Clinician's Guide to CBT for Children to Young Adults

PAUL STALLARD is Professor of Child and Family Mental Health at the University of Bath and Head of Psychological Therapies (CAMHS) for Oxford Health NHS Foundation Trust. He is a clinical psychologist who has worked with children and young people for 40 years using Cognitive Behaviour Therapy (CBT). He is also an active researcher and has been involved in many studies exploring the use and effectiveness of CBT with children and young people.

• About this book xiiiAcknowledgements xvOnline resources xvii1 Introduction and overview 1CBT as an intervention 1CBT as a preventative intervention 2CBT with younger children 3CBT with children and young people with learning difficulties 4Technologically delivered CBT 5Involving parents 6The competencies to deliver child-focused CBT 7Assessing competence 8Cognitive Behaviour Therapy Scale for Children and Young People 9CORE philosophy 13Child-centred 14Outcome-focused 15Reflective 16Empowering 172 PRECISE 19The therapeutic alliance 19Partnership 21Eliciting the young person’s and parents’ understanding and views 22Encourages the young person to participate in decision making 23Involves the young person and parents/carers in planning the intervention 24Encourages the young person to provide feedback about sessions 25Right developmental level 25Ensures an optimal balance between cognitive and behavioural techniques 26Uses simple, clear, jargon-free language 27Uses a variety of verbal (direct and indirect approaches) and non-verbal techniques 28Appropriately involves parents/carers/others 28Courtney has anger outbursts 30Empathy 30Conveys interest and concern using active listening, reflection, and summaries 30Acknowledges and responds to emotional responses 32Demonstrates an open, respectful, non-judgemental, caring approach 33Empathises with parents 34Creative 35Tailors the concepts and methods of CBT around the interests of the young person 35Uses a range of verbal and non-verbal methods 36Creatively uses a range of methods 37Utilises the preferred media of the young person 38Investigation 39Creates a process of collaborative inquiry 39Fully involves young people in the design of experiments 40Helps young people and parents/carers to consider alternative explanations 41Encourages reflection 42Self-efficacy 42Identifies and highlights strengths and personal resources 43Encourages identification of helpful skills and strategies 44Develops personal coping strategies 44Reinforces use of new skills 45Enjoyable and engaging 45Uses an appropriate mix of materials, activities, humour 46Maintains an appropriate balance between task and relationship-strengthening activities 46Attends to the young person’s interests and incorporates them into the intervention 47Presents as positive and hopeful 48PRECISE in practice 48Ella’s obsessional thoughts 48Joshua’s negative thinking 493 A: Assessment and goals 51Undertakes a full assessment of the presenting problem 51Compliments assessment with routine outcome measures (ROMs) 53Negotiates goals and the dates when progress will be reviewed 55Identification of goals 56Prioritisation of goals 57Whose goals? 57Inappropriate goals 58Uses diaries, thought bubbles, and rating scales 59Sarah feels faint 59Tick charts 60Thought bubbles 60Visualisation 61Stories 62Rating scales 63Pie charts 63Theo’s washing 64Assesses motivation and readiness to change 64Pre-contemplation 65Contemplation 67Preparation 67Action 68Maintenance 68Relapse 684 B: Behavioural 69Uses behavioural techniques to facilitate therapeutic change 70Developing hierarchies 70Graded exposure 72Response prevention 74John is worried about germs 75Problems when undertaking exposure 75Young person avoidance 75Clinician avoidance 76Anxiety does not come down 76Is the young person focusing on their anxiety? 77Are parents/carers appropriately involved? 77Uses behavioural techniques such as activity rescheduling and behavioural activation 77Activity rescheduling 77Alison feels down 78Behavioural activation 79Problems when undertaking behavioural activation 80I didn’t feel like doing it 80I did it, but I don’t feel any better 81I did it, but so what? 81It’s not important 81Provides a clear rationale for using behavioural strategies 82Identifies and implements reward and contingency plans 82Models, uses role play, structured problem-solving approaches, or skills training 85Model how to cope 85Role play 87Problem solving 88Skills training 895 C: Cognitions 91Facilitates cognitive awareness 92Cognitive content 92Levels of cognitions 92Freya worries about making a fool of herself 93Uses thought records and bubbles 96Identifies functional and dysfunctional cognitions 98Unhelpful thoughts 99Helpful thoughts 99Identifies common cognitive biases (‘thinking traps’) 99The negative filter 100Blowing things up 100Predicting failure 101Being down on yourself 101Setting yourself up to fail 101Facilitates thought challenging and perspective taking 102What is the evidence? 102The 4Cs 103What would someone else say? 103Jaz falls out with her friend 104Facilitates continuum work using rating scales 104Uses techniques such as mindfulness, acceptance, and compassion 105Mindfulness 105Compassion 107Acceptance 109Kindness 1106 D: Discovery 111Facilitates discovery and reflection through use of the Socratic dialogue 111The Socratic dialogue 113What makes a good Socratic question? 116Mike is worried about his cat 118Common difficulties 120Alternative perspective taking and attending to new or overlooked information 122Perspective taking 122Responsibility pies 123Joshua’s accident 123Attends to overlooked information 124Analogical comparisons 124Systematically testing the assumed relationship 125Marla worries she will pass germs to others 126Behavioural experiments and prediction testing 127Cognition- and prediction-testing experiments 127Planning a behavioural experiment 128Prediction-testing experiments: Caleb thinks he is a failure 129Active experiments: Laura’s social anxiety 130Information gathering experiments: Adam’s formulation 1317 E: Emotions 133Develops emotional literacy by facilitating the identification of a range of emotions 133Helps to distinguish between different emotions and identifies key body signals 135Body signals 135Feeling diaries 135William feels sad 136Emotional logs 137Isabella feels down 137Relaxation, guided imagery, controlled breathing, and calming activities 138Progressive muscle relaxation 139Calming imagery 141Aisha’s calming image 141Diaphragmatic (controlled) breathing 142Change the feeling 143Physical activity, letting feelings go, emotional metaphors, and imagery 144Physical activity 144Let the feeling go 144Emotional metaphors 145Emotive imagery 145Anthony’s humorous image 146Self-soothing, mind-games, and mindfulness 146Self-soothing 146Mind games 147Mindfulness 147Talk with someone 1488 F: Formulations 149Provides a coherent and understandable rationale for the use of CBT 149Linking thoughts, emotions, and behaviours 151Mini-formulations (two- or three-system models) 151Rhiannon is unhappy and scared 152Maintenance formulations 154Naomi cuts herself 154Four-system formulations 155Abdul’s anxiety 156Remember the strengths 157Provides an understanding of important past events and relationships (onset formulations) 158Mary’s anxiety 161Includes parental/family factors in formulations 163Sally’s anxiety 163Activities and goals/targets are clearly linked to the formulation 165Common problems 167Difficulty identifying thoughts or feelings 167Is it important to distinguish between different levels of cognitions? 168I can’t seem to put this together in a formulation 168I’m not sure if the formulation is right 169I can’t seem to find all the information to complete the formulation 1699 G: General skills 171Prepares and brings the necessary materials and equipment to the meeting 171Manages the young person’s behaviour during sessions 172Ensures that sessions have an agenda and clear goals and are appropriately structured 174General update 175Outcome measures update 175Home assignment review 175Session topic 176Home assignment 176Session summary and feedback 176Ensures good timekeeping so that all tasks are completed 177Sessions are appropriately paced, flexible, and responsive 178Responsive 180Gary is worried about germs 180Prepares for endings and relapse prevention 181Relapse prevention 18110 H: Home assignments 185Negotiates home assignments 185Assignments are meaningful and related to the formulation 188Assignments are consistent with the young person’s developmental level 189Assignments are realistic, achievable, and safe 191Refers to goals when planning assignments and to rating scales when reviewing progress 193Harry wants to get fitter 193Fatima’s unhelpful thoughts 194Assignments are reviewed and reflection encouraged 19511 Putting it together 199Anxiety 200Effectiveness 200Rationale informing the intervention 200Core components of CBT interventions for anxiety disorders 201Parents 202Important cognitions 202Depression 203Effectiveness 203Rationale informing the intervention 204Core components of CBT interventions for depression 205Parents 206Important cognitions 206Obsessive-compulsive disorder (OCD) 207Effectiveness 207Rationale informing the intervention 208Core components of CBT interventions for OCD 209Parents 210Important cognitions 210Post-traumatic stress disorder (PTSD) 210Effectiveness 210Rationale informing the intervention 211Core components of CBT interventions for PTSD 211Parents 212Important cognitions 213When it doesn’t go right 213Is the young person motivated to change? 215Sam’s costs of change 217Are the young person and their family engaged with the intervention? 219Jade is anxious and depressed 221How has the intervention been delivered? 22412 Resources 229The Chain of Events 230The Negative Trap 231Four systems 232How did this happen? 233Session rating scale 234Scales of change 235Anxiety intervention plan 236Depression intervention plan 237OCD intervention plan 238PTSD intervention plan 239Motivation 240Engagement 241Intervention delivery 242Reflective practice 243The Cognitive Behaviour Therapy Scale for Children and Young People (CBTS-CYP) 244Beating anxiety 259Fighting back depression 264Controlling worries and habits 270Coping with trauma 275References 279Index 291