1. Working with Adolescents Professor Graham Martin

2. Working with Adolescents (3) Therapeutic Alliance On doing therapy On prescribing

3. 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

4. Therapy No apparent or statistical difference between the psychotherapy subgroup compared with the psychotherapy + medication subgroup

5. Prefrontal Cortex Attention span Perseverance Judgment Impulse Control Organisation Problem Solving Emotions Empathy Compassion

6. 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

7. 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

8. Therapeutic Alliance Set of Tasks Relationship Bond Toward a defined Goal Bordin 1979

9. Joining as an Issue If you dont 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.

10. 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 Therapists personal qualities correlate highly with Outcome Luborsky et al, 1985

11. In a Nutshell You have to like them!

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

13. Ps Predisposing Factors Precipitating Events Perpetuating Features Prognostic Indicators Preventive Opportunities

14. Socratic Questioning (Journalism) Who? What? Where? When? How? How much? Why?

15. Why this young person? From this context? With these features? At this time? And, where do we start?

16. Is it the Young Persons 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 anothers projection? –(cf Munchausen by Proxy)

17. The Family Context Sig. other Father Mother SelfSibling

18. PARAMETERS OF FAMILY FUNCTIONING after Epstein & Bishop (MCMASTER) Roles Problem Solving Communication Affective Involvement Affective Responsiveness Behaviour Control General Functioning

19. Cognitive Behavioural Therapy (CBT)

20. Psychoeducation from RCT, educational materials play a significant role in improvement in depression Robinson, Katon, Von Korff et al., 1997

21. 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

22. 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

23. 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

24. 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

25. 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

26. Cognitive Distortions Overgeneralisation Dichotomous thinking Magnification Personalisation Disqualifying positives Jumping to conclusions Catastrophising Emotional Reasoning Shoulds & Oughts Labels

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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?

36. 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

37. 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 cant do anything, a no lose situation will learn something regardless –Predicted difficulties Feedback from client –Understanding ( summarise main points –Reactions to session

38. On Prescribing

39. 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 childs problem When you dont have the therapy skills Alongside therapy

40. 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 pulse Target nerve cell Neurotransmitter receptor Electrica l pulse

41. 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

42. 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

43. 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 Tourettes Syndrome Hauser & Zesiewicz, 1995

44. 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

45. SSRIs - Concurrent Use SSRIs may substantially increase TCA plasma levels, leading to adverse effects. Scant literature to support concurrent use. Taylor, 1995

46. 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

47. 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

48. 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

49. De Shazer Solution focused Very task focused Demands Customer Status over Visitor or Complainant Seeks Exceptions

50. Group Therapies Review notes that treatments lack specificity and focus on narrow range of deficits Beeferman & Orvaschel, 1994 Dropouts participate less Oei & Kazmierczak, 1997

51. The Spectrum of Prevention Selective Indicated Case identification Standard treatment Rehabilitation Maintenance Universal after Patricia Mrazek and Robert Haggerty, 1994 Mental Health Promotion

52. 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

53. Auseinet.com Commonwealth documents Research reports Online Journal - AeJAMH