para />
Important distinctions are made between psychotherapy and counseling for children/teens compared to adults/couples.
The focus of evaluation must include attention to parent and family processes and factors. Interventions typically include interactions and sessions with parents as well as collateral work with teachers and other school personnel.
Younger children will often be evaluated and diagnosed through behavioral descriptions provided by parents and other adults who know them well as well as through direct observation and/or play techniques. Children of all ages should be screened using behavioral checklists that are norm-referenced for age.
Any child or teenager who requests counseling should be interviewed initially by the primary care provider and referred appropriately. Most referrals will be in response to parental request, however.
Psychotherapeutic interventions with the strongest empirical basis with children include behavior therapy/modification, CBT, and family/parenting therapy. Play therapy has the least empirical support, and insight-oriented therapies appear to be more effective with older children (>11 years).
There is controversy regarding the efficacy of psychopharmacologic treatment in preadolescents, although clear benefits have been demonstrated in some studies. Treatment guidelines for mild to moderate depressed mood and/or anxiety disorders typically recommend pediatric CBT initially, and studies have typically supported this approach in preteen and milder cases.
á
EPIDEMIOLOGY
- ~18.8 million adults suffer from clinical depression, and 20 million suffer from a diagnosable anxiety disorder.
- One in four Americans report seeking some form of mental health treatment in their adult life. This includes generic counseling in nonmedical settings such as work, clergy, or school settings and also includes visits to primary care providers. It is estimated that between 3.5% and 5% of adults in the United States actually participate in formal mental health psychotherapy annually.
- Public health experts report that the majority of those adults with diagnosable psychiatric disorders, however, do not receive professional mental health services. This is due to multiple factors, including failure to identify, noncompliance with psychiatric referral, regional shortages of providers, economic barriers, and excessive time duration from referral to available service.
- A large study conducted between 1987 and 1997 concluded that the percentage of adults in psychotherapy remained relatively stable over that decade, the use of psychopharmacology doubled, and older adults (aged 55 to 64 years) increasingly sought psychotherapy services. In that same study, it was found that psychotherapy duration (number of sessions) decreased substantially and about 1/3 of psychotherapy patients only attended one or two sessions.
RISK FACTORS
The need for psychotherapy or counseling services is directly and indirectly associated with a host of socioeconomic and biogenetic factors, including the general effects of poverty, family or marital dysfunction; life stressors; medical diseases or conditions; and individual biologic predisposition to mental health disorders. á
GENERAL PREVENTION
It is generally assumed that early identification and intervention of child and adolescent psychopathology increases the likelihood of reducing the risk for adult psychopathology, but this has not been sufficiently validated in all categories of psychological disorders. Data support such claims in disorders such as childhood ADHD, anxiety disorders, and habit disorders of childhood, however. á
TREATMENT
GENERAL MEASURES
There is evidence of a "dose effect"Ł in psychotherapy outcomes research, with some investigators suggesting that 6 to 8 sessions are necessary to yield positive initial effects and upward of 15 to 20 sessions for longer term, sustainable therapeutic effects. This dose effect may not be applicable to counseling services with primarily informational or emotional/supportive functions. Also, long-term therapy should be evaluated at 6- to 12-month intervals to determine efficacy. á
MEDICATION
- Psychotherapy is most likely to be accompanied by use of pharmaceutical adjuncts in moderate to severe cases of psychological dysfunction that do not respond to other therapies or in cases of extremely poor quality of life or high risk. The most common examples are in cases of clinical depression or anxiety that clearly incapacitates the patient or significantly reduces his or her quality of life. Patients at risk for suicide or who represent a danger to others are also candidates for acute psychopharmacotherapy. Studies suggest that verbal and behaviorally oriented therapies can add efficacy to medication treatment in both depression and anxiety.
- There is controversy in the research field regarding the efficacy of medication alone versus psychotherapy alone versus combined treatments. The most recent consensus has been that combined treatments in moderate to severe psychological dysfunction are most likely to render positive short-term results and increase the likelihood that such effects can be sustained over time.
ADDITIONAL THERAPIES
- Anxiety disorders
- Panic disorder with and without agoraphobia: CBT, psychodynamic therapy
- Generalized anxiety disorder: CBT
- Obsessive-compulsive disorder: CBT
- Posttraumatic stress disorder: CBT
- Specific phobia: CBT
- Social phobia: CBT
- Mood disorders
- Unipolar depression: CBT, interpersonal therapy, psychodynamic therapy
- Bipolar disorder: family therapy, interpersonal therapy, CBT
- Schizophrenia: psychodynamic therapy, family therapy, CBT
- Eating disorders
- Binge eating disorder: CBT, interpersonal therapy
- Bulimia nervosa: CBT, interpersonal therapy
- Personality disorders
- Substance-use disorders
- Alcohol: counseling, CBT, motivational interviewing
- Cocaine: CBT, counseling
- Heroin: CBT, counseling
- Smoking: 5 A's
- Somatoform disorders:
- Hypochondriasis: CBT
- Body dysmorphic disorder: CBT
COMPLEMENTARY & ALTERNATIVE MEDICINE
A host of nonempirically based psychological and nutritional therapies can be found outside of mainstream medicine and psychological science. Very little or no evidence exists to support such experimental therapies, but all have the considerable power of the placebo effect fueling their anecdotal supports or claims. Placebo effects are also thought to be powerfully enhanced by the use of ingested or applied substances that create real physiologic, although not therapeutic, changes in the patient. If it makes them feel different, they are more likely to believe it helps. á
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
There is evidence of a "dose effect"Ł in psychotherapy outcomes research, with some investigators suggesting that 6 to 8 sessions are necessary to yield positive initial effects and upward of 15 to 20 sessions for longer term, sustainable therapeutic effects. This dose effect may not be applicable to counseling services with primarily informational or emotional/supportive functions. Because many patients cease attendance to psychotherapy sessions after one or a few sessions, most interventions of this type cannot be accurately evaluated by the referring provider. Long-term therapy should also be evaluated for effectiveness at regular periods. á
REFERENCES
11 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.22 World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva, Switzerland: World Health Organization; 1992.
ADDITIONAL READING
- Bortolotti áB, Menchetti áM, Bellini áF, et al. Psychological interventions for major depression in primary care: a meta-analytic review of randomized controlled trials. Gen Hosp Psychiatry. 2008;30(4):293-302.
- Eddy áKT, Dutra áL, Bradley áR, et al. A multidimensional meta-analysis of psychotherapy and pharmacotherapy for obsessive-compulsive disorder. Clin Psychol Rev. 2004;24(8):1011-1030.
- Furukawa áTA, Watanabe áN, Churchill áR. Combined psychotherapy plus antidepressants for panic disorder with or without agoraphobia. Cochrane Database Syst Rev. 2007;(1):CD004364.
- Hunot áV, Churchill áR, Silva de Lima áM, et al. Psychological therapies for generalised anxiety disorder. Cochrane Database Syst Rev. 2007;(1):CD001848.
CODES
ICD10
- Z71.9 Counseling, unspecified
- Z71.89 Other specified counseling
- Z63.9 Problem related to primary support group, unspecified
ICD9
- V65.40 Counseling NOS
- V65.49 Other specified counseling
- V65.8 Other reasons for seeking consultation
- V61.10 Counseling for marital and partner problems, unspecified
- V61.20 Counseling for parent-child problem, unspecified
SNOMED
- 409063005 Counseling
- 171022008 Psychological counseling
- 311764000 Family counseling (procedure)
- 68168001 Marital counseling (procedure)
- 52184009 parent-child problem (finding)
CLINICAL PEARLS
- Combined medication and psychotherapeutic treatments in moderate to severe psychological dysfunction are most likely to render positive short-term results and increase the likelihood such effects can be sustained over time.
- Relapse is common over time and/or as treatments are discontinued.
- Children <10 years may benefit significantly from counseling or psychotherapy alone for symptom relief.
- Older children and those with more severe symptoms typically require psychopharmacologic options in concert with counseling or verbal therapy approaches.