Exploring Psychological Interventions for Adoptive Families

***Overall Thesis Lay Summary*** Prolonged experiences of pre-adoptive abuse place some adopted children at a greater risk of enduring a wide range of neurobiological and psychosocial difficulties. Adoptive parents must manage these difficulties whilst possibly having to cope with their own personal challenges. It is important for families seeking post-adoption support to be informed about the effectiveness and experiences of psychotherapies which can meet the needs of all members of the adoptive family unit. The objective of this thesis project was to complete a comprehensive review of scientific literature examining family-based psychotherapeutic interventions for adoptive families and to evaluate the feasibility and acceptability of one specific family-based psychotherapy for this cohort.
The first chapter presents the systematic literature review which examined studies of domestically adopted families who received a family-based psychotherapeutic intervention. The review identified 17 studies, comprising of 13 different psychological interventions. A narrative synthesis indicated that there is promising preliminary support for integrative psychotherapeutic interventions which include sensory activities, attachment-based play therapies such as Theraplay®, Eye Movement Desensitisation and Reprocessing (EMDR), and Dyadic-Developmental Psychotherapy (DDP). These were most promising within therapeutic formats which provided separate therapeutic input for adoptive parents and/or adopted children, alongside the family-based therapeutic input for the adoptive family. However, this research area lacks quality, and most studies reported a moderate-to-serious risk of bias. Therefore, these findings should be seen as exploratory and not unequivocal.
The second chapter explores the feasibility and acceptability of integrating Theraplay®, DDP, and EMDR with adoptive families. Feasibility was determined by examining recipient attendance patterns and post-therapy assessment measure completion rates. Acceptability was explored through a framework analysis of semi-structured interviews with intervention deliverers (therapists) and recipients (adoptive parents). Overall, the integration of these approaches was deemed both feasible and acceptable. Therapists reported that the integration of Theraplay®, DDP, and EMDR allows them to respond more meaningfully to needs in therapy, that it makes sense, that they feel confident integrating these models, and that the increased freedom makes the therapy easier to administer. Therapists also reported the risk of integrating models for unsuitable reasons at unsuitable times, the presence of uncertainty relating to how to integrate effectively, self-doubt, and feeling increased pressure to make the right decision during therapy. Adoptive parents reported that the integrative therapy was valuable, that it made sense in the context of their child’s early history, and that the therapy is physically and emotionally burdensome but is a burden worth bearing. Issues for parents included the therapy being unable to ameliorate all their difficulties, aspects being difficult to understand, aspects feeling uncomfortable, and the therapy requiring a high level of effort.
Together these chapters provide preliminary evidence demonstrating promise for integrative family-based psychotherapies and that integrative Theraplay®, DDP, and EMDR is both feasible and acceptable as a post-adoption psychotherapeutic intervention. These studies are exploratory in nature and further high quality, controlled, and randomised research examining the efficacy of integrative family-based psychotherapeutic approaches is warranted. Additionally, research developing measures of therapeutic competence and adherence for integrative approaches is also required.

***Systematic Review Abstract*** Objectives: This review (PROSPERO: CRD42021266076) aimed to synthesise the literature exploring family-based psychological interventions for adoptive families, appraise the strengths and weaknesses of the evidence, and report characteristics of promising interventions.
Methods: Seven electronic databases: CINAHL, Cochrane Library, MEDLINE, ProQuest, PsycINFO, Scopus, and Web of Science, four grey literature databases: EThOS, Grey Literature Report, OpenGrey, and Social Care Online, two journals: Adoption Quarterly and Adoption and Fostering, and five relevant websites were searched up to 19.05.2022. Two groups of search terms were searched for within titles, abstracts, and keywords with the terms relating to (a) the population and (b) the intervention. Included studies recruited domestically adoptive families receiving psychotherapeutic interventions delivered to at least one parent and one child. Risk of bias was assessed by the quantitative Risk of Bias in Non-Randomised Studies of Interventions tool and the qualitative Critical Skills Appraisal Programme checklist. A narrative synthesis approach was applied.
Results: The synthesis presents 17 studies including over 682 adopted children and 782 adoptive parents. Findings provide preliminary support for integrative interventions which include aspects of sensory activities, attachment-based play, Eye Movement Desensitisation and Reprocessing, and Dyadic-Developmental Psychotherapy with therapeutic input being provided to children and parents independently, alongside the adoptive family.
Conclusions: Overall, risk of bias was high, certainty of evidence was low, and there was significant heterogeneity across studies, limiting the conclusions that can be drawn. Research examining the acceptability and efficacy of integrative therapeutic approaches for adoptive families is required to provide conclusive implications for clinical practice.

***Empirical Project Abstract*** Objectives: This study aimed to establish the feasibility and explore the retrospective acceptability of an integrative intervention for adoptive families which included Theraplay®, Dyadic-Developmental Psychotherapy, and Eye Movement Desensitisation and Reprocessing.
Design: Feasibility was assessed by descriptive analysis of recipient attendance patterns and post-therapy questionnaire completion rates. Acceptability was explored qualitatively utilising Framework Analysis of semi-structured interviews with intervention deliverers and recipients, with each dataset being analysed separately.
Methods: Purposive sampling recruited nine therapists and 14 adoptive parents from eight families. Credibility was maintained via service user/deliverer consultation, triangulation, member checking, reflexive logs, and quality appraisal checklists.
Results: Attendance and measure completion rates indicated the intervention is feasible. The qualitative investigation suggested the approach is predominantly acceptable for both therapists and adoptive parents. Issues detracting from acceptability for therapists included the risk of integrating models for unsuitable reasons at unsuitable times, uncertainty relating to integrating effectively, self-doubt, and feeling pressure to make the right decision when integrating. Issues for adoptive parents included the therapy being unable to ameliorate all their difficulties, aspects being hard to understand, aspects being uncomfortable and uncertain, and the therapy requiring a high level of effort.
Conclusion: The integration of these models was feasible and acceptable. To enhance acceptability a Delphi study contributing to the development of competency and adherence measures would be valuable for therapists. Adoptive parents would benefit from services taking steps to enhance their understanding and comfort whilst integrating these approaches. Finally, research investigating the preliminary efficacy of integrating these modalities is required.