Psychotherapy For Children & Youth - Psychodynamic Psychotherapy

By Peter Carnochan, PhD, © Copyright 2008.

Psychotherapy Has Helped Kids With

• Depression and anxiety
• Problems in school, attention and learning difficulties
• Adjustment to loss, divorce, or death
• Impulse control, defiant behavior, and aggression
• Social skills, peer and sibling relationships, loneliness
• History of trauma, abuse, or neglect
• Coping with troubled family members or parents with addictions

Psychotherapy Can Help In The Following Areas

Spirit: Yes

Body: Yes

Mind: Yes

Emotions: Yes

Social: Yes

Brief Description Of Psychotherapy

• Psychotherapy is a method for helping children, teenagers and families with emotional and behavioral problems.
• Psychotherapy can help with behavior problems at home and at school.
• Psychotherapy can support children during separations, divorces, and/or grief.
• Psychotherapy can help children heal from the damages of abuses of all kinds.
• There are various methods of psychotherapy (a list of methods can be found later in this chapter). One of these methods is Psychodynamic Psychotherapy.

Brief Description of Psychodynamic Psychotherapy

• Psychodynamic Psychotherapy is based on the idea that many surface behavior and relationship problems are rooted in conscious or unconscious emotional difficulties.
• Using Psychodynamic Psychotherapy, children and parents can begin to understand and become comfortable with underlying feelings that can be confusing.
• During sessions, the therapist will talk to both parents and children to gain greater understanding about the underlying issues.
• With younger children, the primary language of the therapy session is play.
• Through play, children can begin to show the therapist how they have experienced the important situations in their life. A girl who has difficulties making friends, for instance, may learn about making friends by playing a game with the therapist about a group of imaginary animals.
• Psychodynamic psychotherapy (PP) is a practice that requires a significant commitment in terms of time and resources.
• PP has the potential to help change the long term course of a child’s life.
• Because it focuses on underlying emotions and relationships, this type of therapy offers the promise of change that is more than superficial.

Success With Psychotherapy

Mark (not his real name) first came to see me at age six. He had been removed from his home before he turned one, after suffering abuse from his father that had left him with broken ribs and a collapsed lung. Since then, he had been in and out of fifteen foster care placements.

At the beginning of our time together, Mark didn’t have many ideas about how to use his time during the sessions.

I usually give each child I work with their own box, where they can keep whatever they make during a session.

Mark realized that once he had changed some of the art supplies by cutting or drawing, they became his and were moved into his box.

He began to test the limits about how much he could have. In one session he cut a whole ball of string into ten inch pieces. Mark just felt like he needed something, a lot of something, and he couldn’t count on adults to give it to him. At the end of that session his box was full of scraps, useless in themselves, but there were lots of them, and they belonged to him.

As we worked together to make some sense of his feelings of hopelessness and lack, and as he settled into his very good new adoptive home placement, Mark’s ability to imagine and tolerate knowing about his history grew.

After several months of therapy together, he returned to the scraps of string and asked me to tie them together for him. We spent the next several sessions tying the string together with a growing sense of excitement.

As we talked about our project I said: “This string is kind of like your life. It was all cut apart. You feel now like maybe you can tie it together again.” At this point the string began to have meaning and use. He would tie it around the doorknob to keep out potential intruders. He thought he might be able to use it as an escape ladder to crawl out the window. He started to talk about the string as his life ball.

Mark was in therapy for three years. By the end of his therapy, he had developed understanding about his past and a greater sense of trust and safety with me-his therapist, and with his parents. He used these strengthened relationships as a basis for relationships with friends and school.

Several years after the end of his therapy his parents reported that he was doing well in school and was happy.

Psychotherapy Is Appropriate For Ages

• Three to eighteen years.
• When working with children birth to 3, the child needs to be seen with the parent. This therapy focuses on strengthening the attachment between parent and child.

Children & Youth’s Reactions To Psychotherapy

• Some children really love therapy. They feel they have a trusted ally and like the creative activity.
• Other children can feel threatened by therapy and make strong complaints about going, even though the therapy may be helpful.
• If the child complains, parents and the therapist have to determine whether the complaints are part of recovery.

Extra Care Is Needed

• Kids who have gone through significant trauma may need more help in developing the ability to keep out invading, troublesome thoughts and worries. With these children, the therapist needs to be careful not to move too quickly to speak about the painful events because the child can experience this as a repetition of the trauma.
• Before remembering the painful experience, the child must get permission to forget and take part in living. When the child has emotional skills and strengths they can start to remember the trauma – which can be helpful. Being forced to remember too soon can be another painful demand.
• The child has to feel safe enough and ready to remember the painful experience.
• Another area that requires caution is parental commitment.
• It is important that the parents have a commitment to the therapy and understand how emotions can be stirred up in the process.
• Parents need to be committed to a lengthy process. A bit of therapy is usually not helpful when the child has been very hurt.

History

• Psychodynamic Psychotherapy has its roots in the work of Sigmund Freud. Freud was a Viennese medical doctor who began trying to understand the roots of emotional disorders during the 1880’s. He continued to develop his thought through the early 1930’s.
• Freud developed a type of therapy that he called psychoanalysis where he encouraged his adult patients to free-associate, to say whatever they wanted to. He realized that eventually, using this method, most patients would begin to talk about the thoughts and feelings that were most important to them.
• Freud’s daughter, Anna Freud, and a therapist named Melanie Klein (both students of Freud) began working with children in the 1920’s.
• Children, however, are not ready to talk abstractly about their thoughts and feelings.
• To reach children, Anna Freud and Melanie Klein realized that another approach was required.
• They recognized that for children, play is the language of the unconscious. Playing is how children free-associate.

Basic Concepts And Components Of Psychotherapy

• For children to flourish, they need to learn certain skills that allow them to relate with other people.
• They need to be able to adjust their feelings, and know how to use their feelings effectively when interacting with others.
• In health, children should be able to experience a wide range of feelings without becoming overwhelmed.
• In their relationships, children should be able to play cooperatively and competitively with peers.
• With adults, children should be able to put up with the reasonable demands of authority, and make their wishes and concerns known.
• These skills are usually learned in the family setting, and early school environment.
• When children have difficult temperaments or they have a challenging situation at home, it can be hard for them to develop these skills.
• Beginning psychotherapy early can make a big difference in bringing development back on track.
• For children, play is the language of the imagination and feeling.
• Play offers children an avenue to express their strongest feelings and conflicts. In this way, play provides an avenue into the child’s inner world.
• In the context of play, difficult thoughts and feelings can be expressed in a non-threatening way. For example, a child who has a hard time expressing his troubles in words, might be able to draw a detailed picture, using images that reveal his inner feelings. By talking about the drawing instead of the underlying problem, the child can address his issues in a way that feels safe.
• Play offers a controlled setting where a child can try out new behaviors, in the same way that an athlete might work on a new skill during practice.
• Problematic behavior is often an attempt to manage anxiety and feelings of danger.
• In psychotherapy, safety is created by the relationship between the child and the therapist.
• The regular meetings, the therapist’s consistent and careful focus on the child’s worries and the therapist’s acceptance of the child, all add to an increased sense of security.
• When the family understands the nature of the child’s behavior, it can help them find more effective and less frightening responses to the child’s behavior.
• As things begin to feel more safe in their environment, children can take the risk of leaving their old methods of managing anxiety behind, and can begin to develop new, more positive behavior.
• It is important for parents to understand that throughout a course of helpful psychotherapy, children may have intense positive and negative feelings toward their therapist.
• This is part of what allows the therapy to reach the child at the deepest level.

Description Of A Typical Session

• When I work with a child, I begin by meeting with the parents.
• I gather information about the nature of the child’s difficulties and the family’s background.
• After getting a history of the child’s development, I meet with the child.
• Often children will want their parents to stay with them during the first session.
• I tell children that I’m a doctor who helps people with their troubles and worries.
• During a session, children are invited to play with the toys and art supplies in the office.
• With teenagers, I explain to them what I have been told about their situation and ask them to give me their perspective on themselves and their family.
• Some teenagers are quite ready to speak about their thoughts and feelings. Other teenagers may feel unsure about opening up with a stranger.
• With these teens, I work hard to create a more comfortable context for discussion.
• We may begin by speaking about music, movies, or other ordinary topics and allow this to become a springboard for more personal conversation.
• After meeting with the child for several sessions, I will then schedule another meeting with the parents. At this time I will talk to the parents about my impressions of the case and talk about a possible course of treatment.
• It is important for parents to understand the reason for treatment, and to have a good sense of the commitment involved.
• As the therapy continues, the child’s worries and concerns are expressed increasingly in play and drawings.
• As the child starts to trust the therapist, there is room for the therapist to begin to talk with the child about how the themes in the child’s play may be connected to issues and feelings in the child’s own life.

Major Differences Of Opinion Between Practitioners

• There are a lot of differences. Most of the differences are too complicated for a short discussion.
• One important area of difference is about whether it is better to teach new skills, or to deal with underlying fears and anxiety before change can be long lasting.

Fees/Costs In 2007

• In San Francisco, the cost is $100 to $175 per session.
• Parents who need a significantly reduced fee or a fee based upon income, can often find interns who are in training and who are under the supervision of more experienced therapists.

Average Time Per Session

• Sessions last 45 to 50 minutes, one to four times a week.
• Therapy seems to work best when children have at least two sessions a week.

Estimated Length Of Time Before Improvements Can Be Expected

• Some children are able to be helped quite quickly.
• With most children, therapy requires time for enough safety and depth to be established. This process usually takes at least a year.
• When problems are severe, many years of work can be required.

Suggestions To Make Psychotherapy More Effective

• Parents should meet with the therapist regularly: once a week to once a month.
• They can keep the therapist informed about the events in the child’s life.
• The therapist can coach the parents on ways of being more effective at home.
• Parents sometimes have the idea that children should talk about their troubles with the therapists.
• Parents must realize that, for the therapy to go well, there has to be room for playing.
• Parents should understand that conflict and strong emotions are an important part of the therapeutic process.
• During difficult periods in the treatment, parents should collaborate closely with the therapist.

Different Methods of Psychotherapy For Children & Youth

• There are many forms of Psychotherapy for kids: Psychodynamic, Cognitive, Behavioral, Expressive Art.

Other Methods That Complement Psychotherapy

• Occupational therapy
• Family therapy
• Social skills training

Special Training Needed To Work With Children & Youth

• Regardless of their specific degree, clinicians need to have training and supervision in working with children. Inquire about the amount of child experience the clinician has.
• A skilled child therapist will know about child development, and be familiar with the physical, emotional and intellectual issues that effect children.

Education/Certification/Licenses Needed By Practitioners

• In the United States, licenses and training to be a psychotherapist vary by state.
• In the United States, there are a variety of degrees that qualify people to work as therapists: most are Masters Degree programs – that is, education that follows graduation from a university with a Bachelor’s degree.
• Look for degrees like: MSW (Master of Social Work), MFT (Master of Family Therapy). These usually take two years of schooling with additional years of supervised practice.
• After completing a Master’s degree, a therapist can pursue a Doctorate, or PhD.

This qualifies the therapist to be called a Psychologist or Ph.D Social Worker. These degrees usually take a minimum of 4 years in addition to years of supervised practice.

• At the medical level, doctors who have had four years of medical education then complete residencies in psychiatry. Psychiatrists have an MD and this allows them to prescribe medication when indicated.

Professional Associations To Contact For Names Of Local Psychotherapists

• To locate a practitioner, start by asking friends. Word of mouth referral is often a good way to find therapists. Pediatricians, school counselors and officials, and some ministers will also know local therapists.
• The American Psychological Association’s website provides a link to locate a local psychologist: www.apa.org.
• Contact the American Medical Association; 515 N. State St.; Chicago, IL 60610; 800-621-8335; Website: www.ama-assn.org.
• Contact the American Family Therapy Academy (AFTA, Inc.); 1608 20th St., NW; 4th Floor; Washington, DC 20009; Ph: 202-483-8001; Fax: 202-483-8002; Website: www.afta.org.

What To Look For When Choosing The Best Practitioners

• Skill in psychotherapy is a combination of who the therapist is as a person, combined with their training and experience.
• Look for personal qualities you respect: a therapist who is thoughtful, empathic, warm, and is able to think clearly about the child and family.
• Look for someone who can form a positive bond with the child.
• Inquire about their training.

Bibliography

• Greenspan, Stanly and Jacqueline Salmon. The Challenging Child: Understanding, Raising, and Enjoying the Five “Difficult” Types of Children. Jackson, TN: Perseus Books, 1995.
• Miller, Alice. The Drama of the Gifted Child: The Search for the True Self. Jackson, TN: Basic Books, 1997.
• Altman, Neil (Editor), Richard Briggs (Editor), Jay Frankel (Editor), and Daniel Gensler (Editor). Relational Child Psychotherapy. New York: Other Press, 2002.
• Axline, Virginia. Play Therapy. New York: Ballantine Books, 1947.

Peter Carnochan’s Personal Statement

When children are having difficulties at home or at school, I believe psychotherapy can play a key role in helping develop new possibilities and insights. Parents often report that children gain confidence and greater empathy over the course of the therapy. This can result in better relationships and increased focus and enjoyment in school.

To Contact Peter Carnochan, Who Contributed This Chapter

Peter Carnochan; 3609 Sacramento Street; San Francisco, CA 94118; Ph: 415-922-5570;
Email: pcarnochan@mindspring.com

Marie Mulligan’s Comment About Psychotherapy: The right therapist and the right therapy can transform a child’s or youth’s life. I have seen it over and over again. Choose carefully.

Rick Geggie’s Comment About Psychotherapy: I wish every child could be in therapy for as long as they need to be, in order to know themselves, to like themselves and to know how to find trustworthy people from whom to learn. As a principal, I was very sad that therapy was not available to more children. I have seen therapists perform miracles, bringing children and teens back from lives of anger, confusion, and creating havoc. I believe society should spend more money on getting therapy for children. Jails, which are more costly than therapy, would be far less necessary.