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Kongerslev, Mickey Toftkjær

Storebø, Ole Jakob

 89 
 
Scandinavian Journal of Child and Adolescent Psychiatry and Psychology 
Vol. 5(3):89-91 (2017) DOI 10.21307/sjcapp-2017-013 
 
 
Editorial                          Open Access 
 
 
 
 
Towards preference-based and person-centered child and 
adolescent psychiatric service provision 
 
Mickey Toftkjær Kongerslev & Ole Jakob Storebø 
 
 
 
 
Perceptions of high quality service provision in child 
and adolescent mental health are changing. A recent 
editorial in the British Medical Journal (BMJ) called for 
high integrity health care (1) through challenging 
conventional assumptions regarding service 
provision, arguing that: (i) more services will not 
necessarily result in more health, (ii) evidence alone 
should not determine treatment, and (iii) optimal 
health care must include non-health professionals 
(1). As a response, Wolpert and colleagues (2), in an 
intriguing paper published earlier this year in BMJ, 
extended this line of non-conventional thinking 
about improvements of service provision to the field 
of mental health services for children and 
adolescents more specifically. In brief, they argue 
that our field should change from being led by 
professionals who focus primarily on problems (or 
diagnoses) towards person-centered care focused on 
progress and service user preferences.  
Whilst we are sympathetic towards the evidence 
and arguments supporting this “new way” of 
thinking (or re-thinking) about child and adolescent 
mental health care services, we also would stress that 
though it might be non-conventional to the extent 
that it runs contrary to current traditional thinking 
about service provision, it is not entirely new. Indeed, 
many of these ideas are also more or less explicitly 
contained within the World Psychiatric Association’s 
Institutional Program on Psychiatry for the Person 
(also called Person-Centered Psychiatry) (3-4), the 
American Psychological Association’s program on 
Evidence-Based Practice in Psychology (5), 
Evidence-Based Medicine (6), as well as in recovery, 
empowerment and resilience focused movements (7-
8).  
Overall, we believe that a change of the provision 
of child and adolescent mental health care services 
towards a more person-centered and preference-
based model is indicated. That said, ideas and 
movements, be they unconventional or ahead of 
their time, are also always a product of the time and 
context in which they evolved and were formulated. 
Historically, the freedom of the individual combined 
with disbelief in institutionalized sanctioned 
authority has been steadfastly growing at least from 
medieval times and onwards (9-10). More recently, 
the fall of the Nazi regime in World War II spurred 
widespread research on the authoritarian personality 
and also ignited even more widespread disbelief in 
authority (11-12). In general, historically we seem to 
have moved towards more and more disbelief in 
institutionalized authority and focusing more and 
more on the individual and his/her own 
choices/preferences.  
Perhaps somewhat ironically, despite this general 
trend towards heightened individualism and disbelief 
in socially sanctioned authority, many of us, including 
politicians and decision makers, have remained 
committed to an evidence-based paradigm for 
service delivery and development. No doubt, we 
agree that service delivery and developments within 
our field ought to be evidence-based. Yet, the fact 
remains that the available evidence (for example 
Cochrane reviews and NICE guidelines) to guide 
service provisions and interventions in child and 
adolescent psychiatry and psychology remains scarce, 
leaving little actual evidence to guide clinical practice 
and service developments (2, 13). As Wolpert and 
colleagues emphasize, “Supporting shared decision 
making is imperative when the best approach is 
uncertain or untested, as is the case for much of child 
mental health input” (2).  
Currently, much of child and adolescent psychiatry 
is dominated by biological psychiatry. However, 
before the rise of biological psychiatry, attachment 
and family factors were viewed as the most important 
components in the theoretical foundations of child 
and adolescent psychiatry. Biological psychiatry is 
common in Scandinavia, but the focus on 
psychological processes (or the child behind the 
 90 
 
diagnosis) is returning (14). In our region of 
Denmark, for example, the whole department of 
child and adolescent psychiatry has decided that 
mentalization-based theory (15-18) is the common 
frame of reference across all clinics, providing them 
with a shared theory, language, and generic model for 
approaching the children and families under their 
care. Mentalizing is a social cognitive construct 
referring to the very core human capacity of being 
able and inclined to interpret and understand one’s 
own and others’ minds (19). To quote the founders 
of mentalization-based treatment (MBT), Bateman 
and Fonagy, mentalizing can be defined as “our 
ability to attend to mental states in ourselves and in 
others as we attempt to understand our own actions 
and those of others on the basis of intentional mental 
states” (p. xv) (20).  
Shared decision making is important because it 
allows for the children and adolescents to become 
more involved in their own treatment, for example 
through negotiating choice of treatment and its goals. 
Couched in the language of psychotherapy research, 
we could say that preference-based service and 
shared decision making most probably allow for a 
better treatment or working alliance, which has been 
found to be a very robust and global predictor of 
psychotherapy outcomes (21-23). Of course, shared 
decision making is by no means an easy task, not only 
due to the developmental age and cognitive 
capacities of the children accessing our services, but 
also because it requires clinicians to change their 
general approach to meeting their patients. To help 
the children and young people in making choices 
regarding their treatment, various web-based 
resources and apps have recently been developed (2). 
However, when it comes to actual clinical practice 
and negotiating shared decision-making, most of it 
will first and foremost rely on the clinician’s ability to 
mentalize – to mind and keep in mind the mind or 
subjectivity of the child and their parents. As we see 
it, one of the biggest threats to implementation of 
shared decision-making and a mentalizing approach 
is the traditional and conservative expert role of the 
clinicians. Of course, clinicians have experience and 
a privileged insight into the available evidence. 
Nevertheless, whether or not there may be good 
evidence for various treatment choices, clinicians 
need to engage in shared decision-making, and take a 
humble and curious stance (a mentalizing stance) 
when dealing with the patients and families, always 
keeping the whole person in mind (17).  
Challenging as it may be for clinicians to relinquish 
some of their authority ― or perhaps more 
accurately, to share some of the responsibility for 
treatment choice and goals with their patients ― we 
would conjecture that it will have the favorable 
outcome of enhancing treatment alliance and 
adherence through stimulating agency (sense of 
subjectivity and self-efficacy) on behalf of the 
children and adolescents. Seeing the person behind 
the problem or diagnosis is much more than a slogan. 
Basically, it means meeting our patients as persons, 
recognizing their subjectivity and affirming it in every 
stage of treatment. This again rests first and foremost 
on the clinician’s ability to mentalize, and keep on 
mentalizing even amidst emotional turmoil, in times 
of crisis or when the children and their caregivers 
appear dismissive. Children and young people 
presenting to psychiatric services, more often than 
not, have had their mind undermined through 
various forms of developmental trauma and neglect, 
including negative experiences in various contexts 
(e.g. schools) and in their peer groups (24). Hence, 
they are often not used to being mentalized by other 
minds, nor have they had many positive experiences 
with being so. Still the clinician must adopt a 
mentalizing stance from the outset, and stimulate the 
mentalizing capacities of the child and their family 
throughout the entire treatment process and in the 
shared decision-making.  
To conclude, we wish to note that a shift towards 
preference-based and person-centered treatment in 
child and adolescent psychiatry can be seen as 
bringing the “psyche” back into our field (25). 
Though there certainly is a place for biological 
research and treatment in child and adolescent 
psychiatry together with evidence-based practice, in 
the “real world” of the clinics we do not primarily 
deal with brains, abstract cases or diagnoses, but 
rather try to mentalize and help real persons based 
on their experience of their own life, health, 
problems and situations.  
 
 
References 
 
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purpose. BMJ 2015;351:h4448. 
 
2. Wolpert M, Vostanis P, Martin K, Munk S, Norman R, Fonagy P, et 
al. High integrity mental health services for children: Focusing on 
the person, not the problem. BMJ 2017:j1500. 
 
3. Mezzich JE. Psychiatry for the person: Articulating medicine’s 
science and humanism. World Psychiatry 2007;6:65-7. 
 
4. Botol M, Bertelli MO, Salvador-Carulla L, Anagnostopoulos D, 
Appleyard J. Child and adolescent psychiatry. In: Mezzich J, Botbol 
M, Christodoulou GN, Cloninger CR, Salloum IM (Eds.). Person 
Centered Psychiatry. Switzerland: Springer; 2016. p. 445-58. 
 
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5. APA Presidential Task Force on Evidence-Based Practice. 
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85. 
 
6. Storebø OJ, Simonsen E. Evidensbaseret behandling, de generelle 
behandlingsprincipper og gode råd [Evidence-based treatment, the 
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Mathiesen BB (Eds.) Personlighed og personlighedsforstyrrelser. En 
grundbog [Personality and Personality Disorders. Textbook]. 
Copenhagen: Hans Reitzels Forlag, 2017. p. 397-433.  
 
7. Anthony WA. Recovery from mental illness: The guiding vision of 
mental health service system in the 1990s. Psychosoc Rehab J 
1993;16:11-23. 
 
8. Ungar M, Ghazinour M, Richter J. Annual research review: What is 
resilience within the social ecology of human development? J Child 
Psychol Psychiatry 2013;54:348-66. 
 
9. Durkheim E. The division of labour in society. New York: The Free 
Press; 1893. 
 
10. Katzenelson B. Homo socius: Grundlaget for menneskeligt 
samkvem [Homo socius: the foundation of human communion]. 
Copenhagen: Gyldendal; 1999.  
 
11. Adorno TW, Frenkel-Brunswik E, Levinson DJ, Sanford RN. The 
authoritarian personality. New York: Harper & Row; 1950. 
 
12. Milgram S. Obedience to authority: An experimental view: New 
York: Harper Perennial; 1974. 
 
13. Storebø OJ. Evidence-based treatment in the field of child and 
adolescent psychiatry. Scand J Child Adolesc Psychiatr Psychol 
2015;3:97-8. 
 
14. Storebø OJ, Darling Rasmussen P, Bölte S. There is no such thing 
as a child. Scand J Child Adolesc Psychiatr Psychol 2014;2:93-4. 
 
15. Bateman A, Fonagy P. Mentalization-based treatment for 
personality disorders: A practical guide. Oxford: Oxford University 
Press; 2016. 
 
16. Bo S, Sharp C, Fonagy P, Kongerslev M. Hypermentalizing, 
attachment, and epistemic trust in adolescent BPD: Clinical 
illustrations. Personal Disord 2017;8:172-82. 
 
17. Bo S, Kongerslev MT, Larsen KA, Bateman A. 
Mentaliseringsbaseret behandling af borderline 
personlighedsforstyrrelse [Mentalization-Based Treatment of 
Borderline Personality Disorder]. In: Simonsen E, Mathiesen BB 
(Eds.). Personlighed og personlighedsforstyrrelser. En grundbog 
[Personality and Personality Disorders. Textbook]. Copenhagen: 
Hans Reitzels Forlag; 2017. p. 435-72.   
 
18. Bevington D, Fuggle P, Fonagy P. Applying attachment theory to 
effective practice with hard-to-reach youth: The AMBIT approach. 
Attach Hum Dev 2015;17:157-74. 
 
19. Kongerslev M, Simonsen S, Bo S. The quest for tailored treatments: 
A meta-discussion of six social cognitive therapies. J Clin Psychol 
2015;71:188-98. 
 
20. Bateman AW, Fonagy P. Preface. In: Bateman AW, Fonagy P (Eds.). 
Handbook of mentalizing in mental health practice. Arlington, VA: 
American Psychiatric Publishing, Inc.; 2012. p. xv-xxi. 
 
21. Kongerslev MT, Chanen AM, Simonsen E. Personality disorder in 
childhood and adolescence comes of age: A review of the current 
evidence and prospects for future research. Scand J Child Adolesc 
Psychiatr Psychol 2015;3:31-48. 
 
22. Simonsen E, Kongerslev M. Millon’s contributions to the 
international society for the study of personality disorders (ISSPD). 
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23. Shirk SR, Karver M. Alliance in child and adolescent psychotherapy. 
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Towards preference-based and person-centered child and adolescent psychiatric service provision

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