|Contact||Duncan Law, Professional Lead for Psychological Services CAMHS|
|Address||99 Waverley Road, St Albans, Hertfordshire, AL3 5TL|
This service in Hertfordshire provides a fast response and time limited intervention of up to six talking therapy sessions, alongside the wider multi-disciplinary CAMHS Generic team, for children who are looked after by the local authority.
The service has been set up to deliver interventions in line with the principles and best practice of the Choice and Partnership Approach (CAPA) and Children and Young peoples – Improving Access to Psychological Therapies (CYP-IAPT) imitative, with children and young people up to age eighteen years.
The service has embedded the use of collaborative therapy goals and the use of frequent feedback and outcome measures, and the use of evidence based interventions. Progress towards the treatment goals are monitored using a goal focused outcome measures (Law 2013). This is illustrated by means of a case study with a young person using these ideas as part of an intervention using Cognitive Behavioural Therapy (CBT).
To work in a goal focused way using outcome measures and evidence based practice with a young person who had been seen previously within the mainstream tier 3 CAMHS on a number of occasions without improvement, and who was subsequently referred to the targeted LAC team as her family placement was on the verge of breaking down.
The young person had originally been referred for conduct problems which had progressed to the young person complaining of depression and self-harming by cutting themselves on the face and arms.
The young person had previously disengaged from the service and there was the real possibility of them experiencing recurrent depression in adulthood and an increased risk of suicidal ideation if their difficulties were not addressed. (Weisz and Kazdin 2010).
The young person’s mother was concerned that the young person had ADHD but no evidence was found to suggest this. The young persons presentation did not match their description of symptoms and treatment previously had focused on their behaviour with their description of depression being negated.
When meeting the young person I wondered whether the aggressive and anti-social behaviour had led to the depth of their depression not having been fully identified, understood or seen as a priority. I also wondered whether rather than having a major depressive disorder the young person was experiencing dysthymic disorder which can often be seen as a more entrenched maladaptive style which is seen as part of the personality rather than a discrete episode of illness (Fonagy et al 2002), and would fit with them having been referred for conduct problems, and the depression having been overlooked.
What change was introduced and how this was done
Robust outcome measures were used at the start of the intervention – in this case the Revised Children’s Anxiety and Depression Scale questionnaire was completed at the beginning of the second session and these showed fairly high scores for depression.
As part of the CYP-IAPT initiative an agreement was made with the young person and their mother which included a clear description and explanation of the way we would work together using cognitive behavioural therapy and behavioural activation. The Revised Children’s Anxiety and Depression Scale session monitoring forms were shared and an explanation given as to how these would be used.
Time was taken to come to a shared formulation and understanding of their difficulties, exploring current and historical factors, and hopes and wishes for the future. This was done using the white board which allowed for a visual element that seemed to help the young person access their thoughts and feelings about their experiences and to make sense of why they had been feeling and behaving in the way they had, something the young person had been unable to do previously.
Therapy was weekly and symptom tracker and session monitoring questionnaires completed each time. These allowed for open discussion as to progress, or lack of it, alongside psycho-social education about the nature of depression, and helped keep the therapy ‘on track’ and prevent the drop out that had occurred in previous CAMHS referrals. Exploration of maintenance cycles, and avoidance patterns that maintained the young person’s difficulties were drawn up on the white board and photographed so that the young person could look at these between sessions.
The Trust was successful in its bid to be in year 1 of CYP IAPT and so additional training and supervision did not incur costs as these was funded through the CYP IAPT project as were backfill costs.
Feedback from the young person was that they had found working in a focused way helpful. They had particularly liked the collaborative approach and found it helpful to identify and understand their behaviour patterns and how these helped or hindered them reaching their goals. The weekly symptom tracker helped the young person to identify how circumstances affected their symptoms and to recognise that some things were outside of their control. At these times the young person was able to be kind to them-self and to recognise their triumphs in dealing with their many negative life experiences.
The young person was doing better at school and had realistic hopes for the future of going to college.
Challenges included sticking with a new way of working even when not feeling overly confident – this was helped by good supervision and learning from the young person themselves and the feedback they gave during the intervention facilitated by the feedback and outcome measures.
Recognition that what has been learnt about theory and therapeutic strategies requires practice overtime with the complex reality of patients’ lives and ongoing supervision to continuously develop skills and knowledge. Having time between sessions to read and learn about adolescent depression and what works in the therapy room.
Recognising that we learn by our success and failures and whilst many of the CBT approaches used were helpful, given this young person’s life experiences, helping them develop compassion toward themselves was equally important.
These challenges were overcome by ensuring that I allowed at least 30 minutes each week to reflect and plan for sessions. Regular supervision with a CBT clinician allowed for practice of approaches using role play to improve confidence and delivery.
Difficulties in engaging mum and the subsequent breakdown of the young person’s placement at home resulted in the young person being placed in foster care. This initially felt like an absolute failure, but in fact has allowed for them to make enormous progress in terms of understanding themselves and to develop healthy reciprocal relationships with others.
CYP-IAPT feedback and outcome measures are already established in the generic CAMHS team. There is a plan to do a presentation to the staff group in the targeted service on the use of goal focused treatment using outcome measures in the very near future, with the aim of introducing this as a way of working with this client group.
The practice and principles of CYP-IAPT can work successfully with looked after children, and children on the edge of care.
Goal focused treatment works providing the goals are the young person’s/family goals and not something being imposed on them.
Measures can be used in a helpful way clinically if they are introduced as a tool to help sessions stay on track by working collaboratively and using the information from them. Whether this is to be curious as to why something is different week to week, or to recognise progress being steadily made, or equally to be curious if things have got worse, and why this might be.
Good clinical supervision is essential, and time to practice skills/approaches to develop confidence in a safe environment such as supervision really helps.
Children/young people who are looked after can benefit from having a focused approach towards helping them understand what they can do to improve their mental health despite their often negative life experiences.