Effectiveness of Usual-Care Cognitive Behavioral Therapy for Adolescents with School Absenteeism

Objective: Highly-controlled, randomized controlled trials have provided considerable evidence for the efficacy of outpatient cognitive-behavioral therapy (CBT) for patients with school absenteeism and anxiety disorders. However, the effectiveness of outpatient CBT under routine-care conditions for youth with school absenteeism remains unproven. Methods: This observational study used file records to analyze the changes under routine CBT in a sample of n = 49 clinically referred adolescents aged 11 to 18 years with school absenteeism and mental disorders who were being treated in a university outpatient clinic. At the start and end of treatment, we assessed the severity of school absenteeism as well as mental health problems as rated by parents and by the adolescents themselves. Results: The analysis yielded a statistically highly significant decline in school absenteeism (large effect, Cohen's r = 0.80) and in mental health problems (small-to-large effect, Cohen's d = 0.33 to d = 0.82). However, a substantial proportion of the sample remained in the clinical range at the end of treatment. Conclusions: These findings suggest that CBT is effective for adolescents with school absenteeism when administered under routine-care conditions, though the results must be interpreted with caution because of the lack of a control condition.

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.

Parental Validation and Invalidation Predict Adolescent Self-Harm

This study was designed to evaluate family processes theoretically implicated in the onset and maintenance of adolescent self-harm. In the present study, we focus on understanding parental validation and invalidation in response to their adolescent in order to estimate the association between parental responses and self-harm in a high risk group of adolescents. We also sought to determine the influence of psychotherapy on parental validation and invalidation over time during participation in a randomized clinical trial of psychotherapy designed to reduce self-harm. Thirty-eight teens (M age= 14.85; 94.1% female, 55.3% Caucasian, and 17.5% Latino) and their parents participated in three assessments over a six month period corresponding to pretreatment, midtreatment and end of treatment in the trial. Results indicate a robust association between parental validation, invalidation and adolescent self-harm. There were no significant associations observed between parental validation, invalidation, and adolescent suicidal ideation. Observed levels of parental validation and invalidation were not changed during the six-month course of psychotherapy.

Effectiveness of school-based humanistic counselling for psychological distress in young people: Pilot randomized controlled trial with follow-up in an ethnically diverse sample

OBJECTIVES

The aim of this study was to pilot a test of the effectiveness of school-based humanistic counselling (SBHC) in an ethnically diverse group of young people (aged 11-18 years old), with follow-up assessments at 6 and 9 months.

DESIGN

Pilot randomized controlled trial, using linear-mixed effect modelling and intention-to-treat analysis to compare changes in levels of psychological distress for participants in SBHC against usual care (UC).

TRIAL REGISTRATION

ISRCTN44253140.

METHODS

In total, 64 young people were randomized to either SBHC or UC. Participants were aged between 11 and 18 (M = 14.2, SD = 1.8), with 78.1% of a non-white ethnicity. The primary outcome was psychological distress at 6 weeks (mid-therapy), 12 weeks (end of therapy), 6-month follow-up and 9-month follow-up. Secondary measures included emotional symptoms, self-esteem and attainment of personal goals.

RESULTS

Recruitment and retention rates for the study were acceptable. Participants in the SBHC condition, as compared with participants in the UC condition, showed greater reductions in psychological distress and emotional symptoms, and greater improvements in self-esteem, over time. However, at follow-up, only emotional symptoms showed significant differences across groups.

CONCLUSIONS

The study adds to the pool of evidence suggesting that SBHC can be tested and that it brings about short-term reductions in psychological and emotional distress in young people, across ethnicities. However, there is no evidence of longer-term effects.

PRACTITIONER POINTS

School-based humanistic counselling can be an effective means of reducing the psychological distress experienced by young people with emotional symptoms in the short term. The short-term effectiveness of school-based humanistic counselling is not limited to young people of a White ethnicity. There is no evidence that school-based humanistic counselling has effects beyond the end of therapy.

Psychodynamic psychotherapy for children and adolescents: an old friend revisited

The treatment of children and adolescents with psychotherapy is gradually losing ground to psychopharmacology. The author reviews the value the various forms of psychotherapy have in the treatment of children and the importance of having a clear curriculum for teaching this skill in residency programs. Although the importance of psychodynamic psychotherapy has a long history in the treatment of children, the reluctance some faculty have in recommending this form of therapy may be due to limited experience and limited knowledge of its benefits. The author highlights that a psychodynamic diagnostic evaluation is essential to assess a child's suitability for psychotherapy. The characteristics of children who will benefit from psychodynamic psychotherapy, their defense mechanisms, and optimal characteristics of their parents are reviewed. The qualifications a psychiatrist needs to succeed in this endeavor are discussed. Two cases illustrate not only the importance in the suitability of the patient, but also the application of psychodynamic theory to practice.