Cognitive Behavioural Therapy for Adolescents and Young Adults

An Emotion Regulation Approach

Lawrence Howells

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351781831
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychothérapie

Cognitive Behavioural Therapy for Adolescents and Young Adults: An Emotion Regulation Approach provides a unique focus on therapeutic practice with adolescents and young adults, covering everything from psychological theories of adolescence to the treatment of common emotional difficulties.

Beginning with a review of development through adolescence into adulthood, and the principles of CBT, the book highlights problems with traditional models of CBT for adolescents and young adults. In a fresh approach, this book separates CBT from diagnosis and grounds it instead in emotion science. Adolescents and young adults learn not about disorders and symptoms, but about emotions, emotional 'traps', and how they can use CBT to bring about change. There are chapters on fear, sadness, anger, emotion dysregulation, and happiness. Each chapter provides an outline of emotion science, a clear cognitive behavioural formulation ('trap'), and evidence-based interventions. Clinicians are walked through the process using case illustrations.

Cognitive Behavioural Therapy for Adolescents and Young Adults represents a transformation of CBT practice, and will become a valuable treatment manual to training and practising mental health professionals, especially psychotherapists specialising in CBT.

Chapter 1
Introduction

 

There is increasing recognition that the transition from childhood to adulthood is a period with an increasingly widening timeframe. Children are beginning adolescence earlier, whether defined biologically, psychologically, or societally. Adults are emerging later, as defined by psychological, intellectual, or financial independence, or indeed brain development. Adolescence, previously often thought of as the ‘teen’ phase, is now more frequently defined as the period between around 10 until 25 years of age (see Chapter 2).

There is also increasing recognition that this decade and a half is a time of intense difficulty and a time when young people frequently require help. As a result, specialist youth mental health projects and services are beginning to develop across the world; programmes and international conferences are flourishing.

Despite growth in this area and increasing provision of services specifically for adolescents and young adults, there is a relative lack of literature tailored to this age range. The majority of literature categorises itself as either for adults or for children and their families.

This treatment manual aims to provide clinicians with a guide to CBT targeted specifically at those aged between 10 and 25. The book begins with a detailed outline of adolescent and early adult development and provides a context for the remainder of the book (Chapter 2).

Cognitive behavioural therapy (CBT) is an intervention that has developed over the past 50–60 years with a clear foundation in empiricism and testing out each new development. As a result of this, CBT is now the psychological therapy with most evidence for the widest variety of difficulties (Chapter 3). The evidence base for CBT across the age range is also strong. As a result of this, demand for CBT is high and clinical services across the world are stretched. Clinicians are working within settings that place a high value on turnover and have high expectations of the numbers of sessions that can be undertaken. The space for stopping and thinking, reading and learning is squeezed. As a result, clinicians find it difficult to keep up with the evidence and to provide treatment in a manner most consistent with what is most effective (see Chapter 4).

Alongside this, the evidence base for CBT is growing and there are ever-increasing numbers of models for different presenting problems or problems with slightly different foci, depending on their authors. For obsessive-compulsive difficulties, for example, clinicians can choose between five different models (see Chapter 4).

Working as a clinician in everyday practice has therefore become increasingly difficult, and there is little time to research the evidence base for each slightly different presentation, or to effectively keep up with the vast array of different models that are provided within the discipline of CBT. The risk of this situation is that, while the models, when implemented by their proponents in specific populations, might be increasing in effectiveness, the practice of CBT on the ground suffers and its effectiveness declines (see Chapter 4).

This treatment manual aims to provide clinicians with a limited number of discrete, simple, models that they can use to cover the majority of presentations seen in everyday practice with adolescents and young people. It brings together research and evidence in ways that are designed to be clear and easy to understand, so that clinicians can become experts in a few models that they can tailor and apply to the majority of their clients, directing them towards clear, evidence-based interventions.

Increased recognition of difficulty for adolescents and young adults has produced a wide variety of response. Schools, colleges, employers, and other institutions are increasingly providing information about psychiatric disorders as part of ‘mental health’ or ‘emotional wellbeing’ programmes and there are national programmes designed to increase awareness of mental health difficulties.

These kinds of programme are often thought of as unquestionably helpful and yet the evidence is not so positive. The diagnostic model is not as valid or reliable as is often assumed, it tends to decontextualize difficulties, increase stigma, reduce agency, and has a negative impact on identity development (Chapter 4). That the predominant model offered to adolescents and young adults to understand their emotions is an illness model, may well be an important contributory factor to the apparent increase in ‘illness’ in this population. One of the main aims of this book is to provide an alternative framework through which adolescents and young adults can understand their emotions and their difficulties with emotions.

This fresh approach is outlined in Chapter 5, where adolescents and young adults are given the opportunity to understand their difficulties and receive intervention without having to view themselves as ‘disordered’ or ‘ill’. CBT is separated from the diagnostic model and is grounded instead in emotion science. The chapter outlines the theoretical basis before detailing the five principles of the approach: what emotions are, what emotions are for, how emotions are regulated, adolescent development, and the hand brain. Each of these principles is based on evidence from a variety of different disciplines, including academic psychology, neuroscience, and applied psychology. These five principles inform the rest of the book, which is a practical treatment guide for clinicians working with adolescents, young adults, and their families.

Subsequent chapters look at specific emotions: Fear (Chapter 6), Sadness (Chapter 7), Anger (Chapter 8), and Emotion dysregulation (Chapter 9). Each of these chapters explores the emotion in detail, looking at its causes, the impact it has on different aspects of the emotional experience, and then outlines a trap that provides a detailed understanding of what can go wrong. Each chapter contains an intervention section, taking clinicians through exactly what to do and how to do it, with illustrative material. There is a section outlining how these treatment models relate to the evidence base at the end of each chapter. There are two brief chapters on Disgust (Chapter 10) and Guilt and shame (Chapter 11), which look at how these emotions might interact with the traps outlined earlier.

The last chapter is Happiness (Chapter 12). Happiness is not usually included in treatment manuals, but is often a desired outcome for treatment. This chapter outlines what causes happiness, what it is (and isn’t), and its functions. It then outlines the happiness wheel and brings together the interventions, the majority of which are already covered in other parts of the book, that are shown to help adolescents and young adults move towards a life characterised by happiness, wellbeing, and flourishing.

While broad, this book does not aim to cover everything. It specifically neglects:

• Psychosis. This book does not specifically cover psychosis or psychotic phenomena. However, the book does cover many of the difficulties experienced alongside psychosis, for example sadness or social fears.

• Trauma work. This book begins predominantly from a here-and-now perspective. Trauma is included in longitudinal formulations and informs the traps and difficulties in this book, but work designed to support the processing of trauma memories using techniques such as reliving or rescripting is not covered.

• Medication. This is a psychological volume designed for psychologically training clinicians and so medication is not covered.

In summary, this book aims to achieve a number of related objectives:

• Provide a detailed guide to treatment tailored specifically for adolescents and young adults, rather than children or adults.

• Ground treatment in models of psychological development and emotion rather than disorders and illness.

• Provide clinicians with clear, concise CBT formulations and evidence-based treatment plans, all illustrated with case material.

• Cover the full range of different presentations seen in ‘everyday’ clinical practice.

Throughout the book, example case material is used to illustrate the concepts and ideas. In addition, a number of different adolescents and young adults whose therapy has been based on the ideas of this book have provided quotes that are used at the beginning of the chapters. Each individual involved has provided consent for their words to be used for this purpose.

Chapter 2
Adolescent development

I feel like a person of value and I have certain expectations of people. I want to achieve things in my life; I’m still young.

(21-year-old male)

Adolescence is a phase of life which is often negatively perceived by society at large. A survey in 1999, for example, found that members of the general public tended to use words such as ‘rude’, ‘irresponsible’, and ‘wild’ to describe adolescents, and that fewer than half the respondents expected that adolescents would have a positive impact on society (Farkas et al., 1997). This same survey found that people tended to cite a lack of basic values such as honesty, respect, and responsibility as adolescents’ biggest failings. These negative perceptions of adolescence appear to be longstanding; Arnett (1999) cites Aristotle’s quote that youth “are heated by nature as drunken men by wine” and Shakespeare’s a Winter’s Tale:

I would that there were no age between ten and three-and-twenty, or that youth would sleep out the rest … for there is nothing in between but getting wenches with child, wronging the ancientry, stealing, fighting. …

(Act III scene 3)

As well as these societal beliefs, parents tend to perceive adolescence as the most difficult stage of their children’s development (Buchanan et al., 1990).

Despite these negative stereotypes, adolescents themselves report a much more positive experience. The majority of adolescents report good relationships with their parents, other adults, and friends, as well as fairly good levels of wellbeing (Farkas et al., 1997, Laursen, Coy, and Collins, 1998).

The developmental processes taking place during adolescence and early adulthood provide the backdrop to all our work with individuals in this stage of life. It is important that we understand, and can explain these developmental processes to adolescents, young adults, and their families. This chapter therefore outlines the changes taking place during adolescence, in a range of areas, and looks at the theoretical frameworks that have been used to understand this period of life.

What and when is adolescence?

Adolescence is a period of transition. It is the passage between childhood and adulthood and involves accelerated growth in a variety of different areas.

Given that adolescence is a phase of life, it is difficult to define in terms of distinct age ranges. For many, adolescence is synonymous with teenagerhood, suggesting an age range of between 13 and 19. For others, adolescence ends earlier, somewhere around society’s legal age limits relating to the transition to adulthood, for example at 16, the age of sexual consent in many countries, or at 18, the age of the vote. Interestingly, Shakespeare in his quote above chooses the wider definition of 10 to 23, and other early authors have chosen similarly wide definitions, for example 12 to 25 (Hall, 1904).

In today’s society, there are good reasons to adopt a broader age range. Firstly, many of the changes associated with adolescence are beginning earlier; children appear to be entering puberty at a younger age than they did previously (see below) and many other aspects of adolescence (such as sexual exploration) are beginning earlier, fuelled by changes in society and access to information (Bloch, 1995). Other aspects of adolescence, however, are delayed and are occurring later than in previous generations. Across the developed world, for example, young people are spending increasing amounts of time in education and are also financially dependent on their families for longer. These societal changes do not impact equally across society and there is general consensus that the process of adolescent transition has become extended, pluralised, and fragmented (Coleman, 2011). Finally, research into brain development has found that the brain continues to evolve and develop in quite fundamental ways all the way through into the late 20s and early 30s (see below). Given this widening age range, some authors have tended to break down the period into smaller timeframes, for example early adolescence, later adolescence, and emerging adulthood (Patton et al., 2016).

Given the level of individual difference in the rate of transition, it is perhaps imprudent to adopt rigid age ranges to define adolescence. However, to give a rough idea about the population we are considering, adolescence is considered in this book to cover the period between the ages of 10 and 25 yea...