Post Traumatic Stress Disorder

Cognitive Therapy with Children and Young People

Patrick Smith, Sean Perrin, William Yule, David M. Clark

• Editore: Routledge
• Anno: 2014
• ISBN:
  9781317580669
• Edizione: 1
• Argomento: Psychologie
• Categoria: Psychotherapie

Post traumatic stress disorder develops after exposure to one or more terrifying events that have caused, or threatened to cause the sufferer grave physical harm. This book discusses how trauma-focused cognitive therapy can be used to help children and adolescents who suffer from post traumatic stress disorder.

Cognitive therapy is frequently used to treat adults who suffer from PTSD with proven results. Post Traumatic Stress Disorder provides the therapist with instructions on how CT models can be used with children and young people to combat the disorder. Based on research carried out by the authors, this book covers:

• assessment procedures and measures

• 
  
  

• formulation and treatment planning

• 
  
  

• trauma focusedcognitive therapymethods

• 
  
  

• common hurdles.

• 
  
  

The authors provide case studies and practical tips, as well as examples of self-report measures and handouts for young people and their parents which will help the practitioner to prepare for working with this difficult client group.

Post Traumatic Stress Disorder is an accessible, practical, clinically relevant guide for professionals and trainees in child and adolescent mental health service teams who work with traumatized children and young people.

1

Introduction

Cognitive therapy for PTSD with children and young people

Since publication of Beck’s seminal key text (Beck et al. 1979) on cognitive therapy for depressed adults, there has been rapid development of cognitive therapies for a range of disorders across a range of ages. This growth of effective treatments has come about in part because treatment approaches are theoretically based. That is, the careful evaluation of cognitive behaviour therapy (CBT) in randomised controlled trials has been preceded by equally careful evaluation of the cognitive models on which they are based.

The development of CBT for children and adolescents has lagged behind that for adults, but the overarching approach has been the same. Theoretical models of the disorder(s) specify maintaining factors; these are empirically tested in naturalistic or experimental studies; interventions aimed at reversing key maintaining factors are piloted; and finally, comprehensive CBT programmes which incorporate a variety of techniques to target key maintaining factors are tested in controlled trials.

This book is a reflection of the last stage in that process. It has its origins in a therapist guide which was used in a preliminary randomised controlled trial to evaluate cognitive therapy for young people with post traumatic stress disorder (PTSD, Smith et al. 2007), treatment being firmly based on Ehlers and Clark’s (2000) cognitive model of PTSD, suitably adapted for children (Meiser-Stedman 2002). The book is intended as an accessible, practical, clinically relevant guide for professionals working with traumatised children.

Who is this book for?

The book is aimed primarily at professionals and their trainees who work with traumatised children in child and adolescent mental health service (CAMHS) teams. This will include clinical psychologists, psychiatrists, social workers, nurses, occupational therapists, family therapists, and others. Most will be gained from this book by those who have some prior CBT experience, although formal post-qualification CBT training is not required. Regular supervision will be helpful in implementing this treatment approach. It is hoped that this will be a useful resource for those who are experienced in working with children with PTSD, but also as a guide for less experienced trainees. The important point is that this treatment should be implemented by trained and qualified mental health workers in the context of a safe and professional approach to working with children and families – usually within a CAMHS setting.

CBT should be provided by suitably trained and supervised mental health practitioners.

Who can benefit from cognitive therapy for PTSD?

The model on which this treatment is based has empirical support for the 7 to 16 years age group, while the randomised controlled trial evaluating its effectiveness was carried out with 8 to 18-year-olds. Participants in the trial – and those in most of the basic research testing the applicability of the cognitive model – had developed PTSD as a result of single-incident traumatic events such as road traffic accidents and exposure to violence. Primarily then, the approach described here is intended for 7 to 18-year-olds who have developed PTSD as the primary disorder following a one-off trauma.

However, with some adaptation, this treatment is helpful for a broader range of young people. First, it may be used with those who have developed PTSD symptoms relating to more than one traumatic event, following multiple traumatic exposure. In this case, the same principles of treatment will apply, but additional sessions are usually needed in order to process multiple trauma memories. Second, the principles of this treatment approach may be used with children younger than seven years old, including pre-schoolers. Adaptations include more family involvement, less reliance on verbal processing of trauma memories, and a more behavioural approach to working with traumatic reminders.

What is cognitive therapy for PTSD?

The form of cognitive therapy for PTSD described in this book shares many characteristics with the wider family of CBT interventions that are used successfully across a range of disorders and ages. The approach is based on Ehlers et al. (2005) cognitive therapy treatment programme for adults. Treatment components overlap to some extent with other CBT approaches, but differ in a number of key respects.

Cognitive therapy is theory based. The central idea in cognitive theories is that feeling, thinking and behaviour are all interrelated; changes to thoughts will influence feelings and behaviour. Put another way, idiosyncratic appraisals of events (the meaning we give to things) are critical in the regulation of affect and behaviour (Bolton 2005). The cognitive theory of PTSD (Ehlers and Clark 2000) is a detailed and elaborated, disorder-specific example of this central idea, and is described in Chapter 2. When working clinically, cognitive models or theories enable formulations to be developed: presenting problems are understood and explained using the overarching framework of the model. As described in some detail in Chapter 4, this cognitive formulation is a ‘working hypothesis’, subject to change or refinement as further information is gathered. It is also individualised for each client – it is a unique way of understanding each particular young person’s problems. Thorough knowledge of the model is therefore crucial to understanding a client’s problems, and in developing strategies to help. That is, CT for PTSD is far more than a collection of techniques. Cognitive models are sometimes construed as ‘roadmaps’. The model, or map, may suggest many different starting points or routes to change – but it is not prescriptive about how one gets there, about the means of transport. Cognitive theory shows the way, while cognitive therapy uses all sorts of ways to get there, pragmatically encompassing a wide variety of helpful techniques, some of which overlap with, or are drawn from, different therapeutic traditions. The important point to bear in mind here is that therapists must have a thorough grounding in the principles and models of the disorder, as well as skills in implementing the various treatment components with young people, if they are to effectively help their young patients.

CT for PTSD is based on a clear theoretical model which informs the intervention.

As with CBT in general, the therapeutic relationship in CT for PTSD is characterised by warmth, genuineness and accurate empathy. Maintaining high levels of empathy is crucial in carrying out PTSD work with young people, and therapists should be alert to the possibilities of either becoming overwhelmed by the intense nature of the traumatic material, or hardened to it over time. However, the therapeutic relationship in CT for PTSD goes beyond being empathic and supportive: it also characterised by being active, goal-oriented, highly collaborative, and by taking an empirical, scientific approach to problems. Collaboration starts at assessment. Here, the therapist and young person will agree joint goals which will give a clear direction in treatment. Collaboration continues when developing an individualised formulation and a treatment rationale which is shared with the young person, at a level appropriate to their development. During the treatment phase, a strong therapeutic alliance is nurtured. The stance taken is one of actively working together as a team towards agreed goals. A trusting relationship is needed. For example, as will be seen in later chapters, the young person’s attempted solution in dealing with PTSD symptoms is often part of the problem, and young people must be able to trust their therapist if they are to drop these old unhelpful habits and test out new ways of responding to difficulties. ‘Collaborative empiricism’ in CT for PTSD refers to the scientific approach that is taken within sessions. That is, a problem is defined and relevant data are gathered (through self or parent report, or from questionnaires); hypotheses or predictions are made and then tested out in behavioural experiments or site visits; data are monitored and hypotheses are revised in the light of the new findings that have been discovered together. Empiricism and experimentation are emphasised throughout. Therapist and young client are working together as a scientific team, jointly discovering new information that will help to alter old unhelpful ways of thinking and behaving.

CT for PTSD is based upon a therapeutic relationship which is empathic, supportive, goal oriented, and promotes collaborative empiricism.

Put this way, CT for PTSD can appear rather cold, level-headed and overly rational. But this sort of therapy, done well, is none of these things. First, children’s level of felt or displayed emotion in sessions may be intense. Therapists are often working with very high affect, especially at the beginning of treatment. Although expression of strong feelings in itself is not necessarily an aim of therapy, the important point in CT for PTSD is that the all-important cognitions, so central to maintaining the disorder, are invariably associated with strong emotions: cognition and emotion go hand in hand. Second, CT for PTSD is active, energetic and at times fun for young people. It is characterised by discovering new information and learning new ways of responding and behaving, hopefully in a manner that is engaging and interesting. Of course it can be hard at times, but the overall attitude in CT for PTSD is a positive one, looking forward and opening up new possibilities for change.

Finally, there is also a strong education element to CT for PTSD with young people. This is apparent first of all in the initial emphasis on psycho-education for children and parents about the nature of PTSD and its treatment. It comes to the fore in some of the behavioural experiments used to demonstrate the unintended consequences of suppressing thoughts and feelings. Education and new discoveries are of course part of the collaborative empiricism that is a theme throughout sessions. There is also some explicit skills learning for particular problems during the course of CT for PTSD, as described in Chapter 5. Kendall (2006) has thus characterised the role of the therapist in CBT for young people as a coach/educator – someone who is supportive and encouraging, providing opportunities for the young client to try out new strategies, and giving feedback to help them develop new skills. The education element to CT for PTSD is explicit at the final session, where young people are helped to reflect on what they have learned during the course of therapy and to write out a ‘blueprint for the future’, an individualised relapse prevention plan, based on the new discoveries and skills they have learned during therapy.

Psycho-education and learning through doing are core elements of CT for PTSD.

Developmental aspects to cognitive therapy for PTSD

The cognitive model of PTSD (Ehlers and Clark 2000) was developed with adults in mind, but has empirical support for children as young as seven years old (Bryant et al. 2007). Ongoing work (Meiser-Stedman et al. 2007) suggests that at least some aspects of the model may apply to even younger children. This research, and our clinical experience, shows that while the principles of the cognitive model do indeed apply to young children, the nature of the idiosyncratic misappraisals differ between adults and children. That is, subjective meaning seems to play a central role for children, as it does for adults, although the kinds of attributed meaning will be different. From an individual case consideration, Bolton (2005) is reassuring on this point. Rather than being concerned with general questions about the child’s cognitive developmental level, the therapist needs instead to ask the question: ‘What cognition is involved in the maintenance of the problem in this particular case?’ If cognitions and appraisals are involved in the problem for a particular child, then they will need to be addressed; if not, then there is no need. The emphasis is firmly on the assessment of cognitive factors in individual cases.

A related question concerns the developmental level needed to engage in CT for PTSD (Stallard 2002). Reynolds and colleagues specified a number of cognitive abilities needed to engage in a typical CBT programme (such as the ability to distinguish between thoughts, feelings and behaviour; the capacity for logical thinking; memory abilities; a theory of mind). In a series of experiments they found that children as young as five years old show some abilities for many of these tasks (e.g. see Quakley et al. 2003, 2004; Doherr et al. 2005). They conclude that many young children could engage in cognitive therapy when given age-appropriate materials. The materials used in this CT for PTSD programme include handouts and leaflets, worksheets and diaries, and age-appropriate metaphors and experiments. For very young children, the materials differ, with more use of play, drawing and cartoon strips to reconstruct trauma narratives. While the components of CT for PTSD are often very appealing to children and young people, clinical skill and experience are needed to engage young people and to adapt and implement these sorts of techniques successfully according to the child’s developmental level.

CT for PTSD can be used with children younger than seven years of age if appropriately tailored to the child’s development.

A course of cognitive therapy for PTSD with young people

Following detailed assessment, a typical course of CT for PTSD with young people will last between 10 and 12 sessions. The first of these is a cognitive assessment, leading to a shared formulation and agreed treatment goals. The final session is a look towards the future, leading to an individualised written blueprint for relapse prevention. The intervening eight to ten sessions will comprise an individually customised treatment package combining some or all of the CT for PTSD components detailed in Chapter 5.

Sessions are generally held weekly. If less frequent, then some of the momentum in therapy is lost – new learning is not consolidated and new skills are forgotten. For this reason, appointments are scheduled well in advance and reminders given the day before. If appointments are missed, then it is helpful to double up appointments for the following week. Sessions vary in length, but are generally around 90 minutes. Longer sessions may be needed when carrying out imaginal reliving, especially in beginning sessions or when doing substantial work with parents.

CT for PTSD typically involves 10 to 12 weekly sessions.

Each session begins with listing the topics to be covered (setting an agenda), usually followed by a brief check in with the child’s symptoms and problems in the preceding week, referring to the Child PTSD Symptom Scale (CPSS) which the young person completes weekly. Homework review is done early in each session. Depending on the progress of homework, some tasks may be carried forward as new homework for the following week. The main topic for the session will fill most of the remainder of the time: this may be, for example, carrying out reliving or writing, continuing with cognitive restructuring, or designing behavioural experiments. In the spirit of collaborative empiricism described above, feedback from the young person is sought throughout. Towards the end of the session, it is useful to summarise what has been done, and some young people will like to write brief notes as a reminder. The session finishes by setting new homework tasks. These will have arisen naturally from the main topic of the session and will be agreed and set jointly with the young person at the end of the session. The diaries or worksheets that are needed for homework will be handed out, and the young person keeps a note of what they have planned to do before the next session.

Parents or carers will always be seen if available. The varied and important roles that parents and carers may play in CT for PTSD are described more fully in Chapter 5. These may range from supporting the child in attending therapy sessions or completing homework assignments, to being a more active collaborator in treatment (helping to reconstruct trauma narratives, for ex...