PSYCHODYNAMIC PSYCHOTHERAPY

Psychodynamic psychotherapy has the longest organized tradition of the psychotherapies. It is also known as psychoanalytic psychotherapy or expressive psychotherapy.⁷ This psychotherapy can be brief or time-limited, but it is usually open-ended and long-term. Sessions are generally held once or twice per week, with the patient being encouraged to talk about “whatever comes to mind.” This encouragement has been termed the fundamental rule of psychotherapy. The therapist, consequently, is usually nondirective but may encourage the patient to focus on feelings about “whatever comes to mind.” The therapist is empathic, attentive, inquiring, nonjudgmental, and more passive than in other kinds of psychotherapies. The goal of psychodynamic psychotherapy is to recognize, interpret, and work through unconscious feelings that are problematic. Often unconscious feelings are first recognized in transference phenomena. Many psychodynamic psychotherapists choose to ignore positive transference phenomena, but interpret negative phenomena. For example, the patient may express the wish to be the therapist’s friend. The focus would be on the patient’s disappointment and frustration that a friendship cannot occur rather than a focus on the depth of the patient’s longing for a friendship with the therapist. The psychotherapist deliberately avoids answering most questions directly or revealing personal information about himself or herself. This strategy, referred to as the abstinent posture, promotes the emergence of transference phenomena. The abstinent posture leaves a social void that the patient fills with his or her imagination and projections, allowing the therapist access to the patient’s unconscious. The patient will get in touch with intense feelings that have been suppressed or repressed. Catharsis is the “letting go” and expression of these feelings.

At least six major theoretical systems exist under the psychodynamic model; these are summarized in Table 10-1.

Table 10-1 Major Theoretical Systems in the Psychodynamic Model

Psychoanalysis is an intensive form of psychodynamic psychotherapy; several of its characteristics are summarized in Table 10-2. The time and financial cost of psychoanalysis generally puts it out of range for many patients. To date, there is no persuasive evidence that psychoanalysis is more effective than psychodynamic psychotherapy. However, there is emerging evidence that psychodynamic psychotherapy is effective for a number of diagnoses.^13,14

Table 10-2 Characteristics of Psychoanalysis

COGNITIVE-BEHAVIORAL THERAPY

CBT is emerging as a widely practiced psychotherapy for depression, anxiety disorders, and other psychiatric and medical diagnoses. CBT represents a merger of the pioneering work of Aaron Beck¹⁵ (who first developed cognitive therapy for depression in the mid-1960s) and the work of Joseph Wolpe¹⁶ (who, in 1958, described a behavior therapy, reciprocal inhibition, for anxiety disorders).

CBT is built on the assumption that conscious thoughts, feelings, and behaviors interact to create symptoms.¹⁷ In contrast to the psychodynamic model, unconscious inner conflicts and early relationships are considered less important than here-and-now conscious awareness of thoughts, feelings, and behaviors. The therapeutic sessions are structured and collaborative. The therapist defines the goals and methodology of therapy and teaches the patient to observe the interaction of feelings, thoughts, and behaviors. Commonly used cognitive-behavioral techniques are summarized in Table 10-3. There is considerable research support for the effectiveness of CBT for a number of disorders.¹⁸

Table 10-3 Commonly Used Cognitive-Behavioral Techniques

SUPPORTIVE PSYCHOTHERAPY

Supportive psychotherapy has been included in the five core competencies of psychotherapy training. This “user-friendly” psychotherapy has rarely been formally taught in residency or in psychology training programs. In the heyday of psychoanalysis and psychoanalytic psychotherapy during the mid to late twentieth century, advice, suggestion, and encouragement were generally considered unhelpful for most patients with emotional problems. Nevertheless, Wallerstein,¹⁹ reporting on the results of the extensive Menninger Clinic and Foundation Study of Psychoanalysis and Psychotherapy, stated that supportive psychotherapy was often as effective as psychoanalysis at relieving symptoms and achieving enduring structural change.

Supportive psychotherapy is often defined by what it is not. It does not involve analysis of the transference; it does not involve challenging defenses; it does not endeavor to change the structure of personality or character; it does not involve making the unconscious, conscious. Supportive psychotherapy is often indicated to help a patient survive a loss or to get beyond a stressful event. This therapy can be brief but often is long-term. For example, a widow may initially benefit from weekly supportive psychotherapy after the loss of her spouse. After painful grief symptoms have improved, she may see the therapist monthly for an indefinite period for maintenance supportive psychotherapy.

Supportive psychotherapy provides a safe place for the patient to express feelings, to problem-solve, and to reinforce adaptive defenses. Techniques involved in the practice of supportive therapy are summarized in Table 10-4.

Table 10-4 Techniques Involved in the Practice of Supportive Therapy

Hellerstein and colleagues²⁰ suggested that supportive psychotherapy be the default psychotherapy. This “user-friendly” therapy neither generates anxiety nor requires a weekly commitment for an undetermined period of time as with expressive psychodynamic psychotherapy. Research has found supportive psychotherapy to be efficacious. Hellerstein and associates²⁰ proposed a trial of this therapy before the more extensive, more anxiety-provoking expressive psychodynamic psychotherapy.

Several studies of psychotherapy research have found that supportive psychotherapy is effective for a variety of psychiatric diagnoses; Winston and colleagues²¹ have comprehensively reviewed this literature. However, more research is needed to better understand how to integrate supportive psychotherapy with psychopharmacology and with other psychotherapy techniques for specific diagnoses.

BRIEF PSYCHOTHERAPY

Although Olfson and Pincus²² found that the average length of psychotherapy is probably only eight visits, most of these “brief” psychotherapies represent the patient’s unilateral decision to discontinue treatment. Paradoxically, Sledge and colleagues²³ found that if a brief therapy is planned with the patient, twice as many patients continue to the agreed-on endpoint than if no endpoint is agreed on. In other words, having an agreed-on limit to the number of visits reduces the dropout rate by half.

Brief psychotherapy is therefore defined as a psychotherapy with a predetermined endpoint, usually 8 to 12 visits. The theory and technique of brief psychotherapy parallels the established psychotherapy “camps.” Sifneos,²⁴ Malan,²⁵ Davanloo,²⁶ and others describe time-limited psychodynamic psychotherapy. Beck and Greenberg²⁷ have described time-limited cognitive therapy. Klerman’s Interpersonal Psychotherapy (IPT)²⁸ is a time-limited therapy that focuses on here-and-now interpersonal relationships. Budman²⁹ described an eclectic or integrative psychotherapy that includes interpersonal, developmental, and existential issues. Hembree and co-workers³⁰ described a brief behavioral therapy, which includes stress inoculation training and exposure therapy.

Steenbarger³¹ presented six considerations for selection criteria for brief psychotherapy. These six considerations form the acronym DISCUS and are presented in Table 10-5.

Table 10-5 Criteria for Selection for Brief Psychotherapy

Perhaps the most important feature of brief psychotherapy is the activity required of the therapist. The therapist is active in the initial assessment of the patient; active in establishing, early on, the goal of the therapy and the contract for a limited number of sessions; active in keeping the therapy focused on the goals; and active in assigning homework.

There is some controversy concerning the termination of brief psychotherapy. At one extreme, Mann³² advocated a complete termination in order to have the patient confront existentially the meaningful end of the therapy. Mann precluded contact with the patient after termination. At the other extreme is the transition of a weekly 12-session IPT into an indefinite monthly maintenance IPT. Blais and Groves³³ prescribed a recontact after 6 months.

Research evidence for the effectiveness of brief psychotherapy is extensive.^34,35 Brief psychotherapy has been designated by the Psychiatry RRC as one of the five psychotherapies to be included in psychotherapy core competencies. This inclusion, plus mounting pressure from insurers to limit the length of psychotherapy, should lead to more brief psychotherapy. It is also likely that many patients, if given the option, would prefer a time-limited treatment with clear, discrete goals and an active therapist.

PSYCHIATRIC MEDICATION WITH PSYCHOTHERAPY

A patient receiving both psychotherapy and medication becomes part of a complex and multifaceted phenomenon.³⁶ There are two possible approaches to mixing psychopharmacology and psychotherapy: the psychiatrist does both the psychotherapy and psychopharmacology, or the psychiatrist does the psychopharmacology and someone else does the psychotherapy. The former is referred to as integrative treatment, the latter, split treatment. There is virtually no research on whether integrative or split treatment is better for a certain diagnosis or a certain patient. However, there is some research to demonstrate that combining psychopharmacology and psychotherapy is more effective for certain diagnoses than either alone.³⁷ There is also some evidence that it is less expensive for a psychiatrist to provide both the psychopharmacology and the psychotherapy.³⁸

The prevalence of split treatment in the United States is significantly greater than integrative treatment for a number of reasons. First, there is a significant economic incentive for psychiatrists to do psychopharmacology exclusively, either if insurance is used or if patients self-pay. Second, many PCPs refer patients who need psychotherapy to nonmedical therapists. The PCP continues to medicate the patient and a split treatment is established. A third possible reason that split treatment prevails is that recent graduates from psychiatric residency training programs may feel less competent to do psychotherapy than do residents who graduated decades earlier.

There are advantages and disadvantages to integrated care. As mentioned, research has found that integrated care is less expensive for some diagnoses. This finding may be explained by the fact that fewer visits are required with only one practitioner or that medication may be appropriately started sooner if the therapist can also prescribe. Another advantage is the efficiency if all pharmacological and psychosocial issues are known and managed by one clinician (i.e., no time is needed to communicate with another professional). The pitfalls of integrated care include the time pressure to address both psychosocial and pharmacological issues in one visit, as well as the unwitting overemphasis of one modality over the other by the psychotherapist-psychiatrist. For example, a maladaptive response to countertransference issues raised by the patient’s feelings may be to focus more on medicating the feelings than on listening to, and understanding, them.

Split treatment also has advantages and disadvantages. In split treatment, the clinician can focus exclusively on his or her specific expertise. The psychotherapist does not have to reconsider dosages and side effects, and the psychopharmacologist can defer psychosocial issues to the psychotherapist. The pitfalls of split treatment are also significant. The ideal of regular communication between psychotherapist and pharmacotherapist is often hard to accomplish. The shared electronic medical record can accomplish some efficient and constructive communication, but live verbal communication can often capture important nuances that visit notes may not. Another pitfall of split treatment is the expense in terms of time and money. Some insurers will not pay for a psychotherapy visit and a psychopharmacology visit on the same day. So, if both psychotherapist and psychopharmacologist are in the same practice setting, the patient has to come in on separate days. Countertransference can also be a pitfall of split treatments. When the patient is failing, each clinician might unwittingly blame the other clinician and the other modality. Good communication and collaboration between clinicians engender trust and respect, which will benefit the failing patient.

Another pitfall of split treatment is the fact that emergency management or hospitalization often becomes the responsibility of the psychopharmacologist, who sees the patient less frequently and is less aware of psychosocial factors. Better communication and collaboration between clinicians greatly enhances the effectiveness of the psychopharmacologist’s emergency interventions.

A final pitfall of split treatment is that if a bad outcome to the psychotherapy leads to litigation, the psychopharmacologist is almost always included. This cautionary note argues for the psychopharmacologist to know well the psychotherapists with whom he or she is collaborating.

There are important considerations in the sequencing of psychotherapy and pharmacotherapy. For example, Otto and colleagues³⁹ found that adding CBT for a patient with a good response to benzodiazepines for panic disorder improves the success of a subsequent benzodiazepine taper. Marks and co-workers⁴⁰ found that adding a benzodiazepine early in exposure psychotherapy for phobias diminishes the effectiveness of the psychotherapy, presumably by muting the appropriate anxiety provided by graduated exposure.

Although combined medication and psychotherapy are frequently prescribed for many diagnoses, there is little evidence that the combination is more effective than either alone. Psychotherapy alone has been shown to be effective for major depression, dysthymia, obsessive-compulsive disorder (OCD), social phobia, generalized anxiety disorder (GAD), bulimia, and primary insomnia. Combined treatment may be helpful for patients in a real-life clinical setting that may be more complicated than “clean” patients suitable for randomized clinical trials (RCTs). For bipolar disorder and for schizophrenia, psychotherapy alone is contraindicated. Therefore, combined treatment for these diagnoses is standard.

INTERPERSONAL PSYCHOTHERAPY

Interpersonal psychotherapy (IPT) was developed and described by Klerman and co-workers²⁸ in the late 1970s. IPT is a brief therapy that is manual driven and is generally accomplished in 12 to 16 sessions. IPT was inspired by the interpersonal focus of Adolph Meyer and Harry Stack Sullivan and the attachment theory of John Bowlby. In IPT, the therapist is active and the sessions are somewhat structured. Homework is commonly encouraged by the therapy and, on occasion, a significant other may join the patient for a session. After an assessment phase, IPT includes a contract with the patient to meet for a specific number of sessions, as well as an explicit description of what the therapeutic sessions will involve and how the theoretical underpinnings of IPT relate to the goals and strategies of the therapy. IPT does not focus on transference phenomena or the unconscious. In the evaluation phase, the therapist addresses four possible interpersonal problem areas: grief or loss, interpersonal disputes, role transitions, and interpersonal deficits. One or two relevant problem areas are identified that become the focus of the therapy.

IPT has several primary goals: the reduction of depressive symptoms, the improvement of self-esteem, and the development of more effective strategies for dealing with interpersonal relationships. Having identified one or two of the four possible problem areas, the therapist proceeds with six therapy techniques described by Hirschfeld and Shea⁴¹ (usually in order and presented in Table 10-6).

Table 10-6 Techniques of Interpersonal Therapy

A number of well-designed studies have demonstrated the effectiveness of IPT. Perhaps the largest and most often cited is the NIMH treatment of depression collaborative study by Elkin and co-workers.⁴² An often-cited variant of the therapy is maintenance IPT, first described by Frank and co-workers⁴³ at the University of Pittsburgh. Maintenance IPT involves monthly sessions and endeavors to decrease relapse of depression after acute intensive treatment with weekly IPT or antidepressant medication.

The Pittsburgh group found that IPT was more effective than placebo and as effective as imipramine or cognitive therapy for mild to moderate depression. Maintenance IPT has also been found to decrease the relapse rate for recurrent depression,⁴⁴ but maintenance medication should accompany maintenance IPT for recurrent depression.⁴⁵

Research also supports the use of IPT for variants of depression (such as adolescent depression, geriatric depression, dysthymia, and perinatal depression). Two reviews of IPT research have been presented by Weissman and colleagues⁴⁶ and Stuart and Robertson.⁴⁷ The Pittsburgh group⁴⁸ has also studied a variant of IPT with social rhythm therapy for patients with bipolar disorder.

DIALECTICAL BEHAVIOR THERAPY

In the late 1980s, Marsha Linehan^49,50 at the University of Washington in Seattle developed DBT for the treatment of borderline personality disorder. DBT is a structured individual and group treatment that has four goals: mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance. These four goals are considered skills that are taught in carefully structured sessions with a skills training manual and handouts for each session. Mindfulness is the capacity to stop and to take note of thoughts and feelings. At the beginning of each session, the patients are presented with a mindfulness exercise that lasts a few minutes and encourages focus and concentration on the present, a momentary letting go of worldly cares and concerns, similar to a brief meditation or relaxation exercise. Interpersonal effectiveness describes the skill of managing relationships. For example, learning how to balance demands with priorities, learning appropriately and effectively to say no, and learning appropriately and effectively how to ask for help. Emotional regulation describes the skill of decreasing vulnerability to negative emotions and learning how to increase positive emotions. Distress tolerance is the skill of reducing the impact of painful events and emotions. Patients are taught methods of distraction and self-soothing, as well as the skill of “improving the moment.”

Linehan and her fellow teachers of DBT have refused to train solo professionals. Two or more are trained together to establish a program that includes weekly staff meetings. Because borderlines are difficult to treat and manage, the required weekly meeting of staff allows for regular staff support and peer supervision regardless of the years of experience of the staff. Each weekly staff meeting begins with a mindfulness exercise.

Research comparing DBT with treatment as usual in the community has found four significant advantages of DBT: better treatment adherence; better quality of relationships in the patient’s life; fewer self-injurious acts, such as cutting or overdoses; and fewer days in the hospital.⁵¹ Fortunately, health insurers are beginning to fund DBT, recognizing not only the health benefits, but also the benefits in terms of medical economics. In Linehan’s initial research, the DBT-treated borderlines had an average of 8 days of hospitalization for the year of follow-up versus an average of 38 days of hospitalization for borderlines treated “as usual,” creating a significant economic advantage for the insurer.⁵¹

Linehan has used the Hegelian philosophical label dialectical to emphasize three views of reality that are embedded in the therapy: individual parts of a system need to be related to the whole; reality is not static but always changing in response to thesis and antithesis; and the nature of reality is change and process rather than content or structure.

Partly in response to the success of DBT, a group at Cornell (Clarkin and colleagues⁵²) developed a manual-driven, individual transference-focused psychotherapy for borderline personality disorder that is showing promise. DBT has also been found to be effective for women with opioid dependency.⁵³

GROUP THERAPY

Group therapy is defined in this chapter as a group experience led by one or two trained professionals. Groups (e.g., Alcoholics Anonymous [AA], Overeaters Anonymous [OA], Narcotics Anonymous [NA], and Adult Children of Alcoholics [ACOA]) without a designated or trained professional leader can be highly therapeutic. Although these groups have time-tested theoretical underpinnings, we will not include the self-help group in our outline of group psychotherapies.

There are many classifications of group therapy.⁵⁴ Patients may share a common diagnosis (such as breast cancer) or a common experience (such as being a homeless Katrina victim). Groups can be open (e.g., new members may be added as others terminate) or a group may be closed (e.g., all members begin at the same time and the group termina-tes at one time). Open groups may continue indefinitely, and closed groups may be defined (e.g., as in a 20-session experience).

There are two common so-called boundary rules in most groups: First, all revelations in the group are considered confidential. Second, many group therapists discourage or disallow social contact between members outside of the group meetings. Exceptions to this rule might be inpatient groups on a psychiatry service.⁵⁵

Therapy groups (e.g., DBT groups or smoking cessation groups) may have a significant psychoeducational component. Therapy groups differ in terms of theory and technique.

Psychodynamic group therapy focuses primarily on the unconscious determinants of relationships among members (e.g., group members who are in conflict or group members who are always supportive and in agreement with one another) in the group process. The group therapist may focus on unconscious phenomena of the group as a whole or may focus on a conflict between two members. Generally, in a psychodynamic group, the therapist is often silent, nondirective, and observant, which encourages the group to find a direction for itself.

Expressive, supportive, or experiential groups offer members an opportunity to share feelings around a common experience or diagnosis (e.g., a bereavement group, or patients with breast cancer). The group leader provides a focus for addressing the common experience.

Cognitive-behavior group therapy usually provides a structured therapy for a common diagnosis (e.g., all members may have depression or all members may have posttraumatic stress disorder [PTSD]). Cognitive and behavior principles related to the diagnosis are taught to the group. The group members do homework and report back on progress. Mem-bers learn from each other’s experiences and provide each other support.

There are some classic group phenomena that might occur in any kind of group. Bion⁵⁶ described three common resistances to group work: dependency—when the group persistently looks to the therapist or one group member for direction; fight-flight—tensions arise between two or more members and then those members or others threaten to leave the group; and pairing—two members of the group dominate the conversation to the exclusion of the others or in the service of other group members too uncomfortable to get involved.

Therapy groups often have transference phenomena at work either between a patient and the therapist or between a patient and another patient. These phenomena can occur in any therapy group regardless of theoretical focus. These phenomena can be either disruptive or illuminating, but should be recognized and managed by the group therapist.

There is considerable evidence that short-term focused groups are effective,^57,58 but more research needs to be done to identify techniques or patient characteristics that promote success.

COUPLES THERAPY

Couples therapy is defined as a psychotherapy that includes both members of an established partnership. Much literature refers to marital therapy, but many couples that seek treatment are not married. The term couples therapy therefore includes gay partnerships, as well as heterosexual couples who choose not to be married or are not yet married. Conjoint therapy is another term for couples therapy.

The history of couples therapy dates back to, at least, the 1930s with so-called atheoretical marriage counseling and psychoanalytic-focused marital therapy developing independently.⁵⁹ The early psychoanalytic approach addressed the individual neurotic issues of the two patients but generally did not focus on their interaction.

In the early 1960s, family therapy began to emerge and incorporated couples therapy in its theories and techniques. In the mid-1980s, couples therapy became a discipline separate from family therapy.

There are many types of couples therapy based on different theories and techniques. Five of the most widely published and practiced therapies are presented in Table 10-7.

Table 10-7 Types of Couples Therapy

There is considerable research evidence supporting the effectiveness of most of the types of couple therapies described previously.⁶⁶ Behavior marital therapy has been studied the most, especially the brief marital therapies that involve 12 to 20 sessions. Gurman,⁶⁷ in reviewing this research, finds that approximately two-thirds of treated couples have a positive outcome.

Unfortunately, many clinicians who do couples therapy assume that extensive training and experience in individual therapy are adequate credentials. A cautionary quote from Prochaska⁶⁸ is, “Most therapists are about as poorly prepared for marital therapy as most spouses are for marriage.”

With the high divorce rate in the United States, couples therapy will continue to have an important preventive role.

INTEGRATIVE PSYCHOTHERAPY

The tenth and final adult psychotherapy reviewed here may be the most widely practiced.^69,70 Behind the closed and confidential doors of psychotherapy offices, it is likely that psychodynamically focused therapists occasionally use CBT or family systems techniques. Similarly, cognitive-behavior therapists may address transference phenomena embedded in resistance to cognitive-behavioral exercises and homework. In spite of the prevalence of integrative thinking and strategies, integrative psychotherapy did not make the final list of core competencies for psychiatric residency training. An important reason for this is the prevailing opinion of psychotherapy educators that students should learn the theories and techniques separately. This training assumption often indirectly implies that the student-therapist needs to choose one theory and technique and to focus his or her professional development in that one direction. Ultimately, many clinicians out in practice begin the process of integration, but usually well after the structured training years and well beyond supervisory oversight.

The history of psychotherapy integration may go back to the 1932 meeting of the American Psychiatric Association when Thomas French⁷¹ presented a paper that attempted to reconcile Freud and Pavlov. In spite of this early attempt, psychoanalytic and behavioral theory and practice have persistently diverged during the subsequent 75 years. In the mid-1970s, two clinician-teachers first described integrative approaches: Paul Wachtel⁷² in 1977 published Psychoanalysis and Behavior Therapy: Toward an Integration, and Arnold Lazarus⁷³ in 1976 published Multimodal Behavior Therapy.

In 1983, a group of academic psychologists and psychiatrists formed the Society for the Exploration of Psychotherapy Integration (SEPI), which has brought together psychotherapists from all schools to seek enrichment of psychotherapy through integration. There is also now the Journal of Psychotherapy Integration.

An important controversy in psychotherapy integration relates to whether a comprehensive integrated theory of psychotherapy should be developed. Lazarus and Messer⁷⁴ have debated this important issue. Lazarus proposed an atheoretical technical eclecticism unique for each patient, whereas Messer proposed a theory-rich assimilative integration.

Multimodal psychotherapy, described by Lazarus,⁷⁵ is perhaps the most widely known integrative method. Lazarus, as reflected in the debate with Messer, assumed that patients and their problems are unique and too complex to fit neatly into one theory or technique. Therefore, each patient deserves a unique integrative approach. He uses the acronym BASIC ID to promote an integrative assessment and treatment approach:

Whatever works for each unique patient should be used.

Research into integrative psychotherapy is in its infancy.⁷⁶ Because integrative psychotherapy is not manual driven, good research would require a naturalistic focus, which has not yet been done. From their extensive analysis of RCTs in psychotherapy research, Weston and colleagues⁷⁷ concluded that in the real world of clinical practice, specific techniques demonstrated to be effective in RCTs need to be integrated into a unique approach to each complex patient.

INNOVATIVE DIRECTIONS OF PSYCHOTHERAPY RESEARCH

Although most research in psychotherapy has focused, and will continue to focus, on the demonstration of effectiveness, there are some important and innovative efforts to understand other aspects of psychotherapy. Ruffman and colleagues⁷⁸ reviewed early evidence of functional neuroimaging changes with psychotherapy. Marci and Riess⁷⁹ described the use of neurophysiological measures to recognize empathic success and failure between therapist and patient. Ablon and Jones⁸⁰ described the use of the PQS, a unique measure of process in psychotherapy, to determine psychodynamic versus cognitive process in therapy sessions.

CHILD AND ADOLESCENT PSYCHOTHERAPY

As with adult psychotherapy, there are a number of different modalities by which child and adolescent psychotherapy can be practiced. However, it is likely that within child and adolescent therapy there exist even more integrative practices than in adult treatment. Therefore, in any discussion of the various modalities of psychotherapy with young people, one needs to keep in mind the fact that many of these modalities are present in all treatment endeavors.^81,82

Also, just as with the treatment of adults, all interactions between a clinician and a child or an adolescent involve some form of psychotherapeutic action. Issues (such as patient and family compliance, patient improvement, and better communication between patient and clinician) all hinge on the realization that child-clinician interactions follow certain key therapeutic principles that are very much part of the psychotherapeutic tradition. Attention to these issues has great bearing on the treatment of all children in virtually all settings.

This section will discuss many of the same treatment modalities that have already been covered for adults. However, there are important differences among these modalities with regard to child and adolescent treatment, and these differences will therefore be stressed. To best understand these differences, a brief discussion of child and adolescent development is necessary.

MANUAL-DRIVEN THERAPIES AND BEHAVIORAL THERAPIES

As already discussed, there are growing number of manual-driven psychotherapies that are used for both adults and children. These include CBT, IPT, and DBT. These treatments have in common clearly defined procedures with manual-documented instructions. Given these constants, these therapies have enjoyed much greater evidence of efficacy in RCTs, though this is not the same as saying that other, harder-to-study treatments are less effective.

As with adults, CBT has been used very successfully in children and adolescents for anxiety disorders, especially OCD.^88–92 Problems, such as school refusal and depression, have also been found to respond to CBT,^89,93 and IPT has been efficacious with depression among adolescents.^94–96 There is some question, however, as to the effectiveness of IPT for suicidality in younger populations.⁹⁷

Although borderline personality disorder is not usually diagnosed in children before age 18, there are adolescents who engage in borderline defensive structures (such as splitting, all-or-nothing thinking, and affective lability) for which DBT has been found useful in this population.^98,99 Importantly, one might argue that all of these modalities will work best by understanding the child’s developmental plight using techniques such as humor and connection, and, as all of these therapies require a substantial commitment by the patient, none of these techniques will be effective if the child does not want to pursue treatment.

Contingency management is a form of behavioral therapy that is based on clearly defined behavioral goals, rewards for meeting these goals, and consequences for falling short of these goals.^100,101 While incentives based on rewards and consequences are potentially fundamental in parenting, enacting these criteria in a psychotherapeutic setting is tricky and works best with a strong alliance and firm “buy-in” from both patient and family. Management of impulse-related disorders (such as attention-deficit/hyperactivity disorder [ADHD]) often involves some form of contingency management.

Biofeedback is another form of behavioral therapy that involves teaching children relaxation techniques using real-time technological measurements of autonomic arousal. This form of treatment has been very effective in children and adolescents for problems such as chronic pain, as well as for severe anxiety. Because children are increasingly enamored of technology, the use of real-time measurements of variables (such as heart rate or skin conductance) often provides a special treat for children who would otherwise be recalcitrant to treatment.¹⁰²

SYSTEMS-BASED CARE

All patients exist within complex social and environmental systems. However, the multiple environmental changes that characterize the childhood mandate that the therapist be involved with the child’s world; this maximizes the therapeutic impact of the work. The most basic of these interventions involves family therapy and parent guidance.

Parent guidance is the process by which the clinician helps parents to effectively guide, connect with, and, ultimately, parent their children. This therapy requires the clinician’s understanding of development, as well as the child’s unique set of circumstances and the parents’ particular strengths and challenges. Psychodynamic and behavioral techniques are key to this endeavor.^103,104

Similarly, family therapy requires that the clinician understand the dynamics of the family itself and the role of the patient within the family system. Family therapy is discussed elsewhere in this volume, but one should note that treatment of children and adolescents often involves multiple visits with the family even in the absence of a defined family psychotherapy. In fact, all individual treatments with children necessitate some kind of parental involvement.

Similarly, group interventions are often very useful for children and adolescents who might experience social difficulties and feel uncomfortable explicating these difficulties in individual treatment. Children will often tell each other how best to handle a difficult situation, and the universality of the group experience is frequently comforting and beneficial to the child.¹⁰⁵ However, child dynamics can also make the group experience frightening and off-putting in the absence of a good group leader. To this end, the regression that often takes place in all forms of group therapy is perhaps especially present in child and adolescent group treatment. The clinician must be vigilant for this regression, and intervene by interpreting the regression in the context of the group process.

Finally, it is common for therapists to contact schools, camps, and other agencies where their patients might spend their time. Sometimes the most subtle office-based intervention with a child will not be nearly as effective as helping a school, for example, to better understand and appreciate the child in that particular setting. A potentially major difference between child treatment and adult psychotherapy involves this active participation in the child’s external environment.

CONCLUSION

As this chapter has stressed, some forms of therapy are substantially better supported by empirically driven evidence than are others. However, this is not to say that the lack of evidence suggests an overall lack of efficacy for less validated treatment techniques. Among the mainstream forms of psychotherapy, the constant that links all of them is the presence of trust, a solid alliance, and a sense of empathy within the caregiver. Some researchers have even suggested that these qualities are the best predictors of therapeutic success regardless of treatment modalities. To this end, all therapies must strive for connection and nonjudgmental understanding. These characteristics are, in fact, the very qualities that make psychotherapy both effective and rewarding for patient and clinician alike.