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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DEVELOPMENT OF A PSYCHOTHERAPEUTIC APPROACH

The development of treatments requires knowledge of the factors related to onset, course, and recurrence. Cognitive-behavioral treatments for depression and anxiety reflect the putative role that dysfunctional cognitions play in the onset of these conditions (Brent, Kolko, Allan, & Brown 1990; Garber & Hilsman, 1992; Kendall, 1994 Kendall, Korto lauder, Chansky, & Brady, 1992). Family treatments have been recommended for externalizing and internalizing disorders because of the association of family discord, lack of support, and poor parent-child communication with these conditions (Asarnow & Bates, 1988; Asarnow, Carlson, & Guthrie, 1987; Asarnow, Goldstein, Thompson, & Guthrie, 1993; Asarnow, Thompson, Hamilton, Goldstein & Guthrie, 1994; Diamond, Serrano, Dickey, & Sonis, 1996; Patterson, 1982; Puig-Antich et al., 1985; Rutter & Quinton, 1984). Given the multifactional nature of serious antisocial disorders, a broader multisystemic approach has been recommended (Coie et al., 1993; Henggeler et al., 1995).

USE OF TREATMENT IN TESTS OF THEORIES OF ETIOLOGY

As can be noted from our survey of the literature, treatment studies infrequently allow for the possibility of drawing causal inferences about the role of mediating variables. Figure 2 shows a schema for integrating treatment development and a testing model of etiology. For example, both CBT and family therapy could be chosen on the basis of empirical work suggesting cognitive and family domains as critical ones to target for the treatment of youthful depression. Assessment of domains that are purportedly targeted by CBT (e.g., hopelessness, cognitive distortion) or by family therapy (marital conflict, parent-child conflict, support) could be incorporated into baseline, midtreatment, and posttreatment assessments, allowing for the potential examination of specific treatment effects on cognitive or family variables and the subsequent mediation of overall outcomes.

It is important to emphasize that efficacy can be demonstrated without knowing etiology, and that the identification of effective treatments and even mediators of treatment does not necessarily identify the original causes of the treated condition. Treatments may be efficacious even if they do not address etiological factors. For example, cognitive-behavioral treatments, despite being of demonstrated efficacy on adjustment, show a low correlation between alteration in cognitions and in behavior change (Durlak et al., 1991).

CONCLUSIONS

The adult psychotherapy literature strongly supports the central role of the therapeutic relationship and therapeutic empathy in mediating the efficacy of treatment across many treatment models and psychopathological conditions. Surprisingly little attention has been paid to these factors in the treatment of child and adolescent disorders, and, on the basis of the adult psychotherapy research experience, it is important to gather data on so-called "nonspecific" or relationship aspects of treatment. Likewise, studies examining the mediation of treatment by impact on specific domains are few. The importance of assessment and targeting, when appropriate, contextual and developmental factors is emphasized, and the integration of assessment of biological variables into studies of psychotherapy is recommended. Treatment studies can be derived from theoretical models of psychopathology, but can be designed so as to shape and modify these models. Ideally, treatment studies should gather data that can be informative about the impact of putative mediating and moderating variables on outcome and course, so that the results can aid in further modification and improvement in treatments for children and adolescents.