Users' experiences of trauma-focused cognitive behavioural therapy for children and adolescents: a systematic review and metasynthesis of qualitative research

Facilitators and barriers to "Positive Outcomes" from cognitive-behavioral therapy, according to young people: A thematic synthesis

OBJECTIVE

This qualitative review sought to explore how young people (YP) conceptualize positive outcomes from cognitive-behavioral therapy (CBT) and what YP perceive to be the facilitators and barriers to positive outcomes.

METHODS

A systematic literature search was conducted in June 2021 using six online databases. Studies were included if qualitative data were collected from participants who were aged up to 25, had internalizing mental health difficulties, and had received in-person CBT from trained practitioners.

RESULTS

Nineteen studies were included. The Gough Weight of Evidence framework was used to assess methodological and topical quality and relevance. A thematic synthesis identified 34 conceptualizations of positive outcomes, 57 facilitators, and 49 barriers. Descriptive and analytical themes were identified. In line with the review's pragmatic perspective, the latter were worded as practice recommendations: acknowledge YP's perspectives on outcomes, teach tangible CBT techniques, balance autonomy and support, frame CBT as "upskilling," explore nuanced barriers to engagement, and consider the power of group dynamics.

CONCLUSIONS

This review established the range of YP's views about positive outcomes from CBT, as well as facilitators and barriers to achieving these. Findings should prompt CBT practitioners to reflect and consider how their practice might be shaped through reports from YP as experts by experience.

Overlap Between Exposure to Suicidal Behavior and Indirect Interpersonal Violence: Evidence for a More Integrated Approach to Violence Research

This study examines the overlap between indirect exposure to forms of interpersonal violence and suicidal behavior, and the impact of the co-occurrence of these exposures on indicators of depressed mood and substance use among adolescents. Participants were a national sample of 3,917 youth aged 14-15 years, recruited online between June 2018 and March 2020, including an oversample of sexual and gender minority youth. Eight in ten (81.3%) youth reported exposure to indirect interpersonal violence and/or suicidal behavior in their lifetimes: 39.5% reported only interpersonal violence exposure, 5.9% only suicidal behavior exposure, and 35.9% reported both. Youth who reported exposure to interpersonal violence were almost three times more likely (adjusted odds ratio [OR] = 2.78, p < .001) to also report suicidal behavior exposure. Compared with youth having no indirect violence exposure, those with only interpersonal violence exposure were 2.25 times more likely (p < .001), those with only exposure to suicidal behavior 2.93 times more likely (p < .001), and those with both were 5.63 times more likely to report recent depressed mood. The unadjusted odds of any substance use was significantly elevated for each type of indirect violence exposure, with the highest odds seen among youth with dual interpersonal violence and suicide exposure (OR = 4.87, p < .001). For both outcomes, significant findings remained but were attenuated after adjusting for demographic characteristics, non-victimization adversity exposure, and cumulative direct victimization. Findings suggest that the combination of exposure to interpersonal violence and suicidal behavior appears to be particularly impactful. Results highlight that assessment of trauma exposure among adolescents needs to be more comprehensive and include not only direct and indirect interpersonal violence, but also knowledge of other people's suicidal thoughts and behaviors.

Children subjected to family violence: A retrospective study of experiences of trauma-focused treatment

Exposure to adverse childhood experiences is a risk factor for the development of serious psychiatric and somatic illness. Although trauma-focused therapy is effective in reducing symptoms, not all children benefit from it. To improve treatment efficacy, the children's perspective on what they perceive as helpful versus hindering is necessary. This study aimed, retrospectively, to explore how children exposed to family violence experienced treatment at the Child and Adolescent Mental Health Service. Seventeen children and youths were interviewed 4-5 years after treatment. The thematic analysis resulted in five themes: confusion, the need to feel heard, fear of consequences, feelings of pain, and identifying oneself as an agent. The results emphasize the importance of the therapeutic relationship, and that trust, genuine interest, and reciprocity are necessary for the child to engage in treatment. However, neither the child's own agency nor external obstacles such as continuous exposure to abuse should be underestimated in terms of the child's engagement.

The experience of young people receiving cognitive behavioural therapy for major depression: A qualitative study

AIM

Major depressive disorder (MDD) has far reaching impacts for young people, their families and society. Cognitive behavioural therapy (CBT) is one of the first-line treatments for young people experiencing MDD; however, there is limited research examining how young people with MDD experience CBT. The aim of this study was to explore their experience and their views of this intervention.

METHODS

We employed a qualitative research design, with semi-structured interviews and thematic analysis. Eight participants aged between 17 and 24 years who received CBT for MDD in a randomized controlled trial were recruited.

RESULTS

Five themes were identified: the importance of relationship with clinician; the range of useful components within CBT; the ability for CBT to accommodate different techniques and presenting issues; the importance of checking in with clients during the process of therapy; and the impacts of MDD on therapy.

CONCLUSIONS

The findings highlight the importance of clinicians having a youth friendly and collaborative approach that allows a modular delivery of a range of CBT techniques to suit the client's presenting issue and formulation. There is a need to continually check how young people are responding to interventions, and to be aware of potential cognitive deficits and adjust therapy accordingly. This is a small study that provides insight into how young people with MDD experience CBT and avenues to explore for tailoring provision of CBT to enhance the therapeutic experience for this population.

Client and counsellor experiences of abbreviated trauma-focused cognitive behavioural therapy for South African adolescents

Although South Africa has high rates of child and adolescent trauma exposure and associated mental health difficulties, there is a poor evidence base for trauma interventions with youth in this setting. In a resource-constrained context, there is a need for brief evidence-based trauma treatments. However, abbreviated interventions may reduce the acceptability and tolerability of treatment for clients and impact treatment delivery by providers. We developed an abbreviated eight-session version of trauma-focused cognitive behavioural therapy. Using a sequential mixed-methods design, we piloted this intervention with 10 adolescents and their caregivers to assess the acceptability and tolerability of the abbreviated trauma-focused cognitive behavioural therapy model for participants, the degree of counsellor fidelity to the abbreviated treatment manual and counsellor experiences of implementation. The treatment completion rate was 90% and post-traumatic stress disorder symptoms reduced over the course of treatment for all treatment completers. Although there was flexibility in timing and dosing of delivery, counsellor fidelity to treatment components and treatment length was high. Thematic analysis of interviews with participants and counsellors indicated that, within this abbreviated trauma treatment, the therapeutic alliance was able to provide a solid foundation for trauma processing, there was adequate time to practice coping skills and the compressed trauma processing component was difficult but tolerable. Counsellors indicated that a degree of flexibility within fidelity to the abbreviated treatment model enhanced their implementation of the treatment. The findings provide evidence to support a formal evaluation of the abbreviated trauma-focused cognitive behavioural therapy treatment protocol.

Understanding therapists' perceived determinants of trauma narrative use

BACKGROUND

Trauma narratives are a critical, exposure-based component of trauma-focused cognitive-behavioral therapy, yet community therapists rarely use them. Given evidence that intentions to deliver elements of cognitive behavioral therapy vary by component, and that intentions to deliver exposure are the weakest, this study focused specifically on trauma narratives. We drew on a social psychology causal theory (Theory of Planned Behavior (TPB)) and an implementation science framework (the Consolidated Framework for Implementation Research (CFIR)) to glean insight into multilevel influences on trauma narrative use. While the CFIR offers a broad list of factors potentially affecting implementation, the TPB offers causal pathways between individual-level constructs that predict behavior, including the uptake of an evidence-based intervention. The integration of these approaches may provide a more complete understanding of factors affecting therapists' use of TNs.

METHODS

Therapists (n=65) trained in trauma-focused cognitive behavioral therapy completed a survey about their use of and beliefs about trauma narratives. Content analysis was used to identify common beliefs about trauma narratives. A subset of participants (n=17) completed follow-up qualitative interviews, which were analyzed using an integrated approach informed by the CFIR.

RESULTS

While most participants reported high intentions to use TNs, nearly half reported that they did not use TNs in the last 6 months. Survey data indicate a number of TPB-related determinants related to using trauma narratives. Qualitative interviews identified CFIR-relevant contextual factors that may influence constructs central to TPB.

CONCLUSIONS

These results highlight the importance of integrating approaches that address multiple theoretical determinants of therapist behavior, including therapist, organizational, and client factors with causal explanations to explain implementation behavior.

Acceptability of tDCS in treating stress-related mental health disorders: a mixed methods study among military patients and caregivers

BACKGROUND

Noninvasive brain stimulation techniques like transcranial direct current stimulation (tDCS) offer potential new approaches to treat stress-related mental health disorders. While the acceptability of tDCS as a treatment tool plays a crucial role in its development and implementation, little is known about tDCS acceptability for users in mental healthcare, especially in the context of stress-related disorders.

METHODS

Using a mixed-methods approach, we investigated tDCS acceptability among 102 active duty and post-active military patients with stress-related symptoms (posttraumatic stress disorder, anxiety and impulsive aggression) who participated in a 5-session tDCS intervention. Quantitative dropout and adverse effects data was collected for all patients involved in the sham-controlled tDCS intervention. We additionally explored perspectives on the acceptability of tDCS treatment via a theory-based semi-structured interview. A subgroup of patients as well as their caregivers were interviewed to include the views of both patients and mental healthcare professionals.

RESULTS

Quantitative outcomes showed minimal tDCS-related adverse effects (mild itching or burning sensations on the scalp) and high tDCS treatment adherence (dropout rate: 4% for active tDCS, 0% for sham). The qualitative outcomes showed predominantly positive attitudes towards tDCS interventions for stress-related disorders, but only as complementary to psychotherapy. Remarkably, despite the perception that sufficient explanation was provided, patients and caregivers stressed that tDCS treatment comprehension was limited and should improve. Also, the travel associated with frequent on-site tDCS sessions may produce a significant barrier to care for patients with stress-related disorders and active-duty military personnel.

CONCLUSIONS

Acceptability numbers and perspectives from military patients and caregivers suggest that tDCS is an acceptable complementary tool in the treatment of stress-related disorders. Critically, however, if tDCS is to be used beyond scientific studies, adequately educating users on tDCS working mechanisms is vital to further improve its acceptability. Also, the perceived potential barrier to care due to frequent travel may favor home-based tDCS solutions.

TRIAL REGISTRATION

The tDCS intervention was part of a sham-controlled trial registered on 05-18-2016 at the Netherlands Trial Register with ID NL5709 .

"Like a huge weight lifted off my shoulders": Exploring young peoples' experiences of treatment in a pilot trial of trauma-focused cognitive behavioral therapy

Background: The efficacy of trauma-focused cognitive behavioral therapy (TF-CBT) is well-established, yet little work has been done to understand how young people experience this intervention.Method: Semi-structured interviews were conducted with 13 young people aged 17-25 years (M = 20.0, SD = 2.61) who received TF-CBT as part of a pilot trial. Transcripts were analyzed via interpretative phenomenological analysis.Results: Four super-ordinate themes were identified: (i) experience of authentic care, (ii) personal role in therapy and recovery, (iii) talking about trauma is difficult but important, and (iv), transformative change. Young people described authenticity on behalf of the therapist, which seemed to foster emotional connection and comfort discussing trauma. They emphasized the importance of retaining autonomy and control during therapy, and a degree of personal responsibility in their recovery. Talking about trauma was described as difficult and potentially distressing, but also as critical for recovery. Transformative life changes were noted, which had a significant impact on young peoples' future outlook and self-perception.Conclusions: This study suggests that therapists should be attuned to the interpersonal needs of clients, attempt to foster self-determination throughout therapy, and simultaneously recognize the difficulty and importance of trauma work for young people when delivering TF-CBT.

Intimate partner violence in adolescents: Preventive strategies for psychiatric-mental health nurse practitioners

TOPIC

Intimate partner violence (IPV) remains a significant public health problem that is associated with high rates of morbidity and mortality. IPV has become increasingly prevalent in adolescents, with 20% of adolescents between 13 and 18 years reporting physical IPV, and 9% reporting sexual IPV. To assure the best outcomes for adolescents at-risk for or experiencing IPV, it is critical for psychiatric-mental health nurse practitioners (PMHNPs) to implement preventive interventions, spanning from primary to tertiary prevention, to address IPV.

PURPOSE

The purpose of this paper is to provide an overview of primary, secondary, and tertiary preventative strategies needed to improve outcomes for adolescents experiencing IPV within the context of the socioecologial model.

SOURCES USED

Utilizing PubMed, CINAHL, and PsycINFO, a literature review was conducted to identify relevant publications spanning from 2015 to present. Reference lists of identified articles were also searched.

CONCLUSIONS

PMHNPs must be competent in psychoeducation and counseling, screening, and management of comorbidities and safety planning to assure best outcomes for adolescents exposed to IPV.

Childhood Trauma and Psychosis: An Updated Review

There is growing evidence to support the link between childhood trauma and psychosis. Childhood trauma increases the risk for psychosis and affects severity and type of psychotic symptoms, and frequency of comorbid conditions, including depression and substance use. Childhood trauma is linked to more severe functional impairment in individuals with psychosis. There is evidence to support gender differences in the influence of childhood trauma on the course of psychotic illnesses, appearing to be more profound in girls and women. Other biological markers that may explain the link between childhood trauma and psychosis include brain-derived neurotrophic factor and other inflammatory markers.