When life gets in the way: Systematic review of life events, socioeconomic deprivation, and their impact on counselling and psychotherapy with children and adolescents
Abstract:Background
Life events are recognised to link low socio‐economic status (SES) with impaired mental health. Despite attention to patients’ historical environmental circumstances in psychotherapeutic practice, events that occur over the course of counselling and psychotherapy (‘intercurrent’ events) seem to have received little attention in research.
Method
Life events were defined to include those that are chronic and severe, as well as minor, everyday occurrences. Outcomes were restricted to internalising prob… Show more
“…‘Troubled’ dropouts most certainly would have met the criteria for a number of risk factors, and therefore according to Kazdin’s risk-factor model, would have been considered at high risk of dropout. A recent systematic review revealed that intercurrent life events and contextual factors that interfere with treatment have been largely overlooked in the child psychotherapy literature (Blackshaw et al, 2018). ‘Troubled’ dropouts represent a group of young people for whom there were contextual factors that impeded their ability to engage in treatment, reflecting the need for greater attention to be paid to such contextual complexity for delivering effective mental health care.…”
What does it mean to ‘drop out’ of therapy? Many definitions of ‘dropout’ have been proposed, but the most widely accepted is the client ending treatment without agreement of their therapist. However, this is in some ways an external criterion that does not take into account the client’s experience of therapy, or reasons for ending it prematurely. This study aimed to identify whether there were more meaningful categories of dropout than the existing dropout definition, and to test whether this refined categorization of dropout was associated with clinical outcomes. This mixed-methods study used a subset of data from the IMPACT trial, which investigated psychological therapies for adolescent depression. Adolescents were randomly allocated to a treatment arm (Brief Psychosocial Intervention; Cognitive-Behavioral Therapy; Short-Term Psychoanalytic Psychotherapy). The sample for this study comprised 99 adolescents, aged 11–17 years. Thirty-two were classified as having dropped out of treatment and participated in post-therapy qualitative interviews about their experiences of therapy. For 26 dropout cases, the therapist was also interviewed. Sixty-seven cases classified as having completed treatment were included to compare their outcomes to dropout cases. Interview data for dropout cases were analyzed using ideal type analysis. Three types of dropout were constructed: ‘dissatisfied’ dropout, ‘got-what-they-needed’ dropout, and ‘troubled’ dropout. ‘Dissatisfied’ dropouts reported stopping therapy because they did not find it helpful. ‘Got-what-they-needed’ dropouts reported stopping therapy because they felt they had benefitted from therapy. ‘Troubled’ dropouts reported stopping therapy because of a lack of stability in their lives. The findings indicate the importance of including the perspective of clients in definitions of drop out, as otherwise there is a risk that the heterogeneity of ‘dropout’ cases may mask more meaningful distinctions. Clinicians should be aware of the range of issues experienced by adolescents in treatment that lead to disengagement. Our typology of dropout may provide a framework for clinical decision-making in managing different types of disengagement from treatment.
“…‘Troubled’ dropouts most certainly would have met the criteria for a number of risk factors, and therefore according to Kazdin’s risk-factor model, would have been considered at high risk of dropout. A recent systematic review revealed that intercurrent life events and contextual factors that interfere with treatment have been largely overlooked in the child psychotherapy literature (Blackshaw et al, 2018). ‘Troubled’ dropouts represent a group of young people for whom there were contextual factors that impeded their ability to engage in treatment, reflecting the need for greater attention to be paid to such contextual complexity for delivering effective mental health care.…”
What does it mean to ‘drop out’ of therapy? Many definitions of ‘dropout’ have been proposed, but the most widely accepted is the client ending treatment without agreement of their therapist. However, this is in some ways an external criterion that does not take into account the client’s experience of therapy, or reasons for ending it prematurely. This study aimed to identify whether there were more meaningful categories of dropout than the existing dropout definition, and to test whether this refined categorization of dropout was associated with clinical outcomes. This mixed-methods study used a subset of data from the IMPACT trial, which investigated psychological therapies for adolescent depression. Adolescents were randomly allocated to a treatment arm (Brief Psychosocial Intervention; Cognitive-Behavioral Therapy; Short-Term Psychoanalytic Psychotherapy). The sample for this study comprised 99 adolescents, aged 11–17 years. Thirty-two were classified as having dropped out of treatment and participated in post-therapy qualitative interviews about their experiences of therapy. For 26 dropout cases, the therapist was also interviewed. Sixty-seven cases classified as having completed treatment were included to compare their outcomes to dropout cases. Interview data for dropout cases were analyzed using ideal type analysis. Three types of dropout were constructed: ‘dissatisfied’ dropout, ‘got-what-they-needed’ dropout, and ‘troubled’ dropout. ‘Dissatisfied’ dropouts reported stopping therapy because they did not find it helpful. ‘Got-what-they-needed’ dropouts reported stopping therapy because they felt they had benefitted from therapy. ‘Troubled’ dropouts reported stopping therapy because of a lack of stability in their lives. The findings indicate the importance of including the perspective of clients in definitions of drop out, as otherwise there is a risk that the heterogeneity of ‘dropout’ cases may mask more meaningful distinctions. Clinicians should be aware of the range of issues experienced by adolescents in treatment that lead to disengagement. Our typology of dropout may provide a framework for clinical decision-making in managing different types of disengagement from treatment.
“…Also, socio-economic adversities, including poverty and environmental risk factors, have been associated with the onset and maintenance of psychopathological symptoms and low life satisfaction ( 27 ). This relationship has been explained through material deprivation but also increased adverse life events (such as unemployment, abuse and neglect), with consequences for treatment outcomes, including among children and adolescents [e.g., ( 28 )]. Given the recent recession period and current socio-economic strain for many individuals, it seems relevant to recognize that people living in poverty are more likely to experience mental health problems ( 29 ), less likely to access treatment ( 30 ) and less likely to achieve full recovery from emotional psychopathological problems ( 31 ).…”
Section: Explaining Psychopathology: the Role Of Culture Discriminatmentioning
The present paper discusses the role of culture in understanding and treating psychopathology. It describes new perspectives on the conceptualization of psychopathology and on the definition of culture, and how these are intertwined. The impacts of culture, explicit and implicit discrimination, and minority stress on mental health are reviewed, especially in the current era. Culturally-sensitive assessment practices in psychopathology are emphasized, including addressing the multiple cultural identities of the patient, the explanatory models of the experienced distress, specific psychosocial stressors and strengths, and the cultural features of the practitioner-patient relationship in the clinical encounter. The particular case of psychotherapy in working with culturally diverse patients is explored. Finally, mainstreaming of culture in research and clinical training in psychopathology is highlighted, acknowledging that each clinical interaction is a cultural one.
“…Unfortunately, minimal research attention has been devoted to the influence of SLEs on treatment effectiveness with EA clients; however, research with adolescent and adult samples has found that SLEs limit effectiveness (Blackshaw et al, 2018). Kraus et al (2016), for example, noted that SLEs typically predict symptom and life‐functioning treatment outcomes, and variations in counselor effectiveness are in part attributable to the influence of SLEs on client outcomes.…”
Section: Stressful Life Events and Flourishingmentioning
Emerging adulthood seems to be a period of not only heightened risk for mental health symptoms, but also growth toward greater well‐being. Mental health disorders are highest among adults ages 18 to 29 years, yet emerging adults are unlikely to access treatment. However, emerging adults can also experience gains in life satisfaction and interpersonal functioning, and mental health treatment for emerging adults tends to reduce symptoms. This dialectic of risk and growth has prompted a call for a specialty clinical practice focused on emerging adults and highlights a need for treatment effectiveness research that examines symptoms and well‐being. We examined the influence of risk variables on change in a sample of emerging adult clients (N = 187; mean age = 25.82 years; 62.0% female; 75.9% White). Results provide evidence of improvement, conditioned by risk variables. Implications included integrating distinct interventions to reduce symptoms and promote well‐being and addressing intra‐ and interpersonal processes associated with positive development.
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