MODEL FOR THE PRACTICE OF PSYCHOTHERAPY WITH CHILDREN AND ADOLESCENTS
This study represents a model extracted drawn fro practice and international research in the field of psychotherapy with children and adolescents. A number of features specific of this type of treatement are described as important for older stage adressed: the childhood and adolescence.
For clinicians who choose to pracice psychotherapy with children and adolescents is important to know the principels that govern the work practice in both prevention and intervention.
Assessment for psychotherapy
In many cases, child disorders consist of failures observed in terms of the expected progress in one or more dimensions of his/her development and less in the manifestation of certain specific symptoms (Symptoms per se). The assessment will relate to the level of the developmental stage specific to the child’s age.
The social context of reference should be considered. Who takes care of the child and how? Since the child’s ability to conceptualize and verbalize his experiences differ from that of the adult, the technique of investigating the mental level should be appropriate to the subject’s age level and the information thus obtained needs to be completed with stories told by parents / teachers.
Unfortunately, the informers are not always in agreement with one another and with the child. These discrepancies arise from many causes including: informants differ among themselves by way of access to data about the child’s behaviour or emotional state, especially if symptoms occur in specific situations (only at home or only at school); the way an informant uses to assess problems existing in the child’s behaviour differs from one investigator to another; informants are also different due to their consideration or skill that they manifest in reporting their observations, thoughts or feelings.
It is well known the fact that parents are more explicit in reporting certain external behavioural manifestations and that they are accurate in presenting factual information (10). Children, on the other hand, report more easily internalized symptoms (anxiety, depression) and manifest embarrassment to any event related to possible sexual abuse. Despite the possible inconsistencies in the parent-child dyad, the inclusion of parents in the assessment is important.
If individual therapy is selected, their support is necessary for maintaining the alliance and bringing the child to the meeting. If supportive therapy is selected, access to the child’s real-life should be assessed, especially for early ages, when the transmission of the link between the exterior psychic world and the internal one is uncertain. For family counselling, parents play a central role.
The overall purpose of the assessment and of the formulation of the treatment through psychotherapy is not to obtain a description of the problem behaviours, of the thoughts and emotions, but to understand their significance in the child’s relationship with his environment.
The decision on the treatment will have to be adapted to the cognitive, linguistic and social level of the child. Interactive games and / or projective techniques can support this decision. The play or joke element places the child and the therapist into a communication situation much easier.
Role plays, puppets, animals, small figurines allow, through intermediaries, the spontaneous expression of the child’s own characteristic ways of relating to the environment.
The drawing is a window through which one can see the internal world of the child and allowing the observer to assess certain non-verbal functions. In general, assessments through games and drawings are recommended for children aged up to 10 years, while for pre-teens and teens the traditional, verbal methods are recommended.
Individual Psychotherapy: individual psychotherapy in terms of relativity is most suitable for the child with ego-dystonic symptoms such as anxiety, depression, or manifestations of embarrassment on some cases of sexual abuse. Parenting support as well as the support of the environment is used in the therapy.
Contraindications concern the legal implications including secondary gain for the child or family (custody, access to disputes, juvenile delinquency), toxic substance abuse, acute psychosis, or perpetuation of an individual pathology as a result of a severe family dysfunction (“scapegoat”).
Family Therapy: Family therapy is clearly indicated when a consensus is reached on the primary cause of the problem as being interactional, involving distortion of communication, socialization, definition of the role, the boundaries and the structures. Individual pathology has to be minor. The problem manifests itself behaviourally more than at the level of the cognitive or emotional dimension. As in the case of individual therapy, the family must be in panic and the various subsystems must be able to withstand the change of the individuals as well as of the entire family system.
Group therapy. This treatment modality can be used predominantly with teenagers who need acceptance by their peers in particular; that is why their great trust in those of the same age with them more than in adults for problem solving is an important alliance factor. With younger children the focus is on activities rather than on discussions. Solving a common task may lead to the formation of productive social skills.
Any psychiatric distress that interferes with social and behavioural cognition, ranging from depression to learning disorder can form a basis for group therapy. Children are able to enjoy the here and now of solving common problems.
Other interventions. Some therapists believe that intervention through environment is inefficient and of low importance as therapeutic modality. This impact is sometimes best suited to children. Some therapists are called to intervene directly in the world of their patients. Sometimes the therapist himself initiates such contact.
The most important recommendations for an active therapeutic relationship with the environment are: to strengthen the viability of therapy, to activate the modified structure in the child’s life; to assist the child’s needs correctly outside the institution; to get feedback on the impact of therapy in the living environment of the child, to ensure that everybody respects the therapeutic targets achieved and the implementation of treatment strategies.
There are risks of addiction to treatment such as that of the family and of the child. The therapist may unwittingly confirm the family’s failure to help their child, acting with means that they would have at hand, too. Even worse, the therapist may maintain the secondary gain towards the regressive behaviour of the child, allowing the child’s excuses in front of certain responsibilities.
Another danger is the idealization of the therapist as a person who has all the answers, or a magician who can heal the child. These expectations should be moderated and adapted to reality. The therapist introduces him/herself as a person who can facilitate communication with all those who show an interest in children’s problems and can have a supportive role based on real understanding of the child’s needs.
Combining the individual therapy with family therapy can sometimes have a synergistic effect in which achievements can be simultaneous. In family therapy, one can clarify which pathology belongs to whom, suggesting which the most efficient level is where one can intervene.
In general, the decision in favour of a particular type of therapy should be guided by therapeutic purposes. If the patient has a poor development of ego functions, in particular judgment, impulse control and frustration tolerance; a significant deficit of super-ego; therapy will be targeted to support and to improve behaviour. Concurrently family therapy or parental counselling will be performed since behaviour is generally determined by some interpersonal dynamics such as that of the “scapegoat”, inconsistent discipline, or inadvertently strengthening on the part of the parents (Weiner, 1970)(17)
Therapeutic functions of the play
The central role of play in child therapy was compared with hypnosis, free association and fantasy in adult psychiatry (Hug-Helmuth, 1921 Erikson, 1950)(8). Ekstein and Friedman (1957)(6) believe that the game is the royal path, which reach the unconscious child. The play serves four functions: to discharge the energy, to dominate anxiety, to experiment and develop new skills through practice and to find identity through the path of modelling. By playing, the child engaged in a pleasant activity inverts the passive into active and rearranges reality so that the multitude of events may be separated into more digestible portions, thus making it possible to work with trauma.
Involving other people too, the role play illustrates its communicative aspect. Both facets, intrapsychic and interpersonal ones, should be reached during the play therapy. The relationship between the two is dynamic. Understanding of the functions of the play leads to selection of material for the play which, in turn, is determined by the goals of therapy. If the goal is abreaction, catharsis and regression indicated for the inhibited obsessive or traumatized children, the needs must accommodate these situations.
Categories of play therapy
The therapist is a participant in the play with varying degrees of implication. He must simply obey to and accompany the child in the scenario that the child has proposed. He must play the role that has been assigned to him but has to add his own ideas and take initiatives such calling the child on the phone, assigning roles to dolls, thus modelling becomes explicit and makes it possible to gain the child’s confidence. If board games are chosen, then they should be Monopoly or chess.
They can create an atmosphere of free concentration as well as the ability of self-expression.
The game of cards allows the study of anxiety in the face of loss and the ability win a game honourably against an honest partner (the therapist).
Non-directive interventions are better for exploring through insight than the psychoanalytic method. The child perceives the therapist as a transfer figure, a passive observer. Interpretation is done by displacement. Sometimes it is good that interpretations should be less addressed because their intellectualization may reduce spontaneity in expressing emotions.
Limiting the space and setting boundaries
Limiting the space and setting boundaries is a difficult problem in play therapy. The game is largely useful and constructive to maintain the therapeutic alliance and to increase self-confidence. Exclusive motor or affective discharge or performed with the aim to disrupt the therapist and affect his confidence safety or integrity of the office is not constructive and should be limited. Strong countertransference can be mobilized when the child is not controlled. The therapist must confront his own conflicts concerning control, aggressiveness, passivity and narcissism so as to be able to manipulate the primitive discharge of impulses in children. Open identification with an abused child, or with a strong need be liked can lead to paralysis of permissiveness. The inability to tolerate spontaneity or outbursts of anger can lead to premature punitive interventions.
While clarification, confrontation and interpretation are the main tools of the therapist, there are rare the occasions when non-verbal attitudes, such as physical restrictions, are necessary. Restriction should be a choice made ultimately (especially when personal safety or cleanliness is threatened) and it should be accompanied by an explanation of the position adopted: “I am not trying to hurt you. I’m sure none of us wants to hurt the other. I’ll retain you until you can control yourself.”
Retention may involve several issues: it can increase the sexual stimulation, in its literary or symbolic meaning, feeding masochistic desires which belong to the child; it can be a rough deviation from neutrality of the alleged transfer on object. It may expose the therapist to be accused of attack (assault); in the absence of the therapeutic alliance, it can strengthen the fantasies of omnipotence that belong to the child (“See, even you cannot make me subdue.”) Starting with assessment, the therapist can recognize the mastery levels of impulse control and behaviour regulation, so he can use support methods too, such as pharmacotherapy.
Similarly, gestures addressed to physical expressiveness in order to calm the child can reinforce inequality between adult and child and can be interpreted as ways of sexualization the relationship. Prior discussion with parents about the methods they use to calm down their child when he is anxious may lead to creative alternatives (child arrives at the therapy session wearing a peace sign). On the other hand, a handshake at the end of the session may be evidence of mutual respect and a child’s way of saying “thank you”.
Aims of play therapy
Play therapy (or play as part of therapy) acts like a positive force in a number of ways. The relationship itself feeds the development of new identifications, processes distortions transfer and corrects emotional experiences that constitute the trust part in an environment where value judgments do not apply. Ventilation, abreaction and catharsis allow the discharge of emotions that have been repressed. Insight is strengthened.
The role of insight in children is controversial (Shapiro & Esman, 1985)(15). Awareness should not be seen as a panacea but as an aid which is given to the child in order to cooperate effectively. (Carek, 1972)(3). In the child, the self-reflective capacity, as well as the ability to test the reality (observing the ego) is determined evolutionary, while the realistic aim of therapy is to determine the understanding of what a certain behaviour means.
Certainly, achieving the connection between thoughts, feelings and behaviours is the target of therapy in children and helps them to appreciate their own contribution to each. Another goal of therapy in children is that of withdrawing blockages in development. Understanding is sufficient to alleviate distortions in adaptation. Whether they derive in a conscious or unconscious understanding, which are intra- or interpersonally maintained, both results are proof of the end of the therapeutic endeavour with the child.
Ending the therapy may result in a transfer neurosis. “When one leaves this special form of treatment, it is not like someone would die because one may see that person again, but it is like someone left the relationship because one really remains alone with oneself” (Schmukler, 1990).This comment belongs to a boy of 16 at the end of therapy and scores the ambivalent state that the subject feels after he or she must dissolve a strong therapeutic relationship (“bittersweet bond”).
Mature relationship with the object, the genital primacy of the libido and the ability to work are irrelevant or impossible to consider in terms of development for preadolescents and partially fulfilled for adolescents, even to the end of this age. Moreover, the child’s parents’ relationship with the therapist should be considered, too, since the parents’ needs or expectations can frequently extend or shorten the length of treatment, depending on their interests.
The decision when and how to end the treatment depends on the goals established at the beginning of therapy, on the duration and severity of symptoms, and on the orientation of the therapist and on the history of separations suffered in the past.
Short therapies are recommended in cases where symptoms have appeared recently or have a medium severity; goals of the therapy are rather supportive or synthetic; orientation is more cognitive or behavioural; and there is no a traumatic past of separations or an insecure attachment relationship. Long-term treatment is recommended for chronic or severe symptoms, where the goals are connected to conflict resolution through psychodynamic insight; for children who have demonstrated difficulty in attachment or separation from other significant persons in their lives, experiencing early losses or multiple divisions in care.
The decisive factor in discontinuation of the therapy is made up by changes in behaviour that occurs in the real world through the accumulation of progress in relationships with peers, academic efficiency, hobbies or extracurricular activities and family relationships. Knowledge of these areas must have its source directly from parents or teachers, especially in case of younger children. Progress must be clearly determined not only by the acknowledgement and confession of the conflict but especially by engaging in suitable tasks whose development can be reported.
Besides therapy, there are a number of factors which may signal the preparation of the termination of therapy (Weiner, 1970 Carek 1972, Kernberg, 1991)(18,9). These include the reaction to the absence of the therapist with minimal anxiety and good tolerance in the context of a strong therapeutic alliance; preserving a constant attitude towards the therapist, including the ability to remember him even after a long absence or the ability to cope with a strong negative affect (“permanence of the object and constant of object”); identification with the therapist and with his function; less investment in therapy and more in reality; increased level of defences such as humour and sublimation as well as the increase of flexibility, order, especially affective modulation, impulse control, demonstrated by increased tolerance to frustration through the ability to delay gratification, expressing joy and gratitude in connection with reduction of sadness; reduction in symptom, decrease in acting – out and strong stabilization of ego expressed through the ability to make fun of their own selves and empathy towards others; game activities or telling of certain dreams that produce them more pleasure. It is the qualitative not the quantitative changes that are the proof of true conflict resolution. Kernberg cautions that therapy will not have to coincide with holidays or other celebrations because that is not the true test for the child to be able to cooperate in reality.
Therapy with adolescents
Psychotherapy with adolescents remains a challenging problem, reported as difficult by many therapists, (Freud, 1958 Josselyn, 1957)(7). Adolescents turn to their friends or to their parents to receive psychological help, this reflects the reduced availability and the decrease of professional help more than adolescent’s resistance per se (Kellam, Branch, Brown, & Russell, 1981)(12). The statistics show a low frequency of adolescent psychotherapy as intervention limited time. Balser (1966)(2) reports that over 80% of disturbances occurring in adolescence respond well to short term therapy and recent studies have described the supportive therapy . Adolescents generally respond quickly to decent treatment thanks to their flexibility . Seiffge-Krenge (1989) note: “Adolescence is a time when we can detect early serious problems of some pathological potential, providing a unique opportunity for intervention.”
Sub-phases of adolescence
As guidance, it is important to recognize that adolescence is not a uniform process. The early, middle and late periods have different characteristics in their development and should be approached differently from therapeutic point of view.
Early adolescents (aged 12 to 14 years) have a predominantly oral behaviour. Their major concern is their dependency and their important conflict is trust. As pubertal changes, they tend to be action-oriented and less reflexive. Their main requirement is: “I want, I need, I should have.” Therapists dealing with this age have the feeling that they are exhausted or as that serve a pumping station that fills their patients. Approximately, the techniques used are the same as for young children, such as play therapy with accessories.
Middle adolescents (14 years – 16 years), have an anal behaviour. These teenagers declare: “I can do everything by myself”. Omnipotent grandeur, narcissism and the claims, all make the concert of each day. The therapist will tolerate this type of interaction to facilitate differentiation of the self from the other and help the adolescent to feel healthy, with respect to the aggressive promptings. The patient discovers, by reference to the therapist, who he is and who he is not, actually, in the context of non-critical empathy.
Late adolescents (16 years-19 years), declare: “I want to be understood. I want to love and be loved by another person.” They are more able for an ambivalent relationship with the whole subject. Under stress, regression appears. This fluidity challenges the therapist who is unprepared for such situations. Individual therapy is effective, demonstrating respect for autonomy.
Counter transference in therapy with adolescents
When a clinician works with adolescents, his views about this age period as well as his personality are crucial. If the therapist believes, espousing a misconception, that adolescence is inevitably characterized by a disorder, then he will diagnose the psychopathological manifestations wrongly (Offer, 1991)(13). At the same time, if the clinician has residual unresolved conflicts from the period of his own adolescence, he will tend neurotically to be permanently against his patient. Anthony (1969)(1) described the situation in which adults tend to grant adolescents stereotyped attitudes, thus defending from their own narcissistic, sexual and aggressive anxieties.
Teenagers are the rudest critics of adults’ weaknesses. Disidealisation of parental figures is part of their development needs. The result is that the adults’ needs to be flattered, listened to, wanted, to be in control, to be fair, cannot be achieved if young people are attacked. Neurotic fears of being criticized, of making mistakes, of being seduced, expose some therapists to counter transference reactions, especially when they work with border-line subjects. (Kroll, 1988)(11).
Personal beliefs about sexual issues or those about drugs, religion, and politics can intersect with the patient’s ones and the therapist can draw a conclusion of non-existence of a disease which protects his self-esteem.
When adolescents devalue their therapist, efforts must be made to understand the dynamics that accompanies this attitude. Their anger may represent: defence against their needs to be protected which is specific to middle and late periods of adolescence, when the need for dependency is denied; defence against the desire manifested towards the therapist; the projection of a low self-esteem or of an expression of the transfer.
The therapeutic alliance
The therapeutic alliance is characterized by strengthening the ego functions: probing reality, relationships with the object, reasoning, regulating impulses and emotions, control and synthesis accompanying general attitude of curiosity and insight as well as dealing with the affects of panic.
How to maintain the therapeutic alliance is typically related to systematic attention which is given to manifested emotional states “now and here” during treatment. In any case, the first task of the therapist who leads the treatment is to make the connection between thoughts, feelings and behaviours of the subject in a way that the latter has not recognized before.
Sometimes, young people try to distort the therapeutic process, seducing the therapist and luring him into a profane alliance of the super-ego or of the self. (Meek, 1986).
For example, the therapist plays the role of the authoritarian parent (“Why can I not smoke in the office?”) Or the young person is attracted to some sexual or aggressive stimulations by therapist (“Would you like me to tell you what I did with my girlfriend last night?”). Less frequently one may encounter the situations when the profane therapeutic alliance is sought with the pathological defences of the ego through long philosophical discussions that have no other role for the moment than the intellectualization of some primary impulses.
Church (1989)(5), notes that experienced therapists respond neutrally and empathically to their patient’s comments about the therapy and focus more on the emotions that oppose the behaviours. The therapeutic alliance becomes strong. Their interventions are based on the active effect of the “here and now” of the sessions. Therefore “active” means that the therapist meets the immediate needs of the patient, controlling less the launching of assumptions that need to be examined further.
Church believes that adolescents talk more easily about their feelings and thoughts concerning the therapy when therapists respond promptly to the explicit and implicit needs of the relationship. Focusing on affection and cognition brings about a much larger opening than the mere focus on behaviour itself. Unidirectional comments as the offer of advice, opinions (especially when they are not requested) seem to be counterproductive in the therapy with adolescents. Interventions will be based on material provided during each session and not on theoretical interventions.
Confidentiality and contact with parents
The established parameters of confidentiality in psychotherapy apply to this age group, too. The older the adolescent is, the more confidentiality must be cherished. If there are situations in which the therapist is obliged to communicate certain information to the entourage, then he will require the consent of the young patient and even if certain behaviours are communicated to the others, thoughts and feelings of the patient will remain private.
In the relationship with parents, the telephone connexion must remain open in order to receive information from them. In most cases, parents ask the therapist not to tell the young patient about this link. They should know that the therapist reserves the right to inform the youth about these phones, otherwise the therapist will be put in a position to keep secrets. However, the data coming from the family are very helpful, especially with extroverted young people who tend to deny everything or with depressed ones who are relatively reticent.
Parents must be assured that their involvement in the progress of their son’s or daughter’s therapy is important and contributes to the clinician’s understanding of the young person’s problems. Expectations regarding the coercion of either the therapist or the patient are unacceptable. But the fact that the parents know they can call anytime if they need has a beneficial effect on the alliance with the family.
Paradoxical techniques and other parameters
There are certain situations when some adolescents and their families are highly resistant to therapy. It seems that they defeat themselves and the therapist when usual therapeutic interventions are used. In these situations, therapy techniques called paradoxical must be considered (Rohrbaugh, Tennen, Press & White, 1981)(14). These manoeuvres involve risks and they can be used after a careful assessment of the dynamics of the patient and of his family, and preferably by clinicians familiar with these techniques. They work well with structured and rigid individuals or families. These manoeuvres are contraindicated in situations when there is a lack of structure and limits and / or the potential of a dangerous movement to action is high.
There are exceptional circumstances that require special decisions such as placement in a hospital or in a rehabilitation centre. In case of adolescents with severe behavioural disorders (violence, drug use, fleeing home) it is better that they are consult by specialists in adolescent psychiatry.
End of the therapy with adolescents
Regarding the end of the therapy with adolescents, the development level of their tasks is the best marker for determining the success of the therapy and for deciding when it is time to stop it.
Has the young person come to a consensus with his/her own body image and with his/her sexual orientation? Could the patient separate him/herself and become autonomous from parents, giving up the incestuous liaison and dis – idealizing the parental figures? Did he or she start to formulate an ethical belief system? Are there are signs of his/her assuming responsibility regarding the choice of a vocation or of professional training? Has he/she the ability to relate to the entire object noting both positive and negative features of the parents, of the therapists and of other important adults in his/her life? Are the functions of defending the ego and of testing the reality as well as the affection as strong and flexible enough to allow further growth and maturation? Did the sense of identity become more consistent and stable?
If the answers to these questions are affirmative, it is time to end therapy. Anyway, the pathways chosen for the completion depend on the initial goals of the therapy, because the young persons’ ambivalence toward addiction requires flexibility.
One may experiment the gradual decrease in the number of sessions, or may allow the patient to leave the session earlier and return later, giving him/her a sense of control over the entire process.
Young people with more profound disorders need a transitional object, the so-called Teddy bear of adolescence (Ekstein, 1983)(6), to help them conclude the therapy. A business card is often sufficient.
Individualization is greatly helped if the therapist establishes with the young patient a work synthesis on projects outside the therapy office. Thus, the changes that occurred push the young person towards real objectives, while he/she becomes active in their realization.
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