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(p. 341) Integrative Psychotherapy with Children 

(p. 341) Integrative Psychotherapy with Children
(p. 341) Integrative Psychotherapy with Children

Athena A. Drewes

, and John W. Seymour

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date: 26 May 2019

Childhood psychopathology continues at a high and constant rate. Between 17% and 22% of youth (under the age of 18) have experienced a diagnosable emotional, behavioral, or developmental problem (Kazdin & Johnson, 1994). This translates to more than 14 million youth in the United States suffering significant impairments (Prout & Fedewa, 2015). Children are a critically underserved population despite ample recognition of the growing rates of at-risk, suicidal, and antisocial behaviors, and substance abuse (Prout & Fedewa, 2015).

To complicate matters further, treatment dropout rates for children and youth have been found to be as high as 40–60% (Prout & Fedewa, 2015), and there are conflicting viewpoints on whether child psychotherapy is effective (Weisz et al., 2017). For example, a large meta-analysis covering 447 studies (30,431 youths) and synthesizing 50 years of research findings found that youth in the treatment condition fare better than those in the control condition (63% posttreatment probability, ES = 0.46). The strongest treatment effect was for anxiety (0.61), weakest for depression (0.29), and nonsignificant for multiproblem treatments (0.15). The findings underscored the benefits of psychological treatments, as well as the need for improved therapies and more representative, informative research (Weisz et al., 2017). Although psychotherapy studies of children and youth show efficacy when compared with no treatment (Lebow, 2008), effectiveness drops when conducted in real-world settings.

Complicating child psychotherapy is the issue of development, which is shifting and changing, making stable measurements difficult (Lebow, 2008). The child therapist must be familiar with human development because much of what is viewed as problematic in children, with the exception of severe psychopathology or extreme behaviors, might be normal (p. 342) developmental deviation. In addition, many of the symptomatic manifestations in normal children and in child development, such as temper tantrums, enuresis, specific fears and anxieties and sleep disturbance tend to disappear as a function of development and maturation.

Another factor that contributes to the differences between child and adult therapy is that the child’s personality is less likely to be set than the adult’s. The child’s defenses are not as well established, are more pliable, and respond better to therapeutic intervention once a therapeutic relationship and cooperation is established. On the other hand, because of the rapid changes, child clients may be labile, with a wider range of normal emotional and behavioral responses and inconsistency in responding to therapy.

Compounding the difficulty of treatment with children still further is a different motivation than adults have. While adults have some awareness that a personal problem exists, children may not recognize or agree that there is a problem, nor voluntarily initiate therapy. Other adults will make this determination for treatment, resulting in varying degrees of acceptance, compliance, and resistance from the child. In addition, the child usually has little understanding of the therapeutic process and treatment objectives and may even have a distorted view of and misinformation regarding therapy.

Another major difference between child and adult therapy is that the child has limited verbal and linguistic development, which in turn relates to limitations in cognition and abstract thinking. Children may not think in abstract terms, may lack skills to articulate their thoughts and emotions, and may not have a sufficient receptive vocabulary to fully understand what is being asked in an interview or session. Thus, talk therapy with children often fails unless play or play-based interventions are used as a medium of treatment (Drewes, 2009).

These and additional complexities in child psychotherapy virtually require integrative psychotherapies. Child clinicians trained in one theoretical orientation or a single treatment quickly find that one size cannot fit all of the presenting problems and complex circumstances. Since children are not simply little adults, their treatment cannot be scaled-down adult treatment. Developmental stages, systemic environments, referral reasons, and a multitude of additional factors require a flexible, integrative approach to therapy. In addition, an integrative approach with youth will frequently involve other systems in the child’s life, such as parents, family members, and school personnel, and require blending individual, parent, family, and community formats as well.

The Integrative Approach

Foundational Concepts

“Psychotherapy integration is central to child treatment, although at times it is not clearly identified or developed both in the research literature and practice” (Krueger & Glass, 2013, p. 331). The more interventions and systems that can be combined, the more modalities involved in the treatment, the more likely the overall therapeutic goals are realized (Prout & Fedewa, 2015). The treatment focus necessitates looking at “which set of procedures is effective when applied to what kinds of patients with which set of problems and practiced by which sort of therapists” (Barrett, Hampe, & Miller, 1978, p. 428). Because child psychotherapy demonstrates high levels of symptom severity and comorbidity, along with parent and family stressors, a multidimensional approach is necessary (Kazdin, 1996, Kelley, Bickman, & Norwood, 2010).

In addition, an integrative approach to child psychotherapy facilitates broadening the therapist’s theoretical conceptualization of the child’s presenting problems and helps to implement a variety of interventions (Krueger & Glass, 2013). In contrast to linear models of psychopathology (Gold, 1992; Pine, 1985), integrative theories of psychopathology conceptualize it from the viewpoint of multicausation. Equal weight is given to various aspects of personal functioning, such as motives, affects, thoughts, images, and behaviors. These are (p. 343) examined through “psychic structures, developmental needs, biological and maturational processes, intrapsychic motives and conflicts, cognitive and perceptual processes and contents, emotions, and overt actions” (Gold, 1992, p. 56). Each of these components are “influencing, modifying, reinforcing, inhibiting, and perhaps even creating each other” (Gold, 1992, p. 56), and they are seen in a blended and unified whole. Such blending implies a circularity as well as the containment of multiple relationships that are seen between the cognitive, dynamic, interpersonal, and behavioral aspects of the person (Coonerty, 1993).

Because cognitive styles are in the process of formation in children, interventions must be tailored to match them, as well as determining what is developmentally appropriate for the client and for their extended systems of family and school. An integrative approach allows for the addressing of interpersonal challenges as well as external realities of the child client (Krueger & Glass, 2013).

Rather than jumping from one treatment to another, the child therapist develops a prescriptive, integrative approach that broadens the therapist’s concept. Of course, the selection of treatments should not be ruled by a therapist’s preferences or the staying within a comfort zone, but rather through research evidence and clinical expertise (Schaefer, 2003). The prospect of change in one sphere of functioning frequently leads to broad reverberations and changes throughout multiple aspects of the client’s maladaptive functioning (Coonerty, 1993).

In addition, the child’s family and macroenvironment (e.g., poverty, poor housing, disintegrated family structure, alienation, and disenfranchisement) add influential components to the child’s cognitive, dynamic, and behavioral responses (Gold, 1992). This multiple causation model helps move the clinician from narrow theoretical constraints to address the many factors that may be causing or maintaining pathology and inhibiting a young person’s ability to learn and function in a healthy manner.

Integrative treatments are not new to child therapy. Surveys indicate that child clinicians utilize techniques and procedures from a variety of theoretical sources in clinical work with children (Koocher & Pedulla, 1977; Shirk, 1999; Tuma & Pratt, 1982). More than half of surveyed child and play therapists blend techniques (Fonagy et al., 2002; Phillips & Landreth, 1998).

The extensive research conducted on child sexual abuse and trauma also push for an integrative approach. For example, a three-prong integrated trauma treatment (Stein & Kendall, 2004) addressed problematic behaviors and skill development through cognitive-behavior therapy (CBT) interventions; integrated traumatic memories, emotions, and buried parts of the self through psychodynamic interventions; and attended to the actions and reactions in the family system that maintain dysfunctional family interactions. In addition, because trauma memories are imbedded in the right hemisphere of the brain (Gil, 2006; van der Kolk, 2005), the integrative use of nonverbal treatments and strategies utilizing symbolic language, pretend play, and creativity will help access and activate this portion of the child’s brain. Thus, the use expressive arts, play, and pleasurable activities within therapy has been found to be helpful in allowing traumatized and abused children to create their trauma narratives (e.g., Drewes & Cavett, 2012; Gil, 2006; van der Kolk, 2005).

Defining Integrative Child Therapies

In both the child and adult literatures, psychotherapy integration typically refers to the synthesis of diverse schools and methods of psychotherapy. As well, integration refers to combining two or more therapy modalities/formats, such as family, group, and individual therapy (Feldman, 1988; Reeves & Bruno, 2009). Involving the child’s parent into the treatment process, even if only for psychoeducation, is also considered integrative (Krueger & Glass, 2013). Still others refer to traditional talk therapy plus play therapy as integrative. Finally, but not exhaustively, working across systems of care (such as a school setting along with the home environment) is sometimes called integrative (p. 344) (Cook, 2007). In this chapter, we embrace all four types of integration in child work.

Exemplars of Integrative Child Therapies

Child therapy calls for the therapist to wear many hats and be skillful in changing from one therapeutic stance to another in order to meet the needs of the child and of others in the child’s life (Coonerty, 1993; Drewes, 2011a). At one moment, the therapist may find herself intensely involved in a deeply evocative and often intense therapeutic relationship with the child client in which the therapist deals with the child’s internal struggles, sets limits, and acts as an educator or mediator with the child. Then, in the next moment, the therapist needs to engage with a parent or school psychologist or classroom teacher. These often conflicting and rapidly changing roles lead many child therapists to adopt an eclectic prescriptive style in which therapeutic interventions are chosen and then changed according to the most pressing external demand (Coonerty, 1993; Drewes, 2011b).

Initially, child treatment consisted of taking adult models and extending them downward to children (Krueger & Glass, 2013). In particular, cognitive and behavioral approaches were utilized to address behavioral management problems through use of behavior modification techniques, along with addressing parent–child relationship issues. Examples include modifications of the adult psychodynamic together with behavior therapy to treat child behavior problems, using behavior modification techniques along with parent–child relational dynamics (Feather & Rhoads, 1972; West & Carlin, 1980), and the development of a psychodynamic understanding of the meaning of the child’s behavior (Krueger & Glass, 2013).

One of the first integrative attempts was developmentally based psychotherapy (Greenspan, 1997), which merged an understanding of developmental abilities with self-regulatory abilities into a primarily psychodynamic approach. Likewise, assimilative psychodynamic psychotherapy maintains a strong psychodynamic base while integrating cognitive-behavioral and family systems orientations in treating adolescents (Grehan & Freeman, 2009; Krueger & Glass, 2013; Stricker & Gold, 1996).

There are several avenues toward developing an integrative treatment with children. In what follows, we consider several exemplary integrative child therapies according to the four routes: technical eclecticism, theoretical integration, assimilative integration, and common factors (Norcross & Alexander, Chapter 1, this volume).

Technical eclecticism is prescriptive in that it selects the best treatment for the client and the problem. It has been described as more practical than theoretical (Norcross, 2005), with the emphasis on predicting for whom particular interventions work well, rather than why they work well. Exemplars here applied to children include multimodal therapy (Lazarus, 2006) and systematic treatment selection (Beutler, Consoli & Lane, 2005; Consoli & Buetler, Chapter 7, this volume).

Technical eclecticism, utilizing prescriptive play therapy for child treatment, is seen in the case study of an 11-year-old autistic girl with behavioral difficulties (Kenny & Winick, 2000). Using a sequential approach, treatment methods were chosen that built on one another over time, rather than blending them together within one session. In this case study, the rapport-building component of nondirective play therapy was used with directive techniques in targeting maladaptive behavior and providing parent education. The rationale for using a flexible integrative approach was due to the multidimensional aspects of the child’s behaviors along with her developmental delays. Different treatment approaches were combined into a coherent intervention sequence (Shirk, 1999).

Treatment for trauma has several effective integrative approaches for children. Trauma-focused integrative play therapy (Gil, 2009) is a promising manualized, technically eclectic treatment for children who have experienced complex trauma (Krueger & Glass, 2013). Evidence-based trauma-focused cognitive behavior therapy (Cavett & Drewes, 2012; Cohen, Mannarino, & Deblinger, 2006, 2012; Drewes & Cavett, 2012) is integrated with expressive (p. 345) techniques, directive and nondirective play, and mindfulness interventions.

Theoretical integration takes the best elements of two or more approaches to therapy and blends them with the expectation that the result will be more than the sum of the separate therapies. The emphasis is on integrating the underlying theories along with an integration of therapy techniques. Exemplars are Ellen Wachtel’s (2014) psychoanalytic-behavioral-relational integration and the transtheoretical model, which matches principles or processes of change to the child’s stage of change (DiClemente & Prochaska, Chapter 8, this volume). The latter has been subject to hundreds of outcome studies, including with children and their families.

One of the earliest theoretically integrative treatments for children was cognitive behavioral play therapy (Knell, 1993). It blends cognitive and behavioral interventions into play therapy, with the child’s development informing treatment (Drewes, 2009; Knell, 1993). Problematic behaviors are seen as stemming from maladaptive thoughts which impact the child’s feelings and subsequently behaviors. These maladaptive thoughts can be modified by using play-based tasks and applications in therapy while incorporating evidence-supported techniques from cognitive and behavioral orientations (Krueger & Glass, 2013).

An example of theoretical integration is ecosystemic play therapy, developed by O’Connor (2001). The clinician considers the child, his or her problems, and the therapy process within the framework of the child’s ecosystem. It incorporates key elements of the analytic, child-centered, and cognitive-behavioral models of play therapy, as well as elements of Theraplay (Jernberg, 1979; Jernberg & Booth, 1999).

Another exemplar of theory integration is flexibly sequential play therapy for traumatized children (Goodyear-Brown, 2010). A variety of treatment techniques give the child the space in which to disclose and adjust to the sharing of the trauma content (continuum of disclosure), as well as to restore the child’s lost sense of empowerment that occurs due to abuse (experiential mastery plan). The therapist flexibly integrates directive and nondirective approaches. Because of all the various teaching components, knowledge of cognitive behavioral therapy, somatic therapies and mindfulness, and family systems and attachment theories are required. The therapist is not required to be expert in every model, but a working knowledge of how to conduct dyadic interventions and psychoeducational components in working with the parent is needed.

Both parent–child interaction therapy (Eyberg, 1988; Krueger & Glass, 2013) and child parent relationship therapy (Bratton et al., 2006) are evidence-based, parent training programs that exemplify theoretical integration for young children presenting with behavioral, emotional, and family problems. Children’s problem behaviors are addressed by modifying contributing negative parent–child interaction patterns (Bell & Eyberg, 2002). Nondirective play and behavioral contingencies are central to treatment, and concepts such as attachment and social learning theories inform the treatment approach (Krueger & Glass, 2013).

Assimilative integration has also taken root in child therapy, whereby psychotherapists work primarily from their favorite theoretical orientation and then selectively incorporate methods from other models. Therapists maintain a home theory and incorporate techniques from other theoretical orientations, often reinterpreting the meaning of the technique through the lens of the home theory. This integrative path is frequently favored by those child clinicians trained in a single approach. Rather than discard their theoretical foundation as they discover its limitations, clinicians gradually incorporate parts and methods from other approaches and mold these into a new form.

Assimilative integration is common within child treatment but can be difficult to identify when the integration is not explicitly acknowledged. Many unacknowledged integrations occur in treatments that have strong evidence base that identifies them solely as CBT but that employ play techniques (Krueger & Glass, 2013).

(p. 346) Coming largely from a systemic orientation, Ellen Wachtel (2004) integrates family systems, behavioral, and psychodynamic approaches for the treatment of children and their families. She conceptualizes the child’s difficulties as embedded in and reinforced by family interactions, although the treatment focuses mainly on the child as the identified patient rather than the family system. Similarly, an adolescent case study illustrated this integrative model to guide child work by adapting it to the client’s developmental age (Clement, 2011). The therapy draws from cognitive-behavioral, person-centered, and positive psychology orientations.

A good example of assimilative integration is seen in a play therapy case study within a school setting which blended three theories into a cohesive treatment driven by the child’s and/or family’s needs (Fall, 2001). Child-centered play therapy (the home theory) was buttressed with evidence-based Adlerian play therapy and cognitive-behavioral methods along with corresponding techniques (Fall, 2001), and this was shown to be effective. Research has shown that play therapy interventions prove useful in meeting the treatment needs of children and families (Landreth et al., 1996).

Common factors is an approach to integration that identifies clinical principles or change processes shared by several psychotherapies in the hope that these robust commonalities will form the foundation of successful treatment. In a review of more than 50 publications, it was found that 41% of the proposed commonalities had to do with change processes, while only 6% were attributed to client characteristics. The strongest consensus across therapies was the development of a therapeutic alliance, opportunity for catharsis, acquisition and practice of new behaviors, and the client’s positive expectancies (Grencavage & Norcross, 1990). Practice Wise is a web-based program that helps identify common factors across evidence-based child treatments and then matches them to the clients’ needs (Chorpita, Becker, & Daleiden, 2007; Chorpita et al., 2011).

The attachment-focused developmental psychotherapy of Hughes (1997) encourages the use of an integrative model that utilizes play therapy within family work with adoptive children. The commonalities across each of these treatments are the use of play therapy principles, which are utilized within sessions and at home with the parent and child, along with psychoeducational principles of parenting.

Of course, these four pathways to integrative treatment are not mutually exclusive. Consider the work of Goldenthal (2005) who created a model that integrated psychodynamic, behavioral, and contextual theories. At first blush it appears a classic example of theoretical integration; however, the psychotherapy was prescriptive in recommending the right intervention to the right child in the tradition of technical eclecticism. Furthermore, the treatment focuses on the therapeutic relationship—the quintessential common factor—as the central change agent (Krueger & Glass, 2013).

All told, the multiple routes to integration in child psychotherapy offer clinicians several ways through which they can conceptualize patient concerns, address both interpersonal issues and environmental factors, and select from a rich array of efficacious clinical methods. Consequently, the clinician can select interventions and use them in a coordinated and efficient manner (Krueger & Glass, 2013).

Assessment and Formulation

The basic task of assessment in child integrative psychotherapy is similar to any other model of working with children: a comprehensive assessment through multiple sources and methods that collects data on the child’s development (including in utero and birth history), presenting problems and circumstances underlying them, strengths and weaknesses of the child and family as a whole, spiritual and community resources, cultural components, and the family system (Coonerty, 1993; Drewes & Schaefer, 2015). A crucial component in integrative assessment is that the child therapist involves both the parents/caregiver and the child as active collaborators in treatment and treatment planning. The child therapist needs (p. 347) to be attuned to important connections and systemic interplay, working like a skilled detective to piece together a coherent picture that is multilayered and multiconnected. Indeed, each puzzle piece represents only a single dimension (Coonerty, 1993). Thus, careful assessment, be it conducted through formal measures or informal observations, is critical to make the optimal selection of interventions and to coordinate communication among those providing services.

Treatment planning is based on developmental awareness of the child in order to provide direction throughout all stages of therapy, monitor progress, and know when termination can occur. Having a developmental framework prevents establishing unreachable goals and permits the selection of appropriate content and the level of therapeutic interaction that is best suited to the child. Furthermore, as suggested earlier, the child therapist also needs to be sensitive to developmental delays in children, particularly in cognition and language, that impact treatment planning and differentiate them from behavioral or emotional disorders. Psychological testing is not necessarily a prerequisite for treatment but frequently proves useful and, of course, is demonstrably more reliable and valid than informal assessment.

Verbal treatment is ineffective with young children because of their limited abstract thinking and development; consequently, use of non-verbal play therapy is critical for effective treatment (Coonerty, 1993). Verbal treatment is ineffective in early childhood (4–7) because there is a primitive level of development, egocentric thinking, a present-time orientation, along with the child struggling to develop a constant sense of self and other. The child uses internal fantasy without a clear fantasy/reality boundary. In middle childhood (8–13), while children may become more verbal, there is a fascination with rules and complexities of the real world along with the emergence of formal operations; abstract reasoning; and problem solving that needs to be developed and utilized through play-based activities (Drewes & Schaefer, 2015).

Assessment instruments and the integrative process with children must be consistent with the purpose of the assessment, acknowledging the vital contexts and attuning to cultures of the family system. Child therapists can utilize numerous assessment approaches including standardized tests, rating scales, interviews, observations, projective techniques, and informal assessment in order to develop a complete picture from multiple angles and informants,

There are numerous formal norm-referenced, standardized psychological assessment tools for use with children. Popular normative assessments include the Behavior Assessment System for Children, Third Edition, which offers a structured developmental history for ages 2–21 (Kamphaus et al., 2014), Connors Comprehensive Rating Scales for ages 6–18 (Kollins, Epstein, & Connors, 2014), the Achenbach System of Empirically Based Assessment for ages 6–18 (Achenbach & Resorla, 2014); Child and Adolescent Needs and Strengths (CANS, 1999), and the Devereaux Behavior Rating Scale for ages 5–18 (Naglieri & Pfeiffer, 2014). These assessments can be done during an intake with the parent/caregiver.

Observations within the initial sessions with the child can obtain data and frequency counts, as well as provide information for informal hypotheses generation and in vivo identification of strengths and weaknesses. Play-based assessments allow the child therapist to look at the quality of the child’s play and to identify consistent or clinically significant themes. The child’s perceptions of her parents/family, events, and environmental/systemic settings (including school) are examined. In addition, the quality of the expression of affect, ability to regulate affective range, and intensity and level of enjoyment, as well as the ability to soothe, sustain, focus, shift and inhibit attention, and levels of impulsivity and frustration are observed. The child’s maintenance of physical boundaries, as well as the richness or paucity of play content, level of dependent versus independent interactions, and whether the age level and developmental level are congruent with the play and child’s physical abilities are all assessed. Informal assessment tools include (p. 348) projective drawings, puppet interviews, and sentence completions.

The formulation begins with the comprehensive assessment of the symptoms and determinants (internal and external) of the child’s presenting problems. An individualized case formulation describes and explains the child client’s most important disorders and probable causal or contributor variables, along with treatment plans and predicted obstacles as a means for evaluating progress.

The child therapist then looks to prescribe interventions to alleviate the client’s problems, thereby formulating defined treatment goals and detailed “nuts-and-bolts” strategies for achieving these goals. Because the integrative child therapist is not confined by single-school theories, the combination of theories and techniques can strengthen a treatment plan. Individual, group, and family strategies may be integrated, as well as multiple systems of care. A multicomponent, multimodal intervention can thereby address the complex and multidimensional psychological disorders experienced by children.

Processes of Change

Shirk and Russell (1996) proposed 11 change processes as the basis for an integrative model of child therapy. They fall under three broad processes.

  • Cognitive: Schema transformation, symbolic exchange, insight, and skill development

  • Affective: Abreaction, emotional experiencing, affective education, and emotional regulation

  • Interpersonal: Support, corrective relationship, and supportive scaffolding (O’Connor, 2001)

Kazdin and Knock (2003) studied the mechanisms underlying therapeutic change related to symptom improvement in child therapy. They proposed that evidence-based practices can be improved with regard to clinical applicability in real-world settings by studying the discrete mechanisms of therapeutic change. Understanding how change processes work within best practices is the critical link in moving evidence-based practices from research to the service settings of usual care.

As noted earlier, play has a long history in child psychotherapy as it is the natural language and mode of expression for children (Drewes, 2005). Four broad functions of play in child work (Russ & Niec, 2011) are providing a means of expression, communication, and relationship building; insight and working through; practicing new forms of expression and relating; and problem-solving. Depending on which methods are utilized in the integrative approach, the change mechanisms probably differ. Aside from those noted earlier, any number of the following factors may constitute change processes.

  • Cognitive processes: Direct/indirect teaching, schema transformation, symbolic exchange, interpretation-insight, skill development, competence and self-control, accelerated development, creative problem solving, fantasy compensation, and reality testing

  • Emotional processes: Self-expression and emotional experiencing, access to the unconscious, abreaction release and sublimation, affective education, emotional regulation, stress inoculation, counterconditioning of negative affect

  • Interpersonal processes: Validation and support, supportive scaffolding, corrective relationship and attachment and relationship enhancement, power/control, moral judgment and empathy (Schaefer & Drewes, 2013)

Differential therapeutics recognizes that some interventions are more effective than others for certain disorders and particular clients. A client who does poorly with one type of child therapy may do well with another. The greater our understanding of the change mechanisms, the more effective the child therapist can be in (p. 349) applying them to meet the particular needs of his or her clients (Schaefer, 1999).

Therapy Relationship

The therapeutic relationship remains integral to the effectiveness of child work. Indeed, the most robust research (and clinical) finding in the child psychotherapy literature is the strong association between the therapeutic alliance and treatment outcome. A recent meta-analysis of 42 studies of child and adolescent therapy (3,427 clients and parents) revealed an effect size of (d) of 0.39 for the both therapist–child and therapist–parent/caregiver relationship (Karver et al., 2005). The association and prediction of treatment success did not differ by the type of treatment; that is, the alliance “works” in all forms of child therapy.

That relationship can be enhanced by soliciting feedback from the child/family client and by routinely monitoring outcome. This process is the core ingredient to patient progress regardless of the therapeutic approach taken (Duncan, 2013), as is therapist empathy, collaboration, positive regard, and genuineness (Norcross, 2005).

Children are clearly aware that they have been brought to therapy by others who can also force them to attend sessions. The usual adult approach of asking questions, probing into personal feelings, or explaining behaviors usually results in uncooperativeness or strong emotional responses. The therapist needs to explain what the treatment process will be like, not only verbally but also through the use of play-like techniques to communicate the expectation that the relationship is playful, creative, and not always based in verbalizations. Offering factual transparency about the treatment process, collaborative creation of treatment planning, and a nonjudgmental approach toward engagement will help the child to see how this therapeutic relationship will differ from those with peers, teachers, parents, and others (Prout & Fedewa, 2015).

As is most certainly the case in working with adults, creating a safe therapeutic relationship is critical when working with children. The child therapist’s behavior in the session, as well as his or her attitude toward the client, are keenly perceived and reacted to by children. The relationship needs to be fostered and built through transparency, honesty in sharing information, nonintrusiveness, reliability, attunement, and curiosity about the client’s internal experience, coupled with the use of play and humor within sessions. Critical, especially with trauma work, is the sensitive timing and depth of therapeutic interventions.

The therapist’s role will vary depending on the particular approach taken and its application. Thus, the therapist may need to be directive and structured when implementing a behavioral approach or nondirective when creating rapport and a therapeutic relationship or utilizing a more child-centered approach. That is precisely the value of psychotherapy integration.

Methods and Techniques

Integrative treatments offer systematized methods, with the majority designed for specific child disorders. Treatment for trauma has by far been the best developed, followed by treatments for behavioral disorders (Krueger & Glass, 2013). The therapeutic menu of methods in integrative therapies canvass the entire spectrum of interventions. In the evidence-based tradition, we advocate that selection of particular methods be based on all three evidentiary sources: best available research, clinical expertise, and patient characteristics, preferences, and cultures. Research on the efficacy of methods aids clinical decision-making but does not dictate it; much depends on the skill of the therapist (Schaefer, 2003).

As we have indicated throughout this chapter, working with young children includes play-based interventions that are developmentally sensitive and geared to their abilities. Play as therapy (child-centered, nondirective) and play in therapy (directive), includes expressive arts, use of miniatures to create a scene or story in a sand tray, puppet play, drama role play, (p. 350) music, art, therapeutic storytelling, dance, and movement (Drewes, 2009).

Diversity Considerations

Clearly, a child is a product of his or her nuclear family, extended family, neighborhood, cultural and racial heritage, school, town/city, socioeconomic status, and political situation. These systemic components result in multiple causality and feedback loops that significantly impact treatment choices when working with children. Poverty, poor housing, alienation, disenfranchisement, and cultural and gender identities critically influence the child’s cognitive, dynamic, and behavioral repertoire (Gold, 1992). Thus, child therapy attends deeply to diversity considerations and seeks key opportunities to provide effective social intervention beyond just changing a child’s internal chemistry or cognition (Lebow, 2008). The child clinician needs to account for the individual differences within each client, creating a case formulation and treatment plan unique to each child’s needs.

Play is a universal expression of children, and it can transcend differences in ethnicity, language, and other aspects of diversity. It is important for clinicians to be aware of cultural differences that may exist. A study of play therapists found that they rated themselves as not being knowledgeable about racial identity and feeling competent in using this knowledge clinically (Drewes, 2005). This may also prove the case for many other child therapists. All child clinicians need to be sensitive regarding diversity in the assessments used and interventions chosen (especially with regard to what population it was normed on), as well as inclusive in the techniques and materials used in treatment. Having culturally, racially, and ethnically diverse therapeutic toys and materials is crucial (Drewes, 2005). (p. 351) (p. 352)

Outcome Research

In spite of the growth of psychotherapy integration, there is little outcome research on explicitly integrative child therapies (Schottenbauer, Glass, & Arnkoff, 2005; Seymour, 2011), with few systematic reviews of integrative treatment for children (Krueger & Glass, 2013). That’s the bad news. The good news is that by using, in part or in whole, evidence-based child therapies, integrative clinicians can harvest the fruits of that vast outcome research. While there is moderate but clear support for the general effectiveness of child therapies, there continues to be a need to take a cautious and thoughtful approach to child treatment (Prout & Fedewa, 2015).

Child behavioral therapy and outcome research have begun to incorporate a more integrative approach, with assimilative integration becoming more commonplace within CBT (Krueger & Glass, 2013). In general, a trend has emerged of CBT integrating aspects of other treatments, while integrative treatments frequently utilize CBT methods.

Future Directions

Integration is clearly gaining hold in child psychotherapy, but much work remains to be done. More outcome research is needed, especially research identifying change mechanisms of successful child psychotherapy, as well as the prescriptive matching of those change mechanisms to varying clinical circumstances. Further research is needed to illuminate which specific uses of play are most effective with specific presenting problems and within the blending of treatment approaches. Based on our clinical observations and those of our colleagues, we expect that future research looking into these complex processes will wind up providing empirical support for integrative treatments.

Clinically, many cognitive-behavioral treatments for young children would benefit from the incorporation of other approaches, especially less directive techniques. Treatment and research would also be better informed if the play-based techniques included the anchoring theories behind their application.

Perhaps the most severe obstacle to integration comes from territoriality of the purists who hold their single theory to be the best. We advocate for work toward common definitions and language in psychotherapy to decrease the inconsistency of terminology. In that way, a commonly understood experience can be implemented in practice and measured in research (Seymour, 2011).

There still is inadequate training in integrative child therapy in university and internship settings. Consequently, student clinicians are not fluid in thinking about using several different approaches and do not feel (p. 353) well-grounded in responding to the realistic clinical complexities of working with children. Training in academic settings needs to furnish ample and diverse experiences imparting technical and interpersonal skills that then lead to establishing competence (Norcross & Halgin, 2005; Seymour, 2011).

In spite of these and other hurdles, in recent years, the clinical practice of child integrative psychotherapy has grown considerably. It is important that these clinical observations inform research process and outcome research to further enhance the synergy between practice and research. Such convergence between research and practice will not only allow the therapist to borrow flexibly from multiple theoretical positions to tailor treatment to a particular child, but also will result in cost-effective interventions.


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