Ask a bunch of mental health professionals about their biggest frustration in the field, and chances are you will get the same answer: Treatment for common mental health disorders like ADHD, depression, and anxiety is effective for most patients — if they engage fully in treatment. But many don’t. Especially teenagers.
Before it can be effective, young people need to be willing not only to start treatment but to adhere to the plan: take the medicine, or do the cognitive behavior therapy homework. The reality is that whether a treatment works depends on factors beyond the properties of a drug or the techniques in a therapeutic manual, even if they’ve been proven effective in studies. It depends on the patient’s relationship with the clinician, the support of his family, his expectation of treatment working, and his motivation to get better.
These factors aren’t limited to mental health care. They apply to treatment for many chronic diseases, including hypertension and diabetes. Professionals call them “common factors”: therapeutic alliance, expectations for treatment, motivation to participate, and adherence.
Recognizing the impact of these common factors on the success or failure of treatment is “essential practice,” says Alessandro De Nadai, PhD, a clinical psychologist who has researched how attention to common factors can improve treatment outcomes. He hopes that tracking common factors will become standard practice for mental health professionals, to aid clinicians in evaluating their influence on a patient’s progress.
“With any disease, outcomes are going to be variable, and it’s going to vary based on access to treatment, motivation to improve, compliance with treatment, adherence to the treatment that’s advised,” says Ron Steingard, MD, associate medical director and senior pediatric psychopharmacologist at the Child Mind Institute.
Dr. Steingard thinks clinicians need to be trained to effectively use common factors to improve outcomes. “When you’re teaching new doctors, these are important things for them to understand, because they often think that their presence, and knowledge, and power alone is sufficient to get to the endpoint,” he says. “And then you run into people. And people are all very different.”
Families, too, can help improve outcomes if they understand that how they work with clinicians, and how engaged they are in treatment, has a big effect on the outcome.
The therapeutic alliance is the relationship between clinician, patient and, in the case of child and adolescent mental health care, the patient’s family. The basis of the alliance is the bond between doctor and patient. Do the child and the family like and trust their doctor?
“If medicine were being diluted at the pharmacy so that everyone got a half dose, people would be mortified,” says Dr. De Nadai, who teaches at Texas State University. “But this often happens if you have a suboptimal alliance — it also dilutes the treatment.” He suggests that patient families shop around for a doctor they can forge a bond with.
Dr. Steingard sees that bond as key to the patient’s full participation in treatment. “Imagine that I’m sitting here telling you, ‘You may have this disease for a long time, so let’s figure out how to make your life work better,’“ he says. “If you think I’m a jerk, you’re not going to feel comforted by that. If you think I’m an okay guy and I really care, maybe it’s going to help with your motivation. And maybe you’re willing to take a chance.”
Not having a trusting, open relationship also affects treatment by undermining communication between families and the clinician, so critical information isn’t conveyed. “It’s natural to defer to the doctor as the expert,” Dr. De Nadai says. “But parents are the foremost experts in their own children.” Each must learn to seek input from the other — the parent seeking treatment information, and the clinician seeking information about the child’s temperament and behavior.
There are two key “expectancies” in mental health care treatment: what the patient expects his or her role to be and what he or she expects the result of treatment will be. These expectancies can have positive or negative effects on the experience of treatment and the outcome.
Dr. De Nadai says families should make sure they and the clinician have an “agreement on the task and the goals.” It’s not always easy. “A teen might say ‘I want to be cured tomorrow,’ and that may not be feasible,” he notes. But not communicating about goals, not having clear expectancies about the patient’s responsibilities, and letting unrealistic expectations for treatment develop almost guarantee that treatment will fail.
On the other hand, positive but realistic expectations produce better results. Adolescents who expect to see much or very much improvement from treatment improve significantly more than those with lower expectations. In one study, teens who had positive expectations were more likely to follow their treatment regimen. Researchers credited those positive expectations as being responsible for one-third of symptom improvement.
Motivation for behavior change
In physical illness, patients are motivated to get better by the negative effects of the illness. But mental health disorders can be unusual: even if the symptoms are causing distress, they can seem so central to one’s personality and identity that motivation to change is lacking. Imagine a teen who grudgingly goes to a therapist for depression because her parents think she needs help — but who doesn’t participate (and doesn’t get any benefit) because she doesn’t think she needs to be there. Depressed teens often lack confidence that it’s possible to get better, that treatment can work. Dr. De Nadai calls this “a self-sustaining barrier to symptom change.”
Techniques that encourage teenagers to see treatment as relevant to their own goals lead to better outcomes. Dr. De Nadai recommends clinicians be familiar with motivational interviewing (MI), an approach to involving a patient in treatment and exploring her resistance. MI focuses on helping the patient confront ambivalence about behavior change, build motivation, and play an active role in shaping treatment to her own needs.
MI is effective in treatment for substance abuse, where motivation to change is notoriously difficult to nurture. Research also shows it to be effective in teens with anxiety and depression. “Many physicians will have patients with whom it’s hard to find common ground,” Dr. De Nadai says. “Motivational interviewing can really help, especially with the most difficult patients.” Studies have shown that MI participants attended more therapy sessions and were 20% more likely to initiate treatment than controls.
Adherence is whether a patient follows or does not follow (or halfway follows) a prescribed course of treatment. Good adherence is crucial, and not only because treatment depends on taking the medicine or doing the work. It also affects the clinician’s ability to evaluate whether the treatment is appropriate. If the doctor thinks a patient is taking his medication when the patient in fact is not, he will fault the treatment — not the poor adherence. Adherence rates have been reported to be under 50% for medications commonly used in young people, such as SSRIs and stimulants.
For Dr. Steingard, adherence grows out of an inspiring relationship, and sticking to treatment is not so different from sticking with a favorite music teacher or sports coach. “It’s not mystical,” he says. “You’re going to do better if you like the person who’s teaching you, listen to what they say, and at least try the things that they’re suggesting. You’re going to stay on target.”
A study by Dr. De Nadai shows that alliance, motivation and expectancy can all have direct effects on adherence and improve treatment outcomes. But making awareness of common factors a central part of treatment has not caught on widely — yet. It may useful for families to broach the subject to see if their clinician is tuned into them.
Dr. De Nadai offers the following suggestions for parents hoping to leverage common factors and help their child get more out of mental health treatment:
- Check that you, your child, and the doctor are in agreement about your goals for treatment and how you expect treatment to go (including medications or psychotherapy). Work together to resolve any discrepancies among the group.
- Be assertive if you have questions about your child’s diagnosis, treatment, and possible side effects – doctors are prepared to answer these questions.
- Not every doctor is the best fit for your family, even if he or she is a great doctor overall. Seeking a second opinion or another care provider is common if the current treatment setting is not a good fit for you.