Abstract
Psychotherapy is almost universally accepted as a core component of mental health treatment for children and adolescents and families. We now accept psychotherapy as an equal partner to pharmacotherapy in the treatment of children, with meta-analyses and available studies finding both equivalent for many conditions and the combination superior to either alone.1,2,3
The origins of Western child and adolescent psychotherapy can be found in the case report of “Little Hans,” where Freud supervised the father in rendering psychological therapy of Little Hans, yet later disavowed that children could manage psychoanalysis in the way he practiced it. It took his daughter Anna Freud, an educator, and many others who followed, to develop child-oriented psychotherapy techniques. She was familiar with child development and children’s modalities of communication/expression. 4 However, it needs to be noted that many traditional cultures have employed various symbolic narratives and rituals to guide children and parents facing mental health and developmental challenges.5,6
Current challenges around psychotherapy for children worldwide center on access, both in high-income (HI) and low-middle-income (LMIC) nations, as pointed out by Pumariega et al in this issue. 7 Access to psychotherapy is related both to available resources to deliver these modalities to children in need, as well as the acceptability to both families and societies to the forms of psychotherapy available.
Perhaps the most critical factor in the acceptability of psychotherapy is that of culture. Culture shapes both the experiences of psychosocial stressors, the expression of psychological distress, and the explanatory models for different emotional and behavioral disturbances. The American Academy of Child and Adolescent Psychiatry practice parameters on culturally competent child psychiatric practice 8 recommends implementing psychotherapy that is consistent with a family’s cultural beliefs and value system, either routed in those beliefs or adaptation to be acceptable and effective within their belief system. Various studies have examined cultural adaptations of psychotherapy, establishing greater acceptability as well as adherence.9,10,11 This literature suggests that cultural adaptations that occur at a more foundational level and incorporate the family’s values, beliefs, and explanatory models, may result in greater benefits than adaptations made at a more superficial level, such as linguistic translation or therapist-ethnic matching.
The vision of our editorial team was that this special issue of the journal includes a wide range of diverse perspectives and approaches that address the challenge of cultural acceptability of child and family psychotherapy. This issue in itself is transcultural, including contributions both from East (especially India) and West (especially the United States). The authors who were approached to make these contributions did not disappoint our team and have presented a wide range of models and approaches, as well as simultaneously addressing the cultural context in their contributions.
Summary of Contributions to This Issue
We had 3 articles that not only presented innovative models of psychotherapy with children but also based them on traditional Indian cultural beliefs with historical and practice-based evidence. Arora and Jose 12 report on their experience with Solution-Focused Brief Therapy, a postmodern therapeutic approach influenced by social constructionist theory that emphasizes pragmatic solutions to behavioral and interactional problems based on culture and context. Khanna and Rawat 13 report on their work on the Art Circle, a group-based expressive arts modality developed within the Indian cultural context, using qualitative research design to explore therapeutic value and outcomes with 5 children who underwent this intervention. Chauhan et al 14 present an eclectic model of play therapy incorporating psychodynamic, gestalt, client centered, expressive, family, and cognitive-behavioral approaches oriented to the Indian cultural context and illustrated by in-depth clinical vignettes.
The majority of the articles addressed models of Western-based psychotherapies which were adapted for widely diverse populations (gender/sexual diverse, neurodiverse, racial/ethnic/religious diverse, and modern youth culture); though some articles do cover key Eastern-based psychotherapies. Bailey and colleagues 15 report on a case series illustrating the challenges and approaches to treatment engagement in parent–child interactive therapy with parents who have ADHD as well as outcomes from such approaches. Lieneman et al 16 reported on adaptations of psychological therapies for obsessive-compulsive disorder (OCD), cognitive behavioral therapy (CBT), and exposure response prevention (ERP) in the context of neurodiversity (autism spectrum) and gender diversity among youth. Sen and Jagatdeep 17 present their development of adaptations and applications of narrative therapy for sexual and gender diverse youth within the Indian cultural context. Rothe 18 reports on the value of supportive psychotherapy in teaching foundational therapeutic skills to young psychiatrists learning how to work with children and youth. Aggarwal 19 shares adaptations in the therapeutic frame to address the needs of youth in the context of current day youth culture which he has developed practicing psychodynamic psychotherapy. Herrera-Pino et al 20 present an analysis of critical issues in the psychotherapy of Latino children and families, particularly the diversity of the Latino population itself (as well as its national origins and histories) and the role of traumatic stress in their mental health needs. Satyanarayana et al 21 report on their work in the family therapy unit at the National Institute of Mental Health and Neurosciences (NIMHANS), synthesizing key principles of practicing family therapy with adolescents in India based on research evidence and clinical experience, and outlining practice guidelines for utilizing different assessment and intervention techniques based on different family therapy models.
In 2 brief reports, case illustrations of psychotherapy modifications are illustrated in greater depth. Teaford 22 describes a modification of (ERP) for OCD in the context of psychosis, for the treatment of a youth suffering with schizophrenia, which greatly facilitated his recovery and function. Shapiro 23 reports on his use of psychodynamic psychotherapy to address issues related to conflict of cultural and religious identity in Muslim youth.
Finally, a group of articles focused on using modern-day cultural tools psychotherapeutically both to improve access and acceptability. Jennings 24 describes the development of neurodramatic play using both dramatic representation and play techniques as a unique model of expressive psychotherapy. Jo et al 25 review the use of social media and smartphone applications in the delivery of interventions for youth both for treatment and prevention of substance use disorders in youth, leveraging tools that have become synonymous with youth culture. In a more traditional psychiatric context, Kar et al 26 describe the use of the therapeutic milieu in an adolescent psychiatric inpatient unit as a recovery environment for a youth caught up in sexual trafficking and its resulting traumatic impact. Pumariega et al 7 report on the use of case management as a modality to facilitate access to child psychotherapy in the context of pediatric collaborative behavioral health care with primary care providers.
Conclusions
In order to serve a culturally diverse world, psychotherapy must be adapted to reflect the cultural values, beliefs, norms, and resources of different populations and regions. These collections of articles reflect diversity of thought (including explanator models), beliefs, and techniques, both based on practice-based evidence as well as evidence-based practices. As mental health care evolves in a more globalized world, we stand to learn and gain from the exchange of perspectives and techniques across cultures in being able to serve children and families and to apply them within our home cultures and nation-states. It is our hope that these articles will spark such cross-cultural learning, and also serve as an inspiration for budding clinicians and psychotherapists to use their creative abilities and their cultural knowledge in developing effective interventions to serve our children and youth living in diverse environments.
Disclaimer
This editorial expresses the opinion exclusively of the authors, and not necessarily of the journal.