The THRIVE model. (Wolpert et al. 2014:7)
Learning Point Summary
CYP-IAPT has significantly increased access to psychological therapies over the last few years.
CYP-IAPT aims to upskill clinicians in specialist CAMH services and those professionals that have significant contact with CYP in wider community services.
The Department of Health and Social Care and the Department of Education are piloting mental health support teams using evidence-based therapeutic interventions to support education providers in embedding their mental health and well-being strategies.
There are different levels of training in evidence-based therapy.
Evidence-based interventions can be offered by a nurse without any formal therapeutic training as long as it is informed by the evidence base and is supervised appropriately.
9.2 How Has Therapy Evolved?
It is important to have an understanding of the history of therapy and how it has developed over time, so that nurses can make an informed decision about why they may use a specific intervention or refer to the appropriate therapy. Each evidence-based therapy modality has an underpinning philosophy that defines its structure and process. We will consider some therapies and structures later in the chapter.
Understanding and treating human behavioural difficulties can be traced back to the ancient Greek philosophers such as Aristotle and Socrates (Robertson 2010). There was significant development of therapy in the nineteenth century, where mesmerism and hypnosis were dominant throughout the era (Robertson 2010). Walter Cooper Dendy an English psychiatrist developed the term psychotherapeia in his book ‘Psyche: A discourse on the birth and pilgrimage of thought’ (1853). Dendy asserted that psychotherapeia could be used for numerous mental health difficulties including sorrow, distress, grief, anxiety and fear. Dendy considered the writings of the Greeks in great detail and argued that all emotional feelings had physiological impacts too, with examples such as depression simulating sedating medication effects and grief and fear reducing vascular action. Dendy argued that by using psychotherpeia, you could reduce or change the thoughts that are symptomatic in depression and fear, thus improving the patient’s presentation (Dendy 1853).
Sigmund Freud further developed psychoanalysis at the turn of the twentieth century and developed his theories around trauma being related to childhood and sexual oppression in childhood (Rubovits-Seitz 2014). Freud believed, by working with the unconsciousness and where patients could freely associate, that he could reduce the emotional impact on the patient. Brown (1964:17–18) describes Freud as asking his patients to relax on the couch and close their eyes and verbalise about whatever should cross their minds, seemingly helping the patient connect with their unconsciousness and have free association. Freud, according to Brown (Ibid), believed that this verbalisation would allow for “painful emotions to be drained off as if it were a psychic abscess which had been opened and the purulent matter within it evacuated”. Freud’s work was significant as he conceptualised mental function operating separately from biological functions (Solms and Saling 1986). However, Freud was not alone in his development of psychic understanding, with theorists Pierre Janet, a psychical researcher (Evrard et al. 2018), Paul Dubois (1905) who wrote ‘The psychic treatment of nervous disorders’ and other researchers such as Hippolyte Bernheim, James Braid and Jean Martin Charcott were all purposively developing the understanding about psychic phenomena (Wallace and Gach 2008). Criticisms were made about several of the psychoanalytical theories especially from neurologists, who were concerned about the omission of any anatomical or physiological connections being made with the psychic disorders (Ibid). Freud’s work has continued to be developed through psychodynamic therapy through seminal theorists such as Carl Jung (1959) and Melanie Klein (1960).
Further into the twentieth century, many behaviourist researchers were developing their theories, with the most infamous of the time being Ivan Pavlov’s classical conditioning theory, where he commanded dogs to salivate on being presented with a stimuli and Burrhus Skinner’s operant conditioning theory, which demonstrated repeated, learned behaviours for the access of a reward (Mills 1998). Following the behaviourist’s developments, came a wide range of evolving treatments for psychic phenomena. These ranged from Rational Emotive Behavioural Therapy (REBT) by Albert Ellis (1962) which is said to be the major precursor to the Cognitive and Behavioural Therapies (CBT) (Robertson 2010). REBT theory was further developed by A.T. Beck’s (1967) cognitive approach and J. Wolpe’s (1969) behavioural approach. These developments were collaborated and demonstrate our more recent understanding of CBT. Concurrently, marriage therapies developed by Haley (1962) and Greene and Solomon (1963) blended into marriage and family therapy in the 1970s (Kaslow 2000), and further into family therapy throughout the 1980s influenced by seminal researchers such as John Howells (1971), Robin Skynner (1976) and John Byng-Hall (1982).
More recently, toward the twenty-first century, the third wave therapies such as acceptance and commitment therapy, mindfulness-based cognitive therapy, dialectical behavioural therapy, meta cognitive therapy and compassion focused therapy have been developed in a bid to move away from examining content and concentrate on the relationship between concepts (Hayes and Hofmann 2017). Therapies continually develop with increased understanding about the pathology of disorders, human anatomy and physiology and the relationships between the mind and body. The development of therapies is also impacted on by environmental and systemic influencing factors including wider social and cultural change. There are a diverse range of therapies, each with an individual philosophical underpinning. It is important to have some understanding of these, so the right therapy can be offered to the right child, young person or family at the right time. Trained evidence-based therapists can help you understand what therapy will be useful for the given presentation. The National Institute of Health and Care Excellence (NICE) (2019) also offers guidance about what therapies are demonstrated to be effective for specific diagnoses. It is important to make an informed choice about what therapy you offer, as not all therapies are suitable for all people. This is due to the therapeutic framework of each therapy differing significantly. The next section offers detail about available therapies within CAMHS; this is followed by a discussion of some of the fundamental interventions that are central to all therapies and how best to perform these.
Learning Point Summary
Psychotherapy or helping people deal with psychological difficulties can be traced back to the ancient Greeks.
There are many different models of therapy.
Therapy is always developing.
It is really important to ensure the therapy is the right fit for the CYP and not the CYP be fitted for the therapy.
NICE (2019) offers guidance about what therapies are demonstrated to be effective for specific diagnoses.
Trained therapists can help you choose an appropriate therapy or intervention for a patient.
9.3 An Overview of Some of the Therapies
9.3.1 Cognitive Behavioural Therapy
Cognitive Behavioural Therapy (CBT), as previously discussed, was developed from the works of Albert Ellis (1962), A.T. Beck (1967) and J. Wolpe (1969). CBT is an evidence-based treatment for a number of mental health difficulties as indicated by NICE (2019). CBT is fundamentally based on the idea that thoughts have an impact on behaviours and vice versa. When explaining what CBT is to CYP, it is helpful to understand the words ‘cognitive’ and ‘behavioural’; these are long words that CYP’s dont always understand. In practice, it is helpful to ask if they know what CBT means, if they don’t know, then explain each word clearly. Then help them understand how the model of CBT demonstrates the relationship between behaviours and thoughts. An example of this may be asking them what they would do and think if they saw a big spider; you can then relate their thoughts and behaviours in this situation, explaining how this is aligned to the CBT model; ‘the spider is going to get me’, therefore I ‘scream’ and ‘run away’. As the CYP had the thought that the spider was going to get them, this then encouraged them to scream and get to safety by running away. You can explain to the CYP, if you were able to change the thought about the spider, not be scared of spiders or not thinking that the spider wants to get them, and then the behaviour of running away would subsequently change.
CBT also includes three more fundamental influences to the development of a problem, these being the physiology, or what is happening physically to the body, emotions and the environment the problem is related to (Westbrook et al. 2011). In our example of seeing the spider, the physiology may be increased heart rate and breathing, sweating, feeling tense; emotions may be scared, anxious, worried; the environment would change the response of the patient, for example if the patient is in the bathroom with the spider, this is very likely to be a different response if the patient saw spider in the garden or on the television, or if it was a toy or a picture of a spider (Steimer 2002). Within the CBT philosophy, there is an importance to understand the staged levels of thought processes, which include negative automatic thoughts, cognitive distortions, dysfunctional assumptions and core beliefs (Bennett-Levy et al. 2004).
CBT is a structured, time limited and brief therapy that holds collaboration with the patient central to its philosophy. Although in the main this may be the CYP and the therapist, at times parents or friends or significant others could be involved in the therapy as a co-therapist to help the CYP at home and strengthen the support in challenging some of their difficulties. CBT can also be offered in a group setting for some difficulties. CBT is generally in the here and now, although previous experiences are considered in how they may have impacted on the presenting problem. CBT bases itself on empirical evidence, meaning that theories and practice of CBT are evaluated as much as possible to demonstrate its scientific value and effectiveness (Westbrook et al. 2011). CBT does involve the use of Routine Outcome Measures (ROMs) to help identify progress and the helpfulness of CBT and also help understand the development and maintenance of the problem (Hawton et al. 1989). The Child Outcome Research Consortium (CORC) is a national website where you can access free ROMs and other useful information to use in your practice (www.corc.uk.net/) (CORC 2019a, b). CBT would deem the patient as the expert in their own life and see the therapist as bringing expertise to equip the patient with understanding, new experiences and strategies to manage and treat the problem and to support the patient in becoming their own therapist (Westbrook et al. 2011).
It is expected that every CBT session has a collaboratively developed agenda by the CYP and the therapist that will be completed throughout the session. One of the final agenda items will include a ‘homework task’, or ‘activities for home’. Activities for home is a useful phrase if the CYP struggles with the concept of homework; and helps move it away from the school structure. The homework or activities for home is an essential part of the CBT model and is used to inform the subsequent session (Hawton et al. 1989). Without the homework or activities for home being completed, it will be very difficult to move forward with CBT and outcomes are significantly poorer (Kazantzis et al. 2000). It is helpful to describe CBT as offering 10% of the work in the session and 90% completed at home; this emphasises the importance of completing the home tasks but also helps encourage change outside the session where the problem has been developed and therfore will be best treated. Therefore, a CYP who is not willing to complete activites for home is unlikely to be suitable for CBT.
All of the aspects of CBT as detailed above should be initially discussed in a CBT suitability assessment with the CYP. A suitability assessment allows the CYP to socialise to the model of CBT and also offers the therapist time to assess motivation and whether the CYP wants to work within a CBT structure (Roos and Wearden 2009). It is really important to ensure that the therapy is the right fit for the CYP. The incorrect choice of therapy will impact on overall outcome and engagement.
Once an understanding of the problem has been ascertained, the therapist and the CYP will decide together how to best treat the presenting problem. Treatment in CBT will aim to reduce the symptoms identified in the four systems of the model (behaviours, cognitions, emotion and physical state). This will, in turn, reduce the symptoms in another system. The therapist may start with the thought about ‘the spider is going to get me’ and develop a treatment strategy collaboratively with the CYP that targets this aspect. The treatment would help the CYP find new information to think differently about spider getting them, which will subsequently change the behaviours associated with that thought. Treatment in CBT has a wide variety of tools to use including psychoeducation, behavioural experiments, graded exposure, systematic desensitisation, in-vivo work, information collecting, fact finding and cognitive challenges (Bennett-Levy et al. 2004; Hawton et al. 1989; Westbrook et al. 2011). The determinant of treatment being successful is by the achieving of their goal-based outcomes (GBOs), which are set at the beginning of therapy (CORC 2019a, b).
Learning Point Summary
CBT is a structured approach to therapy; the model will not suit CYPs who do not want to work in between sessions and do not want to challenge their difficulties.
CBT is very collaborative and holds the collaboration as central to its philosophy, the therapist and CYP are equal in the therapeutic relationship.
CBT is not just about changing thoughts and CYPs should not be referred for this alone.
It is a short-term evidence-based treatment for a range of mental health difficulties.
CBT works to an agenda and goal-based outcomes and uses ROMS throughout its process.
CBT with CYP is systemically driven and differs from adult CBT.
CBT with CYP can be creative and fun.
9.3.2 Psychodynamic Therapy
The development of psychoanalysis and psychoanalytic therapy has been discussed in this chapter. Psychodynamic therapy philosophy has developed from a range of theories including psychoanalytical, neuroscientific, attachment and developmental theory (Hobson 2015; Luyten et al. 2015; Berzoff et al. 2008).
Psychodynamic theory shares some core tenets with psychoanalytical theory in having equal focus on relationships. The focal points are on the relationship between the CYP and therapist, and the relationship between the CYP and his or her external world (Psychology Today 2019). Psychodynamic therapy usually involves a therapist and CYP being seen individually. It uses the knowledge of previous painful experiences, relationships and events to support the CYP in developing new patterns within relationships and subsequently finding ways to understand emotional experiences. This is done through exploring, clarifying and interpreting events with the CYP through a set of evidence-based interventions (Summers and Barber 2010). Psychodynamic therapy is evidence-based for depression and more recently eating disorders in current NICE guidance (2019).
Two key components within psychodynamic therapy are the considerations about transference and countertransference (Summers and Barber 2010). Both of these phenomena are embedded in the relationships that psychoanalytical and psychodynamic therapy study. Object relational theory helps the therapist to understand how the CYP is able to displace previous emotions and attitudes from their previous relationships, events and experiences to a substitute form or object, which is known as transference (Colman 2003; Brown 1964). Transference can be described in an example of a CYP having an anxious and excessively worried parent that has been overprotective toward the CYP throughout their childhood, which has prevented the CYP from taking many risks and subsequently inhibited developing independence in line with their peers. This relationship with the parent [the object] will be unconsciously replayed throughout the CYP’s current and future relationships. By the therapist gaining some understanding of this process, this will enable the therapist to work with the CYP in developing new pathways in relationships without the object being played out (Sanfeliú and Walters 2014).
Countertransference is embedded within the relationship between the therapist and the CYP and the CYP’s transference. The therapist’s unconsciousness will replay in the therapeutic relationship with the CYP, similarly as in transference from parent to child (Colman 2003). The objects in transference and countertransference have considerable impact on the personal values and assumptions of the therapist and the CYP. It is important for both the therapist and the CYP to explore these and have some understanding of how these are impacting on therapy. Psychodynamic theorists argue that transference provokes a countertransference (King and O’Brien 2011); an example of this may be that a CYP who is working with the therapist is not engaging well in the process despite the therapist’s best efforts. The therapist may start to feel that they are not confident in working with this particular CYP or their difficulty. The therapist becomes frustrated when meeting the CYP, holding feelings of inadequacy and feelings of being ‘stuck’ with the process. The therapist has either an opportunity to openly discuss their feelings with the CYP in an attempt to understand the countertransference to work through the difficulties or the therapist may infer from these feelings that the CYP is not motivated for therapy and ends the relationship. By the therapist having knowledge of transference and countertransference and being able to discuss this with the CYP, then therapy difficulties from transference and countertransference can be worked through (King and O’Brien 2011).
Learning Point Summary
Psychodynamic therapy is a medium-term intervention that focuses on relationships.
It is evidence-based for depression and eating disorders.
Psychodynamic theory uses object relational theory to help understand relationships.
Two key structures within psychodynamic theory are transference and countertransference.
It is usually the CYP and the therapist that attend therapy and no other persons involved.