Current directions in child and adolescent psychotherapy: Overview and introduction to the Special Issue

Childhood and adolescence are critical developmental periods, during which mental health can be particularly sensitive. In recent years, evidence has indicated that the prevalence, and perhaps the impact, of child and adolescent mental health has worsened, both in the United Kingdom and internationally (Kieling et al., 2024; NHS Digital, 2023; Pierce et al., 2025). Alongside this, we have seen considerable efforts in psychotherapeutic provision to respond to shifting priorities, policy contexts and resource constraints; in the United Kingdom, for instance, mental health services for children and adolescents have seen real-term budget cuts, increased referral rates, ‘transformation’ and reorganisation, and sudden changes to working practices in the context of the pandemic (Bentham et al., 2021; Fonagy & Pugh, 2017; Mental Health Taskforce to the NHS, 2016). In this shifting landscape, young people engage with psychotherapeutic provision across multiple contexts, including community services, school-based counselling and digital platforms. This Special Issue aims to explore current directions in child and adolescent psychotherapy, drawing together diverse perspectives to examine how the field is shifting in tandem with continually evolving evidence, principles and contexts. Taking stock is essential not only for consolidating the knowledge and learning occurring across a range of contexts but for identifying key priorities, gaps and ways to integrate perspectives across policy, practice and research. The twelve contributions included in the Special Issue span five key, cross-cutting themes: youth voice and agency, therapeutic alliance, exploration of wider mechanisms, the role of parents and adults around an adolescent, and digital and online contexts. These themes collectively highlight how psychotherapy research and practice are attending to relational, developmental and contextual factors that shape young people's mental health and therapeutic experiences. Over recent years, we have seen increasing recognition that children and young people have the right to have their voices heard in matters affecting them, including in psychotherapy research, policy and provision. This principle is reflected across fields in a range of ways: for instance, at the system level, we see growing use of youth advisory boards in the commissioning and development of services; in research, young people are now more frequently engaged as active partners and participants, helping to shape the questions we ask and the ways we interpret findings. At the individual level, the same principle applies within the therapeutic room. Here, voice and agency are expressed in how the process and outcomes of therapy are co-constructed between a practitioner and a young person (as we will turn to more explicitly later). This necessitates a range of considerations: how can therapeutic practice meaningfully respect and integrate young people's perspectives, while balancing the professional expertise and responsibilities of the practitioner? Engaging with these considerations is vital, not only as a matter of rights, but as a means of deepening and sharpening the field itself. As one young participant in this Special Issue reflects: ‘I think sometimes if it's just psychologists creating the guides, it could be hard to have a true understanding of what it's like to be a young person today […] with as much research as you can do in everything you can't actually be in a young person's brain’ (‘Maisie’; Loades et al., 2025, p. 384). This Special Issue includes several contributions that explore how youth voice, agency and lived experience can be understood and enacted in psychotherapy contexts. Youth voice is featured here both as a dedicated focus of certain papers and as a thread running through broader discussions. Gibson and Stubbing (2025) bring this principle to the conceptualisation and evaluation of change in psychotherapy. Their piece outlines a vision for expanding our concepts of change, to push beyond professional agendas and traditional symptom measures (typically psychiatric in nature) to include wellbeing indicators that are meaningful to young people. They examine existing qualitative research with young people to consider some of the priorities commonly highlighted, pointing to emotional acceptance, developing a comfortable identity, having good relationships and experiencing agency as change indicators that appear meaningful to young people themselves. We join Gibson and Stubbing and others in the field in emphasising the value of understanding young people's voices as a valuable source of evidence that can guide practice. Marriner et al.'s (2025) piece offers a compelling examination of another way youth voice can be useful in shaping therapeutic practices. They examine how young people experience receiving a borderline personality disorder (BPD) diagnosis; this experience is largely under-explored, despite the longstanding and considerable debate about BPD. Speaking with young people and their mothers from two NHS Community Mental Health Services in the West Midlands (a county in England), Marriner et al. examine what their participants describe as the stark and ‘ugly’ reality of living with the experiences labelled as BPD, and how complex it can be to receive this diagnosis, which the study shows can be experienced as symbolising permanent defectiveness and danger. Marriner et al. explore how young people's experiences add further weight to calls for change in how we understand and talk about the difficulties labelled as BPD. We end our encouragement to read this piece with this powerful titular quote from a young person: ‘I see it that I'm ruined, I'm not ever going to be normal, that I'm not normal. It's an actual disorder of my personality, and I find that really hard’ (‘Sarah’; Marriner et al., 2025; p. 8). Therapeutic alliance is widely considered one of the most critical predictors of change in psychotherapy, yet its meaning and application both generally and in child and adolescent contexts are complex and continue to evolve (Cirasola & Midgley, 2023). With children and adolescents, alliance is shaped not only by the dyad between therapist and client, but also by developmental factors, family and institutional dynamics, and wider systemic influences. Contributions in this Special Issue highlight the complexities of building and maintaining alliance with children adolescents, and point towards innovative practices that seek to balance collaboration, power, and youth agency. Douglas et al. (2025) explore the social dynamics at play within formulation—a joint process of establishing a shared understanding and plan for therapeutic work—in talk therapy between young people and clinicians. Through a constructivist grounded theory approach, the authors explored perspectives and experiences from both young people and clinicians. They produce a continuum model whereby power, collaboration and openness remain in flux for young people and clinicians in the process of formulation, dialling up and dialling down from moment to moment. This proposed way of thinking about the dynamics of the formulation process points to a need for continuous reflective work for therapists in pursuing attunement in their engagement with formulation with young people. The authors' reflection on this process as grounded in a ‘shared humanity’ is a compelling reminder of the complex personal and interpersonal processes at play in this area of practice. Therapeutic formulation is inconsistently conceptualised and applied, and as noted by clinicians in Douglas et al. (2025), different approaches tend to be used with different young people. One such formulation example is presented by Zeiler et al. (2025) on the Maudsley Model Anorexia Nervosa Treatment for Adolescents (MANTRa) and illustrates how formulation letters are a promising tool for strengthening therapeutic alliance. These letters are therapists' written summaries of a shared case understanding and are read to patients in person. Although they were seen as challenging and time-consuming, therapists described these letters as being particularly fitting for adolescents in facilitating in-depth reflections, promoting recovery and solidifying the alliance. However, echoing Douglas et al. (2025), the social dynamic is particularly important within formulation. In the case of letters, therapists in Zeiler et al. (2025) note the risk of adolescents idealising the therapist and creating dependency, thus highlighting the importance of carefully considering this method and establishing clear boundaries. As a therapist notes: ‘… but in those moments, these [therapist-patient] roles need to be clarified, and a bit of distance needs to be reestablished’ (‘#05’, Zeiler et al., 2025, p. 404). While evidence remains preliminary, formulation letters illustrate how written communication and read-aloud practices can tangibly support alliance processes, also beyond the end of the therapy. As a therapist reflected in the study, this is an opportunity for ‘giving them something back at the end of their journey and providing them with a feedback like how brave they were engaging into this journey, summarizing the shared journey and explaining the wishes for the future’ (‘#10’, Zeiler et al., 2025, p. 404). A related area where collaboration and youth agency are central is goal-oriented practice, which represents another way of structuring the therapeutic relationship around shared understanding and purpose. Jacob et al. (2025) present a scoping review and thematic analysis of the empirical evidence on goal-oriented practices—the first synthesis of evidence from the last 20 years. Most identified studies described goals being led by young people themselves, aligning with the core ethos underpinning this area of practice and with the wider emphasis in this Special Issue on youth voice and agency in therapeutic processes. However, like therapeutic formulation (Douglas et al., 2025), the authors identified considerable variation in how goal-oriented practices are defined, operationalised and measured in youth mental health and wellbeing contexts, alongside shortcomings in reporting and measuring goal-oriented practices that impact upon understanding and evidence of how goal-oriented practice can support outcomes. This review is an important contribution to our understanding of goal-oriented practices in therapeutic processes with young people, and we echo Jacob et al.'s call for development of best practice principles in this area. Duncan et al. (2025) examine experiences of setting and monitoring goals in school-based counselling among young people in secondary schools in London, and note various aspects of working with goals considered helpful and/or unhelpful. For some, goals provided motivation, a representation of progress and focus, while for others, goals could link to feeling ‘stuck’ and could prompt negative emotions when progress did not feel linear, as articulated by ‘Saffron’: ‘I would get like, happy and I'd think to myself, “OK, I'm making more progress.” But if I'm going down… if the line is going down… then, of course, it kind of… gets me depressed that I haven't made any progress’ (Duncan et al., 2025; p. 673). Reflecting on this, Duncan et al. advocate for providing young people with genuine choice in goal processes—including in whether to set goals at all, and in the manner and frequency of monitoring. Interestingly, Duncan et al. suggest that goal-setting may not be especially salient to young people within school-based humanistic counselling, and encourage further exploration of practices that can support goal setting and monitoring, whom it may work best for, and when. This study provides an insightful exploration of young people's reflections on a practice intended in part to aid their voice in the therapeutic process, and offers important considerations for approaching this with nuance in practice. Another pressing frontier for the field concerns mechanisms of change, with considerable room to further understand the processes by which psychotherapy supports development and recovery among children and adolescents specifically. Moving beyond symptom-focused measures towards process-oriented and idiographic frameworks could offer the possibility of identifying what works, how and for whom. Contributions to this Special Issue illustrate how attention to mechanisms—both within therapy sessions and in assessment practices—can sharpen our understanding of therapeutic change. Of course, therapeutic alliance itself—as explored above—can be understood as a key mechanism of change, underpinning and shaping many of the processes discussed across this Special Issue. We addressed alliance separately here due to its centrality and conceptual complexity, particularly in the context of child and adolescent psychotherapy, and given the multiple contributions that captured this area. We echo Geyer et al.'s (2025) reflection that a growing focus on evaluating the effectiveness of interventions has not necessarily translated into a shift in understanding of key change mechanisms in interventions, particularly in child and adolescent psychotherapy. Geyer et al.'s (2025) examination of how the depth of emotional experiencing is related to therapeutic outcomes for young people was therefore a very welcome addition to this Special Issue, not least because this has previously only been examined among adults, and to a limited extent at that. The authors found that emotional experiencing accounted for a significant—and considerable—proportion of the variance in the change of outcomes (including but not limited to psychological distress) that young people reported over the course of a school-based humanistic counselling intervention. Further work is needed to consolidate these findings, but this study has important implications for the training and competencies of therapeutic practitioners working with children and young people. In a similar vein, a case study analysis by Williams et al. (2025) highlights a longstanding need to move beyond symptom-based frameworks—as also echoed by Gibson and Stubbing (2025) in this Issue—and consider the subjective experiences of young people using holistic, idiographic and developmentally appropriate frameworks to ensure individualised and effective treatments. In this work, Williams et al. explore different mechanisms that may underlie suicidal behaviours among adolescents, considering factors such as personality organisation and motivational dynamics. For example, the authors examined two adolescents whose presentations they assessed to differ markedly, illustrating the diverse ways in which suicidal thoughts and behaviours can function in response to distress. Williams et al. acknowledge ongoing debates about the validity and reliability of personality disorder classifications in young people, and highlight the need to replicate and further explore this approach and their findings with other methods including self-report. Still, this study highlights the potential of attending to underlying mechanisms through which symptoms express and sustain themselves, rather than treating suicidal behaviour as a uniform phenomenon. Over recent years, there has been a shift in how child and adolescent mental health is conceptualised, with dynamic systems perspectives emphasising that young people are embedded within a complex web of interrelated systems, including parents and other key adults. Childhood and adolescence are critical developmental periods in which adult figures play a central role in shaping mental health outcomes. For example, Keleynikov et al. (2025) find that not only does parental mental health relate to children's development, but also parents' reflective functions, including their curiosity, interest and certainty about their child's mental states. These findings, though requiring replication with longitudinal dyadic data, are a welcome addition to this Special Issue and to the way in which we can understand how parental mental health and reflective functioning intersect with young people's therapeutic needs. More broadly, this contribution highlights the need to look beyond individual-level symptoms and to attend to the relational capacities of adults who surround young people in their everyday lives. Samra et al. (2025) extend this perspective to the social and structural environments of sexual and gender minoritised adolescents (SGMA). They examine adult stakeholders' perspectives on the mental health of SGMA, highlighting both barriers to wellbeing such as discrimination, unsafe environments and institutional inertia and enabling factors including opportunities for identity exploration, safe relationships and inclusive practices. We echo their calls for the development of adult-focused education and digital resources that can both support SGMA and facilitate adult learning, alongside systemic change through improved wellbeing monitoring, inclusive school cultures and culturally sensitive interventions. This reinforces the importance of considering adults not only as immediate caregivers but also as part of wider institutional systems that shape adolescent development. Clinical contexts also highlight the importance of parental involvement. Zeiler et al. (2025) highlight therapists' wish to include more parent- and family-focused content in their Maudsley Model Anorexia Nervosa Treatment for Adolescents and young Adults (MANTRa) and include more parent–child sessions: ‘There would be potential to incorporate more [content around family] into the workbook, as I believe that the family is a crucial resource, but it also often involves pursuit of autonomy, detachment, and unspoken conflicts’ (‘#10’, Zeiler et al., 2025, p. 403). Through parent–child dyadic research, Christensen et al. (2025) provide important first insights into mechanisms through which parents can facilitate therapeutic change. In their internet-delivered emotion regulation intervention for adolescents engaging in non-suicidal self-injury, parent-targeted components enabled families to develop shared language and strategies, thereby enhancing communication and providing a structured framework for supporting adolescents' emotion regulation. Attention to dyadic processes is a welcome focus in this Special Issue. These findings suggest that therapeutic outcomes may be strengthened when interventions attend to such processes between parent and child rather than focusing solely on the adolescent. Theories of child development have been recently modified to also account for digital environments, one of the most ubiquitous contexts in which adolescents learn, play and grow. 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