**Working on Adolescent's Motivation to Improve the Outcome Within a Multimodal Treatment**

Gatta Michela, Testa C. Paolo, Del Col Lara, Spoto Andrea, Dal Zotto Lara, De Sauma Maxim and Battistella Pier Antonio

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/52299

### **1. Introduction**

What is motivation? From a psychological point of view it is a force, of psychic nature, which makes the individual show certain behaviour. Freud said that each behaviour, also the most strange, always responds to a motivation and the motivation's meaning is often unknown not only by people in contact with the subject but also by the subject himself. If we wanted to contextualise motivation within the alliance relationship, we could consider the last one as an interaction between two poles: one is the therapist the other is the patient, each with his own intrapersonal and interpersonal features, in a specific space defined by the setting, motivation is one of the intrapersonal patient's characteristics. Therapeutic alliance is a strong predictor of outcome in individual psychotherapy across diverse treatment orientations and modalities both with adult patients [14], [26] and adolescents [10], [13]. Patient's motivation, within the working alliance, during therapeutic intervention has been much studied [21], [7], [15], [30], [24], [25], [29], whereas the motivation associated with the diagnostic moment has been given less importance in scientific literature [22], [17]. Close to the theory there is clinical experience related to the centre we work in. Longitudinal studies about adolescents' therapeutic compli‐ ance and clinical evolution done within our Services [9], [10], [11] showed most of adolescents did not follow therapeutic suggestion about undergoing psychotherapy after the diagnostic process. Compliant and not compliant adolescents were different because of motivation expressed during the diagnostic process: the most of motivated adolescents started therapy, whereas the most of unmotivated adolescents did not. The clinical evolution resulted in association with adolescents' motivation as well: after six months a clinical improvement was statistically more frequent among motivated than among unmotivated adolescents.

© 2013 Michela et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

These results and other ones from literature, evidencing that an early alliance has been found to be a better predictor of outcome than alliance averaged across sessions or measured in the middle or late phase of treatment [26], [12], stimulated us to think of and to evaluate, during clinical practice, some strategies to favour adolescent's motivation to follow therapeutic suggestion given at the end of the diagnostic process. For this reason we think of a diagnostic protocol which considers, with psychiatric diagnosis (ICD 10) and clinical evaluation (psy‐ chopathological investigation), to pay particular attention to motivational aspects. To do that we referred to the experience of interviewing used at the Brent Centre of Young People of London.

preparation, undertakings" because it can allow the adolescent and his parents to understand better the meaning of further treatment. It is stressed the importance of making the adolescent an active part of the process and of involving him in it. For example the interviewer can use the explanation to make easier the understanding and to involve more the adolescent; the adolescent is made aware of the interviewer's concerns and of severity and implications of his problems in his present and future life. On the other hand the interviewer has to guide the intervention. Any reaction is "within the strict limits set by our specific role" [19] and it is important to avoid collusion, carefully not trying to take sides and allocate blame [18]. It's also part of the process setting up the framework of further treatment, if it's necessary. It means helping the adolescent and the family in understanding the meaning of the therapy but also

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The study involved patients attending the Daily Service for Adolescents at the Neuropsychi‐ atric Unit for Children and Adolescents in Padua. The main purposes of this service are the care and rehabilitation of adolescents with severe psychopathological disorders (mood disorders, psychotic disorders, antisocial behavior and personality disorders), particularly optimizing their welfare and providing intervention for these young patients through an integrated clinical and pedagogical approach. Various professional figures cooperate on the therapeutic project and this multi-professional team includes a child and adolescent neuro‐ psychiatrist, a psychologist, two educators and a social worker. Adolescents attending the center undergo an initial diagnostic process, leading to a psychiatric diagnosis formulated according to the ICD 10 [33] and the therapeutic project involves attending a day center.

The centre receives adolescents (males and females from 12 to 18 years of age) with various types of psychiatric and behavioral disorder of moderate to severe degree: it has a capacity to treat approximately 25 patients in all and can simultaneously accommodate up to six adoles‐

The adolescents attend from Monday to Friday from 09.00 to 17.00. Access to the structure is based on individual projects prepared by the team, which establishes the number of weekly visits and their duration. The educators can also implement tailored and/or home-based interventions in situations where an adolescent suffers from significant social isolation, and in acute cases requiring temporary hospital stays, acting as companions and providing support while the patient is in hospital. Patients can also be received in emergency situations (moments of acute crisis, or when a "buffer intervention" is needed while a patient is waiting to join a residential community). These latter interventions do not follow the normal enrolment

**•** to optimize the patient care and education measures for adolescents in situations of

talking together about practical problems [17].

**1.1. The semi-residential adolescent psychopathology service**

cents, with the ratio of one operator to every two patients.

particular mental illness and at particularly crucial times;

**•** to support the families in their educational role;

protocol.

The general goals of the service are:

Looking at the literature we can deduce that the word "interviewing" has been introduced quite recently. Few authors discussed this process (interviewing) itself. The idea of "Inter‐ viewing" with adolescents at the Brent Centre comes from the belief held by M. Laufer that most adolescents were not able to engage in and make use of long term psychoanalytic psychotherapy without some preparatory work, as theorized by Freud (the development of the "observing Ego"). The word "assessment" wasn't used because it reminded to a psychiatric meaning. When the Centre was founded adolescents could come and "walk-in" for any reason. According to the presenting problem, the clinician provided the connection with the general practitioner (GP), the lawyer or the social worker. The aim was to focus on vulnerable adolescents to work on the accessibility, the potentiality for making therapeutic connections. It was considered to work on a long term base and to involve only trained analysts because it takes time and experience to modify the defenses. The results of the first researches showed that the Centre was working with severe neurotic patients and it was considered extremely important to engage the adolescents in order to offer a preventive help. P. Wilson [32] linked intervention in adolescence to the developmental model conceptualized by Laufer and stressed the importance of making an assessment before starting any kind of intervention: " Whatever the extent of intervention, it should be based on an assessment of his feelings about himself, his body and relation to his parents, and designed to contribute towards facilitating progres‐ sive movement and so serve to prevent breakdown and the possibility of mental ill-health in adulthood". From his words, it's possible to consider the interviewing as the preliminary work with the adolescent in which there is an assessment about his way of coping with the adoles‐ cence tasks. In 'Adolescence and developmental breakdown' [17] it is again stressed that the application of the developmental model to the assessment of psychopathology in adolescence is fundamental to make further decisions about management and treatment of the adolescent. The word "interviewing" appears in the paper written by C. Bronstein and S. Flanders in 1998 [4]. In it, the emphasis is put to another meaning of this process, linked to psychotherapy. The process that develops in this first contact with the adolescents we call *interviewing*, though it could also be described as *psychotherapeutic consultation*. It is stressed that a mere assessment followed by therapy can't give the adolescent the possibility to understand what therapy means, leading to a further drop out. It means that the aims of interviewing are both to assess the extent and the nature of the patient's disease and to give the adolescent the possibility to express his feelings and fears, to come into touch with anxiety, to make the "unknown" less frightening. Another aim of the interviewing process could be to set up the framework for further treatment, if this is considered necessary. It means dealing with "plans, arrangements, preparation, undertakings" because it can allow the adolescent and his parents to understand better the meaning of further treatment. It is stressed the importance of making the adolescent an active part of the process and of involving him in it. For example the interviewer can use the explanation to make easier the understanding and to involve more the adolescent; the adolescent is made aware of the interviewer's concerns and of severity and implications of his problems in his present and future life. On the other hand the interviewer has to guide the intervention. Any reaction is "within the strict limits set by our specific role" [19] and it is important to avoid collusion, carefully not trying to take sides and allocate blame [18]. It's also part of the process setting up the framework of further treatment, if it's necessary. It means helping the adolescent and the family in understanding the meaning of the therapy but also talking together about practical problems [17].

### **1.1. The semi-residential adolescent psychopathology service**

These results and other ones from literature, evidencing that an early alliance has been found to be a better predictor of outcome than alliance averaged across sessions or measured in the middle or late phase of treatment [26], [12], stimulated us to think of and to evaluate, during clinical practice, some strategies to favour adolescent's motivation to follow therapeutic suggestion given at the end of the diagnostic process. For this reason we think of a diagnostic protocol which considers, with psychiatric diagnosis (ICD 10) and clinical evaluation (psy‐ chopathological investigation), to pay particular attention to motivational aspects. To do that we referred to the experience of interviewing used at the Brent Centre of Young People of

Looking at the literature we can deduce that the word "interviewing" has been introduced quite recently. Few authors discussed this process (interviewing) itself. The idea of "Inter‐ viewing" with adolescents at the Brent Centre comes from the belief held by M. Laufer that most adolescents were not able to engage in and make use of long term psychoanalytic psychotherapy without some preparatory work, as theorized by Freud (the development of the "observing Ego"). The word "assessment" wasn't used because it reminded to a psychiatric meaning. When the Centre was founded adolescents could come and "walk-in" for any reason. According to the presenting problem, the clinician provided the connection with the general practitioner (GP), the lawyer or the social worker. The aim was to focus on vulnerable adolescents to work on the accessibility, the potentiality for making therapeutic connections. It was considered to work on a long term base and to involve only trained analysts because it takes time and experience to modify the defenses. The results of the first researches showed that the Centre was working with severe neurotic patients and it was considered extremely important to engage the adolescents in order to offer a preventive help. P. Wilson [32] linked intervention in adolescence to the developmental model conceptualized by Laufer and stressed the importance of making an assessment before starting any kind of intervention: " Whatever the extent of intervention, it should be based on an assessment of his feelings about himself, his body and relation to his parents, and designed to contribute towards facilitating progres‐ sive movement and so serve to prevent breakdown and the possibility of mental ill-health in adulthood". From his words, it's possible to consider the interviewing as the preliminary work with the adolescent in which there is an assessment about his way of coping with the adoles‐ cence tasks. In 'Adolescence and developmental breakdown' [17] it is again stressed that the application of the developmental model to the assessment of psychopathology in adolescence is fundamental to make further decisions about management and treatment of the adolescent. The word "interviewing" appears in the paper written by C. Bronstein and S. Flanders in 1998 [4]. In it, the emphasis is put to another meaning of this process, linked to psychotherapy. The process that develops in this first contact with the adolescents we call *interviewing*, though it could also be described as *psychotherapeutic consultation*. It is stressed that a mere assessment followed by therapy can't give the adolescent the possibility to understand what therapy means, leading to a further drop out. It means that the aims of interviewing are both to assess the extent and the nature of the patient's disease and to give the adolescent the possibility to express his feelings and fears, to come into touch with anxiety, to make the "unknown" less frightening. Another aim of the interviewing process could be to set up the framework for further treatment, if this is considered necessary. It means dealing with "plans, arrangements,

London.

232 Mental Disorders - Theoretical and Empirical Perspectives

The study involved patients attending the Daily Service for Adolescents at the Neuropsychi‐ atric Unit for Children and Adolescents in Padua. The main purposes of this service are the care and rehabilitation of adolescents with severe psychopathological disorders (mood disorders, psychotic disorders, antisocial behavior and personality disorders), particularly optimizing their welfare and providing intervention for these young patients through an integrated clinical and pedagogical approach. Various professional figures cooperate on the therapeutic project and this multi-professional team includes a child and adolescent neuro‐ psychiatrist, a psychologist, two educators and a social worker. Adolescents attending the center undergo an initial diagnostic process, leading to a psychiatric diagnosis formulated according to the ICD 10 [33] and the therapeutic project involves attending a day center.

The centre receives adolescents (males and females from 12 to 18 years of age) with various types of psychiatric and behavioral disorder of moderate to severe degree: it has a capacity to treat approximately 25 patients in all and can simultaneously accommodate up to six adoles‐ cents, with the ratio of one operator to every two patients.

The adolescents attend from Monday to Friday from 09.00 to 17.00. Access to the structure is based on individual projects prepared by the team, which establishes the number of weekly visits and their duration. The educators can also implement tailored and/or home-based interventions in situations where an adolescent suffers from significant social isolation, and in acute cases requiring temporary hospital stays, acting as companions and providing support while the patient is in hospital. Patients can also be received in emergency situations (moments of acute crisis, or when a "buffer intervention" is needed while a patient is waiting to join a residential community). These latter interventions do not follow the normal enrolment protocol.

The general goals of the service are:


**•** to construct an integrated clinical and pedagogical project with the various services on different levels and with different institutional roles;

**•** the second meeting is when an observation file is completed (a semistructured inter‐ view) by a "third party" educator, i.e. an educator who has had the least to do with the adolescent so far, in order to guarantee the utmost neutrality in the administering the assessment tool. Then activities are proposed in small groups to see how the adolescent

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**•** at the third meeting activities are proposed on the basis of the adolescent's interests

**•** the fourth and last meeting is where, in addition to the activities already begun at the third meeting, there is also space for a conversation and exchange of ideas with the adolescent, to provide feedback relating to the previous meetings, the adolescent's mode of participation and greater or lesser willingness to enroll at the semi-residential

**5.** The reference educator completes an initial observation file on the trend of the four

**6.** The team assesses the observation period within two weeks after its completion and decides whether to recommend that the adolescent continue with the semi-residential

**7.** The patient and family are informed about the child's progress so far and there is an exchange of ideas relating to the adolescent's and the family's experiences and motiva‐ tions. If all concerned agree to the semi-residential program, this decision is shared and signed jointly by the family and by the physician referring the case to the team, and these parties agree on a first integrated, tailored therapeutic and educational project, and an

*1.3.1. Formulation of the tailored educational project and schedule of attendance at the semi-residential*

This phase is completed by the working team and the object is to prepare a first project in the light of the findings during the preliminary observation period. A record is made of patients' and their families' demographic details, the motives for enrolment on the program, the internal and external activities conducted, the established goals, the general and specific objectives of the course of therapy, a description of the integrated intervention designed for each adolescent

Access is always formulated on the basis of a tailored individual project and the adolescent's weekly attendance is constantly monitored. Punctuality and adherence to the agreed frequen‐ cy of attendance is an important tool for assessing the adolescents' and their families' compli‐ ance with the agreed educational project, as well as being a necessary premise for implementing the semi-residential program. For each patient, a schedule is agreed with the family, the specialist and the adolescent concerned, starting from a minimum of two attend‐

initial schedule for the adolescent's attendance at the center.

of and the timing for assessing their progress and the project.

functions in group situations;

center.

meetings.

*center*

experience or terminate it.

**1.3. The path for taking the patient into care**

ances a week (lasting four hours each).

emerging from the previous interview;

**•** to improve the social involvement of adolescent in their living environment.

### *1.1.1. The multidisciplinary team*

The multidisciplinary team consists of: a developmental neuropsychiatrist responsible for the service, a psychologist-psychotherapist, two educators, a social worker, a coordinator, and an administrative assistant.

There are also trainee psychologists, trainees on the degree course for professional educators at the Faculties of Education Sciences and Psychology, and physicians training in develop‐ mental neuropsychiatry.

The team holds the following meetings:


#### **1.2. Protocol for enrolling new patients at the semi-residential center**

The phase for assessing and enrolling an adolescent at the semi-residential center for adoles‐ cent psychopathologies is completed according to the following protocol.

	- **•** the first meeting is for introductions, observations and free activity (playing, computer, exploring spaces);

### **1.3. The path for taking the patient into care**

**•** to construct an integrated clinical and pedagogical project with the various services on

The multidisciplinary team consists of: a developmental neuropsychiatrist responsible for the service, a psychologist-psychotherapist, two educators, a social worker, a coordinator, and an

There are also trainee psychologists, trainees on the degree course for professional educators at the Faculties of Education Sciences and Psychology, and physicians training in develop‐

**•** a weekly meeting to coordinate their clinical-pedagogical work and program the educa‐

**•** periodical meetings with social-sanitary operators and clinicians to report on the cases being treated in the semi-residential setting to discuss the clinical issues, assess the adolescent's

The phase for assessing and enrolling an adolescent at the semi-residential center for adoles‐

**1.** The case is presented to the team operating at the semi-residential service for adolescent psychopathologies by the psychologist or neuropsychiatrist proposing their enrolment at the Neuropsychiatric Unit for Children and Adolescents and a file is prepared for the

**2.** The case is discussed and, where applicable, a preliminary period of observation and

**3.** A meeting is held with the patient and family to formalize the proposal to start with a preliminary period for the adolescent to get to know the semi-residential service. In addition to patients and their parents, this meeting is also attended by the clinician

**4.** The observation period starts, normally involving four meetings according to the follow‐

**•** the first meeting is for introductions, observations and free activity (playing, computer,

**•** a monthly supervisory team meeting with an outside psychiatrist-psychotherapist.

**•** to improve the social involvement of adolescent in their living environment.

different levels and with different institutional roles;

*1.1.1. The multidisciplinary team*

234 Mental Disorders - Theoretical and Empirical Perspectives

administrative assistant.

mental neuropsychiatry.

tional activities;

The team holds the following meetings:

patient being recommended.

referring them and an educator.

ing schedule:

exploring spaces);

assessment of the adolescent is decided.

**•** a weekly team meeting to discuss the cases;

progress, and recommend new patients for the treatment;

**1.2. Protocol for enrolling new patients at the semi-residential center**

cent psychopathologies is completed according to the following protocol.

### *1.3.1. Formulation of the tailored educational project and schedule of attendance at the semi-residential center*

This phase is completed by the working team and the object is to prepare a first project in the light of the findings during the preliminary observation period. A record is made of patients' and their families' demographic details, the motives for enrolment on the program, the internal and external activities conducted, the established goals, the general and specific objectives of the course of therapy, a description of the integrated intervention designed for each adolescent of and the timing for assessing their progress and the project.

Access is always formulated on the basis of a tailored individual project and the adolescent's weekly attendance is constantly monitored. Punctuality and adherence to the agreed frequen‐ cy of attendance is an important tool for assessing the adolescents' and their families' compli‐ ance with the agreed educational project, as well as being a necessary premise for implementing the semi-residential program. For each patient, a schedule is agreed with the family, the specialist and the adolescent concerned, starting from a minimum of two attend‐ ances a week (lasting four hours each).

### *1.3.2. Periodical clinical interviews and progress monitoring*

For each patient, there are periodical clinical meetings with their own doctors to monitor their psycho-developmental trends and personal response to the therapy. The parental couple is also followed up with regular meetings with a clinician (neuropsychiatrist or psychologist), possibly with the support of an educator.

*1.3.5. Discharge*

The end of the course of therapeutic intervention can be decided by various factors. In the most favorable of outcomes, the project may be concluded because the preset goals have been achieved and the adolescents have regained their social contacts and schooling experience,

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Attendance at the centre may also be interrupted due to poor compliance on the part of the adolescent and/or the family (with repeated and unjustified failures to attend appointments at the semi-residential centre or meetings with clinicians, or inadequate cooperation). The program may also be stopped by the need to include the patient in a residential community. In each case, the conclusion of the project is confirmed during the course of a final meeting attended by all the parties involved (the adolescent, the family, the reference educator, the

The object of the pedagogical activities is to support the adolescents in the course of their development by means of a relationship with the figure of the educator, who serves as an "auxiliary ego" and consequently as a supportive companion. This is achieved by providing a space, which takes practical shape in the rooms at the semi-residential centre, and by designing

In experiences of research applied to different educational settings, various functions have been identified on which the educator's action is concentrated. The educator thus has several

**•** as containment, providing stability and helping the adolescent to manage the dynamics of

The *general educational goals* of the educational process providing the starting point of an

**•** helping the adolescents to gain awareness of their own sentiments, impulses and behavior;

The *activities* in which the psycho-educational process takes shape are designed to achieve the individual objectives of each adolescent's project and rely on fundamental tools, such as providing a setting as a framework in which to enable to the experience of meeting, using the operator's capacity for empathy to create a relationship that can help the adolescent to let their emotional experiences resound inside themselves and thereby increasingly gain control over

**•** helping them to test their abilities in a protected setting and to raise their self-esteem;

and the course of therapy undertaken can be consolidated.

a project that involves customized objectives and timings.

**•** as a mediator between the adolescent and the adult world,

individual educational project tailored to each patient include:

**•** helping them to realistically assess their living environment.

**•** to provide protection in relation to the adolescent's interior conflicts,

**•** to accompany the patient on a path towards a normalizing educational context,

psychologist and the neuropsychiatrist).

**1.4. Pedagogical activities**

functions [23], [28]:

his/her daily life.

This action on the families needs to be supported and empowered to help parents establish a different image of their child from the one they knew before, and make sense of the changes taking place in the child during the period in semi-residential care, as well as providing input on how the parents themselves need to respond to the child on a daily basis. A course of psychotherapy proper for both the adolescents and their parents is often recommended and implemented.

### *1.3.3. Completion of a file for recording changes and reviewing the therapy*

After the first six months of attendance at the semi-residential centre, the educational project is reviewed, and the goals and/or operating methods are expanded and/or diversified, based on a first structured assessment of the adolescent's progress that involves completing and checklist of specific indicators relating to the various areas of intervention (relational, social, autonomy).

#### *1.3.4. Ongoing assessment*

The ongoing assessment of the adolescent's progress is based on various methods:


### *1.3.5. Discharge*

*1.3.2. Periodical clinical interviews and progress monitoring*

*1.3.3. Completion of a file for recording changes and reviewing the therapy*

**•** periodic assessment of files completed by the reference educator,

patient is taken into care and subsequently every six months,

possibly with the support of an educator.

236 Mental Disorders - Theoretical and Empirical Perspectives

implemented.

autonomy).

months).

*1.3.4. Ongoing assessment*

**•** periodic team discussions,

**•** periodic meetings with family,

**•** periodic meetings with teachers,

**•** periodic meetings with reference clinicians,

For each patient, there are periodical clinical meetings with their own doctors to monitor their psycho-developmental trends and personal response to the therapy. The parental couple is also followed up with regular meetings with a clinician (neuropsychiatrist or psychologist),

This action on the families needs to be supported and empowered to help parents establish a different image of their child from the one they knew before, and make sense of the changes taking place in the child during the period in semi-residential care, as well as providing input on how the parents themselves need to respond to the child on a daily basis. A course of psychotherapy proper for both the adolescents and their parents is often recommended and

After the first six months of attendance at the semi-residential centre, the educational project is reviewed, and the goals and/or operating methods are expanded and/or diversified, based on a first structured assessment of the adolescent's progress that involves completing and checklist of specific indicators relating to the various areas of intervention (relational, social,

The ongoing assessment of the adolescent's progress is based on various methods:

**•** observation/assessment charts recorded before and after laboratory activities,

**•** the periodic administration of standardized tests (YSR 11-18) [1] at the baseline, when the

**•** the periodic completion by the team of the Global Assessment of Functioning test [31] (at the time of compiling the therapeutic and educational project and subsequently every six

**•** This assessment and constant monitoring procedure enables the ongoing adjustment of the objectives of the integrated individual projects, which is normally done every 3-6 months. The tests can also be used as a tool for pre-and post-assessment of the effects of the inter‐

vention at the start and end of a specific laboratory activity to evaluate it efficacy.

The end of the course of therapeutic intervention can be decided by various factors. In the most favorable of outcomes, the project may be concluded because the preset goals have been achieved and the adolescents have regained their social contacts and schooling experience, and the course of therapy undertaken can be consolidated.

Attendance at the centre may also be interrupted due to poor compliance on the part of the adolescent and/or the family (with repeated and unjustified failures to attend appointments at the semi-residential centre or meetings with clinicians, or inadequate cooperation). The program may also be stopped by the need to include the patient in a residential community. In each case, the conclusion of the project is confirmed during the course of a final meeting attended by all the parties involved (the adolescent, the family, the reference educator, the psychologist and the neuropsychiatrist).

#### **1.4. Pedagogical activities**

The object of the pedagogical activities is to support the adolescents in the course of their development by means of a relationship with the figure of the educator, who serves as an "auxiliary ego" and consequently as a supportive companion. This is achieved by providing a space, which takes practical shape in the rooms at the semi-residential centre, and by designing a project that involves customized objectives and timings.

In experiences of research applied to different educational settings, various functions have been identified on which the educator's action is concentrated. The educator thus has several functions [23], [28]:


The *general educational goals* of the educational process providing the starting point of an individual educational project tailored to each patient include:


The *activities* in which the psycho-educational process takes shape are designed to achieve the individual objectives of each adolescent's project and rely on fundamental tools, such as providing a setting as a framework in which to enable to the experience of meeting, using the operator's capacity for empathy to create a relationship that can help the adolescent to let their emotional experiences resound inside themselves and thereby increasingly gain control over them, promoting organized behavior patterns, abilities and motivations that can pave the way to satisfactory social relations and an adequate performance in the completion of tasks and the achievement of goals. During their attendance at the center, the adolescents conduct activities designed to develop their personal interests, acquire skills and reinforce their self-esteem. Outings, the preparation of a newspaper, painting, watching films, playing, writing, and dramatizations are activities conducted at the center, individually and in small groups, in the constant presence of the educators. There are also structured laboratories involving pet therapy, horse therapy, art therapy and naturalistic experiences at teaching farms organized in cooperation with other associations, as well as participation in therapeutic winter and summer holiday camps. For many young people, these activities are the only opportunities they have to put themselves to the test away from their usual living environments, to measure themselves against an adventure outside the home, and thereby testing their capacity to manage on their own, to experiment with detachment from the family, to live in groups and share the group's behavioral rules.

indication. This difference with respect to usual diagnostic protocol (where the diagnostic communication and therapeutic suggestion formed the last meeting with the adolescent) was set up with the aim of giving information about semiresidential treatment (what it is, how it works, what it is useful for) (1) and raising adolescent's questions, doubts, fanta‐ sies and anxieties about therapy and to talk about them with the specialist (2); the hypoth‐ esis was that giving voice to these issues and receiving information could be useful to create

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Adolescent's motivation was evaluated at the beginning and at the end of the diagnostic

Recognising and admitting an uneasy state is the first step to deal with it. Being preoccupied with it means to be in touch with anxiety caused by one's own condition and to hinge on this to desire to change. Having the capacity to self observe and describe means to be in touch with

An anamnesis schedule collecting data about adolescent's identification, his/her family,

The psychiatric diagnosis was formulated using ICD 10 [33]. Additionally, we grouped subjects into three categories according to the severity of the psychopathology and pathologic personality organisation as described by Kernberg [16]. Neurotic personality organization is characterized by psychostructural conditions that include: 1) intact reality testing, 2) a consistent sense of self and of other people, and 3) generally rely on mature defense mecha‐ nisms when stressed. At the opposite end of the personality organization dimension are severely disorganized personalities, the Psychotic one which is characterized by: 1) severely compromised reality testing, 2) an inconsistent sense of self and others, and 3) utilize immature defenses. Along the middle of this dimension are personalities organized at the borderline level: 1) the syndrome of identity diffusion, 2) the predominance of primitive defensive

Data about patient's therapeutic compliance and clinical evolution were collected during a visit of control after nine months by the last diagnostic session. They are based on both what was referred by the patient about subjective perception of health state and on what the specialist verified about psychosocial functioning changes in a nine months period. Clinical evolution was evaluated throughout the Global Assessment Functioning Scale (GAF) [31], which was filled in before and nine months after the beginning of the semiresidential inter‐ vention. The GAF is a scale used by the operators to rate a patient's psychosocial functioning and activities, regardless of the nature of their psychiatric disease. It corresponds to Axis V of the DSM IV [2]. The GAF scale comprises 10 levels (further divided into 10 points) and each patient is assigned to a given level on the strength of a scoring system: the higher the score the better the patient's psycho- social functioning. The patients were retested nine months later:

process, considering these three elements according to Marcelli and Bracconier [23]:

one's own inner world and to quite tolerate anxiety coming from conflicts.

psychosocial situation and clinical elements was filled in for each subject.

mechanisms centering around splitting, and 3) maintenance of reality testing.

motivation towards multimodal intervention.

**•** Worry about his/her own psychological state,

**•** Self observing and describing capacities.

**•** Awareness of the disease,

Finally, courses are also organized to support the adolescents' formal education in cooperation with their schools. This involves formulating tailored teaching programs and the presence of teachers at the semi-residential centre.

### **2. Sample**

Sample is formed by adolescents who, during a semester, consecutively came to the Neuro‐ psychiatric Unit for Children and Adolescents in Padua, Italy, requesting a psycho diagnostic evaluation and then were suggested to undergo multimodal intervention at the Daily Service for Adolescents. The main purposes of this service are the care and rehabilitation of adolescents with severe psychopathological disorders (mood disorders, psychotic disorders, antisocial behavior and personality disorders), particularly optimizing their welfare and providing intervention for these young patients through an integrated clinical and pedagogical approach. Various professional figures cooperate on the therapeutic project and this multi-professional team includes a child and adolescent neuropsychiatrist, a psychologist, two educators and a social worker. They are 50 individuals, 33 males (66%) and 17 females (34%), aged 13 to 18 years (mean 15,6 y.). The only exclusion criteria were age below 13, chronic rather than acute psychotic state, QI < 70 and presence of known organic pathology associated with mental disease.

### **3. Methodology**

Neuropsychiatric consultation was articulated into 5 diagnostic interviews with adoles‐ cent and his parents, separately. The last session was deputed to communication of psychiatric diagnosis and therapeutic suggestion. We added to this protocol, which was the usual one, another semistructured meeting finalised to the discussion about therapeutic indication. This difference with respect to usual diagnostic protocol (where the diagnostic communication and therapeutic suggestion formed the last meeting with the adolescent) was set up with the aim of giving information about semiresidential treatment (what it is, how it works, what it is useful for) (1) and raising adolescent's questions, doubts, fanta‐ sies and anxieties about therapy and to talk about them with the specialist (2); the hypoth‐ esis was that giving voice to these issues and receiving information could be useful to create motivation towards multimodal intervention.

Adolescent's motivation was evaluated at the beginning and at the end of the diagnostic process, considering these three elements according to Marcelli and Bracconier [23]:

**•** Awareness of the disease,

them, promoting organized behavior patterns, abilities and motivations that can pave the way to satisfactory social relations and an adequate performance in the completion of tasks and the achievement of goals. During their attendance at the center, the adolescents conduct activities designed to develop their personal interests, acquire skills and reinforce their self-esteem. Outings, the preparation of a newspaper, painting, watching films, playing, writing, and dramatizations are activities conducted at the center, individually and in small groups, in the constant presence of the educators. There are also structured laboratories involving pet therapy, horse therapy, art therapy and naturalistic experiences at teaching farms organized in cooperation with other associations, as well as participation in therapeutic winter and summer holiday camps. For many young people, these activities are the only opportunities they have to put themselves to the test away from their usual living environments, to measure themselves against an adventure outside the home, and thereby testing their capacity to manage on their own, to experiment with detachment from the family, to live in groups and

Finally, courses are also organized to support the adolescents' formal education in cooperation with their schools. This involves formulating tailored teaching programs and the presence of

Sample is formed by adolescents who, during a semester, consecutively came to the Neuro‐ psychiatric Unit for Children and Adolescents in Padua, Italy, requesting a psycho diagnostic evaluation and then were suggested to undergo multimodal intervention at the Daily Service for Adolescents. The main purposes of this service are the care and rehabilitation of adolescents with severe psychopathological disorders (mood disorders, psychotic disorders, antisocial behavior and personality disorders), particularly optimizing their welfare and providing intervention for these young patients through an integrated clinical and pedagogical approach. Various professional figures cooperate on the therapeutic project and this multi-professional team includes a child and adolescent neuropsychiatrist, a psychologist, two educators and a social worker. They are 50 individuals, 33 males (66%) and 17 females (34%), aged 13 to 18 years (mean 15,6 y.). The only exclusion criteria were age below 13, chronic rather than acute psychotic state, QI < 70 and presence of known organic pathology associated with mental

Neuropsychiatric consultation was articulated into 5 diagnostic interviews with adoles‐ cent and his parents, separately. The last session was deputed to communication of psychiatric diagnosis and therapeutic suggestion. We added to this protocol, which was the usual one, another semistructured meeting finalised to the discussion about therapeutic

share the group's behavioral rules.

238 Mental Disorders - Theoretical and Empirical Perspectives

teachers at the semi-residential centre.

**2. Sample**

disease.

**3. Methodology**


Recognising and admitting an uneasy state is the first step to deal with it. Being preoccupied with it means to be in touch with anxiety caused by one's own condition and to hinge on this to desire to change. Having the capacity to self observe and describe means to be in touch with one's own inner world and to quite tolerate anxiety coming from conflicts.

An anamnesis schedule collecting data about adolescent's identification, his/her family, psychosocial situation and clinical elements was filled in for each subject.

The psychiatric diagnosis was formulated using ICD 10 [33]. Additionally, we grouped subjects into three categories according to the severity of the psychopathology and pathologic personality organisation as described by Kernberg [16]. Neurotic personality organization is characterized by psychostructural conditions that include: 1) intact reality testing, 2) a consistent sense of self and of other people, and 3) generally rely on mature defense mecha‐ nisms when stressed. At the opposite end of the personality organization dimension are severely disorganized personalities, the Psychotic one which is characterized by: 1) severely compromised reality testing, 2) an inconsistent sense of self and others, and 3) utilize immature defenses. Along the middle of this dimension are personalities organized at the borderline level: 1) the syndrome of identity diffusion, 2) the predominance of primitive defensive mechanisms centering around splitting, and 3) maintenance of reality testing.

Data about patient's therapeutic compliance and clinical evolution were collected during a visit of control after nine months by the last diagnostic session. They are based on both what was referred by the patient about subjective perception of health state and on what the specialist verified about psychosocial functioning changes in a nine months period. Clinical evolution was evaluated throughout the Global Assessment Functioning Scale (GAF) [31], which was filled in before and nine months after the beginning of the semiresidential inter‐ vention. The GAF is a scale used by the operators to rate a patient's psychosocial functioning and activities, regardless of the nature of their psychiatric disease. It corresponds to Axis V of the DSM IV [2]. The GAF scale comprises 10 levels (further divided into 10 points) and each patient is assigned to a given level on the strength of a scoring system: the higher the score the better the patient's psycho- social functioning. The patients were retested nine months later: an improvement was considered when the GAF score changed to an upper level, an unvaried situation when the score remained in the same level and an aggravation when the score decreased to an under level with regard to the initial scoring.

Adolescent's motivation has been evaluated on the basis of three elements: knowledge of a disease, preoccupation about personal psychological state and self observing and describing capacities. Three categories have been individuated on the basis of this evaluation: motivated adolescents –38%-(who recognise the disease, are worried about it and desire to change it), indifferent adolescents –34%-(who admit and describe the disease, but do not seem worried and tend to minimise their psychological condition) and contrary adolescents 28%-(who arrive to the service obliged by parents, do not recognise a disease and say that it is others' fault if they are there) (graphic 1). The difference between indifferent and contrary categories, considering the psycho-relational way of functioning, is the dimension respectively passive

Working on Adolescent's Motivation to Improve the Outcome Within a Multimodal Treatment

The motivation, evaluated at the first interview, shows that less than half of the cases (38%) agrees on diagnostic process. This result suggests that adolescent's motivation to be helped is an aim of an intervention rather than an assumption. This is confirmed by literature [23] and agrees with the result about arrival status which shows that more than 50% of subjects came because they were referred by others rather than coming by themselves and also in this last case, the visit was requested by parents and not by the adolescent. We wanted to determine whether the variable initial motivation was significantly different among groups defined by gender, age, educational level of family and diagnosis. Statistical analysis evidences that diagnosis, gender and educational level influence in some way adolescent's initial motivation. Actually, distribution of initial motivation in adolescents grouped for sex, educational level and diagnosis is not casual, while age doesn't seem affect initial motivation like the other

**Gender** male Count 6 17 10 33

Total Count 15 21 14 50

Pearson Chi-Square 6,794 2 0,033

**Table 2.** Crosstab: initial motivation in relation with gender

**Initial motivation categories Total**

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**motivated indifferent contrary**

% within gender 18,18 51,51 30,3 100 % within motivation 40 80,95 71,42 66 % of Total 12 34 20 66

% within gender 52,94 23,52 23,52 100 % within motivation 60 19,04 28,57 34 % of Total 18 8 8 34

% within gender 30 42 28 100 % within motivation 100 100 100 100 % of Total 30 42 28 100

female Count 9 4 4 17

Value df Asymp. Sig. (2-sided)

and active which characterizes their resistance to meet the clinician.

factors (tables 2, 3, 4 ).

Chi-Square Tests

*Statistical analysis*: data analysis considers the variable motivation in relation with gender (male/female); age (13-15 years old, 16-18 years old); educational level of family - valued on parent's education degree (low, middle, high); arrival status (voluntary, by referral); support by parents - evaluated by empathetic capacities towards adolescent, availability to come to the interviews, collaborative capacities about therapeutic project (supportive family, not suppor‐ tive family); diagnosis (ICD 10); compliance with therapeutic project (in therapy, drop out, therapy never started); nine months follow up (better, unvaried, worse).

The data are expressed as frequencies and percentages. Variables are expressed using nominal and ordinal scales. Cross-tabulations were analyzed using the chi-square test, considering *P*<0.05 as significant. The analyses were performed using SPSS rel. 14.

### **4. Result and discussion**

The sample is formedby50individuals,33males (66%)and17females (34%),aged13to18years. They were divided in 2 age groups: 13-15 years old (24 subjects, 48%) and 16-18 years old (26 subjects, 52%). 6% attended primary school, 36% secondary school, 56% college and 2% had abandoned school. Gender/age cross tabulation shows that males are younger (61% in age range13-15, 39% in age range16-18) than females (23.5% in age range 13-15, 76.5% in age range 16-18). The family's educational level the adolescents come from, results low in 18%, middle in 62% and high in 20% of cases. Arrival status is by spontaneous request for psychodiagnostic consultation in 40% of cases and by referral in 60% of cases. Diagnosis are summarised in table 1, where comorbility is referred to depressive mood disorder and personality disorder.


**Table 1.** Psychiatric diagnosis according to ICD 10

Adolescent's motivation has been evaluated on the basis of three elements: knowledge of a disease, preoccupation about personal psychological state and self observing and describing capacities. Three categories have been individuated on the basis of this evaluation: motivated adolescents –38%-(who recognise the disease, are worried about it and desire to change it), indifferent adolescents –34%-(who admit and describe the disease, but do not seem worried and tend to minimise their psychological condition) and contrary adolescents 28%-(who arrive to the service obliged by parents, do not recognise a disease and say that it is others' fault if they are there) (graphic 1). The difference between indifferent and contrary categories, considering the psycho-relational way of functioning, is the dimension respectively passive and active which characterizes their resistance to meet the clinician.

an improvement was considered when the GAF score changed to an upper level, an unvaried situation when the score remained in the same level and an aggravation when the score

*Statistical analysis*: data analysis considers the variable motivation in relation with gender (male/female); age (13-15 years old, 16-18 years old); educational level of family - valued on parent's education degree (low, middle, high); arrival status (voluntary, by referral); support by parents - evaluated by empathetic capacities towards adolescent, availability to come to the interviews, collaborative capacities about therapeutic project (supportive family, not suppor‐ tive family); diagnosis (ICD 10); compliance with therapeutic project (in therapy, drop out,

The data are expressed as frequencies and percentages. Variables are expressed using nominal and ordinal scales. Cross-tabulations were analyzed using the chi-square test, considering

The sample is formedby50individuals,33males (66%)and17females (34%),aged13to18years. They were divided in 2 age groups: 13-15 years old (24 subjects, 48%) and 16-18 years old (26 subjects, 52%). 6% attended primary school, 36% secondary school, 56% college and 2% had abandoned school. Gender/age cross tabulation shows that males are younger (61% in age range13-15, 39% in age range16-18) than females (23.5% in age range 13-15, 76.5% in age range 16-18). The family's educational level the adolescents come from, results low in 18%, middle in 62% and high in 20% of cases. Arrival status is by spontaneous request for psychodiagnostic consultation in 40% of cases and by referral in 60% of cases. Diagnosis are summarised in table

1, where comorbility is referred to depressive mood disorder and personality disorder.

**Diagnosis (ICD 10) Frequency(N) Percent (%)** anxiety disorders 18 36 mood disorders 3 6 psychotic disorders 3 6 personality disorders 10 20 behaviour disorders 8 16 eating disorders 3 6 mental retardation 2 4 comorbility (depression and personality disorder) 3 6 Total 50 100

decreased to an under level with regard to the initial scoring.

240 Mental Disorders - Theoretical and Empirical Perspectives

therapy never started); nine months follow up (better, unvaried, worse).

*P*<0.05 as significant. The analyses were performed using SPSS rel. 14.

**4. Result and discussion**

**Table 1.** Psychiatric diagnosis according to ICD 10

The motivation, evaluated at the first interview, shows that less than half of the cases (38%) agrees on diagnostic process. This result suggests that adolescent's motivation to be helped is an aim of an intervention rather than an assumption. This is confirmed by literature [23] and agrees with the result about arrival status which shows that more than 50% of subjects came because they were referred by others rather than coming by themselves and also in this last case, the visit was requested by parents and not by the adolescent. We wanted to determine whether the variable initial motivation was significantly different among groups defined by gender, age, educational level of family and diagnosis. Statistical analysis evidences that diagnosis, gender and educational level influence in some way adolescent's initial motivation. Actually, distribution of initial motivation in adolescents grouped for sex, educational level and diagnosis is not casual, while age doesn't seem affect initial motivation like the other factors (tables 2, 3, 4 ).


**Table 2.** Crosstab: initial motivation in relation with gender


**Initial motivation categories Total**

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**motivated indifferent contrary**

% of Total 10 10

% within diagnosis 19,23 34,61 46,15 100 % within motivation 33,33 42,85 85,71 52 % of Total 10 18 24 52

% within diagnosis 30 42 28 100 % within motivation 100 100 100 100 % of Total 30 42 28 100

borderline Count 5 9 12 26

Working on Adolescent's Motivation to Improve the Outcome Within a Multimodal Treatment

Value df Asymp. Sig. (2-sided)

Total Count 15 21 14 50

With respect to gender (table 2 a), motivated are prevalently females, while indifferent and contrary are prevalently males; these differences are statistically significant (p=0.033). This could be explained by the general tendency of females to be more reflexive and capable of insight than males teenagers, added to the fact that in our sample females are older than males

With regard to the educational level of family (table 2b), the most of motivated adolescents come from family with a middle educational level, the most of indifferent come from family with a low educational level, and contrary prevalently come from family with high educational level (p=0.033). Considering initial motivation in relation with nosographic categories, anxiety disorders and eating disorders are the most frequent diagnosis among motivated; acute psychosis, mood disorders and borderline mental retardation (70<QI<85) are more frequent among indifferent; conduct disorders and personality disorders are prevalent among contrary

We considered motivation categories in relation to Kernberg's personality organisation categories too. It is interesting to note that the association between motivation categories and personality organisation categories (motivated -nevrosis, indifferent- psychosis and contraryborderline), as showed in table 2c, reminds about the kind of bond that usually characterises the clinical relationship with the patient according to different psychofunctional level: the neurotic one (patients motivated to get better given their good reality test and a differentiated sense of social tact and sensitivity), borderline one (patients ambivalent and often oppositive towards therapist, given their lack of capacity for a mature empathy with others, and a lack of mature evaluation of other people, who are seen either as idealized, persecutory or devalued

Pearson Chi-Square 16,743 4 0,002

**Table 4.** Crosstab: initial motivation in relation with diagnostic categories

Chi-Square Tests

and then more mature.

adolescents (p=0.007).

**Table 3.** Crosstab: initial motivation in relation with family's cultural level



**Table 4.** Crosstab: initial motivation in relation with diagnostic categories

**Initial motivation categories Total**

**motivated indifferent contrary**

% within education 11,11 66,66 22,22 100 % within motivation 6,66 28,57 14,28 18 % of Total 2 12 4 18

% within education 41,93 38,7 19,35 100 % within motivation 86,66 57,14 42,85 62 % of Total 26 24 12 62

% within education 10 30 60 100 % within motivation 6,66 14,28 42,85 20 % of Total 2 6 12 20

% within education 30 42 28 100 % within motivation 100 100 100 100 % of Total 30 42 28 100

**Initial motivation categories Total**

10 7 2 19

**motivated indifferent contrary**

% within diagnosis 52,63 36,84 10,52 100 % within motivation 66,66 33,33 14,28 38 % of Total 20 14 4 38

% within diagnosis 100 100 % within motivation 23,8 10

psychosis Count 5 5

medium Count 13 12 6 31

high Count 1 3 6 10

Value df Asymp. Sig. (2-sided)

**family's formal education** low Count 1 6 2 9

Total Count 15 21 14 50

Pearson Chi-Square 10,194 4 0,037

nevrosis Count

**Table 3.** Crosstab: initial motivation in relation with family's cultural level

242 Mental Disorders - Theoretical and Empirical Perspectives

Chi-Square Tests

**psychopathological**

**categories**

With respect to gender (table 2 a), motivated are prevalently females, while indifferent and contrary are prevalently males; these differences are statistically significant (p=0.033). This could be explained by the general tendency of females to be more reflexive and capable of insight than males teenagers, added to the fact that in our sample females are older than males and then more mature.

With regard to the educational level of family (table 2b), the most of motivated adolescents come from family with a middle educational level, the most of indifferent come from family with a low educational level, and contrary prevalently come from family with high educational level (p=0.033). Considering initial motivation in relation with nosographic categories, anxiety disorders and eating disorders are the most frequent diagnosis among motivated; acute psychosis, mood disorders and borderline mental retardation (70<QI<85) are more frequent among indifferent; conduct disorders and personality disorders are prevalent among contrary adolescents (p=0.007).

We considered motivation categories in relation to Kernberg's personality organisation categories too. It is interesting to note that the association between motivation categories and personality organisation categories (motivated -nevrosis, indifferent- psychosis and contraryborderline), as showed in table 2c, reminds about the kind of bond that usually characterises the clinical relationship with the patient according to different psychofunctional level: the neurotic one (patients motivated to get better given their good reality test and a differentiated sense of social tact and sensitivity), borderline one (patients ambivalent and often oppositive towards therapist, given their lack of capacity for a mature empathy with others, and a lack of mature evaluation of other people, who are seen either as idealized, persecutory or devalued persons), psychotic one (patients often not conscious of their diseases, with a rigid relational modalities and then mainly indifferent towards therapy).

like the realization of more supportive rather than expressive intervention with people coming from a low socio-cultural background. It is interesting to note that the change to a motivated category is bigger among contrary than among indifferent adolescents: actually first halved during the diagnostic process, showing major capacities of mobilization (compare scheme 1 and 2). This could be linked to what was said before about the psychopathological features of these subjects: indifferent who are mainly psychotic organised are characterised by a defending setting and a psychorelational functioning which are less flexible and changeable than the one of contraries who enter mainly the borderline and neurotic psycho structural organisations.

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motivation at last interview

motivated indifferent contrary

Evaluation of adolescents and their family showed, among contrary subjects, high frequency of difficult relationships and conflict with parents. This aspect seems preponderant in influ‐ encing the adolescent's feeling towards the specialist and psychological space. It is as if the difficulty with the parents is expressed by the difficulty and refusal in regards to psychiatric consultation, to which the adolescent has been lead by parents rather than coming by him self. In these cases, focusing on problematic relations and working on the relationship with the parental couple in terms of separation/ individuation, seems to favour the use of psychodiag‐ nostic space as one's own rather than as something to be used to attack parents. This was shown by contrary adolescents as major capacity to thinking for them selves, to recognise personal

motivation categories

Percent

70

60

50

40

30

20

10

0

**Scheme 2.** Motivation at the end of the psychodiagnostic process

The aim of the diagnostic process, and overall aim of the last interview, was to create a relationship with the patient whose objective was to become aware of the disease and to want to change. So we tried to change the situation where the specialist evaluates the patient and at the end delivers a verdict - instead we tried to build a collaborative relation with adolescent where the main objective is to give a sense to the symptoms, to verify where the adolescent had stopped and to make the therapy to be perceived as something useful.

motivation at first interview

**Scheme 1.** Motivation at the beginning of the psychodiagnostic process

Adolescent's motivation was evaluated again at the end of the diagnosis process (basing on the same elements). The result was an increase of motivated and a decrease of indifferent and contrary adolescents (scheme 2), without relevant difference regarding gender within the three categories (p=0.19). The relation between motivation and diagnosis looses statistical signifi‐ cance too (p=0.09), whereas educational level remains significant in regard to adolescent's motivation (X2=11.38 (DF4), p=0.023). This result suggests that sociocultural aspects (like educational background) influences thinking capacity more than other more constitutional factors (like gender or psychiatric disorder); moreover, it could make operators inclined to differentiate the way of approaching psychopathology in case of particular cultural conditions, like the realization of more supportive rather than expressive intervention with people coming from a low socio-cultural background. It is interesting to note that the change to a motivated category is bigger among contrary than among indifferent adolescents: actually first halved during the diagnostic process, showing major capacities of mobilization (compare scheme 1 and 2). This could be linked to what was said before about the psychopathological features of these subjects: indifferent who are mainly psychotic organised are characterised by a defending setting and a psychorelational functioning which are less flexible and changeable than the one of contraries who enter mainly the borderline and neurotic psycho structural organisations.
