Alliance rupture and repair in adolescent psychotherapy: What clinicians can learn from research.

The collaborative relationship between a client and therapist, known as the therapeutic alliance, plays an important part in promoting engagement and symptom improvement in adolescent psychotherapy. However, research indicates that alliance strains, called ruptures, are common among this age group, emphasizing the importance of addressing and resolving them for enhanced engagement and better outcomes. Despite this, there is a dearth of age-specific guidelines for effectively fostering a positive alliance and repairing these ruptures. This review examines existing literature to (a) summarize the current understanding of alliance formation in youth psychotherapy, particularly considering the distinct characteristics of working with adolescents, and (b) provide evidence-based recommendations to assist youth therapists in building strong alliances and effectively addressing alliance ruptures with this age group. Existing evidence indicates that while guidance designed for adult therapy can be beneficial, working with adolescents poses unique challenges. These include resistance to treatment, engagement in risky behaviors, confidentiality issues, and parental involvement, which can strain the therapeutic relationship. This emphasizes the importance for youth therapists to understand the unique challenges and developmental stages adolescents face and to adapt their approach accordingly. By doing so, therapists can effectively address the needs of adolescents, fostering a strong alliance and handling any ruptures that may arise. Despite being a relatively new area of study with its inherent limitations, this review underscores the critical role of alliance research in improving therapy for adolescents and guiding the training of therapists who work with this age group. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Power Threat Meaning Framework: a qualitative study of depression in adolescents and young adults.

Introduction: Depression constitutes one of our largest global health concerns and current treatment strategies lack convincing evidence of effectiveness in youth. We suggest that this is partly due to inherent limitations of the present diagnostic paradigm that may group fundamentally different conditions together without sufficient consideration of etiology, developmental aspects, or context. Alternatives that complement the diagnostic system are available yet understudied. The Power Threat and Meaning Framework (PTMF) is one option, developed for explanatory and practical purposes. While based on scientific evidence, empirical research on the framework itself is still lacking. This qualitative study was performed to explore the experiences of adolescents and young adults with depression from the perspective of the PTMF. Methods: We conducted semi-structured interviews with 11 Swedish individuals aged 15- 22 years, mainly female, currently enrolled in a clinical trial for major depressive disorder. Interviews were transcribed verbatim and analyzed with framework analysis informed by the PTMF. Results: A complex multitude of adversities preceding the onset of depression was described, with a rich variety of effects, interpretations, and reactions. In total, 17 themes were identified in the four dimensions of the PTMF, highlighting the explanatory power of the framework in this context. Not all participants were able to formulate coherent narratives. Discussion: The PTMF provides a framework for understanding the complexities, common themes, and lived experiences of young individuals with depression. This may be essential for the development of new interventions with increased precision and effectiveness in the young.

"I can't escape my scars, even if I do get better": A qualitative exploration of how adolescents talk about their self-harm and self-harm scars during cognitive behavioural therapy for depression.

Emerging evidence indicates that perceptions of self-harm behaviours and self-harm scars may thwart recovery from depression, yet limited research has explored adolescent accounts of their self-harm and scars during therapy. This study sought to explore how adolescents describe their self-harm behaviours and scars during Cognitive Behavioural Therapy (CBT) and explore the sociocultural discourses that may influence these descriptions. The participants were six female adolescents (aged 14-17 years old) with clinical depression, who were engaging in self-harm. All participants accessed CBT as part of clinical trial evaluating three psychological treatments for major depressive disorder in Child and Adolescent Mental Health Services. Audio-taped CBT sessions were analyzed using discourse analysis. Within CBT sessions, adolescents drew upon stigma discourses in talking about their self-harm. Adolescent also described their self-harm scars as shameful and stigmatizing, and as "proof" of the legitimacy of their depression. It is important for CBT practitioners to understand the context of sociocultural discourses around self-harm behaviours and self-harm scars, which are reflected in how adolescents with depression describe these within therapy and may serve to maintain distress. The study indicates that awareness of use of language and intersecting sociocultural discourses can inform CBT practice.

We know that when teenagers are in treatment for depression, perceptions of their self-harming behaviours and self-harm scars can impact recovery. We also know that wider sociocultural beliefs around self-harm tend to be negative and stigmatizing, which might impact how teenagers perceive their self-harm and scars. This study aimed to explore how depressed adolescents talk about their self-harm behaviours and their self-harm scars during therapy for depression. The participants in this study were six female teenagers (aged 14-17 years old) with depression, who were engaging in self-harm. These teenagers participated in a type of therapy called Cognitive-Behavioural Therapy as a part of a larger study evaluating treatments for teenage depression in Child and Adolescent Mental Health Services in the UK. The therapy sessions were recorded, transcribed, and analyzed with a focus on the language used by the teenagers to describe their self-harm and scars. Within the therapy sessions, the teenagers talked about their self-harm in stigmatizing ways, which reflected prominent societal-held beliefs about self-harm. The teenagers in the study also believed that while their self-harm scars were shameful and stigmatizing, the scars also provided a sense of validation that their depression was legitimate. The findings of this study suggest that it could be helpful for therapists to consider how wider sociocultural beliefs around self-harm may impact how teenagers talk about their self-harm and scars in treatment for depression.

"You can't really have a relationship with them because they just ask you questions": understanding adolescent dropout - an empirical single case study.

Introduction: High dropout rates are common in youth psychotherapy, including psychoanalytic psychotherapy, yet the reasons behind this trend remain obscure. A critical focus to enhance adolescent engagement could be the therapeutic alliance, particularly in resolving alliance ruptures. This study sought to clarify the complex relationships between the therapeutic alliance, encompassing alliance ruptures and resolutions, and dropout within the context of poor outcome. It investigated a single case of an adolescent with depression who dropped-out of Short-Term Psychoanalytic Psychotherapy, without showing clinical improvement. Method: Data was garnered from diverse sources, including questionnaires, interviews, and session recordings, and analyzed through a mixed-method longitudinal framework. This encompassed views from the adolescent, therapist, parents, and external evaluators. Results: The study identifies several factors impacting the decision to drop out, including initial profound distrust toward the therapist, a complex and difficult therapeutic relationship characterized by unresolved alliance ruptures, and sporadic attendance. External factors including minimal parental engagement with therapy were also seen as detrimental to the adolescent's involvement and progress. Discussion: The research underscores the challenges in engaging adolescents, especially when there may be distrust of professionals, and in the absence of parental involvement with treatment.

Trial protocol for the Building Resilience through Socio-Emotional Training (ReSET) programme: a cluster randomised controlled trial of a new transdiagnostic preventative intervention for adolescents.

BACKGROUND: Adolescence is a period of heightened vulnerability to developing mental health problems, and rates of mental health disorder in this age group have increased in the last decade. Preventing mental health problems developing before they become entrenched, particularly in adolescents who are at high risk, is an important research and clinical target. Here, we report the protocol for the trial of the 'Building Resilience through Socioemotional Training' (ReSET) intervention. ReSET is a new, preventative intervention that incorporates individual-based emotional training techniques and group-based social and communication skills training. We take a transdiagnostic approach, focusing on emotion processing and social mechanisms implicated in the onset and maintenance of various forms of psychopathology. METHODS: A cluster randomised allocation design is adopted with randomisation at the school year level. Five-hundred and forty adolescents (aged 12-14) will be randomised to either receive the intervention or not (passive control). The intervention is comprised of weekly sessions over an 8-week period, supplemented by two individual sessions. The primary outcomes, psychopathology symptoms and mental wellbeing, will be assessed pre- and post-intervention, and at a 1-year follow-up. Secondary outcomes are task-based assessments of emotion processing, social network data based on peer nominations, and subjective ratings of social relationships. These measures will be taken at baseline, post-intervention and 1-year follow-up. A subgroup of participants and stakeholders will be invited to take part in focus groups to assess the acceptability of the intervention. DISCUSSION: This project adopts a theory-based approach to the development of a new intervention designed to target the close connections between young people's emotions and their interpersonal relationships. By embedding the intervention within a school setting and using a cluster-randomised design, we aim to develop and test a feasible, scalable intervention to prevent the onset of psychopathology in adolescence. TRIAL REGISTRATION: ISRCTN88585916. Trial registration date: 20/04/2023.

Understanding change - developing a typology of therapy outcomes from the experience of adolescents with depression.

Outcome measures mostly focusing on symptom reduction to measure change cannot indicate whether any personally meaningful change has occurred. There is a need to broaden the current understanding of outcomes for adolescent depression and identify whether holistic, interlinked patterns of change may be more clinically meaningful.To create a typology of therapy outcomes based on the experiences of adolescents with depression.Interview data from 83 participants from a clinical trial of the psychological treatment of adolescent depression was analysed using ideal type analysis.Six ideal types were constructed, reflecting different evaluations of the holistic impact of therapy: "I've worked on my relationships", "With the insight from therapy, and feeling validated, I can cope with life challenges better", "My mood still goes up and down", "If I want things to change, I need to help myself", "Therapy might help, but it hasn't been enough", and "I don't feel therapy has helped me".Assessing change using outcome measures may not reflect the interconnected experience for adolescents or the contextual meaning of symptom change. The typology developed offers a way of considering the impact of therapy, taking into account how symptom change is experienced within a broader perspective.

In Context: Lessons About Adolescent Unipolar Depression From the Improving Mood With Psychoanalytic and Cognitive Therapies Trial.

This paper summarizes the results of the Improving Mood with Psychoanalytic and Cognitive Therapies (IMPACT) study and its implications for psychological treatment of adolescents with moderate to severe unipolar major depression. IMPACT was a pragmatic, superiority, randomized controlled trial conducted in the United Kingdom, which compared the clinical and cost-effectiveness of short-term psychoanalytic therapy (STPP), cognitive-behavioral therapy (CBT), and a brief psychosocial intervention (BPI) in reducing depression symptoms in 465 adolescents with unipolar major depression, aged 11 to 17 years. Although this was a clinically heterogeneous group of adolescents, some symptoms (eg, sleep and concentration difficulties, irritability/anger) were common and disabling. The trial reported no significant difference among the 3 treatments in reducing depression symptoms. One year after treatment, 84% of participants showed improvement in depressive symptoms (<50% of baseline symptoms) and improved psychosocial functioning, achieving this through different symptom reduction trajectories. Although participants attended fewer treatment sessions than planned, the 3 treatments were delivered with fidelity to their respective models. Ending treatment without therapist agreement occurred in 37% of cases. This was not associated with outcomes by treatment group. Adolescents emphasized the importance of the therapeutic relationship in all 3 treatments. Results suggest that although most adolescents respond to time-limited, structured psychological therapy, subgroups of depressed adolescents are likely to need additional treatment or support. These include adolescents who live in complex circumstances and/or who believe that their needs are not met in therapy, some who stop treatment early, and the 16% to 18% of adolescents who do not respond to treatment. CLINICAL TRIAL REGISTRATION INFORMATION: Improving Mood and Preventing Relapse With Psychoanalytic Psychotherapy and Cognitive Behaviour Therapy; https://www.isrctn.com; ISRCTN83033550.

Repairing alliance ruptures in psychodynamic psychotherapy with young people: The development of a rational-empirical model to support youth therapists.

Alliance ruptures in youth psychotherapy can have a significant impact on treatment outcomes. However, there is currently limited guidance on how to effectively repair these ruptures with young people. This study aims to address this gap specifically in the context of psychodynamic psychotherapy with adolescents. The objectives of the study are (a) to understand the therapeutic interventions and attitudes that either facilitate or hinder the resolution of alliance ruptures and (b) to develop a model for repairing these ruptures within this particular treatment approach. To accomplish this, a task analysis of a previously developed rational model of resolving alliance ruptures was conducted using 16 sessions from short-term psychodynamic psychotherapy with depressed adolescents. The analysis supported some stages of the hypothesized rational model while revealing the need for revisions. As a result, the study developed a rational-empirical model that includes flexible strategies that therapists can use to repair alliance ruptures. This model emphasizes the significance of a collaborative, open, and empathetic approach to resolving ruptures. In contrast, rigid, defensive, or invalidating therapist attitudes can hinder the resolution process. The evidence-based model developed from the study can provide valuable guidance to psychodynamic psychotherapists working with young people, offering insights on how to approach ruptures and employ effective strategies to promote their resolution. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Epistemic trust: a comprehensive review of empirical insights and implications for developmental psychopathology.

Originally rooted in philosophy and sociology, the concept of epistemic trust has recently transitioned to developmental psychopathology, illuminating social-cognitive processes in psychopathology. This narrative review synthesizes empirical evidence on epistemic trust to inform future research. A literature search highlighted 3 areas: i) the development of selective trust in children; ii) epistemic trust in non-clinical adults; iii) its link to mental health. Young children demonstrate selective learning from reliable sources using epistemic cues. Empirical studies beyond childhood were greatly facilitated in the last 2 years with the introduction of the Epistemic Trust, Mistrust and Credulity Questionnaire, a self-report scale measuring epistemic stance. Cross-sectional studies pinpointed dysfunctional epistemic strategies as factors in mental health vulnerability, and some qualitative work offered initial evidence linking restored epistemic trust to effective psychotherapy. For future research, we propose focusing on 3 primary areas. First, empirical investigations in adolescent samples are needed, as adolescence seems to be a pivotal phase in the development of epistemic trust. Second, more experimental research is required to assess dysfunctional and functional epistemic stances and how they relate to vulnerability to mental health disorders. Finally, intervention studies should explore the dynamics of epistemic stances within and between therapy sessions and their impact on therapeutic outcomes.

Short-term psychoanalytic psychotherapy with depressed adolescents: Comparing in-session interactions in good and poor outcome cases.

OBJECTIVE: To identify and describe in-session interaction patterns between psychoanalytic therapists and adolescents diagnosed with major depressive disorder, comparing good and poor outcome cases. METHOD: Audio recordings for 100 psychotherapy sessions from 10 Short-Term Psychoanalytic Psychotherapies were analysed using the Adolescent Psychotherapy Q-Set (APQ). The cases and sessions were evenly divided into two groups (poor outcome and good outcome, 5 patients and 50 sessions per group). Interaction patterns were analysed with an Exploratory Factor Analysis (EFA), while group differences were assessed through t-tests. RESULTS: The EFA revealed three factors: (1) "Open, engaged young person working collaboratively with a therapist to make sense of their experiences", (2) "Directive therapist with a young person fluctuating in emotional state and unwilling to explore", (3) "Young person expressing anger and irritation and challenging the therapist". Factor 1 was significantly more prominent in the good outcome cases, while factor 3, on the contrary, was more significantly related to the poor outcome cases. Factor 2 was equally present in both groups. CONCLUSION: Besides reinforcing to researchers and clinicians the association between a collaborative psychotherapy process with good outcomes, our findings also provide empirical data regarding the role of anger in adolescent depression and the psychotherapy process.

The Reflective Fostering Programme-Adapting a group parenting programme for online delivery in response to the COVID-19 pandemic in the United Kingdom.

OBJECTIVE: In the context of the Covid-19 pandemic and subsequent lockdown restrictions, service providers faced significant challenges in delivering programmes to support their vulnerable service users. Foster carers-an already often isolated group of caregivers - were offered an adapted remote-delivery model of the Reflective Fostering Programme (Redfern et al., Adopt. Foster., 42, 2018, 234) from March 2020. METHOD: This paper outlines the adaptation process of the original programme to online-remote delivery and describes the feedback from participants in the programme. RESULTS: The adaptation of the Reflective Fostering programme to online, remote delivery had both strengths and weaknesses - including wider access to foster carers who might struggle to attend in person and challenge a to maintaining a Mentalizing space online and ensuring confidentiality within a therapeutic space. The programme was overwhelmingly well received by foster carers in this format. CONCLUSIONS: There are opportunities and challenges in the delivery of online therapeutic services, particularly those with a group format. This paper contributes initial reflections to what we hope will be a rapidly developing literature on best practice of supporting group services in an online format.

The use of mentalization-based techniques in online psychodynamic child psychotherapy.

Objective: Psychodynamic child psychotherapy is an evidence-based approach for a range of child mental health difficulties and needs to constantly adapt to meet the needs of children. This study is the first to investigate whether the use of mentalization-based interventions (i.e., a focus on promoting attention control, emotion regulation, and explicit mentalization) predicted a good therapeutic outcome in online psychodynamic child therapy sessions conducted during the COVID-19 pandemic. Methods: The sample included 51 Turkish children (Mage = 7.43, 49% girls) with mixed emotional and behavioral problems. Independent raters coded 203 sessions from different phases in each child's treatment using the Mentalization-Based Treatment for Children Adherence Scale (MBT-CAS). Results: Multilevel modeling analyses showed children with higher emotional lability benefited more from attention control interventions compared to those with lower emotional lability. Discussion: Interventions that focus on developing the basic building blocks of mentalizing may be effective components of therapeutic action for online delivery of psychodynamic child psychotherapy, especially for children with greater emotional lability.

Emotion regulation in children (ERiC): A protocol for a randomised clinical trial to evaluate the clinical and cost effectiveness of Mentalization Based Treatment (MBT) vs Treatment as Usual for school-age children with mixed emotional and behavioural difficulties.

BACKGROUND: The majority of children referred to Child and Adolescent Mental Health Services (CAMHS) in the UK will present with mixed emotional and behavioural difficulties, but most mental health treatments are developed for single disorders. There is a need for research on treatments that are helpful for these mixed difficulties, especially for school-age children. Emotion Regulation (ER) difficulties present across a wide range of mental health disorders and mentalizing may help with regulation. The ability to mentalize one's own experiences and those of others plays a key role in coping with stress, regulation of emotions, and the formation of stable relationships. Mentalization Based Therapy (MBT) is a well-evidenced therapy that aims to promote mentalization, which in turn increases ER capacities, leading to decreased emotional and behavioural difficulties. The aim of this study is to test the clinical- and cost-effectiveness of MBT compared to treatment as usual for school age children with emotional and behavioural difficulties. If effective, we hope this approach can become available to the growing number of children presenting to mental health services with a mix of emotional and behavioural difficulties. MATERIALS AND METHODS: Children referred to CAMHS aged 6-12 with mixed mental health problems (emotional and behavioural) as primary problem can take part with their parent/carers. Children will be randomly allocated to receive either MBT or treatment as usual (TAU) within the CAMHS clinic they have been referred to. MBT will be 6-8 sessions offered fortnightly and can flexibly include different family members. TAU is likely to include CBT, parenting groups, and/or children's social skills groups. Parent/carers and children will be asked to complete outcome assessments (questionnaires and tasks) online at the start of treatment, mid treatment (8 weeks), end of treatment (16 weeks) and at follow up (40 weeks). TRIAL REGISTRATION: Clinical trial registration: ISRCTN 11620914.

Innovative moments with young patients treated for depression: An analysis of post-therapy interviews.

INTRODUCTION: Innovative moments (IMs) pinpoint new and more adaptative meanings that emerge in clients' discourse during psychotherapy. Studies with adult clients have found a greater proportion of IMs in recovered compared to unchanged cases, but similar studies have yet to be conducted with adolescents. AIMS: The paper aims (1) to study retrospectively the emergence of IMs in therapy, using a post-therapy interview, in adolescents that underwent psychotherapy for depression, and (2) to characterize the themes present in IMs identified retrospectively in the interviews. METHOD: Semi-structured post-treatment interviews conducted with 24 adolescents on the experience of taking part in a clinical trial of youth depression, were coded using the Innovative Moments Coding System. After identifying IMs, a thematic analysis identified the prominent themes within them. RESULTS: Higher presence of IMs were found in recovered compared to unchanged cases. Two main themes emerged in the IMs, changes that occurred with therapy and attributions of changes. Recovered cases presented more IMs centred on the self, whereas unchanged cases identified more non-specific changes. CONCLUSION: This study suggests that it is possible to code IMs, identified retrospectively, based on post-therapy interviews with adolescents. Meaningful differences were found between recovered compared to unchanged cases. Therapeutic recovery was associated with a higher focus on the self and more specificity in clients' representations of the change process.

Holding a foster child's mind in mind: study protocol for a cluster-randomized controlled trial of mentalization-based therapy (MBT) for foster families.

BACKGROUND: Children in foster care are psychologically vulnerable and show more social, developmental, and behavioral problems than those living with their family of origin. Many foster parents struggle to care for these children, some of whom have experienced severe adversity. Research and theory suggest that developing a strong and supportive foster parent-child relationship is essential for foster children to become more well-adjusted and experience a decrease in behavioral problems and emotional maladjustment. Mentalization-based therapy (MBT) for foster families aims at increasing the reflective functioning of the foster parents, thus promoting the development of more secure and less disorganized child attachment representations, which is subsequently proposed as a factor that reduces behavioral problems and emotional maladjustment in children and promotes their overall well-being. METHODS: This is a prospective cluster-randomized controlled trial with two conditions: (1) the intervention group participating in MBT, and (2) the control group who receive usual care. Participants are 175 foster families with at least one foster child aged 4-17 years with emotional or behavioral problems. The intervention will be offered to foster families by 46 foster care consultants from 10 municipalities in Denmark. The foster care consultants will be randomized to MBT training (n = 23) or usual care (n = 23). The primary outcome is the psychosocial adjustment of the foster child measured by the Child Behavior Checklist (CBCL) as reported by foster parents. Secondary outcomes include child well-being, parental stress, parent mental health, parent reflective function and mind-mindedness, parent/child relations, child attachment representations, and placement breakdown. In order to explore implementation fidelity as well as practitioner experiences, we will administer questionnaires designed for this study and conduct qualitative research exploring the practice of the MBT therapists. DISCUSSION: This trial is the first experimental study of a family therapeutic intervention based on attachment theory for foster families within the Scandinavian context. This project will contribute with novel knowledge on attachment representations in foster children and the effects of an attachment-based intervention on essential outcomes for foster families and children. Trial registration ClinicalTrials.gov NCT05196724. Registered on January 19, 2022.

Understanding treatment non-responders: A qualitative study of depressed adolescents' experiences of 'unsuccessful' psychotherapy.

OBJECTIVES: This paper aimed to explore the experiences of depressed adolescents who completed but did not 'respond' to standard psychotherapy, based on a lack of improvement in pre-post symptoms scores. DESIGN: This was a qualitative study employing interpretative phenomenological analysis (IPA). METHOD: Seventy-seven adolescents with moderate to severe depression were interviewed as part of a qualitative arm of a randomised controlled trial. Five adolescents' post-treatment interviews were purposively sampled, based on lack of improvement on pre-post symptom scores, and adolescents still scoring above the clinical threshold for depression. The interviews were analysed using IPA. RESULTS: Adolescents made sense of their depression as part of their identity and held negative expectations of therapy. Some aspects of therapy brought up intolerable feelings that contributed to disengagement in the therapeutic process and culminated in disappointing and hopeless endings. On the other hand, where a stronger therapeutic relationship was developed, some participants experienced certain improvements. CONCLUSIONS: Findings highlight how actively exploring the adolescent's therapy expectations, developing a strong early therapeutic relationship and being mindful of the potential impact of endings are important in therapeutic work with adolescents with depression, especially where they may have a strong sense of hopelessness and self-criticism. Moreover, the finding that adolescents experienced improvements in other domains despite a lack of symptom reduction highlights the need to review how treatment outcomes are currently defined. Integrating individual perspectives of therapy with quantitative outcome measures can provide a more nuanced insight of treatment effects.

A systematic review of shared decision making interventions in child and youth mental health: synthesising the use of theory, intervention functions, and behaviour change techniques.

Reviews around interventions to improve shared decision making (SDM) for child and youth mental health have produced inconclusive findings on what approaches increase participation. Importantly, the previous reviews did not explore the use of theory, as well as mechanisms of change (intervention functions) and active units of change (behaviour change techniques). The aim of this review was to explore these factors and ascertain how, if at all, these contribute to SDM. Five databases were searched up until April 2020. Studies met inclusion criteria if they were: (a) an intervention to facilitate SDM; (b) aimed at children, adolescence, or young people aged up to 25, with a mental health difficulty, or their parents/guardians; and (c) included a control group. Data were extracted on patient characteristics, study design, intervention, theoretical background, intervention functions, behaviour change techniques, and SDM. Quality assessment of the studies was undertaken using the Effective Public Health Practice Project (EPHPP) quality assessment tool. Eight different interventions met inclusion criteria. The role of theory to increase SDM remains unclear. Specific intervention functions, such as 'education' on SDM and treatment options and 'environmental restructuring' using decision aids, are being used in SDM interventions, as well as 'training' for clinicians. Similarly, behaviour change techniques linked to these, such as 'adding objects to the environment', 'discussing pros/cons', and clinicians engaging in 'behavioural practice/rehearsal'. However, as most studies scored low on the quality assessment criteria, as well as a small number of studies included and a low number of behaviour change techniques utilised, links between behaviour change techniques, intervention functions and increased participation remain tentative. Intervention developers and clinicians may wish to consider specific intervention functions and behaviour change techniques to facilitate SDM.

Unpacking the active ingredients of internet-based psychodynamic therapy for adolescents.

Internet-based psychodynamic psychotherapy (iPDT) for adolescents has been found to be effective for treating depression, but not much is known about its active ingredients. OBJECTIVE: To explore the techniques used in chat sessions in an iPDT program for depressed adolescents, and to investigate whether they predicted improvement in depression symptoms. METHOD: The study uses data collected from a pilot study. The iPDT consisted of 8 modules delivered over 10 weeks that included text, video, exercises, and a weekly text-based chat session with a therapeutic support worker (TSW). The participants were 23 adolescents meeting criteria for depression. The TSWs were 9 psychology master's students. A depression inventory QIDS-A17-SR was filled weekly by the participants, and a self-rated techniques inventory (MULTI-30) was filled by the TSWs after each chat session. RESULTS: Common factor techniques were the most widely used techniques in the chat sessions. Both common factors and psychodynamic techniques predicted improvement in depression, with psychodynamic techniques predicting improvement at the following week. CBT techniques were also used but did not predict improvement in depression. CONCLUSION: iPDT seem to work in line with theory, where the mechanisms thought to be important for change in treatment were predictive of outcome.

Trajectories of change in general psychopathology levels among depressed adolescents in short-term psychotherapies.

OBJECTIVE: to identify and describe trajectories of change in general psychopathology (p) levels among depressed adolescents who received one of three types of short-term therapies (namely Cognitive-Behavioural Therapy, Short-Term Psychoanalytic Psychotherapy, and a Brief Psychosocial Intervention). METHOD: Participants were 465 adolescents with MDD who participated in an RCT comparing three treatments for depression. Narrow-band measures of depression, anxiety, obsessions-compulsions, and conduct problems were assessed at six-time points, and bifactor analysis was performed to extract p factor scores. These scores were submitted to Latent Class Growth Analyses to identify patterns of change over time. RESULTS: Three different trajectories of change in p were identified. Two trajectories displayed reductions in p across time-points: one a rapid decrease, and the other slower but steady improvement. The third trajectory indicated a limited decrease in p up until the 12th week after baseline but no further improvement at subsequent time-points. Patients' baseline p significantly predicted their outcome trajectories. CONCLUSION: Exploring change in p seemed to describe more parsimoniously the patients' outcomes than the narrow-band assessment of depressive symptoms. Patients with high baseline p were more likely to have poorer outcomes, potentially indicating a need to develop more intensive and tailored treatments for this population.