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

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

psychotherapy?• How does child psychotherapy differ from adult

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

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

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

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 problems.

• 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 psychotherapy".

• 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 settings.

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, 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


• 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 psychotherapy.

• 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 Child’s 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 patients.

• 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 Child’s 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.

Child’s 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.

Child’s 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 play”),

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

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

• 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 changes?

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 relationship),

– 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 perspective.

• 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 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 verbalization.

• Communication of these therapist offered condition can be verbal or non-verbal.


• 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, 1971).

• Indeed, it has often been suggested that empathy, genuineness and warmth are necessary (although not sufficient) conditions for therapeutic change.

• Research has suggested that therapist’s low on the conditions, not only have patients who do not get better – they often have patients that get worse.

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, 1992).

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 statements.

• Interpretations involve therapist's comments regarding the relationships between thoughts, feelings and behaviors or the posing of tentative hypotheses regarding the "meaning" of certain behaviors.

• 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 verbalizations.

• 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 attitudes.

• Once they are better understood, confrontations are used, and, finally, when the child appears ready to accept them, interpretations are offered.

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 issues.

• 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 desensitization”

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 variables

Stages of Psychotherapy: From Referral to

Termination• As we have already seen, only rarely does a child request treatment.

• In most cases the child is referred by some adult.

• 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 person’s 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 experiences.

• 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 regarding– the specific nature of the child's problem behaviors,– the duration of these problems,– any precipitating events,– the situations in which the problem behaviors occur,– how these problems are responded to by others, and– previous attempts to deal with the child's difficulties.

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 problems.

• 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 factors

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 problems.

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

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

• 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 behavior.

• 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 alternatives".

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

• The 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 childhood

Assessment for Psychotherapy• Reisman’s 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 desirable.

• 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 children.

• 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 play.

• 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 goals.

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

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

• 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 concerning – 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 behaviors.

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 necessary.

• 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 earlier.

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 manner.

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

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

• 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 way”.

• 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 termination.

• 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 involvement

• 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 therapist.

• 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 termination

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 interactions,

– 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 treatment).

• 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 experience.

• 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 adolescents.

Assuring Continued Competence

• The development of competency is not a one time thing.

• 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 treatments.

• 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 client?

• An initial response might be that obviously it’s the child.– Isn't it the child whose behavior is of concern?– Isn't it the child who will be seen in therapy sessions?

– Isn't it the child whose welfare is our main concern?• 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 child.

• They are also the ones who pay for the child's treatment - Aren’t they also our 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 difficult.

• 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 distress.

• There, the child may feel there is no problem, see no need for therapy, and indicate no desire for treatment.


• 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?".


• 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 factors;– the age and level of cognitive development of the child,

– 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.


• 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 parents.

• 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.


• 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.


• As Ross has noted, "the involuntary status of the child client may ...play 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

Making • 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 decisions.


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 treatment.


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 handicapped.

• 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.


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 issues.

• Results suggested that children at age 14 were as capable as adults in understanding relevant information and reasoning about treatment decisions.


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 treatment.


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 child’s 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 .


• 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 capacity.

• 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.


• 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 confidential?.

• 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


• 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.


• 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 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.


• 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 confidential.

• 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 psychologists.

• These include such things as;– respecting the rights, dignity and worth of patients,

– 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 records,

– 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 ask!

Child Psychotherapy: Issues of Efficacy and

Effectiveness• 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 published.

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 effects of individual treatment, work in this area is still in its infancy, as compared to that with adults.

Reviews of Child Psychotherapy

• Given the relatively small number of well-controlled studies of child treatment, prevailing views regarding the value of child psychotherapy have historically been shaped by the findings of investigators who have attempted to statistically summarize data from previously published investigations or who have provided narrative reviews of the treatment literature in an attempt to arrive at summary statements regarding the overall value of child psychotherapy.

• Perhaps best known and most influential in this regard is the work of Levitt (1957).

Early Research: Levitt (1957)

• Levitt (1957) reviewed a number of previously published reports of child treatment that provided information regarding improvement - assessed at the close of therapy (18 studies) or at follow‑up (17 studies).

• Treatment methods employed in these studies involved approaches such as "counseling, guidance, placement recommendations to schools and parents, as well as deeper level therapies".

• Children treated in the studies displayed problems which could be loosely termed "neurotic" in nature.

• Taken together, Levitt found the overall improvement rate for children receiving treatment to be 67.05 % at the close of treatment and 78.22% at follow‑up.

The Search for Relevant Controls

• Given that patients often show spontaneous remission in the absence of formal treatment, Levitt attempted to obtain a comparison group, against which to judge the effectiveness of therapy.

• He reasoned that the comparison group should be composed of children as similar as possible to those receiving treatment (e.g., who had been referred for treatment, who had been evaluated, who had been judged to be in need of treatment) but who had not actually participated in psychotherapy.

• Based on these criteria, Levitt chose "clinic defectors" (children referred to mental health professionals, offered treatment but who did not receive it).

Levitt: No Support for Child Psychotherapy ?

• Levitt assumed that for psychotherapy to be considered effective, the rates of improvement found for treated children should be significantly higher than for defectors (whose improvement should reflect only spontaneous remission).

• Levitt found two studies that provided follow‑up data on defectors which, when taken together, suggested an overall improvement rate of 72.5% .

• Comparing these figures with the 2/3 improvement rate for treated children (assessed at the close of therapy), Levitt concluded that the findings provided little support for the effectiveness of child psychotherapy.

Levitt (1963): Additional Study – Same

Findings• Although improvement rates for treated children, evaluated at follow‑up, compared more favorably with these spontaneous remission rates, even these figures were not measurably different and may be seen as reflecting the effects of non specific factors operating after the termination of therapy (Levitt, 1957).

• An additional survey of the literature by Levitt (1963) also yielded similar findings.

A Questioning of Conclusions

• These early findings were viewed by many as representing a strong argument against the effectiveness of child psychotherapy.

• Although the results are certainly not supportive of child therapy, several points have been raised regarding the adequacy of the Levitt study.

• These arguments make an argument of therapy ineffectiveness questionable.

Were Treatment and Comparison Groups

Similar?• Criticisms have centered around the fact that it is unclear whether children in the treatment and defector groups were similar in terms of degree of disturbance.

• Defectors may have been less disturbed and similar criteria may not have been used to rate improvement.

• Further, it is not clear that the treatment & defector groups were assessed over a similar time period.

• For example, in one comparison group, defectors were assessed 8 to 13 years after clinic contact, a time period much longer than children usually stay in therapy.

• This allows an extended period of time for spontaneous remission to occur in the comparison group.

No Appropriate Controls = Confused

Findings• Improvement figures from this group may have inflated the spontaneous remission rates for defectors thus decreasing the likelihood of finding significant differences between treatment and comparison groups.

• To the extent that the treatment and control groups differed on such variables, any comparisons between the groups becomes difficult to interpret

An Alternative Interpretation

• Putting aside methodological issues, an additional point might be made concerning Levitt's findings.

• While there was no overall difference between rates of improvement for treated and non‑treated children, there was a significant degree of variability among studies.

• In considering per‑cent improvement figures at the close of therapy for the various treatment studies, one finds that the figures vary from a low of 43% improvement in one study to a high of 86% in another.

• Rather than suggesting that child psychotherapy is ineffective, the results may actually suggest that sometimes it is quite effective while in other cases it is not

Other of Child Psychotherapy Reviews

• During the 40+ years since Levitt's paper others have reviewed & critiqued the child therapy literature.

• Overall, these reviews suggest that, while some studies provide reason to believe that child psychotherapy can have positive outcomes, limitations inherent in many if not most studies make it difficult to draw any firm conclusions regarding efficacy.

• Barrnett, et al, (1991) suggests "the major conclusion is that many questions regarding child and adolescent psychotherapy, including efficacy, remain untested according to contemporary methodological standards."

The Focus on Meta-Analyses

• Consistent with Barrnett, et al, (1991), most reviewers have commented on the lack of well-designed studies and have attempted to highlight methodological issues that must be considered if research in the area is to advance.

• In addition to qualitative reviews of the child psychotherapy literature, recent years have witnessed significant methodological advances in the application of quantitative methods to assess treatment efficacy across studies.

• These quantitative methods are best represented in an approach to evaluating the results of multiple studies called meta-analysis

The Nature of Meta-Analyses

• Meta-analysis is a statistical method that makes it is possible to simultaneously summarize, integrate, and evaluate treatment effects across studies.

• With this approach, it is possible to consider large numbers of treatment outcome studies that compare treated and control subjects on various dependent measures.

• One can then determine the degree to which significant differences between treatment and control groups are found across studies.

• Given a number of studies, that assess specific variables, it is also possible to highlight those variables that are related to positive outcomes.

A Common Metric: Effect Size

• Central to an understanding of meta-analysis is the concept of effect size.

• As meta-analysis is used to assess treatment effects across studies (which may have used diverse and possibly multiple measures of outcome) it is necessary to derive a common metric that can be used across all studies as an index of treatment effectiveness.

• This common index of effectiveness is effect size.

Calculating Effect Size

• Effect size is defined as– the mean difference in outcome scores between treatment and control groups,

– divided by the standard deviation of the control group (or sometimes the pooled sample).

• Since the effect size index represents differences between treatment and control group means on each outcome measure (expressed in standard deviation units), this index can be used as a dependent variable in assessing the outcome of treatment across studies.

Meta-Analysis: An Initial Study

• An initial study involving the application of meta-analysis to the child treatment literature was conducted by Casey and Berman (1985).

• Here, Casey & Berman reviewed some 75 treatment studies published between 1952 and 1983 which employed both a treatment and control (or alternate treatment) group.

• These studies involved children (age 3 - 15) who displayed a wide range of problems (e.g., aggressive, withdrawn, hyperactive, impulsive, phobic).

Effect Size: Treatment vs Controls

• Studies also involved children who received treatments which varied from behavioral approaches (desensitization, modeling, cognitive-behavioral) to those that involved more traditional approaches to psychotherapy (psychodynamic, client centered).

• Employing meta-analytic procedures to evaluate treatment efficacy, Casey and Berman reported a significant overall effect size of .71

Quantitative Support for Effectiveness

• These findings suggests that, on the average, approaches to intervention in these studies resulted in significant treatment effects.

• Indeed, an effect size of .71 suggests that, at the end of therapy, children receiving treatment were improved to a greater extent than almost three fourths the control group.

• While the effect size obtained, when non-behavioral approaches (client-centered, dynamic) were considered separately, was smaller (.40 for all non-behavioral approaches taken together) the overall results provided some general support for the effectiveness of these more traditional approaches.

Factors Related to Positive Outcome

• This study also yielded information regarding variables which did and did not appear to be related to a positive outcome.

• Treatments appeared to be less effective with aggressive and withdrawn children than with children displaying problems such as phobias and hyperactivity.

• Males seemed to benefit less than females.• No differences were found between children who did and did not receive play therapy or who were seen in individual versus group therapy.

• Therapist characteristics (e.g., sex, experience) were not systematically related to treatment outcome.

Other Meta-Analytic Studies

• A second meta-analysis study was conducted by Weisz, et al (1987).

• Here, Weisz et al. considered the results of 108 controlled treatment outcome studies.

• These studies involved children and adolescents, between the ages of 4 and 18, who displayed a heterogeneous mix of problem behaviors.

• Most of the studies themselves involved relatively homogeneous groups of children, recruited specifically to participate in research studies, rather than children referred for clinically significant problems.

More Significant Effect Sizes

• The results of this meta-analysis yielded an overall effect size of .79 which was documented both at post-treatment and follow-up (5 - 6 months).

• As in the Casey and Berman study, such an effect size is clearly supportive of the overall effectiveness of treatment (Summing across studies, type of treatment, type of problem, etc.).

• Indices of effect size suggested that treatments tended to be more effective when they were behavioral rather than non-behavioral in nature and applied with children (age 4 - 12) rather than adolescents (13 - 18).

• No differences were found between males & females or children with internalizing & externalizing difficulties.

Meta-Analysis: A Contrast With Older

Studies• In comparing findings from these meta-analytic studies with conclusions reached by Levitt (1957, 1963) and others who have reviewed the treatment effectiveness literature, it is clear that the results of results of these meta-analytic investigations provide much clearer support for the efficacy of child treatment methods.

• Despite these more positive findings, it is instructive to contrast the results of the Casey and Berman (1985) and Weisz et al (1987) studies with findings of a subsequent, more clinically relevant, investigation by Weisz and Weiss (1989).

Meta-Analytic Studies With Actual Clinical

Cases • These authors highlight the fact that the many studies included, in prior meta-analytic investigations, may not not have involved children with problems of a clinically significant nature.

• For example, in the Weisz, et al (1987) meta-analysis, children who participated in many of the treatment studies were recruited specifically for these studies rather than being clinically referred due to the severity of their problems.

• This would suggest that many of the studies may not have dealt with problems of a clinically significant nature.

On the Need for More Clinically Relevant

Meta-Analytic Studies• Most investigations involved children who were selected for study because they displayed specific types of problems (e.g., phobias) as opposed to the multiple difficulties often displayed by clinic patients.

• Likewise, treatments provided in these studies were often focused on a specific problem as opposed to the broad spectrum of problems usually seen within a clinical setting.

Meta-Analytic Studies:Limitations

• Finally, in many of these investigations, therapists were specifically selected for purposes of the study and were provided with special training in the treatment employed.

• This can be contrasted with the typical clinical setting where the techniques employed by therapists are not limited to just a few techniques in which they are well versed.

• Many of these statements can also be applied to those studies considered by Casey and Berman (1985).

Meta-Analytic Studies: Questions of

Generalizability• Considering these issues, an important question is whether research findings from existing meta-analytic investigations provide support for the effectiveness of child psychotherapy and other forms of child treatment as these are routinely provided in actual clinical practice.

Meta-Analyses: Findings From a Clinical Setting

• To address this question, Weisz and Weiss (1989) identified a pool of some 262 child outpatients (ages 6 - 17) who had been referred, for clinical services, to one of nine different public outpatient clinics.

• Two groups were selected for further study.• A treatment group consisted of 93 patients who were recommended for, agreed to, and participated in at least five therapy sessions, and who terminated treatment with the concurrence of the therapist.

• A control group was made up of 60 patients for whom treatment was recommended and offered, but who did not participate in treatment intake evaluation.

Meta-Analyses in a Clinical Setting• Therapy outcome was assessed by obtaining Child Behavior Checklist scores on patients in both groups at the time of intake and again six months later.

• CBCL measures were also obtained on a total of 72 continuers and 69 controls at one-year follow up.

• Other measures of treatment outcome included parent ratings of the number and severity of major problems experienced by the child and, for a sub sample of patients, Child Behavior Checklists completed by teachers.

Meta-Analyses: Findings

• Primary analyses involved comparing the treatment (continuers) and control (dropout) groups in terms of changes in Child Behavior Checklist scores at six months and one year post-intake.

• Here, the results suggested that– both groups improved significantly over time, and– there were no significant differences in treatment outcome as a function of group membership at either time period.

• Likewise, no significant treatment effects were found when parent reports of the number and severity of child problems were considered or when teacher ratings of child behavior were analyzed.

Meta-Analyses in a Clinical Setting• In an attempt to compare the findings from this investigation with the results of the Weisz, et al (1987) meta-analytic study, the investigators also calculated measures of effect size for the present data.

• Effect size when Child Behavior Checklist scores were considered were -.24 at 6 months (suggesting that those continuing in therapy were worse off at the end of six months)

• An effect size of .19 was found at one year follow-up.

• Clearly, such findings do not compare favorably with the overall effect size of .79 found in the Weisz et al (1987) study or the effect size of .71 found in the Casey and Berman (1985) investigation.

Meta-Analysis: Findings• Effect sizes obtained for parent ratings of problem behaviors and for teacher ratings were also nonsignificant and of lower magnitude than those found in earlier meta-analytic investigations.

• These findings are in contrast to results of earlier meta-analyses of controlled treatment studies.

• Indeed, they are consistent with the conclusions reached by many previous reviewers of the child psychotherapy literature, in providing little support for the effectiveness of child psychotherapy as it is presently practiced in clinical settings.

Child Psychotherapy Findings: A Critique

• To put these findings related to the effectiveness of child psychotherapy in perspective, there are far fewer outcome studies of traditional child psychotherapy than of behavioral & cognitive-behavioral approaches.

• Few studies of traditional child psychotherapy are methodologically well‑controlled.

• And, while children with significant difficulties are often included, many treatment outcome studies have used non-clinical/non-referred samples, bringing into question the external validity of the findings.

• This makes it difficult to draw firm conclusions regarding the effectiveness (or ineffectiveness) of child psychotherapy

Child Psychotherapy Findings:A Critique

• While attention has recently been focused on more quantitative approaches to assessing the effectiveness of "child treatment“ (e.g., meta-analysis), the fact that much of this work has involved assessing treatment effects on non-clinic samples is a clear issue.

• Much of the research has also involved the evaluation of behavioral or cognitive therapies, rather than those approaches which are, perhaps, more often used in actual clinical settings.

• There continues to be a clear need for well-controlled studies of traditional child psychotherapy, conducted within applied clinical settings.

What Questions Should be Asked?• In considering research in this area, an especially important issue relates to the nature of the questions addressed in the existing psychotherapy outcome literature.

• Here, it can be noted that outcome studies have often been designed to provide information concerning the general issue of psychotherapy effectiveness, with "psychotherapy" being very broadly defined.

• Perhaps, the most obvious example is the work of Levitt (1957) which was reviewed earlier.

What Questions Should be Asked?

• It can be recalled that the "psychotherapy" received by children considered in studies he reviewed consisted of deeper level therapies, sometimes counseling, and sometimes only recommendations to schools and parent's regarding how to deal with the child's problems.

• Further, treatments were provided by therapist's differing in theoretical orientation and professional training.

• And, children displaying a wide range of problem behaviors were considered.

• Similar statements would probably also characterize many other studies found in the literature.

What Questions Should be Asked?• Schwartz and Johnson (1986) have suggested that these studies simply indicate that

• "to the extent it is appropriate to ignore important variables such as the characteristics of the therapist and their orientation, the nature of the patient's problems, and the specific nature of the intervention procedures employed, `psychotherapy' may be judged on the average to be ineffective.“

• As previously noted, however, these findings do not preclude the fact that some types of psychotherapy may be quite effective when offered by some therapists in dealing with some types of problems

What Questions Should be Asked?• Based on considerations such as these, workers in the area have come to seriously question the value of studies like the early investigations reported here.

• The major reason is that it has become increasingly obvious that such studies do not take into account the marked variability in therapy approaches, therapist characteristics, and patients.

• In a widely cited paper, published more than three decades ago, Keisler (1966), commented on this problem by referring to the prevalence of several myths which, at that time, were reflected in much of the existing (adult) psychotherapy research.

Myths of Psychotherapy• Among these were myths of therapist uniformity and patient uniformity.

• The therapist uniformity myth refers to the assumption, that therapist's are more alike than different and that whatever they do with the patient can be considered "psychotherapy".

• The patient uniformity myth refers to the assumption that patients are more alike than different.

• Although Keisler's paper focused on adult psychotherapy, these myths have been well represented in child psychotherapy research as well .

Myths of Psychotherapy• Keisler (1966) challenged these myths, suggesting that studies characterized by an adherence to such myths are likely to obscure important information and are unlikely to provide meaningful findings.

• To illustrate, it may be that some approaches to therapy are generally more effective than others.

• It may also be that some therapist's display characteristics making them more effective than others.

• Patients with some types of disorders may also be more likely to show improvement as a result of therapy than clients with other types of disorders .

Myths of Psychotherapy• Further, these variables may interact with one another, so that a particular approach to therapy is effective with one disorder but not another, so that therapist's displaying certain characteristics may be successful with some patients but not others, and so forth.

• When these possibilities are considered, it becomes obvious that simple treatment‑control group comparisons of children treated within the context of clinical settings are unlikely to yield data strongly supportive of psychotherapy.

Myths of Psychotherapy

• In such studies, some patients may improve while others become worse or show little change, with the overall effect possibly being the finding of no (or only small) differences between treated and non‑treated individuals.

• These findings may mask the fact that therapy may have been very effective with some patients, or that some therapists were able to show a high success rate, or that one therapy may have been quite successful while others were not.

Asking Better Questions• These considerations have led psychotherapy researchers to suggest that, rather than attempting to find an answer to the general question ‑ Is psychotherapy effective? ‑ a more useful question might be: – What types of therapy,– have what types of effects,– with what types of patients,– with what types of problems,– when offered by what types of therapists,

– under what conditions?

Asking Better Questions

• Freedheim and Russ (1992) have suggested an even greater degree of specificity in the questions that should be asked. They suggest researchers should also be interested in asking "Which specific interventions affect which specific cognitive, personality or affective processes.

• It is obvious that attempts to answer the questions posed here necessitate approaches to research that are much more complex than have typically been found in the child psychotherapy literature.

Asking Better Questions• Rather than employing simple treatment‑control group designs which focus on the global question of psychotherapy effectiveness, this approach calls for the use of factorial designs whereby one can assess the interactive (as well as overall) effects of treatment method, and relevant therapist and patient variables.

• Unfortunately, while recent years have seen significant advances in research on the effects of adult psychotherapy, which has attempted to take such considerations into account, research in the area of child psychotherapy has not kept pace with work in the adult area.

• This work remains to be done.

That’s It!

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

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