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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.

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Working with adolescents l.jpg

Working with Adolescents

Professor Graham Martin

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Working with Adolescents (3)

  • Therapeutic Alliance

  • On doing therapy

  • On prescribing

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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

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

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Prefrontal Cortex

  • Attention span

  • Perseverance

  • Judgment

  • Impulse Control

  • Organisation

  • Problem Solving

  • Emotions

  • Empathy

  • Compassion

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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

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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

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Therapeutic Alliance

  • Set of Tasks

  • Relationship Bond

  • Toward a defined Goal

    Bordin 1979

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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.

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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

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In a Nutshell

  • You have to like them!

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Therapist Qualities

Better Outcomes from

  • Engagement

  • High Credibility

  • Warm, empathic approach

  • Accepting stance

  • Liking the patient or family

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  • Predisposing Factors

  • Precipitating Events

  • Perpetuating Features

  • Prognostic Indicators

  • Preventive Opportunities

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‘Socratic’ Questioning(Journalism)

  • Who?

  • What?

  • Where?

  • When?

  • How?

  • How much?

  • Why?

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  • Why this young person?

  • From this context?

  • With these features?

  • At this time?

  • And, where do we start?

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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)

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The Family Context


Sig. other




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  • Roles

  • Problem Solving

  • Communication

  • Affective Involvement

  • Affective Responsiveness

  • Behaviour Control

  • General Functioning

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

    Robinson, Katon, Von Korff et al., 1997

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Cognitive Behaviour Therapy

  • Dispute about unique effect

    Murphy, Carney et al., 1995

  • May reduce relapse

    Fava, Grandi, Zielezny et al., 1996

  • Therapist competency is vital

    Scott, Tacchi, Jones & Scott, 1997

  • Meta-analysis suggests effect size post-treatment

    Reinecke, Ryan & DuBois, 1998

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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

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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

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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”


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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

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Cognitive Distortions

  • Overgeneralisation

  • Dichotomous thinking

  • Magnification

  • Personalisation

  • Disqualifying positives

  • Jumping to conclusions

  • Catastrophising

  • Emotional Reasoning

  • Shoulds & Oughts

  • Labels

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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

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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

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  • 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

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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

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    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

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    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

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    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

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    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

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    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?

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    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

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    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

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    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

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    The Synapse

    Target nerve cell

    Electrical pulse

    Electrical pulse

    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

    Neurotransmitter receptor

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    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

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    SSRIs - complications

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

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

    • Extrapyramidal Reactions

      Arya, Mckenzie & Worrall, 1995

    • Sexual Dysfunction

      Montejo-Gonzalez, Llorca, Izquiero, Ledesma et al., 1997

    • No cardiac conduction abnormalities

      Feighner, 1995

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    SSRIs - complications (contd.)

    • Manic switching

      Jain, Birmaher, Garcia, Al-Shabbout et al., 1992

    • Behavioural activation

      Guile, 1996

    • Aggression not confirmed

      Constantino, Liberman & Kincaid, 1997

    • ? Exacerbation of tics in Tourette’s Syndrome

      Hauser & Zesiewicz, 1995

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    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

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    SSRIs - Concurrent Use

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

    • Scant literature to support concurrent use.

      Taylor, 1995

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    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

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    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

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    Family Therapy

    • Differences between families of depressed/non-depressed.

      Cumsville & Epstein, 1994

      Nilzon & Palmerus, 1997

    • CBT better in controlled study

      Brent, Holder, Kolko, Birmaher et al., 1997

    • Home based family therapy better

      Harrington, Kerfoot, Dyer et al., 1998

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    De Shazer

    • Solution focused

    • Very task focused

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

    • Seeks ‘Exceptions’

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    Group Therapies

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

      Beeferman & Orvaschel, 1994

    • Dropouts participate less

      Oei & Kazmierczak, 1997

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    Mental Health Promotion

    The Spectrum of Prevention



    Standard treatment

    Case identification




    after Patricia Mrazek and Robert Haggerty, 1994

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    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

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    Commonwealth documents

    Research reports

    Online Journal - AeJAMH