatment goals are met the issue of termination arises

• Approaching this issue involves dealing with several questions:– although the initial goals of therapy may have been largely accomplished, are there are other issues that have arisen during the course of treatment

– what specific criteria should be used in judging the appropriateness of termination

The Termination Phase• Once a decision to terminate is made, the therapist must consider:– what issues need to be dealt with in order to effect a smooth termination?

– how many sessions it is likely to take to deal with these issues?

• Dealing with termination necessitates a certain degree of tact and skill on the part of the therapist– issue must be raised without eliciting feelings of rejection in the child, who may have developed a strong attachment to the therapist

The Termination Phase• Reisman (1973) suggests that the topic can best be introduced by general statements

• “… It sounds as though things are going a lot better for you; I wonder if you've given any thought as to what that might mean as far as your coming to see me goes“

• the child should be allowed to express his/her opinions and the therapist may need to modify his or hers

The Termination Phase• Timing is crucial in raising the issue of termination.– should be approached at a time where maximal gains have been accomplished

• Termination should be considered:– when most of the original goals (or later goals delineated during treatment) have been met

– patient, parent and therapist together feel the child is somewhat better equipped to handle future problems as they arise

Implementing Termination• After a decision to terminate has been made there is usually some time that transpires before the end of therapy

• The time may vary from weeks to months during which time loose ends are tied up, separation issues are dealt with and plans for the future are made

• This provides time for the child to lessen his/her dependency on the therapist and to begin to function more independently

More on Termination

• The therapist will be available should unexpected problems arise at some later date

• Therapists may also set a specific time for a follow‑up visit to assess how the child is doing at some point following termination

A Final Note on Phases of Psychotherapy

• As suggested earlier, one cannot simply divide psychotherapy into specific phases, as we have done here.

• These descriptions fail to capture:– the fluid nature of patient‑therapist interactions

– the degree to which therapist behaviors vary depending on the specific child behaviors displayed

– the essence of the therapeutic "process"

Ethical Dilemmas in Child Treatment

• Competency of therapist• Child or Parent as client?• Competency of in treatment decision

making• Confidentiality (particularly with

adolescents)

Empirical Support for Effectiveness of Child Psychotherapy

• Difficult to answer, lack of well-controlled studies

• Some studies find little support for the effectiveness of psychotherapy

• Other studies (meta-analyses) find some support for the effectiveness of psychotherapy though other meta analyses find contradictory results

Psychotherapy Effectiveness

• Lack of well-controlled empirical studies makes it difficult to draw firm conclusions

• More research is needed!

Myths of psychotherapy

• Therapist Uniformity myth– Assumption that therapists are more alike than

different and that whatever they do with the patient can be considered “psychotherapy”

• Patient Uniformity myth– -Assumption that patients are more alike than

different

Myths and Research

• How can you efficiently compare different treatments on different kinds of kids?

• Better questions, rather than general effectiveness, include:– What types of therapy,– Have what types of effects,– With what types of patients,– With what types of problems,– When offered by what types of therapists,– Under what conditions?