When to wait and when to act? An exploration of child psychotherapists’ work with risky adolescents.

Risks taken by adolescents presenting to mental health services can be seen as a communication that, through treatment, can be understood. Psychotherapy can be thought of as an offer of time in which ‘waiting with’ a patient is therapeutic. However, this approach can conflict with the culture of pressured CAMHS services where the pull to act in response to patients’ distress is strong. This research looks at how Child and Adolescent Psychoanalytic Psychotherapists (CAPT) manage the tension between the theoretical stance of waiting and an organisational pull to act. It focuses on adolescent patients who pose a risk to themselves from serious self-harm or suicidal ideation. Five interviews were conducted with CAPTs from clinics within a single NHS Trust where the dominant culture is one of fast action, without psychoanalytic thinking at the fore. Grounded Theory was used to pull together psychoanalytic thinking with data generated through interviewing. Reflexivity of the researcher’s framing of the study, and influence on the interviews, is explored. Key findings: (1) a strong focus was seen on a specific kind of thoughtful action described here as an enhanced therapeutic dyad. It involved a process in which parents were sensitively brought into the therapeutic relationship and requested to take responsibility for certain actions to ensure their child’s safety. The purpose of this action is primarily patient safety, but also promotes long-term change. (2) The impact of an organisation’s capacity to acknowledge the presence of anxieties arising from the work on the ability of clinicians to contain patient anxieties and wait rather than act was noted. The first finding was unexpected and a recommendation is made for an explicit focus, during CAPT training, on the use of thoughtful action as part of therapeutic work with risky adolescents in pressured NHS services.