Transcript Introduction to Psychotherapy with Children & Families

Introduction to Psychotherapy
with Children & Families
PSY 4930
Melissa 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
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
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
Children versus Adults in
Psychotherapy
Important child differences that
impact treatment:
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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
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
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 treatment
OR
– the parents level of tolerance for
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
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
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?
brings about such changes?
What
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
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
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
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
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
“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
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
Stages of
Psychotherapy: From
Referral to
• Only rarely
does a child request
Termination
treatment
• In most cases the child is referred
by some adult:
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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
Reasons for Referral
1. 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 Referral
2. 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
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
Assessment for Psychotherapy
• Other information gathered:
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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
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
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
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
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
The Initial Stage of Psychotherapy
• The initial stage of therapy also
involves a continuation of the
assessment process
• More detailed information is gathered
concerning
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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
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
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
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
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
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 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
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:
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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?