Coming into intensive psychotherapy for adolescents and young adults: An exploration of clinical decision-making

This qualitative study focused on the process of clinical decision-making when making recommendations for intensive psychotherapy for adolescents and young adults. In order to a) learn about which adolescents and young adults come into intensive treatment and b) how they are chosen, the study was separated into two parts. In Study 1, an audit described the population coming into intensive psychotherapy in an adolescent mental health service in a given time period. In Study 2, a case study explored the clinical decision-making process at intake and assessment in the same service. Interpretative phenomenological analysis (IPA), psychoanalytic group theory and thematic analysis were used to analyse the data. The study explored how decisions were made from the point of the referral through to the decision regarding which treatment to recommend and it sought to identify determining factors of the clinical decision-making process. The focus on how a clinical judgement is made, aimed to contribute to the learning about the actual process. The study found evidence for an implicit framework for clinical decision­making about intensive psychotherapy for adolescents and young people. There was consideration of a developmental dimension to the presenting problem as well as the potential impact of trauma. The patient's state of mind was assessed and their motivation was explored. The level of need for containment and the level of intensity needed to challenge resistance were assessed. The quality and level of support from the environment, including parents and network were explored. The study found that the clinicians were looking for movement in the patient's capacity to engage with the assessment process. The research highlighted idiosyncratic features when working with adolescents: the inherent difficulties in the engagement process, the foci on ambivalence and on parental involvement. The study also showed that clinical decision-making is affected by the clinician's subjectivity, while the team's decision­making is affected by case dynamics, the team's own group dynamics and the service's capacity.
Acknowledgements
I would like to thank Emil Jackson and Nick Midgley for supervising and helping me with this project. I would also like to thank Jocelyn Catty as head of research at the Tavistock for her advice. In addition I would like to thank the intake team and the clinicians who participated in this study, for the time and thought given and for their support and interest in this project. Thank you to my friends Georgina Taylor and Millie Jenkins for their comments and support. Thank you also to Richard Meier for his patient proof-reading. Finally I would like to express my gratitude to the NHS Trust in which this research took place, for their support of this project.