Psychotherapy for

Children and Adolescents

Presented by-

Mayank Rajput
Nidhi Mahanta
MPhil Clinical Psychology (Part II)
Psychotherapy is the treatment, by psychological means, of
problems of an emotional nature in which a trained person
deliberately establishes a professional relationship with the
patient with the object of:

(1)removing, modifying, or retarding existing symptoms,

(2)mediating disturbed patterns of behavior
(3)promoting positive personality growth & development
(Wolberg, 2013)
• The means by which goals are achieved are primarily
interpersonal, for which most treatments consist of verbal
interaction.

• In child therapy, the means include talking, playing,

rewarding new behaviors or rehearsing activities with the
child (Kazdin, 2000).
• Psychotherapy does not include interventions that use
biological & medical means of producing change.

• Psychotherapy excludes interventions that have educational

objectives.

• Activities such as chatting with relatives & friends, engaging

in hobbies, merely spending time with significant others are
also omitted from the standard definitions of psychotherapy.
 What makes psychotherapy differ from informal
help?
• The practitioners of psychotherapy are specially trained to
conduct this activity and they are sanctioned by their society
or by a subgroup to which they and the patients belong.

• Their activity is systematically guided by an articulated

theory that explains the sources of the patient’s distress &
disability & prescribes methods for alleviating those (Frank,
2000).
 Child and Adolescent Therapy

• The basic rule in treating disorders in childhood is providing an

adequate climate in which developmental needs are met, opportunities
for impulse gratification supplied, and proper discipline & restraints
imposed.
• Therapeutic interventions will accord with the accepted theoretical
model.
• The majority of child therapy clinics use therapeutic methods that
stress the interpersonal therapeutic relationship, focus on the
presenting problems & encourage therapist activities of a friendly,
active & supporting nature to provide a corrective experience for the
child.
 Child Psychotherapy vs. Adult
Psychotherapy
• Problems are encountered in the normal course of development in
lesser levels. This poses a challenge as to whether & when to
intervene.
• Children rarely refer themselves for treatment or identify themselves
as experiencing distress.
• Their dependence on adults makes them particularly vulnerable to
multiple influences on the severity of the disorder + effectiveness of
treatment, over which they have little control.
• Children are not particularly motivated to come for treatment.

• Children are more likely than adults to project their difficulties onto
the environment, acting out their needs and conflicts while avoiding
inner exploration and self-observation and inhibiting the constructive
use by the therapist of transference as a therapeutic tool.

• Assessment of a child very different/difficult from that of an adult.

• Accompanying parents, teachers, siblings & peers play an
important role in child therapy.

• Quality of the therapeutic relationship between therapist &

child is very different. Certain traits like extraversion,
assertiveness & openness in the therapist have been found to
be related to better outcome (Kelvin et al., 1981).
• Psychopathology in children must, at all times,
be viewed against the backdrop of developmental
norms, in relation to existing family & social
distortions that deprive the child of needs
essential to their growth or subject them to
rejection, violence or overstimulation with which
they cannot cope.
• Gladstone (1964) describes three major groupings of adolescents
for whom different treatment approaches are applicable.

-For those with acting-out character problems, extreme therapist

activity to promote a relationship, a firm setting of limits, & a constant
emphasis on human values & their communication in the relationship.
-For those with neurotic disorders & dependency problems,
emotional catharsis is encouraged, probing of underlying conflicts
towards insight, minimum of interference from therapists.
-For those with schizoid reactions, supportive techniques, experience
sharing, continuous correction of distorted perceptions, educational
correction, filling in of learning deficits.
Some Commonly Used Therapies
for Children and Adolescents
1. Child Psychodynamic Psychotherapy

• Hermine Hug-Hellmuth, first to

attempt to psychoanalyze
children in Vienna in 1920.
• Her key contribution was the use
of spontaneous play, paving the
way for a distinctive language &
technical base for child
psychoanalysis.

1871- 1924
 • According to Melanie Klein, children as
young as two may be treated.
• In Berlin, was the first to develop a concept
of play in therapy and extensively used a
wide range of small toys and wooden
human figure representations in play
along with their interpretations (Lewis,
1996).
• She regarded children’s play as the
equivalent of free association in adults, and
her interpretation vigorously articulated her
conception of children's psychic world
(Gabbard, 2000).
1882-1960
 • According to Anna Freud, children as
young as three years of age may be
analyzed.
• Free association and the couch position,
however, cannot be employed. Instead the
children’s activities in movement, play &
random talk are used for interpretation, as
are stories, dreams, and the children’s
reactions to the therapist.
• She studied how children defended
themselves rather than what they defended
against and emphasized on studying
conflict.
• She encouraged collaboration with
parents, teachers, but no attempt should be
made to offer direct advice.
1895-1982
 • Donald Winnicott, emphasised
early relationships + parental
attunement as key determinants of
normal & pathological development.
• He developed methods such as
drawing, story-telling to help
children with neurotic conflicts &
their parents.
• Focused on the significance of
nonverbal aspects of therapy;
“holding environment”.
• His famous “squiggle game” was the
main mode of communication.
1896-1971
• His legacy of concepts such as
“good enough parenting”, the
facilitating environment & has
been very useful in
understanding the effects of
childhood on later life
(Winnicott, 1965).
 General Method of Therapy:

• Essentially involves a trusting & confidential relationship

between a trained, motivated, caring & accepting person who
provides opportunities to a needy person for expressing
feelings verbally.

• Therapy is usually divided into periods of 30-40 minutes per

session, one to four times a week in a suitable setting and has
three phases.
• Initial phase:

-to foster a therapeutic alliance between the therapist and the child,
which is usually achieved by enabling the child to experience a non-
judgmental, understanding response to his or her behaviour (Lewis,
1974).

• Middle phase:

-the essence is the interpretation of the transference, countertransference

and "working through with communication through play and other
elements of free association."
• Termination phase:

-include some actual achievement of the goals of therapy, e.g.,

disappearance of symptoms, better coping, improved souci-occupational
work, and feelings of pleasure and joy.
-eventually, every therapy stops, either when the child is more or less
along the road toward these goals (Lewis, 1996), or because of treatment
failure without any real progress, or due to insurmountable resistance.
 Therapeutic Action:
• result of a process that includes: overcoming resistances; working
through; remembering and reliving repressed material; the effect of
reconstruction (Loewenstein, 1951).

• provides an introspective opportunity and fosters identification with an

appropriate adult model.

• feeling of being understood changes to hope, leading to therapeutic

optimism and possibly having important therapeutic effects regardless
of any insight that may have been achieved (Rothstein, 1989).
 Indications for Child Psychoanalysis:
• Understanding and treatment of borderline, narcissistic, schizoid,
delinquent, and conduct-disordered children and even psychotic
children.
• Literature agrees with a restrictive indication of child analysis,
primarily for those with internalizing disorders like anxiety,
depression, obsessions, phobias, etc. (Bleiberg, 1997).
• When the child's problems are more external with other recognizable
etiologic factors, solitary use of intensive individual psychotherapy is
not advocated, and the addition of other types of interventions may be
needed to tackle other conflicts, losses, stresses, and physical or
psychiatric symptoms (Lewis, 1996).
 Play Therapy:
• Play is an innate part of growing up that characteristically includes:

-an activity primarily aimed at pleasure

-pleasure is provided by play, usually through a sense of mastery using
creative, intellectual, or physical skills
-the participants initiate and terminate the game on their own volition
-may or may not involve rules
 Difference between Normal and Therapeutic
Play
• The International Association of Play Therapy adopted the
following definition of play therapy in 1947:

"play therapy is the systematic application of the theoretical

model of an established interpersonal process in which trained
play therapists use the therapeutic powers of play to assist
clients in preventing or resolving psychosocial difficulties and
achieving optimal growth and development." (Schefet, 1998).
• In therapeutic play, the therapist does not assume the role of a
playmate, and instead takes a spoken or unspoken stance of
trying to observe and understand the child through play. For
example, if the child engages the therapist in puppet play, the
therapist encourages the child to take the lead and may ask
the child for instruction about how the therapist's puppet
should respond, thus the child's schema is expressed.
 Why use play for therapy?

• Play as a medium of exchange:

-to facilitate communication (Ablon, 1996).
-the child needs to believe that here is someone who truly wants to help
-the child should not feel that the therapist is someone from the "adult
world," but rather he/she should consider the therapist to belong to
his/her own realm of reality
-characteristics of the child that could be observed include: ability to
plan, ability to follow instructions, ability to collaborate, small motor
ability, persistence, etc.
 Some specialities of Play Therapy:
1) Non-Directive Play Therapy-

-proposed by Virginia Axline (1947), it is an extension of the Rogerian

school of psychotherapy.
-the atmosphere is totally permissive and the therapist is a non-
participant observer, encouraging the child to use whatever material is
available according to his or her own wish and for as long as he or she
desires.
-therapist listens to the child's verbalizations with particular attention
paid to the feeling tone and conveys his or her understanding to the
child without any attempt to interpret the message or pass any judgment
-The reflection of feelings is the only task of the therapist.
-Complete freedom in the therapeutic session allows the child to
experience the feelings, fears, and perceptions that arise from their own
life experience and allows them to gain confidence in themselves and
master their own conflicts.
-As therapy progresses, the child's diffused feelings become more
focused, the negative feelings slowly diminish and the child gradually
becomes more capable of experiencing both positive and negative
feelings.
-Under appropriate circumstances, both positive and negative feelings
can be experienced under well-modulated intensity, which is the desired
outcome of treatment.
 Cognitive Behavior Therapy:
• Primary CBT goals are the concurrent development of efficient and adaptive
modes of responding to problematic situations and the elimination or reduction of
maladaptive and inappropriate behaviour.

• Children and adolescents include performance-based procedures as well as

cognitive interventions to produce changes in thinking, feelings, and behaviour
(Kendall, 1991). Thus, CBT recognises the importance of emotional, social, and
contextual views concerning clinical problems in youth, but addresses the
concerns largely with cognitive and behavioural procedures.

• A central goal of CBT is to help the child build a coping template, whether that
means developing a new cognitive structure or modifying an existing one for
processing information about the world.
 Techniques:
1) Activity Scheduling: involves the establishment of goal-directed, enjoyable
activities throughout the child's day. The therapist, child, and parents collaborate
to plan the young person's activities hour by hour.
2) Cognitive Structuring: "faulty" cognitive functioning is changed to thinking that
is more adaptive. The first step involves helping the child identify their self-talk,
whereby the child may be asked to think of thoughts running through their mind.
It is considered to replace maladaptive cognition with more adaptive ideas.
3) Verbal self-instruction training (SIT): Effective in assisting impulsive &
disruptive children who have difficulty controlling their own behavior. The child
is encouraged to speak freely during the desired actions, and the action is learned,
self-instruction becomes sub-vocal, and behaviour is controlled. Also effective
with learning disabled & depressive adolescents.
4) Interpersonal cognitive problem solving: help the child realize that their
problems are not insurmountable or fatal. The major skills taught in this include (a)
developing alternative solutions, (b) consequential thinking, and (c) solution-
consequence pairing. The "turtle technique" involves withdrawing from a provoking
situation and then using relaxation skills (Kendall & Braswell, 1985).

5) Role Playing: the child and therapist act out difficult situations in order to
provide an opportunity for the child to practice their coping skills and to use
previously generated solutions in problematic situations.
6) Self-management skills: includes self-regulation, and self-instructional training
(Whitman et al., 1984). Can be useful for the intellectually disabled. Self-regulation
involves (a) learning self-monitoring skills by accurately identifying and recording a
specific type of behavior; (b) setting acceptable objectives; (c) evacuating the
response; and (d) reinforcing oneself if the standard is met.

7) Behavioral Techniques: CB therapists also make use of relaxation training for

somatic anxiety symptoms.

In practice, a cognitive behavior therapist does not rigidly apply all the previously
described strategies, nor does he/she flexibly apply the procedures in therapy
manuals. In line with the pragmatic nature of CBT, therapists carefully choose
techniques to use with a given child, frequently retooling as the situation changes
and progresses.
 When to use CBT?
• the conceptual basis and evidence base are strongest for four
problems: depression, anxiety, aggression, and attentional problems.
• Many of the more advanced cognitive techniques require that the child
have some knowledge about cognition and be able to use executive
processes, or both.
• As a general rule, older children and adolescents respond better to
cognitive treatments than younger children.
• A final hindrance can be caused by environmental adversity. For
example, children whose home life is repeatedly disrupted by parental
arguments and violence are unlikely to be helped by CBT.