Barriers and Facilitators in Adolescent Psychotherapy Initiated by Adults—Experiences That Differentiate Adolescents’ Trajectories Through Mental Health Care

Abstract

Mental health problems start early in life. However, the majority of adolescents fulfilling the criteria for mental health disorders do not receive treatment, and half of those who do get treatment drop out. This begs the question of what differentiates helpful from unhelpful treatment processes from the perspective of young clients. In this study, we interviewed 12 young people who entered mental health care reluctantly at the initiative of others before the age of 18. Their journeys through mental health care varied significantly despite sharing the same starting point. Our analyses resulted in a model of three trajectories. We describe relational and structural facilitators and obstacles within each trajectory and have formulated narratives highlighting core experiences differentiating them. Trajectory 1 (I never saw the point – Being met as a case) was characterized by a rapid loss of hope, leading the adolescents to conclude that mental health care was not worth the investment. Trajectory 2 (I gave it a go, but nothing came of it – Being met by a therapist representing a rigid and unhelpful system) was characterized by a lingering hope that never materialized into a constructive therapeutic process despite prevailing efforts by both therapists and adolescents. Trajectory 3 (Something good came of it – Being met by a therapist who cares and wants to help) was characterized by genuine meetings, allowing the therapist to transform from an unsafe stranger into a safe, competent, and benevolent adult. We discuss how our results have implications for understanding agency displayed by adolescent clients in therapy, therapist flexibility and authenticity, service organization, and attributional processes influencing clinical judgment and therapeutic processes when adolescent psychotherapy has a difficult starting point (i.e., initiated by adults).

Negotiating System Requirements to Secure Client Engagement – Therapist Strategies in Adolescent Psychotherapy Initiated by Others

“…They, therefore, used complementing strategies to obtain the prerequisite for client engagement – namely, the first meeting between therapist and client, thus, the starting point for the development of the therapeutic relationship. The therapists’ descriptions of their behaviors and strategies also are in line with recommendations for enhancing client engagement in adolescent clients ( Bolton Oetzel and Scherer, 2003 ) and show high degrees of sensitivity to known barriers to seeking and receiving mental health care among adolescents ( Radez et al, 2021 ; Stige et al, 2021 ). Yet, participants reported that their clinical priorities and preferred strategies for client engagement were under pressure.…”

“…This study is part of a larger study on adolescent psychotherapy in which adults initiated the process without the adolescents initially wanting therapy, consisting of individual interviews with adolescent clients and focus group interviews with therapists. Previous publications from the project include an article presenting therapists’ conceptualization of adolescent clients coming to therapy at the initiative of others ( Barca et al, 2020 ), and one on adolescent clients’ experienced barriers and facilitators within different therapeutic trajectories ( Stige et al, 2021 ). Therapists were found to have partly diverging conceptualizations of adolescents coming reluctantly to treatment, represented by the themes: The hurt and distrustful adolescent; The adolescent lacking hope for the future; The adolescent engulfed in the burden of mental-health suffering; and The adolescent as something more than a psychiatric patient ( Barca et al, 2020 ).…”

“…This perspective is, however, important to see in relation to the perspective of the adolescents coming to therapy with this starting point. Analyzing 18 interviews with 12 adolescents who entered therapy at the initiative of others, we found that despite their shared starting point, these adolescents’ trajectories through mental health care differed significantly, largely relating to therapist factors, as well as system organization ( Stige et al, 2021 ).…”

“…Empirical support for therapist flexibility and its impact on later client engagement and improvement in therapy has also been reported ( Chu and Kendall, 2009 ), in line with the above-mentioned focus on therapist responsiveness ( Hatcher, 2015 ; Wu and Levitt, 2020 ). Qualitative studies exploring the adolescent client’s perspective on psychotherapy similarly point to the significance of the therapist-as-person (including transparency, benevolence, and authenticity), the therapist’s management of key issues, like confidentiality, power imbalance, and client agency, and the client’s feeling of being understood, as decisive for the perceived accessibility and usefulness of therapy ( Binder et al, 2011 ; Sagen et al, 2013 ; Gibson et al, 2016 ; Lavik et al, 2018 ; Løvgren et al, 2019 ; Radez et al, 2021 ; Stige et al, 2021 ).…”

“…While only about 25% of children and adolescents fulfilling criteria for mental disorders receive specialized mental health care (Sadler et al, 2018), about half of those offered treatment drop out (de Haan et al, 2013). There is a potential tension between the developmental task of autonomy and the client position of needing help (Bolton Oetzel and Scherer, 2003;Radez et al, 2021;Stige et al, 2021). In addition, many adolescent clients come at the initiative of others, without feeling they need therapy (Karver et al, 2008;Stige et al, 2021).…”