Jenaway, A., Mortlock, D., 2008. Service Innovation. Reformulation, Summer, pp.31-32.
Most child and adolescent mental health services would like to have some access to psychodynamic therapy. However, child therapists trained in psychodynamic therapy are in short supply, and offering long term therapy is not always practical or cost effective. We describe a pilot to see if offering Cognitive Analytic Therapy within a CAMH service is a helpful alternative.
Cognitive Analytic Therapy is a brief therapy, usually 16 sessions, which has developed as an integration between cognitive behaviour therapy and psychodynamic therapy. It has been used mainly in adults and old age services and in naturalistic studies has shown an effect size similar to other psychotherapies (Dunn et al, 1997, Sutton and Hepple). It has been promoted as a particularly useful therapy for those with borderline personality disorder (Ryle and Golynkina, 2000)). Generally for those with more severe personality difficulties, the recommendation is to offer 24 sessions. There are a number of controlled trials underway and there has been one randomised controlled trial of cognitive analytic therapy in 15 to 18 year olds with risk factors for borderline personality disorder in Melbourne, showing that it is more effective than treatment as usual for this group (Chanen et al, 2006).
In the pilot we were interested in whether the therapeutic tools of CAT, the Reformulation letter, Diagram, Rating sheets and Goodbye letter, could be used with adolescents in the same way as with adults, and whether they would be helpful and meaningful to them. We were also interested in how helpful the young person found the therapy overall.
The authors were working in CAMH services in Huntingdon and Cambridge and took on young people aged between 14 years and 18 years for standard cognitive analytic therapy. Referrals were from general practice, other CAMH professionals and some from adult mental health services, of young people who had problems which appeared to be mainly in the area of their interpersonal relationships. At the end of therapy, the therapist filled in a form with demographic details, information about previous treatment, previous time in care, and current social and educational circumstances. Therapists were then asked to rate according to a 4 point scale how helpful each of the four tools of CAT (Reformulation letter, Diagram, Rating sheet and Goodbye letter) had been:
0 = not used as did not seem possible/appropriate
1 = used but the patient did not understand it/like it
2 = used and the patient seemed to understand it and find it somewhat useful
3 = used and patient found it very useful eg. used it during sessions
At the final session, patients were asked to rate on a visual Likert scale of 0 to 10 how helpful the CAT therapy had been and the therapist did a similar rating (0=not at all helpful, 5=somewhat helpful and 10=very helpful). Patients who dropped out of therapy were sent a brief questionnaire, and stamped addressed envelope, asking them to rate the therapy on the same scale and also indicate why they had left therapy earlier than planned.
Seventeen patients were included in the pilot, with an average age of 15.9 years (range from 14 to 18). Five (29%) were boys, all but two (12%) had attended mainstream school, with four (24%) having spent some time being looked after by social services. Fifteen (88%) were thought to have primarily personality difficulties, while 2 (12%) had primarily depressive illness. Thirteen (76%) had a history of self harm. Ten (59%) had received previous psychiatric treatment from specialist CAMH services. Patients attended for an average of 14 sessions (range 3 to 22) and 8 (47%) of patients ended therapy in an unplanned way. Four of these drop outs subsequently sent back rating sheets.
With nearly all patients it was possible to use the standard tools of CAT. In working with adolescents it is important to work hard at engaging them in the therapy process in the first few sessions and this often meant spending quite a bit of time explaining the ideas behind CAT and the reason for taking such a broad view of the young person’s personality and situation, rather than just the presenting problem. We had thought that the Reformulation letter might be too overwhelming for adolescents but actually they seemed less intensely affected than adults. Perhaps because there was less historical information to gather and they are, in general, less focused on the more distant past, and much more focused on what happened last night, and what is going to happen tomorrow. One patient dropped out before receiving the Reformulation letter but all the others collaborated in making the letter a joint understanding of their difficulties. Most patients did not refer to the letter again but a few kept it and used it as something to read through when they felt down or confused. This was reported as being helpful in reminding them of where their difficulties arose, and what they were doing to overcome them. We were conscious that some of the reformulation letters would be seen by parents and so we worked hard to make sure that they were not too critical of parents and presented more of an understanding of the parent’s own difficulties. There were no complaints from parents about the reformulation letters.
The diagram seemed to work well with all the young people, it was often possible to start drawing the diagram together in the first or second session. It seemed important to make the diagrams more interesting and more personalised. For example, by creating a visual representation of the roles, using images rather than just words, or making the whole thing into a picture. This seemed to help the young person take ownership of the diagram and meant they were more likely to use it.
The use of the rating scales seemed least useful with adolescents, it was difficult to focus down to specific problems and aims, and some did not seem to like rating themselves. Goodbye letters were successful for those who stayed to the end of therapy and many wrote their own letter back to the therapist.
The adolescents rated the helpfulness of therapy very highly, although this could partly be due to a wish to please the therapist, as the rating took place at the final session rather than anonymously at a later time. Including those who had dropped out of therapy early, but returned a feedback form, did not reduce the overall rating. All but one of these drop outs said that they had dropped out because of practical difficulties getting to the sessions. We do not know what the 4 patients who did not return a questionnaire thought of the therapy, or their reasons for dropping out.
It does seem possible to use standard Cognitive analytic therapy with adolescents from 14 years old. Even young people with quite significant problems and risky behaviour seem able to use the tools of the therapy and find them helpful. The high drop out rate of 47% is fairly usual for studies of psychotherapy with adolescents (Wierzbicki, M., and Pekarik, G.,1993), and at least some of those seem to have dropped out due to practical difficulties in attending rather than to dissatisfaction with the therapy. Further work needs to be done using more objective measures, and a larger sample size, to see how effective the therapy is.
Chanen, A. et al (2006). A randomised controlled trial of psychotherapy for early intervention for borderline personality disorder. Acta Neuropsychiatrica, 18 (6) 319.
Dunn, M., Golynkina, K., Ryle, A., and Watson, J.P. (1997). A repeat audit of the cognitive analytic clinic at Guy’s Hospital. Psychiatric Bulletin, 21, 1-4.
Dunn, M. and Parry, G.D. (1997). A formulated care plan approach to caring for borderline personality disorder in a community health setting. Clinical Psychology Forum, 104, 19-22.
Ryle, A. and Golynkina, K. (2000). Effectiveness of time-limited cognitive analytic therapy of borderline personality disorder; Factors associated with outcome. British Journal of Medical Psychology, 73, 169-177.
Ryle, A. and Kerr, I.B. (2003). Introducing Cognitive Analytic Therapy, Principles and Practice, John Wiley & sons.
Wierzbicki, M. and Pekarik, G. (1993). A metaanalysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24, 190-195
Dr Alison Jenaway, Consultant Psychiatrist in Psychotherapy, CAMH, Newtown Centre, Nursery Road, Huntingdon.
Debbra Mortlock, Clinical Psychologist, CAMH, Brookside Family Consultation Clinic, Trumpington Road, Cambridge.
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