A Handbook of Integrative Psychotherapies for Children and Adolescents

Dr. Santostefano has provided us with a tour de force: a clinically powerful book that is based on solid research. The case histories are absorbing. The reader becomes a privileged participant with access into the treatment room and the viewpoints of both the child and the therapist. Dr. Santostefano generously provides us with an enriched understanding of his therapeutic interventions. The cases of John, Teddy, Laura, Mary, Harry, and Albert are absorbing and compelling instructional guides of how to engage in the intersubjective process of child psychotherapy.

A prolific writer, Dr. Santostefano has contributed several other major books on child psychology and therapy (1–5). His biobehavioral approach to child psychology in the context of cognitive control and integrative psychotherapy for children and adolescents has established him as a major contributor. This new tome is a mature Santostefano, the wise clinician who gives us a fully integrative approach to theory and treatment. In the process of unifying the behavioral and psychodynamic approaches to theory and treatment, he shows us his skills as scholar, epistemologist, researcher, and clinician.

Dr. Santostefano sees a fundamental dualism in theory and practice that needs to be dissolved so that an integrated model can be substituted. He views eclecticism as a source of “segregation.” Although he is able to identify 230 different forms of psychotherapy, the three dominant approaches—cognitive, behavioral, and psychodynamic—become the focus of his integrative approach. As an epistemologist, Santostefano chooses Hegel’s concept of “dialectics” as the core metaphor to unite the principles of objectivism (that there is true knowledge) and interpretationism (that truths are constructed in experience) into responses to the following issues: how to define knowledge and how is it acquired, how to determine what are the strategies of knowing, how to understand meta-theoretical assumptions, how to describe the metaphors of human functioning, and how all of this leads to changes and growth and approaches to psychotherapy. He is very aware of the importance of the unconscious and tacit knowledge and how even behaviorists have relented and are turning to contructionism, symbolism, meanings, affects, and representation as primary topics and issues for cognitive behavior therapy.

In an integrated model the meaning a child gives to his or her experience is central to therapy. The therapist has to listen attentively. Rather than providing a corrective experience and a core base of knowledge to change the child’s behavior, the therapist attempts to understand the meaning of the child’s messages and connect with the child’s conflicts intersubjectively and intrasubjectively. Although diagnosis is critical to formulating a treatment plan, Dr. Santostefano does not like or adhere to DSM-IV. He espouses a developmental-dialectical approach, which he views as more heuristic than DSM-IV categories. He “removes the barriers to segregating Objectivism (real knowledge) and Interpretationism (subjective knowledge)” by emphasizing developmental processes of change as differentiation, integration, and flexibility of functioning and the dialogue of negotiation. All of this is seen as originating in the perspective of the needs of a child versus the meta-epistemologies of theorists and practitioners. Dr. Santostefano states his position:

Dr. Santostefano defines a hierarchy of 10 issues that should be considered by any theorist employing models of psychotherapy integration for children. This hierarchy includes the following: the need to view behavior as being treated either outside and on the surface or inside and deep; the need to relate what a person does with what a person imagines, thinks, and says; the need to understand the relation between cognition and emotion; the need to understand the meaning a person gives experiences; a recognition of the importance of conscious and unconscious processes; an awareness of how contexts, environments, and situations affect child development and pathology; the recognition of the core principle of psychological conflict; an awareness of how the relationship between patient and therapist affects treatment; understanding the principles of how therapists can be helpful; reconsidering the importance given to verbal labeling and interpretation; and using developmental principles as the glue for integration.

For Santostefano the first 2 years of life are critical in terms of how the relationship between infant and caregiver (mothering object) affects organizational issues of self. In this vein he integrates the approaches of Jean Piaget, Daniel Stern, Louis Sander, Beatrice Beebe, and Frank Lachmann and places “at the center meanings (representations) in infant constructs from experiences.” As these “embodied schemas are gradually translated into symbolic forms” they are extended into and influence schemas that develop in childhood and beyond. The toddler’s schemata eventually become “life metaphors” for the developing self. Therapy is directed at revising a child’s rigid life metaphors, rigid cognitive functions, and rigid modalities “so that what a child does, imagines, and says become interrelated.” The main catalysts of change are identified as cycles of dialectical interactions, enactments, idealization, and internalization. “Promoting flexibility in meanings, cognitive functioning, and modes of expression, then, is the focus of the treatment process.” Verbalization is not the primary vehicle for change because many of the meanings a child gives to experience are preverbal and embedded in the process of interaction. In this sense the therapist becomes an “active participant” in the therapy in much the same way that adult theorists talk about the bipersonal field and the intersubjectivity of the transference.

The shortcomings of the book are 1) a lack of regard for the use of psychotropic medications or an analysis of current trends toward case management versus psychotherapy (and a discussion of the disadvantages of that position) with children and adolescents and 2) the use of the term “dialectical,” which is ill defined, clumsy, and may be confused with Dr. Linahan’s use of the term in “dialectical behavior therapy.” All in all, Dr. Santostefano his written a marvelous book. It should be required reading for any trainee and fellow in child and adolescent psychology or psychiatry.