Psychotherapy is, in one sense, a simple endeavor. An individual and a clinician meet, and in a trusting and open manner, talk through the patient's concerns with the goal of bringing about changes in the person's thoughts, feelings, or behavior. Psychotherapy can be thought of, then, as learning and change brought about through a supportive relationship. Not all forms of psychotherapy, however, are equally effective in bringing about significant or enduring change in a person's adjustment, and the mechanisms by which psychotherapy leads to emotional, social, and behavioral improvement are not well understood. Moreover, psychotherapy with adolescents differs in a number of substantive ways from psychotherapy with adults. Adolescence is a time of transition. Processes of cognitive, social, emotional, and physical maturation can affect the nature and course of symptoms. It is necessary to adapt our psychotherapeutic approaches in order to assist adolescents in managing such changes. There is a general consensus that it is important to adopt a contextual and developmental perspective for describing, understanding, and treating adolescents.
Our understanding of the developmental psychopathology of both internalizing and externalizing disorders, for example, is rudimentary. It can be difficult, as a consequence, to use this research as a guide for clinical practice. Moreover, our understanding of processes of change in psychotherapy, predictors of response to treatment, and predictors of maintenance of gains are only beginning to emerge. From a practical perspective, it is worth acknowledging that a substantial percentage of adolescents do not benefit from psychotherapy, or do not realize a fully adequate response. Moreover, the generalizabilty of findings and approaches to community practice has not been demonstrated. What works in university research clinics may or may not be effective in community settings.
Although the art and science of psychotherapy with adolescents is of relatively recent origin, rapid progress has been made. Early work on psychotherapy with adolescents was based largely on psychodynamic models (Klein, 1950; Kris, 1952; S. Freud, 1953; Fraiberg, 1955; Geleerd, 1957, 1964; A. Freud, 1958; Blos, 1962, 1970; Friend, 1972; Miller, 1974). Many of the assertions of psychodynamic and psychoanalytic models have not been put to test, leading to something of a stagnation in the evolution of psychoanalytic paradigms for understanding and treating youth. With few exceptions (Moran et al., 1991; Altman, 1995) theoretical and clinical development in this area has been slow during recent years.
Psychodynamic models of psychopathology tend, as a group, to be developmentally based. As Tyson and Tyson (1990) note, development occurs along a number of lines during adolescence. Psychodynamic and psychoanalytic writers traditionally view affective lability during adolescence as stemming from a developmental reorganization in the structures and functions of the ego and superego. Stage-specific defenses are needed, from this perspective, to cope with shifting moods. Changes in mood during adolescence are seen as stemming from the activation of memories of early events (Weinshel, 1970) and the recapitulation of early experiences. This notion, that adolescent development is characterized by a recapitulation, reexamination and reworking of earlier themes and conflicts, is central to many psychoanalytic models. Regression in the service of the ego (Kris, 1952), and struggles to develop a cohesive sense of self, as such, are seen as a normal part of adolescent development, and provide a way of understanding emotional and behavioral distress during this period of development. Psychodynamic theorists have proposed that the development of an adult identity stands as a central task of adolescence (Erikson, 1956).
Alternatives to psychoanalytic developmental models have emerged from several quarters over the last 30 years. Among the most prominent are models based on principles of developmental psychopathology (Cicchetti and Cohen, 1995). Rather than organizing development around phases of psychosexual maturation, these models tend to highlight age-related developmental tasks such as attachment formation, physiological and emotion regulation, mastery and cognitive competence, peer relationship formation, and identity development. From this perspective, each developmental task represents a potential challenge to be negotiated. Successful negotiation of early tasks increases the probability for better adaptation with later tasks. Secure attachment during early childhood, for example, appears to predict later peer competence. However, development is viewed as transactional and open to later influence such that early difficulties do not foreclose on the possibility of subsequent adjustment. The pivotal tasks of adolescence involve changes in physical appearance and sexuality, increased autonomy and involvement with peers, identity formation, and the development of romantic relationships.
In addition, the past few decades have witnessed the emergence of cognitive, behavioral, and family systems approaches for addressing a variety of clinically important concerns among youth (for reviews, see Hibbs and Jensen, 1996; Carr, 2000; Kazdin, 2000; Fonagy et al., 2002; Reinecke et al., 2003). A relatively large number of well-designed outcome studies have been completed, and an impressive body of research has been published examining both factors associated with risk for psychopathology among youth and possible mediators of therapeutic change. As research in developmental psychopathology has expanded, new and often quite specific targets for intervention have emerged. As the methodological quality of outcome and process research has improved a number of empirically supported forms of treatment have been developed. In fact, we can say with some confidence that some forms of psychotherapy may be effective for treating some forms of psychopathology experienced by some adolescents.
Early research into the efficacy of psychotherapy for treating youth borrowed heavily from research with adults. Models, methodologies, instruments, and clinical techniques that had been found useful in clinical outcome research with adults were simply applied to a new sample—children and adolescents. It quickly became apparent, however, that processes mediating the expression of behavioral and emotional difficulties among youth may differ from those of adults. Responding to this challenge, recent research has been more sensitive to developmental differences between children, adolescents, and adults.
As noted, a range of physical, social, cognitive, and emotional changes occur over the course of adolescence. These developmental changes and issues must be considered both when developing a clinical treatment plan, and when designing a clinical research project. Developmental changes include puberty, the emergence of formal operational thought, the emergence of an adult identity, increasing emphasis on relationships with peers, decreasing reliance on parents for guidance and support, the establishment of vocational goals, the emergence of sexual interests, and the consolidation of values, standards, and tacit beliefs.
Puberty, for example, is accompanied by a range of changes, both hormonal and physical (Richards and Petersen, 1987; Richards et al., 1993). The physical transformations that accompany puberty can be confusing, exciting, and challenging. The effects of physical maturation on adjustment during adolescence, however, are complex. Significant individual differences exist in the age of onset of puberty and in the rate at which physical maturation occurs. Moreover, there can be asynchronies in development across physical, social, and emotional domains. The effects of physical maturation on psychosocial development and adaptation appear to be mediated by a number of factors including gender, age of onset of puberty, the relative maturity of peers, and cultural, familial, and community beliefs about maturation. That said, hormonal changes accompanying puberty appear to have broad effects on adolescent development. They have been associated with changes in expression of anger, oppositionality toward parents and other adults, sexual behavior, aggression, mood, self-confidence, and level of psychopathology. It is not clear, however, that relations between physical maturation and adjustment are direct. Rather, the effects of hormonal changes accompanying puberty appear to be mediated and moderated by psychological, familial, and social variables (Richards et al., 1993). The effects of puberty on adjustment are clinically important for a number of reasons. Physical maturation during adolescence has significant effects on the social status of the individual, how they view themselves, how their peers see them, and how they are viewed by their family and the larger community. Others expectations for them will change as they mature. Teenagers who appear mature may not, however, be socially, emotionally, and cognitively mature, leading to confusion and conflict. Moreover, teenagers naturally experience a range of thoughts and feelings about their physical and sexual maturation. Their thoughts, fantasies, and expectations about these changes, and their effects on their life and relationships, are worthy of discussion during psychotherapy. This is particularly important when the teen is dissatisfied with the changes in their appearance or the ways that these changes have affected their relationships with others. Physical maturation, and the social changes that accompany it have important effects on adolescent adjustment and can, as a consequence, complicate the practice of psychotherapy with adolescents.
Developmental changes in reasoning also influence emotional and behavioral adaptation during adolescence. As formal operational thought emerges, for example, adolescents may be better able to reflect upon their experiences and motivations, to develop and evaluate alternative interpretations of events, and to examine critically their beliefs and attitudes. They will, as a consequence of developing hypothetico-deductive reasoning, be better able to use ‘standard’ insight-oriented and cognitive-behavioral interventions. As formal-operational thought emerges, however, it may be applied in an egocentric manner (Elkind, 1967). This may lead adolescents to believe that others are as concerned by their behavior and appearance as they are (an imaginary audience) or that his or her emotions are both unique and significant (the personal fable). This can be accompanied by fluctuations in affect. Egocentric thought during adolescence can be associated with a tendency to personalize events, to magnify their significance, and to misperceive their consequences. Clinically, this can contribute to emotional lability as adolescents believe their emotional experiences are ‘more intense’ than those of their peers. It can also contribute to difficulties trusting others (including the therapist) based on the belief that ‘no one really understands me.’ A central task in cognitive-behavioral psychotherapy (CBT) with adolescents, then, is to assist the individual to recognize these misperceptions and to develop more mature forms of reasoning.
Development of autonomy, a sense of personal efficacy, and an ability to function independently of one's parents and family are central tasks of adolescence. Peer support plays a critical role in accomplishing these tasks. Adolescents’ sensitivity to the norms of their peer culture, as well as a desire for acceptance by their peers, can both assist with the process of becoming independent from ones family, and can lead them to become resistant to the authority of their parents and other adults. Moreover, it can lead them to question the beliefs, attitudes, expectations, and values of their families. Clinically disturbed adolescents may, as a result, show little concern for fitting their actions to the norms of adult society. Not surprisingly, such youth can find it difficult to form a trusting relationship with a therapist. This can be exacerbated by a tendency on the part of parents and adolescents to view their problematic behavior as ‘a normal part of growing up.’ Adolescent oppositionality, resistance, and identification with ‘negative’ aspects of their peer culture may be understood, then, within a developmental context. Difficulties becoming independent from one's parents can also be problematic. Insofar as anxieties and ambivalence about autonomy from one's parents, oppositionality, fluctuating self-image, and challenging of accepted beliefs are, in many ways, normal and adaptive parts of the adolescent experience, it can be difficult for clinicians to discriminate normal, healthy adaptation and problematic behavior. The line between normative development and clinical disturbance is often a thin one. Not all adolescents experience turmoil (most, in fact, are reasonably well-adjusted socially and emotionally), and not all turmoil is maladaptive. How we conceptualize turmoil can have important effects on how we develop clinical formulations and on how we approach treatment (Elmen and Offer, 1993).
Epidemiological and clinic-based studies indicate that a substantial percentage of adolescents manifest significant behavioral and emotional difficulties, and that these problems can have adverse effects on their development and adaptation. Early studies of psychiatric illness among adolescents in community samples indicated that between 10% and 20% of adolescents experience some form of psychiatric illness (Langer et al., 1974; Leslie, 1974; Gould et al., 1981; Offer et al., 1987). Unfortunately, the authors typically reported data on youth between 6 and 18 years of age, so one cannot know the rates among adolescents specifically. The Isle of Wight Study (Rutter et al., 1976), a comprehensive assessment of psychiatric symptoms in a sample of over 2000 14–15 year olds in the UK, indicated that approximately 10–15% of adolescents met criteria for a diagnosable psychiatric illness over the course of a year. More recently, a study of the prevalence of psychopathology among Canadian youth indicated that approximately 18% of 4–16-year-old children and adolescents manifest a psychiatric illness (Offord et al., 1987). Although prevalence rates vary for specific disorders, these findings are quite consistent with other studies in suggesting that, at any given time, a substantial percentage of youth manifest a significant psychiatric difficulty (Costello, 1989). Cross-cultural comparisons of rates of psychopathology among adolescents indicate that there may be differences in rates of psychopathology between countries (Bird et al., 1990; Verhulst and Achenbach, 1995; Bird, 1996).
Taken together, studies indicate that approximately 20% of children and adolescents in the USA manifest a clinically significant behavioral, emotional, or developmental difficulty at any given time. Moreover, a substantially larger percentage of youth manifest social, academic, behavioral, or emotional symptoms that, although not of sufficient duration or severity to warrant a DSM-IV diagnosis, adversely effect their adjustment and development. Many teenagers engage in behaviors (such as drug use, unprotected sex, reckless driving, smoking) that, although not diagnostic in their own right, place them at risk for a range of problems.
Many of these disorders tend to persist over time, placing adolescents at risk for adaptive difficulties during adulthood. The long-term outcomes for depression, attention deficit hyperactivity disorder (ADHD), oppositional-defiant disorder, conduct disorder, substance abuse, and many of the anxiety disorders are not positive. Although symptoms may tend to wax and wane in severity, the majority of children and adolescents do not grow out of their disorder. Depression, for example, tends to be a recurrent disorder that can persist into adulthood (Kovacs et al., 1984, 1997; Harrington et al., 1990; Kovacs, 1996). In a similar manner, children and adolescents with ADHD frequently develop persistent academic and social problems. Approximately 30% of adolescents with ADHD continue to meet criteria for this disorder as adults, with an additional 15–20% demonstrating subclinical symptoms that interfere with social and occupational functioning. Left untreated, the prognosis for adolescents with ADHD is poor (Gittelman et al., 1985; Mannuzza et al., 1993; Weiss and Hechtman, 1993). Although not all children or adolescents who develop oppositional-defiant disorder or conduct disorder follow a common developmental course, these disorders are predictive of a range of difficulties during adulthood. Adolescents with externalizing behavior disorders are at an increased risk, for example, for experiencing marital and relationship difficulties, depression, alcohol and substance abuse, poor occupational functioning, and antisocial or criminal behavior as an adult (Loeber, 1988; Quinton et al., 1990; Offord and Bennett, 1994).
Anxiety disorders are common among adolescents (Kashani and Orvaschel, 1988, 1990). Community surveys indicate that between 10% and 18% of nonreferred youth manifest an anxiety disorder at any given time (Kashani and Orvaschel, 1988; McGee et al., 1990). Obsessive-compulsive disorder, for example, is relatively common, occurring in approximately 1 in 200 children and adolescents in the USA (Flament et al., 1988; Valleni-Basille et al., 1994). Although it was once believed that these disorders were transient, it is now recognized that they can have a chronic course and that they place individuals at risk for a range of problems during adulthood (Ost, 1987; Burke et al., 1990; Keller et al., 1992; Orvaschel et al., 1995; Last et al., 1996).
Comorbidity refers to the occurrence at one point in time of several psychiatric disorders. Many adolescents who meet diagnostic criteria for one psychiatric disorder simultaneously meet criteria for one or more additional disorders. Kashani et al. (1987), for example, reported that 100% of adolescents in their sample who met criteria for major depression also met criteria for another disorder. As a number of writers have observed, comorbidity appears to be the rule rather than the exception (Kendall and Clarkin, 1992; Reinecke, 1995).
Comorbidity is important for a number of reasons, both conceptual and practical. The co-occurrence of various clinical disorders can, for example, complicate research into the assessment, etiology, and course of individual disorders. Comorbidity also raises questions as to the validity of current taxonomic systems for classifying clinical disorders. Moreover, comorbidity can complicate the treatment process. It appears, for example, that depressed youth with a comorbid psychiatric disorder may be at increased for recurrent depression, show a poorer response to medications, be at an increased risk for social problems, and be at an increased risk for suicidal ideations and attempts. Similarly, adolescents with oppositional defiant disorder or conduct disorder often also manifest difficulties with alcohol or substance abuse, depression, or a learning disability. These conditions can impede therapeutic progress, and typically warrant additional treatment.
Studies suggest that a several forms of psychotherapy can be helpful in treating clinical depression among adolescents (for reviews see Lewinsohn and Clarke, 1999; Moore and Carr, 2000a; Curry, 2001; Fonagy et al., 2002). Two approaches have received the largest amount of empirical interest and enjoy the strongest support: CBT and interpersonal psychotherapy for adolescents (also referred to as IPT-A).
Attempts have been made during recent years to develop standards for identifying treatments that are efficacious for treating clinical disorders (Task Force on Psychological Intervention Guidelines of the APA, 1995; Chambless et al., 1996, 1998; Weisz et al., 2000). Chambless and Hollon (1998) suggest that for a treatment to be identified as ‘efficacious’ it should, at a minimum, have been found to: (1) be superior to no treatment or a placebo, or equivalent or superior to an alternative treatment of documented efficacy, in a randomized controlled trial; (2) that the treatment be described in a manual; and (3) that the studies used an identified population, appropriate measures, and appropriate analyses. If these standards are met in studies completed at two or more independent sites, the treatment protocol is considered ‘well established.’ Attempts to identify evidence-based or empirically supported treatments has proven controversial, and have important implications for both training and clinical practice (Weisz and Hawley, 1998; Chorpita, 2003).
A substantial body of research indicates that CBT can be efficacious for treating depression among adolescents (Birmaher et al., 1996; Harrington et al., 1998; Lewinsohn and Clarke, 1999; Curry, 2001). Controlled outcome studies suggest that both individual and group CBT can be useful in alleviating dysphoria, and that gains may be maintained over time (Lewinsohn et al., 1990; Wood et al., 1996; Brent et al., 1997; Birmaher et al., 2000). A recent meta-analysis indicated that the effect sizes for CBT for depression among adolescents were moderate to large, and that gains were maintained for up to 2 years (Reinecke et al., 1998). The efficacy of CBT for depression during adolescence appears, then, to be well-established (Curry, 2001).
Although differences exist between cognitive-behavioral protocols, they tend to emphasize the development of specific skills that can be helpful for managing depressed affect. Skills addressed include developing a goal list, monitoring one's mood, engaging in pleasant activities, development of social skills, engaging in activities that provide a sense of accomplishment or mastery, relaxation, conflict resolution and negotiation, identification of cognitive distortions or biases, identification of maladaptive thoughts, rational disputation of maladaptive thoughts, and developing realistic counterthoughts. Recently developed ‘modular’ approaches to CBT tailor therapeutic techniques to the specific needs of individual patients (Curry and Reinecke, 2003).
IPT, a form of psychotherapy developed by Gerald Klerman et al. (1984) for treating depressed adults, has been adapted for use with adolescents (Mufson et al., 1993). The approach focuses on addressing common interpersonal difficulties experienced by adolescents, including challenges associated with autonomy from parents, relationships with peers, and managing the loss of significant relationships. Explicit attempts are made to identify interpersonal factors that are associated with the etiology and maintenance of the depressive episode. Information is gathered about the nature and quality of the adolescent's relationships, their expectations for the relationships, whether these expectations are being met, goals for their relationships, and how they have attempted to accomplish these goals. Particular attention is given to separations and losses, conflict, changes in roles, interpersonal deficits (including social withdrawal or isolation, social skills deficits, and social anxiety), and difficulties encountered in single family homes. Active attempts are then made to address difficulties identified in these domains.
Research on ITP-A has, to date, been positive (Mufson et al., 1994, 1999; Rosselló and Bernal, 1999). Completion of a 12-week ITP-A program has been associated with a significant reduction in symptoms of depression, improved social functioning, and an increased rate of remission from the depressive episode. Moreover, gains appear to be maintained over time. Although research is limited, ITP-A is a promising approach for understanding and treating depressed youth. IPT, as such, would be identified as a ‘possibly efficacious’ treatment for depression among adolescents.
Psychodynamic psychotherapy has a long tradition and is widely used in clinical practice. It remains a dominant paradigm for understanding depression in many psychology, psychiatry, and social work training programs. Psychodynamic psychotherapy endeavors to treat depression by providing adolescents with insight into defenses used in coping with the expression of drives, by identifying and rectifying recurrent relationships issues, by addressing feelings of narcissistic injury, or by establishing a more coherent, integrated, and ‘authentic’ sense of self. Psychodynamic psychotherapy typically is nondirective, long term, and focuses upon the expression and interpretation of events within the therapeutic relationship as a means of bringing about clinical improvement.
Although it is widely used, little systematic research has been conducted examining the efficacy of psychodynamic psychotherapy with clinically depressed youth. No randomized controlled trials of these forms of psychotherapy have been published. Individual psychodynamic psychotherapy has not, then, been demonstrated to be an effective treatment for depression among adolescents. That said, preliminary evidence indicates that adolescents who receive intensive psychodynamic psychotherapy may benefit over time. Target and Fonagy (1994a,b), for example, conducted a chart review of 763 youth receiving psychoanalytic psychotherapy. Of the 65 children and adolescents who manifested a depressive disorder, over 80% demonstrated a significant reduction in symptoms at the conclusion of treatment (the average length of treatment was approximately 2 years). Given the lack of a control group and the tendency of depressive episodes to remit spontaneously within 9–12 months, however, one cannot conclude that these interventions were efficacious in alleviating the depressive symptoms. A lack of supportive evidence cannot, of course, be taken as evidence that psychodynamic psychotherapy is ineffective. Insofar as psychodynamic forms of psychotherapy are among the most widely used in clinical practice, it is unfortunate that they have not been put to empirical test. Further research on these models and approaches is urgently needed.
In conclusion, CBT and IPT appear to be effective in alleviating symptoms of depression among youth. Gains achieved appear to be reasonably stable over time. Evidence supporting the efficacy of psychodynamic and psychoanalytic psychotherapy is scant.
Josh Hernandez is a 15-year-old 10th grader of Hispanic-American heritage. He is enrolled in an honors program at a local magnet school. Josh is the younger of two children, and was referred for assessment and treatment by his parents due to depressed mood, a loss of interest in activities and friendships, declining academic performance, and lethargy. Josh's brother, Enrico, is a freshman at a prestigious private university. Josh's father is employed as an advertising executive and his mother is a college professor. Josh's mother noted that ‘he just looks unhappy… and he has a great deal of difficulty getting up in the morning.’ When asked to elaborate, she noted that, despite his ‘enormous potential’, his grades have been declining since the sixth grade. She reported that he doesn't complete his assignments, and that when he does complete his work he often forgets to turn them in. Josh's father noted that he recently failed two courses, and that he ‘seems lonely and isolated.’ He noted that his son has ‘dropped his friendships’ and that he now ‘hangs with an outsider group’ who are ‘less ambitious.’ According to his father, Josh has ‘no goals’ and ‘doesn't seem to have future plans.’ Josh's parents were also concerned by what they viewed as his ‘bizarre’ behavior.’ They reported, for example, that he occasionally walked with a ‘zombie-like’ gait, that he once took a razor blade and a knife to school but ‘didn't know he had them’, and that he had ‘lived in a computer box’ in his room for several months.
Josh acknowledged his parents’ concerns. He agreed that he is ‘doing less of everything’ and that he spends less time with his friends. He attributed this, however, to ‘having less time to do stuff.’ Josh's parents believe that the changes they have seen in their son's mood and behavior may have been related to the death of a maternal uncle several years before. They noted, however, that Josh and his uncle were not close, and that Josh has never spoken of his death. Josh's difficulties were subjectively severe, and were affecting his social and academic functioning. Josh's specific symptoms included:
affective: dysphoria, anhedonia, flat affect
cognitive: indecision, impaired concentration, forgetfulness, absence of goals, low motivation
physiological: hypersomnia, psychomotor retardation, decreased appetite, ‘zombie-like’ carriage, fatigue
behavioral: social withdrawal, poor academic performance, carrying a razor and a knife, living in a cardboard box, quiet speech, long response latencies.
Josh's medical and developmental histories were unremarkable. He was born at term after an ‘easy’ labor. No prenatal or perinatal complications were reported. His mother recalled that he was an ‘active and cuddly’ infant who ‘liked audiences’ and was ‘warm to people.’ During his preschool years he reportedly was ‘very social and willing to share.’ His language, motor, and self-care milestones were age appropriate. Josh's mother stated, however, that he experienced occasional nocturnal enuresis until he was 12 years of age, and that although he talked a lot at home, he ‘was shy in class’ and ‘wouldn't talk readily to his teachers.’
Josh described his relationship with his parents as ‘fine’. When asked to elaborate, he noted that they ‘never argued’ and that ‘the only point of friction is my grades.’ Josh remarked that he was ‘very close’ to his brother, and noted that he misses him now that he is away at college. Josh's father speculated that he may have been ‘intimidated’ by his older brother's academic success. Although Josh agreed that his behavior and mood had changed, and that his grades had declined dramatically during recent years, he did not feel that this represented a problem. As he stated, ‘everything seems all right to me.’ When asked how he felt about his failed courses, the fact that the principal now required him to take summer school, and that he would not be permitted to take driver's education until he achieved a C-average, Josh remarked, ‘it's ok… I don't care… I just don't think about it much.’ Josh noted that, although he was interested in dating, he did not have a girlfriend. He dismissed his classmates as ‘weirdos’ (who participated in school activities, focused upon maintaining their grades, and talked of applying to college). When asked about his comment that he coped with his declining grades by ‘just not thinking about it’, he stated ‘When I'm pressured or worried by things I just ignore them, I just put it out of my mind… I try not to care one way or another.’ Cognitive avoidance, as such, appeared to be an important coping strategy for Josh.
Josh completed a semistructured diagnostic interview and a battery of objective self-report questionnaires as part of our initial evaluation. Reports by Josh and his parents on the K-SADS indicate that he meets DSM-IV criteria for Major Depressive Disorder, Single Episode. There was no evidence of morbid or suicidal ideations, mania, hypomania, oppositionality, conduct disorder, ADHD, alcohol or substance abuse, anxiety, or a developmental disorder. His Children's Global Assessment Scale (CGAS) score was 42.
Interestingly, no significant elevations were apparent in his responses on a battery of objective rating scales. Josh reported, for example, experiencing no distressing thoughts on the Hollon-Kendall Automatic Thoughts Questionnaire, other than the thought that he ‘wished he was somewhere else’ [than therapy]. In a similar manner, no elevations were apparent on the Young-Brown Schema Questionnaire. Josh did, however, note that he ‘sometimes’ worried about school, and that he felt sad, tired, and mad on the Reynolds Adolescent Depression Scale. His responses earned raw scores of 4, 5, and 6 on the Beck Depression Inventory, Anxiety Inventory, and Hopelessness Scale, respectively. These scores are within the normal range and are not consistent with reports by Josh's parents and teachers, or with observations of his behavior. They appear, as such, to underestimate Josh's current distress. This may be because of a tendency to minimize his concerns, or from a lack of reflective self-awareness.
A number of cognitive, behavioral, and social factors appear to contribute to Josh's current difficulties. He comes from a supportive home that is characterized by high levels of motivation and accomplishment. Both of his parents are well-educated professionals, and his older brother appears to have been an academically gifted student. Josh had done quite well academically throughout elementary school, and had, following in his brother's footsteps, been enrolled in the honors program at a magnet school. Josh's difficulties first became apparent during the sixth grade, and became more prominent during his junior high school years. The timing of the changes in his mood and behavior is telling in that these years mark a transition from the relatively supportive and stable culture of elementary school to the challenging culture of junior high school. Biological and social changes during early adolescence can be difficult for many children, as can the increased demands for autonomy and self-organization.
Although Josh has a stable and supportive family, he has few friendships outside of the family. His tendency to withdraw from his childhood friends, at a time when support from peers is becoming more important, appears to have exacerbated his feelings of isolation. His tendency to denigrate them as ‘weirdos’ and to identify with a group of dysphoric, isolated peers who also were experiencing academic difficulties may compound his difficulties. His supports are few, and his current friends appear to model and reinforce his negative views of himself and his future.
Although Josh is a bright, capable young man, he appears to have a low sense of personal control over important outcomes in his life. As a consequence, his desire to actively address academic and social challenges is limited. He doesn't believe that his efforts will do any good. Rather than approaching problems in a thoughtful manner, he seeks to avoid them. His problem-solving motivation and perceptions of self-efficacy, as such, appear to be low.
Josh's identification with a group of peers that lack specific academic or career goals is of particular concern. He has, by spending increasing amounts of time with them, reduced his opportunities for participating in activities that would give him a sense of pleasure, enjoyment, mastery, or competence. He has, in many ways, become an outsider to the larger culture of his high school.
The development of an adult identity and vocational goals is an important task during adolescence. Josh appears to be experiencing difficulty developing goals or plans. When asked, for example, if he ever thought about his future or had fantasies about what he would like to become, he remarked, ‘No, never… I don't even think about what I'll do next weekend… I'll think about that when Saturday morning comes.’ There may, as such, be impediments to Josh developing an adult identity. Self concept during childhood and adolescence develops, at least in part, from a conviction that one is learning tangible skills that will bring about a desired future, and that you are developing into a defined self within a broader social or community context. The adolescent must, at each step, develop a sense of competence—an awareness that his or her personal way of mastering the tasks of life are a successful and accepted variant of the larger group's identity. Adolescents are not fooled by empty praise and false encouragement. They must succeed by their own whole-hearted and tenacious efforts in mastering tasks that are important to them and that are valued by their family and culture. In this regard, Josh's parents admonishments that he has ‘great potential’ and that he will live up to the achievements of his parents and brother are, in the absence of actual accomplishment, hollow. By withdrawing from the social and academic challenges of adolescence, Josh has created an environment in which he feels incapable. The process of developing an adult identity, including social and vocational goals, appears to have broken down.
Josh was seen on 11 occasions over approximately 2 months. This was followed by four booster sessions over 2 months. His parents attended six of these therapy sessions. As in CBT with adults, sessions were problem oriented, active, and collaborative. They were strategic in that a clear and consistent focus was maintained on identifying beliefs, attitudes, attributions, and information processing deficits that may have contributed to Josh's distress, and to developing cognitive and behavioral skills.
Our first tasks were to develop a list of problems or ‘targets’ for therapy that Josh and his parents could agree upon, to develop a cognitive-behavioral formulation of his difficulties that could be shared with him, and to develop his motivation to participate in treatment. Insofar as Josh felt that everything was ‘going all right’ and that he ‘didn't need treatment’, these were not simple tasks. With this in mind, a patient approach, focusing upon encouraging Josh to discuss how he understood his declining grades, feelings of sadness, and social isolation, was adopted. Although he denied feeling depressed, Josh acknowledged that he often felt ‘tired and bored’, that he was ‘upset’ to have received an F in English, and that he was angry at the teacher for giving him that grade. As he stated, ‘it was unjust… I knew the material, I just didn't turn in the work.’ Whereas Josh felt that his parent's goals for treatment (i.e., develop ambition and goals; have more fun; follow-through on school assignments; be proud of his talents) were ‘fine’, his only goal would be to ‘have more fun.’ We accepted this as a reasonable goal that both Josh and his parents could support, and used it as a basis for introducing the cognitive-behavioral techniques of mood-monitoring and pleasant activities scheduling.
We began by asking Josh to make a ‘daily list’ of times when he felt tired, bored, or irritated. He was able to complete this and, although he was not able to identify specific thoughts or concerns at these times, readily acknowledged that his life ‘pretty much is a drag.’ Overcoming these feelings was, for Josh, a goal he could accept. Using this as a point of departure, we discussed at some length how his thoughts and behaviors may have contributed to his feelings of boredom and irritation, and how, if he had ‘interesting, fun, or challenging things to do’ his life might not be so boring. With some encouragement, Josh noted that he might be interested in trying out for a community play (he'd done well in several school productions in the past), that he was interested in designing a costume for Halloween, and that he might be interested in working to earn money to purchase video games. Using these goals as a foundation, several principles were discussed—the importance of having a clear objective, of ‘persisting when the going got tough’, of breaking tasks into their component parts, and of approaching problems in a flexible manner. By using goals that the teenager can accept, principles of CBT for depression among adults can be adapted for use with youth.
Although Josh did not consistently complete his cognitive homework assignments, he noted that his mood had improved when he attempted them. This was used to motivate further efforts on his part. After 4 weeks of therapy, Josh's depression scores had declined. His parents and teacher's noted the improvement in his mood, and his grade in physics had improved from an F to a C. When asked how he accomplished this, he noted that ‘I worked hard, I did a lot of work… I got a list of the work that was missing, did it all, and turned it in.’ This improvement was quite gratifying to Josh. During this time he also began participating in enjoyable activities (such as going out with friends, going to the movies with his parents, and watching boxing on cable TV) on a regular basis. Simplified forms of standard cognitive-behavioral interventions (i.e., mood monitoring, rational problem solving, and mastery-pleasure scheduling) were effective in improving his mood and in providing Josh with an enhanced sense of personal efficacy. As he noted, however, he still had ‘a feeling that something's not right… I don't know what… it's a bad intuition.’ This comment became a point of departure for us to introduce cognitively based techniques.
Josh's tendency to avoid thinking about distressing events in his life remained problematic. He experienced a great deal of difficulty reflecting upon his thoughts, feelings, and motivations, and so was unable to complete standard Dysfunctional Thought Records (DTRs) or ‘three column’ exercises. He also was unable to speculate as to what others might think when confronted with problems. Although his parents noted that he could be kind, they observed that Josh was not an empathic or sensitive young man. His rational problem-solving skills and ability to empathize with others were poorly developed, and he did not see how his thoughts might influence his emotional reactions to events. This process of cognitive avoidance was, for Josh, an active one. When asked, for example, to ‘think about what went through your head the moment you learned you got the F in English’, Josh turned away from the therapist and refused to respond.
We approached this difficulty obliquely, by discussing how other teenagers might solve problems in their lives. Rather than addressing his academic and social difficulties, we discussed vignettes—common problems that many teenagers might encounter. Based upon work on rational problem-solving and problem-solving motivation, we discussed how teenagers might react if they had scratched their father's car, and if they had been encouraged by friends to shoplift in a mall. A multistep problem-solving strategy was developed. Specific steps included: (1) Relax; (2) Identify the problem; (3) Brainstorm various solutions; (4) Evaluate them, look at positive and negative consequences, look at both short- and long-term effects; (5) Say ‘Yes’ to one; (6) Evaluate whether it works. Although we intentionally had not discussed events in his life, Josh was open to use this RIBEYE approach, noting that it ‘sounded sensible’ to him.
The following week Josh remarked that he now had a goal—he wanted to look for a summer job. Given his long-standing lack of motivation and difficulty developing a vision of his future, this was a positive development. Applying the problem-solving strategies we had developed the week before, Josh developed a four-step plan for finding work. He noted that he planned to walk into neighborhood stores and talk with the managers, search for jobs on-line, check the classified ads, and talk with contacts recommended by his parents. Within a week he had found a job assembling sets for a local theatre company.
Given our success in developing Josh's rational problem-solving skills, and using them with situations that were not ‘emotionally laden’, we next began to explore maladaptive thoughts that may have contributed to his academic difficulties. Using a standard ‘three column technique’, Josh observed that he experienced a number of negative automatic thoughts when asked to complete tasks at school. These included, ‘There's nothing I can do about this’, ‘How long do I have to endure this [work]’, ‘I don't know if I can do this’, and ‘This is going to get worse.’ These thoughts were accompanied by a significant increase in feelings of anxiety. As Josh remarked, ‘I start to feel really pressured and worried… it goes from 25% up to 100%.’ He was able to recognize, as well, that his subsequent attempts to ‘put it out of my mind’ served to reduce his feelings of anxiety. As he stated, ‘as soon as I ignore it, the feelings drop down to 0 to 10%’. Josh's cognitive avoidance, as such, appeared to serve an adaptive function.
During subsequent sessions we focused upon encouraging Josh to openly experience and express his feelings of anxiety, sadness, worry, and frustration, rather than pressing them from awareness. As he had enjoyed work in the theatre, he was encouraged to practice ‘acting happy, sad, and angry’, and to note how others react. He attempted to use the rational problem-solving skills he had developed to actively cope with problems that occurred on a day-to-day basis. These interventions were accompanied by the introduction of assertiveness training activities (to reduce his passivity and social avoidance) and communications skills training (with an emphasis placed on assisting him to identify negative emotions, to describe these feelings to others, and to more clearly express his goals and desires). He and his parents were encouraged to practice the cognitive-behavioral skills he had learned, and to use contingency management techniques to motivate him to persist with tasks that were tedious or frustrating. A list of the specific cognitive-behavioral tasks we used is presented in Table 30.1.
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Table 30.1 Cognitive-behavioral interventions for depression used with Josh
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We concluded by reviewing cognitive-behavioral skills that had been the most helpful for Josh and by anticipating challenges he might face in the future. During our four booster sessions Josh noted that several techniques had been particularly useful, including goal setting, realistic thinking, rational problem-solving, and attempting to identify and develop sources of support. Josh was able to distinguishing a lapse (a ‘brief problem’) from a relapse (‘spiraling down’), and to develop plans for coping with ‘extreme problems’ that might occur. As he noted, ‘I've just got to not catastrophize… then I'll go with what works.’ At the conclusion of treatment Josh was motivated to graduate from high school and stated that he hoped to attend college. He was not sure, however, where he would like to apply or what he might want to study.
At the conclusion of treatment Josh was much improved. His parents observed that he was ‘very cooperative’, that he ‘had friends and is behaving better… he's polite and he's getting his work done and turning it in.’ When asked about his mood they noted that he ‘cheers up… and laughs a lot.’ Josh's CGAS score at the conclusion of treatment was 72 and he no longer met diagnostic criteria for major depression.
Looking forward, several concerns remained. Specifically, his parents noted that he continued to show a ‘lack of passion and direction.’ This was consistent with our observation that he rarely, if ever, fantasized or thought about his future, and that he had no long-term goals or aspirations. Although his depressive episode had been successfully treated, Josh was only beginning to develop a more mature adult identity. Developing vocational goals, a capacity for more intimate personal relationships, and a sense of the possible self he would like to become were tasks that remained for him to address.
Several protocols have been developed for treating child and adolescent anxiety disorders. Controlled outcome studies completed over the past 15 years indicate that behavioral psychotherapy and CBT can be useful in treating generalized anxiety, school anxiety, specific phobias, panic, and obsessive-compulsive disorder among youth (for reviews see Ollendick and King, 1998; Moore and Carr, 2000b; Barrett, 2001; Piacentini et al., 2003).
Based upon cognitive and behavioral models, these approaches endeavor to alleviate anxiety by teaching children and adolescents to monitor their moods, anticipate situations in which they are likely to become anxious, identify specific distressing thoughts, and respond to these cues by actively using cognitive and behavioral coping strategies. Exposure and desensitization, relaxation training, guided imagery, rehearsal of adaptive ‘self-statements’, and encouragement of adaptive coping attempts are frequently used. Parent and family sessions are typically included in these treatment programs, both to address parental behaviors that may be maintaining the child's anxiety and to provide them with strategies for managing their child's anxiety at home. Cognitive strategies (which focus upon reducing cognitive distortions, developing coping skills, and enhancing perceptions of control or efficacy) and behavioral approaches (which emphasize desensitization to anxiety-provoking stimuli and operant reinforcement of adaptive coping) are typically used together (Kendall et al., 1992).
Types of anxiety experienced by children and adolescents vary with age. Forms of anxiety that may be normal at one age (such as a fear of separation from parents during the toddler years) may be quite inappropriate at a later age. The most common source of anxiety during adolescence is peer rejection, and the most frequent anxiety disorders are social anxiety, panic, and agoraphobia. As adolescents develop the capacity for hypothetico-deductive reasoning, they become increasingly able to envision a range of potential threats, dangers, and sources of social embarrassment. Rates of social anxiety among adolescents are not surprising given the central importance of peer relationships for negotiating independence from one's family and for developing mature sexual relationships. Cognitive-behavioral models suggest that anxiety disorders tend, as a group, to stem from unrealistic appraisals of threats related to normative fears (Piacentini et al., 2003). It is these appraisal processes that are the focus of treatment.
CBT has been found effective for treating school phobia (Blagg and Yule, 1984; King et al., 1998), overanxious disorder (Kendall, 1994; Kendall et al., 1997), overanxious disorder and specific phobia (Barrett et al., 1996), panic disorder (Ollendick, 1995) social anxiety (Hayword et al., 2000), generalized anxiety (Cobham et al., 1998), and obsessive-compulsive disorder (March et al., 1994; Wever and Ray, 1997; deHaan et al., 1998; Franklin et al., 1998). Although few long-term follow-up studies have been completed, those that have been published are promising. Results suggest, for example, that gains achieved in CBT may be maintained for up to 3 years (Kendall and Southam-Gerow, 1996).
Whereas the large majority of these studies used individual or group therapy protocols, at least one has included a parental treatment package. Parents of anxious children and adolescents often experience high levels of anxiety themselves, and the possibility exists that this may lead parents to behave in ways that exacerbate and maintain their children's difficulties. With this in mind, Cobham et al. (1998) conducted a controlled outcome study that included a structured parental anxiety management component. As might be expected, this intervention had a significant effect, but only for those youth with highly anxious parents. The value of addressing parental anxiety when working with anxious youth is worthy of additional study. At a minimum, clinicians should attend to the moods of their patient's caregivers and the ways in which this may affect the child's adjustment. If appropriate, parents might be referred for treatment to address their feelings of anxiety.
If there is a drawback in these findings, it is that much of this work has been with prepubertal children and young adolescents (13–14 years of age). Few studies have been completed examining the treatment of anxiety among older adolescents, and samples typically include adolescents with a range of diagnoses. Moreover, psychotherapy is typically contrasted with a wait-list control, rather than another accepted form of treatment. Studies of psychotherapy for obsessive-compulsive disorder have used an open trial design, and many of the participants received concomitant medications. More formal comparisons of psychotherapy with pharmacotherapy, then, would be helpful.
Although psychodynamic psychotherapy is widely used in treating anxious youth, no controlled outcome studies have been completed examining its efficacy or effectiveness with anxious adolescents. A chart review of anxious children and adolescents completed by Target and Fonagy (1994a) indicated that a substantial percentage of youth with separation anxiety, phobias, and overanxious disorder improved over the course of treatment. Given the lack of a control group, however, it cannot be concluded that these interventions were effective in alleviating patients’ anxiety.
Conduct problems, including aggressive behavior, disobedience and defiance at home and at school, and major rule violations, are among the most persistent and difficult to treat clinical problems in adolescence (Eyberg et al., 1998). They are among the most common reasons for clinical referral, reflecting their high prevalence rates (Hinshaw and Anderson, 1996) and the fact that they can be quite distressing to parents and school officials. Traditionally, serious conduct problems have been treated with long-term, dynamically informed psychotherapy aimed at offsetting major ego deficits in the form of low frustration tolerance, limited self-awareness, impaired empathy, compromised interpersonal relations, or a fragmented, noncohesive sense of self. Often psychotherapy is only one component of a broader milieu treatment, either in a residential setting, group home, or therapeutic school. Such intensive treatment is viewed as necessary because of the breadth of impairment found among conduct disordered youth. Recent evidence, however, has suggested that aggregating conduct disordered youth in residential or group treatments can have unintended, deleterious effects (Dishion et al., 1999).
Over the last two decades, substantial energy and resources have been devoted to clinical trials for conduct disordered youth (Lochman et al., 2003). A review identified 10 treatments that have been supported by controlled outcome studies (Brestan and Eyberg, 1998). However, closer inspection shows that most of these treatments were designed and implemented with children rather than adolescents, or at best, with young adolescents. For example, many of the skill training interventions such as social problem-solving training (Kazdin, 1996), parent management training (Patterson, 1976), and some forms of anger management training (Lochman et al., 1981) were designed for and principally evaluated with children ages 13 and younger. Although these treatments appear to be quite promising for altering disruptive and aggressive behavior in children, their efficacy with adolescents has not been adequately addressed. ‘Upward extension’ of these treatments may not be warranted given findings showing a negative association between treatment effects and age for parent management training (Strain et al., 1981).
Three treatments have been developed for and evaluated with conduct disordered adolescents. The first is anger control training with stress inoculation (Feindler, 1991). At the core of this intervention is the view that youth with delinquent and aggressive problems have serious difficulties with the expression and regulation of anger. The treatment, then, principally aims at teaching youth a variety of coping strategies for reducing angry arousal. Therapy focuses on helping youth to identify anger provocation cues, to suppress immediate anger responses with self-instructions, to modulate arousal with relaxation or self-instructional techniques, and to consider consequences of aggressive behavior or explosive anger. In addition, a portion of the treatment is directed toward training individuals to behave in an assertive rather than an aggressive manner. Treatment is offered in both individual and group formats, and typically is time limited (12–25 sessions). It should be noted that, although this approach emphasizes psychoeducation, the treatment is not didactic. Rather, therapists model the components of anger management, and adolescents role-play skills under varied conditions of anger arousal.
Outcome research on anger control therapy has produced promising but mixed results. Across three published studies (Schlichter and Horan, 1981; Feindler et al., 1984, 1986) with delinquent or seriously behaviorally disordered youth, results have shown benefits in problem-solving abilities, teacher reported self-control, and reductions in penalties for disruptive behavior in school. Not all outcome measures showed a similar pattern of benefits, and the three studies have evaluated different forms of the intervention. Thus, while promising, this cognitive-behavioral treatment is not a ‘well-established’ treatment. Further, given the complex nature of conduct disorder and delinquency, the relatively narrow focus of this intervention may limit its generalizability. It may lack the therapeutic scope to be a ‘stand alone’ treatment for these challenging clinical problems.
Among the most promising treatments for adolescent conduct disorder are family-based therapies. A growing body of research suggests that disrupted family relations, poor parental monitoring, inconsistent discipline, and cross-generational continuities may contribute to aggressive and disruptive behavior among youth (Hinshaw and Anderson, 1996). Based on these findings, family processes have been targeted for intervention. Functional family therapy draws heavily on social learning formulations of noncompliance and aggressive behavior. At the core of this intervention is the view that aggressive and disruptive behaviors are maintained through patterns of family interaction that unintentionally reinforce problem behaviors while failing to reward prosocial behaviors. One recurrent pattern involves negative reinforcement. An adolescent may, for example, respond to limits or requests with aversive behaviors such as whining, arguing, or threatening. His or her parent, in order to reduce the aversive interaction, responds by disengaging or withdrawing. The youth's aversive behavior has been reinforced by the removal of the request, and the parents’ disengagement is reinforced by the reduction in aversive interactions. Not surprisingly, over time, families with conduct-disordered youth appear to be quite disengaged and lacking in cohesion. Further, youth fail to comply with parental limits and requests.
Functional family therapy (Alexander and Parsons, 1982) attempts to modify such dysfunctional family patterns by altering parental monitoring and disciplinary strategies. Similar to the approach of Patterson et al. (1992), parents are taught to use basic social learning principles for managing youth behavior. Several additional components complement the core behavioral approach including family sessions designed to improve communication and increase family reciprocity, and sessions aimed at facilitating negotiation among family members.
Several outcome studies have supported the efficacy of functional family therapy for delinquent youth. In one study (Alexander and Parson, 1973), functional family therapy was compared with client-centered family groups and psychodynamic family counseling for the treatment of juvenile offenders. Observed patterns of family interaction and youth recidivism rates were among the primary outcomes. For both sets of measures, functional family therapy outperformed the other active treatments. In fact, recidivism rates in the functional family therapy condition were approximately half the rates found in the other conditions (25% versus 47% and 50%). There have been several additional studies of functional family therapy, and the overall pattern of results has been quite promising. However, as the treatment has evolved over time, it is not clear that the required conditions for replication have been met (Chambliss and Hollon, 1998). As such, functional family therapy should be viewed as a ‘probably efficacious’ treatment for youth conduct problems.
Because conduct disorder is multidetermined, emerging treatments increasingly emphasize comprehensive, multicomponent interventions that address multiple pathogenic processes at multiple levels of context. Multisystemic therapy (MST; Hengeler et al., 1998) is an integrative and comprehensive approach to treating youth conduct problems and antisocial behavior. Unlike traditional, comprehensive treatments that remove the adolescent from his or her social environment through placement in residential treatment settings, MST aims at restructuring multiple levels of the youth's environment in order to promote pro-social functioning. Drawing on Bronfenbrenner's (1979) ecological model of development, individual behavior is viewed within the context of multiple, nested contexts. Relevant context is not limited to the family, as in functional family therapy, but extended to the school, neighborhood, peer group, and broader community, as well as to linkages among these systems.
MST draws upon methods from a number of empirically based treatments. For example, interventions at the family level might include communication training as well as methods from strategic or structural family therapy. Integration of specific interventions is guided by a core set of principles. MST begins with the assumption that the purpose of assessment is to understand the fit between identified problems and the functioning of multiple systems. Psychiatric diagnosis is not the primary aim, instead MST therapists attempt to identify processes at multiple levels that support or impede adaptive functioning. In turn, therapeutic interventions attempt to use systemic strengths, for example, a committed extended family, as levers for change. All interventions are present focused and action oriented. Typically, many interventions focus on specific contingencies that sustain problematic behaviors. Therapist and family agree upon specific, well-defined goals, and progress is closely monitoring, including family feedback on treatment fidelity.
A growing body of evidence supports the use of MST as a treatment for serious, conduct-disordered adolescents (Henggeler et al., 1998). Compared with treatment-as-usual, MST shows superior ability to reduce conduct problems, including the use of illicit substances. Perhaps its greatest strength resides in its power to reduce recidivism among adjudicated adolescents. It is noteworthy that long-term follow-up reveals that MST effects are sustained over time. Consequently, MST is one of the most promising treatments for conduct problems in adolescence. It is tempting to label MST as a ‘well-established’, empirically supported treatment. However, such a label requires replication by an independent team of investigators. Hopefully, current efforts to replicate these findings will yield comparably impressive results.
Jackie is a 14-year-old, European-American female who was referred to our clinic because of multiple school suspensions from eighth grade. According to her mother's report, Jackie was highly argumentative at home and at school, defiant in relation to teachers, and failing the majority of her courses. Her mother was also concerned about low self-esteem. An initial diagnostic assessment did not reveal a significant pattern of depressive symptoms, but did uncover long-standing difficulties with impulsivity and inattention, a common set of comorbid problems with conduct disorder. Closer evaluation also indicated a pattern of rule violation and minor acts of property destruction. Jackie acknowledged that many of her friends were using drugs and alcohol, but denied personal use. Mother and daughter agreed that they had a highly conflicted relationship, and their reports were supported by clinically elevated scores on the Issues Checklist, a measure of parent–teen conflict. Jackie's father was only peripherally involved and was reported to have substance abuse problems.
Because of her symptoms of ADHD, in addition to symptoms of conduct disorder, Jackie was referred for a medication consultation. Second, in order to address Jackie's problematic interactions with teachers, her social problem-solving skills were targeted for intervention in individual therapy. Third, her mother was involved in parent management training to deal with Jackie's disruptive behavior at home and at school. In order to manage school behavior, a collaborative program was developed between Jackie's mother and school personnel involving the use of a weekly report card for assignments and behavioral outbursts. In brief, school personnel systematically monitored her behavior while her mother delivered consequences (largely positive) for gradual improvement in homework and self-regulation.
In individual sessions, the therapist attempted to engage Jackie in social problem-solving training. Like many young teens with conduct problems, Jackie was a reluctant participant in therapy. As a result, her therapist worked very slowly to build rapport by closely listening to Jackie's ‘weekly tales’ of her adventures with peers, and with substantial talk about music and fashion. With the gradual development of rapport, her therapist attempted to identify what Jackie might want from their meetings. Jackie acknowledged that she didn't want to ‘flunk’ for a second time, and her therapist amplified what it would mean to be 15 and still in middle school. Together they decided to spend a portion of each session on developing new strategies for coping with the demands of school.
Initially her therapist had Jackie identify problematic situations at school. Again, her problems with attention made self-monitoring difficult, but with medication, her ability to examine situations improved. Most of the difficult situations involved perceptions that she was being treated unfairly by a teacher. Her typical solution was to vent her anger by cursing or walking out of class. Integrating methods from cognitive therapy, her therapist introduced the concept of negative automatic thoughts and assigned Jackie the task of catching these rapid cognitions when she felt anger. Although Jackie was disinclined to complete homework, she readily reviewed situations in session. The primary goal at this point was to encourage Jackie to consider alternative interpretations of evocative situations in order to reduce immediate responding. Next her therapist introduced basic problem-solving steps including; breaking down the problem, defining the desired outcome, brainstorming alternative solutions, evaluating the solutions in terms of consequences, and implementing a plan. Problem-solving training began with hypothetical situations then proceeded to situations Jackie encountered at school or at home. With each plan, Jackie and her therapist role-played variations on different situations with the therapist providing feedback, or modeling alternative strategies.
After about 4 months (15 sessions) of working individually with Jackie and her mother, dyadic sessions were started in an effort to reduce mother–daughter conflict. Early sessions revealed problematic communication behaviors, including rampant use of sarcasm, verbal attacks, and put-downs by both mother and daughter. Drawing on the marital communication literature, the therapist modeled active listening skills and practiced these skills with the dyad over a series of sessions. After Jackie and her mother rated the intensity of various conflicts, the therapist began with a low intensity issue (washing the dishes), and introduced problem-solving communication (similar to what Jackie had been working on individually). The therapist closely monitored problematic communication, e.g., verbal put-downs, and stopped their interaction when breaks in problem solving occurred. It should be noted that the therapist was lavish in her praise for the dyad when they successfully negotiated low intensity conflicts. In addition, she assigned positive joint activities for mother and daughter each week. Gradually, the dyad worked on increasingly intense conflicts as they acquired more of the basic skills, and could monitor their own breaches in problem solving.
After 6 months of treatment, scores on the Issues Checklist showed a substantial reduction in problem intensity, although problem frequency remained elevated compared with adolescent norms. Jackie had been suspended from school only one time during the 6-month course of treatment, in contrast to three suspensions during the month proceeding treatment. Both mother and daughter reported an improved relationship, and Jackie was promoted to high school at the end of the school year.
Over the last two decades, there has been substantial progress in the field of psychotherapeutic treatments for adolescent disorders. A major trend has been the development of specific treatments for specific diagnostic groups. The assumption that a single form of therapy—be it psychodynamic, behavioral, or family therapy—can be generically applied to a broad range of adolescent problems has been laid to rest. Similarly, the assumption that all forms of therapy are equally effective has not been supported. This is not surprising given recent research in developmental psychopathology. Evidence indicates that psychopathology among youth is multiply determined, that there are a range of developmental pathways or trajectories for each disorder, and that different combinations of factors are implicated in the development and maintenance of different conditions. There is simply too much diversity in pathogenic processes that contribute to and maintain different disorders to allow us to maintain that all forms of psychotherapy are equally effective. Our understanding of developmental psychopathology, however, is far from complete. Research into factors that place individuals at risk for developing specific conditions and that exacerbate or maintain their difficulties will serve as a sound foundation for developing more effective treatments. Much work, however, remains to be done.
A major limitation of the current literature stems from the design and goals of efficacy trials. Randomized controlled trials are designed to demonstrate that specific interventions can be effective for treating specific clinical problems in specific populations. In an effort to demonstrate the effects of specific treatments, the requirements of experimental control can result in clinical trials that are less than ‘clinically representative’. Findings from randomized controlled trials completed in research clinics may or may not, as a consequence, be generalizable to community clinics or private practice settings. The inclusion and exclusion criteria for patients with particular disorders, for example, can result in samples that differ in important ways from typical clinical referrals where high levels of comorbidity and low levels of family functioning are common. Similarly, therapists with limited caseloads are trained to deliver a specific, well-defined intervention, are closely monitored, and are carefully supervised. Unfortunately, such a high commitment to treatment integrity is not possible in many clinical practice settings. Thus, a major limitation of, and a major question for, psychotherapy researchers involves the transportability of these promising approaches to ‘clinically representative’ practice. That said, several points are worth noting. First, many efficacy trials do include patients that are seriously impaired and highly symptomatic. The promising results of MST trials cannot be discounted, for example, because the participants did not manifest serious conduct problems. In fact, most youth in these studies were court involved. Second, it is worth acknowledging that the generalizability of treatment effects is a scientific and technical question. It is one that will be resolved through systematic research rather than partisan debate. Finally, research in cardiology, oncology, and more recently, psychiatry indicates that treatment integrity and clinician expertise may be associated with improved outcomes, at least when working with more severely ill patients. It is not enough, as such, to demonstrate that empirically supported therapies can be effective in community settings; it will also be necessary to train clinicians in their use and to encourage them to use these approaches appropriately.
A second limitation involves the assessment of outcomes. Although clinical trials are more systematic in gathering objective outcome data than typical clinical practice, several shortcomings are worthy of note. First, the field has been far too concerned with symptom reduction. Most studies include multiple measures of specific symptoms associated with particular disorders (e.g., self-report and interview measures of depressive symptoms) without adequate attention to functional outcomes that are related to long-term adaptation. For example, research on outcomes for youth with major depression would be well advised to include measures of peer relationships, family functioning, and academic performance as indicators of change. Second, few studies have provided evidence of long-term stability of gains. Outcomes typically are assessed at posttreatment and 6–12 months later. For many disorders, especially those with a remitting/recurring pattern, long-term follow-up assessments are needed. Admittedly this is a costly enterprise, but evidence that emerging treatments divert youth from deviant developmental pathways over the long haul would be a powerful incentive for their dissemination and implementation.
A range of adolescent disorders and a number of widely practiced forms of therapy have not been adequately evaluated. Although anxiety, depressive, and conduct disorders make up the bulk of adolescent referrals, there are a number of clinical problems that deserve increased attention. One set of problems that often emerge during adolescence are the eating disorders, bulimia and anorexia nervosa. Research on treatments for these problems in adolescence lags behind research with adults (LeGrange, 2003). Again, given important developmental differences between adolescents and adults, it is not clear that treatments developed with adults can be readily extended to adolescents. The fact that most adolescents live with their family and interact with them on a daily basis is no small consideration.
Similarly, research on treatments for adolescents with posttraumatic stress disorder is virtually nonexistent. As many adolescent females have a history of sexual abuse or assault, work in this area is sorely needed. Moreover, a history of trauma can complicate the treatment of other clinical conditions. A significant percentage of youth with depression, anxiety, or substance abuse problems, for example, have experienced abuse or neglect, or come from environments characterized by violence. These experiences can contribute to the development of maladaptive coping strategies and can interfere with the treatment process. Finally, research on treatments for adolescents with varying combinations of comorbid disorders is needed. Research in community clinic settings indicates that most referred youth present with three or more diagnosable disorders (Weisz et al., 1998). Relatively little is known about the treatment of such multiproblem youth. Questions about the ordering, integration, and decision rules for applying multiple interventions are clearly underdeveloped.
As noted, a number of widely used treatments have received little attention in the research literature. Most prominently, psychodynamic psychotherapy with adolescents has received scant attention in clinical trials. Given the large adult literature on psychodynamic and psychoanalytic psychotherapies, and the development of psychodynamic psychotherapy protocols (Luborsky, 1984) it is evident that these approaches can be systematically evaluated in clinical trials (Barber and Crits-Christoph, 1993; Crits-Christoph and Connolly, 1998). However, because of the therapeutic allegiances of most investigators, dynamic treatments are rarely studied. When they are, they are often addressed in poorly designed trials or case reports. A new generation of psychodynamic investigators is needed to address this substantial gap in the literature. Similarly, many forms of family therapy have received little systematic evaluation. Although there is a growing body of research on structural and behavioral family therapies, systemic, strategic, and narrative therapies have been understudied. Although case studies represent a reasonable starting point for treatment development, evidence-based practice requires a higher standard of evaluation.
Clearly, the most pressing question for psychotherapy research with adolescents involves the evaluation of promising, efficacious treatments under clinically representative conditions. Can treatments that have been shown to be efficacious in research clinics provide the same benefits to clinically referred youth in community settings? If not, what types of modifications need to be made to produce positive outcomes? Can community practitioners deliver efficacious treatments with sufficient fidelity such that beneficial outcomes will be realized? How much training and supervision is needed to produce positive outcomes in clinical practice? In brief, how flexible are these promising treatments? Will the demanding conditions of everyday practice undercut their integrity and dilute their effectiveness? These are some of the questions to be addressed by the next generation of clinical trials.
One major issue that is likely to emerge in the effort to evaluate treatments under clinically representative conditions involves treatment engagement and attrition. It is a sad fact that most youth referred for treatment receive no more than one session of psychotherapy (Gould et al., 1985). Research on attrition from community clinics reveals high levels of early attrition, estimated between 40 and 70% (Armbruster and Kazdin, 1994). Obviously, treatments cannot be expected to produce significant effects when minimally or partially completed. Thus, a critical question involves identifying processes that enable patients to receive an adequate dose of treatment.
Emerging research shows that the development of a positive, working alliance between youth, parents, and their therapist may hold the key to treatment engagement and completion (Kazdin et al., 1997; Garcia and Weisz, 2002). Further, a recent meta-analysis of relationship predictors of treatment outcomes (Shirk and Karver, 2003), shows that relationship variables are modest, but consistent, predictors of treatment outcomes across a range of treatments for youth. An important question, then, naturally arises—which therapist actions and strategies promote a positive, working alliance, and with which patients? Although a growing number of studies have examined alliance-outcome relations in youth treatment, virtually no research on alliance development and therapist facilitating behaviors has been published (Shirk and Russell, 1998). Psychodynamic theorists (e.g., Meeks, 1971) have long emphasized the fragile nature of the therapeutic alliance with adolescents, yet emerging treatment models rarely address this issue in any detail. In part, this reflects the absence of evidence, beyond single case narratives, to support specific recommendations. Thus, research is needed to examine sequences of early therapeutic interactions to identify specific therapist behaviors and styles that promote alliance formation with adolescents.
Such studies could be part of a new research agenda focused on linking specific therapeutic processes with treatment outcomes.
We can be optimistic about the benefits of psychotherapy for treating anxiety and depressive disorders experienced by adolescents. The treatment of conduct disorder remains a vexing problem, but the emergence of comprehensive and systematic interventions, such as MST, hold significant promise.
The number and quality of psychotherapy outcome studies has increased dramatically over the past 10 years. Unfortunately, this growth has largely been limited to behavioral, cognitive-behavioral, and interpersonal approaches. Well-designed studies of psychodynamic, psychoanalytic, and systemic therapies are lacking, as is research into processes mediating therapeutic change among youth. Case reports and open trials can be useful in the initial stages of developing a treatment approach. They are entirely inadequate, however, as a basis for developing evidence based treatment guidelines or for refining existing treatment programs. The efficacy and effectiveness of psychotherapeutic interventions with adolescents can only be demonstrated though randomized controlled outcome studies that use a range of sensitive outcome measures. To be sure, recent attempts to develop guidelines for evidence-based clinical practice have proven controversial. Conducting clinical research can be daunting, and the generalizability of findings from university clinics to community settings has not been demonstrated. Moreover, it is quite clear that even the best empirically supported treatment programs are less than fully adequate. All are in need of refinement. That said, our treatment practices can only develop if they are subjected to careful, objective scrutiny.
As we have seen, a substantial body of evidence now exists indicating that psychotherapy can be beneficial for adolescents with behavioral and emotional difficulties. More important questions, however, remain—Are some forms of treatment more effective than others? Are some interventions more effective than others for specific problems? Are there developmental, cultural, or gender differences in response to treatment? How can we understand the relative equivalence of different forms of psychotherapy? Are variations in therapeutic technique needed as a result of developmental changes in cognitive, social, and emotional functioning over the course of adolescence? What are the moderators and mediators of therapeutic change? Although we do not have clear answers to many of these questions, the findings we have reviewed allow us to draw a number of tentative conclusions.
Therapy works.
Not all forms of treatment are created equal—some appear to be more effective than others.
Although preliminary findings are promising, controlled comparative outcome studies and process research are needed.
Strategic, problem-focused forms of therapy are more effective than nondirective, long-term treatments.
The successful treatment of adolescent conduct disorder requires attention to the broad contexts that maintain problematic behavior.
There appears to be a dose–response relationship—regular, active participation in therapy is associated with better outcomes.
An active, collaborative therapeutic relationship may facilitate clinical improvement.
Patients perceptions of efficacy, competence, and optimism may mediate outcome.
The social environment (both family and peers) is important. It is important to attend to both stressors and social supports.
Behavioral, emotional, and social difficulties experienced by adolescents can have pernicious effects that persist into adulthood. It is important, then, to include long-term assessments as a part of both clinical practice and research. We should, at the same time, attempt to insure that our interventions have broad, positive effects on adolescents’ development.
We should, in short, adopt the broad view. We should keep both the forest and the trees in view. Our treatments may be narrow in the sense that they are designed to reduce immediate distress, to alleviate specific symptoms, and to prevent negative outcomes over a short period of time. These are not unimportant goals. At the same time, adolescents behave in ways that shape their environment and their experiences. We all do. As a consequence, specific interventions may have a larger effect on the adolescent's social, educational, and emotional adjustment. Psychotherapy, then, may serve as a transition or inflection point in the adolescent's life. It may place them on a more positive or adaptive developmental trajectory. Our challenge, then, is to develop interventions that both alleviate immediate distress and that support the long-term development of our patients.
We return, then, to the question with which we began—What constitutes an effective treatment? The answer depends, of course, on how one defines ‘effective.’ This, in turn, depends on our goals for treatment, what we view as acceptable evidence, our definition of ‘objectivity’, and what we consider to be an acceptable design or methodology for accumulating evidence. To say that a treatment is not ‘empirically supported’ or ‘evidence based’ is not to say that it is without support. Many forms of evidence—including open trials, case series, clinical observations, and professional consensus—are accepted as reasonable by many individuals.
To be sure, reduction of symptomatology is an important goal. As important, however, are the effects of our interventions on the social, academic, and emotional development. In reviewing the results of psychotherapy outcome research approximately 10 years ago Reinecke (1993, p. 397) noted that ‘Our goal, in the larger sense, is not simply to assist the adolescent in resolving immediate concerns, but also to support ongoing development—to assist him or her in developing the capacity to form mature, trusting relationships and to function effectively as an adult—in short, to love and to work.’ These sentiments remain true today. The effects of an intervention can be assessed in a number of ways, and broader effects may not be apparent for some time after the treatment has been completed. Moreover, interventions can be useful even if they do not alleviate the individual's presenting problems. Consider, for example, the suicidal adolescent. An intervention that reduces the risk of further suicide attempts may be quite beneficial, even if feelings of sadness or anxiety persist. An intervention that prevents an ominous outcome, or which places an adolescent on a more adaptive developmental path, may be quite beneficial. Documenting these effects, however, can be challenging.
A number of innovative and efficacious interventions have been developed during recent years. Our goal, as clinicians and scholars, is to refine, develop, evaluate, and disseminate them such that they can be used to alleviate distress and enrich the lives of adolescents.