Kaplan + Sadock's Synopsis of Psychiatry, 11e

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31.18a Individual Psychotherapy

Psychotherapy with children and adolescents generally is more directed and active than it is with adults. Children usu- ally cannot synthesize histories of their own lives, but they are excellent reporters of their current internal states. Even with adolescents, a therapist often takes an active role, is somewhat less open-ended than with adults, and offers more direction and advocacy than with adults. Nurturing and maintaining a therapeutic alliance may require educating children about the process of therapy. Another educational intervention may entail assigning labels to affects that have not been part of a youngster’s experience. The temptation for therapists to offer themselves as a quasi- parent role model for children may stem from helpful educa- tional attitudes toward children. Although this may sometimes be an appropriate therapeutic strategy, therapists should not lose sight of the potential pitfalls of engaging in a highly parental role with their child and adolescent patients. Parents and Family Members Parents and family members are involved in child psychotherapy to varying degrees. For preschool-age children, the entire thera- peutic effort may be directed toward the parents, without any direct treatment of the child.At the other extreme, children can be treated in psychotherapy without any parental involvement beyond the payment of fees and transporting the child to the therapy sessions. Most practitioners, however, prefer to maintain an alliance with parents to obtain additional information about the child. Probably the most frequent parental arrangements are those developed in child guidance clinics—that is, parent guidance focused on the child or the parent–child interaction and therapy for the parents’ own individual needs concurrent with the child’s therapy. Parents may be seen by their child’s therapist or by someone else. Recently, increasing efforts have been made to shift the focus from the child as the primary patient to the child as the family’s emissary to the clinic. In such family therapy, all or selected members of the family are treated simultaneously as a family group. Although the preferences of specific clinics and practitioners for either an individual or a family therapeu- tic approach may be unavoidable, the final decision regarding which therapeutic strategy or combination to use should be derived from the clinical assessment. Confidentiality The issue of confidentiality takes on greater meaning as children grow older. Very young children are unlikely to be as concerned about this issue as are adolescents. Confidentiality usually is preserved unless a child is believed to be in danger or to be a danger to someone else. In other situations, a child’s permission usually is sought before a specific issue is raised with parents. Advantages exist to creating an atmosphere in which children can feel that all words and actions are viewed by therapists as simultaneously both serious and tentative. In other words, chil- dren’s communications do not bind therapists to a commitment; nevertheless, they are too important to be communicated to a third party without a patient’s permission. Although such an attitude may be implied, sometimes therapists should explicitly discuss confidentiality with children. Most of what children do and say in psychotherapy is common knowledge to the parents.

both the MBSR and the TAU groups reported significantly reduced anxiety, depressive, and somatization symptoms, and improved self-esteem; but only the MBSR group reported sig- nificant declines in perceived stress, obsessive symptoms, and interpersonal problems. Furthermore, although more than 45 percent of the MBSR group showed changes in diagnoses at the end of the study (such as no longer meeting criteria for a mood disorder) none of the TAU group was found to have remitted from a diagnosis. Mindfulness meditation practices have been applied in vari- ous forms to a multitude of psychiatric conditions including mood disorders, chronic pain syndromes, anxiety disorder, and ADHD. Mindfulness, according to Kabat-Zinn, is characterized by paying complete attention to the present moment without judgment, with an ability to be aware of inner and outer experi- ences in the present. There are many forms of meditation which incorporate mindfulness, and both MBSR, and Mindfulness- Based Cognitive Therapy (MBCT) developed by Teasdale, can be considered forms of mindfulness meditation. There is evi- dence based on neuroimaging studies that mindfulness medita- tion can induce specific brain states. One study indicated that Vipassana meditation is associated with activation of the rostral anterior cingulate cortex as well as the dorsal medial prefrontal cortex. There is evidence to suggest that mindfulness medita- tions can improve attention, and that these changes may lead to clinically important improvements. Yoga originated in ancient India, and while there are many varieties, key components include physical postures, controlled breathing, deep relaxation, and meditation. Randomized con- trolled trials using yoga have provided evidence of its benefit as an adjunctive intervention in mild depression, sleep distur- bance, and attention problems. Clinical trials comparing yoga to cooperative game playing or physical exercises in children with ADHD found moderate improvements in ADHD symp- toms when yoga was added as an adjunct to medication. There is some evidence suggesting that yoga may be beneficial as an adjunctive intervention for mild depression, even in the absence of medication and potentially for schizophrenia, as an adjunct to medication. The Role of Play Observing play and engaging in play with children can be extremely informative in assessing developmental abilities, and in understanding sensitive situations. This is particularly rele- vant for young children, and for children who have experienced trauma, which is difficult to describe in words. Although the choices of play material vary among therapists, the following equipment can constitute a well-balanced play- room or play area: multi-generational families of dolls of vari- ous races; dolls representing special roles and feelings, such as police officer, doctor, and soldier; dollhouse furnishings with or without a dollhouse; toy animals; puppets; paper, crayons, paint, and blunt-ended scissors; a sponge-like ball; clay or something comparable; tools such as rubber hammers, rubber knives, and guns; building blocks, cars, trucks, and airplanes; and eat- ing utensils. The toys should enable children to communicate through play. Therapists should avoid fragile objects that can break easily, that can result in physical injury to a child, or that can increase a child’s guilt.