Time-Limited Adolescent Psychodynamic Psychotherapy

A Developmentally Focussed Psychotherapy for Young People

Stephen Briggs

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9781138366664
• eBook ISBN: 9780429772238
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Time-Limited Adolescent Psychodynamic Psychotherapy: A Developmentally Focussed Psychotherapy for Young People will be an indispensable clinician's guide to the practice of Time-Limited Adolescent Psychodynamic Psychotherapy (TAPP), providing comprehensive instruction on the theory and delivery of this distinctive model of psychotherapy.

TAPP is a manualised brief psychodynamic psychotherapy of 20 sessions, for young people between, approximately, 14 and 25 years, combining psychodynamic psychotherapy with psychosocial understanding of adolescent difficulties. It places emphasis on the therapeutic engagement of young people and works with a developmental focus to effect change and growth. Divided into two parts, "Conceptual Framework" and "Practice", this book combines digestible scholarly analysis with case studies to effect a one-stop practitioner's guide to TAPP.

Time-Limited Adolescent Psychodynamic Psychotherapy: A Developmentally Focussed Psychotherapy for Young People will be of immense value to clinicians working with young people, researchers engaging with evaluating TAPP and students of psychotherapy.

Chapter 1

Introduction

“Adolescence is one of the most radical of all the developmental periods.”

(Anderson & Dartington 1998, p. 2)

Introduction

This book is about an approach to time-limited psychotherapy, Time-Limited Adolescent Psychodynamic Psychotherapy, which is known by its acronym, TAPP. The recent emergence of time-limited approaches for working with young people is clearly a response to current service delivery priorities; time-limited models can be developed as a pragmatic response to demands on services and resource limitations. These factors are present for, and increase the current utility of, TAPP; however, in its concepts and practice, TAPP also takes a more positive approach to time-limited psychotherapy. It aims to increase the engagement of young people in psychotherapy and to provide a structured therapeutic approach, which is highly relevant for young people experiencing the often extended and uncertain transition to adulthood in contemporary social contexts. Relating to the significantly changed social contexts for young people is an important consideration for adolescent psychotherapy.

Discussion of this period of life involves engaging with a fissure that runs through the subject; whilst the term ‘adolescence’ retains currency for psychological thinking about this period of development, social studies and a significant amount of national and international policy refer to ‘youth’ and ‘young people.’ The different terminology highlights an important difference for understanding the age period involved; the idea of an upper age limit of 18 years has been institutionalised, including in mental health services, despite increasing evidence that the period of transition to adulthood – into the twenties – continues the development of ‘adolescence’ socially, internally and neurologically (Blakemore 2018; McGorry 2018). In contrast, the period of ‘youth’ is usually taken to extend to the mid-twenties, but can underplay the importance of the changes of early adolescence, following the onset of puberty. In this book the psychological and social are both treated as important aspects of adolescence, that is, of the crucial developmental processes of this period.

In addition to attending to current contexts for young people, TAPP is distinctive in its therapeutic aims. The importance of the developmental process has long been recognised when working therapeutically with young people; it is a crucial and radical process of change and growth. However, in TAPP the emphasis on development is heightened so that the aim of therapy is to focus on an aspect of disturbance in the developmental process for each individual. Working with the structure of the time-limited approach provides therapeutic impetus that enhances opportunities for change, the reduction of problems and the establishment of developmental capacities in the individual that continue after the therapy ends. This approach of TAPP has been found in practice to offer a powerful, often intensive process for growth and change. TAPP is becoming more widely used in the UK and internationally; practitioners are finding it a helpful way of working with young people, and there is now sufficient experience with the approach to justify gathering together experiences, distilling them and making them more widely available in this book.

Adolescent psychotherapy

Providing meaningful and effective therapeutic interventions for young people with mental health difficulties is a vital task. Every generation has its distinctive difficulties with adolescence. Thinking about adolescence is essentially interactive and intergenerational; as in previous generations, adults are worried about and by adolescents, and adolescents are worried about themselves and society. Adolescence is characterised by the intensity of powerful emotions and energies, flowing “when the tide of life is running strongly” (Williams 1978, p. 311), creating tensions between creativity and its counterpart of a more destructive kind. Adults can be disturbed by encountering adolescent emotionality, be caught up with it and defend against it; rivalry is never far away from interactions between adults and young people (Bradley 2017). Society identifies folk devils and experiences moral panics (Cohen 2002). Therefore, thinking about adolescent difficulties necessitates a reflective approach that differentiates concerns and reactions; in psychoanalytic terms, there is always much to think about in the counter-­transference when working therapeutically with young people.

In order to relate effectively to young people, adolescent psychotherapy requires distinctive skills, training and the adoption of a therapeutic stance that enables orientation to adolescent development and its ambiguities of expression and communication. Adolescence is a radical period of development because the changes that follow puberty are intense and far reaching, involving the loss of childhood relatedness to adults, starting to live in a new, adult, sexual body and re-evaluating relatedness to the self and others. The adolescent process underpins development and drives it; the young person is confronted with the push to progress and the pull to try to hang on to childhood. Being in such a radical process of change means being out of balance, in oneself; the capacity “to bear to continue the experience of being naturally out of balance, as well as an environment that can support this” (Anderson & Dartington 1998, p. 3) enables the young person to grow with the emotional demands of integrating the changes of adolescence into his sense of himself and his relationships with others. Being able to work therapeutically with in the developmental process is a different way of working; it makes adolescent psychotherapy distinctive.

Mental health difficulties in adolescence

Globally there is increasing awareness of the importance of recognising mental health difficulties experienced by young people and providing access to appropriate health care; mental health difficulties in adolescence are recognised as a threat to long-term well-being. Steps to reduce societal discrimination, stigma and isolation for people experiencing mental health difficulties are important in creating a climate in which young people can more easily access mental health care. That young people – especially those with the most needs – find it difficult to access, engage in and sustain therapeutic help is a long-standing concern (Baruch 2001; O’Reilly et al 2013).

Concerns about young people’s mental health difficulties are heightened by reports that increasing numbers of young people have such difficulties, including depression, self-harm, suicide, eating disorders, anxieties, and the effects of abusive and exploitative relationships. Surveys consistently identify higher numbers of young people reporting mental health difficulties in childhood and adolescence (Pitchforth et al 2018). The increase could be partly explained by young people being more able to recognise and seek help for their difficulties, which indicates that efforts to reduce stigma are having a positive effect; on the other hand, more young people indeed may be experiencing mental health difficulties (Gunnell et al 2018). However, this has created a problem referred to as the ‘treatment gap’ (Rice et al 2017): “a range of policy reports have identified a persistent gap between identifying the needs of children and young people and their access to timely, high-quality help and support” (CQC 2017, p. 30). Shortfalls in funding, exacerbated during austerity, critically hamper the aim of creating a comprehensive child and adolescent mental health service (CAMHS), whilst transition to adult mental health services results in up to 50% of young people under 25 disengaging (CQC 2018). The quantitative pressure inevitably impacts on quality; high-quality – and thus usually more expensive – interventions are more under pressure than easier, cheaper to deliver interventions. Yet there is a wealth of evidence that more intensive and high-quality interventions can make a difference for young people, not least in preventing disturbances in adolescence from becoming long-term psychosocial and mental health disorders that persist into adulthood (Patton et al 2014).

In these contexts of anxieties about demands and the management of risks, delivery of mental health services for young people conflates factors that are involved in young people’s difficulties: diagnosis of mental health disorder, social vulnerability and disturbances emanating from the process of development and change in adolescence. Cottrell and Kraam (2005, p. 115) pointed out over a decade ago that young people in mental health services present “with troubling predicaments, not neat diagnoses”. Clinicians in CAMHS and other services working with young people with mental health difficulties, including educational settings, are aware on a daily basis that few young people present with simple, single issues such as depression but many have a complex combination of mental health difficulties, difficulties relating to adolescent development and current life tasks, and social vulnerability, including backgrounds of deprivation of various kinds, having experienced abuse, family disruptions, being in care, being teenage parents, having offended, seeking asylum, being homeless and being discriminated against in black and minority ethnic (BME) communities (CQC 2017, p. 43). Requirements for evidence-based practice also contribute to a simplification of adolescent problems; evidence for effectiveness in interventions, which are usually based on a single issue, primarily depression, contrasts with the complex nature of the problems young people present.

Changing contexts of adolescence

Alongside the changing landscape of the provision of therapeutic interventions for young people, wider social changes have transformed the contexts of adolescence. Throughout the adolescent development period, from societal encouragement of the ‘pseudo-sexuality’ of pre-pubescent children, with implications for the body and sexuality (Lemma 2015b), to the extended pathways in the transition to adulthood, young people encounter new and different socio-cultural contexts. Thinking about adolescence means paying attention to these changes: new patterns of friendship and ways of relating to others, experiences of intimacy and separateness driven significantly by the impact of online and social media, new vulnerabilities, especially evidenced by concerns about increasing adolescent mental health problems, and new possibilities relating to the body, sexuality and gender. Adolescence is characterised by diversity, socially and culturally; the diversity of ethnic identities demonstrates there are different notions and constructions of adult identity.

Transitions to adulthood create deeply contradictory situations; young people may be psychologically ready to leave home, take up a career and/or enter a sexual partnership, but continue to depend on parental support. It is more realistic to see adolescents moving into adulthood piecemeal or in uneven ways, becoming positioned as ‘more adult’ in specific domains – such as relationships, employment and becoming a parent (Briggs 2008). Pathways into adulthood have become extended into the third decade, a factor that is not usually represented in services, which have a divide at the age of 18. The exceptions that treat adolescence as a discrete entity and provide services beyond 18 demonstrate a more adolescent-centred approach, supporting the integrity of this most crucial developmental period and allowing professionals to develop the specialised skills needed for working with young people (McGorry 2018). Transformation of the social context has generated new and different psychological tasks and has required specific qualities to negotiate transitions that have become extended, less structured, ‘disembedded,’ and more uncertain (Côté 2014; Furlong & Cartmel 2007).

Time-limited psychotherapy for young people

Short-term or time-limited psychotherapies have been demanded increasingly for mental health services working in these contexts; when developed to meet economic constraints shorter therapies are attractive, but perhaps for the wrong kinds of reasons (Lemma et al 2011); on the other hand, some reasons for developing time-limited therapies may be thought of as ‘better’ ones. These include helping young people engage in therapy, providing structured interventions to meet the needs of young people experiencing fragmentation during the transition to adulthood and addressing the kind of predicaments that young people bring to therapy. Some psychoanalytically oriented interventions have recently been developed, notably Short-Term Psychoanalytic Psychotherapy (STPP) (Catty 2016), and Mentalisation-Based Therapy for Adolescents (MBT-A) (Rossouw & Fonagy 2012). This is a relatively new development; apart from the work of Shefler (2000) it is hard to find earlier models of time-limited psychotherapy designed specifically for young people. Despite the wide recognition of the importance of therapeutic interventions for young people, there are relatively few evidenced psychodynamic interventions (Abbass et al 2013); there continues to be the need to develop interventions that are effective, meaningful and relevant for young people. Interventions for adolescents that can be delivered in the context of the limited resources of public services, as well as in the private sector, are urgently needed.

Time-Limited Adolescent Psychodynamic Psychotherapy (TAPP): origins and overview

TAPP is for adolescents and young adults in the age range of 14–25. The age range reflects the key objective of providing a therapeutic approach that maintains the integrity of the period of adolescent development, including taking account of the extended transitions to adulthood when adolescent development continues to be a process in which the young person is involved. The age range is that of the United Nations definition of youth (UNESCO 2018). In practice, TAPP is for young people whose difficulties can be related to problems and disturbances of the adolescent developmental process, and for whom an individual psychotherapy is indicated. TAPP is a structured therapy which consists of three phases: engagement and assessment, consisting of four sessions at weekly intervals; treatment, of 16 weekly sessions; and post-treatment review, with a minimum of one session six to eight weeks after the end of treatment. The aim is not to try to solve all problems in 20 sessions; a focus for therapy is identified with the aim of harnessing the power of the adolescent developmental process to generate change and growth. A therapeutic focus on developmental difficulty and disturbance aims to recover the individual’s capacity to meet developmental challenges. Therapeutic structures of time and focus are used to help young people manage transitions in their often complex, confusing and fragmentary social and cultural contexts. TAPP is a psychodynamic approach, based on a psychoanalytic understanding of adolescent development and therapeutic relationships, and focuses on emotionality and relatedness. It is a depth therapy, working with unconscious processes and in the therapeutic relationship with transference and counter-transference to effect internal change. Engagement of young people in the therapeutic relationship is critical and this is facilitated in TAPP by working with the young person’s active involvement in identifying a developmental focus; it aims to help the young person develop an interest in his own life and difficulties. TAPP works with the social and cultural experiences of adolescence, and explores the meaning of the social and cultural contexts in young people’s development and in understanding the difficulties that have brought them to therapy.

TAPP has its origins in the Brief Therapy Workshop in the Tavistock Clinic’s Adolescent Department, when in the mid-1990s, Louise Lyon brought her expertise in brief therapy to establish the Brief Therapy Workshop. This was simultaneously a departure from and application of the Adolescent Department’s model of psychotherapy, applying the core principles of the individual psychotherapy approach to the task of developing a shorter, time-limited model; similar developments had occurred in family therapy, group therapy and very brief psychotherapy consultations in the Young People’s Consultation Service (Young & Lowe 2012; Lyon 2004). The Adolescent Department’s approach emphasised reaching out to young people in difficulties through thinking psychoanalytically about the adolescent developmental process (Anderson & Dartington 1998). It was rooted in a multi-disciplinary approach; distinguished clinicians developed a distinctive model of psychotherapy which drew, in the hands of various clinicians, on Klein and post-Kleinian, Winnicottian and Freudian approaches, of which the post-Kleinian work of Wilfred Bion was especially influential. It applied an experiential process for engaging adolescents in therapy, including, for example, an initial assessment process consisting of four weekly meetings. Psychotherapy was usually open-ended, frequently involved more than one session a week and some young people were offered and received intensive psychotherapy of three or more sessions a week.

Throughout the history of brief psychotherapy, the development of a time-limited model has divided opinion. The members of the Brief Therapy Workshop consisted of a mixed group of staff and trainees, very much like the model that had earlier been used for the development of adult brief psychotherapy by David Malan (see Chapter 2). The approach was based on the Adolescent Department’s emphasis on the adolescent developmental process and aimed to identify how the individual’s difficulties or presenting problems and symptoms could be thought of in terms of an impasse in development. The aim was to work in depth with the transference and counter-transference. A striking feature observed through clinical experience was that the developmental issue, identified as a focus for time-limited psychotherapy, came to be replicated in the transference especially in the process of termination. The TAPP model, which initially used the acronym TPP-A, was discussed in publications (Briggs 2010a; Briggs & Lyon 2011; Briggs & Lyon 2012).

TAPP has evolved significantly in recent years, through practice in a range of different settings, whilst retaining the key features developed in the Brief Therapy Workshop, including the timescale and the concept of developmental focus. In current practice the focus on engagement has been extended, as has working with different kinds of developmental focus, and with diverse therapeutic aims for young people with different needs and difficulties. In current practice, the psychosocial dimension is important, relating the therapeutic approach to the young person’s internal and developmental difficulties and disturbances to contemporary issues for adolescents and the ...

Table of contents

• Cover
• Epigraph
• Half-Title
• Title
• Copyright
• Dedication
• Contents
• Foreword
• Acknowledgements
• 1 Introduction
• PART I Conceptual framework
• PART II Practice
• Bibliography
• Index