Child and adolescent anxiety psychodynamic psychotherapy (CAPP) is a new, manualized, brief psychotherapy based on psychoanalytic principles tested in an open, pilot clinical trial by Barbara Milrod, Theodore Shapiro, Charles Gross, and others in 2013. It is a developmentally modified version of panic-focused psychodynamic psychotherapy (PFPP), which is an efficacious psychodynamic psychotherapy for anxiety disorders supported by the most robust data.
CAPP is a meaning-seeking, psychodynamic treatment for children ages 8 to 16 who suffer a range of anxiety disorders, including generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, panic disorder, and co-morbid post-traumatic stress disorder. In the pilot study, only children and teens with primary generalized anxiety disorder, social anxiety disorder and separation anxiety disorder were included. These are common conditions, which share disabling anxious preoccupations, anticipatory anxiety and avoidance, and impair children’s and families’ lives substantially. Many anxious children go on to become anxious adults.
The treatment manual articulates a symptom-focused 24-session psychoanalytic psychotherapy, which allows clinicians to intervene by collaboratively identifying the underlying unconscious meanings of anxiety symptoms and maladaptive behaviors and to communicate the emotional meaning of these symptoms to the child, thereby demystifying symptoms and rendering them less intense. The treatment is conducted from a developmental perspective, and the book includes ample clinical examples of how to approach children and adolescents at all phases of adaptation. The goal of CAPP is to free children of the burden of symptoms, which inhibit and constrain the child in her/his life.
Clinical examples demonstrate CAPP can help children and adolescents:
Reduce anxiety symptoms by articulating anxious fantasies in words and developing an understanding of the emotional meaning of symptoms and associated behaviors.
Enhance children’s skill of reflection and self-observation of one’s own and others’ motivations, ideas, and behaviors, with the expectation of continued use after treatment ends (improvement in symptomspecific reflective functioning).
Diminish children’s use of avoidance, age-inappropriate dependence and rigidity by helping them to see that underlying emotions such as guilt, shame, anger as well as wishes and desires that seem unacceptable can be tolerated and understood.
Understand fantasies and compelling emotional significance surrounding the anxiety symptoms.
Reduce symptoms’ magical qualities and powerful impact on the child by articulating personal meanings in language.
The manual provides a detailed description of psychodynamic treatment principles and techniques for children and adolescents with anxiety and emphasizes the patient as a participant and collaborator with the therapist in the task of uncovering the meanings of anxious phenomena and maladaptive behaviors. A developmental perspective is emphasized at all times. Techniques of interviewing and interpreting geared towards youth of various ages are explained and examples are given.
The CAPP manual offers a guide to opening, middle and termination phases of psychotherapy. The opening phase serves to obtain the history of the symptoms, to establish a therapeutic alliance with the youth and his/her parents and to identify core psychological dynamisms that contribute to the child’s anxieties. From the outset, the therapist pays attention to the beginning transference development, as well as countertransference reactions, which, for example, in anxious children, can include feeling the need to quickly assuage patients’ distress. The therapist addresses maladaptive behavioral patterns early but sensitively, and interprets defenses before addressing conscious or unconscious fantasies.
During the middle phase, the therapist and patient collaboratively understand the previously identified central psychological conflicts and core dynamisms as they pertain to the anxiety symptoms. As new material emerges, adjustments to the initial formulation can be made. The therapist interprets defense mechanisms and attends to the deepening transference to the therapist. The developing understanding of the meaning of the anxiety symptoms results in a progressive improvement in reflective function, which is followed by improved functioning. Multiple examples of therapeutic interactions are given in the text.
The termination phase describes how the ending of treatment presents a unique opportunity to review psychological and symptomatic changes that have occurred and also to revisit earlier symptoms, in particular in the context of the common re-arousal of symptoms in which separation conflicts are now experienced with the therapist in the transference. New venturesome behaviors that point toward adaptive and sensible autonomy seeking are encouraged, without the burden of previous maladaptive restrictions.
In separate chapters, we elucidate the historical background of child psychodynamic psychotherapy and emphasize the importance of a developmental perspective by discussing clinical vignettes of children and adolescents of various ages in psychotherapy for anxiety disorders. Attention is also given to the nature of parent involvement in the treatment, which depends on the developmental stage of the child.
A section is devoted to each anxiety disorder, detailing characteristic psychodynamic factors and conflicts, transdiagnostic treatment techniques, as well as specific diagnosis-dependent adaptations.
Taking a longer-term perspective, CAPP has potential in the following areas:
It is a psychoanalytically informed, meaning seeking treatment that is more easily incorporated into public health mandates due to its time-limited frame. It can thus potentially be made accessible to greater numbers of patients.
Clinicians of various theoretical backgrounds can be trained in this method, thus making the treatment accessible to a patient population that normally would not have access to psychoanalytically informed treatments.
The programmatic approach provides the basic manual backbone for further study.
It seems likely that time-limited symptom-focused psychoanalytic psychotherapy approaches can be extended to other diagnoses, for example to depressive disorders.
This manual, Child and Adolescent Anxiety Psychodynamic Psychotherapy (CAPP): A Manual Based on Psychoanalytical Principles, is intended to be useful for clinicians of all disciplines (psychiatrists, psychoanalysts, psychologists, psychotherapists of all guilds), and for clinicians from diverse theoretical backgrounds who treat children. It will appeal to the student reader, as well as to the experienced clinician seeking a roadmap to brief psychodynamic psychotherapy for anxiety in children. It will be published by Oxford University Press.
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From the Issues in Child and Adolescent Psychoanalysis Editor
In this article, the authors describe their new short-term psychodynamic treatment for anxiety in children and adolescents.
There is no question this is a timely contribution to the field, since anxiety in children is very common, including a variety of subtypes. Untreated anxiety in children has serious sequelae in adulthood. The authors provide a meaningful contribution to the psychiatry literature because most of that literature, especially the empirical literature, relies on the utilization of behavioral models for treatment, or the utilization of psychotropic medications. For psychoanalysts, the incorporation of this treatment into a manual (Child and Adolescent Anxiety Psychodynamic Psychotherapy (CAPP): A Manual Based on Psychoanalytical Principles) is one more addition to the growing psychodynamic empirical base, which should provide greater acceptance of psychoanalytic ideas by the general scientific field.
This volume offers an alternate way to approach anxious children—understanding the motivators that provoke so much anxiety, and helping the child develop inner resources so he/she can cope more adaptively when stresses occur in the future.
—Leon Hoffman