Introduction
Primary healthcare (PHC) is the most accessible institutionalized health service for most people (Bofill Moscardó et al., Reference Bofill Moscardó, Fernández Corchero, Villegas Briz, García del Moral and Bandera2010; Wissow et al., Reference Wissow, van Ginneken, Chandna and Rahman2016; Mulvaney-Day et al., Reference Mulvaney-Day, Marshall, Piscopo, Korsen, Lynch, Karnell, Moran, Daniels and Shoma Ghose2018; Brino, Reference Brino2020; Charach et al., Reference Charach, Forough Mohammadzadeh, Belanger, Lipman, McLennan, Parkin and Szatmari2020). It can then be the most appropriate setting to provide comprehensive healthcare given its accessibility, continuity of care, and the confluence of health data, creating a space in which relationships of trust between service users and healthcare professionals can be developed (Bofill Moscardó et al., Reference Bofill Moscardó, Fernández Corchero, Villegas Briz, García del Moral and Bandera2010; Ministerio de Sanidad, 2011; Buitrago Ramírez et al., Reference Buitrago Ramírez, Ramón Ciurana, Levy Chocrón, María del Carmen Fernández, Javier García, Carmen Montón and Jorge Luis Tizón2018; Zurro, Pérez, and Badia, Reference Zurro, Pérez and Badia2019; Brino, Reference Brino2020).
An increase of mental health consultations in PHC had already been observed in Spain prior to the start of the COVID-19 pandemic. Since then, a vast amount of research has been published on the populations’ mental health needs (Jacques-Aviñó et al., Reference Jacques-Aviñó, López-Jiménez, Medina-Perucha, de Bont, Gonçalves, Duarte-Salles and Berenguera2020; Ma et al., Reference Ma, Mazidi, Li, Li, Chen, Kirwan, Zhou, Yan, Rahman, Wang and Wang2021) and PHC pressures to respond to the increasing demand of (sub)clinical mental health issues (Brino, Reference Brino2020; Imfeld et al., Reference Imfeld, Darang, Neudecker and McVoy2021). Subclinic mental health consultations correspond to 20% of PHC appointments among children and adolescents (Bofill Moscardó et al., Reference Bofill Moscardó, Fernández Corchero, Villegas Briz, García del Moral and Bandera2010). In line with this, the National Health System’s Mental Health Strategy in Spain between 2009 and 2013 (Ministerio de Sanidad, 2011) already included the need to approach subclinical mental health issues in PHC. Some regions in Spain have also recognized different health professionals’ capacity and training to attend to mental health needs in PHC (Buitrago Ramírez et al., Reference Buitrago Ramírez, Ramón Ciurana, Levy Chocrón, María del Carmen Fernández, Javier García, Carmen Montón and Jorge Luis Tizón2018). While a specific mental health diagnosis may not be identified, interventions to enhance psychological and social well-being can still be effective. A caring response and trusting relationship with healthcare professionals can already have a positive impact in these cases (Sabrià, Reference Sabrià2017; Pidano et al., Reference Pidano, Segool, Delgado, Forness, Hagen, Abebe Gurganus, Honigfeld, Hess, Hicks and Morgan2020).
Addressing mental health among children and adolescents is within PHC competencies and responsibilities (Bofill Moscardó et al., Reference Bofill Moscardó, Fernández Corchero, Villegas Briz, García del Moral and Bandera2010; Brino, Reference Brino2020). The need for healthcare consultations is usually identified through families, but also through the Child Health Program (Asociación Española de Pediatría de Atención Primaria, 2009) and the Health Promotion and Education Program (Ministerio de Educación, 2008) health promotion strategies that are routinely implemented in schools in Spain. PHC consultations are usually initiated due to recurrent physical problems in which a primary organic cause can be ruled out (e.g., headaches, abdominal pain, dizziness, tics, enuresis, among other symptoms) (Castelló et al., Reference Castelló, Fernández de Sanmamed, García, Mazo, Mendive and Rico2016). Some symptoms are directly related to emotional factors, adaptation processes, or problems within family systems. In such cases, children and adolescents express their distress through disruptive behaviours, fears, irritability, drug use, and self-harm behaviours, among others (Schaefer, Reference Schaefer2012; da Silva Panizza, Reference da Silva Panizza2015; Fahrutdinova and Nugmanova, Reference Fahrutdinova and Nugmanova2015; Lorås, Reference Lorås2018; Salazar Valadez and Puc Herrera, Reference Salazar Valadez and Puc Herrera2019). Very importantly, these symptoms and emotional manifestations alter children and adolescents’ daily life, their families and school environments (Buitrago Ramírez et al., Reference Buitrago Ramírez, Ramón Ciurana, Levy Chocrón, María del Carmen Fernández, Javier García, Carmen Montón and Jorge Luis Tizón2018). For this reason, it is essential to address them at PHC, where nursing professionals can play a prominent role.
General protocols have been developed to ensure prevention and early detection of subclinical mental health issues, and interventions have been implemented to address mental health among children and adolescents in children and adolescents (Wissow et al., Reference Wissow, van Ginneken, Chandna and Rahman2016; Mulvaney-Day et al., Reference Mulvaney-Day, Marshall, Piscopo, Korsen, Lynch, Karnell, Moran, Daniels and Shoma Ghose2018; Brino, Reference Brino2020; Charach et al., Reference Charach, Forough Mohammadzadeh, Belanger, Lipman, McLennan, Parkin and Szatmari2020). However, these are often unspecific and rarely applied in clinical practice (Moreno and Moriana, Reference Moreno and Moriana2013). Gestalt therapy (GT) (Peñarrubia and Naranjo, Reference Peñarrubia and Naranjo2008) and systemic pedagogy (SP) (Traveset Vilaginés, Reference Traveset Vilaginés2007) are approaches that include techniques based on learning through the physical body and the use of metaphors. They consider the valuable role of family systems and have already been found to be useful in mild and moderate mental health cases (von Sydow et al., Reference Von Sydow, Retzlaff, Beher, Haun and Schweitzer2013; da Silva Panizza, Reference da Silva Panizza2015; Fahrutdinova and Nugmanova, Reference Fahrutdinova and Nugmanova2015; Lorås, Reference Lorås2018). Available evidence also suggests that these approaches can help prevent the worsening of emotional distress and physical symptoms, as well as decrease referrals to specialized mental health services (Bofill Moscardó et al., Reference Bofill Moscardó, Fernández Corchero, Villegas Briz, García del Moral and Bandera2010). The latter aspect is especially relevant considering the pressures experienced in PHC worldwide due to the COVID-19 pandemic (Legido-Quigley et al., Reference Legido-Quigley, Tomás Mateos-García, Campos, Gea-Sánchez, Muntaner and McKee2020).
Both GT and SP are appropriate for children and adolescents since they are applied through playing (with drawings, the use of dolls, theatre, or stories) as a way to discover, express, accept, and self-manage emotions (Stevens, Reference Stevens1992; Oklander, Reference Oklander1998; Goleman, Reference Goleman2000; Colodron, Reference Colodron2010; Costa Martínez, Reference Costa Martínez2015). They are also useful to practice social skills and promote well-being (24). There are three main dimensions in GT and SP (the three ‘orders of love’) (Hellinger, Reference Hellinger2011): (1) Belonging: every individual belongs to a social group (the first is one’s family), and any experience of social exclusion may cause distress and disruptions in the person’ system; (2) Hierarchical order: in every social group there is a hierarchical order, and discomfort may appear when this hierarchy breaks; (3) Balance between giving and receiving: when there is an imbalance in what an individual gives and receives, relationships worsen. Overall, disruptions in any of these three dimensions can lead to emotional and physical distress (Hellinger, Reference Hellinger2011).
Despite previous evidence (von Sydow et al., Reference Von Sydow, Retzlaff, Beher, Haun and Schweitzer2013; da Silva Panizza, Reference da Silva Panizza2015; Fahrutdinova and Nugmanova, Reference Fahrutdinova and Nugmanova2015; Lorås, Reference Lorås2018; Salazar Valadez and Puc Herrera, Reference Salazar Valadez and Puc Herrera2019), these approaches are still considered controversial (Hellinger, Reference Hellinger2011) and consequently not generally implemented. Besides, no evidence has been found in PHC paediatric services. Nevertheless, taking a holistic perspective to understand and care for children and adolescents’ mental and physical health can have a positive impact on mental and emotional health outcomes (Bofill Moscardó et al., Reference Bofill Moscardó, Fernández Corchero, Villegas Briz, García del Moral and Bandera2010; Moreno and Moriana, Reference Moreno and Moriana2013; Castelló et al., Reference Castelló, Fernández de Sanmamed, García, Mazo, Mendive and Rico2016). The main aim of this study was to explore the perceptions on GT and SP techniques in paediatric mental health-related consultations in a PHC centre in Catalonia in 2018–2019, among families, healthcare, and education professionals.
Methods
Research design
This is a qualitative study using semi-structured individual interviews, conducted with families and professionals between 2018 and 2019. Data were collected after paediatric PHC consultations with 42 children and adolescents, using GT and SP techniques implemented in mental health-related consultations in Agramunt (Spain) in 2018–2019. Metaphoric and projective techniques, using drawings, invented tales, toy images, and dramatization were used to identify, in a quick and simplified way, children and adolescents’ emotions. The main aim of these consultations was to draw emotional awareness, not only to children and adolescents but also to their families, as they were present during healthcare consultations (9–14). The first author (TPP) was responsible for conducting the consultations on GT and SP. TPP is a certified primary education teacher and nurse, who has over 30 years of experience as a paediatric nurse in PHC. She has completed a 4-year training in Gestalt for Children and Adolescents, and other courses in GT and SP, including one on Gestalt and Psychopathology. Besides, TPP has completed postgraduate programmes on Health Education, Research in Nursing and Systemic Pedagogy. TPP’s experience was considered as optimal to conduct the consultations. Researchers ensured that participating in the study did not interfere with the healthcare of participants and the children and adolescents who participated in the GT/SP consultations.
Quality and rigour were assessed by following Guba & Lincoln’s criteria (Guba and Lincoln, Reference Guba, Lincoln, Denzin and Lincoln1994), by ensuring the research’s: (1) credibility (e.g., confidence in the realities presented in the findings); (2) transferability (e.g., findings are applicable to the context where the research has been conducted and data can inform other contexts); (3) dependability (e.g., findings are consistent and the research can be replicated), and; (4) confirmability (e.g., findings are true to participants’ accounts and researchers’ motivations, interests, and perspectives have been clearly exposed). We also used the Critical Appraisal Skills Programme (CASP) tool (Long et al., Reference Long, French and Brooks2020). See Additional File 1 for more details on how the CASP checklist was used for this publication.
Participants, sampling, and recruitment
Participants were: (1) family members of children and adolescents who had taken part in a healthcare consultation using GT/SP techniques; (2) health and education professionals (nurses, doctors, teachers, pedagogues, and psychologists). Professionals were required to have some experience working with children and adolescents, or to have experience with GT/SP. One participant was a last-year nursing trainee who had experience of attending GT/SP consultations in PHC. All other professionals were registered professionals. Sampling was purposive and selective. All families of children and adolescents that had participated in the GT/SP sessions were telephoned by the principal investigator (TPP) to invite them to participate in a qualitative interview. All 42 individuals involved in GT/SP sessions accepted to take part in the study. Moreover, professionals involved in the child and youth health programmes in one PHC service and one high school were invited to participate. TPP contacted 18 by phone, and 15 agreed to participate.
Data collection
Forty-two semi-structured interviews were conducted with families, and 15 professionals (7 working in healthcare and 8 in educational settings). Interviews lasted between 15 and 90 min. Data collection with family members took place in one PHC. Interviews with professionals were conducted in their workplaces. All interviews were moderated by TPP using a previously piloted thematic guide. Interviews were audio-recorded and stored in an encrypted file. Anonymity and confidentiality were ensured at all times throughout the study. Data saturation was reached for both participant groups. Quantitative data on sociodemographic characteristics, main reasons for the consultation, and the perceived effectiveness of GT/SP techniques were also collected, to support qualitative data.
Data analysis
Thematic analysis was used to analyze qualitative interviews (Berenguera et al., Reference Berenguera, Fernández de Sanmamed, Pons, Pujol, Rodríguez, Saura, Mahtani and Cofiño2017). The analysis process was as follows: (1) Reading of transcripts and field notes; (2) Identification of relevant topics and texts; (3) Fragmentation of the text into units of meaning; (4) Coding of texts with a mixed strategy through inductive codes and predefined codes; (5) Elaboration of themes by grouping codes. The researchers used an analytical pre-established framework, based on the objectives of the study, and considered inductive codes and emerging themes; (7) Analysis and interpretation of themes to finalise the thematic framework. LMP led the qualitative data analysis; triangulations were done with TPP and AB.
Sociodemographic characteristics, main reasons for the consultation, and the perceived effectiveness of GT/SP techniques were analyzed by calculating frequencies (percentages) for categorical variables. Means, medians, and ranges were calculated for continuous variables. Likert scale questions (with answers between 0 and 10) were categorized into three values ‘Little’ (<5), ‘Moderate’ (5–7), and ‘A lot’ (8–10). TJL performed the statistical analyses, using SPSS for Windows, version 25 (SPSS Inc., Chicago, IL).
Results
Participant characteristics, main reasons for consulting, and perceived GT/SP effectiveness
Over half of family members (N = 42) were women (59.5%). Median age was 40 years old, ranging between 18 and 70. The ages of the children/adolescents they cared for were between 4 and 18 years old (Median = 11). Most children/adolescents were referred by paediatric services (35.7%) and by family members (33.3%). Families were mostly born in Span (76.2%) and had completed secondary (47.6%) or primary (33.3%) education. Anxiety and fear (31.0%) were the most common reasons for consultating, followed by somatic symptoms (e.g., headaches) (26.2%). There was no referral to mental health services in 64.3% of cases. Moderate (42.9%) or high improvement (50.0%) was reported by families as a result of the GT/SP sessions. See Table 1 for more details.
Family members’ characteristics and perceived effectiveness of GT/SP consultations (N = 42)
Professionals interviewed (N = 15) were aged 20–63 years old (Median = 47.5), 87.5% were women and almost all held Spanish nationality (93.7%). Their professional area was education (31.5%), psychology or pedagogy (25.0%), medicine (18.7%), and nursing (18.7%).
Main findings
Four themes were identified: (1) perceived improvement of emotional distress, (2) improvement of intra-family relationships and other social relationships, (3) positive impact of GT/SP in PHC, and (4) barriers and opportunities for the implementation of the GT/SP in PHC centres (see Table 2 for interview quotes).
Family members and professionals’ interview quotes
Perceived improvement in emotional distress
Both families and professionals perceived GT/SP sessions as to have a positive impact on children and adolescents’ emotional distress. According to participants accounts, GT/SP techniques promoted the identification, acknowledgement, expression and, ultimately, the management of emotions. Participants perceived that children and adolescents seemed to experience less sadness, fear, anger, irritability, stress, anguish, and apathy. An improvement in self-esteem was also reported by family members, and professionals considered that GT/SP could support self-esteem. Some children and adolescents seemed to begin to attend to their own needs and to set healthy boundaries in their social relationships. Improvements in school performance and physical symptoms were also discussed.
Improved intra-family and other social relationships
GT/SP sessions also appeared to produce positive changes in family members. They helped them to improve their own emotional management, and contribute to healthier family relationships, even among those who embodied a passive role during the sessions. As professionals also noted, the decrease in family members’ concern when perceiving positive changes in children/adolescents, and a greater sense of control, seemed to lead to a more relaxed family environment that reduced intra-family conflicts and improved emotional management. Based on the narratives of both family members and professionals, GT/SP sessions appeared to improve social relationships in children and adolescents. Participants attributed these changes to children/adolescents’ improved mood and emotional health, as well as families’ reporting being less concerned and less in need for emotional health interventions. On the other hand, some narratives suggested that some family members were reluctant to explore their own responsibility in the difficulties expressed by children/adolescents, a perspective that was also shared by some professionals. Despite having a positive effect, family members discussed that GT/SP techniques were not always applied at home. Professionals understood that it could be challenging to involve families into applying GT/SP techniques at home and once GT/SP consultations were over.
The positive impact of GT/SP in PHC
Interviewed professionals viewed the application of GT/SP as a way to obtain richer information on the emotional health of children and adolescents. This allowed them to have a more holistic view to children and adolescents’ health. GT/SP were also tools to work on children, adolescents, and their families’ emotional and mental health. Applying GT/SP in PHC was considered to be very positive, given the high accessibility of PHC services, and the high knowledge that paediatric professionals often have of the child/adolescent and of their context. Family members also appreciated having GT/SP consultations available in PHC, given the accessibility of PHC services. Other positive aspects that professionals commented on were the potential decrease in prescriptions, and the decrease in the ‘psychiatrization’ of children and adolescents, by reducing referrals to specialized mental health services.
Barriers and opportunities for the implementation of GT/SP in PHC centres
Professionals shared that GT/SP techniques were difficult to implement in the current public health system, aswith other ‘alternative’ intervention techniques. Some professionals mentioned structural barriers such as organizational models, physical spaces to implement GT/SP, lack of funding and time constraints. These were identified as barriers to create spaces of trust and confidentiality. Overall, professionals mentioned that the GT/SP did not fit with the paternalistic perspective under which some professionals worked with, habitual clinical training and the healthcare system’ structure. On the other hand, GT/SP were not part of the curriculum at universities. This meant that training was more difficult to access, and limited the implementation of GT/SP. Reasons for the lack of access to GT/SP mentioned by participants were that the GT/SP was considered an ‘alternative psychological therapy’ and, therefore, it was not promoted or embedded in conventional health interventions.
Discussion
This study includes qualitative data on the perceptions of families and professionals around implementing GT (Peñarrubia and Naranjo, Reference Peñarrubia and Naranjo2008) and SP (Traveset Vilaginés, Reference Traveset Vilaginés2007) techniques in PHC consultations with children and adolescents. Data were collected following the implementation of GT/SP consultations in a PHC pediatric service in Agramunt (Spain) with 42 children and adolescents, and their families. Overall, participants considered GT/SP could have a positive impact, both on emotional and physical symptoms experienced by children and adolescents. Besides, participants mentioned how they believed GT/SP could be beneficial to the emotional health of family systems, and to enhance social participation and relationships. Participants also highlighted how having GT/SP in PHC could make these techniques (and their benefits) particularly accessible to children, adolescents and their families. On the other hand, professionals referred to barriers for implementing GT/SP in PHC.
Understanding (and addressing) health during childhood and adolescence in a more holistic way, including emotional well-being, is crucial to promote full physical and mental health (Castelló et al., Reference Castelló, Fernández de Sanmamed, García, Mazo, Mendive and Rico2016; Nelson, Reference Nelson2019; Brino, Reference Brino2020). Available research suggests that applying GT/SP could help reduce referral to specialized services, avoiding medicalizing some emotional problems that can be resolved over PHC consultations. It could also contribute to reduce the over-attendance of children, adolescents and their families. Above all, these approaches could help to improve the well-being of children and adolescents, and to prevent future health, educational, and social problems (Bofill Moscardó et al., Reference Bofill Moscardó, Fernández Corchero, Villegas Briz, García del Moral and Bandera2010; Buitrago Ramírez et al., Reference Buitrago Ramírez, Ramón Ciurana, Levy Chocrón, María del Carmen Fernández, Javier García, Carmen Montón and Jorge Luis Tizón2018; Brino, Reference Brino2020). In order to attain this, non-judgemental communication between healthcare professionals and families is imperative (Pidano et al., Reference Pidano, Segool, Delgado, Forness, Hagen, Abebe Gurganus, Honigfeld, Hess, Hicks and Morgan2020). Our research offers a description of the perceptions of families and professionals on GT/SP consultations. These are aligned with previous research and suggest their overall acceptability and favourable stance toward such techniques being implemented in PHC paediatric services. However, as participants in our study noted, it would be advisable to consider how families can apply and maintain GT/SP techniques at home.
As discussed by professionals in our research, specialized training for PHC professionals is essential (Imfeld et al., Reference Imfeld, Darang, Neudecker and McVoy2021). Moreover, one of the most notable barriers participants identified is the required paradigm shift in healthcare (Traveset Vilaginés, Reference Traveset Vilaginés2007), if the use of GT/SP was to be incorporated into emotional and mental healthcare consultations (Foucault, Reference Foucault1989; Haque and Waytz, Reference Haque and Waytz2012). In the contect of healthcare, this is inevitably linked to the need to change the paradigm in which health and the current healthcare system are constructed (Haque and Waytz, Reference Haque and Waytz2012). These changes would require to establish new roles within healthcare (Imfeld et al., Reference Imfeld, Darang, Neudecker and McVoy2021). The contribution of nursing professionals is of particular significance, especially in the light of their role in the implementation of child health programmes (Asociación Española de Pediatría de Atención Primaria, 2009), and health promotion programmes within educational settings (Ministerio de Educación, 2008) in Spain. It is also important to consider that, as our participants have indicated, the implementation of GT/SP may not be a significant time commitment. Nevertheless, it is essential to evaluate the necessity of restructuring and organizing material and temporal resources to accommodate this novel approach that prioritizes emotional well-being as a crucial aspect of child and adolescent health (Wissow et al., Reference Wissow, van Ginneken, Chandna and Rahman2016).
One of the limitations of this study is that the qualitative interviews were conducted in a relatively structured manner, which may have resulted in a lack of depth in the data dollected. Additionally, we were unable to obtain the experiences of children and adolescents, which could hace provided valuable insights. These limitations must be taken into account when interpreting the results of this study and may be addressed in future research. Moreover, it is essential to examine the viability and cost-effectiveness of employing GT/SP techniques in PHC settings. It is crucial to consider the experiences of both service users and providers. Future studies could concentrate on investigating the differential impact of GT/SP and evaluating GT/SP interventions, for instance, by testing various interventions in a randomized controlled trial. Qualitative methodology can be valuable in deepening the evidence on the implementation and differential cost-effectiveness of GT/SP.
Notwithstanding the aforementioned limitations, this project offers a preliminary insight into the potential of GT/SP to address emotional issues among children and adolescents in PHC settings, based on the perceptions of families and professionals. This may provide a foundation for further research aimed at enhancing the provision of emotional health services for children and adolescents in PHC. In the light of the above, this study can be viewed as an initial step towards investigating the potential applications and implications of GT/SP techniques in the field of PHC. This is particularly relevant given the neecessity to address emotional and mental health concerns among younger populations. Nevertheless, further research is required to ascertain the acceptability, implementation and effectiveness of these techniques, as there is currently a dearth of evidence in this regard. Additionally, it would be beneficial to provide training for professionals and to review public health policies in order to facilitate the integration of GT/SP approaches.
Conclusions
This study offers an overview of the perceptions of families and professionals on the use of GT/SP to address emotional and mental health issues among children and adolescents in PHC settings. The results of this study are useful to inform future research on GT/SP and in the field of emotional and mental health. Future research could focus on investigating the acceptability, implementation and cost-effectiveness of GT/SP consultations in paediatric PHC.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1463423624000379
Acknowledgements
We would like to thank all participants who took part in this study.
Funding statement
This study was funded by the Institut de Recerca en Atenció Primària Jordi Gol i Gurina (IDIAPJGol), through the ‘Research Projects in Primary Healthcare’ call in 2017, granted to TPP (4R18/037-1). The project received a research grant from the Carlos III Institute of Health, Ministry of Economy and Competitiveness (Spain), awarded on the call for the creation of Health Outcomes-Oriented Cooperative Research Networks (RICORS), with reference RD21/0016/0029 (Network for Research on Chronicity, Primary Care, and Health Promotion [RICAPPS]), cofunded with European Union – NextGenerationEU funds.
Competing interests
None.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the Spanish Law on Biomedical Research (14/2007) and the Spanish Law on Data Protection (3/2018) and with the Helsinki Declaration of 1975, as revised in 2008. The study was evaluated by the IDIAPJGol Research Ethics Committee and approved on May 4, 2018 (P17/227). All participants gave their verbal and written consent prior to taking part in the study.
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