When adolescents stop psychological therapy: rupture-repair in the therapeutic alliance and association with therapy ending

therapeutic alliance consistently predicts dropout from psychological therapy, and ruptures in the therapeutic alliance may also predict dropout, yet there is a dearth of research with adolescents. This study investigated whether markers of rupturerepair in the therapeutic alliance were indicative of different types of treatment ending in adolescents who received psychological treatment for depression. Data were from the IMPACT study, a trial investigating the effectiveness of therapies for adolescent depression. Participants were randomly allocated to receive a psychological therapy: Brief Psychosocial Intervention, Cognitive-Behavioural Therapy or Short-Term Psychoanalytic Psychotherapy. The sample (N=35) comprised adolescents who had either completed their treatment (n=14) or dropped out (n=21) according to their therapist. Dropout cases were further classified as dissatisfied (n=14) or got-whatthey- needed (n=7) based on post-therapy interviews with the adolescent and therapist. Selected audio-recordings of therapy sessions were rated using the Rupture Resolution Rating System and Working Alliance Inventory (observer-version). Therapeutic alliance and rupture-repair during therapy were similar for completers and got-what-they-needed dropouts, while dissatisfied dropouts had poorer therapeutic alliance, more ruptures, ruptures were frequently unresolved, and therapists contributed to ruptures to a greater extent. Qualitative analysis of the sessions led to the construction of three categories of therapist contribution to ruptures: therapist minimal response; persisting with a therapeutic activity; and focus on risk. Results suggest that ruptures, especially when unresolved, could be regarded as warning signs of disengagement and dropout from psychological treatment. Future research should investigate how ruptures may be effectively identified and resolved in treatment with adolescents

Approaches to assessment in time-limited Mentalization-Based Therapy for Children (MBT-C)

In this article we describe our clinical approach to assessment, formulation and the identification of a therapeutic focus in the context of time-limited Mentalization-Based Treatment for Children (MBT-C) aged between 6 and 12. Rather than seeing the capacity to mentalize as a global construct, we set out an approach to assessing the developmental 'building blocks' of the capacity to mentalize the self and others, including the capacity for attention regulation, emotion regulation, and explicit mentalization. Assessing the child's strengths and vulnerabilities in each of these domains provides a more nuanced picture of the child's mentalizing capacities and difficulties, and can provide a useful approach to case formulation. The article sets out an approach to assessment that includes a consideration of mentalizing strengths and difficulties in both the child and the parents, and shows how this can be used to help develop a mutually agreed treatment focus. A clinical vignette illustrates the approach taken to assessment and connects it to routine clinical practice

The Clinical Challenge of Mentalization-based Therapy with Children Who are in "Pretend Mode"

The “pretend mode” is one of the so-called “pre-mentalizing modes of thinking”, which were first introduced by Target and Fonagy over 20 years ago. In a series of papers about play and reality, “pretend mode” thinking was understood as a mode of pre-mentalizing thinking which is typical in the early years, but which can reappear in a more problematic way in adults. Although the concept of pretend mode was first introduced in a developmental context, as a clinical term it has primarily been discussed in the context of adult or adolescent psychotherapy. This paper suggests that the pretend mode is a valuable clinical concept for therapists working with school-age children, but that its use in this context needs some clarification. After reviewing how pretend mode has been understood as a normal part of early development, this paper goes to demonstrate the various roles of pretend mode in clinical work with school-age children and sets out a number of clinical strategies that may be used in therapeutic work

The Herts and Minds study: feasibility of a randomised controlled trial of Mentalizationbased Treatment versus usual care to support the wellbeing of children in foster care

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.Background: There is a lack of well-designed randomized controlled trials (RCTs) to investigate the efficacy of psychological therapies for children in foster care with emotional and behavioural difficulties. Mentalization-based therapy (MBT) focuses on supporting the carer-child relationship by promoting reflective capacity. This study examined the feasibility and acceptability of an RCT of MBT, delivered in a family-format, for children who are in foster care in the UK. Method: Herts and Minds was a phase II, blinded feasibility RCT with follow-up of at 12 and 24 weeks post-randomisation. Participants were children (age 5-16) in foster care referred to a targeted mental health service, who had some level of difficulty as identified by the Strengths and Difficulties Questionnaire (SDQ). Aims were to assess: the feasibility of recruitment processes and study uptake; capacity to train mental health practitioners to deliver MBT to an acceptable level of treatment integrity; establish acceptability and credibility of MBT as an intervention for children in foster care; establish feasibility and acceptability to participants of conducting an RCT; and estimate the likely treatment efficacy effect size. Participants were randomly allocated to either MBT (n = 15) or Usual Clinical Care (UCC) (n = 21) individually or in sibling groups. A range of qualitative and quantitative data was gathered to assess feasibility. Results: Feasibility was established with regard to: capacity to recruit participants to a study; capacity to train mental health practitioners to deliver MBT to an acceptable level of treatment integrity; acceptability and credibility of MBT; and feasibility and acceptability to participants of conducting an RCT. A number of issues made it difficult to estimate a likely treatment efficacy effect size. Conclusion: With modifications, it is feasible to run an RCT of MBT for children in foster care. Both the therapy and research design were acceptable to participants, but modifications may be needed regarding both the timing of assessments and the identification of appropriate primary outcome measures. Given the lack of evidenced based therapies for this population, such a trial would be a significant contribution to the field. Findings may be useful for other groups planning clinical trials of psychological therapies for children in foster care. Trial registration: ISRCTN 90349442. The trial was retrospectively registered on 6 May 2016.Peer reviewedFinal Published versio

Facing Shadows: working with young people to coproduce a short film about depression

Background: IMPACT (Improving Mood with Psychoanalytic and Cognitive Therapies) is a multi-centre randomised controlled trial of three therapeutic interventions for the treatment of depression in young people. IMPACT- My Experience (IMPACT-ME), a qualitative research study, followed up a sub-sample of families involved in IMPACT to explore young people's experiences of therapy and depression. Members of the IMPACT-ME steering group, who brought their own experiences of depression and engaging with mental health services, were keen to find ways to provide information about depression and help-seeking beyond traditional academic audiences, specifically to other young people experiencing depression and wondering where to turn: their chosen medium was film. Here we describe and reflect on the four-day coproduction workshops in which researchers, young people and film-makers coproduced 'Facing Shadows', a short animation about depression and therapy (https://www.youtube.com/watch?v=LdmRPKUhNEY). Main body: We outline the process, focusing on the four-day creative, collaborative workshop in which young people shared their experiences, decided on the tone, tenor and message of the film, identified their primary audience and produced the bulk of the audio and visual material. The adults acted as facilitators: developing a creative, collaborative learning environment in which trusting relationships could flourish, as well as offering guidance, instruction, advice and support. To date the film has been viewed around 12,000 times on YouTube. The young people learned new skills, felt listened to and enjoyed the process. They produced a film which sends a hopeful message to other young people, '… that they are not alone'. Conclusion: We reflect on the creative participatory workshop approach which transformed the project from dissemination to an insightful learning experience for young people and researchers alike

Psychological Mediators of the Association Between Childhood Emotional Abuse and Depression: A Systematic Review

Background: A number of existing meta-analyses and narrative reviews have already addressed the relation between childhood adversity and depression, yet none of them has examined the specific link between emotional abuse and depression highlighted by previous research. It is no longer appropriate to regard childhood maltreatment as a unitary concept when considering its effects on subsequent depression; instead, subtypes of childhood maltreatment need to be scrutinized separately. This review addresses this significant gap by critically evaluating empirical studies examining psychological mediators of the relationship between childhood emotional abuse and subsequent depression. / Methods: A systematic search of nine electronic databases was conducted to identify eligible studies published in English between January 1980 and January 2020. Given the heterogeneous outcomes of eligible studies and the inconsistent reporting of indirect effects, a narrative synthesis, rather than a quantitative meta-analysis, was conducted. An appraisal of methodological quality was also included. / Results: We identified 34 papers, comprising 18,529 adults and 3,434 adolescents, including 888 clinical participants. Our synthesis suggests that studies on mediators in the emotional abuse–depression link have focused on five clusters of intervening variables: early maladaptive schemas, cognitive-personality variables, emotion dysregulation, interpersonal styles, and stressful negative events. Only 11 studies identified the unique contribution of emotional abuse to depression by controlling for other forms of childhood maltreatment. / Conclusions: Our findings support several routes with relative consistency (e.g., early maladaptive schemas, hopelessness, negative cognitive styles, brooding rumination, overall emotion dysregulation). Because psychological mediators function as a complex interrelated system, controlling for the interrelation between them is important. The evidence for the purported mediating role of the factors identified in this review should be considered with caution given the relative dearth of large-scale, adequately powered longitudinal studies. This review proposes a comprehensive multilevel theoretical framework as a basis for future research

Teenage Boys in Therapy: A Qualitative Study of Male Adolescents' Experiences of Short-Term Psychoanalytic Psychotherapy

Adolescent boys have the highest rates of disengagement and drop out from mental health services. Further, research suggests that when boys do enagage with services, they may value therapies that provide practical strategies rather than those that advocate the exploration of thoughts, feelings, and relationships. Research is therefore needed to gain a better understanding of teenage boys’ experiences of participating in such therapies. This qualitative study aimed to explore the therapeutic experiences of five male adolescents (aged 16 to 18 years) with moderate to severe depression, who engaged in Short-Term Psychoanalytic Psychotherapy (STPP) as part of a randomized controlled trial. Interpretative Phenomenological Analysis of semi-structured interviews was used for an in-depth and idiographic exploration of their experiences. Three themes were identified: ‘Pain in therapy for a worthwhile purpose’, ‘A relationship unlike others: creating a space for reflection’, and “Ending with ‘a little bit of relief and a little bit of hope’”. The findings offer insight into factors that made it possible for these adolescents to engage in and benefit from STPP – a positive therapeutic relationship and gaining self-understanding – and, aspects that hindered their engagement and led to premature endings. This knowledge could inform clinical practice with depressed adolescent boys