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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Nevertheless, comparison between active cognitive or behavioral versus a supportive or more nonspecific treatments have resulted in superiority in the "active treatment," indicating that a supportive relationship may be necessary, but not sufficient, to treat clinically referred child and adolescent patients (Alexander & Parsons, 1973; Cohen & Mannarino, 1996; Kazdin, Esveldt-Dawson, French, & Unis, 1987; Wood, Harrington, & Moore, 1996).

Attitudes and Thoughts

Problem-solving skills training (PSST) attempts to ameliorate deficient problem-solving skills found in many youths prone to aggression (Dodge, Price, Bachorowski, & Newman, 1990; Dodge & Somberg, 1987; Kendall Ronan, & Epps, 1991). While PSST has some evidence to support its efficacy, data are not available to show that changes in specific skills or attitudes mediate behavior changes (Kazdin, 1996).

Studies of cognitive-behavioral treatment in depression and anxiety (Barrett, Dadds, & Rapee, 1996; Kendall, 1994; Lewinsohn & Clarke, 1990) have not assessed the extent to which behavioral changes are mediated by cognitive changes. A meta-analysis of cognitive-behavioral treatment outcome studies in disruptive children and adolescents found changes in cognition and targeted behavior in treatment were not significantly correlated (r = -.22; Durlak, Fuhrman & Lampman, 1991). These results are consistent with the dismantling strategy of Jacobson et al. (1996) in depressed adults, in which the behavioral activation component of cognitive-behavioral therapy (CBT) was as effective as the entire CBT package, calling into question the specificity with which CBT is associated with change in dysfunctional attitudes. Furthermore, a study comparing pharmacotherapy and CBT in depressed adults demonstrated equivalent change with respect to automatic thoughts, indicating that change may be secondary to the relief of depression rather than the cause (Simons, Garfield, & Murphy, 1984).

Regulation of Affect

Relatively little work has been done on the role of the regulation of affect in child and adolescent psychotherapy. Kendall (1994) used stability of affect in the face of an anxiogenic situation (public speaking) to assess therapeutic progress. Kovacs and Bastiaens (1995) conceptualized ability to monitor and stabilize affect as a key to the etiopathogenesis and treatment of early-onset affective illness, and Rotheram (1987) advocated the use of affective regulation to assess and stabilize suicidal youths, but such interventions have not been rigorously evaluated. Regulation of anger is an important component of treatment for disruptive disorders (Feindler, Ector, Kingsley, & Dubey, 1986), and for children who have suffered physical abuse (Whiteman, Fanshel, & Grundy, 1987).

Skills and Behavior

Most psychodynamic and cognitive approaches make the assumption that behavioral change occurs secondary to "deeper" changes that are more specific to the nature of either kind of treatment. However, many treatments do target behavior directly, whether through individual, dyadic, or family settings. Results from these collective studies suggest general improvements across dimensions of child dysfunction (Weisz, Donenberg, Han, & Kauneckis, 1995), especially among cognitive-behavioral applications (Kendall & Panichelli-Mindel, 1995). A recent meta-analysis evaluated the efficacy of social competence training (SCT) for various treatment modalities, outcome variables, and client characteristics (Beelmann, Pfingsten, & Losel, 1994). Overall, SCT was moderately effective, with an overall weighted effect size (ES = .47). Greater effects were found for specific social-cognitive skills (ES = .77) than for social interaction skills (ES = .34) or social adjustment (ES = .18), suggesting that improvement in skills does not necessarily result in improvement in functioning. Similarly, an interpersonal problem-solving skills intervention for young adult suicide attempters resulted in improvements of problem-solving skills, but not in suicidality (McLeavey, Daly, Ludgate, & Murray, 1994).