oa Editorial

The Annual Meeting of the American Society for Adolescent Psychiatry (ASAP) took place in New York, March 26-27. 2011. This issue contains three articles based on presentations at the meeting. The theme of the meeting was “From 9/11 to 2011-a Ten Year Update on Adolescent Psychiatry.” Two of the presenters-Craig Katz and Cynthia Pfeffer-both psychiatrists-were in New York City at the time of the terrorist attacks on the World Trade Centers on September 11, 2001, and afterwards worked to organize and deliver mental health care to people affected by the disaster. As Dr. Pfeffer points out in her paper on children and adolescents who experience disasters (see page 197), 9/11 was a turning point in American history in many ways. Much was learned afterwards about the needs of populations exposed to disasters. The extensive media coverage of the 9/11 disaster meant that many children far from the site of the attacks-even those as far away as Seattle-experienced symptoms of traumatic stress. Dr. Katz describes the efforts that were made to set up emergency psychiatric services in various locations in New York City using volunteer psychiatrists and other mental health professionals to staff them. In his article on disaster psychiatry (see page 187) he discusses elements of an effective mental health system for disaster work and concludes that an optimal system would attend to a population's mental health needs pre-disaster in addition to providing much needed services post- disaster. The challenges are enormous and the resources inadequate. Ten years after 9/11, a residual group, including many who were first responders, still suffer with aftereffects of the disaster, both in terms of posttraumatic stress disorder and impaired functioning. Subsequent disasters, such as Hurricane Katrina, proved to be just as devastating in terms of both immediate and long term effects. The oil spill in the Gulf of Mexico, in which loss of life and injuries were confined to the oil rig that exploded, has had a major impact on the mental health of residents of the coastal areas affected by the spill, by its consequent economic disruption and the destructive effects on the environment that these people call home. Alan Ravitz, a child and adolescent psychiatrist who has done over 500 custody evaluations, also presented at the ASAP meeting. Here he draws on his extensive knowledge of the research literature on the effects of divorce and distills his vast clinical experience in working with families and children in the context who are involved in “high conflict” divorces (see page 204). While high levels of parental conflict are common at the time of separation, litigation, and the issuance of the final divorce decree, only in 20 to 30% of divorces does a high level of conflict continue and become chronic. The effects can be devastating for children and adolescents. Based on his experience both as a forensic evaluator in over 500 cases of contested custody, and as a therapist for divorcing families and their children, Dr. Ravitz offers suggestions for working with adolescents whose parents are involved in high conflict divorce. Writing on the gap between research findings and clinical practice, Elizabeth Sburlati and colleagues from Australia assert that evidence is growing that insufficient training is offered to therapists in clinical practice to equip them to effectively implement evidence based treatments (EBTs) for youth psychiatric disorders (see page 210). This is a serious charge but in my experience has certainly been validated when I've tried, for example, to find a therapist to do cognitive behavior therapy with a youngster with obsessive-compulsive disorder. Training programs in psychiatry are now mandated to teach a variety of EBTs (although how uniformly this requirement is being implemented is unclear), but what about practitioners who completed their training before these mandates went into effect? Furthermore, there is no requirement that therapist competency in delivering EBTs be assessed. In a recent review Weerasekera and colleagues stated (2010, p. 10): “Although competence and proficiency are emphasized as outcomes of training, and despite the availability of objective, evidence-based methods to assess competence, use of these methods has not been required… Historically, training residents in psychotherapy has depended largely on process notes, with residents graduating without ever having been observed conducting psychotherapy. One wonders how comfortable we would be undergoing a surgical procedure with a surgeon trained in a similar manner!” The practice of evidence based psychiatry does not mean that the therapeutic relationship can be ignored—there can be no psychotherapy without a therapeutic relationship. An American Psychological Association Task Force recently made the following points (2011): • The therapy relationship makes substantial and consistent contributions to psychotherapy outcome independent of the specific type of treatment. • The therapy relationship accounts for why clients improve (or fail to improve) at least as much as the particular treatment method. • Practice and treatment guidelines should explicitly address therapist behaviors and qualities that promote a facilitative therapy relationship. • Efforts to promulgate best practices or evidence-based practices (EBPs) without including the relationship are seriously incomplete and potentially misleading. • Adapting or tailoring the therapy relationship to specific patient characteristics (in addition to diagnosis) enhances the effectiveness of treatment. • The therapy relationship acts in concert with treatment methods, patient characteristics, and practitioner qualities in determining effectiveness; a comprehensive understanding of effective (and ineffective) psychotherapy will consider all of these determinants and their optimal combinations. Three articles by practitioners who reflect on their work address the issue of the therapist-patient relationship. All three describe how to get through to adolescents who are challenging at best. The authors of all three articles have definitely earned their stripes and know what they are talking about. Perry Bach has spent his career in the public sector and worked in mental health systems in California and Colorado. He describes his approach to the initial interview with adolescents who often have been through the system for years and have no interest in seeing yet another psychiatrist whom they assume will ask them more meaningless questions. By understanding the adolescent's point of view, and imagining what he or she is probably thinking during the interview, the interviewer is able to convey a genuine appreciation for the young person's need for autonomy and is careful to respect the adolescents point of view (see page 214). Glen Pearson, who worked in a state hospital, a private hospital, and is now in outpatient psychotherapy practice, all in Texas, draws on his experience to describe how active involvement on the part of the therapist in the adolescent patient's life is necessary to promote therapeutic change (see page 218). Finally, Thomas Bratter, the head of a residential school in Massachusetts for gifted but dysfunctional adolescents, explains his “compassionate confrontation” approach to convincing students at the school to turn their lives around (see page 227). All of these therapists are following in a long tradition in adolescent psychiatry, which early on recognized that a more active approach than that usually taken with adults was necessary to engage adolescents in the treatment process.....