Product reviews for Psychotherapy with Adolescents and Their Families

During the past century, psychologists' understanding and treatment of clinical problems have advanced as a result of developments in theory and research. More recently, a separate force has come to have a profound impact on how therapists practice. Although the question of whether some forms of therapy are more effective than others remains unresolved (Nathan, Stuart, & Dolan, 2000), managed health care, with its explicit goals of managing costs and providing shareholders with a profit, has imposed a short-term, goal-directed, symptom relief model on the field. Although cognitive-behavioral therapists' training leaves them well suited to this approach, other therapists, the most notable being psychoanalytically trained therapists, have found it to be antithetical to their view of treatment.

Managed health care has changed the landscape of independent practice. A greater number of individuals seeking therapy are choosing therapists to whom they can pay a nominal copayment. Therapists who are not trained in the symptom relief model required by managed care companies must either change how they practice or attempt to build a practice that does not accept insurance reimbursement. Moreover, even though the bureaucracy fostered by managed health care requires considerable accountability and documentation, graduate training programs often do not include instruction on this aspect of professional practice. These elements of practice include making rapid assessments, writing effective treatment plans, and keeping track of treatment authorizations. As a result, many therapists lack the skills needed to negotiate the managed care maze successfully.

Psychotherapy With Adolescents and Their Families: Essential Treatment Strategies is an important tool in helping therapists adapt. It is a manual that provides practitioners with a source of behaviorally defined objectives, goals, and interventions for writing treatment plans for managed care companies. The target audience is any therapist who bills managed health care for the provision of mental health services for adolescents and their family.

The book is organized into several sections. The first two chapters address the state of psychotherapy in the age of managed care, and the author, a seasoned social worker, offers advice about how to navigate the often enigmatic managed care maze to improve the likelihood of having sessions approved. For example, Warren recommends that “goals that are not achievable within three months should be avoided or replaced with more focused, resolvable goals. Managed care providers want quick, cost-effective change using modalities that are consistent with the client's needs” (p. 4). She also advises the reader to “divide a complex goal into several simpler goals [to
increase the likelihood that] a case manager will see a gradual improvement and authorize further sessions” (p. 5).

The Interventions
The core of Psychotherapy With Adolescents and Their Families consists of treatment objectives and a multitude of goals and strategies for 41 Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV; American Psychiatric Association, 2000) diagnoses encountered in an adolescent population. Each chapter includes a description of the diagnosis and a menu of overall treatment objectives, followed by numerous goals with matching therapeutic interventions.

A unique contribution of this book is the recognition that adolescents' mental health problems affect and are affected by their family. Therefore, therapists often work with parents and other significant family members. To address this dynamic, the author has written goals and interventions for the adolescent and parents as well as for the family as a whole. Not only does this acknowledge that parents and adolescents come to therapy with different goals, but it is consistent with developments in the literature on empirically based treatments that incorporate interventions for family members in effective practice (Kazdin & Weisz, 2003). The result is a cookbook from which therapists can choose goals and strategies that match their clients' needs.

The interventions are clearly written and solution focused. They range from basic to complex and are informed by a variety of schools of thought, including cognitive-behavioral and family systems theories. I have chosen the following pairs of goals and interventions for an adolescent with separation anxiety disorder to illustrate the differences among the types of goals. For example, Warren matches the adolescent's goal to “understand underlying dynamics that lead to maladaptive behavior and stress” with the intervention to “explore ways in which anxieties manifest themselves (e.g., fear of leaving home, catastrophe, being “too good')” (p.89). She lists a separate group of goals for the parents, including to “recognize fears and feelings of negative self-blame related to the problem” (p. 86). She matches this goal with the therapist's intervention to “evaluate parents' fears and negative self-blame for the adolescent's problem” (p. 86).

Finally, each diagnosis includes a set of goals for the family as a whole. One such goal for a family with an adolescent suffering from separation anxiety disorder is to “demonstrate boundaries, alliances, triangles, and emotional currents that may exacerbate the anxieties” (p. 93). This goal is matched with the intervention to “explore family boundaries using sculpturing, a useful technique for understanding triangulation, alliances, and emotional currents” (p. 93). A brief description of this intervention is offered in the appendix.

The reader will note that the goals are written from the perspective of the client (adolescent, parent, etc.). This encourages parents to discuss treatment goals with clients in an effort to have them take ownership of the goals. Nevertheless, navigating the goals can take some practice, as they are not organized to aid therapists' search for goals. A cross-referencing scheme to identify the goals that apply to a particular treatment objective would be useful. This type of information is well-suited to the data management capabilities of home computers, and the publisher would be wise to develop an application to help therapists easily select goals and interventions for use in treatment plans.

Similar Books
Psychotherapy With Adolescents and Their Families evokes comparison with a recent title with similar aspirations: The Adolescent Treatment Planner (Jongsma, Peterson, & McInnis, 2002), from the treatment planner series published by Wiley. The books are similar in that they offer numerous treatment goals and interventions for a series of adolescent problems. The current book differs in several ways, most notably with the inclusion of separate goals for parents and families, as I have already described. However, the goals and interventions in the Wiley title are more easily navigated.

Furthermore, the interventions in Psychotherapy With Adolescents and Their Families are written in a more general language. For example, among the interventions for depressed adolescents, Warren writes, “Explore and clarify underlying feelings of depression” (p. 180), whereas Jongsma et al. (2002) stated, “Reinforce the client's open expression of underlying feelings of anger, hurt, and disappointment” (p. 51).

Another difference is the organization of treatment objectives by DSM-IV diagnoses instead of by presenting problems, as in the Wiley series. There are a greater number of disorders and interventions listed in Psychotherapy With Adolescents and Their Families, including depression, bipolar disorder, eating disorders, general medical conditions, sleep disorders, and substance disorders. Warren differentiates interventions for a greater variety of anxiety disorders than did Jongsma et al. (2002).

Unique to Warren's book is the inclusion of critical incident stress debriefing and impulse control disorders. However, Warren does not include problems found in the Wiley series, such as academic underachievement, adoption, and sexual identity confusion. She does include the treatment of relational problems, such as conflict among siblings and issues related to divorce. Warren appropriately points out that these are classified as V codes and therefore are unlikely to receive session authorization from managed care unless an Axis I disorder is present.

A final distinction from Jongsma et al. (2002) is the inclusion of a variety of resources. That is, the author provides several reproducible forms (e.g., psychosocial intake, session record, session notes) that are useful to document therapy for managed health care companies. A separate chapter offers brief descriptions of an assortment of therapeutic techniques. The descriptions range from interventions that can be easily integrated into a session to techniques that require additional training and supervision to implement properly. Warren includes an array of cognitive-behavioral homework forms, including a negative thought log and steps to constructing a rational response. However, readers will have to find other sources to instruct them on how and when to use these forms properly if they are untrained in cognitive therapy.

The selection of these techniques and handouts appears somewhat random and is presumably based on the fact that the author finds them useful. Therefore, the reader will have to determine whether the particular resources are applicable to his or her specific needs. The author also provides lists of more universally helpful resources, including psychotherapeutic games, self-help books, support groups, and Web sites.

Conclusion
The author does an effective job of meeting her goal of providing a manual to help therapists find the types of interventions to list in a treatment plan for managed care. Psychotherapy With Adolescents and Their Families is most helpful to therapists who need guidance writing solution-focused treatment plans, especially if they work with the families of adolescents as well as with the adolescents individually. Therapists who work with parents and families and who require the forms provided will be well-served by Warren's book. However, those who work infrequently with families and who do not need the resources provided in Warren's book are likely to prefer Jongsma et al. (2002) for its ease of navigation and more precise writing. Nonetheless, graduate students, recent licensees, and experienced therapists adapting to the demands of managed health care will find this to be a valuable resource.

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Jongsma, A. E., Peterson, L. M., & McInnis, W. P. (2002). The adolescent psychotherapy treatment planner (3rd ed.). New York: Wiley. Kazdin, A. E., & Weisz, J. R. (2003). Evidence-based psychotherapies for children and adolescents. New York: Guilford Press. Nathan, P. E., Stuart, S. P., & Dolan, S. L. (2000). Research on psychotherapy efficacy and effectiveness: Between Scylla and Charybdis? Psychological Bulletin, 128, 964-981.