Psychotherapies

Psychotherapies are commonly used therapies for children and young people. They can help children and families understand and resolve problems, change their behaviour and change the way they think and feel about their experiences.

Cognitive Behavioural Therapy (CBT) can be used to successfully treat depression, anxiety disorders, some eating disorders and obsessive compulsive disorder.

Mindfulness involves paying attention to thoughts and feelings to become more aware of them, less caught up in them, and better able to manage them. Emerging evidence suggests it may be a useful strategy for reducing stress and anxiety, improving mood and enhancing relationships. It’s often delivered as a school-based intervention.

During mentalization-based treatment children and young people work directly with a therapist to improve their ability to recognise thoughts and feelings, and then to explore and examine them to see if they’re valid. It’s used as a treatment for self-harm and depression, early development trauma and anxiety.

Interpersonal psychotherapy focuses on relationships with other people and how thoughts, feelings and behaviour are affected by relationships. It can be used as a treatment for mood disorders, such as depression, and eating disorders.

Short-term psychodynamic psychotherapy is a therapeutic process that helps children and young people think and talk about how they feel about themselves and others. It can be helpful for treating a wide range of conditions and disorders, including anxiety and depression.

Family therapy focuses on improving the way the family works as a whole, and has evidence for effectiveness in anorexia and substance misuse.

  • Introduction

    There are several different types of psychotherapies but, in essence, they are ‘talking treatments’ that involve therapeutic conversations and interactions between a therapist and a child or family. This kind of therapeutic intervention can help children and families understand and resolve problems and change their behaviour. Many are relationship based treatments, which aim to either improve a child or young person’s relationships, or use their relationships as the mechanism by which they are delivered (Green 2015).

    Cognitive Behavioural Therapy (CBT)

    Cognitive behavioural therapy (CBT) is one of the most extensively researched forms of psychotherapy. It’s a collaborative treatment that can be delivered in various formats – one to one with a child or adolescent, in a group or with parents or family.

    CBT has been used to treat several different mental health conditions in children and young people, including depression, post-traumatic stress disorder, anxiety disorders, eating disorders, and obsessive compulsive disorder. CBT can help children to recognise their feelings and the bodily sensations that go with them, clarify their thoughts, develop coping skills and explore whether doing these things makes a difference (James 2015).

    Mindfulness

    Mindfulness is a mind-body based approach that helps people change the way they think and feel about their experiences and, in particular, stressful experiences. It involves paying attention to thoughts and feelings to become more aware of them, less caught up in them, and better able to manage them (MHF, 2015).

    Mindfulness approaches have been used in the treatment and support of a wide range of mental and physical health problems. Some mindfulness programmes have achieved significant reductions in symptoms and relapse rates in mental ill health (MHF, 2015).

    Mentalization based treatment (MBT)

    MBT is based on the concept that some people, for example those with attachment difficulties or borderline personality disorder, have a poor capacity to mentalise. In children and young people, it has been used as a treatment for self-harm and depression, early development trauma and anxiety.

    Mentalisation is the ability to think about thinking; to examine thoughts and beliefs and decide whether they’re useful and realistic (Green 2015). It’s about the ability to “step back” from potentially harmful thoughts and urges and to understand the thinking behind them. This extends to understanding other people’s thoughts, emotions, beliefs, wishes and needs.

    During MBT children and young people work directly with a therapist to improve their ability to recognise thoughts and feelings, and then to explore and examine them to see if they’re valid (Green 2015). This can help children and young people to resist impulses and choose a different way to behave.

    MBT can be a short or long-term intervention, and can be used with families as well as individual children (Muller & Midgely, 2015).

    Interpersonal psychotherapy

    Interpersonal psychotherapy focuses on relationships with other people. It helps people to explore how their thoughts, feelings and behaviour are affected by relationships, and how they in turn affect their relationships with others (Green, 2015). It can help children and young people, and their families, to find out how to strengthen their relationships and find better ways of coping.

    Interpersonal psychotherapy is time limited and runs for up to 16 weekly sessions. It can be used as a treatment for mood disorders, such as depression, and eating disorders.

    Short term psychodynamic psychotherapy (STPP)

    Psychodynamic psychotherapy is a therapeutic process which helps children and young people think and talk about how they feel about themselves and others. During a session, a therapist may help a child talk about what’s happening to them now and what’s happened in the past, and then help them to make connections between the two. This type of therapy also focuses on the unconscious mind and the things that we do without thinking.

    In children and young people, psychodynamic psychotherapy is a treatment for a wide range of conditions and disorders, including anxiety and depression, conduct disorders and early developmental trauma and abuse (Midgley & Kennedy, 2011). Short term means the intervention lasts for up to 40 sessions.

    Family therapy

    Family therapy focuses on changing the interactions between or among family members, with the aim of improving the way the family works as a whole, or the way that individual members of the family work (Bjornstad 2005).

    There are quite a few different types of family therapy, but all are designed to help people make sense of difficult situations, and work together to develop new ways of thinking about and managing these difficulties.

  • What we know already

    Cognitive Behavioural Therapy (CBT)

    A recent review of 36 meta-analyses looking at the impact of CBT in children and young people found that, overall, it was effective for reducing the symptoms of anxiety, depression and post-traumatic stress disorder (PTSD) (Crowe & McKay, 2017). The effects of having CBT as a treatment for these conditions was greater when it was compared to having no treatment, than when compared with other types of treatment (usually another form of psychotherapy) (Crowe & McKay, 2017).

    Compared to having no treatment, CBT improves the symptoms of anxiety as well as its remission, and it’s likely to be more effective at doing that than some medications, such as fluoxetine and sertraline (Whang 2017). Taking sertraline and having CBT alongside it may also be more effective than having either treatment on its own (Whang 2017).

    Self-help books and other active therapies may be as effective for anxiety as CBT (James 2015).

    For children and young people with Autistic Spectrum Disorder (ASD), specifically designed group and one to one CBT interventions may be effective at reducing anxiety (Reaven, 2012).

    Cognitive-behaviour therapy, often with exposure with response prevention, may be an effective treatment for Obsessive Compulsive Disorder (OCD) in children and adolescents (Krebs and Heyman, 2015). Exposure with response prevention is when a young person gradually confronts their feared and holds back from carrying out compulsions such as, handwashing (Krebs and Heyman, 2015). This helps to reduce their anxiety.

    A specific manual-based form of cognitive behavioural therapy (CBT) has been developed for treating bulimia and other common related syndromes, such as binge eating disorder. There is a small amount of evidence that CBT for bulimia nervosa and similar syndromes works, but the quality of evidence is variable and sample sizes are often small (Hay et al, 2009).

    Family therapy

    Family therapy is a common treatment for young people with anorexia nervosa. The evidence suggests that, overall, family therapy may be effective compared to usual treatment (Fisher 2010). However, research also indicates that if families have therapy separately (ie parents and young person see someone separately) it may be more effective than having therapy together (Le Grange et al, 2016).

    There is evidence for the effectiveness of family therapy for substance use in young people, compared to other treatments such as cognitive behavioural therapy (CBT), group therapy and motivational enhancement therapy (MET) (Tanner-Smith et al., 2013).

    Mindfulness

    There is not as much mindfulness research with children and young people as there is for adults, and some of the studies include small numbers and have other limitations, so conclusions are tentative and further research is needed. However, the limited research so far suggests that mindfulness may be beneficial for children and young people with:

    • Attention Deficit Hyperactivity Disorder (ADHD) symptoms (Van der Oord et al., 2012; Weijer-Bergsma et al., 2012)
    • Anxiety (Crowley, 2017)
    • Depressive symptoms (Zenner, 2014)

    Mindfulness may also support young people’s mental health more broadly, by improving mood and  problem-solving abilities and by enhancing relationships in those with serious mental health concerns (van Vliet 2017)

    Mindfulness-based training in schools is giving promising results, showing some beneficial effects on student’s abilities to deal with stress, develop coping strategies and build resilience (Zenner, 2014)

    Mentalization based treatment

    Research so far indicates that mentalization based treatment may be an effective treatment for self-harm and risk-taking behaviour and depression in adolescents (Ougrin et al, 2015, Rossouw et al, 2012).

    Short term psychodynamic psychotherapy

    There is some evidence to suggest that STPP is effective at treating a wide range of mental health disorders in children and young people, including anxiety, depression, eating disorders and borderline personality disorders (Abbas et al 2013).  However, many of the research studies exploring STPP are small and have methodological issues, which makes it difficult to draw any firm conclusions with confidence (Midgley & Kennedy, 2011).

    Interpersonal psychotherapy

    Interpersonal psychotherapy is currently used as a treatment for moderate to severe depression in children and young people. The 2015 NICE guidance concluded that there is limited evidence to show that it is more effective than standard care or waitlist in increasing the chance of remission and reducing the symptoms of depression (NICE 2015). A 2017 meta-analysis (Pu et al, 2017) supports and strengthens that conclusion, finding that interpersonal psychotherapy was significantly more effective than control conditions at reducing symptoms and improving quality of life for young people.

  • Areas of uncertainty

    Cognitive Behavioural Therapy

    There are several treatment areas where the evidence-base for cognitive behavioural therapy is unclear or insufficient to draw robust conclusions. These include:

    • reducing violence in children and adolescents (Özabacı, 2011)
    • preventing depression (Hetrick, 2016)
    • increased self-awareness and reporting of depressive symptoms in schools (Stallard 2012)
    • computer based CBT programmes for depression and anxiety (Richardson 2010)

    It’s not clear how effective psychotherapies are at treating depression in children and young people, as a treatment on their own or in combination with anti-depressants (Cox et al, 2014). The evidence showing the relative effectiveness of psychological interventions, antidepressant medication and a combination of these is limited and more research is needed (Cox et al, 2014).

    We don’t know whether the improvements made in symptoms immediately after CBT are maintained in the long-term (James 2015). Evidence suggests that any effects of CBT are largely maintained over time for childhood depression, anxiety, and PTSD (Crowe & McKay, 2017). However, research studies have varied widely in their follow up of participants, so we can’t say with any certainty whether the impact of CBT continues in the long-term (Crowe & McKay, 2017).

    We also don’t know the best way to deliver CBT to children and young people; individually, in a group or with or without parental support (Crowe & McKay, 2017). The evidence so far suggests that CBT delivered in any of these ways may be beneficial, but more research is needed (Crowe & McKay, 2017). There’s very little evidence too about the effects of CBT on other areas apart from symptom reduction, such as quality of life and general day to day functioning (Crowe & McKay, 2017).

    Family therapy

    There isn’t evidence to be able to establish whether family therapy offers any advantage over other types of psychological interventions(Fisher, 2010).

    The current evidence base is too diverse and sparse to draw any conclusions about the overall effectiveness of family therapy in the treatment of ASD (Spain 2017) or ADHD (Bjornstad, 2005).

    Mindfulness

    All in all, mindfulness-based interventions in children and young people are promising. However, the diversity of studies causes problems. It’s not clear whether the improvements seen in mental health and well-being are due solely to mindfulness, or what it is specifically about mindfulness practices that makes them effective (Kallapiran, 2015).

    There is also such a wide range of different mindfulness programmes that making comparisons between interventions is challenging. In school based interventions, how a program is accepted and adopted within a particular school context will also influences its effects. (Zennor, 2014)

    Mentalization based treatment

    MBT as a treatment for self-harm shows real promise, particularly because there are few other effective alternatives. However, the research so far is limited and the drop-out rate has sometimes been high (Rossouw et al, 2012).  Larger, longer-term studies are needed to explore the effectiveness of MBT and how it is delivered.

    Short term psychodynamic psychotherapy

    Until relatively recently, there has been little standardisation of STPP, so it has been difficult to compare like with like across research studies (Green 2015). So, we don’t know what it is about STPP that makes it effective and in whom. Some research also indicates that there is a possible ‘sleeper effect’ with STPP, where the benefits emerge sometime after treatment (Green 2015). However, this needs further research to confirm it.

    Interpersonal psychotherapy

    Interpersonal psychotherapy for adolescents with depression has been developed from an adult model and has been relatively under researched compared to other psychotherapies such as CBT. Although interpersonal psychotherapy has showed itself to be promising when tested in academic research settings, we don’t yet know how well it works when translated to a community setting where most young people will be seen and treated (Mufson 2010).

    It’s also unclear whether interpersonal psychotherapy is effective at treating younger children with depression (no studies have been carried out) or whether it reduces the risk of suicide (very few studies have explored this) (Pu et al, 2017)

  • What's in the pipeline?

    CBT isn’t effective for everyone, but at the moment we don’t know who it will work for and who it won’t. There is an ongoing research effort to try and predict what the outcome of CBT as a treatment will be in certain groups of people (McMain 2015). This will help clinicians in practice to prescribe the most appropriate and effective treatment for individual children and young people.

    Schools contribute strongly to risk and resilience factors for mental health, and programmes to promote mental health are among the most effective of school health promotion programmes (Stewart Brown 2006). A large evidence base has been developed stretching back over many years, but there is more in the pipeline looking at:

    • For example, there is an ongoing Cochrane Review exploring the effects of preschool and school-based mindfulness programmes for improving psychosocial health and cognitive functioning in young people aged 3 to 18 years (O’Toole 2017).
    • A programme called the Resilience Programme, based on MBT, is being implemented in schools in five different countries in several populations, including children with ADHD (Bak et al, 2015). The programme is a web-based modular mental health education program that can be used in general mental health promotion as well as in supporting people with mental health problems.
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