Psychotherapy experiences of young people in foster care

Worldwide approximately 8 million children live in ‘alternative care’ settings, such as foster care (Gharabeghi, Charles & Kananagh, 2016); with nearly 6,000 children in Ireland living in such settings (Tusla, 2020).

Although elves may only go to therapy to help their ‘elf-esteem’, there are many reasons why young people in care may be referred. Children in foster care experience a disproportionate number of adverse childhood experiences (Scozzaro & Janikowski, 2019) and mental health disorders (Trickett, Negriff, Ji & Peckins, 2019) so are more commonly referred for psychotherapy.

There is a body of evidence linking improved therapeutic outcomes and reduced drop out during psychotherapy with treatments that have been tailored to client preferences (Norcross & Cooper, 2021). This has led to a renewed focus on personalised psychotherapy. In order to personalise treatment, it is important to understand how the needs of different groups may vary.

A recent study has been undertaken with young people who are in a foster care placement in Ireland to address the lack of research focusing on this hard-to-reach group (Gilmartin et al, 2022).

What should psychotherapy focus on to ensure treatment is tailored and relevant to young people in foster care?

Methods

Young people were recruited through a variety of strategies via the adults who worked with them, for example social workers. There is a lack of clarity in the paper surrounding the exact routes for recruitment.

A qualitative interpretive phenomenological analysis (IPA) was undertaken of seven individual interviews with young people aged between 13-18 years old in foster care in Ireland. Interviews followed an interview schedule. Further information about the researcher who conducted the qualitative interviews and their previous experience using an IPA methodology would have been useful.

The manuscript details how transcripts were read and re-read, exploratory notes were made, reviewed and discussed. Connections, inter-relationships and patterns were then mapped to provide the themes. There is limited information on the data analysis to allow comment on its rigour as no supplementary information has been included.

Results

The analysis led to four main themes:

1. Being powerless: young people lacked the power to start or stop therapy which fostered feelings of anger or resentment.
2. Risking relationship: young people experienced difficulties forming a relationship with their therapist.
3. Opening up: young people struggled to share their feelings and experiences.
4. Finding connection: young people experienced the benefits of building relationships and learning about themselves.

The authors describe the often harrowing experiences of the young participants in forming and maintaining relationships during turbulent journeys through the Irish care system. Naturally, young people were wary of new relationships and expressed their desire for “genuine, emotionally connected relationships” with therapists. Difficulty sharing feelings should be understood in this context, and young people in this study demonstrated it was possible to overcome these challenges with time and understanding. This study found that the interviewees identified a need to focus on identity development and personal exploration during treatment, in some cases with the assistance of their foster carers.

Prior attachment issues that young people in care brought to therapy were a particular challenge that required patience, time and individualised support. When therapists were able to help young people feel valued and emotionally recognised the therapeutic outcomes were improved and they were able to successfully build additional relationships outside of therapy sessions.

This qualitative study found that young people struggled to form a relationship with their therapist and also struggled to share their experiences and feelings.

Conclusions

Despite the challenges of navigating psychotherapy with this population, the manuscript is a hopeful discussion that provides useful suggestions for practitioners about how best to engage young people in foster care during therapy. The findings note:

Sensitivity to the particular attachment needs of young people in foster care is emphasised, together with flexibility and variety in approach.

The authors conclude that “sensitivity to the particular attachment needs of young people in foster care is emphasised, together with flexibility and variety in approach”.

Strengths and limitations

Although the analysis was based on interviews with only seven young people, this is an appropriate sample size for the analysis technique used (Smith, Larkin & Flowers, 2009). The authors were clear in their aims for the study and used a suitable methodology to explore it. The young people interviewed were all White volunteers in relatively stable foster placements; the findings cannot be generalised to other young people in foster care. The generalisability of the findings was further limited by recruitment through institutional ‘gatekeepers’ whom the authors acknowledge likely selected young people who they thought would be most interested, had positive therapy experiences or who were perceived to be able to provide quality narratives to the researchers. Despite the many challenges discussed by these selected participants in stable placements, it is likely the reality of undertaking psychotherapy for many young people in more transient foster care in Ireland is worse. As is often the case with young people or vulnerable groups, the authors note many young people were not asked to participate due to assumptions that the process would be stressful or uninteresting. Although the authors note the benefits of a practitioner in the field in utilising their networks to recruit participants through foster carers and professionals known to them, there is no consideration of the ethical implications of this. It is disappointing that all eligible young people were not approached, but due to the lack of previous research on the topic this study still adds substantially to the literature. In fact, the findings of this study highlight the want of young people to be given agency and trust in making decisions for themselves.

This study provides an important focus on an oft under-researched population: young people in foster care.

Implications for practice

This impactful research is an important first step towards recognising and guiding the need for psychotherapy to be tailored to young people in foster care who are already experiencing many challenges. Practical suggestions include:

• Therapists meeting with foster carers and social workers to facilitate “relationship building and information exchange” prior to meeting young people.
• Therapist focus on “recognising, respecting and prioritising young people’s needs” and personal flexibility.
• Therapy itself should be “boundaried and negotiated” and of sufficient length to foster trust. In practice this may mean not offering time-limited therapy options or addressing unrealistic expectations.
• Creating a young person friendly environment with art materials, for example, to promote self-expression and individualism.

This research provides an opportunity for practitioners and researchers to read about the experiences of young people who may otherwise not get the chance to share their experiences of psychotherapy. Young people in foster care may move placements, lack power and opportunity to provide such feedback in clinical settings. This research asks them about what is important to them during psychotherapy and will be a useful benchmark for ensuring future therapies meet the identified needs. The authors suggest future research should consider the views of young people in foster care experiencing psychotherapy alongside the views of their foster parents and therapists.

Therapists should meet with foster carers and social workers prior to meeting young people in foster care.

Statement of interests

None.

Links

Primary paper

Gilmartin D, McElvaney R & Corbally M (2022) “Talk to me like I’m a human” An interpretative phenomenological analysis of the psychotherapy experiences of young people in foster care in Ireland. Counselling Psychology Quarterly.

Other references

Gharabaghi K, Charles G & Kavanagh H (2016) Alternative care strategy – International services project. Toronto, Canada: Ryerson University.

Norcross J & Cooper M. (2021) Personalizing psychotherapy: Assessing and accommodating patient preferences. Washington: American Psychological Association.

Scozzaro C & Janikowski T (2015) Mental health diagnosis, medication, treatment and placement milieu of children in foster care. Journal of Child and Family Studies, 24(9), 2560–2567.

Smith J, Larkin M & Flowers P (2009) Interpretative phenomenological analysis: Theory, method and research. London: SAGE.

Trickett PK, Negriff S, Ji J & Peckins M (2011) Child maltreatment and adolescent development. Journal of Research on Adolescence, 21(1), 3–20.

Tusla (2020). Quarterly service performance and activity report quarter 4 2019. Tusla Child and Family Agency. Retrieved April 19th 2022.

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