The authors of this paper would not expect to find quite different results among adolescents without DMCs, with the exception of results related to the adolescent-therapist relationship. Note, however, that, as the participants in this study were all voluntarily receiving therapy, the authors can imagine that adolescents who were not in therapy by choice might answer differently.
The facilitators of and barriers to psychotherapy engagement that emerged from this study were ranked as major (strong) and minor (less strong) according to their recurrence rate of the related data in the interviews (quantitative criterion) and the emphasis placed on these interview data by participants (qualitative criterion). From this perspective, below, the authors discuss the results of this study. As the authors conducted an inductive content analysis, the structure of this section is based on the key findings of the study.
The adolescents’ attitudes towards therapy
All participants had a positive attitude towards treatment. The vast majority of the participants in this research clearly acknowledge the benefit of receiving treatment and express explicit desire to undergo treatment. This is not consistent with the findings of prior studies, according to which adolescents frequently do not perceive the need for psychotherapy [
4,
54]. It is argued that adolescents may lack the cognitive abilities and experience to fully understand the rationale behind treatment and doubt that it will have any meaningful impact on them [
5]. Furthermore, it is argued that adolescents are less able than adults to assimilate and integrate, analyse, synthesize and evaluate the information provided, even though they may completely recognize the (short-term, but not the long-term) benefits of the recommended treatment [
19]. Moreover, it should be highlighted that “it is unclear how well adolescents with psychiatric problems appreciate their disorder and treatment recommendations …” [
55]. Note, however, that the researchers included only adolescents who we considered competent to make decisions and were already in therapy. As anticipated above in the Introduction section, a subset of adolescents with mental disorders are likely to be decision-making competent in specific contexts. These adolescents can be effectively involved in the SDM process and hence effectively engage in their treatment
. To that effect, many theorists suggest that “children may have far more potential to understand complex illness concepts than they have previously been given credit for” [
56].
Many of the participants were of the opinion that the remission of the symptoms would be a good reason for premature termination of therapy, which in turn may hinder the effective delivery of mental health services [
57]. It is important that quite a few adolescents seem to try to “have control” of the therapeutic relationship, setting their own terms for treatment delivery, which they mainly relate to the quality of their relationship with the therapist (see below). This corresponds with adolescents’ desire for immediate results and focus on short-term outcomes and is consistent with the egocentrism of adolescence. Adolescents’ perceived limits to their freedom to “choose”, tendency to regard psychotherapy as an effort to control them and as in conflict with their striving for autonomy, and stereotype-based inaccurate impressions of psychotherapy may be significant barriers to therapy engagement. This is particularly so when adolescents in therapy fail to perceive themselves as needing therapy and participate in therapy because others want them to be in therapy [
5]. Αdolescents have a propensity towards risk-taking and short-term reward (reward reactivity) due to asymmetry in the development of various structures in the adolescent brain [
23,
27]. In addition, adolescence is characterized by the perception of invincibility and egocentrism (failure to inhibit self-perspective) [
58,
59]. Many participants clearly and unequivocally stated that they were afraid of nothing. Naturally, this agrees with the feeling of invincibility and risk-taking during adolescence.
As all of the participants were actively engaged in therapy, it is likely that their prevalent symptoms are potential facilitators of their engagement in therapy. In that regard, the interesting finding that early remission of symptoms may increase the risk of early withdrawal from therapy should be highlighted. A possible explanation may be that the remission of symptoms may considerably reduce both public stigma (related to mental disorder) and self-stigmatization. In addition, with the remission of the symptoms, the need for follow-up is eliminated.
Last, it is noteworthy that our participants did not hold beliefs about mental illness, mental health treatment or terrifying hospital experiences that contributed to poor treatment engagement, as Stafford and Draucker recently found in their study [
54].
The important adolescent-therapist relationship
The vast majority of participants in this study reported that they had developed a meaningful connection with their therapist. They said that this was a significant facilitator of their therapy engagement. They stressed their belief that negative experiences with their therapists would be a major barrier to their therapy engagement. The findings were consistent with previous studies [
5,
54]. The literature has long acknowledged the adolescent-therapist relationship as crucial for adolescents’ engagement in treatment [
5]. Adolescents’ perceptions of therapists predict therapeutic outcomes [
5]. Treatment engagement is decisive in an effective therapeutic process and in achieving successful outcomes and ‘may be particularly relevant early in treatment’ [
4]. The better the treatment engagement, the more favourable the therapy outcomes may be.
Several participants mentioned trust in the therapist. Adolescents are more likely to seek health care if their provider guarantees confidentiality, but in providing confidential care, a balance among the needs of the adolescent patient, the parents, and the provider must be considered [
60]. In the literature, distrust of psychotherapists is most commonly reported as a barrier to therapy engagement in Latino adult populations. Furthermore, adolescents want a relationship with their therapist that carries a genuine sense of mutual trust [
54,
61‐
68]..
Participants in this study desired a humane, approachable therapist who would collaborate with them and treat them as equals. Therapeutic engagement is “a reciprocal interaction in which both therapist and client(s) have a responsibility for establishing an effective rapport”, namely, creating an optimum working collaboration between the therapist and adolescent [
5]. Adolescents should be offered a way to build rapport with the therapist. They should participate fully and engage in positive interactions to achieve successful therapy. Healthcare providers’ ability to engage adolescents increases the likelihood of continuation of treatment [
69]. Positive attitudes of psychotherapists towards their patients are more engaging than the more traditional neutral stance often assumed by psychotherapists. Adolescent-therapist agreement, i.e., co-endorsement of aetiological beliefs, may significantly facilitate treatment engagement by promoting communication/openness, adolescent-therapist interaction, and adolescents’ perceived usefulness of treatment [
70].
Oetzel and Scherer argue that “succeeding as a psycho-therapist with adolescents can be challenging” [
5]. The authors state, “establishing a strong therapeutic alliance with adolescents require that therapists express empathy and genuineness … and increase choice in therapy” [
5].
Many participants expressed their need to feel that their therapist would understand them and that he or she would be a source of support. Participants appreciated the fact that the therapist gave them thoughtful and effective advice. This is inconsistent with prior literature [
68]. They perceived their therapist as empathic, caring, open, and sincere.
Some participants said, “the therapist understands me”. It is true that both the therapist and adolescent should be minded to ‘understand’. Indeed, reciprocal understanding between the adolescent and therapist is of great importance. Understanding how adolescents perceive mental illness may be important for therapists to improve engagement [
71]. If providers motivate adolescents to understand the value of treatment, they may increase the engagement of adolescents, who will be less likely to terminate prematurely [
72]. It is crucial to bear in mind that adolescents may undervalue or overestimate the importance of their psychological symptoms and may be ashamed of reporting them [
5]. It is possible to identify different treatment engagement profiles [
73]. Note, however, that treatment motivation should be distinguished from treatment engagement [
74]. Motivational interviewing, used as a pre-treatment intervention, is a promising way to facilitate engagement in adolescent mental health settings [
75].
Empathy is necessary for developing a therapeutic alliance with adolescents but is not sufficient. Adolescents appreciate therapists who are committed to them and their well-being.
Some participants said that they wanted the therapist to be precise and that they wanted to feel comfortable with him or her. Sincerity, candour or “being real” with adolescents is a crucial therapy engagement facilitator. Candour implies telling adolescent patients the truth tailored to the adolescents’ developmental capacities. Cognitively immature adolescents require the therapist to use simple inquiries devoid of abstract terms, concrete examples, and guidance on how to establish therapeutic rapport [
5].
Some participants stated they were willing to interrupt treatment if it contradicted their values. Respect for the personal values of the adolescent is crucial both in the therapist’s approach and for the adolescent’s therapeutic goals. In relation to the above, it should be mentioned that each minor experiences the outside world in his or her own unique way, even though he or she lives in the same social-cultural context as other children [
76].
All the aforementioned features of a therapeutic relationship are necessary to develop an effective SDM process that predicts effective treatment engagement in adolescents. Therapists should establish a climate that enables a thorough exchange with adolescents and their families, which allows for flexible and respectful SDM [
77]. Furthermore, therapists should balance the views of parents and children [
78] while making every effort to involve the adolescent’s family in the decision-making process [
36,
79,
80].
It is important for therapists to go beyond the provision of adequate, clear, concise and unbiased information to the patient [
81]. Therapists have to empower and stimulate adolescents to fully engage them in the process of making shared decisions, with their own values derived from their own viewpoint, preferences and emotions [
11,
81]. Importantly, the irrational decisions of adolescents that are nevertheless coherent with their “internal rationality” may be regarded as internally reasonable decisions [
82]. SDM ‘is increasingly being suggested as an integral part of mental health provision’ [
6], especially in the context of child and adolescent psychiatry [
7]. However, while a subset of adolescents are decision-making competent [
17,
83], therapists may have challenges engaging adolescents with mental disorders in SDM [
6,
84].
The role of peers
Acceptance by peers and improvement of social skills as essential preconditions for acceptance in the social environment seem to constitute a strong motive for seeking treatment. This is not surprising. Adolescents pursue their need for independence by placing a considerable emphasis on attempting to shift from dependency on parents and family towards greater belonging among peers [
5]. Many writers highlight the participation of adolescents in groups of peers as a necessary process of maturation, experimentation and finally discovery of the true self [
86‐
88].
Potential social stigma against mental illness and their inability to deal independently with their difficulties pushes adolescents to conceal their receipt of treatment from their social circle while they simultaneously seek help to integrate into it and to develop trusting relationships with peers. The mental disorder-related stigma attitudes of peer groups towards adolescents in psychotherapy may result in adolescents feeling scorned [
5].
However, our research has shown that stable and tested friend relationships can function to encourage adolescents towards therapy and that there is a distinction between “companions” and “friends”. In that regard, it should be highlighted that peers, even though they often are not part of the medical conversation, may actually motivate a (mentally or not) ill adolescent to be more socially active, thus improving his or her DMC [
23]. Indeed, in a peer context, an observed adolescent may want to send a social signal to his or her peers [
29]. The developmental processes that underlie the sensitivity of adolescents to peer influence are poorly understood [
29]. At any rate, it should be highlighted that the influence of peers on outcomes in psychiatric mental health contexts remains poorly understood [
19].
The role of family
In almost all of the cases, adolescents were backed by family to some extent. Adolescents in the study acknowledged the important role of family in their decisions. Tsiantis et al. state that when an adolescent comes for therapy, he or she has already been exposed to familial, friend and social influences, and this can make his or her attitude towards treatment positive [
89].
It is very important that parents first note there is a problem and persuade the adolescent to seek treatment, because, as a participant said, “if the family doesn’t accept the problem, then nor does the child” [
89]
. Although this was not the case for the participants in our study, adolescents often underestimate the importance of and need for treatment and are involuntarily referred by parents and other health care providers [
90]. Furthermore, not only in mental health care but also in other health care contexts, parents may facilitate adolescents’ DMC more than physicians do, creating the context for adolescents’ competent decision making [
6]. Parents can be a barrier to or facilitator of an adolescent’s treatment decision [
91]. The American Academy of Pediatrics claims that parents have no absolute legal right to make autonomous treatment decisions regarding their children [
17]. Parents do have a responsibility to preserve family relationships and further the best interests of their children. According to the model of constrained parental autonomy, parents can “balance the “best interest” of the minor patient with his or her understanding of the family’s best interests …” [
17]. At any rate, it is important to highlight the fact that parents and physicians do not always understand what is in adolescents’ best interest [
92]. When parents perceive their children’s mental health problems to be serious, they are more likely to seek mental health therapy for their children [
54,
93]. However, while the majority of families perceive the need for treatment, that perceived need may not be associated with treatment engagement [
94].
Adolescents’ and parents’ needs and perceptions regarding the need for and barriers to care may differ. It is important to align adolescents’ and parents’ needs throughout treatment [
91]. Moreover, a collaborative relationship between the family and the health provider may increase engagement [
4].
Additionally, it is important to bear in mind that the influences of parents and family on outcomes in psychiatric mental health contexts are poorly understood [
19].