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

Abstract

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.

Goal setting with young people for anxiety and depression: What works for whom in therapeutic relationships? A literature review and insight analysis

“…In some cultures, advice is sought from family and religious leaders over mental health professionals (e.g., [ 50 ]). Organisational level factors have also been found to hinder and influence therapeutic processes [ 40 ]. Further research is needed into referral routes, and intersections between systems, practice, and young people’s preferences.…”

“…Finding common ground and a shared understanding are particularly pertinent in youth mental health settings, where there are multiple stakeholders involved [36][37][38], which can be a balancing act [39]. Establishing this mutuality of situations is considered the key facilitator of engagement when referred for therapy by others [40]. Further, ownership of goals located with young people is important [41], which in turn gives young people ownership of their care, which can be motivational [42,43].…”

Facilitating children’s in-session involvement in child and family therapies: A dynamic framework of clinical practices.

“…This fourth practice also corroborates earlier studies on what facilitates children's involvement in therapy and what characterizes good practice in allied fields. The significance of being open to different ways of communicating (e.g., Table 4; Stige et al, 2021), addressing children at their level (e.g., Table 2; Jungbluth & Shirk, 2009), creating an environment where children can express themselves freely (cf. Table 12; e.g., Ferguson, 2016;Gorin et al, 2021;Seim & Slettebø, 2017;Winter et al, 2017) aligning with children (e.g., Table 4; O'Reilly & Kiyimba, 2013), and maintaining flexibility when responding to youth's needs (M. S. Karver et al, 2018) applies to both staying relevant and facilitating inclusion.…”

“…Hence, practitioners' possibilities to facilitate children's involvement are not necessarily determined by factors they can easily control (cf. Stige et al, 2021).…”

Challenging clinical situations in child and adolescent psychiatry: Therapists’ experiences of and attitudes towards deliberate practice and virtual reality

“…Av deltakarane rapporterte 30,2 % å oppleve slike situasjonar ofte eller svaert ofte i den opphavlege undersøkinga (Stige et al, 2019), medan 54,2 % av deltakarane i denne undersøkinga rapporterte å oppleve slike situasjonar ofte eller svaert ofte. Dette er i tråd med forsking, som viser at fråfallsraten i psykisk helsevern for born og unge er høg (de Haan et al, 2013), og der det å engasjere ungdomsklientar i eit felles terapeutisk prosjekt både er ei sentral og ei krevjande klinisk oppgåve som behandlarar brukar mange ulike strategiar for å løyse (Stige et al, 2021).…”