The most effective treatment plan for any young person with a mental disorder will include some form of psychotherapy. At the very least, any treatment plan will include the formation of a therapeutic alliance with you as the care practitioner and psychoeducation about diagnosis, treatment, and prognosis. Several evidence-based textbooks teach more advanced psychotherapy techniques for working with children and adolescents (e.g., Christophersen and VanScoyoc 2013; Kendall 2012; Weisz and Kazdin 2010). These psychotherapy skills are typically learned during training programs when senior practitioners supervise trainees. Although we recommend these texts and psychotherapy training to everyone who regularly works with children and adolescents, in this chapter we introduce different kinds of psychotherapy, discuss how to select a particular psychotherapy, and explain how to engage a child and her caregivers in psychotherapy.
Psychotherapy is an important treatment strategy for young people for many reasons. It is almost always the safest treatment option we can offer and has the least potential for adverse effects. For specific problems, such as disruptive behavior or suicidality, it also has shown superior efficacy over psychotropic medication interventions. In addition, the psychotherapeutic literature has shown that when a person attributes a behavioral change to her own efforts, the change is more enduring than a behavioral change she attributes to an external source, such as a medication (Alarcón and Frank 2011).
However, the changes that result from psychotherapy generally are not immediate—we expect it to take a month or two of regular sessions before a child or an adolescent begins to manifest the benefits of psychotherapy. This delay is part of the reason why it is important to stratify the severity of a young person’s mental distress. If a child or an adolescent is having moderate to severe difficulties, our preferred treatment 268plan is more likely to include a combination of both psychotherapy and medication to encourage the most rapid and reliable results. For young people who have a mild degree of mental health difficulties, our treatment plans typically begin with psychotherapy alone. Of course, these are broad generalizations, and many exceptions exist. For instance, even with severe oppositional defiant disorder, we prefer to start treatment with behavioral management training instead of psychotropic medications. In contrast, it is clinically reasonable to initiate treatment for severe attention-deficit/hyperactivity disorder with stimulant medications alone.
If you decide to recommend psychotherapy, it can be difficult to know which psychotherapy to recommend because there are a large (and growing) number of different validated psychotherapies that can be delivered to children. For example, on its Web site (www.nrepp.samhsa.gov), the U.S. Substance Abuse and Mental Health Services Administration lists more than 200 different research evidence–based psychotherapies for young people. Fortunately, even though these therapies have significant differences, they are often variations on a small number of themes. For example, TFCBT seems like a confusing acronym, but it is actually a trauma-focused version of cognitive-behavioral therapy, a widely practiced evidence-based psychotherapy.
Even after you identify the appropriate psychotherapy for a particular child or adolescent, it can be difficult to engage a young person and her caregivers in the therapy. In meta-analyses, between 25% and 75% of children and adolescents in mental health treatment prematurely discontinue (de Haan et al. 2013), a finding that illustrates the challenges of delivering treatment. Engagement in psychotherapy can be a barrier because of stigma, ambivalence about behavior change, doubts about the efficacy of psychotherapy, the time investment it requires, or financial barriers. You can help by communicating appropriate expectations for psychotherapy with a patient and her caregivers, informing them of the efficacy of psychotherapy, the delayed response, and its enduring benefits.
How else can you engage a patient and her caregivers in psychotherapy?
• Explain the diagnosis in a way that the patient and her caregivers can fully understand.
269• Explain the rationale for the psychotherapy treatment plan (e.g., as the safest or most effective approach).
• Briefly describe what the recommended psychotherapy experience would be like.
• Ask if they have any concerns about that approach in order to address them.
• Provide the family with a list of recommended practitioners.
• Follow up with the family to address any problems that arise.
This last follow-up step in particular is important because families often get discouraged if they run into an insurance coverage restriction or have trouble finding an available practitioner. Discussing what happened with the referral provides you an opportunity to amend the care plan. In general, referrals are most successful when you can match a patient and her caregiver with a therapist with whom they form a therapeutic alliance (Roos and Werbart 2013).
After all, the heart of all psychiatric treatments is the therapeutic alliance you establish when a patient identifies treatment goals and you ally yourself with the patient as she pursues those goals. You form an alliance between yourself and your patient with the goal of mobilizing healing forces within your patient by psychological means. Your ability to form these alliances profoundly influences the efficacy of your work for the patient, as well as your satisfaction with this work (Summers and Barber 2003).
To assist you, we prepared descriptions of different types of psychotherapy that are commonly considered with children and adolescents and a list of conditions for which their use has been validated as effective by research (Table 15–1).
270TABLE 15–1. Commonly recommended child and adolescent psychotherapies
Therapy |
General description |
Typical indications |
Cognitive-behavioral therapy (CBT) |
Teaches patients how to correct illness-related cognitive errors in thinking (e.g., the depressed patient thinking “nothing ever goes right for me”) and coaches/encourages patients to try out different behaviors (i.e., behavior activation)—both of which lead to changes in how the person feels. Assigning practice and trials between sessions is a core feature. Desensitization via supported exposure to one’s fears is typically used for anxiety. |
Anxiety disorders (all) Depressive disorders Oppositional defiant disorder Eating disorders Substance use disorders Posttraumatic stress disorder |
Trauma-focused CBT |
Most commonly cited version of trauma therapy in children. Starts with building therapeutic support and educating about posttraumatic stress disorder. Like other successful trauma therapies, treatment requires patients to face their own trauma narrative to desensitize, reduce pathological avoidance, and reduce the trauma memory’s control over their future. |
|
271Dialectical behavior therapy |
Very specialized version of CBT; requires attending skills groups (to teach problem solving, emotional regulation, distress tolerance, and interpersonal effectiveness skills) and attending individual therapy sessions. Mindfulness and meditative exercises are often used to assist. Uniquely helpful for treatment-resistant, chronically suicidal patients. Most supportive research is with adults. |
Chronic and significant suicidality and self-harm |
Family therapy |
Many different styles and approaches, but all focus on the family relationship or interaction patterns that cause dysfunction and help the family system to amend that pattern (rather than identifying a mental health diagnosis to treat or saying that the problem resides within an individual). |
Eating disorders Conduct disorder Depressive disorders Substance use disorders |
Group therapy |
Addresses interaction pattern problems, as in family therapy, while providing more disorder-specific support within a group of strangers having similar challenges. Peer-based learning can be uniquely effective. Therapists must steer group members away from inadvertently teaching unhealthy behaviors. |
Anxiety disorders |
272Behavior management training |
General term for programs that teach and encourage skillful parent or caregiver responses to challenging child behaviors. Positive interaction time between the parent and the child is encouraged because it must accompany behavioral management steps in order to work. Changing caregiver behaviors is key rather than changing the child through individual therapy sessions. Also known as parent management training. |
Oppositional defiant disorder Conduct disorder |
Applied behavioral analysis |
One-on-one specialized intensive behavioral management training that gradually teaches socially normative behaviors via small achievable elements, with each element reinforced by a reward (such as rewarding the child making any “h” sound as step in teaching use of “hello”). Highly resource intensive in terms of the required therapist hours and continuous treatment planning. |
Autism spectrum disorder |
273Social skills training |
Variety of class-based, group, and one-to-one techniques to teach basic behavioral and cognitive skills, reinforce prosocial behaviors, and teach social problem solving. More potent when delivered in a group rather than a one-to-one setting because of peer learning influences. |
Oppositional defiant disorder Attention-deficit/hyperactivity disorder Autism spectrum disorder |
Relaxation training |
Biofeedback, deep breathing, progressive muscle relaxation, and mindfulness are examples of strategies used to increase mind-body awareness and the ability to electively calm the heights of emotional reactions. Must be practiced when not in crisis in order to develop the skills needed for times of crisis. |
Anxiety disorders Depressive disorders |
Motivational interviewing |
Therapeutic interaction regarding health behavior(s) around which a patient needs to change but has significant reluctance. Nonconfrontationally and nonjudgmentally helps patients to state their own reasons for changing, to resolve their own ambivalence, and to state what actions they could take to change. Most supportive research is with adults. |
Substance use disorders 274 |