Most research into CBT (cognitive behavioural therapy) for teenagers has focused on whether it works or not, with largely positive results. Surprisingly little attention has been paid to finding out what it is actually like for a teenager to undertake CBT.
Deanna Donnellan and her colleagues have made an initial effort to plug this gap, conducting in-depth interviews with three teenage girls who’d completed a course of individual CBT, asking them about their perception of the therapy and what it meant to them.
The pseudonymous interviewees were Mary, who had problems with sickness and anxiety; Katherine, who had anxieties around her appearance and restricted her eating; and Samantha, who experienced low mood and practised self-harm. The teenagers were aged 15 years on average.
One the main themes to emerge related to progress and change. Mary saw the therapy in terms of helping to remove her problems; Samantha saw it as more than that, as a chance to move forward in her life; and Katherine felt she had developed new perspectives on life and the future. All three experienced increases to their self-efficacy (their confidence in their own abilities). Donnellan and her colleagues pointed out a related practical insight here – they found the teenagers clearly had “ultimate goals” for therapy (such as a growth in character or a return to “normality”), which could be hidden beneath the immediate aims of the CBT.
Another key theme to emerge related to engagement with therapy. The teens were mostly disengaged and passive at the start, but they gradually began to participate more. Mary achieved this engagement by taking some control – she agreed to take on some of her homework tasks around eating, but refused others. Samantha didn’t say much at the start, but came to realise that she could benefit from exploring her emotional issues. Katherine felt desperate and unable to make decisions at the start, but the graded nature of the therapy helped her feel more stable.
The researchers said issues of control were very important in teen therapy given that most teenagers’ therapy will have been instigated by their parents. “Power and its ability to impact negatively upon therapeutic potential might … be mitigated by a process of collaboration and encouraging the client to negotiate their position in the therapeutic relationship,” they said.
What about rapport with the therapist? Although she benefited from therapy, Mary was not on the same page as her therapist:
“for an example she might use someone being scared of dogs and how the thoughts of the dog biting them would make them cross the road (…) it was like relates nowhere near to like feeling sick and how feeling sick affects ya it was nothing near that”.
Mary blamed part of this on her therapist seeming “really old”. “I think for most teenagers,” Mary said, “… you’d feel easier to talk to someone who, not obviously dead young, but d’ya know not someone in their 50s or something or like old.” In contrast, Samantha was pleasantly surprised at her therapist’s ability to relate to her situation:
“It was a bit disconcerting cos she like, not knew about it, but knew how to like deal with all this stuff, which I wasn’t entirely expecting but it was helpful.”
The final theme related to the structure of the way therapy was delivered. Mary felt like some of the progress was too slow and there was frequent repetition. For Samantha, the structure and predictability of CBT was an advantage, and the boundaries laid down by her therapist helped her feel safe. Katherine also liked the graded pace of therapy, with the gentle start helping her to feel more comfortable.
Donnellan’s team said their interviews were a “tentative” first step towards finding out what CBT is like for young people. The findings demonstrate “the importance of the process of therapy, just as much as the content,” they said. Based on this, some practical recommendations include: recognising the importance of the first stages of therapy for engaging with a teenage client; addressing the teen client’s preconceptions about therapy; and finding out the pace and style they’d like the therapy to progress at.
“The service delivering CBT needs to promote the young person as being in control from the outset,” the researchers said, “regardless of who is making the decision to access therapy. This may set the scene for them to develop control over their problems and establish stability in their life.”
Donnellan, D., Murray, C., and Harrison, J. (2012). An investigation into adolescents’ experience of cognitive behavioural therapy within a child and adolescent mental health service. Clinical Child Psychology and Psychiatry, 18 (2), 199-213 DOI: 10.1177/1359104512447032