Evidence‐based child and adolescent psychotherapy: It's not what you think

Abstract

In clinical practice, I have often encountered the supposition that evidence-based psychotherapy for children and adolescents is synonymous with cognitive behaviour therapy (CBT). 1 CBT is commonly thought to be more effective than other forms of treatment for young people, such as psychodynamic or play therapy, 2,3 and is often described as 'the treatment of choice' for youth, 4 with other therapies seen as lacking an evidence base. 1 A scientific approach to choosing treatment requires that we examine our assumptions and their empirical basis. In this article, I question the assumption of CBT's superiority and briefly review the empirical data on the efficacy of play therapy and psychodynamic therapy with young people. I then address considerations in choosing therapies that are likely to be most helpful.Psychotherapies for children and adolescents are based on a wide range of theoretical orientations. I focus here on psychodynamic (psychoanalytic), client-centred and CBT approaches. Psychodynamic therapy is distinguished by its exploration of emotions, fantasy and efforts to avoid distressing feelings; identification of patterns of experience; developmental focus; and focus on relationships, including the therapeutic alliance. 5 In psychodynamic play therapy, play is seen as the child's natural form of communication and essentially takes the place of adult patients' verbalisations. 6 Many play therapists practise from a client-centred theoretical perspective, which emphasises the child's innate capacity for self-healing, the therapist's warmth and acceptance for the child, creation of conditions of free expression for the child, respect for the child's problem-solving capacities and non-directiveness. 7 Although adolescents often prefer talk therapy (which may have a psychodynamic, client-centred or other theoretical orientation), play therapy can be used with this age group. 8,9 CBT is based on the assumption that thoughts affect feelings and behaviour, and emphasises directly changing cognitions 10 through teaching children coping skills, promoting their self-control and enhancing their self-efficacy, with the child's active participation. 11Despite CBT's popularity, for three decades, meta-analyses have demonstrated that play therapy is effective for a wide range of childhood mental health problems. [12][13][14][15] In four meta-analyses, weighted mean effect sizes for play therapy range from 0.65 to 0.80 over 42 to 94 studies, [12][13][14][15] representing moderately large to large effects. 16 Fully three-quarters of children treated with play therapy are better off than the average untreated child, paralleling findings in adult psychotherapy. 17 Likewise, a meta-analysis of 11 studies of short-term (40 visits or less) psychodynamic treatment for youth indicates a large effect (weighted mean g = 1.07), 18 consistent with a qualitative literature review that documents psychodynamics psychotherapy's effectiveness for children and teens, 19 as have more recent studies with children 20 and adolescents. 21 The ...