Positive events in psychotherapy: What do adolescents and young adults say is helpful?

Adolescence, derived from the Latin “adolescentia,” indicates the transition period from childhood to adulthood. It is marked by significant physical, cognitive, emotional, and social changes. The conclusion of adolescence, typically around age 19, is defined by the acquisition of developmental tasks that help individuals build their identity and prepare for adulthood. These tasks, as described by Havighurst (1948), contribute to happiness and success when completed but lead to difficulties when unmet. In recent years, a new life phase, post-adolescence or young adulthood, has emerged in Europe, reflecting prolonged dependence on the family of origin and delayed identity formation. This is paralleled by the American concept of Emerging Adulthood, where young people explore various life directions (Arnett, 2002). Young adulthood is a crucial period, showing both differences and similarities with adolescence.

These years between 18 and 26 represent a period of psychological development, where young adults bridge the differences between adolescence and adulthood, influenced by new roles, responsibilities, and social context changes (Cauffman et al., 2010). Compared to adolescents, young adults take more time to consider difficult decisions, are less influenced by rewards, are more sensitive to potential costs, and have better impulse control.

Despite these peculiarities, adolescents and young adults share several similarities, which is why they are often grouped together as a single population of interest. Both groups, in fact, go through a transitional period characterized by internal and external movements, as well as a continuous search for separation and individuation (Havighurst, 1948). Socially, the transition to adulthood is becoming more unpredictable and is increasingly shaped by individual choices rather than social structures (Steinberg, 2013; Settersten & Ray, 2010). Although young adults engage in less risky behavior and are healthier than adolescents, they live more independently from parents and have less supervision, which can increase vulnerability. These features may extend the period of potential harm often associated with adolescence (Harris et al., 2006; Neinstein, 2013; Schulenberg & Maggs, 2002). Also, although adolescence and young adulthood are distinct phases, both involve continuous cognitive and motivational changes in the brain that can affect the ability to understand and negotiate with others. This makes the transitional phase a period of uncertainty and opportunity, where social and institutional support is crucial to facilitate a path toward a more stable future (Arnett, 2004; Furstenberg, 2010; Roisman et al., 2004).

Another important aspect that unites the two developmental stages described is the therapeutic alliance, which in psychotherapy with adolescents and young adults assumes a collaborative dimension. It should be considered that the independence and self-determination typical of these developmental stages can serve as significant normative-evolutionary obstacles that may complicate the achievement of an agreement between client and therapist (Karver et al., 2018; Meeks & Bernet, 2001). Moreover, it seems beneficial to involve caregivers, who are often responsible for bringing them to therapy and/or covering its financial cost (Cirasola et al., 2021). This implies that the construction of long-term therapeutic goals can be complex, especially if the young person has little self-awareness of their problems or cognitive difficulties, which are also influenced by brain changes occurring during adolescence and young adulthood (Bonnie et al., 2015).

There is substantial evidence regarding the effectiveness of psychotherapy with children and adolescents (Goodman, Calderón, & Midgley, 2022), more so when the therapists follow evidence-based psychotherapies (EBPs) (Weisz et al., 2013) such as Multisystemic Therapy (e.g., Timmons-Mitchell et al., 2006), Cognitive-Behavioral Therapy (CBT; e.g., Stallard, 2022), Interpersonal Therapy (IPT; e.g., Gunlicks-Stoessel et al., 2010), Psychodynamic Therapy (PDT; e.g., Midgley et al., 2021), and Mentalization-Based Treatment (MBT; e.g., Rossouw & Fonagy, 2012).

Goodman and Halfon (2021) found two successful treatment paths for children: one focused on mentalization, which improved emotional regulation, and another centered on providing support, which helped, for example, contain oppositional behaviors. Mentalization, by fostering trust and collaboration, enables patients to learn from new experiences and adjust their understanding of social relationships. Providing support, offering encouragement or approval to patients, helps them cope with stress, challenges, or emotional difficulties. These processes might be more important than specific therapist knowledge shared during therapy.

The investigation carried out by Goodman, Calderón and Midgley (2022) involving thirty-one expert clinicians from diverse therapeutic backgrounds indicated the presence of two effective processes in adolescent therapy across four distinct presentations of widely adopted therapy models (Psychodynamic Therapy- PDT; Mentalization-Based Treatment- MBT; Cognitive-Behavioral Therapy- CBT; Interpersonal Psychotherapy- IPT): the promotion of mentalization and the provision of support. Utilising the Adolescent Psychotherapy Q-Set (APQ), the researchers found PDT and MBT seem to involve the change process by promoting mentalization, while CBT and IPT seem to change process by providing support.

Cirasola and Midgley (2022), in their critical review of alliance with younger clients, emphasise its role as a crucial mechanism of change in their psychotherapy. Over the last few decades, researchers have made efforts to better understand the temporal precedence of the alliance and symptom change through sophisticated designs and analyses (Falkenström & Larsson, 2017; Zilcha-Mano et al., 2014). In youth psychotherapy, some studies have identified a significant association between early alliance and later symptom severity, even when controlling for initial severity (Chiu et al., 2009; Labouliere et al., 2017; Marker et al., 2013). More recently, Cirasola et al. (2021), using data from the IMPACT study, a randomised controlled trial comparing cognitive-behavioral therapy, short-term psychoanalytic psychotherapy, and a brief psychosocial intervention in the treatment of adolescent depression, controlling for pretreatment symptom severity and prior symptom change, found that average alliance ratings by adolescents (N = 224) and therapists (N = 139) early in therapy had a weak but significant association with subsequent symptom change.

Alliance with younger clients is particularly relevant also because adolescents’ motivation to participate and collaborate in treatment may differ from that of adults. The systematic review by Gulliver, Griffiths and Christensen (2010), covering both qualitative and quantitative literature on perceived barriers and facilitators to help-seeking for mental health problems in adolescents and young adults, highlighted that young individuals are often directed to treatment by others (such as parents, family, or teachers) and rarely seek therapy independently. Additionally, adolescents and young adults may lack motivation to seek therapeutic help because attending mental health services conflicts with their developmental needs, especially regarding peer acceptance, autonomy from parents, and their high dependence on parents to solve problems. So, while working with adolescents requires respecting their individuality, agency, and confidentiality as conditions for a robust alliance (Gulliver et al., 2010; Wilmots et al., 2020), caregivers are often involved in their children’s therapy in various ways: they are frequently the reference source that may contribute to the initial assessment or some sessions, and even when not directly involved in their children’s treatment, they are often responsible for bringing them to therapy and/or its financial cost (Cirasola et al., 2021). Additionally, it is essential to remember that, in the case of a minor, the consent of both parents or legal guardians is a crucial aspect for undertaking any form of treatment (APA, 2002).

Consequently, therapists need to build an alliance not only with the direct stakeholders (adolescent or young adult) but also negotiate an alliance with their caregivers, often defining different goals as these may diverge between the young person and the caregivers. Working with parents is crucial to strengthen the youth’s alliance with the therapist. The ability to provide parents with psychoeducation, respectful challenges, empathy, and support at a deeper level than currently possible is likely to be beneficial, even though it might require more clinical hours dedicated to the caregiver/s. Clinical time can be saved by engaging in preventive work, shorter work, and potentially ensuring safer and more lasting outcomes with the adolescent (Marks, 2020).

Without mutual commitment, parents/guardians can be seen as obstacles to their children’s treatment, and therapists working with adolescents may perceive them as intrusive or disengaged from the adolescent’s therapy. A sense of demoralisation about the prospects of fruitful engagement may become the professional response to parents who appear angry, inflexible, enmeshed, jealous, or avoidant (Marks, 2020).

The significant challenge in adolescent and young adult therapy lies in the fact that research in this field does not provide many clinical indications, especially when working with adolescents from non-Western cultures in which adolescence is not defined in the same terms of individuation/separation as in Eurocentric societies (Cirasola & Midgley, 2022). To fill this gap, qualitative research methods could provide insights about adolescents’ experiences of their treatment. The research on significant events in psychotherapy (any reaction, intervention, or response that resonates for the patient, which marks a turning point in the therapeutic relationship, Elliott, 1985) allows us to investigate in-depth meanings attributed by patients to their experiences in therapy.

A recent study conducted by Calabrò, Cassera and Aschieri (2024) examined the impact of events that hinder the therapeutic alliance in psychotherapy with adolescents. Adolescents remembered as particularly problematic events connected to therapists’ misuse of diagnosis, lack of responsiveness, inappropriate focus of sessions, abstractness, poor management of the differences in opinions between patient and therapist, non-response to their need for protection and patient blaming. Also, adolescents experienced problems in the management of the therapy setting, such as when they perceived session discontinuity, broken confidentiality and unclear boundaries between therapist’s private/work life. Participants to the study also reported as problematic their lack of internal motivation and internalised stigma about therapy, the interferences from their environment with regards to attending or interrupting therapy and their concerns for its economic sustainability. Facing these difficulties let participants feel a range of negative emotions, and painful experiences such as rejection, confusion and overwhelm. Despite the distress for the negative events they experienced, the discriminant element that emerged has been the way the therapeutic dyad was able to identify and repair the rupture in the relationship or not. In conclusion, all 14 participants considered psychotherapy potentially beneficial. Participants who opted to seek another therapist used the negative events encountered in their previous treatment as a guide for what they did not want to experience in the next one. Others left therapy with ambivalence, acknowledging both the negative aspects of treatment and some positive aspects that made them open to the possibility of starting a new treatment with a different therapist in the future.

Building on the findings of this research, the present study seeks to identify positive events categorised as helpful within the therapeutic setting. This endeavour aims to offer a deeper insight into patients’ psychotherapy experiences. In a future perspective, the gathered information will empower therapists to better understand their patients’ perspectives and adeptly manage constructive events occurring within the realm of psychotherapy.

Objectives

This study aims to investigate the positive events that have facilitated the engagement and satisfaction for treatment with adolescents and young adults. Specifically, the goal is to deepen the patients’ perspective regarding how specific episodes in therapy were seen as helpful and positive, and which variables could contribute to promote clients’ appreciation of their therapy.

Method

The research follows the significant events paradigm (Arnkoff et al., 1993; Elliott et al., 2001) and the narrative-hermeneutic approach (Bruner, 1986), focusing on the subjective experiences of adolescents and young adults with regard to significant events in psychotherapy. In this study, the interviews are analyzed to extract the key patterns of meaning. Thematic analysis (Braun & Clarke, 2006) is employed to build a hierarchical system of categories based on the text. In this approach, the researchers do not begin with a pre-defined classification of events; instead, they start with the clients’ narratives to develop bottom-up an empirically grounded classification of events. As Bryman (2008) sustain, the amount of data collected in qualitative research is not fixed or calculable, but continues until saturation is reached. That is, study data were collected until emerging concept shave been explored and additional data were not producing fresh insights.

In this regard, the study followed the Consolidated criteria for reporting qualitative research (COREQ) (Tong, Sainsbury & Craig, 2007). In the following sections we report in square brackets the corresponding number of each information to the list of criteria.

Results

Six typologies of helpful events emerged from the coding [31]: events connected with the management of the therapeutic setting; events related to the definition of therapy goals, events that qualify the role of the therapist; collaborative events between therapist and client; events connected with clients’ internal world; events connected with clients’ external world. Each theme was composed of different sub-themes [32]. Tables 1-6 summarise the structure of the categorization. The text below reports one excerpt from participants for each sub-theme. More examples for each sub-theme are given in the online Appendix A [30].

Discussion

Consistent with Burton and Thériault (2020) and Hilsenroth et al. (2004), most of the adolescents who participated in this study attributed the cause of meaningful and constructive events in therapy to specific characteristics and actions of the therapist. All participants (N = 13) reported that significant events occurred a few months after the beginning of therapy (3-4 sessions), aligning with literature indicating the initiation of therapeutic alliance construction during this period (Burton & Thériault, 2020; Hilsenroth et al., 2004).

The six-themes derived from this study focus on several elements that our participants deemed relevant in their treatments. First, the emphasis on the management of therapeutic setting suggests that the therapists’ responsibility is to frame the “rules” of the sessions, stressing the importance of the definition of the “how" rather than the “what" (i.e., the content) (Safran & Muran, 2003) particularly when working with this type of clients. A common feature among sub-themes emerging in this domain, such as Definition of Privacy Boundaries, Availability Between Sessions and Flexibility of Session Frequency was their change with time. The boundaries of privacy, the availability of therapists between scheduled sessions and the frequency of the sessions were flexibly renegotiated between adolescents and their therapists, allowing a better fit between the structure of the therapy and the changing needs of clients.

Also the theme Definition of Therapy Goals and sub-themes Addressing Adolescent’s Priorities and Redefining the Style and Purpose of therapy stress the positive appreciation for a patient-centered care, in which therapists follow adolescents’ agendas and flexibly adjust the goals and the process with which the treatment is delivered to adolescents’ changing requests and needs. Specifically, eleven out of thirteen adolescents emphasized the significance of therapists’ ability to address their priorities. This finding aligns with recent literature on assessing and accommodating therapy to adult patients’ preferences (Cooper et al., 2023). Jacob et al.’ study (2022) found similar conclusions with adolescents. They underlined the importance of collaborative goal setting and agreement between young individuals and their therapists regarding personalized and meaningful outcomes on specific topics.

The theme Role of The Therapist stresses the importance, for adolescents clients, of some features that qualify their therapists’ behaviors and attitudes in treatment. The adolescents we interviewed appreciated events in which their therapists displayed their own personal characteristics and caring attitudes toward their clients in the therapeutic relationship (Egozi, Tishby & Wiseman, 2021). What emerges from the analysis of the sub-themes (Active Engagement, Construction of Epistemic Trust, Self-disclosure, Authenticity of Personal Relationship, Emotional Responsiveness, Affinity with the Client) is the relevance of the therapist’s self for adolescents. Being able to show care, interest, and responsiveness help adolescents develop trust in the importance of reaching their goals in therapy and attending carefully to the therapists’ views and advice. In the interviews we collected, affinity between clients’ and therapists’ personal features emerged at a later stage during the therapy, and it seems to be something that adolescents saw and built “on top” of their transformative experience, or at least after it started to unfold.

The Collaboration theme emerged in all interviews, and encompassed various activities, so that in our data it seemed to be a cross-cutting process that adolescents valued in many different circumstances, even when not explicitly mentioning it. In the sample of participants we interviewed, five adolescents completed with the same therapist a collaborative assessment prior to the onset of the actual treatment. Such assessment was explicitly considered by them as an integral component of their therapy, and was appreciated because it allowed adolescents to give their own versions of what the test scores mean for them, adding their individualised meaning to test data. The collaborative meaning-making, noticed by all participants, started in many cases from the discussion of the testing results in which therapists and adolescents tried to come up with joint understandings of the clients’ struggles observed through the lenses of assessment results. In other cases, collaborative meaning-making was conveyed by the use of open questions from the therapist, through which adolescents could make connections between previously unrelated aspects of their lives and experiences. Collaboration encompassed also the development of “ways of being in the room “unique to each adolescent-therapist dyad, and such intimate and deep connection was accompanied in some cases by an authentic care for the person of the therapist by the clients.

The fifth theme (Client’s Internal World) included processes that focused on the emotional, cognitive, narrative and representational aspects of adolescents’ functioning. The adolescents we interviewed appreciated being helped in developing greater self-understanding. The quality of the improved understanding about themselves seemed to have two specific features. First, it contrasted shame for their supposed inadequacies, either by normalising it or by judicious self-disclosures on the part of the therapist. Second, it framed symptoms, behaviors or problems that were previously deemed as “negative” by clients as smart adaptations to less-than-optimal environments provided them by their parents or social environment. Within this context of understanding, adolescents were able to appreciate the healing effect of sharing topics that were hard for them to address, regulate painful emotion with the support of the therapist, eventually accepting more of their experiences.

The Client’s External World theme underlined the importance of addressing directly and indirectly the context in which adolescents live their everyday life. Some adolescents we interviewed reported a benefit to the treatment from the real inclusion of their parents to some of the sessions. During such sessions, therapists helped adolescents and their parents to discuss problematic issues that were lingering in their relationships, and to attain better communication among family members. In some other cases, therapists helped adolescents to revise their view of their parents, or approach problems in their life differently, which led to a new way of dealing with issues outside the room of the therapy. Finally, adolescents appreciated the involvement and support from therapists when they felt that their relational network needed more structure and ressources.

Conclusion

Therapy with adolescents can be a rewarding experience for therapists, but poses several challenges. How to keep in mind the family concerns for their children, foster alliance with the parents, and validate adolescents’ realization of the shortcomings of their environment? How to maintain the boundaries of privacy with adolescents when planning to do family sessions with their relatives? How to maintain a professional role with clients who highly value authenticity, openness and reciprocity in their treatment? How to be collaborative with adolescents, value their input in conjoint meaning making and also expand their views and self-understanding by adding information about their functioning?

The recent article by Calabrò, Cassera, and Aschieri (2024), addressing adolescents’ perceptions of hindering events in their therapies, illuminated several potential pitfalls for therapists when responding to these challenges. The current study indicated that therapists effectively navigated such obstacles, as reported by the participants, and helped to shed light on what adolescents valued in their therapy, offering an informative perspective on “what worked” in their treatment.

When comparing the main findings of Calabrò and colleagues with the current study, first it becomes evident that the management of certain relational variables plays a crucial role in guiding therapy towards a positive trajectory. These variables include: the therapist’s alignment with the adolescent’s objectives, the utilization of diagnosis to enhance self-awareness and foster epistemic trust in clients, the incorporation of therapy into adolescents’ daily experiences rather than engaging solely in abstract discussions, the facilitation of open dialogue and collaboration encompassing both areas of agreement and disagreement between adolescents and therapists, and the demonstration of authentic care and concern for adolescents’ well-being by therapists.

Second, the interventions that were deemed as most positive were those protecting adolescents from their shame, and those that provided a new, more compassionate and understanding perspective on themselves. One could wonder if the lack of these interventions might have been connected with the shame, stigma, lack of internal motivation lamented by participants in Calabrò et al. (2024).

Third, the management of the setting appears to hold significant importance. This includes remaining flexible to adolescents’ needs while ensuring session continuity, maintaining openness and a personalized approach while upholding clear boundaries between personal and professional lives, and involving parents in therapy while respecting confidentiality with adolescents. These tasks were identified by adolescents interviewed in both studies as the key focal points for therapists.

These seems to be common therapeutic factors in adolescents’ therapy and are present in different therapeutic approaches. As early as 1988, Fishman stated that “the most powerful therapeutic intervention at a social level for working with adolescents is family therapy" (p.4) because the family is the “crucial point” in every adolescent’s life. In systemic family therapy, the goal of the intervention is to reframe the negative views of parents for “dysfunctional behaviors” of adolescents as symptoms of a larger set of needs in the family that need to be acknowledged and seen to promote the development of the system (Aschieri, Fantini, & Bertando, 2013).

In the Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) model, parents play a key role in the ongoing care of the child. In an interview with thirty youths aged 11 to 17, Dittmann and Jensen (2014) found that it is important for children to recognize their parents’ ability to handle hearing about their experiences, as it can help restore the parents’ role as a “protective shield” (Pynoos, 1994). Although the youths valued confidentiality and predictability in what was shared during sessions, many found that sharing information was beneficial and appreciated.

In the 4-C model (competence, consent, confidentiality, and competing interests), it is important to discuss confidentiality with decision-making authorities, such as the child, parents, or guardian, before treatment begins (Sori & Hecker, 2006; Sparta & Koocher, 2006). As Koocher (2008) notes, successful therapeutic alliances rely on mutual trust and privacy of sensitive content (Harbour, 2004). It is essential to recognize the legal authority of parents or guardians and their interests in the child’s well-being, while aiming for a mutually acceptable understanding of confidentiality. Adolescents may prefer to discuss private matters, such as peer conflicts, school issues, smoking, alcohol, and sex, without their parents. Establishing clear boundaries around necessary secrets and when disclosures are necessary, such as threats of harm, helps clinicians negotiate acceptable limits with all parties at the beginning of treatment.

Another resource for therapists working with adolescents is the Therapeutic Assessment with families with adolescents’ model (TA-A; Tharinger et al., 2013). Despite being designed as a short-term consultation and presenting more research on its effectiveness with adult clients (Durosini & Aschieri, 2021), Therapeutic Assessment offers various solutions to navigate in the complexities of working with adolescents and their families.

In Therapeutic Assessment (TA-A), the central focus lies in addressing both parents’ questions about their child and adolescents’ questions about themselves. Within this framework, privacy boundaries are determined by the questions posed by participants. Specifically, assessors initially agree with adolescents to disclose all pertinent information to parents to address their queries about the adolescents. Simultaneously, assessors request parents to respect complete privacy regarding information concerning adolescents’ inquiries about themselves. This agreement enables assessors to collaborate with adolescents in exploring answers to all questions through testing and interviews, and to jointly plan the inclusion and shaping of responses to parents’ inquiries. Collaborating with adolescents in this manner helps them feel that the assessment prioritises their concerns, while also allowing parents to perceive that the therapist/assessor is addressing their own objectives. Building on this foundation, collaboration during the assessment progresses to individualizing tests interpretation based on adolescents’ input and to link their testing outcomes to life challenges, both identified by parents and recognized by adolescents themselves. Therapeutic Assessment (Finn, 2007; Fantini et al., 2022), rooted in intersubjective and humanistic psychology, encourages assessors to cultivate an open and supportive rapport with adolescents, embodying a balance between “compassion and firmness” (Finn, 2005) that aligns with adolescents’ need for support and guidance as well as their desire to gain insights into their psychological functioning. This model of authentic and collaborative involvement of adolescents and their families exemplifies a promising strategy for initiating and sustaining a productive therapeutic alliance, not only with adolescents but also with their families.

Given that the research has documented the association of the therapeutic alliance, also defined as the consensual or collaborative bond between clinician and client (Finn & Tonsager, 1997; Shirk & Karver, 2003), with treatment retention, participation, and outcomes of therapy for young adolescents (e.g., Castro-Blanco & Karver, 2010; Shirk & Karver, 2003), it could be argued that the present study contributes to a better understanding of how clinicians can form a strong and constructive therapeutic alliance with their young clients.

Adolescents and young adults differ from adults both psychologically and socially, leading to the need for new frameworks like Emerging Adulthood (Arnett, 2002) and Young Adulthood (Confalonieri & Grazzani Gavazzi, 2002) to better understand their experiences. These developmental stages influence how therapeutic alliances form and evolve during therapy.

For adolescents, the therapeutic relationship is characterized by a need for trust, emotional closeness, and respect for their individuality, action, and confidentiality (Cirasola et al., 2021; Gulliver et al., 2010). This is crucial for building a strong bond with the clinician, as adolescents may feel more engaged when they are deeply heard and understood. In addition, for both adolescents and young adults, therapy must consider their unique developmental stage, as emotional needs and autonomy differ from those of adults.

A key difference in youth psychotherapy is the involvement of caregivers, which is less prominent in adult therapy. The alliance with caregivers, whether through initial assessments or ongoing support, plays a central role in therapy. In this regard, several studies provide evidence that parental control plays an important role in the lives of adolescents (Bean et al., 2006; Lamborn & Felbab, 2003; Hoeve et al., 2009; Kincaid et al., 2011; Inguglia et al., 2022). Therapists must balance the alliance with both the young client and their caregivers, who often have diverging goals and perspectives. Parental involvement can significantly impact treatment, reinforcing the therapeutic alliance and helping to navigate the delicate balance between fostering independence and providing necessary support (Cirasola et al., 2021).

In conclusion, adolescence and young adulthood represent distinct developmental stages that influence the therapeutic process. Therapists must tailor their approaches to these stages, emphasizing trust, respect for autonomy, and the crucial role of caregivers in fostering a positive therapeutic outcome (Cirasola & Montinari, 2012; Gulliver et al., 2010).

From a future perspective, the results of this study could help therapists working with adolescents and young adults to better understand their clients’ viewpoints and to adequately manage significant events that might serve as an important “bridge” to engage the adolescent throughout the course of psychotherapy. Regarding potential future research directions, it is possible to hypothesize that there may be specific differences within the sample according to the age of the client, particularly between adolescents and young adults. This could be explored in future research to identify those significant events that can improve clinical work with a focus on adolescence or young adulthood.

Ethics and consent

The study conforms to the Declaration of Helsinki on the Ethical Principles involving Human Participants, and research protocol was approved by the IRB of Catholic University of the Sacred Heart, [approval number #51-23; 25.05.2023]. Prior to each interview, the Informed written consent was collected from each potential participant (or from their legal guardians, if clients were younger than 18 years old) and L.C. addressed and discussed potential participants’ questions and comments about their participation in the study.