Criteria of Progress in Child Psychotherapies According to Psychotherapists¹

Critérios de Progresso em Psicoterapias de Crianças na Avaliação de Psicoterapeutas

Criterios de Progreso en Psicoterapias de Niños en la Evaluación de Psicoterapeutas

Abstracts

This study aimed to perform a survey with psychotherapists, regarding the criteria they consider relevant to measure the progress of children in psychotherapy and whether the criteria indicated by them differ according to the therapist’s theoretical approach. Therapists were contacted electronically and answered a questionnaire composed of items with criteria of positive change present in the literature. Participants were 154 child therapists from different regions of Brazil. The analysis regarding the criteria of positive change that the participants indicated and their theoretical approach suggested that, despite the theoretical differences, in practice psychotherapists seem to adopt similar criteria to interpret progress in child psychotherapies. The criteria mentioned may be useful for a better systematization of the psychotherapy techniques for children. However, due to the lack of elements to evaluate the sample’s representativeness, caution is advised in generalizing the results.

child psychotherapy; evaluation; change

O trabalho teve como objetivos fazer um levantamento junto a psicoterapeutas de crianças, de várias abordagens teóricas, sobre os critérios que consideram relevantes para aferir progresso e se estes diferem de acordo com as linhas teóricas. Os terapeutas foram contatados por meio eletrônico. Responderam a um questionário com itens compostos por critérios de mudança positiva presentes na literatura. A amostra foi composta por 154 terapeutas de crianças de diferentes regiões do Brasil. A análise envolvendo os critérios de mudança positiva e a abordagem teórica do participante sugeriram que apesar das diferenças teóricas, os psicoterapeutas, na prática, parecem se apoiar em critérios semelhantes para interpretarem o progresso em psicoterapias infantis. Os critérios mencionados poderão ser úteis para uma melhor sistematização das técnicas de psicoterapias infantis. Entretanto, devido à falta de elementos para avaliar a representatividade da amostra, sugere-se cautela na generalização dos resultados.

psicoterapia infantil; avaliação; mudança

El trabajo tuvo como objetivos realizar un trabajo junto con psicoterapeutas infantiles, de varios aproximaciones teóricas diferentes, sobre los criterios que consideran relevantes para mensurar progreso y si estos criterios difieren de acuerdo con las diferentes líneas teóricas. Los terapeutas fueron contactados por medio electrónico. Respondieron a un cuestionario con puntos compuestos por criterios de cambio positivo presentes en la literatura. La muestra se compuso de 154 terapeutas infantiles de diferentes regiones de Brasil. El análisis involucrando los criterios de cambio positiva y la aproximación teórica del participante sugirieron que, a pesar de las diferencias teóricas, los psicoterapeutas, en la práctica, parecen apoyarse en criterios semejantes para interpretar los progresos en psicoterapias infantiles. Los criterios mencionados podrán ser útiles para una mejor sistematización de las técnicas de psicoterapias infantiles. No obstante, debido a la falta de elementos para evaluar la representatividad de la muestra, se sugiere cautela en la generalización de los resultados.

psicoterapia infantil; evaluación; cambio

Psychotherapy with children can be defined as an intervention that aims to address diverse problems that cause emotional stress, interfere in the day-to-day life, hinder the development of adaptive skills, and/or threaten the well-being of the child and others around them (Weisz, Jensen-Doss, & Hawley, 2006). It is carried out by psychotherapists according to different theoretical approaches and professional formations. Regarding the approaches, the more traditional are the psychoanalytic, person-centered, behavioral, and cognitive-behavioral (Cartwright-Hatton & Murray, 2008; Deakin & Nunes, 2008; Dorfman, 1951/1992; Kazdin, 2000; Klein, 1932/1996; Serralta, Pole, Nunes, Eizirik, & Oslen, 2010;Silvares & Souza, 2008). The psychodynamic aspect was recently derived from the psychoanalytic approach (Mito & Yoshida, 2004; Romanowski, 2004; Yanof, 2005). The person-centered approach is combined with other approaches with strong humanist bias, such as gestalt therapy, transactional analysis, psychodrama, and systemic therapy (Fossum, Handegard, Martinussen, & Morch, 2008; Oaklander, 1978/1980).

A major concern in psychotherapy is to assess whether it is successful, i.e., whether it managed to lead the patient to the desired changes. In the clinical practice, most psychotherapists are guided by theoretically based criteria to assess the progress of the patients. In these cases, the results of the therapies tend to be considered satisfactory when they fulfill the expectations of the therapist, who tends to translate them in conceptual terms attuned to their theoretical framework (Yoshida, 2012). Despite the theoretical literature that can be applied to the positive changes that occurred, these changes are always evidenced in alterations in the conduct and behavior of the child and can thus be described in behavioral and/or attitudinal terms. With this, the theoretical differences between the therapists are minimized and a common knowledge base can begin to be established (Kazdin, 2000; Meissner, 2007; Oliveira, 2002; Prebianchi & Cury, 2005; Weisz et al., 2006).

An example of a “more attitudinal” perspective of positive change in child psychotherapy can be found in the study by Kernberg (1995), which highlights, from the psychoanalytic point of view, the following aspects of change in the child patient as progress indicators: when the child presents a more realistic idea of the psychotherapist and his/her functions having a better relationship with him/her, based on greater trust; the play develops in a pleasant way, taking advantage of it to elaborate and resolve conflicts; the defenses become more flexible and more evolved; and the child starts to present behavior appropriate for the age, i.e., starts to reenter the normal course of development.

The review of the literature indicates a certain confluence of criteria, among which are highlighted: a good therapeutic bond, the expression of affection, the importance of the parents in the process, and evidence of greater independence and autonomy on the part of the child. (Cartwright-Hatton & Murray, 2008;Castonguay, 2011; Cia, Pamplin, & Del Prette, 2006; Langer, McLeod, & Weisz, 2011; Mergenthaler, 2008; Rosado y Rosado, 2007; Shirk, Karver, & Brown, 2011; Silvares & Souza, 2008; Weber, Selig, Bernardi, & Salvador, 2006).

In adult patients, the exploration of the emotions, when accompanied by reflection on them, allows a better comprehension and interpretation of the situations experienced (Mergenthaler, 2008). At the beginning of the treatments these emotions tend to be predominantly negative, as they are associated with the complaint and the conflicts that led the patient to the psychotherapy. However, as there is progress, they often lead to the expression of more positive emotions (Yoshida, 2012). In the case of children, the occurrence of reflection on the emotions is not usually so evident, expressing a lot more through changes in the play and more affective communication with the therapist. These criteria refer to the integrative focus in psychotherapies, which attempts to build a coherent structure for comprehending or predicting change and for determining the choices of the procedures used in psychotherapies that are associated with the change, and more specifically, the progress (Wachtel, 1982). The relevance of a positive therapeutic bond is highlighted as the main predictor of progress in psychotherapy by many authors, especially those in favor of the common factors, within the integrative approach (Castonguay, 2011).

The integrative movement in psychotherapy emphasizes the fact that psychotherapists of different approaches seem to adopt practices and criteria of assessment much more similar than an analysis based only on the theoretical and epistemological principles would suggest. Therefore, the importance can be perceived of empirically verifying how Brazilian therapists assess positive changes in child psychotherapies and to what extent they would be in accordance with the global trend of integration. Accordingly, to investigate, with the psychotherapists, which criteria they use in the practice to assess positive changes in their child patients, and to express the degree of relevance of these, as indicators of progress throughout the care, were defined as the goals of this study. Furthermore, the study aimed to analyze similarities and differences in the criteria of progress adopted by the therapists, according to the declared theoretical approach.

Method

Participants

The sample was composed of 154 therapists (150 psychologists and four psychiatrists) that performed psychotherapy consultations with children. Of these 89% were female. Regarding the distribution by region of the country, 42.21% of the sample worked in the southeastern region; 38.96% in the southern region; 12.34% in the central west region; 3.9% in northeastern region; and 2.6% in the northern region. They had graduated between 2000 and 2009 (57.79%), with a mean length of practice in child psychotherapy of around 11 years and a median length of 8 years. With regard to the theoretical approach, half of the sample was identified as psychoanalysts, followed by psychodynamic therapists (28%), behaviorists (20%) and humanists (12%). Only 5% identified themselves as others [transactional analysis (n= 1), Jung (n= 2), psychodrama (n= 1), systemic (n= 4)]. Some respondents were from two or more approaches (psychodynamic and psychoanalytic, 7.14%; psychodynamic and cognitive-behavioral, 1.95%; psychodynamic and cognitive; 1.3%; psychoanalytic and cognitive, 0.65%; psychodynamic, psychoanalytic and cognitive, 0.65%; psychodynamic, psychoanalytic, cognitive-behavioral, 0.65%, and gestalt therapy and cognitive-behavioral, 0.65%).

Instruments

Data collection was conducted through a questionnaire specifically constructed for the study, which consisted of statements about behaviors and attitudes commonly associated in the literature with the progress of children who are in psychotherapy. The answers to the questionnaire were on a Likert type scale, where 1 corresponded to very relevant and 5 very little relevance. The questions were divided into three blocks composed by: 33 statements related to situations that occur in the session; 25 situations external to the sessions, as reported by the parents and/or teachers; and six questions to characterize the profile of participants.

Procedure

Data collection. For the data collection a letter explaining the project was sent to all the Regional Psychology Councils (RPCs), requesting authorization for the dissemination of the study to their members, which included the research project and a copy of the Ethics Committee approval. Authorization was obtained for the dissemination of the study from the following RPCs: RPC-01 (DF, AM, RR, AC, RO); RPC-04 (MG, ES); RPC-07 (RS); RPC-08 (PR); RPC-09 (TO,GO); RPC-10 (PA,AP); RPC-12 (SC); RPC-14 (MS); RPC-16 (ES) e RPC-17 (RN). These RPCs published a link to the study on their websites and some (RPC-07, RPC-09, RPC-12, RPC-14, RPC-16, RPC-17) sent e-mails to their members inviting them to participate in the study. The others, such as the RPC-06 (SP), explained that they did not have authorization from the registered professionals for this type of dissemination. The RPC-02 (PE) stated that it does not provide this type of service due to what was determined in meetings of this RPC. The RPC-13 (PB) claimed that it could not disseminate this study as it was already disseminating others, and the other RPCs, despite the insistence, did not reply.

In addition to the formal contact established through the RPCs, the authors resorted to personal contacts with Brazilian psychotherapists in various regions of the country. These were in turn asked to invite other colleagues from their networks, thereby seeking to enlarge the sample to the maximum and to compensate for possible under-representation of regions. In this process, although the focus of the study was psychotherapists trained in psychology, four psychiatrists who learned of the survey also were willing to cooperate and were integrated into the sample. Electronic letters of invitation were sent to all, along with the link to the questionnaire, to be completed and returned electronically. All ethical considerations were adopted, including the guarantee of anonymity of the participants.

Data analysis. The responses to the questionnaire were first analyzed in relation to the relative frequencies of each criterion of positive change, within the psychotherapy session and situations external to the sessions. Their distribution in relation to the relevance attributed by the participants in situations within the sessions and situations outside them was specifically evaluated. Next, Multiple Correspondence Analyses (MCA) were performed to determine how the items of the questionnaire could be grouped considering: the theoretical approach of the participant and the relevance attributed to the criteria of positive change in the psychotherapy session and situations outside the sessions. MCA is an exploratory, descriptive technique that does not allow comparisons. It is applicable to situations where the researcher wants “to examine the relationship between nominal categorical variables and/or between the categories of these variables” (Pereira, 2004, p. 149). MCA presents the results in the form of clusters, according to the association between the variables. The clusters are represented as graphical displays, in which the distance between points can be interpreted as the similarity between these points (when they are in the same dimension) or as the association (when in different dimensions). The more the categories of a variable are associated with the categories of another variable, the closer are the points related to them. When the inertia is greater, the distribution of the categories of the variables into different groups is greater (forming conglomerates similar to the “constellations” in an astronomical map). For higher consistency in the analysis, the variables of the study were grouped into three categories of response for the generation of the graphical displays: very relevant (1), moderately relevant (2), andirrelevant (3, 4 and 5). In this article, the graphical displays were not reproduced as they would need to be reduced to a scale that would make them unintelligible, due to their small size.

Ethical Considerations

An electronic procedure was used to conduct the data collection, depended on the voluntary participation of the participants without any constraint. The anonymity of the participant and the possibility of withdrawal at any time, even after sending the data to the researchers, were guaranteed. The study fulfilled all the criteria of RN 196/1996, which regulates research with human subjects in the country. Furthermore, the project was approved by the Human Research Ethics Committee of PUC-Campinas (1009/10).

Results

Table 1 lists the 33 questions and their relative response frequencies provided by the total sample (N= 154), for the criteria of progress being made in the psychotherapy sessions.

Table 1
Distribution of the Relative Frequencies (f %) of the Responses of the Total Sample (N = 154) for the Criteria of Evaluation of Progress in Child Psychotherapy Sessions

No.	Criteria for Evaluation of Progress	1*	2	3	4	5
1	Diversifies the games	33.12	55.84	5.19	5.84
2	Talks about his/her fears	67.53	25.332	1.95	3.90	1.30
3	Demonstrates conflicts through games and play	78.57	18.83	1.30	1.30
4	Takes the initiative in games	46.75	45.45	4.55	3.25
5	Demonstrates trust in the therapist	74.03	21.43	1.95	1.95	0.65
6	Makes associations between the game and his/her life situation	58.44	27.92	7.79	5.84
7	Directs the games giving orders to the psychotherapist	24.68	38.31	17.53	14.94	4.55
8	Follows the rules of the games (e.g. Monopoly, checkers, etc.)	34.42	49.35	8.44	6.49	1.30
9	Tolerates losing games	51.95	39.61	4.55	1.95	1.95
10	Establishes affective communication with the therapist	67.53	26.62	3.25	2.60
11	Demonstrates comprehension of the reason(s) for being in psychotherapy	50.65	36.36	6.49	5.84	0.65
12	Makes present for the therapist in the sessions (e.g. drawings, collages), on special occasions (Easter, Christmas, end of psychotherapy)	11.69	33.12	25.97	23.38	5.84
13	Sleeps, sometimes, for some time.	15.58	22.08	32.47	13.64	16.23
14	Bring, toys from home	12.34	32.47	24.03	24.03	7.14
15	Wants to take toys home	11.69	44.81	12.99	21.43	9.09
16	Wants to take home drawings and collages made in the session	17.53	40.91	14.29	17.53	9.74
17	Describes situations outside the session	52.60	37.01	5.84	3.90	0.65
18	Demonstrates humor in the games	44.81	40.26	9.74	4.55	0.65
19	Describes fights occurring between the parents	44.16	42.86	8.44	2.60	1.95
20	Represents fights between parents in the games	52.60	36.36	9.09	1.30	0.65
21	Represents fights between children in the games	50.65	37.01	9.74	1.95	0.65
22	Does not abandon the game when something goes wrong	53.25	31.82	9.09	4.55	1.30
23	Visually explores the environment of the consultation room	26.62	47.40	12.34	12.99	0.65
24	Moves around the room with confidence	31.82	53.25	4.55	9.09	1.30
25	Puts the toys away at the end of the session without resistance	34.42	46.75	9.09	9.09	0.65
26	Tells the therapist a secret about distressful situations	41.56	33.77	14.94	8.44	1.30
27	Demonstrates anger at the therapist verbally	48.05	29.87	12.99	7.14	1.95
28	Demonstrates anger at the therapist through the games	51.30	33.12	9.09	5.84	0.65
29	Asserts his/her will in playing the games.	30.52	45.45	14.94	7.14	1.95
30	Describes dreams and/or nightmares experienced during the week.	46.75	34.42	11.04	5.84	1.95
31	Demonstrates interest in the games offered	33.12	44.16	11.04	11.04	0.65
32	Creates new rules for games that have rules, according to his/her convenience (e.g. Monopoly, checkers)	33.12	35.06	12.34	13.64	5.84
33	Focuses on the game or design for long periods.	34.42	42.21	11.69	10.39	1.30

• Note. In bold, the modal value of the distribution. *1 - very relevant; 2 - moderately relevant; 3 - irrelevant; 4 - little relevance; 5 - very little relevance.

The criteria of change in the sessions considered very relevant by most of the sample (> 50%) (Table 1) were: 3 - Demonstrates conflicts through games and play (78.57%); 5 - Demonstrates trust in the therapist (74.03%); 2 - Talks about fears (67.53%); 10 - Establishes affective communication with the therapist (67.53%) 6 - Makes associations between the games and his/her life situations (58.44%); 22 - Does not abandon the game when something goes wrong (53.25%); 17 - Reports situations encountered outside the session (52.60%); 20 - Represents fights between the parents in the games (52.60%); 9 - Tolerate losing the games (51.95%); 28 - Demonstrates anger at the therapist through the game (51.30%); 11 - Demonstrates comprehension of the reason(s) for being in psychotherapy (50.65%) 21 - Represents fights between children in the games (50.65%).

Criteria 1 - diversifies the games (55.84%) and 24 - Move around the room with confidence (53.25%) were considered moderately relevant(alternative 2) as criteria of progress in the children’s sessions by the majority of the participants (> 50%) (Table 1). Criteria 7, 8, 12, 14, 15, 16, 23, 25, 29, 31, 32 and 33 did not reach 50%, although they received, in this alternative, the largest number of responses.

Regarding the alternatives irrelevant, little relevance andvery little relevance no criterion obtained a majority of responses (> 50%). However, when the responses of these three alternatives were added together it was observed that the criteria - 13 - Sleeps sometimes, for some time (62.34%), 14 - Brings toys from home (55.2%) and 12 - Makes presents for the therapist in the sessions (e.g. drawings, collages, etc.)., on special occasions (Easter, Christmas, end of the psychotherapy) (55.19%) achieved percentages greater than 50% of the sample, suggesting that they corresponded to situations not considered to be associated with progress in child psychotherapy sessions. This characteristic is supported by the median value (= 3) of these items.

Table 2 shows the relative frequencies of the responses of the participants (N= 154) to the criteria of progress in situations outside the sessions (as reported by the parents/or school). It can be seen that the criteria considered very relevant (alternative 1) by the majority of the sample (> 50%) were: 1 - Presents improvement in relationships with family members (parents, siblings, grandparents) (85.71%); 3 - Presents improvement in relationships with classmates and teachers (78.57%); Demonstrates interest in new activities (games, sports, music, among others) (61.69%); 11 - admits his/her mistakes (60.39%), 13 - Expresses anger verbally (58.44%); 8 - Accepts the limits imposed by parents regarding schedules, the need to do lessons and/or tidy things (54.55%); 9 - Manages to solve problems alone (54.55%); 7 - Protects him/herself from attacks by siblings and/or classmates (53.90%); 14 - Verbally expresses jealousy (53.90%); 25 - Takes care of him/herself and his/her appearance (52.60%); 4 - Demonstrates interest in new people (neighbors, classmates) (51.95 %); and 21 - Sleeps all night (51.95%). No criterion relative to situations outside the sessions was highlighted as moderately relevant by the majority of the participants (> 50%). Also, no criteria were marked aswithout relevance, little relevance or very little relevance, by the majority of the sample (> 50%).

Table 2
Distribution of the Relative Frequency (f %) of the Criteria of Evaluation of Progress in Situations Outside the Sessions (as Reported by the Parentes or School), for the Total Sample (N = 154)

No.	Criteria for Evaluation of Progress	1*	2	3	4	5
1	Presents improvement in relationships with family members (parents, siblings, grandparents)	85.71	12.99	0.65	0.65
2	Demonstrates interest in new activities (e.g. games, sports, music)	61.69	32.47	4.55	0.65	0.65
3	Presents improvement in relationships with classmates and teachers	78.57	19.48	0.65	1.30
4	Demonstrates interest in new people (neighbors, classmates)	51.95	36.36	7.14	3.90	0.65
5	Plays alone with toys and games	33.12	47.40	11.04	6.49	1.95
6	Asserts his/her will when playing with siblings and/or classmates	25.32	50.00	15.58	7.79	1.30
7	Defends him/herself from attacks by siblings and/or classmates	53.90	40.26	3.90	1.30	0.65
8	Accepts the limits imposed by parents regarding schedules, the need to do lessons, and/or tidy things	54.55	35.71	7.79	1.95
9	Manages to solve problems alone	54.55	33.77	5.19	6.49
10	Apologizes when he/she goes too far or behaves improperly	46.75	40.26	8.44	3.90	0.65
11	Admits his/her mistakes	60.39	27.92	7.79	3.90
12	Seeks to fix things (toys, objects, etc.)	48.05	37.01	10.39	3.90	0.65
13	Expresses anger verbally	58.44	30.52	4.55	5.84	0.65
14	Expresses jealousy verbally	53.90	35.71	4.55	5.19	0.65
15	Has good academic performance (grades in the subjects compatible with his/her skills and abilities)	44.81	44.16	3.25	7.14	0.65
16	Shows excitement about going to the psychotherapy sessions	24.03	45.45	19.48	8.44	2.60
17	Talks with the parents about things occurring at school	44.81	40.26	7.14	6.49	1.30
18	Talks with the parents about things occurring in the psychotherapy sessions	20.78	38.31	24.03	14.29	2.60
19	Shows interest in homework	31.17	47.40	11.69	9.09	0.65
20	Generally cares for notebooks, books, and school materials	28.57	49.35	14.29	6.49	1.30
21	Sleeps all night	51.95	35.06	7.79	5.19
22	Does not have nightmares	30.52	46.75	14.94	6.49	1.30
23	Eats well	40.91	43.51	11.04	3.90	0.65
24	The parents are satisfied with the care	41.56	44.16	9.74	3.90	0.65
25	Takes care of him/herself and his/her appearance	52.60	36.36	7.14	3.25	0.65

• Note. In bold, modal value of the distribution.*1 - very relevant; 2 - moderately relevant; 3 - irrelevant; 4 - little relevance; 5 - very little relevance.

The Multiple Correspondence Analyses (MCA) were then conducted to verify how the items could be grouped, considering the theoretical approach of the participants. For the generation of graphical representations the items were initially grouped according to three categories of responses: very relevant (1),moderately relevant (2), and irrelevant (3, 4 and 5). According to the graphical displays generated, the following associations were suggested as the main ones between the type of theoretical approach and the criteria of progress highlighted by the items: Psychoanalytic approach and items 1, 10, 3, 4 and 9 very relevant; cognitive-behavioral approach and items 2, 3, 4, 5, 6, 9, 10, 11, and 22 very relevant, and item 12moderately relevant; psychodynamic approach and items 4, 9, 11, 26, 29 and 33 moderately relevant and items 12, 13 and 16irrelevant; other approaches (gestalt therapy, psychodrama, transactional analysis, and systemic) and item 3 very relevant, and items 12, 13 and 16 irrelevant. These associations are presented inTable 3.

Table 3
Main Associations Between the Theoretical Approach and the Criteria of Progress in the Session According to the Multiple Correspondence Analysis (MCA)

Item*	1	2	3	4	5	6	9	10	11	12	13	16	22	26	29	33
Psychoanalytic	VR		VR	VR			VR	VR
Psychodynamic			VR	MR			MR	VR	MR	IR	IR	IR		MR	MR	MR
Cognitive-Behavioral		VR	VR	VR	VR	VR	VR	VR	VR	MR			VR
Others			VR							IR	IR	IR

• Note. VR - Very Relevant; MR - Moderately Relevant; IR - Irrelevant. *Items - see Tables 1 and 2 of this article for access to the content.

Through the Multiple Correspondence Analysis (MCA), the relationships between the criteria of change outside the child psychotherapy session and the theoretical approach of the participant were also examined. The main associations were: psychoanalytic approach and items 5, 6, 16 and 24 moderately relevant, and item 18 irrelevant; psychodynamic approach and items 1, 2, 3 and 24 very relevant, and items 5, 16 and 22 moderately relevant; behavioral-cognitive approach and items 1, 3, 2, 24 very relevant; other approaches (gestalt therapy, psychodrama, transactional analysis, and systemic) and items 2, 4, 5, 6, 9, 16, 18, 22, 23 and 24 moderately relevant. Table 4 briefly presents these results.

Table 4
Main Associations Between the Theoretical Approach and the Criteria of Progress Outside the Session According to the Multiple Correspondence Analysis (MCA)

Item*	1	2	3	4	5	6	9	16	18	22	23	24
Psychoanalytic					MR	MR		MR	IR			MR
Psychodynamic	VR	VR	VR		MR			MR		MR		VR
Cognitive-Behavioral	VR	VR	VR									VR
Others		MR		MR	MR	MR	MR	MR	MR	MR	MR	MR

• Note. VR - Very Relevant; MR - Moderately Relevant; IR - Irrelevant. *Items - see Tables 1 and 2 of this article for access to the content.

Discussion

The predominance of psychologists in the sample was due to the fact that the instrument was disseminated in the psychological environment, the percentage of women in the sample (89%) approximately corresponds to that of Brazilian psychologists (Pfromm Netto, 2006). Accordingly, the study sample seems to be representative of the broader universe of psychotherapists in relation to gender. Regarding the distribution by region of the country, the sample was predominantly represented by psychotherapists of the southern (39%) and southeastern (42%) regions, in which traditionally the majority of psychologists are concentrated (Bastos & Gomide, 2010) and also most probably child psychotherapists. However, as no systematic survey data were found, the generalization of the results should be made cautiously.

In relation to the year of graduation, the majority (approximately 58%) graduated between 2000 and 2009, with the median of the distribution being 8 years. That is, the sample consisted of therapists with reasonable experience in child psychotherapy, which confers reliability to the data. With regard to the theoretical approach, the higher incidence of psychoanalytic (50%) and psychodynamic therapists (28%) suggests that the hegemony of psychoanalysis persists in our environment, giving the sample a conservative profile with regard to theoretical orientation. This trend is reinforced by the presence of behaviorists (20%) and humanists (12%) as representatives of the second and third more common approaches. Although constituting a small percentage (13%), it is interesting to note that some participants identified with more than one approach, which indicates the possibility that the integrative approach will gain strength, following the current trend, as observed in other countries (Rosado y Rosado, 2007).

The criteria of change considered by the participants as most relevant in the sessions with the children, and highlighted in the responses to the questionnaire (demonstrates conflicts through games and play; demonstrates trust in the therapist; talks about fears; and establishes affective communication with the therapist), corroborate the majority of studies that shows how important the therapeutic relationship is, translated as a good therapeutic bond, which in turn is linked to the efficacy of the therapy, whichever approach is used (Deakin & Nunes, 2008; Fossum et al., 2008; Langer et al., 2011;Meissner, 2007; Oliveira, 2002; Serralta et al., 2010; Shirk et al., 2011). When it is possible to establish a good bond, the children are able to express themselves more freely with regard to their conflicts and fears, which can be understood as a demonstration of trust in the therapist.

In situations outside the sessions (as reported by the parents and/or school) the criteria considered more relevant by representatives of all the approaches were those that were aimed at improving the interpersonal relationships. These being: presents improvements in the relationships with family members (parents, siblings, grandparents); presents improvements in relationships with classmates and teachers; demonstrates interest in new activities (e.g. games, sports, music, among others); and admits his/her mistakes. The good existence of children in society is in fact an expression of the good development of their personality, as it suggests that they are finding appropriate responses to obtain satisfaction for their needs (Mito & Yoshida, 2004).

The Multiple Correspondence Analysis (MCA), involving the criteria of progress in the child psychotherapy session, suggested that only item 3 (demonstrates conflicts through games and play) would have been considered Very Relevant (Table 3) by the participants of all approaches. This criterion seems to effectively summarize the foundation of child psychotherapy, in which play is considered to be the natural way for children to express themselves.

The evaluations Very Relevant and Moderately Relevant appear to be associated with the psychoanalytic, psychodynamic and cognitive-behavioral approaches, but not with the other approaches, with items 4 (takes the initiative in games), 9 (tolerates losing games) and 10 (establishes affective communication with the therapist) (Table 3). In all three cases, the playful expression is valued in assessing the progress. Specifically item 10 refers to the establishment, by the child, of affective communication with the therapist. This item confirms the observations of the literature.

Regarding the other items, except items 11 and 12 which will be analyzed below, an association was found between the assessment and the theoretical approach of the participant (Table 3), only in relation to one specific approach. In this sense, the following considerations seek to understand these associations in the light of their respective theoretical bases.

Regarding the psychoanalytic approach, item 1 appeared to be associated with the very relevant evaluation. This refers to the criteria, “to diversify the games”. According to Kernberg (1995), when the game unfolds in a pleasant way, this is when the children show more ability to tolerate their conflicts and frustrations, and a development process is found to be underway. The increase in tolerance toward frustrations makes the children deal with their internal conflicts, maintaining a greater integration of the ego. With this they remain for longer in the depressive position, characterized by the predominance of depressive anxiety, decreased guilt, coexistence of love and hate for the object, and attenuation of the division processes.

Regarding the cognitive-behavioral approach, the items considered very relevant were: item 22, “Does not abandon the game when something goes wrong”, item 6, “Makes associations between the game and his/her life situations”. To not abandon the game when something goes wrong reveals persistence and determination, both cognitive skills related to coping ability. Furthermore, it also assumes that the children tolerate frustration. Accordingly, this criterion coincides with the psychoanalytic approach (Castonguay, 2011). Regarding the association between the game and life situations, there is an emphasis on the cognitive aspect of the play. Item 5, which refers to the demonstration of trust in the therapist, and item 2, “Talks about his/her fears”, were also considered very important by the psychotherapists of the cognitive-behavioral approach. As noted above, to talk about their fears, as well as being an expression of the contingency skill, is an expression of trust in the therapist and one of the main goals of psychotherapy, whether for adults or children. This is, therefore, the criteria considered essential for the efficacy of the treatments (Kazdin, 2000).

In the psychodynamic approach there was an association of various items considered to be of moderate relevance (items 4, 9, 11, 26, 29, and 33) and irrelevant (items 12, 13, and 16). Item 29, “Asserts his/her will in the conduct of games” and item 33, “Concentrates on the game or drawing for long periods”, are criteria related to a certain amount of autonomy of the child in relation to the psychotherapist, this being one of the goals of the treatment (Mito & Yoshida, 2004). Item 26, “Tells the therapist a secret about distressful situations”, would be an indicator of trust in the therapist.

Item 16 “Wants to take home drawings and collages made in the session” and item 13 “Sleeps, sometimes, for some time”, were considered irrelevant by both psychodynamic therapists and those of other approaches. That is, in spite of them corresponding with the behaviors observed in child psychotherapies, they would not be linked to progress. In the psychodynamic approach, such behaviors are usually understood as an expression of the resistance and difficulty of the child in making contact with the sufferings (Kernberg, 1995). By considering them irrelevant, the psychodynamic psychotherapists remained consistent with the theoretical foundations. Furthermore, as the therapists of other approaches also did not considered them relevant, there is once again a convergence of opinions, despite the theoretical approach.

Item 11, “Demonstrates comprehension of the reason(s) for being in psychotherapy” was considered by the participants of the cognitive-behavioral approach as very relevant, which supports the theoretical premise that the progress would be related to the possibility of understanding, by the patients, that they have difficulties and that they need to actively collaborate to face them (Bandura, 1986/2008; Moura, Grossi, & Hirata, 2009). This same item was considered moderately relevant by the psychodynamic therapists, probably due to the relevance they attach to the unconscious aspects of the personality (Romanowski, 2004; Yanof, 2005).

Item 12, which refers to making presents for the therapist in the sessions (e.g. drawings and collages) on special occasions (Easter, Christmas, end of the psychotherapy), was considered by the psychodynamic therapists and those of other approaches as irrelevant. The concordance in the assessments, therefore, indicates another consensus in the area. The humanist psychotherapists considered item 3 to be very relevant, and items 12, 16 and 13 to be irrelevant, coinciding with the psychodynamic approach. This might be due to the fact that the theoretical framework of the humanistic therapies is influenced by both child and relational psychoanalyses, which are also the basis of psychodynamic psychotherapy (Dorfman, 1951/1992). Items 3 (demonstrates conflicts through games and play), 4 (takes the initiative in games), 9 (tolerates losing games) and 10 (establishes affective communication with the therapist) were the items assessed as most relevant by the psychotherapists of all approaches in this study.

For all the approaches, it is indispensable that the children express themselves according to their development and that the form of this expression occurs through play, which will gradually change (Moura et al., 2009). Thus, it is concluded that despite the theoretical differences value was given to: the playful expression, the autonomy, and the tolerance of frustration always in a climate of trust that is established through affective communication with the therapist. These common criteria refer to the integrative approach in psychotherapy, specifically to the aspect of the common factors. That is, in spite of the differences between the theoretical assumptions, the psychotherapists seem to rely on similar criteria to interpret the change in the child psychotherapy sessions.

Regarding the criteria for change outside the session (Table 4), the participants from the cognitive-behavioral and psychodynamic approaches considered the same items (1, 2, 3 and 24) to be very relevant. These items are consistent with the psychodynamic theory that considers the family involvement and a better relationship with the family members to be important factors for change. Psychodynamic authors argue that this is one of the best criteria to indicate efficacy (Mito & Yoshida, 2004; Oliveira, 2002;Palacio Espasa & Manzano, 1987). As do the cognitive-behavioral therapists that are using treatment of children with family involvement and have achieved positive results (Moura & Silvares, 2008).

Concerning the items considered moderately relevant, there was agreement among the psychoanalysts, psychodynamic therapists and other psychotherapists regarding items 16 and 5 outside the session. These relate to the theory of Klein (1932/1996) that considers the desire for reparation as an indication of development, i.e., the desire to “repair” the good object and because of this the feeling of excitement about going to the psychotherapy sessions, with them therefore able to reduce the anxiety and guilt. The fact of the child managing to play at home alone would be another indicator of movement toward assuming greater responsibility for his/her own impulses.

Item 23, Eats well; item 9, Manages to solve problems alone; and item 4, Demonstrates interest in new people (neighbors, classmates). This is explained because when progress occurs in the psychotherapy these are expressed in the external environment and, according to Oaklander (1978/1980), specific indicators exist regarding how the child’s behavior changes. For this author, according to the reports from the parents and school, the child is interested in outside activities that may involve games, clubs and friends, begins eating better, and has a certain amount of autonomy.

Items 1, 2, 3 and 24 were considered relevant by the respondents of all approaches. They contemplate a better expression of the children becoming interested in other activities and an improvement in the relationships with people close to them, especially their family. The expansion of the psychic and social universe corroborates empirical evidence that highlights the success of child psychotherapy being directly related to family involvement (Cartwright-Hatton & Murray, 2008; Cia et al., 2006; Silvares & Souza, 2008; Weber et al., 2006).

Conclusions

It was possible to identify criteria that are significant in the psychotherapeutic practice of various approaches. There seems to be concordance regarding the need for a good relationship with the therapist, and for confidence to expose their fears and difficulties by expressing them through play.

The Multiple Correspondence Analysis (MCA) involving the criteria of change in the child psychotherapy session and the theoretical approach of the participant, suggested that, despite the theoretical differences, the approaches valorized in the session were: the playful expression, the autonomy, and the tolerance of frustration always in a climate of trust that is established through affective communication with the therapist. Outside of the session, according to reports from the parents or school, the items considered most relevant were those which contemplated a better expression of the child, obtaining an interest in other activities, and an improved relationship with people close to them, especially the family. That is, in spite of the differences between the theoretical approaches, in the practice the psychotherapists seem to rely on similar criteria to interpret the change in the child.

The criteria investigated may be useful for a better systematization of child psychotherapy techniques and may also contribute to indicating the signs of progress and thus guide psychotherapists in their interventions. However, it must be remembered that there is no information to assess the degree of representativity of the sample, with regard to the total number of Brazilian child psychotherapists and the percentage of therapists by theoretical approach, or by region of the country. Accordingly, caution should be exercised in generalizing the results and it is suggested that further quantitative and qualitative studies can be performed in order to deepen the results obtained.

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• 1
  Article derived from the doctoral dissertation of the first author, under the guidance of the second, defended in 2012 in the Graduate Program of the Pontifícia Universidade Católica de Campinas.
• Support: Coordination for the Improvement of Higher Education Personnel (CAPES).

Publication Dates

• Publication in this collection
  Jan-Apr 2014

History

• Received
  5 Mar 2012
• Reviewed
  2 Mar 2013
• Accepted
  5 July 2013