Course Philosophy
What is child psychotherapy
Child psychotherapy refers to the practice of the principles and techniques of psychotherapy which aim to modify and solve emotional, cognitive, behavioral and interpersonal problems in children. The goals of child psychotherapy are mainly three: detecting behavioral excesses, accelerating behavioral deficits and maintaining behavioral acquisitions (Polemikos, 1997).
Approaches in child psychotherapy
As with adult psychotherapy, there is a wide variety of approaches in child psychotherapy. According to Kazdin (1988), at present, over 230 methods are used in the child’s psychological treatment, and Karan (1986) estimates that there are around 400 different approaches in child psychotherapy. The main theoretical tendencies are psychoanalytic, psychodynamic, client-centered, behavioral and cognitive.
In contrast to adult psychotherapy, in child psychotherapy the application of different methods and techniques is primarily dependent on the developmental factors, respectively on the child’s age: preschool, school or adolescent (Simeonsson and Rosenthal, 1992). Another major difference compared to adult psychotherapy is that children often do not express their problems and difficulties in words. Children often express their problems and despair through actions: nocturnal enuresis, escape from home, crying or crises, becoming apathetic or socially withdrawn, setting fire to the house or acting in any way that can attract the attention of adults.
Individual child psychotherapy has been divided into three categories: insight-oriented therapy, supportive psychotherapy and structural developmental approaches (Freedheim and Russ, 1992).
In insight-oriented psychotherapy the focus is on the inner conflicts of the child aimed at helping the child to develop its internal structure and to change the balance between ego, id and superego. One of the most important therapeutic techniques in this approach is interpretation.
Supportive psychotherapy focuses on problem solving techniques and coping strategies. It focuses on the problems of everyday life and the conflicts here and now, without discovering anxious material. The mechanisms of change are considered to be catharsis, collective emotional experiences, alternative problem-solving strategies, alternative ways of looking at a situation or oneself, and awareness of the fact that there is someone there who provides help and support. Supportive therapy is considered appropriate for children with major developmental problems, with a relatively poorly developed ego, while insight-oriented psychotherapy is considered to be more appropriate for children with good ego development, who can tolerate anxiety, they struggle with internal conflicts, they trust adults and they can think of their behavior and what it means (Freedheim and Russ, 1992).
Psychotherapy focused on structural development is appropriate for children with structural deficits due to early developmental problems, such as children with borderline psychotic disorder or narcissistic disorder. These children do not have sufficiently developed cognitive and affective functions and cannot differentiate between fantasy and reality, between inside and outside, between themselves and others. Also, these children have difficulties in integrating the positive and negative feelings they have towards a particular person. The role of the therapist is to serve as a stable character that helps the child develop those functions of the ego as much as possible (Freedheim and Russ, 1992).
Speech and wordless psychotherapy
Although psychotherapy has in fact been defined as “healing through words”, children cannot express themselves very well verbally and cannot clearly communicate their problems, fears, anxieties, needs and desires. However, this obstacle can be overcome by playing. Play therapy is a psychotherapeutic method that can be used with great success to help children solve their problems. Typically play therapy involves the interaction between a therapist and a child and is psychodynamically oriented. While playing the children either do not speak or talk to themselves, toys or the therapist. The child’s play is regarded as communication, and the change of the game as a deepening of the conversation or an effort to avoid or change the subject (Reisman and Ribordy, 1993). According to psychodynamic approaches (Freud, 1946, Klein, 1966), the symbolic content of the child’s play reflects the child’s unconscious conflicts and fantasies. Klein said that the equivalent of adult free associations in psychoanalysis is play in children. Although Melania Klein’s work on child analysis and their object relationships has been controversial, her approach is used worldwide today.
On the other hand, person-centered psychotherapy starts from the assumption that the abnormal behavior is the result of adverse conditions in the person’s life, the behavioral problems of the child being caused by the criticism and the domination of the adults. Unlike psychodynamic psychotherapy, which explores a person’s past, client-centered therapy does not focus on the past for the sake of the past, but only to the extent that the therapist needs the past to understand the present.
Client-oriented play therapy, developed by Axline (1947), is based on non-directional or client-centered therapy by Carl Rogers. It is considered of primary importance to build a warm and friendly therapeutic relationship.
Behavioral therapy is based on the assumption that behavior is primarily the result of learning and environmental factors, rather than internal factors. The behavioral therapeutic methods do not try to discover the hypothetical causes underlying the abnormal behavior, they do not try to reveal unconscious motives and conflicts, but they apply the principles of learning in order to modify the maladaptive behavior. In behavioral therapy, classical conditioning and learning by imitation or modeling are central. According to long-term studies, the elimination of abnormal behavior does not lead to symptom substitution as psychodynamically oriented psychotherapists argue.
Integrative psychotherapy with children and adolescents
Our training course (Integrative strategic psychotherapy with children and adolescents) is derived from two psychotherapeutic models we created in the course of time: integrative strategic psychotherapy for adults and a model called “The Wizarding School Program for children”.
Integrative strategic psychotherapy is a research-informed approach to psychotherapy, organized around the centrality of the therapeutic relationship. It works with a model of the Self, which integrates several major theories in a coherent framework based on research in neurobiology and attachment. The basic principles of integrative strategic psychotherapy take into account the common elements of most psychotherapeutic approaches. In other words, the common therapeutic factors are considered the main forces behind therapeutic change, whilst the therapeutic relationship stands out among these factors. At the core of the therapeutic relationship are the client and therapist variables, and in this context the left-right brain hemisphere interplay is considered crucial for a positive therapeutic outcome.
Integrative strategic psychotherapy proposes that there are a series of central assumptions found in most theoretical approaches to psychotherapy and that the growing body of knowledge needs to constantly influence the way we conduct therapy. Whilst presenting a coherent model of the Self and a series of core principles, integrative strategic psychotherapy leaves room for integrating even more theories and models of intervention.
We are working with a four-domain model of the Self (proto-self, core self, plastic self and external self – derived from Damasio’s theory of the Self), intersected by six psychological axes: biological, cognitive, emotional, psychodynamic, transgenerational and existential. The behavioural domain was not considered separately, taking into account that each of the afore-mentioned domains results in a behavioural impact. Attachment relations shape the proto-self and the resulting core self is an output of attachment issues and the core set (contained in the core self). In the mind of the child mental states of other individuals become represented within the neural functioning of the brain, leading to the formation of the core self. The interaction of self with others at a nonverbal, emotional level, through the output of the right hemisphere of both infant and caregiver becomes mapped in the brain at the level of core self. The emerging proto-self takes in the signals from caregivers and maps the changes, leading, together with other factors, to the foundation of the core self. Therefore the core self becomes the second order neural mapping for attachment (first order neural mapping being contained in the proto-self). The proto-self is primarily non-verbal, while the core self is a combination of verbal and nonverbal neural maps. This concept is congruent with what transactional analysis theory describes in terms of scripts (formed primarily at a non-verbal level) and counterscripts (verbal level), with the attachment theory and psychodynamic theories.
Secure attachment, the development of the core self and the integrating role of verbal and non-verbal processing are fundamental for collaborative interpersonal relationships, in the same time involving the process of neural integration. In other words, integration is achieved at both intra- and inter-personal level.
The human brain has both the capacity to differentiate and integrate its functioning, being genetically capable of “connecting to other brains”. The first-order neural maps are contained in the proto-self; the core self consists of second order neural maps, whilst the third-order neural maps of the plastic self are the result of the way the individual interacts with others. Secure attachment leads to coherence between the here-and-now core self and the plastic self. Individuals learn from childhood different adaptive strategies for communicating with others, and these communication patterns are disrupted in the presence of insecure attachment. The neural integration of the processes dominant in the left and the right hemisphere lead to coherence, but for this coherence to occur, the right hemisphere needs to be ‘properly addressed to’ in childhood.
The perception of emotion in an adult creates a resonant emotional state in the infant. The link between the perception of non-verbal cues and brain activation is a mechanism through which the emotional states of two individuals are coordinated. Thus, a relational state and an internal state are simultaneously constructed. Inner experience (the plastic self) is organized in this interactive context.
Although there is very little consensus when it comes to the nature and status of the Self, most psychotherapists agree that the sense of Self is a fundamental feature of human experience. Each major psychotherapeutic orientation describes the Self as a part of a global hologram: accurately but incompletely (Fall, Holden & Marquis, 2010). The integrative strategic model does not mean to claim it manages to capture ‘the entire hologram’, but it takes a step forward toward the understanding of the complex system which is the human mind.
Within this framework, we integrated the particularities of child and adolescent psychotherapy. A major difference in comparison to adult psychotherapy is that many times children cannot verbalize their problems and difficulties. But all children play and playing is an important part of a child’s development. Through playing children learn the abilities they need for participating in their world, and while they play, children improve their knowledge and the understanding of the self, of others and of their physical world.
According to current studies, child psychotherapy needs to take into consideration various approaches in order to obtain the best results. The therapist can use both insight-oriented and problem solving interventions. The therapeutic relationship is facilitated by the fact that the therapist is a playing partner for the children, working with the children, and using a language that is specific for children. By taking part in the game, the therapist is a permissive adult who facilitates the child’s implication at multiple levels. In the same time the child is offered the necessary safety for involvement in the activties and imagery that facilitate therapeutic change.
One of the present dilemmas in child psychotherapy is how much should the therapist get involved in playing with the child. But the therapist’s implication and direction of implication seems to depend on the general theoretical approach.The way in which the therapist uses playing in therapy also depends on the way the therapist conceptualizes the mechanisms of change. Freedheim & Russ (1983, 1992) identify 6 major mechanisms of change in individual child therapy: 1. Expression, catharsis and the labeling of feelings; 2. The corrective emotional experience; 3. Insight, non-experience and working with the game, labeling feelings, thoughts and events, and interpretation for conflict resolution and working with the problem; 4. Problem solving techniques and coping strategies; 5. Object relations, internal representations and interpersonal development: probably the most important aspect is the therapist’s relationship with the child; 6. Non-specific variables: expectancy for change, and the child’s feeling that he/she is not alone.
Our integrative programme centres on the child’s thoughts, fantasies and his/her environment; it ensures a strategy for developing more adaptive thoughts and behaviours (the child is taught coping strategies for feelings and situations); it is structured in a directive manner and it is goal oriented, more than having an open ending; the program incorporates some empirically demonstrated interventions (i.e. modelling); and it allows for the empirical examination of the treatment. This conceptual frame also has common ground with the more traditional person centred and psychodynamic approaches, namely: the importance of the therapeutic relationship, communication through playing, therapy as a safe place and playing as a means for giving clues to the child. Technically speaking, our program is close to supportive psychotherapy, the main techniques used in the program being focused on problem solving strategies, alternate ways of perceiving the self and the situation, acknowledging available help and establishing a therapeutic relationship based on trust, coping strategies and solving immediate problems.
In addition, we take into account the fact that the child’s problem doesn’t exist in isolation, but emerges in the context of family dynamics which can cause, maintain or modify the child’s behavioural patterns. Consequently, the therapeutic approach is centred not only on the child, but also on the interpersonal relations and family transactions.
TRAINING CURRICULA- CHILD AND ADOLESCENT PSYCHOTHERAPY
Our training programme, with a duration of 2 and a half years, is designed for psychotherapists who wish to specialize in child and adolescent psychotherapy.
UNIT 1. Prenatal development and birth. Neurobiology
1. From conception to birth: 1.1. The zygote; 1.2. The embryo; 1.3. The fetus. 2. The prenatal development of the brain (2.1. The genome, the epigenome and brain development; 2.2. Environmental influences on the prenatal development of the brain; 2.3. The neurobehavioural development of the human fetus); 3. The fetal experience; 4. Potential problems in prenatal development; 5. The perinatal environment (5.1. The birth process; 5.2. The baby’s experience; 5.3. The social environment surrounding birth).
UNIT 2. Child development
1. Biological foundations of development (1.1. Hereditary influences on development; 1.2. Hereditary disorders; 1.3. Hereditary influences on behaviour); 2. Cognitive development (2.1. Piaget’s theory; 2.2. Vygotsky’s sociocultural perspective; 2.3. Information-processing perespectives; 2.4. Intelligence; 2.5. Development of language and communication skills; 2.6. Meta-cognition. The theory of mind); 3. Social and personality development (3.1. Emotional development; 3.2. Attachment; 3.3. Development of the self concept; 3.4. Sex differences and gender role development; 3.5. Aggression, altruism and moral development); 4. The context of development (4.1. The family; 4.2. Peers, schools and technology)
UNIT 3. Adolescent development
1. Biological changes associated with puberty (1.1. Hormonal changes; 1.2. Brain development in adolescence; 1.3. Physical growth and transformation); 2. Moral developmentin adolescence (2.1. Kohlberg’s theory of moral development; 2.2. The nature of morality; 2.3. The construction of morality); 3. Identitiy formation (3.1. Erikson’s theory of identity formation; 3.2. The nature of identity; 3.3. The construction of identity); 4. Social changes associated with adolescence (4.1. Friendships and peer groups; 4.2. Changes in family relations; 4.3. School transitions); 5. Cognitive development in adolescence; 6. Emotional and personality development in adolescence; 7. Dating and sex; 8. Employment in adolescence; 9. Positive behaviours, problem behaviours and resiliency in adolescence
UNIT 4. The integrative strategic model in working with children and adolescents
1. The fundamental principles of the integrative strategic model; 2. The therapeutic alliance and the therapeutic relationship in working with children and adolescents (2.1. Building the therapeutic alliance; 2.2. Developing the therapeutic relationship; 2.3. Therapist variables; 2.4. Modalities of the therapeutic relationship); 3. The model of the Self in integrative strategic psychotherapy and its relationship with the Self in main therapeutic orientations (3.1. The Self in integrative strategic psychotherapy; 3.2. The Self in psychodynamic models; 3.3. The Self in cognitive-behavioural models; 3.4. The Self in humanistic- existential models); 4. The neurobiology of the Self and attachment theory; 5. The six psychological axes; 6. Diagnosis on the psychological axes
UNIT 5. Clinical assessment in working with children and adolescents
1. The initial assessment of the child (1.1. Information obtained from parents; 1.2. Information from collateral sources (i.e. school); 1.3. The initial interview; 1.4. The assessment of child/adolescent development and functioning); 2. Diagnostic and assessment methods (2.1. Parent/teacher questionnaires and parent assessment; 2.2. Child/adolescent questionnaires; 2.3. The use of drawing in the assessment process; 2.4. Projective tests; 2.5. Behavioural assessment; 2.6. Cognitive assessment; 2.7. Observation of child play; 2.8. Family interactions; 2.9. Social abilities; 2.10. Considerations regarding the clinical assessment of adolescents); 3. School assessment; 4. Neurobiological assessment; 5. Infant assessment; 6. Report writing
UNIT 6. Causes and mechanisms of problem development
1. Personal predisposing factors; 2. Personal maintaining factors; 3. Contextual predisposing factors; 4. Contextual maintaining factors; 5. Precipitating factors; 6. Protective factors
UNIT 7. Pathology in infancy and early childhood
1. Sleep problems; 2. Toileting problems; 3. Learning and communication difficulties; 4. Autism and pervasive developmental disorders
UNIT 8. Pathology of middle childhood
1. Conduct problems; 2. Attention and overactivity problems; 3. Fear and anxiety problems; 4. Repetition problems; 5. Somatic problems
UNIT 9. Pathology in adolescence
1. Drug abuse; 2. Mood problems; 3. Anorexia and bulimia nervosa; 4. Schizophrenia
UNIT 10. Child abuse
1. Physical abuse; 2. Emotional abuse and neglect; 3. Sexual abuse
UNIT 11. Major life transitions
1. Foster care (1.1. Epidemiology; 1.2. Attachment disruption; 1.3. The decision to make a foster placement; 1.4. The transition to foster care; 1.5. Adjustment to foster care; 1.6. Assessment; 1.7. Principles of practice; 1.8. Treatment foster care; 1.9. Permanency planning); 2. Separation and divorce (2.1. Epidemiology; 2.2. Reasons for divorce; 2.3. Effects on parents; 2.4. Effects on children; 2.5. Developmental stages of family transformation; 2.6. Step-parents; 2.7. Therapy programmes; 2.8. Child custody evaluations); 3. Grief and bereavement
UNIT 12. Play therapy
1. The meaning of play for the child; 2. Approaches to play therapy (2.1. Psychoanalytic approaches to play therapy; 2.2. Humanistic models; 2.3. Systemic models; 2.4. Group play therapy; 2.5. Solution-focused play therapy; 2.6. Cognitive- behavioural play therapy; 2.7. Narrative play therapy; 2.8. Integrative play therapy); 3. Characteristics of play therapy; 4. Play therapy techniques; 5. Play therapy with adolescents
UNIT 13. Expressive arts therapy for children and adolescents
1. Art versus language; 2. Art-therapy as a container; 3. The therapeutic process in art-therapy; 4. Approaches in child and adolescent art-therapy; 5. The integrative approach in art-therapy; 6. Facilitating artistic expression; 7. Assessment and the decoding of symbolic messages; 8. Music therapy in child and adolescent psychotherapy
UNIT 14. Narratives and life scripts in child and adolescent psychotherapy
1. The child’s model of the world (1.1. Internal working models and the child’s model of the world; 1.2. Life script and counterscript); 2. Child and adolescent narratives (2.1. Narratives and fantasy; 2.2. Children’s narrative perspectives; 2.3. The neurobiology of narratives; 2.4. Narratives of trauma; 2.5. Developmental narratives; 2.6. Successful narratives) 3. Narrative techniques in child and adolescent psychotherapy
UNIT 15. Clinical hypnosis in child and adolescent psychotherapy
1. Developmental considerations; 2. Suggestibility and hypnotizability in children and adolescents; 3. Specific induction methods for children and adolescents; 4. Trance deepening techniques; 5. Hypnoanalytic techniques; 6. Self-hypnosis; 7. Clinical applications of child and adolescent hypnosis
UNIT 16. Cognitive-behavioural therapy for children and adolescents
1. Case conceptualization and treatment planning; 2. Session structure; 3. Introducing the treatment model and identifying problems; 4. Identifying and connecting feelings and thoughts; 5. The Socratic dialogue; 6. Cognitive and behavioural techniques in working with children and adolescents; 7. Working with CBT
UNIT 17. Family therapy
1. The principles of systems theory; 2. The cycle of family life; 3. Bowen family systems therapy; 4. Experiential family therapy; 5. Structural family therapy; 6. Psychoanalytic family therapy; 7. Cognitive-behavioural family therapy; 8. Solution-focused family therapy; 9. Integrative models of family therapy; 10. The parents and the child’s mental health
UNIT 18. School and community. Ethical issues
1. The effect of culture and ethnicity on children and adolescents; 2. The child in school; 3. The development of the child’s social abilities; 4. Preparing children and adolescents to become adults; 5. Psychotherapist and school cooperation; 6. Child protection; 7. Ethical issues regarding research in child and adolescent psychotherapy.
Personal development
Personal development is centered, on the one hand, on the development of communication abilities, relational abilities and self-reflection, and on the other hand on self-discovery, so that the trainees discover the way in which their personal history helps or constraints their professional tasks, and their own responses to professional dilemmas.
Taking into account the level of personal development needed in working with children, entry in the training programme is conditioned by at least 25 hours of personal therapy, in addition to the 250 hours of group personal development.
Supervision
Supervision focuses on consolidating the integration of theory and practice and the development of a professional attitude. Supervisees can have an insight regarding their own clinical activity and they have the opportunity of discovering what they already do well and what they might improve or replace.
Supervision implies respect for the supervisee’s knowledge and experience and emphasizes the way in which the supervisee’s experience is relevant in his/her current professional practice.
Supervision is provided by ACCPI supervisors.
Within the child psychotherapy training programme psychotherapists are required a minimum of 100 hours of supervision.