# Psychiatric Disorders/childhood disorders/Psychotherapy

Psychotherapy with children and adolescents can be divided into individual, family and group approaches. Individual therapies are usually either psychodynamically informed or a cognitive- behavioural intervention, often with variations of cognitive or behavioural interventions depending on the age of the child, cognition being treated or the experience and training of the psychiatrist. Key elements across types of psychotherapy include therapy designed to be appropriate to the developmental stage of the child, all therapy being delivered within a family construct (not just ‘family therapy’) and the therapist being suitably trained and their work is related to a known theoretical framework. Behaviour therapy is usually symptom focused where the symptom is a problematic behaviour. Therapy is often brief, may involve the parent as a ‘coach’ and helps promote desired behaviours and eliminate the problem behaviour. Whilst initially in the clinic or hospital, behaviour therapy works well in the real-world, addressing actual difficult symptoms such as agoraphobia or social phobia. Therapy tends to be practical, ‘here and now’ and there is little emphasis on cognitions or dynamic insights. An example of behaviour therapy is ‘flooding’ the child with separation anxiety disorder by assisting the parents to take the child to school and then leaving the children with teaching staff. Or if the same is done in a more gradual fashion then this may be more akin to desensitization. Cognitive behavioural therapy (CBT) expands on behaviour therapy by adding interventions that identifies problematic thoughts or cognitive schema and introducing practices that directly challenging unhelpful thoughts and replace the with more helpful cognitions. There is considerably variation within CBT as regards the extent to which therapy focuses on behaviour, on cognitions or even on the underlying patterns of thinking and relating which form the fertile ground from which symptomatic thoughts and behaviours may arise. CBT is active, often ‘now’ orientated and relies on out of session work by the child, often with parent assistance. Home work is a feature of CBT. Some CBT interventions are manualised and this greatly aides their formal research evaluation. Indeed the evidence base for many CBT programs is more robust than other forms of psychotherapy. There exist CBT packages for children who experience depression and different types of anxiety such as OCD, panic-agoraphobia and social phobia. It is perhaps the manualisaton, the growing evidence base and the relative brevity of these forms of therapy that may result in their rapidly increasing popularity over recent years. Psychodynamic psychotherapy generally is longer term. While it is the existence of the presenting problem that is the stimulus for treatment, the therapy is generally more focused on helping the patient to gain insight, to understand the patterns in their thinking, feeling and relating which cause repeated difficulties and to be able to communicate in more healthy ways. Although the description of psychodynamic psychotherapy may resemble that of other therapies, for instance schema based cognitive behaviour therapy, it is marked out from these by its trade mark technology which is the focus on the way the patient relates to the therapist and to material from the patient’s unconscious mind. The focus on the “underlying” may be problematic if the therapy does not seem sufficiently relevant to the presenting symptom, but does have the potential for personal growth and resilience should symptoms recur at a later time. Dynamic approaches vary across the child and adolescent span. At younger ages therapist employ more creative techniques such a drawing and play. Indeed Art and Play Therapy are generally psycho-dynamically informed and require further training and supervision. Longer term strategies have great value especially for seriously abused children and youth who are often in crisis and cannot make use of the structure inherent to CBT and the motivation required. With these individuals psychodynamically informed support and containment can be very helpful. With improvement the focus of psychodynamic therapy can alter from support to more insight oriented techniques or incorporate elements of CBT. There are many schools of family therapy and there are many differences between these. What they have in common is a perspective which brings to the foreground, not the inner world of the child or adolescent (though for some schools this remains important), but the relationships, communication patterns and shared beliefs within the family and other social systems within which the patient lives and functions. The developmental life cycle perspective is as integral to understanding families as it is to thinking about individuals. Some presentations can best be understood in terms of difficulties in negotiating family life cycle stages e.g. teenager becoming more independent and eventually leaving home and what this means for other family members and relationships. A narrative approach to family therapy might explore the way the family members understand their difficulties and whether there are alternative understandings which might lead to new possibilities. Family counselling and psychoeducation is also part of the repertoire of family interventions, often to help families cope with presentations that may be primarily biological not family dynamic in origin, for instance assistance coping with the behaviour of an autistic child. Confusion may arise with family therapy in terms of who is the patient. Some families bringing an identified patient are comfortable with the idea that the whole family is the patient and that all in the family will need to change. Others find this an alien concept and feel blamed when family therapy is recommended for a problem which, to them, resides within one member. It may be helpful to explore this and to address the issue of family being helped to help one of its members versus family being treated as the patient.