efpp research workshop report
october 17th, 2008, Stockholm, Sweden
 
 

EFPP WORKSHOP REPORT: Erica Foundation, Stockholm, Sweden

RESEARCH IN CHILD AND ADOLESCENT PSYCHOTHERAPY: How to do research and how to implement the Results in Clinical Praxis.

by Charlotte Jarvis
Consultant Child and Adolescent Psychotherapist
charlottejarvis3@btinternet.com

The idea for a child psychotherapy research workshop had emerged at an earlier European Federation for Psychoanalytic Psychotherapy workshop. The Erica Foundation, which is based in Stockholm and has a history of undertaken research into child psychotherapy, took this idea forward and managed to secure a grant to run this invitational workshop. The grant enabled the Erica Foundation to accommodate and feed participants who had to get themselves to Stockholm. On Friday 17 th of October researcher-practitioners from various European countries and three Americans met at the Erica Foundation, which is based in a spacious arts and crafts style building in Stockholm.

The workshop structure utilised a Group Relations model: specific issues were highlighted and presented or ‘spoken to’ by individual participants in the large group; following this small ‘home groups’ debated the issues raised and then contributed back to large group discussions. This structure provided forums for communication and discussion but also facilitated independent thought.

In this report I will not attempt to review the whole workshop experience but will highlight some aspects of the workshop and the debate topics.

In the opening lecture Nick Midgley gave a rich overview of research on child and adolescent psychodynamic psychotherapy, and the issues that research has raised for the profession. He drew on some key texts (Russell and Shirk, 1996; Kazdin, 2000; Kennedy, 2004; Kennedy and Midgley, 2007) containing detailed literature reviews. Although research to date has made limited in roads into studying the therapeutic process Nick gave examples of three types of Process Research:

  • Descriptive studies of CPT process (to understand how and why therapy works requires a specification of what actually transpires in a therapy session, Shirk and Russell, 96)
  • Hypothesis testing studies, examining links of process to outcome.
  • Theory development studies, which create methodological challenges.

The relatively limited range of process research to date makes it premature to draw conclusions about their value but Nick suggested that potentially they offer a theoretically meaningful, empirically based understanding of the process of child psychotherapy.

Professor Robert Russell has co-authored books and papers with Prof Stephen Shirk. Both are clinical psychologists teaching in US universities and are involved in a range of projects applying research into clinical practice with child and adolescent psychotherapists of various approaches.

On the first full day of the workshop Prof Russell spoke on ‘Approaches to measuring change in child psychotherapy’. He discussed traditional approaches to tracking changes in psychopathology by employing measures (e.g. self, observer report), tests (e.g.: educational, language), or functional measures (of absences, grades etc.). He also described the contemporary context in terms of improved understanding of the developmental course of psychopathology and the burgeoning interest in the role of genetics which is bolstered by a new generation of instruments and techniques which report on neuro-anatomical (MRI), neuro-chemical (SSRIs), neuro- functional (fMRI), and developmental (path-analysis) aetiology.

This aspect of his presentation - the increasing ability of researchers to observe and describe these manifestations in terms that represent a different scientific paradigm and are relatively unfamiliar to the theoretical and knowledge base of Child and Adolescent Psychotherapy - felt like a difficult challenge for the workshop.

Robert Russell also described non-traditional research approaches developed by clinical research practitioners (Ken Howard, 1993) to address the failure of formal research endeavours to provide clinically useful answers. This involves building a clinical data base consisting of time series data collection (session by session or at regular intervals) allowing the development of a comparative ‘growth’ standards analysis of successful cases. Cases in progress can then be measured and assessed against this. One outcome of this approach is the recommendation that practitioners draw on a spectrum of treatment models which may be combined.

Prof Stephen Shirk spoke about ‘What happens in the therapy room: Can we create an understanding of the processes that lead to change?’ The RCT research model has tended to emphasise the search for variation and differences rather than the commonalities present in psychotherapy practice. However, recent research into change processes and beneficial outcome has focused on the quality of the therapeutic relationship (or alliance) highlighting it as the key factor in successful outcome. Shirk discussed some of the issues that exploration of this hypothesis will raise for psychodynamic child psychotherapy research:

  • How to conceptualise the therapeutic relationship, or alliance, in Child Psychotherapy?
  • Is the alliance distinct from the transference?
  • Should the alliance be conceptualised as an attachment relationship?
  • And if so, can children report, or are the most important features unconscious?
  • What then are the implications for measurement?

The small group discussions in response to this talk reported back some interesting themes to the large group, these included:

  • the content, contextualisation, intonation and pace of interpretation;
  • the differences between friendship and psychotherapy;
  • what a psychotherapist brings that parents don’t;
  • the tools and frames used by psychotherapists;
  • looking at play: qualities, contents and processes;
  • the broadening of the concept of therapeutic alliance, to include negative aspects and meaningfulness;
  • the impact of shame in therapeutic relationships, counter transference problems and supervision;
  • the overvaluation of clusters of cases, and issues of how to cluster.

A presentation from Prof Michael Rustin followed: ‘How do we stimulate clinically based research?’ He described the development of the UEL-Tavistock Child Psychotherapy doctorate research model which is rooted in clinical practice. He spoke about some of the research studies undertaken during the first phase of the Doctorate (by Drs. Jan Anderson, Marguerite Reid, Debbie Hindle) and explained that the new clinical doctorate, offered to all qualifying Tavistock trainees, would increase participation in qualitative research but not offer the same depth of study.

I took on the topic: ‘How and what we learn from the patients’ by exploring the potential for involving patients in participating in outcome evaluation employing ‘rich’ clinical measures. I also spoke about how audit and patient feedback can identify patient groups who do not engage in treatment and thus enable clinicians to consider radical changes to service delivery in order to meet the needs of the ‘un-reached’ patient populations. This topic was also discussed by Agnete Thoren who reported on an element of EPOS (Erica Process and Outcome Study), a study undertaken at the Erica Foundation (Anderson et al, 2007) exploring children’s experiences of child psychotherapy.

Dr Cathy Urwin (Tavistock) addressed: ‘How are research findings implemented in clinical praxis’. Her excellent talk generated interesting small group discussions. Here are some of the points raised:

  • What is evidence? How useful are RCTs in this context?
  • Research in clinical praxis raises organisational and institutional issues;
  • The place of training, workshops, and supervision in this context;
  • How to develop research that stimulates curiosity in clinicians rather that feelings of fear or threat;
  • How to develop a research agenda in relation to the existing knowledge base;
  • Humans have limited ability to handle complex information. What happens when research doesn’t confirm what we are looking for?

The workshop concluded with summarising comments from a panel that included Dr Eilis Kennedy (Tavistock) who proposed that Evidence Based Practice is more of a help than hindrance to Child Psychotherapists. She reminded us that EBP developed in order to assist clinicians ask questions of ‘experts’ and challenge dogma. EBP (Trowell, 2007) has assisted Child Psychotherapists find a place in the NICE guidelines on Childhood Depression and this led to a major grant for an upcoming grant for a RCT examining the outcome of CBT, Child Psychotherapy and Treatment as Usual for adolescents with depression. Dr Kennedy commented that the gap between research and practice is a complex issue and concluded by emphasising her interest in two themes: a move away from different ‘brands’ of therapy towards understanding what approaches have in common; and the importance of context for research and practice.

Celeste Schneider, an American psychoanalyst interested in child and adolescent process research, undertook an integrated review of the various talks, and lectures and an appreciation of the conference structure and the importance of communication. She thought that the psychoanalytic community’s common difficulty in managing doubts and containing ineffectiveness is assuaged when practitioners seek help from each other and through journals, literature and conferences. For her a key issue emerging from the conference was the conflict in the research debate between complexity and reductionism.

Prof Rolf Sandell’s concluding comments related to the importance of kindness and caretaking in clinical work and its place in the research debate. He also spoke about managing variation, complexity and heterogeneity, suggesting that a researcher needs to have two or more perspectives in mind in order to appreciate difficulties and grapple with conflict towards synthesis. He spoke about the increasing complexity and incomprehensibility of research literature and the importance of attending to clinicians attitudes to research.

Of the final comments from the floor (and in the spirit of celebrating complexity and heterogeneity) I will highlight Prof Russell (who came all the way from California, for the weekend!) who spoke up for abstraction as a research methodology that allows a view of commonalities, and hence integration and complexity. His most recently published research study demonstrates this approach (Russell, 2007).

The workshop was chaired by Dr Gunner Carlberg, the current Director of the Erica Foundation, and Prof Siv Boalt Boëthius, who was previously the Erica Foundation director, who together with their staff and associates were wonderfully welcoming hosts. The final discussion explored ideas and methods for supporting and developing the healthy research culture that child psychotherapy has developed and looked forward to the possibility of a future workshop and events that would continue to forge international links and support research that will benefit practitioners, commissioners and most importantly children, parents and families.

 

References

Anderson, J (03) The mythic significance of risk taking. Journal of Child Psychotherapy, Volume 29, Number 1, 75-91

Anderson, J (04) Risk-taking, dangerous behaviour in Childhood: Child protection and clinical strategies. Journal of Social Work Practice, 18, 1,19 - 32

Andersson, G., Boalt Boethius, S. Svirsky, L. & Carlberg, G. (2006). Memories of significant episodes in child psychotherapy: An autobiographical approach, Psychology and Psychotherapy: Theory, Research and Practice, 79:229-36.

Bleuter, L & Howard. K (93). Clinical utility research and Introduction. J of Clinical Psychology, 54,3, 297-301

Hindle,D (2007) Clinical research: a psychotherapeutic assessment model for siblings in care. Journal of Child Psychotherapy, Volume 33, Issue 1, 70 – 93

Jarvis, C. Trevatt, D. & Drinkwater, D. (2004) Parenting Teenagers: Setting Up and Evaluating a Therapeutic Parent Consultation Service: Work in Progress. Clinical Child Psychology and Psychiatry, 9(2)

Jarvis, C (2005) Parenting Problems: Research and Clinical Perspectives on Parenting Adolescents. Journal of Child Psychotherapy. 31(2)

Kazdin, A.E. (2000). Psychotherapy for Children and Adolescents: Directions for Research and Practice. New York: Oxford University Press.

Kazdin, A.E. (2003). Psychotherapy for children and adolescents. Annual Review of Psychology, 54, 253-276.

Kennedy, E. (2004) Child and Adolescent Psychotherapy: A Systematic Review of Psychoanalytic Approaches. London: North Central London Strategic Health Authority

Kennedy, E. and Midgley, N. (2007) Process and outcome research in child, adolescent and parent-infant psychotherapy: a thematic review. London: North Central London Strategic Health Authority

Reid, Marguerite (03) Clinical research: the inner world of the mother and her new baby?-born in the shadow of death . Journal of Child Psychotherapy, Volume 29, 2, 2003

Reid, Marguerite (07). The loss of a baby and the birth of the next infant: The mother's experience. Journal of Child Psychotherapy, V: 33, 2, 181 – 201

Russell RL, Shirk SR. (98) Child Psychotherapy Process Research. In T.H. Ollendick & R.J. Prinz (Eds.) Advances in Clinical Child Psychology; 20:93-124.

Russell, R.L., et al. (2007) Core processes components in psychotherapy; A synthetic review of P-technique studies. Psychotherapy Research.

Shirk S, Russell RL. Change Processes in Child Psychotherapy: Revitalizing Treatment and Research. New York: Guilford Press, 1996.

Trowell, J., Joffe, I., Campbell, J., et al (2007) Childhood depression: a place for psychotherapy. European Child and Adolescent Psychiatry, 16, 157 –167.

Urwin, C (07) Revisiting 'What works for whom?': A qualitative framework for evaluating clinical effectiveness in child psychotherapy. J. Child Psychotherapy , 33,2
134-160

 


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