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Psychotherapy and Psychiatric Hospitalization


Psychotherapy

Psychotherapy is the first-line treatment for most child and adolescent psychiatric disorders, because this type of treatment generally produces outcomes similar to pharmacotherapy, with less risk of harm. Even with disorders such as schizophrenia, bipolar disorder, and attention-deficit/hyperactivity disorder (ADHD) for which medication is the first-line treatment , adjunctive psychotherapy can convey considerable additional benefit. Because pediatric primary care practitioners (PCPs) likely will be referring youth with psychiatric disorders for psychotherapy, they should be familiar with basic information about child and adolescent psychotherapy.

Overall, psychotherapy is moderately effective in reducing psychiatric symptomatology and achieving remission of illness. In a 2017 multilevel meta-analysis of almost 500 randomized trials over 5 decades, there was a 63% probability that a youth receiving psychotherapy fared better than a youth in a control condition. Effects varied across multiple moderators, including the problem targeted in treatment. Thus, the mean posttreatment and follow-up effect sizes were highest for anxiety, followed by behavior/conduct, ADHD, and depression, and lowest for multiple concurrent comorbidities. Effect sizes varied according to outcome measure informant, with youth and parents generally reporting larger effects than teachers. Ethnicity moderator tests showed no significant differences in treatment benefit between majority Caucasian samples and majority non-Caucasian samples.

A variety of psychotherapeutic programs have been developed, with varying levels of effectiveness ( Table 34.1 ). Differences between therapeutic approaches may be less pronounced in practice than in theory. The quality of the therapist–patient alliance is consistently an important predictor of treatment outcome. A positive working relationship, expecting change to occur, facing problems assertively, increasing mastery, and attributing change to the participation in the therapy have all been connected to effective therapy.

Table 34.1
Effective Psychotherapies for Specific Behavioral Health Disorders
Adapted from Society of Clinical Child and Adolescent Psychology: Effective child psychotherapy. http://effectivechildtherapy.org/content/ebp-options-specific-disorders . Accessed March 5, 2017.
DISORDER WELL ESTABLISHED * PROBABLY EFFICACIOUS †
Anorexia Family therapy: behavioral Family therapy: systemic
Individual insight-oriented psychotherapy
Anxiety Individual CBT CBT + parent component
CBT + medication
ADHD Behavioral parent training Combined training interventions
Behavioral classroom management
Behavioral peer interventions
Organization (executive function) training
Autism Individual, comprehensive ABA Individual, focused ABA + DSP
Teacher-implemented ABA + DSP Focused DSP parent training
Bipolar None Family psychoeducation + skill building
Depression, child Group CBT Behavior therapy
Group CBT + parent component
Depression adolescent Group CBT Group CBT + parent component
Individual interpersonal psychotherapy Individual CBT
Individual CBT + parent/family component
Insomnia Individual CBT
ODD and CD, child Individual/parent management training Group CBT
Individual CBT Group/parent management training
Problem-solving skill training
Group assertiveness training
Multidimensional treatment foster care
Multisystemic therapy
ODD and CD, adolescent Combined behavioral therapy, CBT, and family therapy CBT
Treatment foster care
OCD None Individual CBT
Family-focused individual CBT
Personality Disorders None Dialectical behavioral therapy
PTSD Trauma-focused CBT Group CBT
Social phobia None Group CBT
Specific phobia None None
Substance use Group CBT Family-based treatment, behavioral
Individual CBT Motivational interviewing
Family-based treatment, ecologic
Self-injury Individual + family CBT + parent training Family-based therapy
Psychodynamic individual + family
ADHD, Attention-deficit/hyperactivity disorder CBT, cognitive-behavioral therapy; ABA, applied behavioral analysis; DSP, developmental social-pragmatic; ODD, oppositional defiant disorder; CD, conduct disorder; OCD, obsessive-compulsive disorder; PTSD, posttraumatic stress disorder.

* Two or more consistent randomized controlled trials demonstrating superiority of treatment over control groups; conducted by independent investigators working at different research settings.

† Same as above, but lacking independent investigator criterion.

All psychotherapy interventions involve a series of interconnected steps, including performing an assessment, constructing working diagnoses and an explanatory formulation, deciding on treatment and a monitoring plan, obtaining treatment assent/consent, and implementing treatment. Psychotherapists ideally develop a treatment plan by combining known evidence-based therapies with clinical judgment and patient/family preference to arrive at a specific intervention plan for the individual patient.

Behavior Therapy

Behavior therapy is based on both classic (Pavlovian) and operant (Skinnerian) conditioning. Both approaches do not concern themselves with the inner motives of the individual, but instead address the antecedent stimuli and consequent responses. The treatment begins with a behavioral assessment with interview, observation, diary, and rating scale components, along with a functional analysis of the setting context, immediately preceding external events, and real-world consequences of the behavior. A treatment plan is developed to modify the maladaptive functions of the behavior, using tools such as positive and negative reinforcement, social and tangible rewards, shaping, modeling, and prompting to increase positive behavior, and extinction, stimulus control, punishment, response cost, overcorrection, differential reinforcement of incompatible behavior, graded exposure/systematic desensitization, flooding, modeling, and role-playing to decrease negative behavior.

Behavior therapy has shown applicability to anxiety disorders, obsessive-compulsive and related disorders, behavior disorders, A DHD, and autism spectrum disorder.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) is based on social and cognitive learning theories and extends behavior therapy to address the influence of cognitive processes on behavior. CBT is a problem-oriented treatment centered on correcting problematic patterns in thinking and behavior that lead to emotional difficulties and functional impairments. The CBT therapist seeks to identify and change cognitive distortions (e.g., learned helplessness, irrational fears), identify and avoid distressing situations, and identify and practice distress-reducing behavior. Self-monitoring (daily thought records), self-instruction (brief sentences asserting thoughts that are comforting and adaptive), and self-reinforcement (rewarding oneself) are key tools used to facilitate achievement of the CBT goals. Table 34.2 outlines the key descriptive features of CBT that can be used by PCPs when describing CBT to patients and their family members.

Table 34.2
From Coffey SF, Banducci AN, Vinci C: Common questions about cognitive behavior therapy for psychiatric disorders. Am Fam Physician 92:807–812, 2015.
Core Components and Characteristics of Cognitive-Behavioral Therapy

  • One 60- to 90-minute session each week, typically for 6-12 weeks

  • Symptom measures typically are collected frequently.

  • Treatment is goal-oriented and collaborative with patient as an active participant.

  • Treatment is focused on changing current problematic thoughts or behaviors.

  • Weekly homework typically is assigned.

CBT has good-quality evidence for the treatment of depression, anxiety, obsessive-compulsive disorders (OCDs), behavior disorders, substance abuse, and insomnia (see Table 34.1 ). For many childhood psychiatric disorders, CBT alone provides outcomes comparable to psychotropic medication alone, and the combination of both may convey additional benefit in symptom and harm reduction.

Modified versions of CBT have shown applicability to the treatment of other disorders. Trauma-focused cognitive-behavioral therapy (TF-CBT) involves a combination of psychoeducation; teaching effective relaxation, affective modulation, and cognitive coping and processing skills; engaging in a trauma narrative; mastering trauma reminders; and enhancing future safety and development. TF-CBT is considered the first-line treatment for posttraumatic stress disorder (PTSD).

Dialectical behavioral therapy (DBT) is a CBT approach targeted at emotional and behavioral dysregulation by synthesizing or integrating the seemingly opposite strategies of acceptance and change. Dialectic conflicts (wanting to die vs wanting to live) often exist in the same patient and are important to address. The 4 skills modules— mindfulness (the practice of being fully aware and present in the moment), distress tolerance (how to tolerate emotional pain), interpersonal effectiveness (how to maintain self-respect and effective communication in relationships with others), and emotion regulation (how to manage complex emotions)—are balanced in terms of acceptance and change. Patients who receive DBT typically have multiple problems; the treatment targets, in order of priority within a given session, are life-threatening behaviors, such as suicidal and self-injurious behaviors or communications; therapy-interfering behaviors, such as coming late to sessions, cancelling appointments, and being noncollaborative in working toward treatment goals; quality-of-life behaviors, including relationship and occupational problems and financial crises; and skills acquisition to help patients achieve their goals. DBT has shown promise for the treatment of personality disorders, suicidal behavior, bipolar disorder, and other manifestations of emotional-behavioral dysregulation.

Interpersonal Psychotherapy

Interpersonal psychotherapy (IPT) focuses on interpersonal issues that lead to psychological distress. Patients are viewed to having biopsychosocial strengths and vulnerabilities that determine the manner in which they cope or respond to an interpersonal crisis ( stressor ). Symptom resolution, improved interpersonal functioning, and increased social support are the IPT targets. IPT has proved to be a well-established treatment for adolescent depression.

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