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Psychotherapy: definitions, mechanisms of action, and relationship to etiological models

Journal of Abnormal Child Psychology, Feb, 1998 by David A. Brent, David J. Kolko

In this paper, several definitions of psychotherapy are offered, and some potential mechanisms of action of psychotherapy are delineated. The use of theories of etiology in the development of psychotherapeutic approaches is described, and the application of clinical trials to test theories of etiology and to modify treatments are advocated. Examples to illustrate these issues in psychotherapy research are presented from the literature. Strategies to further psychotherapy research in youthful populations are recommended.

DEFINITIONS OF PSYCHOTHERAPY

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Frank (1973) has defined psychotherapy as a "type of social influence exerted by a trained and socially sanctioned healer on a person or persons who suffer and are seeking relief, through a series of defined contacts." Winnicott's (1971) whimsical definition of psychotherapy as "two people playing together" recognizes the shared nature of effective psychotherapy. Another definition of psychotherapy that captures some of the same elements is Butler and Strupp's (1986) "systematic use of a human relationship for therapeutic purposes." One additional definition is offered by the authors: Psychotherapy is a modality of treatment in which the therapist and patient(s) work together to ameliorate psychopathological conditions and functional impairment through focus on (1) the therapeutic relationship; (2) the patient's attitudes, thoughts, affect, and behavior; and (3) social context and development.

The third set of domains, social context and development, are particularly salient for research in child and adolescent psychotherapy (Kazdin, 1991; Kovacs & Lohr, 1995; Tolan, Guerra, & Kendall, 1995). Contextual domains include parental psychopathology, family interaction, school, peers, neighborhood, and service system, and each of these components can contribute a substantial amount of the variance to outcome. Treatment must be framed in developmental terms, because children and adolescents vary tremendously as a function of development, namely, in social skills, cognitive capabilities, social expectations, and role in the family. Developmental differences may influence the format, acceptability, and focus of treatment. For example, a cognitive-behavioral intervention for a child needs to be much more concrete than one for a high school student. The developmental needs and abilities of the child with respect to autonomy or dependence on parents may mediate the acceptability and outcome of individual versus family therapy. Adolescents have much greater freedom to select their own environments and peer groups, which in turn can be important foci for treatment.

POSSIBLE MECHANISMS OF ACTION OF PSYCHOTHERAPY

Figure 1 shows a schema of how psychotherapy may act, with the potential mechanisms of actions of therapy mediated or moderated through the therapeutic relationship, the patients' attitudes and thoughts, affect, skills and behavior, developmental factors, and contextual issues. Each of these domains is discussed below.

Relationship

The contribution of therapeutic empathy and a good working alliance to positive clinical outcome has been demonstrated in several clinical trials of adult patients (Burns & Nolen-Hoeksema, 1992; Cooley & Lajoy, 1980; Luborsky, McLellan, Woody, O'Brien, & Auerbach, 1985; Murphy, Simons, Wetzel, & Lustman, 1984). Although these effects are often referred to as "nonspecific," in reality, the cultivation of a helping alliance involves very specific tasks, including the enhancement of patient involvement, good interpersonal relationship skills, and a consistent therapeutic orientation (Lafferty, Beutler, & Crago, 1989; Luborsky et al., 1985). Frank (1973) has posited that the reversal of demoralization is one common active ingredient in all psychotherapies. From the patients' points of view, provision of support, understanding, and advice have been reported as most critical to good outcome (Cooley & Lajoy, 1980; Murphy et al., 1984). There appears to be a reciprocal relationship between therapist and patient behavior in both good and poor outcome psychotherapy. According to Henry, Schacht, and Strupp (1986), in "good outcome" therapy, the therapist is described as "helping and protecting, affirming and understanding," whereas the patient is seen as "disclosing and expressing." In "poor outcome" psychotherapy, the therapist tends to be "blaming and belittling," whereas the patient is depicted as "walling off and avoiding." Not surprisingly, therapists tend to attribute success to technique, whereas patients attribute a good outcome to the therapist's support and understanding (Feifel & Eells, 1963; Mathews, Johnson, Shaw, & Geller, 1974). Despite the very strong evidence in the literature of the importance of empathy and therapist effects on outcome, this has not been examined systematically in child and adolescent psychotherapy studies, perhaps because "little glory is derived from showing that the particular method one has mastered with so much effort is indistinguishable from other methods in its effects" (Frank, 1976).

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Psychotherapy: definitions, mechanisms of action, and relationship to etiological models

Journal of Abnormal Child Psychology, Feb, 1998 by David A. Brent, David J. Kolko

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