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Title: Child%20Psychotherapy

Child Psychotherapy
  • James H. Johnson, Ph.D., ABPP
  • University of Florida

Child Psychotherapy Pre Test
  • What is child psychotherapy and how does it
    differ from other treatments?
  • Who is a good candidate for child/adolescent
  • How does child psychotherapy differ from adult
  • 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?

Child Psychotherapy Pre Test
  • What kind of ethical dilemmas does one confront
    when engaging in child psychotherapy?
  • What empirical support is there for the
    effectiveness of child psychotherapy?
  • To what extent is the question Is psychotherapy
    effective a productive one to ask?
  • What are the Myths of Psychotherapy
  • How does and understanding of these Myths lead
    to better research?

Approaches to Child Treatment Overview
  • There are numerous approaches to the treatment of
    behavioral/psychological problems of childhood
  • Several examples of treatment approaches,
    suitable for use with children, have cited
    throughout this course.
  • For example, we have considered behavioral
    (operant, classical conditioning),
    cognitive-behavioral and psychopharmacological
    approaches when discussing a number of childhood
  • There are also family therapies, group therapies,
    residential treatments, as well as others that
    have also been used with children.

Child Psychotherapeutic Approaches
  • There are other treatment approaches that are
    most closely associated with the term "child
  • These approaches are of special significance, as
    for many years, they represented the primary
    non-biologically-oriented methods for treating
    the psychological problems of children.
  • And, despite some temporary decrease in
    popularity, due to the development of competing
    methods of treatment, there appears to be a
    renewed interest in these approaches.
  • At present, they are among the most widely used
    treatment approaches in applied clinical

Characteristics of Psychotherapy
  • In some respects, all of the treatments we have
    considered could be viewed as "psychotherapeutic"
    in the most general sense.
  • Nevertheless, there do seem to be some general
    characteristics of approaches usually referred to
    by this label.
  • For example, psychotherapy is commonly thought of
    as an interpersonal process, involving a verbal
    and/or nonverbal interchange between a patient
    who exhibits psychological problems (often
    assumed to be of an intrapsychic nature) and a
    professional who wishes to be of help.
  • These approaches are usually based on a Medical
    Model of psychopathology.

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
  • in order to facilitate constructive personality
    and behavior change.
  • Psychoanalytic and client-centered approaches
    have been the child treatments most often
    considered within this category.
  • Interpersonal approaches would fall into this
    category as well.

Children versus Adults in Psychotherapy
  • While it is generally agreed that there are
    special considerations that must be taken into
    account in treating children with psychological
    problems, it has been argued that the basic
    principles involved are quite similar to those
    involved in the treatment of adults.
  • It has been suggested that the major difference
    between working with adults and children lies in
    the need to alter therapy techniques to
    accommodate the child's level of cognitive and
    emotional development.

Children versus Adults in Psychotherapy
  • Children, for example, are conceptually more
    concrete, linguistically less competent, and less
    introspective than adults.
  • They are less likely to see themselves as
    displaying difficulties and less likely to see
    the value of talking about their problems.
  • They most often become involved in treatment due
    to the concerns of others, rather than as a
    result of their own level of personal distress.
  • They are often less motivated to participate in
    treatment and to share common treatment goals
    with the therapist

Children versus Adults in Psychotherapy
  • While all of these issues must be taken into
    account when working with children in treatment,
    two factors are worthy of special comment .
  • the child's level of cognitive development
  • his/her dependence on the parents

Level of Cognitive Development
  • The child's more immature cognitive and
    linguistic skills often require that a much
    greater emphasis be placed on non-verbal
    communication and interactions than is the case
    with adults.
  • Thus, child psychotherapy is often carried out
    within the context of play activities rather than
    involving the level of verbal interchange which
    usually characterizes adult or even adolescent
  • Play is often considered a major vehicle for
    change in child psychotherapy.
  • This is particularly true when dealing with very
    young children who are limited in terms of their
    verbal skills.

Level of Cognitive Development
  • As the age of the child increases there is likely
    to be 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.

The Childs Dependence on Others
  • The child's dependence on others may require that
    the therapist deal with persons other than the
    patient to a much greater degree than is
    typically the case in working with adult
  • Children seldom refer themselves for treatment
    but usually become involved in treatment because
    some adult, usually a parent, has become
    concerned enough about the nature of their
    behavior to seek help.
  • This referral may well reflect the child's need
    for treatment.
  • In other cases, it may be related to the parents
    lowered level of tolerance for what is
    essentially normal, although possibly
    problematic, child behavior

The Childs Dependence on Others
  • . Depending on the nature of the assessment
    information obtained, the focus of the
    intervention may be either on
  • the child's problematic behavior
  • or factors such as high levels of parenting
    stress, lack of adequate parenting skills, or
    perceived lack of competence in the parenting
    role - which may contribute to strain on the
    parent-child relationship.

Childs Dependence on Others
  • Parents may also influence the outcome of child
    treatment in other ways.
  • For example, with adults, continuing in therapy
    is related to variables such as
  • the patient's relationship with the therapist,
  • current levels of patient distress, and
  • whether the patient feels that therapeutic gains
    are being made.
  • Whether the child stays in treatment often has as
    much to do with parental as with child factors.

Childs Dependence on Others
  • Factors that determine whether parents choose to
    allow their child to continue in treatment may
    include the following.
  • parent schedules,
  • the degree to which parent's view the child's
    therapy as having credibility (all they do is
  • 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,
  • This makes it necessary for child therapists to
    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
  • The greater complexity of child treatment also
    results from the fact that child psychopathology
    and the need for treatment is often intimately
    related to factors operative within the family.
  • Examples might include
  • child difficulties that are related to ongoing
    parental conflict or
  • maladaptive communication and interaction
    patterns existing within the family.
  • In these instances it is often necessary to deal
    with other family members in order to effect
    therapeutic changes in the child.

Principles of Psychotherapy as Applied to Children
  • Again, while many of the basic principles of
    psychotherapy may be the same for adults and
    children, the immaturity and dependent status of
    the child may require significant modifications
    in the application of these principles.

Elements of Change in Child Psychotherapy
  • Child psychotherapy is usually undertaken with at
    least two goals in mind.
  • A resolution of the problem behaviors that
    resulted in the child being referred, and
  • Bringing about some sort of general personality
    change that will reduce the likelihood of the
    child's developing problems in the future.
  • A relevant question is - what goes on in
    psychotherapy to bring about these types of

Elements of Change
  • In an excellent discussion of traditional
    approaches to child psychotherapy, Tuma (1989)
    has suggested that therapeutic changes are
    attributable to
  • General Factors (certain aspects of the therapy
  • Specific Factors (various therapy "techniques",
    that may be employed within the context of the
    therapy relationship).

General Factors in Psychotherapy
  • General factors include
  • The opportunity for catharsis (the opportunity
    to talk about one's problems with a therapist and
    express feelings about important issues),
  • Attention from the therapist (interacting with
    someone who listens and communicates an attitude
    of acceptance),
  • Reinforcement effects (therapist reinforcement
    of appropriate in-therapy behavior), and
  • Expectancy effects (the creation of positive
    expectations for change by the therapist)

Therapist Offered Conditions
  • In commenting on the important role of therapist
    attention, Tuma gives special consideration to
    several "therapist offered conditions" described
    by Rogers (1942 1951).
  • Here, it is suggested that change in therapy is
    enhanced, not simply by giving the child one's
    undivided attention, but through the therapist
    responding in a way that communicates empathy,
    non-judgmental warmth and genuineness.

Therapist Offered Conditions
  • Empathy relates to the therapist's communications
    that he or she cares for the child and is able to
    understand the child's problems from the child's
  • Genuineness refers to therapist characteristics
    of openness, honesty, and authenticity which
    leads the child to believe that the therapist is
    one who can be trusted.

Therapist Offered Conditions
  • Therapist warmth involves the ability of the
    therapist to communicate an atmosphere of
    non-judgmental acceptance where the child can
    feel secure in dealing with even sensitive and
    anxiety arousing topics through play or through
  • Communication of these therapist offered
    condition can be verbal or non-verbal.

Therapist Offered Conditions
  • Tuma has emphasized the importance of these
    characteristics by citing the results of numerous
    research studies that link these variables to
    positive therapy outcome (see Truax Mitchell,
  • Indeed, it has often been suggested that empathy,
    genuineness and warmth are necessary (although
    not sufficient) conditions for therapeutic
  • Research has suggested that therapists low on
    the conditions, not only have patients who do not
    get better they often have patients that get
  • Deal with patient needs - rather than your STUFF!

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, ("Mm-hmm", " I see what you mean",
    " That is interesting, Wow) used to facilitate
    further discussion or to communicate the
    importance a particular topic, and
  • confrontations, which encourage the child to deal
    with some therapy-related issue (e.g., pointing
    out that the patient may have played some role in
    a problem he/she had with another child).

Specific Factors in Psychotherapy
  • Therapists also frequently use clarifications to
    help the child understand the significance of
    certain behaviors.
  • At one level a clarification may simply involve
    descriptions of the patient's behavior or a
    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 mother doll
    really hard ").
  • In other instances, clarifications are designed
    to help the child understand and label feelings
    of which he or she may be unaware.
  • In this respect the clarification is similar to
    the technique of "reflection of feeling" often
    used by client-centered therapists

Specific Factors in Psychotherapy
  • Reflection of feeling usually involves the
    therapist commenting on the child's feeling
    state, as reflected in his/her behavior.
  • An example of such a reflection might be a
    statement such as "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 seen as useful in
    helping the child develop verbal labels for
    feelings, thus making them less confusing and
    overwhelming to the child (Freedheim Russ,

Interpretation in Child Therapy
  • An additional technique used by most child
    therapists, at least to some degree, is
    interpretation of the child's play or verbal
  • Interpretations involve therapist's comments
    regarding the relationships between thoughts,
    feelings and behaviors or the posing of tentative
    hypotheses regarding the "meaning" of certain
  • They are used to increase the child's
    understanding of the causes of his/her behavior.
  • They may vary from interpretations that deal
    with material close to consciousness to those
    that are designed to bring unconscious material
    to awareness.

Interpretation in Child Therapy
  • A good example of an interpretation might be a
    tentative statement like "I wonder if your not
    going to school is one way of making sure your
    mother is safe during day", as it might be used
    with a child who is refusing to go to school as a
    result of separation anxiety.
  • It must be noted that with interpretations,
    proper timing is essential.

Preparing the Way for Interpretations
  • Questions, clarifications, exclamations, and
    confrontations prepare the way for the
    interpretive process.
  • Typically, early comments by the therapist are
    centered on empathic and accepting
  • Later, as important areas are pursued in more
    detail, questions (or their equivalent) and
    clarifications are used to gain a fuller
    understanding of the child's feelings and
  • Once they are better understood, confrontations
    are used, and, finally, when the child appears
    ready to accept them, interpretations are

The Role of Interpretations
  • Interpretations serve a crucial function in
    helping 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.

Emotional Reexperiencing
  • Freedheim and Russ (1992) highlight the nature of
    this process by indicating that the emotional
    reexperiencing of major conflicts is often an
    essential part of therapy.
  • It allows the child to express, think about, play
    out, and consequently process ambivalent emotions
    and conflictual material.
  • It involves graded exposure to conflict laden
  • Many traditional psychotherapists would see this
    working through process as an essential
    ingredient of effective psychotherapy.

Working Through
  • By using techniques like the ones described here,
    within the context of a good therapeutic
    relationship, the child is assumed to develop a
    better awareness of his/her feelings as well as
    insight into the causes of problem behaviors.
  • This may lay the foundation for "working through"
    significant conflicts and developing more
    adaptive ways of relating and behaving through
    learning alternative problems solving strategies
    and methods of coping.
  • Working Through Loss An analogy to

Psychotherapy The Big Picture
  • It should be emphasized that 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

Stages of Psychotherapy From Referral to
  • As we have already seen, only rarely does a child
    request treatment.
  • In most cases the child is referred by some
  • Parents, teachers, and pediatricians are probably
    the most common referral sources.
  • Referrals are also frequently made by Juvenile
    Courts and Youth and Family Service agencies.
  • In essence, referral for treatment is almost
    always based on some other persons perception of
    the child's behavior as abnormal.

The Referral Process
  • Some parents (perhaps because of poor coping
    abilities or the experiencing of high levels of
    stress) have little tolerance for child behaviors
    that are seen as normal by most other parents and
    child experts.
  • As a result, they may view certain normal
    behaviors as troublesome enough to warrant their
    seeking help in dealing with them (Goodness of
    fit issue).
  • This may suggest the need for parents to be
    involved in treatment as well as the child, or
    perhaps instead of the child

The Referral Process
  • In other cases children display genuine
    adjustment problems.
  • Some of these may relate to intrapsychic
    conflicts due to the child's intrinsic emotional
    make-up, some type of trauma, or other life
  • Some children display behavior problems due to
    disturbed home and social environments.
  • Others display emotional problems or act out
    secondary to learning disabilities.
  • Still others display psychological problems
    secondary to some physical condition.

Assessment for Psychotherapy
  • Given the range of factors that result in
    referrals a 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, and
    whether the problem is amenable to psychotherapy
    or must be dealt with in some other way.

Assessment for Psychotherapy
  • If it is determined that the child has
    difficulties that make them a good candidate for
    psychotherapy, the assessment may provide
    information about potential goals and information
    to guide the nature of treatment.
  • The assessment process often begins with a
    parental interview.
  • Here the clinician may obtain information
  • the specific nature of the child's problem
  • the duration of these problems,
  • any precipitating events,
  • the situations in which the problem behaviors
  • how these problems are responded to by others,
  • previous attempts to deal with the child's

Assessment for Psychotherapy
  • Additionally, the clinician may inquire about the
    child's developmental history, medical history,
    school performance, peer and family relationships
    and any other factors that might impact on the
    child and family and contribute to the child's
  • An assessment is usually also made of the
    parent's expectations regarding child behavior,
    disciplinary methods used, and the degree to
    which parent variables seem to contribute to the
    child's difficulties.
  • In general, an attempt is made to get a good
    description of the presenting problems, other
    difficulties, and at least preliminary
    information regarding possible contributing

Assessment for Psychotherapy
  • The parent interview is frequently supplemented
    by an interview with the child.
  • With very young children this interview may
    involve seeing the patient in a playroom where
    the clinician can interact with the child and
    observe the nature and appropriateness of
    his/her behavior (with some talk).
  • With an older child the interview may focus more
    on verbal than play behaviors.
  • Typically the emphasis is on obtaining
    information, similar to that solicited in the
    parent interview, as well as information
    regarding the child's perceptions of his/her
    difficulties and life circumstances.

Assessment for Psychotherapy
  • This interview process itself 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
  • 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 drug
    treatments, behavioral interventions, family
    therapy, or various forms of environmental
  • As Reisman (1973) has pointed out, 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
  • Reisman notes that children with behavioral
    problems often come from chaotic homes and social
    environments that may contribute to their
  • This may make modification of the child's
    environment a more appropriate treatment approach
    than psychotherapy.
  • With other problems like autism, the need for
    treatment is not in doubt.
  • But, the appropriateness of treating these
    children with psychotherapy must be questioned
    due to their deficits in communication (this is
    not to imply that other forms of treatment may
    not be of value).

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
  • 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
  • The notes that in these cases its use is
    associated, at times with dramatic suddenness,
    with the occurrence of favorable changes in
    attitudes and behavior.

Assessment for Psychotherapy
  • It should be noted that these problems he is
    speaking about are mild' from the point of view
    of the professional, who is knowledgeable about a
    wide spectrum of behaviors.
  • For children who experience fears, unhappiness,
    inhibitions, immature habits or behaviors,
    difficulties getting along with others and
    failures in school, as well as for their involved
    parents, such problems are extremely troubling
    (Reisman, 1973).
  • He notes that these kinds of disturbances
    constitute the majority of those that occur in

Assessment for Psychotherapy
  • Reismans comments suggest that, while child
    psychotherapy, may be the preferred approach for
    treating certain childhood problems, there are
    conditions for which it is neither useful nor
  • Proper pre-therapy assessment, which focuses not
    only on possible intrapsychic but also on
    biological, environmental, and family variables
    that may contribute to the child's difficulties,
    is essential in determining those instances where
    psychotherapy is most appropriate.

The Setting for Psychotherapy
  • Unlike therapy with adults, where treatment is
    conducted in the therapist's office or a therapy
    room, the setting for child psychotherapy is
    often a playroom, especially for very young
  • The choice of this setting is based on the
    proposition that, while adults and adolescents
    may communicate best through the use of language,
    children can communicate more effectively through
  • Although the role of play and the meanings
    ascribed to play behaviors vary, depending on
    the therapist's orientation, play is seen by many
    clinicians as an important vehicle for
    patient-therapist interaction.

The Structure for Psychotherapy
  • The structure within which psychotherapy is
    carried out is not only defined by the physical
    setting, but also by the frequency and duration
    of therapy sessions.
  • While session length and frequency of therapeutic
    contact may vary depending on the nature of the
    child's difficulties and practical considerations
    it is most common for sessions to be 45 - 50
    minutes long and to be scheduled once or twice
    per week.
  • Whatever the decision regarding session length
    and frequency, this information is discussed with
    the child to provide a relevant structure
    regarding the extent and nature of the
    therapeutic involvement.

The Structure for Psychotherapy
  • 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.
  • This structure, in terms of the defined frequency
    and length of therapy sessions, along with the
    provision of appropriate play materials provides
    the primary context in which the therapist and
    child engage in the process of psychotherapy.
  • With older children and adolescents the setting
    may be an office with various games and/or play
    materials rather than a playroom.

The Initial Stage of Psychotherapy
  • In this phase the foundation is built for later
    stages of treatment.
  • Early sessions usually involve providing the
    child and the parent with
  • general information regarding the nature of
    psychotherapy (preparation),
  • developing, at least, tentative agreed-upon goals
    for treatment, and
  • discussing the role of the therapist, the
    patient, and the parents in working toward these
  • Issues such as the confidentiality of information
    provided by the child in therapy and any limits
    on confidentiality are also considered at this

The Initial Stage of Psychotherapy
  • The initial stage of therapy also involves a
    continuation of the assessment process.
  • Through additional contact with the parents,
    verbal interactions with the child, observations
    of play, or a combination of these, the
    therapist comes to know the patient better and
    gains additional and more detailed information
  • the nature of the child's difficulties,
  • important areas of conflict,
  • defense mechanisms,
  • adaptive and maladaptive methods of coping, and
  • factors which appear to contribute to problem

The Initial Stage of Psychotherapy
  • The information noted here is essential in
    helping the clinician develop a conceptual
    framework for understanding the child's problems
    which can serve to guide the therapy process.
  • An additional characteristic of this beginning
    stage of therapy has to do with the development
    of a patient-therapist (and, with younger
    children the parent-therapist) relationship.

The Initial Stage of Psychotherapy
  • Therapists with a client-centered orientation
    typically place the greatest emphasis on the
    patient-therapist relationship, and see the
    relationship as the primary vehicle through which
    personality and behavioral change occurs.
  • However, developing adequate rapport with the
    patient (and parents) is viewed as necessary by
    most therapists regardless of orientation.
  • Indeed, a good therapeutic relationship with the
    patient (and parent) cannot be overemphasized.
  • 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 also occur through the
    child's learning of limits which may be imposed
    on behavior within therapy sessions.
  • It is usually suggested to patients that therapy
    is a place where they can feel free to speak of
    anything they wish and they are encouraged to
    express themselves freely.
  • Most therapists are accepting of a range of
    behaviors exhibited by the child patient.
  • There are, however, certain behaviors which may
    be viewed as unacceptable and which demand a
    response on the part of the therapist.

Setting Limits in Therapy
  • For example, most therapists would agree that
    limits should be set against hitting or otherwise
    behaving in a physically aggressive manner toward
    the therapist.
  • 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 during sessions,
    the inappropriate demonstration of physical
    affection, or engaging in other behaviors that
    might interfere with treatment.

Dealing with Limits in Child Therapy
  • Setting limits may involve therapist behaviors
    ranging from simple statements that certain
    behaviors are unacceptable to physical restraint
    in extreme cases.
  • In most instances relatively few limits are
    needed and therapists only invoke them when
  • For instance, a child is not routinely told that
    he/she cannot hit the therapist of 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
  • The imposition of limits should be done in such a
    way that the therapist conveys his/her continued
    acceptance of the child as a person, while at the
    same time conveying the unacceptability of
    certain behaviors.
  • It is assumed that this limit setting is
    therapeutic, in addition to reducing the
    immediate problem behavior, because
  • it provides lessons in self control,
  • provides the child with a sense of security, and
  • 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
  • Finally, limit setting is a good example of why
    stages of therapy cannot be separated in more
    than an arbitrary 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 using the assessment information,
    and the evolving patient-therapist relationship,
    to effect patient change through the application
    of treatment methods such as those described

The Middle Stage of Therapy
  • The actual treatment methods used may 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
  • 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.
  • While their use is often characteristic of this
    stage of therapy these techniques would almost
    certainly be accompanied by the use of other
    treatment methods (e.g., problem solving with
    older children).
  • 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 the goals set earlier
    show promise of being met the issue of
    termination arises.
  • Approaching this issue involves dealing with
    several questions.
  • For example, although the initial goals of
    therapy may have been largely accomplished, one
    might ask
  • Are there are other issues that have arisen
    during the course of treatment that the child and
    his parents or the therapist feel need to be
    dealt with.
  • A second question has to do with the specific
    criteria one should adopt in judging the
    appropriateness of termination.

The Termination Phase
  • Given that a decision to terminate is made, one
    must ask how this can be best accomplished
  • 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? and so forth.
  • Dealing with the issue of termination
    necessitates a certain degree of tact and skill
    on the part of the therapist.
  • The issue must be raised so that the patient, and
    his/her parents, and the therapist can discuss it
    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
  • This needs to be presented "slowly, deliberately,
    and matter of factly, so that the child does not
    feel compelled to respond to them in a certain
  • Reisman notes there should always be room for the
    client to express his/her opinions and for the
    therapist to modify his or hers .

The Termination Phase
  • Timing is crucial in raising the issue of
  • Ideally, the topic should be approached at a
    time where maximal gains have been accomplished.
  • This is not to imply that the child must be a
    tower of mental health for termination to be
    considered, as adopting this as a criterion would
    often necessitate an indefinite therapeutic
  • It seems more appropriate that the issue be
    considered when most of the original goals (or
    later goals delineated during treatment) have
    been met and the patient, parent and therapist
    together feel the child is somewhat better
    equipped to handle future problems as they arise

The Termination Phase
  • Reisman suggests
  • ... it is clear that for many clients
    psychotherapy ends, not with a giddy rush into a
    bright new day, but with a sober appraisal of
    accomplishments and a resolve to deal with
    problems as they come (p. 74)".

Implementing Termination
  • After a decision to terminate has been made there
    is usually some time that transpires before the
    end of therapy.
  • The length of time is usually determined jointly
    by the therapist, the child, and the parents.
  • 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
  • During this time sessions may be spaced more
    widely to decrease the child's reliance of the
  • This also allows time to make a final assessment
    as to whether the child is really ready for
    termination or whether further work is necessary
    before therapy can be ended completely.
  • Termination per se is usually accomplished by
    making the child and parent aware that the
    therapist will be available should unexpected
    problems arise at some later date.
  • At this time some therapists will also set a
    specific time for a follow-up visit to assess how
    the child is doing at some point following

A Final Note on Phases of Psychotherapy
  • As suggested earlier, one cannot really divide
    psychotherapy into specific phases, as we have
    done here.
  • Although one can speak of what typically
    transpires at various stages in a very general
    way, these descriptions fail to capture
  • the fluid nature of patient-therapist
  • the degree to which therapist behaviors vary
    depending on the specific child behaviors
    displayed and
  • the essence of the therapeutic "process".

Ethical Issues in Child Treatment
  • The consideration of ethical issues is essential
    in the realm of child treatment.
  • Ross (1980) has suggested that the ethical
    implications of treating an individual's
    psychological problems increase in magnitude as
    an inverse function of that individual's freedom
    of choice.
  • When it is considered that most children enter
    therapy because their behavior is judged
    problematic by adults, and that their continuance
    may relate more to parental commitment to
    treatment than their own, the need to consider
    the rights of the child becomes apparent.

Ethics in Treatment
  • Here, we will briefly consider several ethical
    issues which may arise in the process of child
    psychotherapy (as well as in other types of child
  • As ethical questions often do not lend themselves
    to single straight-forward answers, our purpose
    is simply to raise a number of issues that need
    to be considered by those seeing children in
    treatment rather than necessarily attempting to
    pose universally applicable solutions

The Issue of Competence
  • Standards for ethical conduct, such as the
    American Psychological Association's Ethical
    Principles of Psychologists and Code of Conduct,
    (APA, 2002) are quite explicit regarding the
    issue of competence.
  • Practitioners must be responsible for maintaining
    high standards of conduct, recognize the
    boundaries of their competence, and only provide
    services in areas in which they are skilled as a
    result of their education, training or
  • This has direct implications for those working
    with children.

The Issue of Competence
  • Related to treatment, ethical standards would
    clearly suggest that if a professional receives a
    referral for child treatment and is unqualified
    in this area, he/she is ethically bound to refer
    the child to someone who is competent to treat
    the child.
  • General training in clinical psychology (or
    psychiatry, or social work) does not necessarily
    qualify one to offer psychological services to
    children as many existing training programs fail
    to provide adequate didactic and clinical
    experiences in working with children and

Assuring Continued Competence
  • The development of competency is not a one time
  • It is a continuing and ongoing process.
  • Ethical standards dictate that psychologists must
    maintain an awareness of current scientific and
    professional information in their fields of
    activity and maintain competence in the skills
    they use.
  • An example would be empirically supported
  • It is necessary for the psychologist working with
    children to be involved in ongoing continuing
    professional education to remain up-to-date
    regarding clinical methods that have been found
    to be most effective in working with the children
    he/she serves.

Child or Parent as Client?
  • A perplexing problem often encountered in child
    treatment relates to the question - Who is the
  • An initial response might be that obviously its
    the child.
  • Isn't it the child whose behavior is of concern?
  • Isn't it the child who will be seen in therapy
  • Isn't it the child whose welfare is our main
  • But, what of the parents?
  • One can usually assume they also have the
    child's best interest in mind and are legally
    responsible for the care and welfare of the
  • They are also the ones who pay for the child's
    treatment - Arent they also our client?

Child or Parent as Client?
  • While most therapists attempt to work in the best
    interest of the child, while also attending to
    the concerns of the parents, there are times
    where considering the rights of both can be
  • A frequent issue is one where the child is
    brought to treatment against his/her wishes.
  • Often the problem involves behaviors that pose a
    problem for parents, rather than causing child
  • There, the child may feel there is no problem,
    see no need for therapy, and indicate no desire
    for treatment.

Child or Parent as Client?
  • Ross (1980) suggests that such a situation poses
    a significant conflict in values - respecting
    the child's rights may violate the parent's right
    to seek and obtain help for their child.
  • To further illustrate the dilemma Ross asks "...
    Does a 7-year-old really have the right to refuse
    treatment? Are we not entitled, maybe indeed
    required, to have mature adult judgment override
    the immature judgment of a child?
  • But at what point does a child's judgment cease
    to be immature? At ten, thirteen, sixteen,
    eighteen? And is it really determined by
    chronological age?".

Child or Parent as Client?
  • It would appear that we cannot arbitrarily state
    whether parent or child wishes should be given
    the greater weight in such a decision.
  • The decision may vary depending on a number of
  • the age and level of cognitive development of the
  • the child's degree of disturbance,
  • the degree of disturbance noted in the parents,
  • the degree to which the therapist feels treatment
    is warranted and the like.

Child or Parent as Client?
  • Ethical dilemmas of this type arise, not only at
    the point where therapy is being considered, but
    throughout the treatment process.
  • One might ask - Whose concerns should be
    emphasized in setting the goals for treatment?
  • In most instances determining treatment goals is
    accomplished through thoughtful discussions
    involving the therapist, the child, and the
  • In instances where parents and child have similar
    legitimate goals, that are reasonably consistent
    with what the therapist feels can be
    accomplished, there is no problem.

Child or Parent as Client?
  • The situation can be quite different when the
    patient is an adolescent whose parents desire
    greater compliance, respect, and a "more
    acceptable" group of friends and the youth's
    goals center on "finding himself" and developing
    greater independence.
  • Or where the child simply rejects those goals the
    parent's feel are important.
  • The issue of child versus parent rights may also
    come up in dealing with termination in instances
    where the child and parent have different
    opinions concerning the desirability of
    continuing therapy.

Child or Parent as Client?
  • As Ross has noted, "the involuntary status of
    the child client may a role at every
    stage of treatment, from beginning to end.
  • While not providing pat answers as to how to deal
    with such ethical dilemmas he suggests that,
    perhaps the clinician "is not simply an agent of
    the parents or the child but must determine how
    best to serve all concerned (p. 67)".
  • In order to accomplish this it may be important
    to involve each of the parties in the decision
    making process.

Children's Competence in Treatment Decision
  • The resolution of many issues of this type seems
    importantly related to one's view regarding the
    child's competence to participate in treatment
    decision making.
  • Although ethical considerations seem to argue for
    involving the child in making decisions regarding
    his/her treatment, whenever possible, this does
    not always happen.

Competence in Treatment Decision Making
  • Adelman et. al, (1984), for example, reported a
    study of 42 children/adolescents (median age 15
    years), referred for therapy by school personnel,
    teachers, or a result of a parent-referral.
  • Focusing on 35 cases where a referral was part of
    the IEP, it was found that the child was excluded
    from the referral decision making process in 80
    of the cases.
  • This failure to include children in the decision
    making process occurred in spite of the fact that
    27 of the 35 children were rated as having an
    adequate understanding of what therapy involved
    and were judged competent to participate in such

Competence in Treatment Decision Making
  • While all of the reasons for excluding the
    children from the decision making process in this
    case are not clear, it would seem that it was not
    due to their inability to participate.
  • It would seem more likely that their exclusion
    resulted from a view, shared by many adults, that
    adults are the ones most capable of making
    informed decisions regarding children's need for

Competence in Treatment Decision Making
  • There may be some instances where it may be
    inappropriate for the child to be brought into
    the decision making process.
  • This may be in cases where the child is very
    young, seriously disturbed, or seriously mentally
  • In most cases, however, there seems to be little
    reason to assume that most children are incapable
    of actively participating in making decisions
    regarding their treatment.

Competence in Treatment Decision Making
  • Data relevant to children's competence to
    participate in decision making have also been
    provided by Weithorn (1980).
  • In this study Weithorn presented groups of
    normals (age 9 to 21 years) with a number of
    vignettes, specifically related to problems of a
    psychological and/or physical nature.
  • She attempted to assess the ability of those at
    different ages to deal with relevant treatment
  • Results suggested that children at age 14 were as
    capable as adults in understanding relevant
    information and reasoning about treatment

Competence in Treatment Decision Making
  • Although using more immature reasoning, even
    9-year-olds were found to generally reach the
    same treatment decisions as older groups.
  • These findings, along with others, suggest that
    older adolescents may be quite capable of making
    adequate treatment decisions.
  • Even elementary school children can make
    reasonable decisions regarding routine
    treatment-related issues.
  • Thus, it seems important to include at least
    older children and adolescents in making
    treatment decisions whenever possible and to
    actively involve them in discussing the goals of

Competence in Treatment Decision Making
  • Involving children and adolescents in treatment
    decision making would seem appropriate not just
    from an ethical standpoint.
  • Including the child in the decision making
    process may have other positive effects.
  • One positive effect may involve enhancing the
    childs motivation and decreasing the resistance
    to treatment that sometimes comes with being
    excluded from the decision making process.

The Issue of Confidentiality
  • An additional issue, addressed by the APA Ethics
    Code has to do with confidentiality.
  • The Ethics Code clearly states that
    confidentiality of professional communications
    about individuals must be maintained.
  • Regarding children, it is only with permission
    that confidential professional communications can
    be shared with others.
  • It is further noted that the psychologist is
    responsible for informing the client of the
    limits of confidentiality .

The Issue of Confidentiality
  • It seems clear that information obtained from a
    child must be treated as confidential unless the
    parent/patient gives permission for the
    information to be divulged.
  • This principle, not only protects the client's
    right to privacy, it also facilitates treatment,
    as it insures that therapy sessions are a place
    where even sensitive material can be dealt with
    in confidence.
  • It is common for child reports to be shared with
    other professionals working with them in some
  • But even here, sharing of information is only
    done with the consent of the legal guardian. It
    seems important that permission of the child also
    be obtained, if possible.

The Issue of Confidentiality
  • Other issues can be raised regarding the issue of
    confidentiality in child psychotherapy.
  • One touches on the previously discussed topic of
    parent versus child rights.
  • Do children in treatment have the right to assume
    that what transpires in therapy sessions is truly
  • Or, do parents have a right to be informed
    regarding the process of their child's treatment?
  • There are no simple answers to this question,
    especially when it is considered that in most
    states parents have a legal right to see their
    child's records if they desire

The Issue of Confidentiality
  • Here, it would seem appropriate to attempt to
    strike a balance between the rights of the parent
    and child whenever possible.
  • Perhaps parents could be kept informed in a very
    general way as what is happening in therapy but
    without discussing specific topics or issues
    dealt with during treatment sessions.
  • The guiding principle would again be that
    whatever is done should involve a course of
    action which the therapist sees as being in the
    best interest of all concerned.

The Issue of Confidentiality
  • A second issue has to do with other limits which,
    of necessity, must be placed on confidentiality.
  • For example, statutes in all states now require
    that professionals, who have reason to suspect
    child abuse, report these suspicions to an
    appropriate protective services agency.
  • By law, if a child in therapy reports having been
    physically or sexually abused (or neglected) the
    therapist must report the incident.
  • Likewise, most therapist's would feel obligated
    to respond to situations where the child may be
    at risk for harming himself/herself or others,
    even if this resulted in a breech of

The Issue of Confidentiality
  • In other instances, such as in cases where the
    treatment of a child has been ordered by the
    courts, the therapist may be required to inform
    the judge or the child's probation officer if
    therapy sessions are missed.
  • Indeed, under such circumstances one can only
    assume very limited confidentiality.
  • Given that there are limits on the extent of
    confidentiality, the therapist is obligated to
    take these into account, in interacting with the
    child and his/her parents.

The Issue of Confidentiality
  • For both therapeutic and ethical reasons it would
    seem important to discuss the issue of
    confidentiality with the parent and child .
  • Specifically it is important to inform both
    parent and child at the outset of therapy about
    limitations regarding the extent to which
    material considered in therapy can be kept
  • FINAL NOTE Permission does not mean unlimited
    freedom to communicate personal health
    information (HIPPA).

Ethics An Overview
  • While we have focused on several ethical issues,
    most relevant to child treatment, the APA Ethics
    Code also deals with other issues relevant to all
  • These include such things as
  • respecting the rights, dignity and worth of
  • avoiding undue invasions of privacy,
  • being aware of personal problems and conflicts
    that might impair effectiveness with patients,
  • the documentation of patient care through careful
  • prohibitions against sexual involvement with
    patients, as well as other guidelines governing
    professional work.
  • It is essential that all psychologists be
    conversant with these ethical guidelines
    governing professional behavior.

Ethics A Child Bill of Rights
  • Koocher (1976), following the lead of Ross
    (1974), has suggested a children's "Bill of
    Rights" to address child ethical dilemmas. It is
    suggested that four basic principles, if taken
    seriously, serve as general guides in dealing
    with problems like the ones discussed here.
  • 2) the right to be treated as a person,
  • 3) the right to be taken seriously, and
  • 1) the right of the child to be told the truth,
  • 4) the right to participate in decision making.
  • In reviewing these four "rights" it is clear that
    they simply involve treating the child with the
    same degree of respect as would be accorded an
    adult seen in clinical practice Not a lot to

Child Psychotherapy Issues of Efficacy and
  • To what extent is individual psychotherapy
    efficacious or effective in resolving the
    psychological problems of childhood?
  • A survey of practitioners would almost certainly
    yield claims of effectiveness, with many
    clinicians seeing therapy as being so obviously
    of value that formal evaluation is unnecessary.
  • Others, however, would argue that a determination
    of efficacy and effectiveness should be made by
    conducting relevant investigations instead of
    relying only on the subjective impressions of
    clinicians who employ such procedures and who may
    be heavily invested in their worth.

Child Psychotherapy The Lack of Good Studies
  • One problem which has plagued the field from the
    start relates to the lack of well-controlled
    studies of child psychotherapy.
  • Indeed, research related to the efficacy and
    effectiveness of more traditional approaches to
    child treatment continues to lag far behind work
    related to adult psychotherapy - both in terms
    of the number and the quality of studies

The Lack of Good Studies
  • To highlight the dearth of studies, it can be
    noted that Barnett, et al (1991) found only 43
    published studies of child psychotherapy outcome
    between the years of 1963 and 1988 (and, there
    were far fewer prior to 1963).
  • They noted that, while there were as many as
    three to four child psychotherapy studies
    published per year between 1963 1973, only five
    effectiveness studies were published between 1973
    and 1988.
  • This suggests a sharp decline in child
    psychotherapy research, at a time when research
    on the efficacy of adult treatments appeared to
    be on the upswing.

Quality Issues in Child Psychotherapy Research
  • The relatively poorer quality of the work in this
    area is also suggested by the fact that Barnett
    et al found some 51 of the 43 studies they
    reviewed to be methodologically flawed in
    multiple areas.
  • No study was judged to be without at least one
    serious methodological problem.
  • While recent years has seen some increased
    attention to methodological rigor and more
    sophisticated approaches for quantifying the