Working with Adolescents

Professor Graham Martin

Working with Adolescents (3)

• Therapeutic Alliance

• On doing therapy

• On prescribing

A South Australian Study of Depressed Adolescents:

Therapy

There was no difference between those who had Cognitive Behavioural Therapy compared with those who did not

There was no difference between those who had Cognitive Behavioural Therapy compared with those who did not

TherapyTherapy

• No apparent or statistical difference between the psychotherapy subgroup compared with the psychotherapy + medication subgroup

Prefrontal Cortex

• Attention span• Perseverance• Judgment• Impulse Control• Organisation• Problem Solving• Emotions• Empathy• Compassion

Family Therapy Alliance

“that aspect of the relationship between the therapist system and the patient system that pertains to their capacity to mutually invest in, and collaborate on, the therapy”

Pinsof and Catherall, 1986

Therapeutic Alliance

“Building the Therapeutic Alliance is a creative process, a central issue for all age groups, since in its absence, there can be no therapy”.

Dorothy M Marcus, 1998

Therapeutic Alliance

• Set of Tasks

• Relationship Bond

• Toward a defined Goal

Bordin 1979

Joining as an Issue

If you don’t join with all members of the system early then therapy is doomed. The relationship between therapist and family can become so tenuous that early termination results.

Level of Alliance

• Level at the start of therapy predicts Outcome

Ryan and Cichetti, 1985

• Positive patient statements correlate with rated benefits

Luborsky et al, 1983

• Therapist’s personal qualities correlate highly with Outcome

Luborsky et al, 1985

In a Nutshell

You have to like them!

Therapist Qualities

Better Outcomes from– Engagement– High Credibility– Warm, empathic approach– Accepting stance– Liking the patient or family

Ps

• Predisposing Factors

• Precipitating Events

• Perpetuating Features

• Prognostic Indicators

• Preventive Opportunities

‘Socratic’ Questioning(Journalism)

• Who?

• What?

• Where?

• When?

• How?

• How much?

• Why?

Why?

• Why this young person?

• From this context?

• With these features?

• At this time?

• And, where do we start?

Is it the Young Person’s problem?

• Is the young person causing the problem for the parents, or in the family?

• Is the young person ‘the symptom of the family’?

• Is the young person accepting another’s projection?– (cf Munchausen by Proxy)

The Family Context

Sig. other

Father

Mother

Self Sibling

PARAMETERS OF FAMILY FUNCTIONING

after Epstein & Bishop (MCMASTER)

• Roles

• Problem Solving

• Communication

• Affective Involvement

• Affective Responsiveness

• Behaviour Control

• General Functioning

Cognitive Behavioural Therapy (CBT)

Psychoeducation

from RCT, educational materials play a significant role in improvement in depression

Robinson, Katon, Von Korff et al., 1997

Cognitive Behaviour Therapy

Dispute about unique effectMurphy, Carney et al., 1995

May reduce relapseFava, Grandi, Zielezny et al., 1996

Therapist competency is vitalScott, Tacchi, Jones & Scott, 1997

Meta-analysis suggests effect size post-treatmentReinecke, Ryan & DuBois, 1998

CBT Assumptions

Cognitive activity affects behaviour

Cognitive contents & processes can be monitored

& changed

Behavioural (& emotional) change may be

affected through cognitive change

Dobson and Dozois, 2001

Other assumptions

Processing of information is active & adaptive

Individuals derive meaning from their experiences

using information processing

Belief systems are idiosyncratic

New information is assimilated into existing belief

systems

Automatic Thoughts Specific, discrete essential words

Shorthand distilled format

Not a result of deliberation, reasoning, or reflection - “Just

happen”

Not sequential as in goal directed thinking or problem solving

Autonomous – patient does not need to make any effort to

generate & can have difficulty “switching off”

Beck

Core Beliefs

Learned through childhood experiences

2 broad categories – helplessness and ‘unlovability’

Core dysfunctional beliefs latent during low stress periods

Reactivated by negative experiences that resemble

conditions under which original beliefs were formed

Cognitive Distortions

Overgeneralisation

Dichotomous thinking

Magnification

Personalisation

Disqualifying positives

Jumping to conclusions

Catastrophising

Emotional Reasoning

Shoulds & Oughts

Labels

Cognitive Triad

• Negative view of self, the world, and the future central to

maintenance of depression

• Beck (1983)subsequently proposed that individuals were

particularly likely to experience depression if there is a

congruence between negative life events & depresso-genic

schemata

Research

Presence of high levels of depressive symptomatology in children with negativistic attributional styles and presence of internal, stable, global negative style:

increases risks of further depression in adolescence

suggests causal role of attributional style in development

of depression

pessimistic attribution style predicts future increases in

depressive symptoms among adolescents irrespective of

negative life events

Spence et al., 2002

Research

40% of adolescents who responded to CBT relapsed within 6 months

Significant number of adolescents discontinue treatment prematurely, do not comply or remain depressed at end of intervention (approx 33%)

Younger children seem to better Need to investigate involvement of family

Spence & Reinecke, 2004

Major CBT strategies

• Behavioural activation:• Getting the person to do something

– Monitoring activities, pleasure, mastery

– Scheduling activities

– Graded task assignment

• Cognitive activities– Distraction techniques

– Time set aside for thinking

Major CBT strategies

• C-B strategies– Identifying negative thoughts

– Questioning negative thoughts

– Behavioural experiments

• Preventative strategies– Identifying assumptions

– Challenging assumptions

– Use of set-backs

– Preparing for future

Initial Interview

• Assessment of current difficulties

• Symptoms

• Life problems, e.g., interpersonal, medical, practical

• Associated negative thoughts

• Onset/development/context of depression

• Hopelessness/suicidal thoughts/lack of energy

• Agreed problem list

Initial Interview

• Goal definition – may change later but helps correct unrealistic expectations, provides a standard against which to monitor progress, focuses attention on the future.

• Presentation/acceptance of treatment rationale

• Practical details – what is involved e.g., homework, between session tasks, frequency

Initial Interview

• Introduction to basic relationship between negative thoughts & depression

• Possibility of change• Beginning intervention• Specific:

» Select first target» Agree appropriate homework, monitoring/reading

• General:» Give Client experience of CBT style (focus on specific issues, active

collaboration, homework)

• Overall aims:» Establish rapport» Elicit hope» Give pt preliminary understanding of model» Get working agreement to test it in practice

Subsequent sessions

• Set agenda• Weekly items

– Review events from last session– Feedback from client on last session– Homework review (emphasises self-help, independent

functioning)– Outcome?– Difficulties?– What has been learned?

Subsequent sessions

• Major topic for session

• Specific strategies (e.g., relaxation, learning evaluate automatic thoughts

• Specific problems (e.g., difficulties that have arisen during week)

• Long term problems

• List in order of priority

Subsequent sessions

• Homework assignments• Task

– Should follow logically from session content– Needs to be clearly defined

• Rationale– explicit e.g., to test the idea that I can’t do anything, a no lose

situation will learn something regardless– Predicted difficulties

• Feedback from client– Understanding ( summarise main points– Reactions to session

On Prescribing

When to prescribe?

• When a rapid response is needed

• When danger may be an issue

• With an older rather than a younger child

• Where the diagnosis is more clear

• Where it is clearly the child’s problem

• When you don’t have the therapy skills

• Alongside therapy

The Synapse

Drugs such as SSRIs () block the return of serotonin () to its release site. More of the neurotransmitter reaches the target nerve cell, enhancing synaptic transmission

Electrical Electrical pulsepulse

Target Target nerve nerve cellcell

Neurotransmitter Neurotransmitter receptorreceptor

ElectricaElectrical pulsel pulse

Selective Serotonin Reuptake Inhibitors (SSRIs)

1996 review found 3 double blind, placebo controlled trials (65), 16 open label trials (322) and 23 case reports (41).

DeVane & Sallee

1997 (10yr) revue of metabolism noted paucity of pharmacokinetic data on young people

Leonard, March, Rickler & Allen

SSRIs - complications

Meta-analysis on 62 RCTs - 10% lower discontinuation rate than TCAs;

Fabre, Abuzzahab, Amin, Cleghorn et al., 1995

Extrapyramidal ReactionsArya, Mckenzie & Worrall, 1995

Sexual DysfunctionMontejo-Gonzalez, Llorca, Izquiero, Ledesma et al., 1997

No cardiac conduction abnormalitiesFeighner, 1995

SSRIs - complications (contd.)

Manic switchingJain, Birmaher, Garcia, Al-Shabbout et al., 1992

Behavioural activationGuile, 1996

Aggression not confirmedConstantino, Liberman & Kincaid, 1997

? Exacerbation of tics in Tourette’s Syndrome

Hauser & Zesiewicz, 1995

SSRIs - Toxicity

34 of 52 cases experienced no symptoms from up to 1400mgms

all but 3 of 38 adolescents/adults treated in hospital; 10 of 14 children treated at home;

lavage in 37, no other therapy; mild CNS, CVS, GI symptoms only

Klein-Schwartz & Anderson, 1996

SSRIs - Concurrent Use

SSRIs may substantially increase TCA plasma levels, leading to adverse effects.

Scant literature to support concurrent use.

Taylor, 1995

The Current Debate

• There have been deaths, but causality is hard to prove

• The recommended drug (Fluoxetine) was said to cause deaths 10 years go

• Probably a media beat-up

Social Skills Training

Structured Learning Therapy reliable; better in males

Reed, 1994

Problem Solving Treatment effective for major depression

Mynors-Wallis, 1996

Interpersonal Therapy recovery maintained to 1 year

Mufson & Fairbanks, 1996

Family Therapy

Differences between families of depressed/non-depressed.

Cumsville & Epstein, 1994

Nilzon & Palmerus, 1997

CBT better in controlled studyBrent, Holder, Kolko, Birmaher et al., 1997

Home based family therapy betterHarrington, Kerfoot, Dyer et al., 1998

De Shazer

• Solution focused

• Very task focused

• Demands ‘Customer’ Status over ‘Visitor’ or ‘Complainant’

• Seeks ‘Exceptions’

Group Therapies

Review notes that treatments lack specificity and focus on narrow range of deficits

Beeferman & Orvaschel, 1994

Dropouts participate lessOei & Kazmierczak, 1997

The Spectrum of Prevention

SelectiveSelective

IndicatedIndicated

Case identificationCase identificationStandard treatmentStandard treatment

RehabilitationRehabilitationMaintenanceMaintenance

UniversalUniversalafter Patricia Mrazek and Robert Haggerty, 1994after Patricia Mrazek and Robert Haggerty, 1994

Mental Health PromotionMental Health Promotion

Prevention of Depression

Protective Factors & Resilience

Temperament building

Resilience building in school

Learned Optimism programs

Options and Choices; personal judgment

Developing sense of self through sport, games, drama

Developing supportive relationships at peer level

and with adults

Stress inoculation

Developing national pride

Auseinet.com

Commonwealth documents

Research reports

Online Journal - AeJAMH