Child Therapy: Concepts, Strategies, and Decision Making

This small book about child psychiatry therapy is number 15 in the Brunner/Mazel Basic Principles Into Practice Series, devoted to a variety of unrelated mental health topics sitting on the interface between the general principles of psychology and the specialized treatment of illness. Child psychiatry and child psychoanalysis were both once considered odd stepchildren of adult psychiatry and adult analysis. My adult analyst colleagues used to ask, “When is psychoanalysis not psychoanalysis?” The answer: “When it’s child analysis, which is play therapy.” Another once too frequent prejudice was expressed by the bemused, superior comment, “They [child psychiatrists] are loonier than the monsters they treat.” These attitudes could probably have been attributed to stranger anxiety, which has evaporated in the atmosphere of massive rates of child violence and child abuse in the United States. Now both child and adolescent psychiatry are legitimate subspecialties that recently have become increasingly popular choices for new graduating psychiatrists facing a suddenly tough job market.

The authors of this book, clinical professors of psychiatry in Texas, provide us with a vivid slice of the experience of treating children in private practice in today’s hurry-up, brave new world of cost cutting and third-party payers. They show us in detail how even in this environment the therapist must begin intervention with a detailed assessment of child, parents, and availability of helping resources proceeding to creation of a therapeutic alliance, selection of the most apt treatment modality, and, finally, the process of termination. The array of treatment options are outlined; these include cognitive behavior therapy, group therapy, family therapy, consultation with the school, and medication management. The most extensive effort is given to descriptions of individual therapy.

Consistent with this last emphasis, the book’s orientation is clearly developmental (the patient’s treatment must always incorporate consideration of the next expected social, cognitive, and biological milestone), and psychodynamic (meaning is elicited, symptoms and deficits are to be understood, and talking is important). In their introduction, the authors say that they “hope our language will not be a barrier to your understanding,” a wish not always fulfilled. In communicating principles of treatment, they have an unfortunate tendency to string together lists of adjectives and nouns, and sometimes they reach too far into the world of the arcane. If David Rappaport’s concept of “the ego’s autonomy from the environment was protected by the Id, while the ego’s autonomy from the Id was protected by the capacity for perception, motility and memory” has clinical relevance to the treatment of any real child, I will eat the preceding sentence.

The authors emerge as sensitive clinicians, however, through the skillful use of 18 case examples covering the social and psychoeducational psychotherapy waterfront and illustrating the wide diversity of roles and activities the contemporary child psychiatrist must master. These range from fostering hope, promoting adaptation to particular kinds of stress, and changing the family milieu to using play therapy in getting to significant meaning and understanding.

The chapter devoted to managed care is perhaps too brief in view of the lengthening shadows that health maintenance organizations are casting over all of our therapeutic efforts. There are extensive discussions of ethical aspects of treatment and the need for further outcome research, two subjects too often neglected by many longer books devoted to the psychiatry of children.

The most important contribution of this book is the demonstration of the clinical advantages of allowing sufficient time to listen carefully to the child, to comprehend fully the meaning conveyed by both words and behavior at home, at school, with and without the presence of peers, and in the office. The value of assisting the child by hook or by crook—even by medication—to attain the next developmental landmark is beautifully illustrated. I recommend the book particularly to the younger professional who is not yet addicted to the managed care therapy dictum, “Brief is better, and briefer is better still.”