Interaction Structures in Psychodynamic Psychotherapy for Adolescents

Despite advances in psychotherapy research showing an evidence-base for psychodynamic psychotherapy (PDT) in adolescents, developmentally specific treatment characteristics are under-researched. We aimed to identify interaction structures (IS: reciprocal patterns of in-session interactions involving therapist interventions, patient behaviors, and the therapeutic relationship) and assess associations between IS and outcome. The study cohort comprised 43 adolescents (Mage = 13.02 years) with nonclinical, internalizing, and comorbid internalizing–externalizing problems in PDT. A total of 123 sessions from different treatment phases were rated based on the Adolescent Psychotherapy Q-Set (APQ). Outcome was assessed with the Brief Problem Monitor-Youth (BPM-Y) administered repeatedly over the treatment course. Principal component analysis of APQ items resulted in five IS, named “Negative Therapeutic Alliance”, “Demanding Patient, Accommodating Therapist”, “Emotionally Distant Resistant Patient”, “Inexpressive Patient, Inviting Therapist”, and “Exploratory Psychodynamic Technique” (EPT). Multilevel modeling analyses with Bayesian Markov chain Monte Carlo (MCMC) estimations indicated a two-way interaction effect between EPT and problem levels at baseline such that patients with lower problems at baseline showed good outcome in the context of EPT, whereas an inverse relationship was found for patients with higher problems. Findings provide empirical evidence for characteristic components of PDT for adolescents and preliminary answers about who benefits from psychodynamic techniques.

Psychotherapy Dropout: Using the Adolescent Psychotherapy Q-Set to Explore the Early In-Session Process of Short-Term Psychodynamic Psychotherapy

Research suggests that short-term psychodynamic psychotherapy (STPP) is an effective treatment for depression in adolescence, yet treatment dropout is a major concern and what leads to dropout is poorly understood. Whilst studies have begun to explore the role of patient and therapist variables, there is a dearth of research on the actual therapy process and investigation of the interaction between patient and therapist. This study aims to address this paucity through the utilisation of the Adolescent Psychotherapy Q-set (APQ) to examine the early treatment period. The sample includes 69 adolescents aged 16–18 years with major depressive disorder receiving STPP as part of the First Experimental Study of Transference Work–in Teenagers (FEST-IT) trial. Of these, 21 were identified as dropouts and were compared to completers on pre-treatment patient characteristics, symptomatology, functioning, and working alliance. APQ ratings available for an early session from 16 of these drop out cases were analysed to explore the patient-therapist interaction structure. Results from the Q-factor analysis revealed three distinct interaction structures that explained 54.3% of the total variance. The first described a process of mutual trust and collaboration, the second was characterised by patient resistance and emotional detachment, the third by a mismatch and incongruence between therapist and adolescent. Comparison between the three revealed interesting differences which taken together provide further evidence that the reasons why adolescents drop out of therapy vary and are multidimensional in nature.

Negotiating System Requirements to Secure Client Engagement – Therapist Strategies in Adolescent Psychotherapy Initiated by Others

Background: Many adolescent clients come to treatment reluctantly, at the initiative of others. Adolescents also quit therapy prematurely more often than adult clients do. This points to the value of finding good ways to engage adolescent clients in treatment and understanding more of what therapists do to achieve this task.Methods: We used focus group methodology to explore therapist strategies and behaviors to engage adolescent clients who come to therapy at the initiative of others. Ten focus group interviews with a total of 51 therapists were conducted with existing treatment teams from seven different clinics in community mental health care for children and youth. Reflexive thematic analysis was used as a framework to guide the analytical process.Findings: Navigating a position allowing the therapist and adolescent to meet and work toward a shared understanding of the situation and what could help was considered the main gateway to client engagement. To do this, therapists had to manage the pull between system requirements and their obligation to the individual adolescent client, represented by the theme Managing system requirements. The process of working with the adolescent to ensure engagement is represented by the four themes: Counteracting initial obstacles for client engagement – “You are not trapped here”; Sharing definitional power – “What does it look like to you?”; Practicing transparency – “I want you to know what I see”; and Tailoring as ideal – “I will design this therapy for you.”Implication and conclusion: Therapists want to understand their adolescent clients’ position better, and subsequently adjust the treatment goals and techniques to establish sufficient common ground to allow both the therapist and adolescent to find the therapeutic project worthwhile. However, system requirements and service organization were found to obstruct and influence these processes in several ways, pointing to the significance of exploring the interplay between system organization and therapeutic practice more thoroughly. There was also a variation between therapist behaviors described by different therapists within the same treatment teams, as well as systematic differences between treatment teams, pointing to the importance of future research differentiating wanted from unwanted variation in treatment.

The Bridge - February 2021

The February 2021 edition of The Bridge contains blogs and research digests, with a focus on child and adolescent psychotherapy.

Confidentiality at the interface of an adolescent psychotherapy service

AimsAims included to explore how, within a London trust, staff at the interface between patients, relatives and access to services view their understanding of confidentiality, and to determine ways to improve knowledge if needed.BackgroundConfidentiality is essential to the trust and development of clinician-patient relationships. National policies set guidance on how confidential information should be recorded, secured and shared. However, confidentiality breaches are reportedly common within health professions. Working with adolescent patient groups brings additional issues regarding confidentiality. Care-givers who contact services, often desiring containment, may experience a sense of uncertainty when confidentiality policy prevents details being shared about a young person's clinical experience.MethodStakeholders were identified from the multidisciplinary team, with a collaborative rather than ‘top-down’ approach. Administrators in patient-facing roles were surveyed to ascertain current understanding and frequency of involvement in confidentiality issues. Based on feedback, a flowchart prompt was designed, ensuring it reflected best practice. Qualitative and quantitive data were collected before and after a two month implementation period.ResultAll respondents (n = 10) dealt with confidentiality issues at work, with 50% experiencing issues daily. 33% respondents did not feel confident dealing with confidentiality queries at work. The majority (60%) had received confidentiality training, but all respondents thought extra information would be useful. Of possible interventions, 70% supported a flowchart. Following an implementation period, 100% respondents re-surveyed agreed they felt confident dealing with issues related to confidentiality at work. The majority of respondents had used the flowchart and found it useful (83%). Qualitative data gathered suggested rolling-out the project elsewhere.ConclusionA lack of confidence surrounding issues with confidentiality, including information sharing, was identified. This can negatively impact patient engagement and delivery of care. The introduction of the confidentiality flowchart demonstrated improved understanding of, and confidence in, patient confidentiality issues. The small sample size means there are limitations in extrapolating findings to wider contexts. However, it is likely that more confidentiality training and practical information for NHS staff at the interface between patients, clinicians and services would reduce the risk of confidentiality breaches and reinforce positive relationships with services.

Barriers and Facilitators in Adolescent Psychotherapy Initiated by Adults—Experiences That Differentiate Adolescents’ Trajectories Through Mental Health Care

Mental health problems start early in life. However, the majority of adolescents fulfilling the criteria for mental health disorders do not receive treatment, and half of those who do get treatment drop out. This begs the question of what differentiates helpful from unhelpful treatment processes from the perspective of young clients. In this study, we interviewed 12 young people who entered mental health care reluctantly at the initiative of others before the age of 18. Their journeys through mental health care varied significantly despite sharing the same starting point. Our analyses resulted in a model of three trajectories. We describe relational and structural facilitators and obstacles within each trajectory and have formulated narratives highlighting core experiences differentiating them. Trajectory 1 (I never saw the point – Being met as a case) was characterized by a rapid loss of hope, leading the adolescents to conclude that mental health care was not worth the investment. Trajectory 2 (I gave it a go, but nothing came of it – Being met by a therapist representing a rigid and unhelpful system) was characterized by a lingering hope that never materialized into a constructive therapeutic process despite prevailing efforts by both therapists and adolescents. Trajectory 3 (Something good came of it – Being met by a therapist who cares and wants to help) was characterized by genuine meetings, allowing the therapist to transform from an unsafe stranger into a safe, competent, and benevolent adult. We discuss how our results have implications for understanding agency displayed by adolescent clients in therapy, therapist flexibility and authenticity, service organization, and attributional processes influencing clinical judgment and therapeutic processes when adolescent psychotherapy has a difficult starting point (i.e., initiated by adults).

The policy context for research into child and adolescent psychotherapy

Mental illness in children and young people is recognised as a major public health concern with evidence of rising prevalence, possibly exacerbated by COVID-19.

Psychotherapy with Children and Adolescents

Psychotherapy with children and adolescents presents its own set of unique ethical challenges and considerations. Unlike psychotherapy with adults, children are often referred to therapy by adults (e.g., parents or teachers), meaning that the circumstances and context for which they present to therapists or clinicians differ from the circumstances of most adults. This chapter provides an overview of ethical considerations specific to children and adolescents including issues of competence, confidentiality, boundaries, use of specific therapeutic techniques, and attention to diversity. The authors advocate for moving away from a traditional bioethical or risk management approach with clients, towards a relational approach to child and adolescent psychotherapy ethics, in which therapists and clinicians pay special attention to context, family dynamics, and culture. It is essential that mental health professionals involved in psychotherapy with children and adolescents engage in continuous reflection on ethical issues and work to best understand their clients in context so they can provide optimal services.