S Fortune, M Psych Sc (Clinical Spec)., R Phillips, MFCC and M Rimm, FRANZCP, Campbell Lodge, Child and Youth Mental Health Services, Counties Manukau District Health Board, Auckland, New Zealand.

Development theorists argue that placing in adolescents in therapeutic groups augment the key developmental task of separation from the family unit while simultaneously providing access to an influential peer group. Traditional group therapy for adolescents consists of encouraging them to reveal and discuss the problems when paradoxically they are facing developmental forces of adolescence where being unremarkable, normal and the same as everyone else are of premium importance. As a result attempts to run groups with adolescents contributing the material for discussion is often met with high levels of resistance and high drop out rates particularly for boys. Outcome measures for group therapies for this age group are minimal, but generally demonstrate poor compliance and variable outcomes so it would appear that the potentially powerful influence of the adolescent peer group is often not maximised in traditional group therapies (Mishna, Kaiman, Little, & Tarshis, 1994).

From a service delivery perspective groups offer significant opportunities to outpatient mental health services to offer treatment to a large number of patients with relatively low levels of clinical input hours. Therapeutic Storytelling Intervention (TSI) is an innovative group therapy technique based on a book ‘Gem of the First Water’ (Phillips, 1989) and is being used in a community child and adolescent mental health service. TSI was written and developed by psychologist and family therapist, Ron Phillips. TSI follows the adventures of a peer/hero facing common adolescent struggles such as the consequence of poor impulse control, making connections between feelings and behaviours, grief, drugs and alcohol, peer relationships and parental relationships. TSI guides participants through a series of developmental steps across the duration of the group moving from the introduction of a new behavioural repertoire in an external context followed by cognitive reorganisation and personal application, culminating in reflections on old behaviour and the development of new goals.

TSI is usually delivered in a group setting over a period of 16 sessions of 45-60 minutes duration. The clinician/group leader tells story based on a chapter of ‘Gem of the First Water’ in an oral, trance-like manner for approximately 25 minutes. This is followed by a series of questions focusing on the characters challenges and behaviour in that segment of the story. After period the external focus on characters of the story is gradually shifted towards the group members themselves by linking their behaviour with that of the character. The speed at which this transition is made, within and across sessions, is flexible and allows the clinician to employ a range of strategies which prevent the group process from stagnating or being ‘hijacked’ by disruptive group members.

Several significant departures from many group traditional approaches should be noted. A key tool used in this group therapy is paradox, there are only two rules in the group (1) “I wouldn’t dream of talking when you are, and vice versa” and (2) “be honest with yourself and the process – if you don’t want to say something just pass”. This approach contrasts with long periods of time generating and contracting rules for the group. The use of externalised material for group discussion provides safety for oppositional, anxious or depressed adolescents and prevents the disintegration of the group due to a lack of material for discussion within a group session.

This study aimed to describe the children and adolescents attending group therapy and examine the retention of these patients.

Method

Setting and Participants

Catchment area: This study is based 347 children and adolescents who attended TSI group therapy at a public outpatient child and adolescent mental health service in South Auckland, New Zealand. The catchment area for this service is populated by more than 400,000 of which more than one third are under 20 years. At the last census European/Pakeha made up 52% of the community, Pacific peoples 27%, Maori 17% and Asians 15% of the community. The rates of unemployment (10.1% in this area vs. 7.5% nationally), single parent families (23% vs. 19%), number of people living in each house (3.3 vs. 2.7) and proportion of adults with no educational qualifications (29% vs. 27.6%) are higher in this community compared with other parts of New Zealand (Statistics New Zealand, 2002). It is acknowledged that the local context will influence the wider applicability of this information.

The Clinic: A multidisciplinary team including child psychiatrists, clinical psychologists, psychiatric nurses, social workers and family therapists work with children, adolescents and their families who represent the 3-5% of the population in greatest need of psychiatric services. Children and adolescents up to the age of 20 years (if still in school) are treated using a combination of crisis interventions, family therapy, group therapy, medication and individual therapy. Attempts are made to involve the wider systems of care for the young person including the family, school, social work agency, police and health care providers with which they have contact. Inpatient admissions are possible at a regional child and adolescent psychiatric unit.

Selection of participants: Patients were assessed by two mental health clinicians as part of usual clinic practices and a treatment plan generated which may include any combination of family therapy, group therapy, medication, or individual therapy. All patients who attended the clinic between 1997 and 2001 and who were referred to group therapy were included in this study.

Procedure and Measures

The primary investigator collated demographic data from clinical records and individual attendance data at each group session, which was collected by administrative staff for all patients. A clinical profile of patients attending TSI was generated in 1999 as part of quality improvement using a using a pre and post measure design. The primary investigator distributed questionnaires to group members and their parents attending the initial group session and again at the completion of the group process. Parents of all patients completed the Childhood Behaviour Checklist (CBCL). Children completed the Childhood Depression Inventory (CDI) and adolescents completed these measures and the McMaster Family Assessment Device (FAD) and Beck Scale for Suicide Ideation (BSSI). These measures were found to have acceptable reliablity with this population with Cronbach alpha ranging from .83 (FAD) to .95 (BSSI).

Psychiatric diagnoses were not routinely generated by clinicians during the period of this study and are therefore not reported. However a study conducted by the primary investigator suggests that nearly 50% of patients present with a mood disorder, 17% present with disruptive behaviours, including conduct disorder and oppositional defiant disorder, 7% have PTSD and 27% experienced difficulties such as childhood sexual abuse, parent/child relationship issues or neglect. More than half of patients have comorbid psychiatric disorders (Fortune, 2002). This population is also known to experience high rates of known risk factors for psychosocial distress such as suicide behaviour, substance abuse, parental psychopathology, physical abuse and childhood sexual abuse (Fortune, 2002).

Data Analysis

Data were entered into the Statistical Package for the Social Sciences (SPSS), Version 11.5 for Windows, on an IBM compatible PC. Data were checked for errors and the necessary corrections made. Preliminary descriptive statistics were conducted to check assumptions underlying the use of parametric and nonparametric methods. An alpha of 0.05 was used for all statistical tests.

Results

The early TSI groups were particularly targeted at boys but over the period of the study TSI has been increasingly utilised with both girls and boys. One quarter (n = 78) of group participants are Maori and two thirds European/Pakeha (n = 238). Two thirds of patients attending the group were adolescents and one third were under the age of 12 years.

Table 1

Demographic profile of group participants

Between three and six groups were completed each calendar year with variance reflecting fluctuating staffing numbers, particularly in 2000. The groups were conducted over an average of 16 sessions but can be condensed to 9 sessions if required or extended for up to 20 sessions dependant on the requirements of the group members and clinicians.

Table 2

Duration and number of participants in each group 1997 - 2001

Three out of every five patients attended more than 60% of sessions and were described as ‘graduates’ with no significant difference in rates of graduation between males and females. Half of non-graduates had legitimate reasons for dropping out of the group such as moving out of the area or the family having significant problems with transport. Average attendance among patients who commenced TSI was 65% from 1997 - 2001. Among graduates average attendance rates were between 86% - 89% which allows for one session missed due to illness and another to attend a school camp or similar.

Maori were more likely than other ethnic groups to begin the TSI group but fail to complete it while Pacific Island children and adolescents were more likely to be referred to the group by their key worker and but fail to commence the group (x2 (6, N = 347) = 34.32, p = .000).

Crisis re-presentations appear to be significantly lower in comparison with outcome studies of similar populations (Beautrais, 2000) with 3% of graduates representing with deliberate self-harm between 1997 and 2001.

Table 3

Attendance and retention rates for group participants 1997 - 2001

From figure it can be seen that average attendance at group sessions declines with an increasing number of sessions, but not among those who graduate from the programme. It appears that successful engagement with the therapeutic process can be defined by a return after session three.

Figure 1

Average attendance rates per session for graduates, non-graduates and total sample

Pre and post test data were available for a sub-set of 46 children and adolescents. Using the CBCL measure, parents rated significant reductions in withdrawn (t(25) = 3.05, p = .005), somatic (t(25) = 2.50, p = .02) and anxious/depressed behaviours (t(25) = 2.55, p = .02) among their offspring. Parents also rated their children has having fewer attentional difficulties (t(25) = 2.88, p = .008). Parents reported an overall improvement in their child’s behaviour at the completion of the group compared with at the beginning of the group process (t(25) = 3.15, p = .001).

Table 4

CBCL scores pre and post group intervention

Children and adolescents who completed the CDI before and after the TSI group rated themselves as significantly less depressed at follow-up (t(33) = 2.41, p = .02) with the strongest effect seen in the domain of perceived ineffectiveness where the mean score fell from 2.97 (SD = 2.29) to 1.76 (SD = 1.78) (t(36) = 3.10, p = .004).

Table 5

Childhood Depression Inventory scores pre and post group

Adolescents perceived an improvement in the way in which their family functioned at follow-up using the McMaster Family Assessment Device (t(21) = 2.21, p = .04). The strongest improvements were seen in the extent to which adolescents felt the roles of family members were clear and congruent (t(21) = 2.77, p = .01) and the degree to which family members were affectively connected and involved with each other (t(21) = 2.69, p = .01).

Table 6

Family functioning as perceived by the adolescents

Adolescents reported a significant reduction in their overall suicidality following the group compared with prior to attending the group (t(17) = 2.73, p = .01).

Conclusions

This naturalistic outcome study suggests that TSI is successful method of communicating with multi-problem children and adolescents who are hard to reach using many traditional methods. Those attending TSI groups were selected for this study because they formed a coherent and trackable cohort of patients who had received a manualised treatment. While cognisant of the hierarchy of research design with regard to power, sample size and control for confounds, this study make an important contribution to exploring methods of engaging and retaining distressed young people in treatment and provides a foundation on which to build successful clinical interventions. The data in this study form the basis of a randomised controlled trial which is currently being established.

The most outstanding result of this study is that children and adolescents with severe mental health disorders and high rates of co-morbidity were engaged in an outpatient group treatment programme and that the overall retention rate of 60% is significantly higher than found in many similar programmes. TSI is equally successful in retaining boys and girls in treatment. The high rate of retention is of particular interest to clinicians who are attempting to generate creative ways of treating children and adolescents in community mental health settings. Many patients and their families do not share mental health professional views that ongoing follow-up is beneficial to them reflected in compliance rates as low as 20 -30 % with outpatient treatment (Coatsworth, Santisteban, McBride, & Szapocznik, 2001; King, Hovey, Brand, & Wilson, 1997; Rotheram-Borus et al., 1999; Spirito, Plummer, Gispert, Levy, & et al., 1992). Dropout occurs rapidly with a median survival rate of only three sessions (Trautman, Stewart, & Morishima, 1993) compared with average retention of 16 sessions demonstrated in this study.

Pre and post group data suggest that both parents and patients perceive an improvement in their general mental health and behaviour. Parents rated their children as having fewer behavioural problems and less symptoms of depression, anxiety and attention difficulties. Similarly participants rated themselves as more effective with greater enjoyment of life and lower rates of overall depression, suicidality and more positive perceptions of the way in which their family functioned.

Groups are intrinsically attractive from both developmental and service delivery perspectives. However oppositional adolescents and those who have ‘failed’ previous treatment programs strongly resist efforts to utilise their ‘issues’ as material upon which the group session is dependant. Frequently such adolescents will act out in order to disrupt the group and/or terminate their inclusion. TSI precludes the destruction of the group by this route by providing ‘safe’, externalised material for group discussion. TSI rapidly engages resistant, hopeless and depressed adolescents, enabling family and other therapy to proceed with the amelioration of risk factors.

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