Which therapies can be used for young children and adults? - Chapter 1


What is the use of theories in the treatment of young children and adults?

Specified theories based on empirical research can be used as a guide for the design, the implementation and the evaluation of treatment programs for children and adolescents. An important aspect of these guiding theories is that they are based on empirical research. These theories can help us in clinical work and in empirical evaluation.

The most direct and useful theories for clinical work are theories that explain the processes of change. Because of the focus is on young people, theories focusing on psychological change and aspects of human development that develop during childhood are important.

The ability to recognize and solve a problem is an essential component of adequate adaptation. Therefore, many psychological treatments for young people focus on problem solving, as this is an important basis for the quality of psychological health. Problems are common, and can arise without provocation or effort. However, solutions are less common, often requiring employment of cognitive strategies (arising from a person's active use of thought and therefore costing time and effort). These cognitive problem-solving strategies arise from experience, observation and interaction with others. Intentional and planned interventions can maximize these strategies. Information processing plays a role in this. Dysfunctional information processing requires attention and modification. Correcting erroneous information processing and learning strategies to overcome this are valuable steps in the treatment of psychological disorders for young people.

Our emotional states, both positive and negative, affects our cognitive and behavioural skills and are therefore important in cognitive behavioural therapy (CBT). Positive and negative emotions are not extremes of the same continuum. Both have their own continuum. Emotions can sometimes interfere with problem solving. Learning about the nature and regulation of emotions is important for one's state of well-being. Effective cognitive problem solving requires an understanding of the experience and modification of emotions, so effective interventions require recognition, consideration and therapeutic attention from emotional states.

Psychosocial problems are interpersonal (social) and involve adapting maturing psychological states and changing family roles. Social relationships are therefore important for healthy psychological adjustment. Therapy is also an interpersonal  process, and therefore social and interpersonal domains are important in clinical interventions.

Involving parents in the treatment increases the likelihood of positive outcomes of the treatment. However, although parents play a crucial role, the nature of this involvement may vary depending on the type of problems and the level of child development (increasing parental control is useful, for example, in conduct problems, but not with anxiety problems).

CBT often follows a manual-based or structured treatment. This gives direction and organization to treatments based on what is known about a disorder. This empirical basis optimizes the outcomes of treatment in young people. It also helps therapists in being focused on their goals and provides a pace and sequential steps towards achieving goals. This does not mean that such treatments should be inflexible and rigid, instead the intention is to apply them with some flexibility. The general treatment strategies should be adhered to, but personal adjustments should also be incorporated into the treatment process.

So the theory emphasizes helping young persons by adjusting cognitive information processing in a social context, through the use of structured, behavioural-oriented treatments, with attention to emotional states and the involvement of the young persons. If necessary, members of a social group are involved. A guiding theory is necessary, but not sufficient. Empirical evidence for an intervention is also important.

What is the cognitive and behavioural perspective?

The cognitive and behavioural perspective consists of an integration of cognitive, behavioural, emotion-focused and social strategies. It does not value only a single model, but considers the relationships between cognition and behavior, the emotional state and overall functioning of the organism in a larger social context. Therefore, cognitions, emotions, action and the social environment are all involved in psychological difficulties and disorders, but for each disorder, the influence of each domain can vary. Because behavioural patterns occur in specific and often interpersonal environments, CBT focuses on the social context.

Parents: consultants, employees or co-clients?

Parents are often involved in the treatment, even though there is a great need for empirical evidence about what the most optimal nature of their involvement is. Parents can be consultants and provide information about the nature of the problem. However, if parents themselves have any contribution to the child's problem, they become co-clients in the treatment itself. The parents become employees when they assist in the implementation of the treatment. More research is needed into the ideal form of involvement and parental role in relation to the age of the child and the disorder.

What is known about the role of the attitude of the therapist?

A therapist’s attitude refers to the mental attitude of a therapist. A therapist is a coach, and is supportive but demanding. The therapist as a coach can be described by three concepts:

  • Therapist as a consultant/employee: The therapist is a person who does not have an answer to everything, but has ideas that are worth trying. Aims to develop the client's skills (e.g. problem solving). The child/adolescent and therapist communicate in a collaborative and problem-solving way.
  • Therapist as a diagnostician: Integrating data and judging it with a background of knowledge about psychopathology, normal development and psychologically healthy environments in order to make meaningful decisions. Information from parents/teachers is valuable, but not sufficient. Multiple, different sources and the knowledge of the diagnostician must be taken into account in order to determine the nature of the problem and the treatment plan.
  • Therapist as a teacher: A therapist helps the patient to learn and improve cognitive skills and emotional development during an intervention. A good teacher makes students think for themselves, a good coach is involved, active and involved in the cognitive and behavior process of the individual.

Thus, the attitude of the cognitive-behavioural therapist has a collaborative quality (therapist as consultant), which integrates and decodes social information (therapist as diagnostician) and who learns through experiences with involvement (therapist as a teacher). A high quality intervention ensures that the client can attach meaning to the experiences and the way in which he/she will behave, feel and think in the future.

What about cognitive functioning and adaptation in young people?

Within psychopathology and psychological therapy, cognitive functioning relates to social information processing. Cognition is a complex system consisting of multiple facets:

  • Cognitive content: information that is represented or stored currently (the content of cognitive structures) (first reaction to experience).
  • Cognitive processes: processes that explain how the cognitive system works (e.g. how we receive and interpret experiences).
  • Cognitive products: the resulting cognitions, which arise from the interaction of information, cognitive structures, content and processes. For example, causal attributions.

Psychopathology may be related to problems in the areas above. Effective therapies should consider all of the above factors as relevant and related to the individual client. Cognitive content, processes and products play a role in the meaning of events in an individual's environment (something happens, someone reacts, interprets the situation, has certain thoughts and feelings about it). Cognitive structures arise as accumulation of experiences in memory that serve to filter or screen new experiences. Cognitive schemas are themes of these structures, which makes a child anxious, for example. When a child learns that the dentist can be painful, he or she may become scared when he or she has to go to the dentist later. Cognitive structures can involve automatic cognitive and trigger information processing of events. Cognitive products reflect the influence of existing cognitive structures. In therapy, a young person should be helped to form cognitive structures that will have a positive impact on their future experiences.

Distortions and deficits

Dysfunctional cognitions are maladaptive, but not all dysfunctional cognitions are the same. Understanding the nature of the cognitions is important for treatment. Regarding cognitive processes, a difference should be made between cognitive deficiencies (absence of thinking/processing when it is useful, e.g. in impulsivity/ADHD –  deficiencies) and cognitive biases (dysfunctional thought processes, e.g. in the case of anxiety/depression –  distortions). When looking at disorders, it is often possible to determine whether there are deficiencies or distortions because of over- or under-control. In under-control, one is less able to inhibit oneself, and there are deficiencies in behaviour, such as ADHD, impulsivity and aggression (externalizing problems). For example, individuals with these characteristics can experience problems in activating, planning, and monitoring cognitive processes. In children with problems in  overcontrol, there are biases, such as anorexia, anxiety and mood disorders (internalizing problems). For example, individuals with anxiety may have distortions about how people view them, or what is expected from them.

  1. In behavioural differentiation, it is important to take into account under- and overcontrol.
  2. Cognitive differentiation should look at deficiencies and biases.
  3. There are meaningful relationships between under- and overcontrol.

How can one develop coping?

The role of cognitive concepts (expectations, attributions, self-talk, beliefs, biases, deficiencies, schematics) are emphasized in the development of both adaptive and maladaptive behavior and emotional patterns. These concepts also play a role in the processes of behavioural change. Little is known about the organization and interrelationship of these cognitive concepts. A potential model needs to be a development model, organized by time. Time plays a large role because cognitions can occur before, during and after events. See Figure 1.1 on page 16 for the model: Attributions are formed over and over, usually shortly after the event. These last briefly but can have long-term impacts. Repeated behavioural events (especially events with high emotional impact) can result in cognitive consistency (cognitive structures, attribution style, and beliefs). These are more stable than a single attribution and therefore more predictive of the behavior. This also creates life expectancy. The higher the emotional intensity in an event, the greater its impact on the development of cognitive structures. Therapy should therefore focus on creating behavioural experiences with positive emotional intensity.

When do we need interventions?

Psychologically sound adaptation, as naturally ensued, is built on dealing with challenges in life. When someone is on the right track in terms of adaptation, interventions are unnecessary. However, when someone experiences problems in different domains, one can acquire skills to deal with this in therapy. The goal is then to make the client better prepared for inevitable difficulties in life, by acquiring skills for problem solving.

What are rational expectations of the therapist?

Mental health professionals often expect to be able to help all clients. This expectation is irrational and maladaptive, because therapy is not a cure for all problems. Rational expectations that therapists can have are for example the belief that interventions can help towards successful adaptation, and that clients benefit from the skills learned in therapy. However, there is not always success in therapy and relapses can occur. Also, therapy is not a cure for psychopathology, but a management strategy. Moreover, therapy does not lead to ideal outcomes for every participant.

Positive outcomes after therapy are often explained by 'the power of positive thinking'. However, it is more about diminishing negative thinking. Moreover, individuals who always think positively are not always psychologically healthy. Having negative thoughts is normal when it happens once in a while. It is a matter of adjusting the ratio of negative and positive thinking in therapy to a healthy relationship. In a healthy individual, that ratio is 2:1, in someone with depression the ratio is 1:1.

After therapy, there may also be ‘latent effects’; positive outcomes that do not show themselves immediately after treatment but only at a later point in development.

In addition, there may be ‘spill-over’ effects, which means that positive outcomes associated with the treatment of the child are also present for the parents, sisters/brothers or other individuals who were not target of treatment.

How can change be conceptualized?

How do we conceptualize the changes needed in therapy? It is not that existing cognitive structures should be obliterated. Instead, therapy helps to create new schemes and strategies rather and replace previous dysfunctional structures. This can be reached by exposure to multiple events simultaneously and focusing on cognitive and emotional processes.

What can be concluded?

It is important to take into account the fact that children are often sent to mental health services, while adults seek out help themselves. Because of this distinction, it is important to create a nice, affective environment and also create motivation in children that did not seek out help for themselves. Trust, respect and the child-therapist relationship is essential for the therapeutic process.

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