342 Chapter 40
suggest it is as effective in treating depression in adolescents as in adults,
and has an effect of the same order as cognitive-behavioural therapy.
Individual counselling and psychotherapy
There are differing levels, on a continuum from support and counselling
at one end to psychodynamic psychotherapy at the other:
Support and counselling. This includes unburdening of problems to a sym-
pathetic listener, ventilation of feelings within a supportive relationship,
and discussion of current problems with a non-judgemental helper.
Advice may be given. The main aim is to relieve symptoms and restore
the status quo prior to the difficulty, or come to terms with an event.
Intermediate levels of psychotherapy. Interpersonal psychotherapy (IPT) as
described above is an example of this.
Psychodynamic psychotherapy. Here, a prolonged deep interpersonal re-
lationship is fostered, during which both intra- and interpersonal pro-
cesses are revealed and analysed. Disturbing early experiences may be
relived, allowing conflicts that underlie symptoms to be explored and
insight gained, and conflicts to be worked through and resolved without
handicapping defences. Advice is not given. The aim is thus more than
symptomatic relief: it is reintegration and change in personality func-
tioning towards greater wholeness and maturity. Psychoanalytic interest
in children’s symptoms dates back to Sigmund Freud, who described
the case of little Hans in 1909; in the 1920s his daughter Anna Freud
elaborated child psychoanalysis, as did Melanie Klein in the 1930s.
Later, Virginia Axline developed play therapy more formally. During
sessions the therapist may feed back interpretations and formulations
not only of material the child brings up, but also their immediate style
of relating during the session.
A major issue in individual work at all levels is the quality of the inter-
personal relationship between therapist and patient. Several adult studies
show that irrespective of the particular form of personal therapy given,
one of the major determinants of outcome is the warmth and empathy of
the therapist. One way of addressing the need for this empirically would
be to give the same (or as similar as possible) treatment by correspondence
or in a manual. In the field of parent-training for child conduct disorder,
studies show that these approaches are indeed effective, although less so
than when a live therapist is involved.
In child and adolescent psychiatry, much work for the benefit of the
child is done through the parents, and counselling and support for parents
are part of many clinicians’ basic repertoire irrespective of their child’s
disorder. It may be a major component in helping parents to come to terms
with a diagnosis of intellectual disability, or in coping with their child’s
depression. Studies on counselling in these settings suggest parents find
the apparent attitude of the clinician to them central (‘likes me, likes my
child’), and want an informal atmosphere where they can ask questions.