Across the life span, the prevalence of mental disorders is highest in those aged 12 to 25 years, with more than one in four young people dealing with a mental disorder in any 12-month period. Self-harm and suicide are significant risks for this age group, with suicide being the leading cause of death for Australians aged 15 to 24 (AIHW, 2014). Mental illness during this key developmental period can have significant long-term impacts, yet this age group is the least likely to accept the support they need.
There is often a resistance from young people to initially seek help. However, psychologists themselves have also often shied away from working with young people due to the difficulties of engaging youth in therapy.
Challenges engaging youth
Attitudes towards therapy
One of the greatest difficulties of working with young people is simply getting them through the office door and addressing their unhelpful beliefs about therapy. Negative beliefs are commonly held due to stigma surrounding mental health problems, or regarding their own or friends’ negative past help seeking experiences. As young people are regularly forced to attend therapy by their parents or other caregivers, they are also often in denial about the severity of the presenting problem, believe that the psychologist will not be helpful in addressing their particular concern, or that their difficulties will not be taken seriously.
Other barriers to youth’s engagement with therapy include not wanting to acknowledge that there is a problem, embarrassment or shame about the problem, a fear of judgement from others or that they will be seen as ‘crazy’, and concerns about their privacy and confidentiality. Identifying and addressing such fears – including where there are limits, such as duty of care and confidentiality – must be done quickly, empathetically and in developmentally appropriate language.
Young people’s ability to self-disclose
Operating under the current landscape of limited therapeutic sessions and ensuring evidence-based approaches are implemented, generally requires psychologists to undertake comprehensive psychosocial assessments in the first session. The expectation that an individual will be comfortable and willing to disclose such personal information to someone they do not yet know or trust is immense for clients of all ages, yet particularly problematic for young people who are still navigating social norms, struggling with their identity, possibly experimenting with risky behaviours, and in an unequal youth/adult relationship with their clinician. Young people often experience this personal and direct questioning, in an unaccustomed social format, to be intrusive and threatening, rather than as a supportive and caring attempt to understand them in their entirety. As a result, it is not uncommon for young people to not attend the subsequent session.
Not designed for adolescents
Most therapeutic approaches are developed for either children or adults. As such, young people often find these approaches ‘childish’, or may be challenged by techniques that are beyond their cognitive capacity. Additionally, many cognitive approaches rely on ‘rational’ thought processes, yet developmental processes in adolescence commonly involve experimenting and pushing boundaries beyond what an adult might consider ‘rational’ or safe.
Adolescence and early adulthood are crucial periods of physical, cognitive, emotional, psychological, and social development. During this period, young people experience a range of biological changes including sexual maturation, increases in height and weight, and changes in hormones. Cognitive style gradually shifts from a concrete ‘black and white’ understanding of the world to a more abstract view where ‘shades of grey’ become apparent. Young people gradually gain autonomy by moving away from a reliance on parents to a greater confidence with peers and romantic partners. Furthermore, their sexual identity is increasingly formed through periods of exploration and experimentation. Key social milestones are also achieved, such as finishing school, gaining work and new financial autonomy, moving out of the family home, beginning a serious intimate relationship, and/or having children. Each of these changes and milestones can detrimentally impact a young person’s thought processes, functioning and coping ability, or put them at risk of harm.
Clinicians who successfully engage with young people have an understanding of the developmental stage and cognitive capacity of their young clients and are able to adapt approaches accordingly. They must also delicately balance the need to ensure safety and challenge unhelpful thought patterns, while allowing the young person to engage in, what are generally considered, developmentally appropriate behaviours that allow for an exploration of their self-identity. Clinicians who struggle with this balance risk not adhering to their duty of care, deterring the young person from disclosing future thoughts or behaviours, or reduce the likelihood of youth clients returning to therapy at all.
Developing a therapeutic relationship
Arguably, one of the most important components in engaging young people in therapy is fostering strong therapeutic relationships. As young people are likely to enter therapy feeling unsure or threatened about the process, worried about what the clinician or others will think of them, and fearful that their parents will find out about any risky or illegal behaviours they might be engaging in, for therapy to continue beyond the first session, it is essential that clinicians are able to promptly put young people at ease and provide non-judgemental, developmentally appropriate support during the first session.
One way of fostering a supportive therapeutic relationship, while obtaining a holistic understanding of the young person in the first session, is to use a psychosocial interview guide especially developed for young people. First developed by Goldenring and Cohen (1988) and later updated by Klein, Goldenring, and Adelman (2014), the HEEADSSS 3.0 is recommended by both the Royal Australasian College of Physicians and New South Wales Health. HEEADSSS 3.0 stands for Home, Education and employment, Eating and exercise, Activities and peer relationships, Drug and Alcohol Use, Sexuality, Suicide and depression, and Safety (and/or Spirituality). Although not explicitly included, clinicians working in mental health specific areas should also ensure they discuss issues related to anxiety, psychosis and mania, and any conduct issues (Parker, Hetrick, & Purcell, 2013). The HEEADSSS 3.0 framework has been found useful in helping clinicians working in youth mental health services to engage with young people and build rapport, while providing accurate reflections of current mental health and functioning (Parker et al., 2013) .
HEEADSSS 3.0 does not dictate a formal interview; rather, it is a strength-based framework that reduces feelings of shame in young people while promoting their ongoing engagement in therapy by facilitating the development of a good therapeutic relationship. It does this by opening discussions with the arguably least threatening domains of home and education, and progressively moving through to the domains considered more embarrassing or stigmatised. This encourages young people to slowly increase their comfort with the therapist and the process of verbal disclosure, before they discuss difficult issues. Note that while the acronym works for most young people, where a young person might be experiencing difficulties in the earlier domains such as at home or school, it might be best to leave discussion of these domains until later in the initial session.
Essential to getting young people to open up and engage in this process, is using open-ended and non-judgemental questions (See Table).
Fostering ongoing engagement in therapy
Shared decision-making
Young people generally have a desire, and the capacity, to engage in decisions around their healthcare. Therefore, rather than providing an ‘expert’ opinion on the best course of treatment, one of the most important ways in ensuring ongoing engagement in therapy is to undertake an open discussion with the young person around their treatment options. This ‘shared decision-making’ approach ideally provides young people with the opportunity to select the treatment option that best fits their values and preferences. Engaging in such a discussion is likely to lead to greater treatment satisfaction, improved mood, and improved overall health outcomes.
Tracking of session satisfaction and outcomes
For young people to continue to engage in therapy, they also need to be satisfied in the approach and see evidence that it is working for them. When used effectively, session rating scales help diminish the perceived ‘power imbalance’ by providing young people the opportunity to give ongoing feedback as to whether they are satisfied with the therapist’s approach. Outcome rating scales allow for progress to be mapped over time, which helps young people review their experience, reflect on their success, and improves ongoing engagement in therapy.
While several different options for these types of scales exist, scales that have strong empirical evidence include the ‘Session Rating Scale’ and the ‘Outcome Rating Scale’ (Miller, Duncan, Brown, Sorrell, & Chalk, 2006). Both of these have several electronic options to aid tracking over time.
Use of technology in therapy
Young people are early adopters of technology, seamlessly integrating it into their everyday lives. Thus, therapy should be no different. Technology can be used to support processes at all stages of therapy. For example, when compared to verbal assessments, electronic assessments have been shown to increase rates of disclosure as young people experience reduced fears of judgement and a greater ability to articulate their emotions. Apps can also be used to track client satisfaction and outcomes as an alternative to traditional paper-based diaries and mood tracking.
While not all young people will want, or have the capacity, to use technology, the seamless integration of apps and other technology into therapy will increase engagement by many young people as it reflects how they operate in their everyday lives. However, seamless integration requires clinicians to be very comfortable with the technology themselves. The risk of disengagement from therapy following a young person’s observation that their psychologist is not comfortable using something they recommended to their client is problematic.
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Practical tips for engaging young people
Don’t begin a session by asking why the young person is here
Begin by engaging with the young person with non-confronting topics. For example, if they were listening to music in the waiting room, ask what they were listening to. Then ask if they have any expectations or past experiences of therapy and explain the process of both the first session and the full therapeutic approach. Being clear on the processes and guiding the initial discussion may help put young people at ease.
Be open and honest about confidentiality
Ensure that the discussion around confidentiality and privacy is held before any personal information is discussed. Such a conversation will likely need to address the type of information that might need to be shared with parents or other caregivers.
Ensure the development of the therapeutic alliance is paramount in the first session
While it is important to obtain as much clinically relevant information as possible in the first session, the primary goal should be the development of the therapeutic relationship to ensure the young person is going to return for a second session. There is little point in having all the necessary information if the young person does not return to engage in therapy.
Be genuine and authentic
Young people are likely to see through any attempt an adult makes to ‘be cool’. While they will respond to a relaxed and inviting atmosphere, do not use language or an approach that is not authentic to the way you work.
Provide sufficient time for a young person to respond and be okay with silence
The therapeutic environment is often new and challenging for a young person. Frequently, they may experience internal conflict regarding whether they want to answer a question, and too often clinicians will sense discomfort and change topics before a young person had a chance to answer. Provide time and space for them to contemplate their responses.
Use a strength-based approach and identify resilience
Young people often fail to see their own strengths and coping abilities. Helping them to realise these early in therapy can help them to feel success and may promote ongoing engagement.
Know your technology well and be flexible
Never get a young person to use an app or website that you have not fully investigated yourself. Be knowledgeable about what the app does and why you think it might be helpful for that young person. However, do not force technology onto them; suggest multiple options (including those that do not rely on technology) and ask them to try each and decide what works best for them.
Don’t be the ‘expert’
Be warm and friendly and do what you can to reduce the perceived power imbalance. Engage in shared decision-making processes and ask for young people’s ongoing feedback on whether your approach works for them.