Afterword

It was early in 2009 that the authors of this book first sat down together, to begin work on writing a treatment manual of ShortTerm Psychoanalytic Psychotherapy for adolescents suffering from depression. Funding had been secured for the IMPACT trial (Goodyer et al., 2011), and although an earlier clinical trial (Trowell et al., 2007) had offered evidence for the effectiveness of the approach - albeit with a relatively small sample - and a treatment manual had been used in that study (Trowell, Rhode, & Hall, 2010), there was still much work to be done. Between them, the members of the STPP manual writing group had many years of clinical experience working with depressed young people, in a variety of clinical settings, but for most of us it was the first time to be involved in a research study of this scale and, in particular, to be involved in writing a treatment manual. What kind of document were we hoping to create?

It is fair to say that, traditionally, there has not been a very favourable view among the psychoanalytic community towards treatment manuals (Taylor, 2015). The increasing demand for treatment manuals has occurred in the context of the rise of the evidence-based practice movement and, in particular, as part of the emphasis on RCTs as a means of evaluating the effectiveness of therapy. Treatment manuals are valued in research because they offer a replicable and systematized approach to therapeutic interventions, which supports one of the key features of clinical trials: the measurement of fidelity to the treatment being studied (Perepletchikova & Kazdin, 2005). After all, what is the value of saying whether a therapy is effective if you cannot say what the therapy entails?

But for a variety of reasons many clinicians have long been suspicious of manuals, often viewing them as inflexible, rigid, and restricting therapists from tailoring their intervention according to the needs of the individual client (Barron, 1995; Strupp & Anderson, 1997). Treatment manuals have also been criticized as potentially undermining the therapeutic relationship (Arnow, 1999), and they have been seen as especially unsuitable for less structured approaches to treatment, such as psychoanalytic psychotherapy, where the therapist's clinical intuition and creativity is seen as a core component. For example, Goldfried and Wolfe (1998) argued that the key skills of a psychoanalytic psychotherapist run counter to the idea of manualized therapy, while others have suggested that to manualize a psychoanalytic treatment would be an over-simplification of the rich dynamics between client and therapist (Addis & Krasnow, 2000).

It was therefore with some trepidation that our group began this work. In a study that tried to capture some of the experience of this process (Henton & Midgley, 2012), an independent researcher undertook interviews with those involved in the STPP manual writing group. In those interviews, members spoke about feeling daunted, hesitant, and un-skilled. As one of the writing team put it: "I think how one properly represents what is a very private activity in a public area, well that's problematic. And it does raise all kinds of anxieties about wanting to be sure that one does justice to practice . . ." (p. 207). Likewise, when we later interviewed some of the STPP IMPACT therapists themselves, many spoke about how nervous they had been about what "working with a manual" would be like. When one was asked what came to mind when she thought of treatment manuals, she replied: "a bit rigid, and you know, having to stick to the book . . . rather than be . . . free". Another said that before starting work on the IMPACT trial, she simply "couldn't understand how you could create a manual [for psychoanalytic psychotherapy]" (Vadera, 2014).

So how did we as a group overcome these doubts? As one of us put it, "we educated ourselves - we had to read, and understand, and come to grips with the issues" (Henton & Midgley, 2012, p. 208).

Part of that was reaching an understanding of what kind of treatment manual it should be. In the middle of the process, one of the writing team explained:

[In] a prescriptive manual . . . you will do so and so, and so and so, and you won't do so and so . . . and you are to educate yourself in the treatment. And then the other way of thinking . . . is a way of describing and capturing normal practice . . . providing the framework, around which to say . . . this is what psychotherapy would look like if you did this; and if you did that, it wouldn't be STPP. [Henton & Midgley, 2012, p. 209, emphasis in original]

Having reached some kind of understanding of what kind of treatment manual we hoped to write, and also a shared view of why we were writing it, the process itself proved to be remarkably stimulating, offering us the opportunity to reflect on our practice and try to reach a shared understanding of the core elements of STPP with young people. The therapists who used the manual also reported positively on the experience (Vadera, 2014). Their experience was in line with research that has suggested that many therapists tend to have negative views of treatment manuals before they have had personal experience of using them, but they then develop more positive attitudes after they have had the opportunity to do so (Forbat, Black, & Dulgar, 2015). This has turned out to be true for psychoanalytic therapists as well. For example, Busch, Milrod, and Sandberg (2009) found that being directly involved with the manual developed a richer understanding of the practical use of implementing treatment manuals and seemed to challenge some of their own preconceptions, while Taylor (2015) argues, based on the experience of developing a manual for the Tavistock depression study (TADS; Fonagy et al., 2015), that such manuals can contribute significantly to the advancement of psychoanalytic knowledge. A similar trajectory was found in the present findings, with the manual described by some of the child psychotherapists involved in the IMPACT trial as "workable" and "a useful resource" (Vadera, 2014), which they drew on to inform their work, without feeling as if they were being told "how to be a child psychotherapist".

The work presented in this book is the result of this process, and it was further enriched and informed by the experience of those clinicians who worked on the IMPACT trial, as well as colleagues from Norway who are using the STPP manual as the basis for their own research study, known as FEST-IT (Ulberg, Hersoug, & Hoglend, 2012). Through supervision meetings, and through regular gatherings of the therapists working with the manual, we obtained feedback on which areas were insufficiently developed; what key aspects were missing; and where we had simply got it wrong. With the valuable editorial support of Jocelyn Catty, the group was able to refine and revise the manual, enriching it with vignettes based on composite cases drawn from the IMPACT trial.

This book is our attempt to share what we have learned about working psychoanalytically in a time-limited way with depressed adolescents. It joins a growing number of treatment manuals attempting to describe psychoanalytic therapy with children and young people, including important work by Milrod, Busch, and Shapiro (2004) on psychodynamic approaches to the adolescent with panic disorder; Gottken and von Klitzing's (2014) manual for short-term Psychoanalytic Child Therapy (PaCT); and Hoffman, Rice, and Prout's (2016) manual of regulation-focused psychotherapy for children with externalizing behaviours. Although very different from each other, each of these books attempts to offer a clear and clinically meaningful account of psychoanalytic therapy with children and young people.

There are a number of reasons why we want to make this manual available more widely. First, we hope to share some of the experience of psychoanalytic therapy with children and young people with a wider audience, in a form that can help to demystify some elements of our work. We also know that treatment manuals such as this provide a basis for empirical research - something that is urgently needed in the field of psychoanalytic child psychotherapy. When the findings of the IMPACT trial are published, we hope they will provide a better understanding of which young people benefit from STPP - and which do not. In due course, the data from this clinical trial will be combined with data from the various "sibling" studies to the IMPACT trial, which have explored the experience of the young people and families taking part (IMPACT-ME; Midgley, Ansaldo, & Target, 2014), as well as studies looking at the genetics and the neuroscience of adolescent depression (Hagan et al., 2013) and how these may both mediate the response to therapy and also change as a result of a successful therapeutic intervention. We hope that bringing together these different types of data will enable us to understand more about the nature of adolescent depression itself; the key moderators and media?tors that impact on treatment outcome; and the change mechanisms that explain the process by which psychotherapy facilitates growth and development. More specific questions about STPP that we hope researchers will come back to include the role of transference interpretation (a question that is being specifically focused on by the FEST-IT study in Norway); the reasons why some young people drop out of therapy (currently being explored by a doctoral student working with data from the IMPACT and IMPACT-ME studies); and the role of parent work in short-term psychoanalytic therapy with adolescents.

And it is not only researchers who we hope can take this work forward. Over the coming years, it will be important for child psychotherapists to find out whether STPP can be successfully offered in a range of clinical settings and with a range of young people with depression. The Association of Child Psychotherapists (ACP) has shown great support for the approach, including the setting up of an Implementation Group and assistance with the creation of a network of STPP supervision groups around the UK to support clinicians' STPP work and to promote the development of the model. Some of these groups may want to explore whether the model of STPP set out in this book can be adapted to other clinical populations, such as adolescents who self-harm or those who have eating disorders or emerging personality disorders. If so, what adaptations to the model would be needed, and how effective would such work be? Others may want to find out whether it will be possible to train less highly qualified professionals in STPP. Preliminary analysis of the treatment tapes from the IMPACT trial has already indicated that qualified child and adolescent psychotherapists in the UK, who until now have had relatively little experience of working with treatment manuals, were able to offer the therapy with a relatively high level of treatment fidelity. But given the limited number of child psychotherapists in the UK - and elsewhere - there is also scope to consider training other professionals with appropriate clinical experience and personal therapy in the STPP model and to evaluate whether these less-qualified professionals would be able to offer the therapy in an equally effective way. This issue would be important if STPP were ever to be offered as part of nation-wide programmes such as the UK's CYP-IAPT programme, given the relatively limited number of specialists in CAMHS clinics around the UK. If this approach were shown to be effective, then child psychotherapists might thus enable more services to offer STPP through providing training and ongoing supervision to a broader CAMHS workforce. But would such a development work, or would it lead to the quality of therapy being lost, at the cost of poorer outcomes for young people?

As these questions make clear, we hope that the publication of this STPP manual is not only the end of a long, but rewarding, piece of work, but also the start of a whole range of new activities - all of which can ultimately contribute to improving the mental health and well-being of children and young people.

Nick Midgley

 
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