Review: Therapist factors and their impact on therapeutic alliance and outcomes in child and adolescent mental health - a systematic review

Understanding the importance of therapeutic alliance during physiotherapy treatment for musculoskeletal pain in children: a scoping review

Introduction

Musculoskeletal pain affecting children is common. Rehabilitation and treatment effectiveness can be influenced by multiple individual and contextual factors. The need for more rigorous evaluation of physiotherapy treatment for children's pain, identification of the role of specific techniques, and exploration of the influence of the therapeutic alliance is needed. This scoping review of research aimed to examine: (1) What are the perceptions of children, parents, and physiotherapists about the importance of therapeutic alliance during musculoskeletal pain treatment? (2) What are the key characteristics of therapeutic alliance during a child's musculoskeletal pain treatment from the perspectives of children, parents, and physiotherapists? and (3) What are the perceived impacts of therapeutic alliance (positive and negative) during a child's physiotherapy treatment for musculoskeletal pain?

Methods

The scoping review, based on Arksey and O'Malley's framework and reporting was guided by PRISMA-ScR. The search strategy was based on three concept blocks: (1) Study population: Children (<18 years); (2) Medical condition: Any musculoskeletal pain (acute, chronic primary, chronic secondary); (3) Intervention: Qualitative exploration of experience of physiotherapy treatment delivered by a physiotherapist from the perspective of a child, parent, or physiotherapist. The search (no date limit) was conducted in February 2024 across Medline, AMED and CINAHL.

Results

Following duplicate removal and assessment of eligibility of the initial 236 articles, nine articles were included; of these, only one specifically aimed to explore therapeutic alliance and it was the only paper to directly mention therapeutic alliance. All nine articles presented the child's experience. One overarching theme "Finding resilience within me through therapeutic alliance" and three main themes: "A trusted guide through the ups and the downs of rehabilitation"; "Having a route map"; and "Take me seriously but make it fun" were identified.

Discussion

Therapeutic alliance was considered important by children, parents and physiotherapist and it influenced child and parent perceptions of physiotherapy and overall treatment outcomes. Physiotherapists can foster the children's resilience when experiencing musculoskeletal pain by providing disciplinary expertise, connecting and collaborating with the child by becoming their trusted guide, and co-creating a route map for rehabilitation by helping them to learn about their body, pain and recovery timeline.

Predicting fidelity and treatment outcomes in savoring interventions among mothers of young children

Savoring impacts parents' emotions and parent-child relationship quality. Using data from a randomized controlled trial (N = 164 mothers of 18-27-month-olds, 37 interveners) conducted with a community sample in the United States, this study examined predictors of fidelity and treatment outcomes across two savoring preventative interventions (relational savoring and personal savoring). Treatment outcome indicators were selected from a battery administered immediately post-intervention (maternal closeness to child) and at a 3-month follow-up (maternal sensitivity, reflective functioning). We examined whether intervener education level (bachelor's degree/no bachelor's degree) predicted fidelity (Research Question 1), whether intervener education level predicted treatment outcomes (Research Question 2), and whether fidelity predicted treatment outcomes (Research Question 3). In many cases, intervener education background was not related to fidelity or treatment outcome; however, interveners without bachelor's degrees showed greater adherence to the protocols on some scales (higher positivity, higher secure base, higher calm matching) and sessions with these interveners were associated with greater increases in maternal sensitivity. Regardless of the intervener education level, redirecting attention to the positive and calmly matching participants' tone were associated with higher maternal reflective functioning, and higher secure base scores were associated with greater closeness. Findings have implications for the training and implementation of prevention programs for parents.

Access to best-evidenced mental health support for care-experienced young people: Learnings from the implementation of cognitive therapy for PTSD

OBJECTIVES

Rates of PTSD are up to 12 times higher in care-experienced young people (CEYP) compared to their peers. Trauma-focused CBTs (tf-CBT) are the best-evidenced treatment for youth with PTSD, yet, in practice, CEYP often struggle to access this treatment. We worked alongside services to understand barriers and facilitators of the implementation of cognitive therapy for PTSD (a type of tf-CBT) to CEYP.

DESIGN

This was an active, open implementation trial.

METHODS

We recruited 28 mental health teams across England, including general CAMHS, targeted CAMHS for CEYP and social care-based teams. From these teams, participants were 243 mental health professionals, from a wide variety of professional backgrounds. Following recruitment/intervention training, teams participated in rolling three monthly focus groups and individual interviews, to understand what helped and hindered implementation. Data were analysed using a framework analysis conducted using CFIR 2.0.

RESULTS

Almost half of the teams were able to implement, but only approximately one quarter with CEYP, specifically. Universal barriers that were discussed by almost all teams particularly highlighted service structures and poor resourcing as major barriers to delivery to CEYP, as well as the complexities of the young person and their network. Unique factors that differentiated teams who did and did not implement included commissioning practices, the culture of the team, leadership engagement and style, and the development of supervision structures.

CONCLUSIONS

Findings offer key considerations for mental health teams, service leads, commissioners and policy-makers to enhance delivery of best-evidenced mental health treatments like CT-PTSD, for CEYP.

Rethinking Racial Matching in Children's Mental Health: The Need for Racially Conscious Therapists

In a given year, 1 in 6 youth will experience a mental health disorder.1 Prevalence data reveal that anxiety (9.4%), attention-deficit/hyperactivity disorder (9.8%), and behavior problems (8.9%) are the most common mental disorders in youth.2 With the coronavirus disease (COVID-19) pandemic, psychiatric needs skyrocketed because of factors such as isolation from social networks, disruption in routines, reduction in physical activities, and increased social media use.3 As a result, symptoms of depression and anxiety doubled and suicide attempts rose, which illuminated the mental health crisis among children and adolescents.4,5 More concerning, this trend has had a disproportionate impact on racially minoritized communities, who also had to grapple with significant compounding stressors related to inequitable health care access, police brutality, xenophobia, and more.6 For instance, exposure to personal and indirect racial discrimination through channels such as social media resulted in elevated worry and stress among Black and Asian American youth.6 Furthermore, across different racial groups, the percentage of youth injured from a suicide attempt only increased for Black youth from 2019 to 2021.7 Despite these needs, mental health service use rates among racially minoritized youth remain low compared to those of their White counterparts. Moreover, once and if care is provided, racially minoritized youth report poorer quality services, contributing to premature termination and unmet mental health needs.8 Thus, strategies that promote racially minoritized youths' engagement in services are warranted to address mental health inequities.

Predicting recurrent chat contact in a psychological intervention for the youth using natural language processing

Chat-based counseling hotlines emerged as a promising low-threshold intervention for youth mental health. However, despite the resulting availability of large text corpora, little work has investigated Natural Language Processing (NLP) applications within this setting. Therefore, this preregistered approach (OSF: XA4PN) utilizes a sample of approximately 19,000 children and young adults that received a chat consultation from a 24/7 crisis service in Germany. Around 800,000 messages were used to predict whether chatters would contact the service again, as this would allow the provision of or redirection to additional treatment. We trained an XGBoost Classifier on the words of the anonymized conversations, using repeated cross-validation and bayesian optimization for hyperparameter search. The best model was able to achieve an AUROC score of 0.68 (p < 0.01) on the previously unseen 3942 newest consultations. A shapely-based explainability approach revealed that words indicating younger age or female gender and terms related to self-harm and suicidal thoughts were associated with a higher chance of recontacting. We conclude that NLP-based predictions of recurrent contact are a promising path toward personalized care at chat hotlines.

Self-efficacy, motivation, social support, and alliance as predictors of youth psychotherapy outcomes in usual care

OBJECTIVE

We examined how youth self-efficacy, motivation for treatment, social support, and therapeutic alliance relate to psychotherapy outcomes of patients receiving services at outpatient community clinics. We hypothesized that (1) these variables would increase throughout the course of therapy, (2) baseline scores would predict initial ratings of distress, (3) baseline scores would predict the rate of change in symptoms throughout treatment, and (4) changes in these variables would be associated with symptom change over the course of treatment.

METHOD

Participants included 150 adolescents at community outpatient treatment centers. Data was collected prior to beginning treatment, and every three weeks afterward until termination. We used hierarchical linear modeling (HLM) to address our hypotheses.

RESULTS

We found that (1) youth ratings of self-efficacy, social support, and motivation increased throughout treatment, (2) initial self-efficacy and social support were associated with initial levels of distress, (3) ratings of youth self-efficacy at intake predicted its rate of change over therapy, and (4) changes in all variables during therapy were related to lower distress at termination.

DISCUSSION

Results suggest that these variables may affect the trajectory and course of treatment in community-based treatment settings. These results may have implications for treatment planning to maximize treatment effectiveness.

Supporting Adolescents Bereaved by Suicide or Other Traumatic Death: The Views of Counselors

Adolescents bereaved by suicide and other traumatic death may experience strong grief reactions and increased risks of mental health problems and suicidal behaviour. As timely access to professional help can be critical, it is essential to understand how counselors perceive suicide bereavement in adolescents and how they work with this population. This study aimed to examine the perspectives of counselors (N = 34). Eleven participated in an individual semi-structured interview and 23 others in group interviews. Thematic analysis yielded three themes: (1) Building a relationship with the bereaved adolescent, (2) Offering support tailored to the needs of the grieving adolescent, and (3) Offering strengths-based and sustainable support. Counselors' skills, attitudes, content-related expertise, and approaching the adolescent's grief within their developmental context were deemed essential for building a therapeutic relationship and offering viable support. The findings may inform good practices in counseling bereaved adolescents to facilitate positive mental health outcomes.

Patient personality and therapist responses in the psychotherapy of adolescents with depressive disorders: toward the Psychodynamic Diagnostic Manual - third edition

Depressive disorders in adolescence pose unique challenges for assessment and treatment, particularly due to their high comorbidity with various personality disorders. Moreover, young depressed patients may elicit very intense and difficult-to-manage emotional responses in therapists (in this context, countertransference). This study aimed at empirically identifying specific personality disorders (or subtypes) among adolescents with depressive pathology and exploring distinct countertransference patterns emerging in their psychotherapy: 100 adolescents (58 with depressive disorders; 42 with other clinical conditions) were assessed by their respective clinicians (n=100) using the psychodiagnostic chart-adolescent of the Psychodynamic Diagnostic Manual (PDM) - second edition, and the therapist response questionnaire for adolescents. Results showed that depressed adolescent patients exhibited marked traits of four personality subtypes (i.e., depressive, anxious-avoidant, narcissistic, and borderline) characterized by different levels of mental functioning and personality organization. These subtypes were predictably related to specific clinicians' emotional responses, even when controlling for the intensity of depressive symptomatology. Patients with depressive or anxious-avoidant personality subtypes evoked more positive countertransference responses, whereas patients with narcissistic or borderline subtypes elicited strong and hard-to-face emotional responses in therapists. Consistent with the next edition of the PDM, the study emphasizes the importance of comprehensive psychodynamic assessment in the developmental age, which frames depressive disorders in the context of accurate emerging personality and mental functioning profiles. This approach, which also relies heavily on the clinician's subjective experience in therapy, provides crucial information on how to specifically tailor interventions that more effectively meet the needs of adolescents with these heterogeneous and complex clinical conditions.

Therapist's effect on children's therapeutic alliance: A naturalistic study

OBJECTIVES

The therapeutic alliance (TA) has been shown to be a predictor of psychotherapy treatment success. In the case of psychotherapy with children, there is a dearth of information on TA's role. The aims of the paper are: (1) To estimate the therapist effects on children TA; (2) to investigate if therapists' TA predicts children's TA; (3) to analyze if children's age and sex predict children's TA; (4) to evaluate if the therapist's characteristics predict children's TA.

METHODS

The sample consisted of 77 children undergoing psychotherapy in Argentina, and the therapists (N = 29) providing services to those children. The assessment tools utilized for the study included the Therapy Alliance Scale for Children and the Personal Style of the Therapist Questionnaire (PST-Q).

RESULTS

Findings indicated that 2% of the children's TA was explained by the therapists (ICC = 0.02), while 17% of the therapists' TA was explained by the therapists (ICC = 0.17). Therapists' TA predicted children's TA. Children's age and sex did not have an effect on their own TA. Moreover, therapists with more experience achieved higher scores of children's TA. Finally, the Operative dimension of the PST had a negative effect on children's TA (i.e., therapists who prefer more spontaneous interventions over structured ones may experience higher levels of therapeutic alliance with child patients).

CONCLUSION

We found a positive effect of the therapist's TA on children's TA, especially in the preference for using more spontaneous intervention techniques. We discuss the implications of the findings on the training of psychotherapists who provide services to children.

Perceptions of the key components of effective, acceptable and accessible services for children and young people experiencing common mental health problems: a qualitative study

BACKGROUND

Children and young people's (CYP) mental health is a major public health concern internationally and the recent Covid-19 pandemic has amplified these concerns. However, only a minority of CYP receive support from mental health services due to the attitudinal and structural barriers they and their families encounter. For over 20 years, report after report has consistently highlighted the shortcomings of mental health services for CYP in the United Kingdom and attempts to improve services have been largely unsuccessful. The findings reported in this paper are from a multi-stage study that aimed to develop a model of effective, high-quality service design for CYP experiencing common mental health problems. The aim of the stage reported here was to identify CYP's, parents' and service providers' perceptions of the effectiveness, acceptability and accessibility of services.

METHODS

Case studies were conducted of nine different services for CYP with common mental health problems in England and Wales. Data were collected using semi-structured interviews with 41 young people, 26 parents and 41 practitioners and were analysed using the Framework approach. Patient and Public Involvement was integrated throughout the study with a group of young co-researchers participating in data collection and analysis.

RESULTS

Four key themes defined participants' perceptions of service effectiveness, acceptability and accessibility. Firstly, open access to support with participants highlighting the importance of self-referral, support at the point of need and service availability to CYP/parents. Secondly, the development of therapeutic relationships to promote service engagement which was based on assessment of practitioner's personal qualities, interpersonal skills and mental health expertise and underpinned by relational continuity. Thirdly, personalisation was viewed as promoting service appropriateness and effectiveness by ensuring support was tailored to the individual. Fourthly, the development of self-care skills and mental health literacy helped CYP/parents manage and improve their/their child's mental health problems.

CONCLUSIONS

This study contributes to knowledge by identifying four components that are perceived to be central to providing effective, acceptable and accessible mental health services for CYP with common mental health problems irrespective of service model or provider. These components could be used as the foundations for designing and improving services.

A systematic review and meta-analysis of clinician behaviors and characteristics related to alliance building with youth clients

The literature on developing alliance with youth clients has severely lagged behind that of adults. To date, there has been no meta-analytic review and limited qualitative synthesis of clinician variables which may contribute to the alliance with youth clients. Systematic literature search found a total of 49 relevant citations. Of the identified articles, 13 (27.08%) reported quantitative methods. Results of the qualitative review suggested that the majority of this research has focused on developing an emotional bond and a sense of collaboration. Meta-analysis found significant relations between alliance building and reducing variables and alliance (r_{alliance building} = 0.17; r_{alliance reducing} = -0.24). This analysis revealed specific behaviors particularly facilitative to youth alliance development, including collaborating with the client, finding common ground, exploring subjective experiences, orienting to treatment, providing praise, and enhancing facilitative conditions. In contrast, clinician lapse and pushing the client to talk were most predictive of a worse alliance. These results indicate certain behaviors which may be particularly important for clinicians to facilitate and not impair youth alliance formation. There is a need for greater youth alliance formation research to better determine how alliance formation may differ across stages of development and treatment modalities.

Bringing nature into CAMHS inpatient services: reflections for the implementation and integration of training into practice

Poor mental health is a global concern and is exacerbated by recent challenges concerning COVID-19 and the climate emergency, with significant consequences to individuals and to society. Increasing evidence demonstrates that nature-based approaches (NBAs) have numerous benefits to mental health services and the people they support with mental health needs. Despite these benefits, understanding how to integrate these approaches into practice is challenging. In this paper, we report our findings from a recent qualitative study with staff from a CAMHS inpatient unit who had recently undergone NatureWell Facilitator training. This is a particular approach to working with people in nature developed by The Natural Academy. Participants identified the importance of implementation of discreet, novel NBAs, as well as integrating nature into current practice, the benefits when fostering psychologically safe and therapeutic relationships with staff, and the clinical and operational factors when carrying out NBAs in these settings.

Therapeutic relationships within child and adolescent mental health inpatient services: A qualitative exploration of the experiences of young people, family members and nursing staff

Child and adolescent mental health services (CAMHS), especially inpatient units, have arguably never been more in demand and yet more in need of reform. Progress in psychotherapy and more broadly in mental health care is strongly predicted by the therapeutic relationship between professional and service user. This link is particularly pertinent in child and adolescent mental health inpatient services where relationships are especially complex and difficult to develop and maintain. This article describes a qualitative exploration of the lived experienced of 24 participants (8 young people, 8 family members/carers and 8 nursing staff) within inpatient CAMHS across four sites in the UK. We interviewed participants individually and analysed the transcripts using thematic analysis within a critical realist framework. We synthesised data across groups and present six themes, encapsulating the intricacies and impact of therapeutic relationships; their development and maintenance: Therapeutic relationships are the treatment, Cultivating connection, Knowledge is power, Being human, The dance, and It's tough for all of us in here. We hope these findings can be used to improve quality of care by providing a blueprint for policy, training, systemic structures and staff support.