Endorsement by NICE and an expansion in provision make this a good time to consider what CBT can offer for psychological problems. Dr Alexander Scott explains
Alexander Scott MBChB MSc Haringey Child and Adolescent Mental Health Services Staff Grade Doctor in Child and Adolescent Psychiatry Barnet, Enfield and Haringey Mental Health NHS Trust
Cognitive behavioural therapy (CBT) is a form of psychotherapy or "talking cure" that has been shown to be effective for a wide range of psychological problems and shows promise in many others. Up to now it has been used more with adults but there is a growing body of evidence of its usefulness in children and young people for conditions that include depression, generalised anxiety disorder, obsessive compulsive disorder, school phobia, eating disorders, self-harm and conduct problems. Journal of Family Health Care 2009; 19(3): 80-82
_ Cognitive behavioural therapy (CBT) is evidence based and increasingly important in current mental health practice
_ CBT treatment usually targets thoughts and behaviours. It encourages clients to challenge maladaptive thinking styles and unhelpful behaviours and replace them with more realistic thoughts and better coping strategies
_ Though most research has been with adults, there is increasing evidence that CBT techniques can be effective for children and young people
_ CBT can be used for psychological problems such as depression, generalised anxiety disorder, school phobia, eating disorders, conduct disorders, and self-harm
_ It has also been useful in some physical problems, such as irritable bowel syndrome and chronic pain syndromes
_ Most CBT is delivered in CAMHS settings but simple cognitive interventions, usually lasting a few weeks, are being developed that may be suitable at Tier 1 and Tier 2 levels
Cognitive Behavioural Therapy (CBT) is a form of psychotherapy, or "talking cure", that is becoming increasingly important in current mental health practice. It has been widely recommended by the National Institute for Clinical Excellence (NICE) in its guidance on mental health problems1. For children and young people, NICE has recommended CBT as a first-line treatment in depression2, post-traumatic stress disorder3 and obsessive compulsive disorder4, and it is recommended as a possible component of treatment for attention deficit hyperactivity disorder (ADHD)5 eating disorders6 and many other conditions. It is very important in terms of government policy, as can be seen from its prominent place in the Increasing Access to Psychological Therapies Programme (IAPT)7. CBT is mentioned specifically in the National Service Framework as one of the range of treatment modalities that CAMHS services should endeavour to provide8.
History of CBT
CBT grew out of psychological theory which was developed over the course of the 20th century. It has its basis in psychological models of learning theory, in the works of Pavlov and Skinner. Early behavioural therapists such as Wolpe and Rachman developed treatments which worked solely on modifying clients' behaviour and, through this, their symptoms. This included treatments such as exposing people with phobias to the thing that they feared while pairing this with techniques like relaxation training. Later, Beck and others also paid attention to the client's thinking process, and worked on changing symptoms through changing cognitions, for example thoughts, beliefs, interpretations and expectations of events.
Principles of CBT treatment
Current CBT techniques combine these approaches into one unified treatment. The principles of how CBT works are often represented by a "hot cross bun" model (see Figure). CBT stresses how thoughts, feelings, behaviour and physical symptoms interact. Depression, for example, is a condition that includes symptoms in different areas of this diagram. There are symptoms which are feelings, such as low mood or anxiety; symptoms that are thoughts, such as guilty thoughts or suicidal thinking; symptoms that are behaviours, such as isolating oneself from friends and social contact; and physical symptoms such as fatigue or loss of appetite.
CBT psychological models stress that these symptoms interact and can actually cause and/or maintain each other. For example, in depression we might experience physical symptoms like fatigue; this causes us to think thoughts such as "this must mean that I am unwell and must therefore rest", so we resort to behaviours like staying in bed, and this, because of the lack of social contact and inactivity it causes, leads us to feel low in mood.
CBT treatment usually targets the client's thoughts and behaviours. It encourages clients to challenge maladaptive thoughts and thinking styles in order to replace them with better and more realistic ones, and to replace unhelpful behaviours with more adaptive coping strategies. These changes help bring about changes in feelings and physical symptoms. We might draw a comparison here with physical treatments, such as antidepressants in depression. Antidepressants could be said to affect the feelings of low mood and, through this, the thoughts, behaviours and physical symptoms are improved. Thoughts are challenged by asking clients to note down their thoughts associated with distressing feelings. These thoughts are then examined, with the therapist specifically asking about the evidence the client has for these thoughts and whether the client has any alternative explanations for them. Clients are encouraged to modify their behaviour by the use of "behavioural experiments" that the client carries out themselves, where the merit of more rational adaptive behaviours can be demonstrated to them.
Features of CB
CBT differs from other therapies in many ways, but three important features of CBT are:
1. CBT is collaborative
In CBT the client and therapist work together to help alleviate symptoms. The therapist will, to a greater or lesser extent, share their opinion and formulation of the case with the client (in contrast to more psychodynamic forms of psychotherapy where the therapist's formulation of the case may be largely undiscussed with the client).
2. CBT is time-limited
The therapist and client will usually agree a certain number of treatment sessions at the start of treatment. This may be extended, but very long periods of treatment are unusual. Treatments will typically be of the order of 12-18 weekly sessions but can be considerably less.
3. CBT is symptom-focused
The therapy will discuss the client's symptoms in the "here and now". It does not generally involve analysis of events in the distant past, but instead looks at current thoughts and behaviour and their relationship to current symptoms.
Conditions that respond to CBT
As noted above there are many conditions where CBT has been successfully applied. Most research in CBT to date has focused on adults and at present comparatively little work has been done with CBT in children. There is, however, an increasing body of evidence that CBT techniques can also be effectively used with children and young people9. This has been demonstrated in a wide range of conditions, such as school phobia, eating disorders, self-harm and conduct problems10, as well as those mentioned below. It has also been found useful in some physical problems, for example irritable bowel syndrome and chronic pain syndromes. Results from research on CBT in a range of conditions are given below.
Generalised anxiety disorder
Ledouceur11 et al found an overall response rate of 77% for CBT for generalised anxiety disorder (GAD) in their sample.
Obsessive compulsive disorder
Response of childhood obsessive compulsive disorder (OCD) to CBT has varied widely. Some studies have shown extremely impressive results, for example Barrett12 obtained an 88% response rate to CBT, vs. a 0% response rate in her waiting-list control group. However, other studies have achieved significantly lower response rates. Overall, reviews such as Cochrane13 have been positive.
Many studies have demonstrated the effectiveness of CBT for depression in children and adolescents. Reinecke9, in a review and meta-analysis of using CBT with depressed and dysphoric adolescents, calculated the overall effect size of CBT in depression to be 1.02, a "large-effect" size. His findings suggest that there are both short- and long-term effects of using CBT approaches to treat depressive symptoms in depressed and dysphoric adolescents.
Post-traumatic stress disorder (PTSD)
Several studies have shown CBT to be effective in childhood PTSD, for example Smith14 found CBT to have a 92% response rate compared to a 42% response rate to a waiting-list control.
Involving the parents and the family
CBT is primarily an individual intervention and, after assessment, children are usually seen on a one-to-one basis by the therapist for treatment sessions. However, despite the individual emphasis of the treatment, parents and carers can expect to be involved in treatment; for example, homework forms an important part of the therapy and this may require adult support and encouragement and/or supervision. Also, some successful CBT interventions have been developed working only with parents, for instance treatments for infant and child sleeping problems15.
There is no particular lower age limit for CBT: provided that children are sufficiently advanced in their psychological development to be able to understand and make use of the CBT models, then they can be given CBT. However, CBT appears to be more effective for children as they get older. Durlak16 suggests that although CBT has been shown to be effective for children as young as 5-7 years, it achieves markedly better results with children aged 11 years and over.
Learning disability and other special considerations
Children with special considerations such as learning disability may benefit from CBT but careful consideration of their development and understanding will be necessary in judging whether it is appropriate. Generally speaking, children will first have an assessment from the Child and Adolescent Mental Health Service (CAMHS) to determine whether a CBT intervention is appropriate for them.
Other ways in which CBT can be delivered
CBT can be delivered in a variety of forms as well as on a face-to-face basis. Several self-help books have been written based on cognitive behavioural techniques, some with catchy titles such as "Cognitive Behavioural Therapy for Dummies"!17 Some are aimed at parents18 and exist as an option for them, but if in doubt it is advisable to consult the local CAMHS. CBT has also been packaged into computerised interventions, some of which have been recommended in technology appraisals by NICE19.
Accreditation as a CBT therapist
Formal accreditation as a CBT therapist is provided by the British Association for Behavioural and Cognitive Psychotherapies20 (BABCP). To qualify for accreditation, most professionals will undertake training and supervision in CBT techniques as part of their work (there are only a few formal, taught courses that lead directly to accreditation). People seeking accreditation must first have qualified in an approved "core profession", such as nursing, social work, medicine and clinical psychology.
Although people who are formally accredited can and should be regarded as CBT "experts", other CAMHS professionals may well use CBT techniques as part of their interventions. Most CBT interventions will be delivered in CAMHS settings, although simple cognitive interventions, especially brief ones, are being developed that may be appropriate at Tier I and Tier 2 levels. There are many courses that teach cognitive techniques, often in the context of specific conditions. Details of some (usually the more advanced courses) can be found on the BABCP website (see Resources).
CBT is a treatment that has been developed from a sound theoretical basis in psychological learning theory. It has been shown be effective in a wide range of conditions and shows promise in many others. Up till now it has been used more with adults although there is a growing body of evidence of its usefulness in children.
Resources and further informationBritish Association for Behavioural and Cognitive Psychotherapies (BABCP)
Professional association and registered charity which accredits CBT therapists and provides conferences, courses and other professional information and opportunities. Members include nurses, counsellors, psychologists and psychiatrists.
BABCPhttp://www.babcp.com/ Victoria Buildings, 9-3 Silver St, Bury BL9 0EU E-mail email@example.com Tel 0161 797 4484 Fax 0161 979 2670
1. National Institute for Clinical Excellence [NICE]. Summary of Cognitive Behavioural Therapy Interventions Recommended by NICE. See NICE: 2007/08 Published Programme. Available at http://www.nice.org.uk/usingguidance/commissioningguides/cognitivebehaviouraltherapyservice/specifying/SummaryCBTinterventions.jsp (accessed 8 June 2009). See also 2007/08 Commissioning Guides Published Programme. Cognitive Behavioural Therapy for the Management of Common Mental Health Conditions (April 2008). Available at http://www.nice.org.uk/usingguidance/commissioningguides/cognitivebehaviouraltherapyservice/commissioning.jsp (accessed 8 June 2009)
2. Depression. National Institute for Clinical Excellence [NICE]. Depression in Children and Young People. Identification and Management in Primary, Community and Secondary Care. Clinical Guideline 28. NICE, 2005. http://www.nice.org.uk/guidance/CG28 (accessed 21 Apr 2009)
3. National Institute for Clinical Excellence [NICE]. Post-traumatic stress disorder (PTSD). The management of PTSD in adults and children in primary and secondary care. Clinical Guideline 26. March 2005. http://www.nice.org.uk/nicemedia/pdf/CG026NICEguideline.pdf (accessed 21 April 2009)
4. National Institute for Clinical Excellence [NICE]. Obsessivecompulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical Guideline 31. NICE: November 2005. http://www.nice.org.uk/nicemedia/pdf/cg031niceguideline.pdf (accessed 21 Apr 2009)
5. National Institute for Clinical Excellence [NICE]. Attention deficit hyperactivity disorder. Diagnosis and management of ADHD in children, young people and adults. Clinical Guideline 72. NICE: September 2008. http://www.nice.org.uk/Guidance/CG72/NiceGuidance/pdf/English
6. National Institute for Clinical Excellence [NICE]. Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. Clinical Guideline 9. NICE: January 2004. http://www.nice.org.uk/nicemedia/pdf/cg009niceguidance.pdf
7. Department of Health [DH]. Improving Access to Psychological Therapies. DH, 2009. http://www.iapt.nhs.uk (accessed 21 April 2009)
8. Department for Education and Skills [DfES] and Department of Health [DH]. National Service Framework for Children, Young People and Maternity Services. The Mental Health and Psychological Well-being of Children and Young People. CAMHS Standard. DfED/DH, 2004 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4089114 (accessed 27 April 2009)
9. Reinecke M, Dattilio F, Freeman A (eds). Cognitive Therapy with Children and Adolescents. New York: Guilford Press, 2003
10. Hawton K, Salkovskis PM, Kirk J, Clark DM (eds). Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide. Oxford: Oxford Medical Publications, 1989
11. Ladouceur R, Dugas, MJ, Freeston MH, Léger E, Gagnon F, Thibodeau N. Efficacy of a cognitive-behavioural treatment for generalized anxiety disorder: evaluation in a controlled clinical trial. Journal of Consulting and Clinical Psychology 2000: 68(6): 957-964
12. Barrett P, Healy-Farrell L, March JS. Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: a controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry 2004: 43(1): 46-62
13. O'Kearney RT, Anstey K, von Sanden C. Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004856
14. Smith P, Yule W, Perrin S, Tranah T, Dalgleish T, Clark DM. Cognitive-behavioral therapy for PTSD in children and adolescents: a preliminary randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry 2007: 46(8):1051-1061
15. Sadeh A. Cognitive-behavioral treatment for childhood sleep disorders. Clinical Psychology Review 2005; 25(5): 62-628. Review
16. Durlak JA, Fuhrman T, Lampman C. Effectiveness of cognitivebehavior therapy for maladapting children: a meta-analysis., 1991. Psychological Bulletin 1991; 110(2): 204-214
17. Willson R, Branch R. Cognitive Behavioural Therapy for Dummies. Chichester: Wiley, 2006
18. Cresswell C, Willetts L. Overcoming Your Child's Fears and Worries. London: Constable Robinson, 2007
19. National Institute for Clinical Excellence [NICE]. Depression and anxiety - computerised cognitive behavioural therapy (CCBT). Technology appraisal TA97.(Review of Technology Appraisal 51.) NICE, February 2006 http://www.nice.org.uk/Guidance/TA97/Guidance/pdf/English (accessed 28 April 2009)
20. British Association for Behavioural and Cognitive Psychotherapies. http://www.babcp.com/ (accessed 27 April 009)
21. Greenberger D, Padesky CA. Mind Over Mood: A Cognitive Therapy Treatment Manual for Clients. New York: Guilford Press, 1995