Abstract
Psychotherapies for the youth have resulted from the confluence of 3 major disciplines: adult psychology and psychiatry, developmental neurology and pediatrics, and developmental psychology and ethology. Since their humble origins in the psychoanalytically oriented play therapy and the related theories in the pre-War Germany, over more than a century, they have embraced diverse theoretical views that include but not limited to the integration of developmental issues, evolution of the child guidance movement, and the various influences of institutional and social policies. Such a rich journey has eventually resulted in evidence-based practices (EBPs)—powerful interventions for children and families for complex behavioral problems. In this chapter, we attempt to trace the blooming field of youth psychotherapies in their historical contexts, provide an account of the existing gaps of knowledge, briefly narrate the modern-day developments, mostly regarding the multimodal/eclectic treatment aspects and finally, given their rapid growth, we speculate about their (positive) future.
Child and adolescent therapies have progressed considerably, as reflected in the number of controlled studies, their methodological quality, and identification of evidence-based treatments. Despite the methodological difficulties in outcome studies, the field has witnessed major advances regarding the efficacy of selected treatments in child and adolescent psychotherapy and good quality meta-analyses do suggest that 75% of children and young people who attend therapy benefit from it. However, despite the comforting data related to efficacy, major challenges still remain, especially in regard to patient engagement and dropout rates, gap in knowledge about what works and why it works, cultural sensitivity, and data of cost- effectiveness—just to quote a few. Several key areas have been neglected in research, such as the mechanisms of change, the moderators of treatment outcome, and the generalizability of the research findings to the clinical practice arena—this has greatly limited what we know about treatment and partly explains the relative lack of personalized psychotherapies and scarcity in their dissemination/generalization despite the documented evidence on their efficacy. Tailoring treatment more specifically to each patient may be necessary to reduce this nonresponsiveness and dropping outs, as one treatment does not fit all. This necessitates the need for eclecticism—to combine youth psychotherapies with other modes of treatments, such as medications, neuromodulation interventions, and Yoga and mindfulness-based cognitive therapy. Future practice for treatment of mental health conditions in the youth will likely adapt to this huge need for development of eclectic modalities and also reflect cost effectiveness and cultural sensitivity to an increasingly diverse population.
Youth Psychotherapies: Various Types
Around 1799, Jean-Marc Itard’s intensive interventions to “civilize” the 11-year-old boy, who he called “Victor” (the “wild boy of Aveyron”), was probably the earliest documented evidence of a successful child psychotherapy. 1 Victor, who was discovered living in the wild and presumably on his own since the age of 2 or 3, was brought to Itard’s home and had many hours of daily psychotherapy with the goals to establish interpersonal contact and basic communication skills: sounds like Viktor’s behavior would fit a description on the autistic spectrum. Psychotherapy for the youth is defined as a form of psychiatric treatment that involves therapeutic conversations and interactions between a trained therapist and a child/adolescent or family. It can help them understand and resolve problems, modify behavior, and make positive changes in their lives. In some cases, a combination of medication with psychotherapy may be more effective than either modality alone. Child and adolescent psychiatrists are trained in different forms of psychotherapies and, if indicated, are able to combine these forms of treatment with medications to help alleviate the child or adolescent’s emotional and/or behavioral problems. These psychotherapies can be delivered either individually (one-on-one) or in a group setting; can be done in an in-person setting (face-to-face) or remotely as well, by using a tele-psychiatry setup. Psychotherapy is not a quick fix. Rather, it is a complex and rich process that, over time, can reduce symptoms, provide insight, and improve the youth’s functioning and quality of life. In this chapter, we attempt to trace the blooming field of youth psychotherapies in their historical contexts, provide an account of the existing gaps of knowledge, briefly narrate the modern-day developments, mostly regarding the multimodal/eclectic treatment aspects and finally, we speculate about their future.
There are several types of psychotherapy that involve different approaches, techniques, and interventions. The American Academy of Child and Adolescent Psychiatry
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enumerates the currently used psychotherapies for the youth, some of which are listed below:
From Psychoanalytically Oriented Play Therapy to the Third Wave of CBTs and Eclecticism: Evolution of Youth Psychotherapies Over More Than a Century
Psychoanalytically oriented play therapy (or simply, play therapy), which falls largely but not exclusively in the realm of psychodynamic theory, still stands as a dominant and enduring approach to child treatment in existing surveys, 14 although family therapy and briefer versions of the behavioral therapies today may well be its current contenders. Since their humble origins in the form of play therapies that were rooted in the psychoanalytic theories in the pre-War Germany, youth psychotherapies, over more than a century, have embraced diverse theoretical views that include but not limited to the integration of developmental issues, evolution of the child guidance movement, and the various influences of institutional and social policies. Over this long-time span, the systematic evolution of the youth psychotherapies has resulted from a rich and interdisciplinary confluence of 3 major disciplines: (a) adult psychology and psychiatry, (b) developmental neurology and pediatrics, and (c) developmental psychology and ethology. Sigmund Freud’s15, 16 classic case of Little Hans provides the earliest account of a psychodynamic therapy with a child: this case represented the beginning of the mainstream child psychotherapy. Important to note here that, Freud did not personally conduct the therapy of Little Hans; rather, he directed the boy’s father, who observed and reported on his son’s behavior to Freud. Sigmund Freud recognized several technical problems distinguishing the psychoanalytic techniques in children from those in the adults, thanks to his genius! Some of these technical differences in child psychoanalysis include the inability to use verbal free associations, the more rapid transference reactions in children and the need to obtain extra-analytic support and information to sustain the treatment, and the more rapid transference reactions in children.16, 17 These distinctions provided the initial foundation for the development of child psychoanalysis and play therapy, around the First World War, led by Melanie Klein in prewar Berlin and Anna Freud in prewar Vienna. Moving treatment from the child’s home to the therapist’s consultation room, introducing toys that did not belong to the child but could be used for interpretation within the therapeutic relationship, and importance of prenatal development were the most notable amongst Klein’s several important contributions to child psychotherapy. Contributing significantly to this evolving field, Anna Freud’s seminally important work emphasized the essential role of a positive therapeutic alliance, the crucial role of the preanalytic phase to establish this positive alliance, and the use of drawings and dream interpretations to facilitate the expression of therapeutic materials. She also focused on the importance of the parent guidance and extraanalytic contacts with the caregivers for the psychosocial development of the child. 18 Post First World War emerged the field of experimental psychology that informed and enriched further the child psychotherapies. For example, Watson and Raynor’s 19 experimentation with the fearful Little Albert was probably the earliest documented evidence of conditioning strategies for systematically treating fear. This was replicated subsequently in the therapeutic work of Mary Cover Jones 20 —with close resemblance to the modern-day desensitization therapy.
In an important shift, the child psychotherapy of the 1930s moved away from the psychoanalytic open-ended interpretive model and instead focused more on focal, here and now, pragmatic and goal-directed approaches. 18 Also, there was an impetus toward appreciation of the impact of child developmental factors on the treatment process. Informed by several important theoretical and social changes, the post-Second World War saw the emergence of 2 important therapies, that is, family therapy, that recognized the significant importance of family members outside mother, and also, behavior therapy with its emphasis on the specificity in therapeutic planning and systematic efforts to measure the efficacy of the interventions. In this context, it is worth mentioning the important work of Virgina Axline 21 who is widely regarded as a pioneer of play therapy in the United States. Her basic assumption was that children have both a positive “growth impulse” and the ability to solve their own problems. Moving away from the techniques such as free association and focus on/interpretation of the unconscious, the cornerstone of her approach was nondirective child treatment, that is, play/art as the child’s natural medium for self-expression without any need for any specific directions in this regard.
In between 1950 and 1970, many significant contributions to the child psychotherapy enriched the field further, mostly led by the British psychoanalyst and pediatrician Donald Winnicott, along with his contemporary thinkers such as DW Fairbairn, Michael Balint, and John Bowlby. Winnicott 22 in his several books including the Playing and Reality (1971) and over his 200 papers elaborated upon many seminal ideas that formed the foundational cornerstones for the subsequent development of important child therapies as well as parenting projects. These crucial concepts were: “good enough parenting,” “holding environment,” “true self and false self,” and the notion of the “transitional object”—just to quote a few. About the techniques and the contexts of child psychotherapy, Winnicott elaborates: “Psychotherapy has to do with two people playing together…. it takes place in the overlap of play between these two… in this process, the therapist is in a to and fro between two things: being that which the child is developmentally capable of finding and being her(him)self, waiting to be found.” 22
Psychotherapy in the early 1970s took an important turn when Aaron Beck, swaying away from the contemporary psychodynamic school of thoughts, developed CBT, a new type of therapy for depression in adults. His basic cognitive theory of depression proposes that persons susceptible to depression develop inaccurate/unhelpful core beliefs about themselves, others, and the world as a result of their learning histories. Since then, in addition to its widespread applications in almost all psychiatric conditions in adults, CBT has been adapted and studied for children, adolescents, couples, and families. Adding to these important developments, the 1960s saw the rapid growth of the community mental health center movement that helped formalize the social- and preventive medicine/psychiatry. Finally, the mid-1980s saw the advent of managed care: health insurance coverage for psychotherapy became a powerful force for its continued practice while at the same these policies urged the therapies to be targeted, time- limited, practical, and rapid. Thus, intermittent therapy for children became the standard practice and such therapies did not rely on any one single treatment but instead used several treatment strategies simultaneously. This was the birth of newer forms of psychotherapies, such as the eclectic psychotherapies. In its uniquely integrative ways, eclectic therapy pulls from various therapy techniques to discover and implement the most effective treatment for each individual instead of following a predefined methodical structure, instead of following a predefined methodical structure.
The early 1990s witnessed another very important psychotherapeutic development, more so in the Western world, in which spirituality was embraced into the psychotherapeutic work rather than being deliberately ignored. This remarkable development in the 1990s gave rise to the third wave of CBT. 23 Until this point of time in the Western world, both in the psychodynamic and the CBT traditions, patient’s spirituality which is vital to the well-being, was unfortunately alienated from the main stream psychotherapeutic work. It is noteworthy that, since its inception in the 1960s, CBT underwent three waves in its course so far. In its first wave, behavior remained the main focus (classical behavior therapy and animal experimentations) and emphasis was placed on the mechanisms influencing the behavior, for example, classical conditioning and operant learning. In the second wave, the focus shifted from the behavior to the thoughts and the information processing system that gives rise to the behavior (classical CBT). The second wave also saw the extension of CBTs to the youth, incorporation of the CBT concepts into family therapy, and also extending the indications of CBTs beyond depression that eventually gave rise to the development of more targeted and disorder specific CBTs. In contrast to the earlier focus on the behavior and the thoughts in the first- and second waves respectively, the third wave of CBT gave primacy to the metacognitive and existential themes such as spirituality, cognitive fusion, and metacognition, Yogic philosophies, mindfulness, dialectics, acceptance, directed meta-visualization, and so on. In conceptualizing both the well-being as well as the illnesses, these metacognitive themes have been part and parcel of life in the Asian cultures since ancient times. However, their integration into the main stream psychotherapies of the West is a rather very recent and welcome development. Having a strong focus on the spirituality and other aspects of positive psychology, the third wave CBTs emphasized the contextual and experiential change strategies with the clients in addition to the traditional didactic and behavioral components. Important therapeutic competencies in the third wave CBTs include but not limited to listening carefully with an open mind without judging, learning how to listen for the language of spirituality, ask existential questions and collaboratively formulate and interpret the client-specific meanings of their spiritual and religious experiences, and learning how to manage negative religious countertransference. Thus, one can appreciate that the techniques used in the third-wave therapies are quite heterogeneous. However, their many commonalities include: (a) emphasis on the form rather than on the content, (b) the abandonment or cautious use of content-oriented cognitive interventions, (c) collaborative empiricism, (d) active incorporation of the humanistic and spiritual strengths and values into the therapeutic work, and (e) the use of skills deficit models to delineate the core maintaining mechanisms of the addressed disorders. 11 The new and integrative models of psychotherapies in this category include the MBSR, 7 mindfulness- based cognitive therapy (MBCT), 24 ACT, 9 DBT, 8 mentalization-based therapy (MBT), 25 and Y-MBCT. 11 In a recent review, authors 23 conclude that the available evidence now allows all third-wave CBTs to be considered as empirically supported.
TIMBER as an Evidence-based and Eclectic Therapy for the Adults and the Youth
TIMBER is the prototype among the 7 Y-MBCT models developed by Pradhan et al
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that cover most of the psychiatric conditions in disorder specific ways. The other 6 Y-MBCT models that have been tested in the adults and the youth are listed below:
Mindfulness-Based Graded Exposure and Response Modification Mindfulness-Based Rehabilitation of Reading, Attention and Memory Mindfulness-Based Cognitive Therapy, Insomnia module Mindfulness-Based Cognitive Therapy, Eating disorder module
Summary of the Efficacy Trials of the Youth Psychotherapies and Gap of Knowledge
In the early 1990s, research into the effectiveness of psychotherapy for children still lagged far behind that on adult treatments, and had often been of poor quality. In trying to explain why, the researchers have identified three mains reasons: (a) ethos/prevalent beliefs that therapy work cannot be evaluated in research terms without losing the experiential essence; (b) problems of operationalizing the measures of change in the various therapeutic situations; and (c) the fact that child psychotherapy training, unlike some other forms of psychological therapies, has not traditionally been based in academic departments. 32 Fortunately, within 10 years of this, the field has made significant progress in regard to youth psychotherapies and the links between child psychotherapy trainings and university departments are stronger than ever before. 33 The findings of a whole range of meta-analyses of the outcome of adult psychotherapy found that patients who received treatment were about 0.74 of a standard deviation better off than those offered no treatment (ie, effect size = 0.74), with few differences between the various types of treatment. 34 Equivalent meta-analyses of the psychotherapies of children were carried out by Casey and Berman, 35 and Weisz et al, 36 who found a similar overall effect size to the treatment (ie, 0.71). However, some of the findings of these meta-analyses were imprecise and didn’t make much sense. For example, there appeared to be little difference in outcome depending on the type of treatment, the length of treatment, or even the type of problem treated. Also, the types of treatment described in these studies bore little resemblance to those used in clinical practice (eg, only 3.6% of the reviewed studies were of individual psychotherapy and only 1% were psychodynamic treatments).
These important limitations provided the impetus for carrying out more research in recent time. The four meta-analyses conducted from 1985 until present times, for ages 2–18 years, and consisting of 298 acceptable RCTs of the youth psychotherapies (more than 300 treatment programs) provide some broad and meaningful findings, as listed below
34
:
In general, those children who had some form of psychological therapy did better than those that did not. The overall effect sizes of youth psychotherapies range from 0.7 to 0.8 (suggesting moderate efficacy). Children with internalizing disorders (eg, anxiety) had better response. Younger children generally responded than older children, although among the older group therapy was more likely to be successful when the child was suffering from anxiety and/or had referred themselves for treatment. Most change appeared to take place in the first 6 months of treatment. For more severe difficulties, longer and more intensive treatments appeared to be necessary.
While these findings and this progress are important, we’re still in the dark with many questions left unanswered: this gap has greatly limited what works or even more importantly, what doesn’t work in a psychotherapeutic intervention. These unanswered questions are: the mechanisms of change, the moderators of treatment outcome, and the generalizability of the research findings to the clinical practice arena—just to quote a few. Process research in psychotherapy is the empirical study of what actually takes place in a psychotherapy treatment and it also explores the answers for why and how change takes place as the consequence of a therapeutic intervention. 37 Unfortunately, the process research in youth psychotherapy is seriously lacking and instead, focus has been mainly on the final outcomes in “good” or “bad” terms. For example, only 3% of outcome studies incorporated any analysis of the actual process of treatment. 38 Also, lack of demonstrated efficacy for many psychotherapies has been mistaken as lack of evidence. These mechanistic data that can only come from the psychotherapy process research will remain crucial because they offer the potential bridge across between researchers and clinicians, with potential uses in the training and supervision of therapists, with the ultimate aim of not only evaluating treatment, but also finding ways of improving clinical outcomes and developing new psychotherapeutic interventions as well. Important to note that some of the most persuasive process-research have involved single cases of child psychotherapy. 39 While the focus on a single case limits the degree to which the findings 40 can be generalized, it allows for a much more in-depth exploration of the therapeutic process, thereby making the findings more clinically rich and meaningful. For this reason, many of the research in recent years has moved away from “process-outcome” studies to a more theoretically informed analysis of the therapeutic as well as the change process, often focusing on the understanding of a small number of cases and explored in the context of a specific theoretical concept.
Despite the replicated beneficial effects of several evidence-based treatments (EBTs) for youth psychopathology, their dissemination is not moving very fast, and still a vast majority of the tested treatment programs have not made their way yet into the standard everyday clinical practice. Possible reasons are many: most of our everyday clinical practice continues to be characterized by interventions that do not rely on cognitive-behavioral principles and are not derived from the clinical trials literature and many of the EBTs are neither user-friendly, nor culturally sensitive with uncertain/unknown cost-benefit data. Very importantly, most EBTs have been designed for single problems or disorders whereas fact remains that most children referred to everyday clinical care settings present with multiple cooccurring problems and disorders. The research conditions differ from those of everyday clinical care (efficacy vs effectiveness)—a real disconnect between the research and the clinical worlds.
In the field of adult psychotherapy, Lambert and Barley
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have assessed the relative impact of each of the various therapeutic and extratherapeutic factors on the treatment outcomes, when all studies are combined together, and they identified the following:
Only 15% of the relative impact could be ascribed to the therapy techniques; as high as 40% of the relative impact came from the extratherapeutic factors (eg, client’s ego strength and willingness to engage in therapy, spontaneous remission of the clinical condition etc); 30% of the impact came from the relationship factors (eg, level of therapeutic alliance and facilitative conditions); and 15% came from the expectancy factors (eg, belief in treatment).
However, such quantitative data on the youth psychotherapies are yet to be known 34 and despite these important progresses, we are still a long way from the kind of evidence base that will be needed to make a strong case for fully informed decision-making in regard to youth psychotherapies.
Conclusions and Directions for the Future
Psychotherapies for the youth have resulted from the confluence of three major disciplines: adult psychology and psychiatry, developmental neurology and pediatrics, and developmental psychology and ethology. From their origin from the psychoanalytically oriented play therapy and related theories in the pre-War Germany, youth psychotherapies have embraced diverse theoretical views over more than a century, and their multidisciplinary evolution, integration with the allied fields, and their rich progress have resulted in evidence-based psychotherapies (EBPs)—powerful interventions for the youth and families for complex behavioral problems. Youth EBPs have progressed considerably, as reflected in the number of controlled studies, their methodological quality, and identification of EBTs. This evolution resulted chiefly through the sheer demands for services for a variety of clinical populations and socioeconomic forces. Summary of 4 good quality meta-analyses conducted so far suggest that about 75% of children and young people who attend therapy benefit from it.41, 42 Despite some of the methodological difficulties in outcome studies that were mentioned earlier, we do find major advances regarding the efficacy of selected treatments in child and adolescent psychotherapy. 43 However, despite this remarkable progress, several key questions still remain unanswered, such as the mechanisms of change, the moderators of treatment outcome, and the generalizability of the research findings to the clinical practice arena—just to quote a few. This has greatly limited what we know about treatment and partly explains the nonresponse and dropout rates, especially in multicultural settings. For example, some 40% to 50% of children and adolescents with depression are not responsive to treatment, with dropout rates of 40% to 60%.44, 45 Tailoring treatment more specifically to each patient may be necessary to reduce nonresponsiveness and dropping out, as one treatment does not fit all. Thus, tailoring treatment more specifically to each patient may be necessary to address these important issues, as one treatment does not fit all. This necessitates the need for eclecticism—to combine the youth psychotherapies with other modes of treatments, such as medications, disorder-specific neuromodulation interventions (such as, magnetic and electric brain stimulation protocols), and Y-MBCT modalities. 11 Also, there are still unmet needs to address the real disconnect between the research and the clinical worlds, to acquire the much-needed psychotherapy process-outcome research data as well as data on the theoretically informed analysis of the therapeutic as well as the change processes in the field of youth psychotherapies. These authors do remain hopeful that the future evidence-based practices for the youth mental health conditions will adapt to these unmet and huge needs, that is, for the development of efficacious, eclectic, and cost-effective treatment modalities, which need to reflect the cultural sensitivity as well, to an increasingly diverse clinically afflicted population.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.