The Alliance With Young People: Where Have We Been, Where Are We Going?

The therapeutic alliance is considered an important mechanism of change in youth psychotherapy. Accordingly, it has become one of the most investigated psychotherapy variables. Yet, the theoretical and empirical literature on the alliance with young people is complex and has received criticism. This article aims to (a) critically review the existing knowledge on the alliance in youth psychotherapy from its definition to the existing research and (b) discuss some of the implications of this knowledge for clinical practice ad future research. This review highlights that the alliance in youth psychotherapy, as commonly measured, has a significant, although small, impact on outcomes; and that the alliance-outcome association may be influenced by the young person and the therapist's characteristics, as well as therapy types. This points to the importance of finding tailored ways of fostering a strong alliance when working with young people and questions the assumption of the alliance as a generic aspect of all types of youth psychological treatments. Attention to repairing alliance ruptures also emerged as key, especially to preventing early dropout in adolescent therapy. It is argued that despite its limitations, alliance research in youth psychotherapy can have important clinical implications to improve youth psychotherapy. A resumption of a conversation between the clinical and research field on the alliance is needed to better understand the nature and role of this important variable when working with young people and to use this knowledge to inform and improve clinical practice and therapeutic training. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Use of the Strengths & Difficulties Questionnaire to identify treatment needs in looked after children referred to CAMHS

© The Author(s) 2019Background: In England and Wales, the Strengths & Difficulties Questionnaire (SDQ) is used to assess and monitor looked after children’s (LAC) mental health; and some targeted CAMHS teams use it to decide who can access services. However, the ability of the single-informant SDQ to identify LAC who need mental health treatment is insufficiently understood. Methods: 144 LAC referrals to a Targeted CAMHS Team were screened as part of a larger study. To establish how well the SDQ identified children who required treatment, Total Difficulties Scores (TDS) from single-informant SDQs submitted at referral were compared to treatment recommendations following routine CAMHS assessment in a real-world setting. To explain the results, clinicians (n=9) from the team were interviewed and key themes identified using Thematic Analysis. Results: Optimal accuracy calculations for SDQs completed by carers (TDS=17, sensitivity .67, specificity .57), teachers (TDS=17, sensitivity .79, specificity .71) and young people (TDS=14, sensitivity.79, specificity .42) compared to the outcome of routine CAMHS assessments indicated that the number of children whose treatment needs were not identified by their SDQ score may be unacceptably high. Key themes from clinician interviews identified possible gaps and limitations: Developmental Trauma and Attachment Difficulties, A different kind of ‘patient?’, Seeing the bad but neglecting the sad, and The importance of clinical judgement. Conclusions: Contrary to UK Government policy, this study suggests that the single-report SDQ should not be relied upon as a sole means of identifying mental health difficulties in this vulnerable, high-risk population.Peer reviewedFinal Accepted Versio

Understanding treatment non-responders: A qualitative study of depressed adolescents' experiences of 'unsuccessful' psychotherapy

OBJECTIVES: This paper aimed to explore the experiences of depressed adolescents who completed but did not 'respond' to standard psychotherapy, based on a lack of improvement in pre-post symptoms scores. DESIGN: This was a qualitative study employing interpretative phenomenological analysis (IPA). METHOD: Seventy-seven adolescents with moderate to severe depression were interviewed as part of a qualitative arm of a randomised controlled trial. Five adolescents' post-treatment interviews were purposively sampled, based on lack of improvement on pre-post symptom scores, and adolescents still scoring above the clinical threshold for depression. The interviews were analysed using IPA. RESULTS: Adolescents made sense of their depression as part of their identity and held negative expectations of therapy. Some aspects of therapy brought up intolerable feelings that contributed to disengagement in the therapeutic process and culminated in disappointing and hopeless endings. On the other hand, where a stronger therapeutic relationship was developed, some participants experienced certain improvements. CONCLUSIONS: Findings highlight how actively exploring the adolescent's therapy expectations, developing a strong early therapeutic relationship and being mindful of the potential impact of endings are important in therapeutic work with adolescents with depression, especially where they may have a strong sense of hopelessness and self-criticism. Moreover, the finding that adolescents experienced improvements in other domains despite a lack of symptom reduction highlights the need to review how treatment outcomes are currently defined. Integrating individual perspectives of therapy with quantitative outcome measures can provide a more nuanced insight of treatment effects

Understanding change – developing a typology of therapy outcomes from the experience of adolescents with depression

Background: Outcome measures mostly focusing on symptom reduction to measure change cannot indicate whether any personally meaningful change has occurred. There is a need to broaden the current understanding of outcomes for adolescent depression and identify whether holistic, interlinked patterns of change may be more clinically meaningful. Objective: To create a typology of therapy outcomes based on the experiences of adolescents with depression. Method: Interview data from 83 participants from a clinical trial of the psychological treatment of adolescent depression was analysed using ideal type analysis. Results: Six ideal types were constructed, reflecting different evaluations of the holistic impact of therapy: “I’ve worked on my relationships”, “With the insight from therapy, and feeling validated, I can cope with life challenges better”, “My mood still goes up and down”, “If I want things to change, I need to help myself”, “Therapy might help, but it hasn’t been enough”, and “I don’t feel therapy has helped me”. Conclusion: Assessing change using outcome measures may not reflect the interconnected experience for adolescents or the contextual meaning of symptom change. The typology developed offers a way of considering the impact of therapy, taking into account how symptom change is experienced within a broader perspective

‘Trust me, we can sort this out’: a theory-testing case study of the role of epistemic trust in fostering relationships

Novel psychological theories are often conceived in a general or heuristic form that can benefit from development and granulation through context-specific theory testing. Here, a theory-testing single case study methodology, adapted from an approach developed in the field of psychoanalysis, is presented. The study exemplifies this methodology though an interrogation of the explanatory value of a relatively new child development theory, the theory of epistemic trust, in the context of the relationship between a foster carer (“John”) and a young person in their care (“Buster”). Using in-depth interview material, the ways and extent to which the theory of epistemic trust could aid understanding of this fostering relationship are examined. We discuss the implications for the development of the theory of epistemic trust and the applications of these findings to social work contexts. The strengths and limitations of this theory-testing case study approach are explored

The Evidence-Base for Psychodynamic Interventions with Children Under 5 Years of Age and Their Caregivers: A Systematic Review and Meta-Analysis

Experiences in the first years of life can shape a range of outcomes throughout the lifespan. Effective early interventions have the potential to offset negative outcomes associated with early adversity. A broad range of psychodynamic interventions are available to children under five and their caregivers but there is a lack of research synthesizing the current evidence for their effectiveness. This paper presents a systematic review and meta-analysis of the evidence for the effectiveness of psychodynamic interventions for children under 5 years of age and their caregivers. Following a systematic search of 10 databases and screening for eligibility, 77 papers were included in the review. Most studies reported positive outcomes on a range of parent and infant domains. The meta-analyses of controlled studies found significant effects of psychodynamic interventions compared to control conditions on parental reflective functioning, maternal depression, infant behavior, and infant attachment. No significant differences between psychodynamic and control interventions were found for parental stress, and parent-infant interactions. Very few studies were rated as good quality and further high-quality research is needed

The therapeutic relationship in Cognitive Behaviour Therapy with depressed adolescents: a qualitative study of good-outcome cases

Objectives. This paper aimed to explore client experiences of the therapeutic relationship among adolescents with good outcomes after receiving Cognitive Behaviour Therapy (CBT) for moderate to severe depression. Design. This was a qualitative study employing Interpretative Phenomenological Analysis (IPA). Methods. As part of a randomized clinical trial, 77 adolescents with moderate to severe depression were interviewed using a semi-structured interview, which was audiorecorded. Five of these interviews, with adolescents aged 14–18 years who completed CBT and had good outcomes, were purposively sampled and analysed using IPA. Results. The findings indicated that a positive therapeutic relationship was fostered with therapists who respected the adolescents’ autonomy and sense of individuality, while offering experiences of emotional closeness and connection. This was achieved by balancing the dual roles of being ‘friendly’ and affable, with being a ‘professional expert’ thereby embodying a collaborative and egalitarian approach. Conclusions. The therapeutic relationship in CBT can help to motivate adolescents to engage with cognitively and emotionally challenging tasks. By providing an understanding of what helps and hinders the development of a positive therapeutic relationship, the current findings offer important insight into how therapists can foster positive relationships with depressed adolescents. This knowledge will make it more likely that adolescents will engage in the treatment process and in turn experience greater therapeutic gains

Mapping the journey from epistemic mistrust in depressed adolescents receiving psychotherapy

Although the theory of epistemic trust has started informing research in clinical populations and in psychotherapy, no study has yet explored the phenomenon of epistemic trust and mistrust in depressed adolescents receiving psychotherapy. The present study aims to address this gap by creating a typology of depressed adolescents’ experiences regarding their different journeys through the course of psychotherapy in relation to issues of epistemic trust and mistrust over a 2-year period. This study is based on a post-hoc analysis of interview data collected for a broader purpose. A total of 45 semi-structured interviews at 3 time points were conducted with 15 adolescents (80% female; M age = 15.28, SD = 1.79) who entered treatment with indications of epistemic mistrust or hypervigilance. These interviews were qualitatively analysed using Ideal Type Analysis. Three distinct journeys of adolescents’ experiences were identified. Some experienced a shift from epistemic mistrust to epistemic trust which seemed to be associated with the experience of therapy; other adolescents also showed a shift but did not consider it as an outcome of therapy; and finally, some adolescents reported continued mistrust over the 2-year period. An interpersonal component within or beyond therapy may be the key to breaking the vicious cycle of epistemic mistrust and generating epistemic trust; but not all depressed adolescents in therapy achieve this. Particular attention should be drawn to depressed adolescents who have difficulty making use of therapy and/or their broader social environment. Psychological interventions may need to openly address their issues of mistrust in early sessions as epistemic mistrust or hypervigilance may hinder paths to learning both within and beyond therapy. Treatments that intervene at the level of the wider social system are encouraged

No typical care story: How do care-experienced young people and foster carers understand fostering relationships?

Although an understanding of the lived experience of foster care relationships can provide valuable information to guide social work practice and policy, few such studies have been carried out. This article presents findings from a qualitative investigation exploring experiences of relationships between foster carers and the young people in their care. Eight care-experienced young people and nine foster carers participated in interviews and focus groups. Interpretative Phenomenological Analysis (IPA) was used to explore their experiences. The insider’s perspective was further amplified through engaging peer researchers with experience of fostering relationships – one a young person who had been in care, the other a long-term carer. Two overarching themes were identified. Firstly, participants made sense of fostering relationships through comparisons with birth family ones, particularly in relation to the impact of care systems, continuing biological family relationships and foster care language. Secondly, previous experiences created barriers to forming positive fostering relationships, but when these were overcome the experience could be life changing. The implications of these findings for social care policy regarding foster carer support, training and matching guidelines are discussed

Trajectories of change in general psychopathology levels among depressed adolescents in short-term psychotherapies

Objective: to identify and describe trajectories of change in general psychopathology (p) levels among depressed adolescents who received one of three types of short-term therapies (namely Cognitive-Behavioural Therapy, Short-Term Psychoanalytic Psychotherapy, and a Brief Psychosocial Intervention). Method: Participants were 465 adolescents with MDD who participated in an RCT comparing three treatments for depression. Narrow-band measures of depression, anxiety, obsessions-compulsions, and conduct problems were assessed at six-time points, and bifactor analysis was performed to extract p factor scores. These scores were submitted to Latent Class Growth Analyses to identify patterns of change over time. Results: Three different trajectories of change in p were identified. Two trajectories displayed reductions in p across time-points: one a rapid decrease, and the other slower but steady improvement. The third trajectory indicated a limited decrease in p up until the 12th week after baseline but no further improvement at subsequent time-points. Patients’ baseline p significantly predicted their outcome trajectories. Conclusion: Exploring change in p seemed to describe more parsimoniously the patients’ outcomes than the narrow-band assessment of depressive symptoms. Patients with high baseline p were more likely to have poorer outcomes, potentially indicating a need to develop more intensive and tailored treatments for this population