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Cognitive Behavioural Therapy (CBT)
Cognitive behavioural therapy is a form of therapy with a wide application to many psychological problems. It is particularly used for depression, anxiety, and self-esteem problems. It is used for other problems like anger management, personality problems, and post-traumatic stress disorder.

It is based on the principle that thoughts can affect feelings and actions or behaviour. The style of thinking of a person is set by early life experiences and ongoing experiences. It is also affected by illness. Depressive illnesses affect the style of thinking, making it more likely that a person thinks in a negative way.

A person may have a style of thinking that can be anxious, aggressive, depressed, calm and rational, or a mix of these, (often at the same time). Some of the interactive stories relate to styles of thinking, and try and demonstrate how changing the way a person thinks can affect or change outcome.

Cognitive behaviour therapy works in the present, and requires both general and specific skills.

General skills are relevant to all forms of therapy. These are:-
1. Empathy
2. Genuineness
3. Warmth
4. Understanding
5. Awareness of boundaries
Specific skills are:-
1. Collaboration, agreeing on goals, tasks and limits of therapy
2. Active and directive, rather than passive and reflective
3. Scientific, finding the evidence for distorted or unhelpful styles of thinking
4. Open, in what is going on, sharing the theory with the patient
5. Problem orientated
A common sequence of cognitive work would be:-
1. Assessment and engagement work, checking that collaboration is present
2. Presenting the model, and how it relates to the patient?s problems
3. Developing a language in therapy, identifying feelings, describing them and situations
4. Identifying thoughts, and the unhelpful or dysfunctional nature of these
5. Finding the evidence for and against the truth of these identified thoughts
6. Experimenting with alternative more helpful thoughts and behaviours. Noticing how feelings change with thoughts.
Other important tasks might be:-
1. Risk assessment and management, a necessity if very suicidal, depressed or aggressive
2. Monitoring of medication
3. Checking their support network (friends, family and school/ college)
The behavioural part of CBT is just as important, especially for younger teenagers, those who are very inactive because of anxiety or depression, and for those that have problems identifying their thoughts.

Tasks can include:-
1. Planning pleasurable activities
2. Rewards for achieving certain behaviours (including self-reward)
3. Being realistic about what behaviours can be achieved
4. Planning graded programmes for other behaviours, such as returning to school, studying
5. Experimenting by changing behaviour, what happens to feelings and thoughts?

There are lots of self-help books, CDs, and Internet sites for adults, less so for teenagers. Some of the sites, are linked to in the relevant problem areas, particularly depression and anxieties.
Therapeutic approaches and motivational interviewing
Although not specific to working with teenagers, here is some information about motivation, therapeutic work and initial assessment. You can substitute teenager for family or child as required!
You can download a fuller version as a word document

Introduction
Careful assessment conducted in a style that is acceptable to the teenager and family is a key ingredient in the first step of providing some form of treatment or ?therapy?.

Person centred assessment/therapy
There has been a cultural shift away from doctors and professionals being experts and infallible to being sources of knowledge and help. This is set out in the Governments NHS plan. The plan aims to establish ?expert patients?, and to make records and professional correspondence available. Recent classifications of the type of interaction between patients and professionals include:
· Informed or consumer
· Paternalistic or expert
· Shared or collaborative
Many people with problems will want to adopt an expert stance with the doctor, but some do not, and want to actively participate in decision-making, including the choice to decline, or stop treatment.

Assessment of user wishes as a driver for change
People visit professionals to find or obtain:-
  • A cause for the problem
  • Support from medicine or another service to help with a known problem
  • Information to enable them to deal with the problem
  • A prognosis or prediction about a problem
  • Reassurance that they are doing the right thing about a problem
  • Reassurance that they are not ill
  • Evidence that they are ill
  • An opportunity to discuss other problems not directly related to the presented problem
  • Treatment for a problem

  • During assessment or therapy, an important question is how does change actually occur? The trans-theoretical model for change proposed by Prochaska and DiClemente (1992) suggests that the professional has to acknowledge which stage the patient is at when first seen. Some patients come in a stage of pre-contemplation, where change is not considered. They may however be in an action stage that is proving ineffective. In such circumstances, the patient may be very committed to continue using (or wanting) an ineffective approach (action stage), and not be willing (pre-contemplation stage) to explore or acknowledge possible different approaches. A common example is where people see a GP wanting (and often demanding) an anti-biotic for a cold or sore throat. The doctors may believe that there is no evidence that antibiotics work, and indeed may cause harm if given. Despite this, the patient wants antibiotics, and may think and feel less able to cope if the antibiotic is not given.

    In CAMHS as in other medical services, these issues are dealt with on a daily basis, and numerous psychotherapeutic techniques have developed to help families move from a pre-contemplation to contemplation stage. For instance, in family therapy, ideas of narrative, curiosity and social constructivism are used; while in individual cognitive behavioural therapy the therapist aims to establish a collaborative approach to develop a focus for work.

    Professional centred assessment/therapy
    The approaches used in assessment by CAMHS professionals are drawn from the diverse theoretical and professional knowledge bases, such as biomedical, family systems, social learning theory and psychodynamic, operating within multi-disciplinary CAMHS teams. Hence, there is variability in the way CAMHS professionals approach and conduct their initial assessment. However, what many of these traditional approaches to assessment have in common is that assessment is viewed primarily as a process of gathering information about the teenager, the family and the presenting difficulties in order to arrive at a clinical judgement about the nature, cause, likely course and treatability of the problem. Ultimately, assessment is seen as a means to an end, that is, case formulation and intervention.

    DRIVERS OF CHANGE IN ASSESSMENT/ THERAPY

    1) Assessment of need.
    A common definition of a need is the ability for the need to benefit from health care. Patients may want a certain type of help, but may or may not demand it during the first session. In addition within a family there may be many different views about these demands and wants. Individuals within a family can thus be viewed to have different perceptions of need that may or may not be explicitly stated in the assessment interview. The family?s differing perceptions of need may not necessarily match the view of the professional. The professional will form an opinion about the need for health care of the family. This will depend on a number of factors including

    · The professionals
    · Current help being offered for each problem
    · Whether the help is effective in reducing the severity of the problem
    · The professionals underlying beliefs about what works for the presenting problem, (the evidence base)
    · Whether the family is willing to accept the help that will be proposed
    · Whether the resources are available to offer this help within or outside of the CAMHS service.

    Thus the professional uses expertise and knowledge to assess needs from multiple viewpoints and makes a decision.

    2) Assessment and management of risk.
    A particular duty of professionals is the assessment of risk; the risk people within the family pose to each other and to others outside of the immediate household. Self harming behaviours are common presented problems, but other forms of harm, such as abuse, and reckless behaviour by adolescents (sexual, or substance misuse) may not be mentioned. The consultant may have to gather such information, both from direct questioning, by observation, and from others involved. Managing risk becomes a task for the family and other professionals with and without statutory responsibility. Contextual factors that alter risk include social or family support, or support from agencies. Clinical factors affecting risk include the level of depression or psychoses. In some circumstances where the risk of harm is high, care proceeding may be necessary, even if this is not perceived to be necessary.

    3) ?Fit? between Consultant and Family
    The consultant?s skill lies in finding a way of deploying their expertise and specialist knowledge, from whatever theoretical model they derive in a form that both meets the family?s needs and fits with their expectations. Moreover, the challenge to the consultant is to make their intervention useful and meaningful to families. Hence consultations would be judged as ?successful? if the user rated them as holding promise or hope. Consultations are custom-built but in general they lead to common categories or classes of outcome for the family: -

    1. An explanation of, and a reflection on, the cause of the problem(s) with the family but with no specific advice.

    The decision for the consultant here is how and when to make their opinion explicit to the family. If asked by the family for a professional opinion, the task is then to deliver it so that it promotes new insights and possibilities without inducing blame or guilt.

    2. Advice giving and guidance, in order to enable a family to use their own strengths to deal with the problems. Advice may include written material such as self-help literature.

    As with opinions, advice giving requires the consultant to make fine judgements about appropriateness, timing and acceptability. Moreover, families may arrive with particular priorities and agendas about the type of advice they want. For instance, some parents arrive armed with specialist knowledge about CAMH problems obtained from the Internet, which can add to the complexity of advice giving and creating challenges for us as consultants.

    3. Signposting to, or referral on to, an external agency.

    4. Referral on to a specific treatment or assessment programme (e.g. a specialist form of therapy or multidisciplinary assessment / treatment).

    The family?s experience of the assessment is critical in determining dynamic outcome. If the style and content of the assessment does not match with the hopes and expectations that families bring to their first appointment they may not want to return. Moreover, it is likely that the family experience of the initial assessment affects the quality of any subsequent engagement with therapy, which, in turn, predicts clinical outcome. In sum, the way that CAMHS specialists approach assessment matters and therefore it warrants greater attention and should be theorised and researched with more vigour.

    ASSESSMENT VERSUS THERAPY
    Effective assessment may contain similar features with effective therapy. According to Bateman & Fonagy (2000), effective psychotherapeutic treatments contain seven common features: -

    a) A clear structure
    b) Effort is put into enhancing compliance with treatment
    c) They have a clear focus
    d) They are theoretically highly coherent to professional and patient
    e) They are relatively long term
    f) They encourage an interpersonal relationship, allowing the therapist to be relatively active rather than passive
    g) They are well integrated with other services


    Compare this with our definition of the ingredients of a consultation and advice service (Heywood et al, 2002):
    · Brief and focused
    · reflects on the process of referral
    · elicits parental expectations and wishes
    · identifies and works with any ambivalence or blame
    · assesses severity and need
    · negotiates clear and realistic goals for the consultation
    · agrees realistic goals for any therapeutic intervention that may follow the consultation
    · attempts to demystify the process of therapy and avoids ?missions impossible?
    · allows families to ?opt in? with ?informed consent? to therapy
    · avoids ?drifts? into therapeutic relationships and ?therapy by stealth?
    · Initially, take a non-expert stance with the family.
    · Assess whether the family want or need therapy.
    · Assess whether there is agreement between family members.
    · To think about patterns of discourse used by the family and by the consultant.
    · Be alert to the emergence of issues pertaining to risk.

    This can be reduced to the following four tasks: (Street and Downey 1997)
    1. Develop an interactive understanding of the referral process
    2. Develop an interactive view of the problem
    3. Understand the family?s ideology of the problem
    4. Ascertain the family?s expectations of the consultation and consultant

    1) Develop an interactive understanding of the referral process
    Initially, we would be asking the family about how they came to be referred to the service, (without necessarily asking for information about the nature of the problem) with questions such as, ?Who suggested you should come to this service?? and ?What did the referrer say was the reason s/he was referring you?? This helps to develop an understanding as to whether there are discrepancies between the referrer?s concept of the problem and the family?s notion of what is wrong, and to elicit any early indications of the family?s hopes and expectations.

    2) Develop an interactive view of the problem
    Once the consultant has a better idea of how the family came to be referred to the service (and thus whether they are, in solution focused therapy terminology, pre-contemplative ?window shoppers? or ?browsers? or have definite designs on therapy, and are therefore active ?customers?, (DeShazer 1985)) , it is then important to listen to and understand the family?s view of the problem. By listening and reflecting, the family has, perhaps for the first time, the opportunity to ?hear? their ?story? told by the consultant. It can be useful to read out the referral letter as this helps to focus ?problem description?.

    At this stage, families frequently want to give all the details, often rapidly, to the consultant, which can make it difficult to intervene. One way of slowing the process down is to check out with the family your understanding and to repeat back their version of events. It is useful to take an example and follow it through so the consultant begins to develop a ?behavioural understanding? of the problem. That is, with the family?s story about their difficulties, together a picture of events develops. Use phrases such as, ?So you?ve told me that incident B happened after incident A, so what happened next?? and ?Have I got this right???.

    3) Understand the family?s ideology of the problem
    As we have stressed the stages of consultation are not discrete and tightly structured, therefore the family?s ideology of the problem can emerge at any stage point in the process. Thus the consultant must be alert to this and prepared to take note and, if necessary, develop implicit references to parents understanding of causation at any point in the consultation. An illustration of family ideology unfolding when the consultant is engaged in reaching an interactive understanding of the referral process is apparent in the following extract.

    In the process of eliciting the family?s causal attributions and explanatory frameworks it is important to: -

    · Avoid imposing consultant?s meaning or solutions onto the problem
    · Remain neutral
    · Try and expand families meaning and understanding through summarising, reflecting and questioning

    4) Ascertain the family?s expectations of the consultation and consultant
    It is often the case that the process of gathering information leaves little room for exploration about what would be most useful to the family. With some families, feeding back a lack of clarity can be useful whereas with others, it could be disastrous. Often families arrive with an expectation that the consultant will ?give? them something - advice or an opinion - and will therefore be disappointed if this doesn?t happen. In a more traditional setting, these may be the types of families we ?lose? because they do not attend again. The important difference then in consultation is to discuss their expectations and to think with them about the implications of advice giving.

    Once the consultant has established what it is the family expects, rather than simply deliver the goods, part of the consultation process is to have a conversation about the impact of what this outcome might bring. For instance, if the family want advice about a particular problem, ask them ?What advice do you think is likely to work?? or ?How would things improve if I offered that advice?? or ?What kind of advice were you expecting?? This again gives clues as to how the family will utilise the information and may encourage the family to generate their own solutions.

    Giving advice can sometimes require tentative and sensitive handling, particularly as many parents attending CAMH services already feel to blame for their children?s difficulties. This is perhaps more difficult if the consultant has identified a need for change in a particular area before the family have. When offering advice, the therapist should check out with the family whether they have understood and whether they think that the advice is a useful way forward. This may highlight similarities and differences in opinions between family members.

    Advice can also be given in the form of a letter once the session is over, which may include a brief recapitulation of the assessment. The NHS plan suggests that professional correspondence is copied routinely to families and thus, if the therapist does write a letter, it may serve the purpose of informing the GP or other professionals involved. Most of the letters we have written to families have been to summarise the session and the advice given, particularly when one parent is absent from the session. This helps the parent feed back to the other about what they may need to think about in-between sessions.

    Some families want to share their concerns about their child?s problems and simply need reassurance that either they are doing the ?right? thing or that it is nothing too serious, so they ask for the consultant?s opinion. The skill of the consultant is to assess whether this should be delivered at that specific moment or whether further exploration of the parents? views, for instance, would be more productive.


    References
    Bateman AW, Fonagy P, 2000. Effectiveness of psychotherapeutic treatment of personality disorder. British Journal of Psychiatry, 177, 138-143

    Connor DF, Fisher SG (1997), An Interactional Model Of Child and Adolescent Mental Health Clinical Case Formulation. Clinical Child Psychology and Psychiatry, 2, (3): 353-368.

    DeShazer, S. (1985) Keys to Solution in Brief Therapy. New York: Norton

    Digiuseppe R, Linscott J, Jilton R (1996), Developing the therapeutic
    alliance in child ? adolescent psychotherapy. Applied and preventive psychology 5: 85-100

    Eminson DME (1993). Assessment in Child and Adolescent Psychiatry.
    In Seminars in Child and Adolescent Psychiatry (eds Black D, Cottrell D) Gaskell Press.

    Kroll L, Green JM (1997), The Therapeutic Alliance in Inpatient Child Psychiatry. Development and Initial Validation of a Family Engagement Questionnaire. Clinical Child Psychology and Psychiatry, 2, (3): 431-447.

    Street, E. and Downey, J. (1996) Brief Therapeutic Consultations: An Approach to Systemic Counselling. Chichester: Wiley.
    Needs assessment and self-assessment
    The self assessment part of this site is based in part on needs assessment research (Kroll et al 1999). A brief summary is given here. Software for the research version is available to download from:- http://www.gac.man.ac.uk/autoneed, or click on this link

    For more details about the research version and other alternative research versions that are available (customised for specific projects), contact Leo Kroll.

    The clinical version of the Salford Needs Assessment schedule for Adolescents can be downloaded here.

    Kroll L, Woodham A, Rothwell J, Bailey S, Tobias C, Harrington RC, Marshall M. 1999. Reliability of the Salford Needs Assessment Schedule for Adolescents. Psychological Medicine, 29, 891-902
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