Trauma‐focused CBT with maltreated children: A clinic‐based evaluation of a new treatment manual

The effectiveness of a locally developed trauma‐focused cognitive behavioural therapy (TF‐CBT) program for maltreated children with post‐traumatic stress disorder (PTSD) was examined across different therapists in a child protection clinic setting. An earlier phase of the research piloting the program had provided promising results. This second phase involved two studies evaluating the completed TF‐CBT manual delivered by (a) the developer and (b) other therapists. A single‐case multiple‐baseline design was used to demonstrate the controlling effects of the treatment on PTSD symptoms and child coping. Eight 9–13‐year‐old abused children with PTSD were treated. Positive outcomes support the effectiveness of the TF‐CBT program delivered by both the developer and other therapists. The study design and methodology were robust enough to confirm empirically the clinically beneficial effects and potential for this new program. It was also apparent, however, from study limitations, including missing data for some patients, that there are a number of challenges in carrying out such research in a busy child protection service setting with multiply‐abused patients. This paper considers implications and ways forward for engaging in empirically supported practice as well as future development and research.     

A behaviour modification technique for the hyperactive child

This paper describes a procedure for the conditioning of attending behaviour in a brain-injured hyperactive boy.

Observations of the behaviour of two hyperactive children were made in the classroom setting. These observations were made from an observation bootn adjoining the classroom and provided data on the frequency of occurrence of the following high rate responses: walking, talking, distraction, “wiggling”. Each child was observed for a minimum of ten minutes a day, four days a week. Following several weeks of baseline observation, the conditioning procedure was begun with the expel imental subject. The conditioning trials took place in the classroom setting. During each time interval in which one of the high rate responses did not occur, S received an auditory stimulus (secondary reinforcer). This auditory stimulus had previously been paired with the delivery of candy and pennies. The stimulus was dispensed by a radio device which activated an earphone worn by the subject. At the end of each conditioning trial, S received whatever candy or pennies he had “earned”.

The data show that the control subject showed no significant change in the frequency of occurrence of the high rate responses during the three month period. The experimental subject showed a significant decrease in non-attending behaviour. This reduction in rate was maintained over a four week extinction period.     

A comparison of the effects of child management and planned activities training in five parenting environments

This study compared the effects of two procedures designd to enhance the extratraining effects of behavioral parents training. Twenty parents of oppositianal children were randomly assign to either a child manangment training condition or a combined child management plus planned activity condition. A further 10 nonproblem children and their parents serve as a social validation group. Observation of both parents and children behavior were conducted in each of five home observation setting (breakfirst time, kindy (kindergarten) or school exit, a structured playtime, bathtime, and bedtime). Both training procedures result in change in both child oppositional and parents oversive behaviosr in all observation settings. In addition, desire positive parents behaviour also improve in all setting. Treatment effect were maintained in all setting at 3-month follow up. Composition between oppositional children following treatment and children in the social validation group showed that they each displayed similarly low lavels of oppositional behaviour in all settings. The inplecation of the results for faciliating generalised changes in behavioral parent training are discusssd.This study was supported by a grant from the National Health and Medical Research Council (NHMRC324 82 579049). We wish to thank all families, therapists, and observers who participated in the project.     

'Paradox: a pivotal point in therapy'

This paper describes a family who had been known to the professional caring agencies for some five years. At the time of treatment, the family had fifteen-year old twin sons whose frequently aggressive behaviour was the focus of the referred problem. It was agreed that the author would attempt to work with this family should they be re-referred, with a view to offering an alternative mode of treatment. A structural framework of therapy was tried, but very shortly therapeutic attempts to help solve the problems were assimilated by the family and seemed to serve only to ensure their continuation. At this point, a powerful paradoxical intervention was tried in order to free both family and therapists from perpetuating a 'more of the same'. This tactic allowed time for treatment from a more structural base to continue. In this context, consideration is given to the nature of pathological and therapeutic double binding. Some of the difficulties inherent in attempting new methods of treatment from within a traditional casework setting with its statutory responsibilities are also discussed.     

Coercive uses of mandatory reporting in therapeutic relationships

Mandatory reporting legislation was enacted with little consideration of its consequences for ongoing therapeutic relationships. One consequence is the unanticipated and coercive uses of the law in mental health settings. Thirty therapists and 25 child protective service workers were interviewed about their experiences with mandatory reporting in therapy relationships. The interviews revealed unanticipated as well as coercive uses of mandatory reporting in therapeutic relationships, including prompting crisis in family systems to promote change, and using reporting or threats of it to enforce attendance and engagement in therapy. Therapists'd anger and view of reporting as a form of power or tool for social control also related to coercive uses of mandatory reporting. The special case of coercion in mandated cases resulting from mandatory reporting legislation is discussed as well.     

Manual‐based cognitive behaviour therapy for chronic fatigue syndrome: therapists' adherence and perceptions

Several randomized controlled trials have indicated that cognitive behaviour therapy is an effective treatment for chronic fatigue syndrome. In 1 of these studies 13 therapists applied cognitive behaviour therapy for chronic fatigue syndrome in 83 chronic fatigue syndrome patients. In the present study therapists' adherence and perceptions of the manual are studied. Following completion of the study the therapists were asked to complete a questionnaire. Audiotaped sessions were conducted to verify the therapists' adherence. Analyses of the audiotapes showed that in 87% of the sessions this appeared to be the case. The questionnaire revealed that the therapists found it more difficult to treat patients with chronic fatigue syndrome than to treat patients with psychological or other physical problems. Treatment aspects posing the most problems were integrating individual problems into the standardized treatment, dealing with the patients' lack of confidence in the treatment and handling insufficient motivation.     

Manual-based cognitive behaviour therapy for chronic fatigue syndrome: therapists' adherence and perceptions

Several randomized controlled trials have indicated that cognitive behaviour therapy is an effective treatment for chronic fatigue syndrome. In 1 of these studies 13 therapists applied cognitive behaviour therapy for chronic fatigue syndrome in 83 chronic fatigue syndrome patients. In the present study therapists' adherence and perceptions of the manual are studied. Following completion of the study the therapists were asked to complete a questionnaire. Audiotaped sessions were conducted to verify the therapists' adherence. Analyses of the audiotapes showed that in 87% of the sessions this appeared to be the case. The questionnaire revealed that the therapists found it more difficult to treat patients with chronic fatigue syndrome than to treat patients with psychological or other physical problems. Treatment aspects posing the most problems were integrating individual problems into the standardized treatment, dealing with the patients' lack of confidence in the treatment and handling insufficient motivation.     

Morita therapy and behaviour therapy

The work of Morita is briefly described against the background of the development of psychology and psychiatry in Japan. It is shown that Morita had a theory of personality remarkably like that which Eysenck was later to develop, although more limited in scope. The therapy which Morita devised for neurotic disorders of a dysthymic kind is described and compared with similar forms of behaviour therapy which are now used in the West. Morita therapy is shown not to be dependent on Zen philosophy, as is sometimes supposed, and its radical difference from psychoanalytic therapy is demonstrated. It is suggested that behaviour therapists and Morita therapists have much to gain by cooperation.     

Pavlov and the foundation of behavior therapy

The foundation, achievements, and proliferation of behavior therapy have largely been fueled by the movement's foundation in behavioral principles and theories. Although behavioral accounts of the genesis and treatment of psychopathology differ in the extent to which they emphasize classical or operant conditioning, the mediation of cognitive factors, and the role of biological variables, Pavlov's discovery of conditioning principles was essential to the founding of behavior therapy in the 1950s, and continues to be central to modern behavior therapy. Pavlov's reliance on a physiological model of the nervous system, sensible in the context of an early science of neurology, has had an implication for behavior therapists interested in the study of personality types. However, Pavlov's major legacy to behavior therapy was his discovery of "experimental neuroses," shown by his students Eroféeva and Shenger-Krestovnikova, to be produced and eliminated through the principles of conditioning and counter-conditioning. This discovery laid the foundation for the first empirically-validated behavior therapy procedure, systematic desensitization, pioneered by Wolpe. The Pavlovian origins of behavior therapy are analyzed in this paper, and the relevance of conditioning principles to modern behavior therapy is demonstrated. It is shown that Pavlovian conditioning represents far more than a systematic basic learning paradigm. It is also an essential theoretical foundation for the theory and practice of behavior therapy.     

To be in touch

This study examined the constellation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – that emerged in the psychodynamic therapy (PDT) of a child diagnosed with borderline personality disorder and treated by two doctoral student therapists. Identification of these interaction structures can inform therapists of what might be expected from patients with particular symptom or behaviour patterns and how interactions change over time. This study also examined each session’s adherence to three session prototypes: PDT, cognitive-behavioural therapy (CBT) and reflective functioning (RF) process. The Child Psychotherapy Q-Set (CPQ) is a 100-item instrument that assesses the processes within a single psychotherapy session. Items reflect a wide range of therapist attitudes and behaviours, patient attitudes and behaviours and interactions between therapist and patient. Experts used the CPQ to define PDT, CBT and RF process session prototypes. The results suggested that four distinct interaction structures could be identified and that their constellations differed between the two therapists and also differed over time within each treatment. Therapists were more structured and accommodating early on in their treatments and more interpretive later. Prototypical PDT process was more prominent in the sessions than RF process, which in turn was more prominent than CBT process. Unique therapeutic processes are at work in every dyad, despite holding the patient and theoretical orientation constant. An effective treatment in one dyad might not work in another due to therapist-specific and dyad-specific effects.     

Aversive and positive conditioning treatments of homosexuality

Thirty-one male homosexual patients were randomly allocated to receive either aversive therapy, in which unpleasant shocks were associated with pictures of nude males; or positive conditioning, in which pictures of nude women were associated with similar pictures of men and later with pictures of heterosexual relationships. The patients were further randomly allocated to receive either procedure according to a forward or backward conditioning paradigm. Before, 3 weeks and 1 yr following 5 days of treatment, the patients were shown a film containing at 1-min intervals 10-sec segments of pictures of nude women or men. During this and all treatment procedures their penile volume responses were measured.

The positive conditioning technique proved ineffective and hence acted as a placebo treatment control for the aversive therapy. Patients reported significantly greater reduction in homosexual feelings and behaviour following the latter. After both the aversive and the positive conditioning technique, patients showed significantly less penile volume increase to the pictures of men. There was no trend for this change to be greater following aversive therapy. It was concluded that this therapy reduced the secondary reinforcement value of homosexual stimuli but did not alter sexual orientation.     

An exposure approach to alcohol abuse

The drinking behaviour of alcoholics was firstly analysed in terms of antecedents, behaviour and consequences. Thereafter, treatment consisted of exposure to the antecedents of drinking, whilst patients were prevented from drinking. Five out of the six patients attained abstinence from drinking by the end of therapy, this abstinence being maintained over follow-ups of up to 9 months, and also noted an absence of desire to drink at the end of therapy. The possible mechanisms in operation during treatment are discussed, including operant or classical conditioning, teaching of self control and cognitive invalidation.     

Therapeutic techniques vs therapeutic relationships in child behavior therapy

The parents of 56 children who had received behavior therapy rated a number of variables, including the degree to which they viewed the therapeutic relationship versus the specific techniques used in treatment as important, the extent to which the child improved in therapy, and the child's present functioning. Therapists also provided ratings of clinical improvement. Even though parents gave the highest ratings for the importance of the relationship in therapy, the correlation between technique and clinical outcome was statistically significant while the correlations between the relationship and outcome was not. These statistical associations also held when therapists rated improvement. Also, therapists saw greater improvement in children than did the parents. Over-all, the results support the view that the relationship and techniques are interwoven and are both perceived as important factors in treatment.     

Gender and conversational behaviour in family therapy and live supervision

The association between supervisors' and therapists' gender and the conversational behaviour of four supervisors, nineteen trainee family therapists and twenty clients before, during and after eighty-eight live supervisory phone in events were examined in this study. Clients' co-operation was not directly related to the gender of therapists and supervisors. The quality of supervisors' collaborative behaviour was highest for events in systems where male supervisors were supervising male therapists and lowest for events in systems where male supervisors were supervising female therapists. In systems containing female supervisors and male therapists, therapists engaged in frequent collaborative behaviour and less frequent teaching behaviour with their clients. The quality of therapists' collaborative and supportive behaviour was highest in these systems. The unexpected results of this study suggest that the way supervisors interact with therapists and therapists interact with clients does not conform to gender stereotypic conversational behaviour in which males are directive and females affiliative. It may be that individuals whose conversational behaviour does not conform to gender stereotypes decide to become family therapists or that family therapy training helps people develop alternatives to gender-stereotypical conversational behaviour.     

Clinical commentary by David Trevatt,Clinical Manager of ‘Hear and Now’ Adolescent Counselling Service,Redbridge and Manager of Open Door's Parenting Teenagers Project,Haringey

Leading the charge to link intervention research with clinical practice is the development of process research, which involves a detailed analysis of specific therapeutic processes over the course of treatment. The delineation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – can inform therapists of what may be expected from patients with particular patterns of symptoms or behaviours in their clinical practice and how interactions change over time. Using the Child Psychotherapy Q-Set, this study aims to compare the different interaction structures that emerged in the two-year psychotherapy of a six-year-old child conducted, for one year each, by two doctoral-student therapists in a university-based community mental health clinic. The study allows for exploration of the independent role of the therapist in the psychodynamic therapy of a child diagnosed with Asperger's disorder. The results suggest that four distinct interaction structures between child and therapist could be identified in this psychotherapy and that the interaction structures differed between the two therapists and also differed over time within each treatment. The implications of these findings for training and clinical practice are discussed.     

Treating Parents and Children Together

SUMMARY

In this paper I look at two traditions of psychotherapy with children: family therapy {here considered in its common paradigm of systems theory and not in its diversity of approaches) and individual psychodynamically oriented child therapy. The author examines how, in these two modalities of treatment, the real world of the parent-child relationship, which remains mostly a world of women and children, tends to be left out in practice. Many family therapists “exclude” children from their sessions and concentrate on the marital relationship while child therapists “exclude” parents from the core of the therapeutic process. The issues for therapists and the consequences for adults and children in families in this com-partmentalization of services are examined within a feminist framework. The development which is advocated is for therapists to expose themselves fully to the world of the parent-child relationship as a fust step in reexamining their stereotypical views of motherhood and fatherhood which trap women in conflicted and potentially exploitative situations and do not consider that children actively construct their own relationships.     

ABSTRACTS OF LITERATURE

A research study in a private outpatient clinic for children attempted to parcel out factors that influence choice of psychotherapy. Instruments used were a 197-item Q-sort based on statements of preference (not practice) for treatment modality from the clinic therapists (psychiatrists, psychologists, and social workers), 86 demographic variables, and the Douglas Thom Child Guidance List of presenting complaints. Results indicate that 127 of the 197 factors reached significance in terms of consensus. Indications and contraindications for individual therapy, family therapy, marital therapy, group therapy, and combinations thereof are listed.     

Playing Together: DIR and Child Psychodynamic Therapy

ABSTRACT

This article describes the integration of the developmental, individual difference, relationship model (DIR) and relational child psychodynamic therapy. DIR is an effective treatment for many children with uneven development, not only for those on the autistic spectrum. The importance for child psychodynamic therapists to understand individual differences, as delineated by occupational and speech/language therapists, and to include parents within the treatment will be discussed throughout this article and in a particular case. An understanding of individual differences makes psychoanalytic formulations, especially about the body, more accessible and actionable. Overlooking the contribution of individual differences to a child’s play and development has consequences for progress in treatment. Together, DIR and child psychodynamic therapy can most effectively integrate “psyche” and “soma” (Winnicott, 1949). The child psychodynamic therapist’s particular expertise, in such areas as countertransference enactments and unconscious meaning, crucially contributes to this integration.