Different approaches to psychotherapy

There is a wide variety of jargon associated with various types of psychotherapy. Each approach has its own 'language' and associated special techniques. However, there is no evidence that any one method is better than another, and it would appear that the personal preference of the professional involved is more important in determining which approach is used rather than the characteristics of the child. Whichever approach is used it is likely that there will be the same common themes in the focus of treatment. Common themes include dealing with feelings of anxiety and insecurity, difficulties in relationships, low self-esteem, and a feeling of failure. These emotions are often generated by difficulties with aggression, jealousy, sexuality, and death.

There are a number of contrasting and often opposing theoretical notions that underpin different approaches to psychotherapy. There is no evidence that one viewpoint is any better than another. Nevertheless, it is important that the therapist has at least thought about these matters and has some idea why a particular approach might be more helpful. Some of the main contrasting issues that need to be considered are outlined below.

A focus on the past versus the present

The child comes to psychotherapy with a range of problems rooted in the past. A decision has to be made whether to focus the therapy on trying to understand and come to terms with the past, or to consider how a child might best cope with what is actually happening in the here and now. The danger in concentrating primarily on the past is that it may interfere with the child's ability to cope with the present and plan for the future. While it is important to learn from what has happened in the past, children tend to learn more from what is happening in the present in their daily lives. Understanding how their emotional stress was generated in the first place may not lead to a resolution or to a greater ability to deal with current problems. It is generally helpful to start therapy with a recognition of what has happened in the past and a consideration of how that might affect what is happening in the present. In a few cases it may be helpful to focus more on the past if the child has clearly become preoccupied with a particular issue from the past and is unable to move on. Normal development moves on so rapidly during childhood that any fixation in the past can have serious consequences, thus every effort needs to be made to promote and sustain developmental progress.

Theory versus common humanity

While it is undoubtedly helpful to have a theoretical framework within which treatment can take place, the observation that different psychotherapeutic approaches for the same type of problem can be equally effective suggests that the precise theoretical framework underpinning treatment may not be that important. Shapiro and Esman(19 have suggested developments to psychoanalytical practice that allow for more flexibility and openness in therapy, thus making the process much less intimidating. This view supports the work of Carl Rogers(5) who suggested that the basic human qualities of trust, genuiness, and understanding are perhaps the most important qualities in psychotherapy. It is not an unusual experience for therapists to find that their early cases turn out to be the most successful, which is probably due to the enthusiasm and therapeutic optimism of the new therapist. It is clearly important to hold on to these therapeutic qualities as one becomes more experienced.

Supportive counselling versus in-depth psychoanalysis

It is easy to assume that the more intensive the psychotherapy and the more it explores the deep unconscious world, the more effective it must be. Clearly there is no reason why this should be the case. (1...1.) For example, one would not expect a surgeon to cut deeper for greater effect or a physician to prescribe more medication than is necessary. This would only increase the adverse effects of the treatment. It is not difficult to see that regular psychoanalysis two or three times per week could be quite disruptive to family life merely as a result of the time commitment alone. There are also other potential problems for children who are treated with intensive psychoanalysis over a period of years, as this may delay or shape a child's development in an unhelpful way. On the other hand, it might be equally inappropriate to commence supportive counselling for a child who is deeply disturbed and whose need for loving care and protection is not being met. These primary and basic needs must always be given priority. Supportive counselling may be appropriate in some children who are too psychologically vulnerable for more intense psychotherapy. (1..2)

Cognitive therapy versus psychoanalytically based psychotherapies

There has been an increased interest in cognitive therapy and cognitive-behaviour therapy, where the emphasis is much more on the here and now and the behavioural consequences of abnormal thought patterns. (1,3) The techniques used in cognitive therapy for anxiety and depressive disorder are described in Chapter. 6.3.2..J and Chapter. respectively. The only modification that is required for their use in children is to adapt them to the developmental stage and the level of cognitive ability that the child has reached. (14) Cognitive therapy has a theoretical advantage for use in children in that its focus is more on the present and the future, in contrast to most psychoanalytically based psychotherapy. Its approach is strongly based on learning new ways of coping. Cognitive therapy is pragmatic and active rather than passive and reflective, making it generally more appropriate for the needs of younger children. Unfortunately, there is little evidence to support the theoretical underpinning of the various cognitive models of childhood disorders. (15)

Limit setting versus free expression

It is a common dilemma to know how much freedom children should be allowed to express themselves. Some children appear to enjoy pushing the limits to see how far they can go. Other children appear far too inhibited and need encouragement to express themselves. Part of the art of child therapy is to strike a comfortable balance between control and freedom. Children gain very little from disruptive and destructive behaviour, even if they normally tend to be quiet and inhibited. Indeed, they rapidly develop overwhelming feelings of anxiety and insecurity if they do not feel sufficiently contained. It is essential that the therapist retains a very clear notion of what behaviour is acceptable and what is unacceptable. There is a responsibility for the therapist to set the scene and establish the boundaries of acceptable behaviour within the therapeutic context. Should the child go beyond the limit then a warning should be given, and if the child persists it is quite acceptable to end the session early or at least until the disruptive behaviour has stopped. The therapist's reaction to bad behaviour should make it quite clear that the behaviour is unacceptable. The emotional response should be neutral or sad, in much the same way that one might behave in a shoe shop when a desirable new shoe does not fit as expected.

Closeness versus distance

It is natural for an adult to be physically much closer to younger children and then to become more distant as they grow older. For example, it is quite natural for an adult to hold the hand of a 3- or 4-year old and to physically guide the child. On the other hand, any physical contact with a teenager can easily be misconstrued and is likely to be most unwelcome. In addition to the developmental perspective, every child has its own preferred degree of closeness or distance from other people. The task of the therapist is to judge what is right for each occasion. It is absolutely essential that the therapist must always avoid intruding into the child's space in any way that could be construed as abusive. This may prove difficult where children are unsure of their boundaries and seek out physical contact (in cases of sexual abuse, children may seek out sexual contact). However, to maintain an artificial physical or emotional distance can be perceived as disinterest or even rejection by some children. To achieve a comfortable level of emotional warmth and physical closeness in therapy is obviously a very important matter, but a relaxed approach in the therapeutic relationship is generally best.

Individual versus group therapy

There are no agreed guidelines to determine which child would benefit from an individual or from a group approach to psychotherapy. Some children, however, find the emotional intensity of undivided adult attention too much to cope with and learn better from others in a group situation. As the selection of cases for group psychotherapy tends to be determined by the therapist's skills, there is no clear evidence that one approach is better than any other. Nevertheless, there is a growing literature on group therapy for children (16> and an increasing interest in this method of treatment if only because the cost per case is likely to be less.

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