Let’s Talk about CBT has a new sister podcast: Let's Talk about CBT: Practice Matters with a brand-new host Dr Rachel Handley, CBT therapist and Consultant Clinical Psychologist.
Each episode Rachel will be talking to an expert in CBT who will share their knowledge, experience, research and professional and personal insights to help you enhance your practice and help your patients more effectively. Whether you are a novice or a seasoned clinician we hope you will find something to stimulate thought and encourage you in your work.
This episode Rachel is talking to Prof. Richard Meiser-Stedman, a leading expert in PTSD in children and adolescents, about Cognitive Behavioural Therapy for PTSD in young people. The episode covers the CBT model for the maintenance and treatment of PTSD, adaptions for working with young people, evidence, challenges and complexities, getting good treatment to the young people who need it and how to survive and thrive as a PTSD therapist.
If you liked this episode and want to hear more, please do subscribe wherever you get your podcasts. You can follow us at @BABCPpodcasts on X or email us at [email protected].
Useful Links:
Link to Prof Richard Meiser-Stedman’s publications including RCTs on CT for PTSD in children and adolescents: https://www.researchgate.net/profile/Richard-Meiser-Stedman
UK Trauma Council website: https://uktraumacouncil.org
NICE guidance: Post-traumatic stress disorder NICE guideline [NG116], 2018, https://www.nice.org.uk/guidance/ng116
Materials hosted by UK trauma council – videos: https://uktraumacouncil.org
Books:
Post Traumatic Stress Disorder: Cognitive Therapy with Children and Young People (CBT with Children, Adolescents and Families), Patrick Smith, Sean Perrin, William Yule and David M. Clark: Routledge, 2009
Working with Complexity in PTSD: A Cognitive Therapy Approach, Hannah Murray, Sharif El-Leithy: Routledge, 2022
Treating Trauma and Traumatic Grief in Children and Adolescents, Second Edition, Judith A, Cohen, Anthony P. Mannarino, Esther Deblinger: Guilford, 2017
Credits:
Music is Autmn Coffee by Bosnow from Uppbeat
Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee
License code: 3F32NRBYH67P5MIF
Podcast produced by Steph Curnow for BABCP.
Transcript:
Rachel: Welcome to Let's Talk About CBT Practice Matters, the BABCP podcast for therapists using Cognitive Behavioural Therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who share insights that will help you understand and apply CBT better to help your patients.
Today, I'm really pleased to be joined by Professor Richard Meiser-Stedman. Richard is a professor in clinical psychology at the University of East Anglia and a leading expert in PTSD in children and adolescents, having completed research in the area for over two decades. One of his earliest research papers, published in 2002, was entitled Towards a Cognitive Behavioural Model of PTSD in Children and Adolescents.
And since that time, he's contributed enormously to research led clinical progress and published a multitude of papers in the area. He led the ASPECT study, looking at the early natural course of traumatic stress reactions and early treatment for PTSD in children and adolescents, for example, and the DECRYPT trial evaluating cognitive therapy as a treatment for PTSD in UK Child and Adolescent Mental Health Services.
So welcome Richard. We're really delighted to have you here.
Richard: Thanks for inviting me.
Rachel: And I'd just like to add to all of those accolades, that as a clinician whose passion is working with adults and PTSD, I have been a long-time admirer of your really important work, which can really stem the tide of a lifetime of suffering for children exposed to trauma. And as a friend, I also greatly admire the fact that you've been so prolific and productive while somehow effectively parenting four children of your own with your equally impressive wife, Caroline. Can you tell us a little bit, Richard, as we start about what got you interested in the field of PTSD in children and young people professionally and personally?
Richard: Yeah, so, I studied psychology as an undergraduate degree at the University of Nottingham and it was a really good training in psychology, and I really enjoyed cognitive psychology. I really enjoyed thinking about how it might be applied to understanding mental health difficulties. I had some interest in being a clinical psychologist even before I went off to study at university and I thought that that sounded like the career for me. And, just things came together around, yeah, the science around PTSD, this condition. And I thought, oh, this is something I'd like to explore further. I felt like I'd got just a kind of, a flavour of research and what it could offer in terms of understanding really difficult mental health problems as an undergraduate student. And I thought, well, let's, let's keep going. Let's see if I can do a PhD. And so, you know, there's just so many things going on in PTSD, just from my initial studies. I just remember thinking, this is absolutely fascinating. There's so many aspects of how the brain is working and how our cognition is functioning that that are dysregulated.
And there was this wonderful paper by Chris Brewin, Stephen Joseph and Tim Dalgleish back in 1996 that had come out just before I started university, which was really drew me in. During university, I got involved in a few things and it's just hearing about people's lives as you do. People start to tell you more things and I did a bit of work on something called Nightline and you started to hear people's stories. And it was clear that trauma can have such a, such a powerful impact on people. And I just felt this, this is something I'd love to know more about. I'd love to see if this is something I could contribute to and I thought, well, maybe if I did some work in this, maybe that'd be a good springboard to a career in clinical psychology,
Rachel: And why kids in particular?
Richard: because Bill Yule and Patrick Smith were happy to supervise me.
Rachel: So, it's the right people in the right place at the right time?
Richard: I mean, only an idiot would do child PTSD research because it's way more complicated than doing adult PTSD research. I mean, adults, they come in and they can say, yes, I'll do your study, I'll do your questionnaire And, it's straightforward and you tend to assume that adults have a reasonably good understanding of things and, you know, they've met all the major developmental milestones. I have no idea how I ended up doing child PTSD. I would have been much happier working with adults.
But, no, I really enjoyed working with children. It's obviously more complicated. There's just a lot more going on, but I managed to get a PhD place funded at the Institute of Psychiatry, as it was then called and Bill Yule who passed away last year, and Patrick Smith, who's now a professor down at King's were happy to, supervise me, and it's just been a huge pleasure to work with them for over 20 years.
Rachel: And as someone who works with adult PTSD, I always think that the really smart and creative people are doing exactly that work. Cause as you say, it's so much more complex to apply this work, with kids who maybe have a lot less autonomy over their system and, and how they can, effect change in their lives.
So, you've been researching the impact of trauma on children and young people for more than 20 years then?
Richard: I started in 2000 doing a PhD, and so, yeah, I was working with Bill Yule and Patrick Smith, and I was an ambulance chaser, so I was, I worked down at King's College Hospital working with children and teenagers, so 10 to 16 year olds who'd been involved in some sort of road traffic collision or an assault, some sort of physical assault. We recruited over a hundred children and young people who'd come through King's and we followed them up and we were trying to understand what was their initial reaction to that kind of experience and then what happened to their reactions over time? At that point, I think Anke Ehlers had done one study with children and Paul Stallard over in Bath had been doing some work with children, but this is our first London study and, Yeah, it was an important piece of work, it was a real eye opener. I know we were learning lots of things about how you can do research with this population, it was a different era in terms of research governance, but we were learning lots and, yeah, it was an important project. We got some good papers out of it. We were understanding a lot about, more about how, what happens to children and young people in terms of their mental health over time after trauma. And, and why is it that some children, mercifully only a minority, but some children would go on to have chronic difficulties as a consequence, so more persistent PTSD.
Rachel: And that's the puzzle that people like Anke Ehlers and others have started with really, isn't it? Why some people recover from these awful events and, and others don't. And I wonder what you've learned about the factors that shape responses to trauma and how those differ perhaps in children from those shaping adult responses to trauma.
Richard: I get asked this question from time to time. I'm still not convinced we found a massively different mix of factors that drive PTSD in children compared to adults. A lot of the things that come up in this, say the cognitive model of PTSD that Anke Ehlers and David Clark proposed, they still seem to be really important. So, the kind of key planks would be to give people a reminder of sort of the nature of the memories that children develop for trauma, traumatic experiences, what the trauma and their reactions to the trauma mean? So how do they see themselves in particular, but also other people in the world after the trauma? How do they see their own mind and brain and body after the trauma? Their reactions to the trauma and how are they coping? What are they doing? So obviously, are they using avoidance? But are they, there's a bit of a paradox that people might be using avoidance quite hard, but there also might be overthinking the trauma quite a lot, why did this happen to me? And so on.
So those sorts of factors, certainly in that study of 10- to 16-year-olds, we got some evidence that all those processes were important. And in this intervening 20 years, there's been a lot more evidence gathered in the UK, Europe, North America, Australia, Asia, but increasingly all around the world, suggesting that those processes, which my colleague, Tim Dalgleish sort of summarizes as the memories, meanings and management or maladaptive coping. There is loads of evidence that those factors are really crucial to driving PTSD in children. I guess the other, complicating factor, of course, is how their family's doing. That’s the key thing. Now, of course, that can be an issue for adults as well. How's your partner or family, children, how they're responding, that's going to affect your mental health and perhaps how you recover from trauma. But yeah, I guess for children, particularly younger children, that's especially acute and studying that has been, something I've been privileged to do with some important colleagues, people like Sarah Halligan, Rachel Hiller and Cathy Creswell have done work in this area as well, and it's been fantastic to work with them on this.
Rachel: You've mentioned the memory, meaning management sort of model. Many of our listeners will be very familiar with the Ehlers and Clark model of PTSD. Others won't, won't be working in this area very often.
In CBT, we really love a good, good formulation, ideally with boxes and arrows and, you know, we're recording this podcast around Easter. So, hot cross buns and other Easter themed baked goods are very much appreciated. However, where this is an audio podcast. So, here's your challenge:
Can you give us an explanation about how PTSD develops and is maintained in young people? Ideally without repetition, hesitation, deviation, boxes, arrows, or other visual aids.
Richard: Right. When you're involved in a trauma, when a child or teenager is involved in trauma, they've just got an awful lot of material to make sense of. They've got to make sense of what they've seen, heard, smelled, felt in their body, and they've got to construct some sort of coherent memory for that experience. They've also got to make sense of what this means. What does it say about them and other people? They've got to decide what to do with all this information. What we're finding is that sometimes when we, we can get stuck in terms of making sense of this material, children and teenagers can get stuck in terms of making sense of this.
Bit of repetition there. They might find that these memories, it's very hard to make sense of what happened. And so, and it's very painful. And so then they might start pushing those away. They just might start using avoidance and then they're unable to kind of make sense of what the implications are for them and their world so that they're not able to come up with a coherent account and memory of what happened. The kind of memory that doesn't come popping up all the time, and they may go on thinking of themselves in a bad way so that something happened was all their fault or the fact that this happened implies something bad about them that means they're a bad person. And so, if they can't come to terms with this and make sense of this information, yeah, that they can be left with what we call PTSD. So these horrible memories that keep popping off, all the kind of arousal, feeling sort of scared, jumpy and on edge, all these, the core, those core difficulties of PTSD persist over time.
Rachel: That was excellent. And not, not a box or an arrow in sight. Well done.
Richard: I didn't even need to say vicious cycle.
Rachel: Extra points.
So given this, what are the key elements of cognitive therapy for PTSD with children and young people? And how does that link to what we know and what you've described so beautifully around the problem development and maintenance?
Richard: Yeah, thanks Rachel. That's, so our role is, when we're doing cognitive therapy for PTSD is to, in my view anyway, is to help children make sense of what they've been through. So, even a trauma that lasts as little as, say, 90 seconds, you might have to spend hours unpacking it, because the memories are so overwhelming, laden with all sorts of strong emotion. There's all kinds of sensory elements that they're trying to make sense of. And yeah, there's all these beliefs around what this means for them. And what do they do in response to this? How do they respond to this? So what we're trying to do is provide a space for them to make sense of this material. So what's one of the key things we want to do at the outset, what we're trying to do is really give them some hope and a kind of good understanding that PTSD isn't this sort of thing they're going to be stuck with for the rest of their life. They're not sort of damaged, contaminated or scarred psychologically in a permanent way. So, we want to give them a nice coherent account of PTSD and sort of demystify the whole thing. And of course, to some extent PTSD, it is a really normal thing. And it’s something that's advantageous in many respects. If you live in a war zone, PTSD symptoms are probably going to keep you alive. So we want to sort of not, maybe not make PTSD a friend, but we certainly don't want to see PTSD as this sort of evil villain or it's a sign that your brain is sort of damaged or something's gone wrong with you. So, we want to kind of give that hope and give a nice clear understanding of what the child's going through.
Rachel: Cause that can be really scary, can't it? You know, feeling like you're completely out of control of what's going on with flashbacks and memories.
Richard: Well, yeah, and so this is one of the things perhaps adults struggle to realise around children, even at a young age, they really might think there's something desperately wrong with them, that they might think there's something about their reaction is, is really warped or, or gone seriously wrong.
But yeah, for me, this is one of the intriguing things about PTSD. So much of this is actually just the brain doing what probably it's meant to do, in the aftermath of trauma or when we're trying to live in an uncertain chaotic world, having memories that kind of essentially are protecting you and making you aware of threat, possible threats is a good thing. But of course, when the threat is no longer around and life is safer, then those symptoms aren't helping anymore, or those difficulties aren't helping anymore. So, we want to make PTSD not the enemy. But I guess in trying to do this, though, we are trying to encourage children and young people to drop strategies that they've been relying on successfully for a while, sometimes weeks, months, maybe even years. So yeah, avoidance, try not pushing this stuff away. They can get very sophisticated and very able at doing that and so of course we want to persuade them that this isn't a good way forward. And so we're trying to make the case for confronting this material, these horrible memories and what it all means and working through that.
So, we've got to start by winning their trust, giving them some hope and a better understanding of what they've been through and then giving them that a safe environment, a safe space to sort of make sense of this material. So, using a lot of the strategies that CBT has to offer. So, things like imaginary living, some kind of exposure work, but I mean, I know I'm not sure exposure was the best way of thinking about it, but I think sometimes we're trying to create a coherent account. It's an act of creation rather than exposure therapy. I think we're trying to create a coherent memory for these experiences. And, you know, the cognitive restructuring skills that we're using all the time. In some ways, because PTSD should be straightforward because it's a particular event. If you took, if you're taking a single event, you're dealing one very specific experience. And so that hopefully that gives our work a real focus. But those are the sorts of things that we're trying to do.
Rachel: we know that the reality often in children's services is we're not dealing with a single event, trauma, that it can get a lot more complex than that, can't it?
Richard: So many people do get over the traumas without much professional help, even the multiple trauma survivors, even young people who have children, young people have been through multiple traumas, many will do okay, maybe even do really, really well. So, there's considerable differences, and I think we're still trying to unpack that. But sometimes people, children and teenagers can make sense of support around them. And, sometimes they've got someone they trust, someone who's on their side, who then just naturally gives them that space to talk through what's going on. Maybe it helps them to not feel like there's something wrong with them, they're not damaged, and maybe they've coped in a sensible way, or they've done the best they could in very difficult circumstances.
So, I've certainly seen children and teenagers who've been through some really horrendous things, multiple traumas even, and they've done okay with it, they've found a way through. With multiple traumas it does get harder, but what we can try and do is try and find. a way forward so we can, we can use those, the techniques we have in cognitive therapy for making sense of this. It just takes more time.
Rachel: And again, I'm often struck with that with my adult patients. When we do a sort of history, when we're doing an assessment and maybe they're suffering from PTSD to something that's happened in adulthood. And maybe there is vulnerability there from childhood trauma, but also the enormous number of situations they may have come through really with great resilience and strength is often very striking, and actually quite humbling when you, when you hear how people have managed to come through so much in their lives. So is this effective cognitive therapy for PTSD with kids and is it effective across the age span? Does it matter what age the child is that you're working with?
Richard: Yeah, that’s the sort of million-dollar question isn't that's what people really want to know. I mean, the evidence is really clear and I guess one of the things I find professionally really frustrating and hard is just the gulf that exists between what we know about treatments for PTSD in children and teenagers and kind of how confident people feel and what people do in routine practice. I guess sometimes perhaps CBT practitioners and perhaps we get accused or thought of as being a bit arrogant, but all a bit kind of our way is the only way. There might be other ways, but at the moment the treatment with the most evidence by some margin is some form of trauma focused CBT.
So cognitive therapy for PTSD is what we're most used to in the UK. Obviously based on the Ehlers and Clark model, and that's been adapted quite successfully for children. Patrick Smith down at King's led the charge on that. His work in that has just been really inspiring to me, and it's been great to work with him.
So, so that model is, it's got evidence in children and young people, but there's various other models of different forms of trauma focused CBT in children, teenagers. It's been shown to work very well as well. and the, the most, the most well studied one is the Judith Cohen, Esther Deblinger, Tony Mannarino manual that was developed in the east coast of the US.
So all these different approaches, there's others as well, there's prolonged exposure of PTSD, there's narrative exposure therapy, there's cognitive processing therapy. The bulk of this evidence suggests that children respond really well to these kinds of treatments, that they get big improvements in terms of PTSD, also depression.
And we've seen this pattern when you compare this kind of treatment to a waiting list, but also when you compare this kind of treatment to sort of more powerful control group, like say supportive counselling, something like that, when you actually get a good therapeutic relationship with another human being, even then these forms of trauma focused CBT, so things like cognitive therapy for PTSD in particular, most evidence comes from the US and this manual from Cohen and colleagues, even say compared to some other active control therapy, like supportive counselling, these forms of therapy outperform that. So, we've got really robust evidence now that these sorts of therapies work, and much of my life now is really dedicated to thinking, well, how can we get the word out? How can we deal with therapist anxieties and concerns around this, this kind of therapy?
Rachel: And that is, that's a really helpful message, isn't it? That there are, there are therapies that work. when kids have, have experienced the most awful, experiences and awful traumas, but you hinted there in the, at the, the gulf between research and practice, but also that there might be concerns, anxieties, and maybe even myths that underpin therapist's anxieties about using this kind of work. It sounds like all the evidence based approaches you've talked about being trauma focused, actually focusing on talking about, or as you said, creating a coherent account of what happened during the trauma, I wonder if it would be helpful to do a bit of a, a true or false to some of these anxieties or myths that, that are out there.
So, here's, here's a starter for 10. Children shouldn't be made to relive or talk about their traumas as it will be re traumatising- true or false.
Richard: Well, I mean, you shouldn't make people do anything, right? So, so, so I wouldn't want to make a child and I don't think you could make a child do reliving, because, in my experience, these kids are really smart and they're good at using avoidance. So if they don't want to buy into whatever we're doing, they won't do it. So you've got to make the case and buy them in.
But I mean, yeah, doing some of the more intense sort of therapy techniques like reliving, which is a powerful technique, really, really important, really, really useful helpful for processing the trauma, really getting into the heart of what children's memories are like and what happened for them during the trauma and making sense of those awful, worse sort of moments during the trauma. It's a powerful technique. And, now I've not seen evidence that that's re traumatising, wherever re traumatisation is- it's not very well-defined idea, but, no, I, I think it's a really powerful and helpful technique.
And it's definitely one we encourage people to use.
Rachel: So I think we're, we're saying false, but we're, we're holding that judgment on making people do anything in therapy, caveating that. How about this one? Children shouldn't have trauma focused cognitive therapy as we might inadvertently create false memories.
Richard: yeah. I mean, I've never heard of this sort of coming up as a big issue, sort of clinically or in terms of sort of the legal context. I mean, obviously, sometimes children have to give evidence. and that's, that's a big deal. And that needs to be handled really carefully and well, and I've always sort of encouraged people to take proper counsel and advice on how to handle those issues and work closely with the police and so on. So again, all those caveats to one side though, I don't think, I don't think we're creating false memories. I think, I don't think that's going to happen.
Rachel: So true or false then, is it impossible to apply trauma focused cognitive therapy with children as they're not sufficiently cognitively developed to process their memories?
Richard: Oh, that's false. That's just, that's a very easy one. That's false. Children can easily have got the, if you can, yeah, you can do this work with children. I mean, and there's a few trials now, even with sort of really quite young children, sort of, Four, five, six that they do very well, with these sorts of approaches. So, it's false to think that children can't get the benefit from this kind of stuff. And that's one that really pains me because, if you're an adult and something horrific happens to you, you've got hopefully a few different people you could turn to. But then if we're kind of saying to children, oh, this is too awful, we don't want to broach the subject. Then essentially, you're robbing children of really valuable sources of support. When we put sort of children's sort of emotions on the sort of, well, they're too precarious to sort of, it's, they won't be able to handle it. Then essentially, we're just depriving them of a fairly normal way of making sense of things. So talking things through, telling the story, this is what humans have done for a long period of time.
Rachel: And so final true or false, and you've spoken a bit about the role of parents, the potential role of parents in PTSD or caregivers. How about the idea that it's better to work with the adult caregivers of children with PTSD than to do any work with the children directly?
Richard: I'm fairly comfortable that that is false. Children, I think I've said this twice already, they're not stupid. They've got their own ways of handling things and they're trying to manage a difficult situation. One of the things they'll do is not tell their parents what's going on, how bad it is, because they don't want to upset mum and dad, I've seen that quite a bit.
So, and this is a hard thing to acknowledge as a parent, but your, that your children have their own lives to some extent. And they are trying to manage it their own way. And maybe if younger children, they're going to, obviously they're going to lean more on their parents for protection and managing emotions, but certainly by the time they're a teenager, often they're going their own way. And so, if you don't give the children space to talk through these things openly away from their parents, then it's very easy for them to sort keep shtum that they won't let on how bad it is. Similarly, actually parents will be trying to hide away their own, their own feelings as well. So, so what I'm getting at is that we need to give children that space to kind of, that opportunity to make sense of things. That doesn't mean we exclude parents from therapy, far, far from it. I think that they can be vital.
Rachel: So you've talked a bit about the key elements of treatment. You've talked about sort of normalising a, you know, saying this isn't a dangerous thing that's happening to you and your brain. You've talked about some reconstruction of the memory or a coherent narrative around that you've talked a bit about exposure and cognitive restructuring. Typically, if you were to think about a typical good course of therapy with a young person, and I know no two people are people are the same, what, what would that look like?
Richard: I think a key moment early on in therapy is when something clicks, when the model clicks. So, we often use a sort of cupboard metaphor, which is, I mean, it’s probably common to a lot of adult work as well. But I mean, we find that pretty constructive and useful for children and teenagers. It's a nice sort of concrete metaphor. It's very kind of visually powerful. It just sort of seems to click and it gives a sort of a good way forward for therapy. You're clear about what you're trying to do. You're not trying to make children think about these things for the sake of it. You're trying to sort of tidy something away. And it's a nice realistic metaphor, isn't it? The cupboard metaphor, it's not like we have a magic wand that where we can get rid of these memories. We're saying it's always going to be with you. It's always part, it's part of who you are now. It's part of your memories, but it's going to be sort of put away neatly on the shelf. And so it won't come popping out at you.
So, I think that kind of realisation that, oh, okay, this makes sense, I think the next big realisation in therapy is fairly critical for me is when, in general terms, when a child or young person realises, ah, I can talk about this and, you know, nothing horrendous happens. There's a sort of aha moment where you haven't resolved it all, you haven't kind of processed the whole thing, you haven't got a completely coherent memory, you haven't kind of been through all the worst spot, the worst moments of trauma, the hot spots, but they've just got that sense of, ah, I can talk about this and my world doesn't collapse, and I don't kind lose it in some sense. That's a big moment.
I guess often then there's a sort of, when they're taking charge of their memories, when they realise it's that those are their memories, and they can edit them and add to them as they see fit. When they're in the driving seat again, I think that's quite important when they realise that. So, so when, when it's going really well, you're not doing much cognitive restructuring, you're letting them cognitive restructure. And for some children, young people, they can run with that really, really easily and there's lots of aha moments then when they're going, oh yeah, I, I don't have to think about it like that.
So that's really good when we're just sort of stepping back and letting them do the work. I love that when that happens. those are the kinds of things, but I guess you have to be, specific and stick with the hard moments sometimes and really not let go, and really help the young person sort of go to those tough moments and to make sense of them. And so there is a kind of degree of being sort of persistent with the young person, with their consent, obviously, and trying to work with them hard on those, those moments. But there are some moments you've got to crack.
So, one young person I was working with, it was a very unusual trauma. Lots of different things had happened in a short space of time, a series of attacks from someone. And they were working really hard in therapy. And I didn't know why they were still quite stuck. And I thought, well, why aren't they getting better? They're working really hard here. And we did another reliving of one moment. And this, this was a moment where it all kind of came together. The client realised that this key moment that, and they'd forgotten this, that there was a key moment. They thought that one of their parents was going to get hurt badly and that was a key fear that they had at that moment in time. And that changed the whole experience, made it much, much more severe, but then they lost consciousness, they the young person, not the parent. And so, so this was sort of stuck in mind and untouched. And it was when we did some reliving around that moment, that when this client realised that was the big fear. And we were able to then update that. Sometimes you have got to dig into these memories and be quite persistent. And when you get to that, there'll be like a key moment is, oh, I thought that at that point, and that's the really horrible thought. That's the really key.
And when the young person gets that realisation and they can reframe that, then we can see some real change. So those are the sort of main ideas for me.
Rachel: So it's that real persistence in understanding the meaning for the individual, that detective work around what's gone on, what's happened. Linking to what we were saying earlier, that's really hard to do if you're in any way avoiding talking about the trauma or either the therapist or the, or the young person is avoiding that.
Um, it's very difficult to get that detail, isn't it? That can really unlock the trauma
Richard: Absolutely. Yeah. Yeah.
Rachel: And so you've been applying this therapy for many years. You've also taught many, many people, about PTSD and cognitive therapy for PTSD and young people and supervised many people working in this way. In your experience, where do therapists get stuck or what are your most frequently asked questions or, or tricky issues that come up?
Richard: I, I think there is this big fear around retraumatisation and, and I don't really know where it comes from because we've got some data now and what people think about it. So I'm hoping to get that out later this year, but, it’s a very poorly understood idea, and so it's this sort of fear that haunts people around retraumatisation. But it's almost like a lore now. I would say, that if you talk about something in detail with a therapist, in detail, and you really go, and you really make sense of this material, and you really confront the material, it tends to then get easier. And there's a few, there's, as you know, there's a few different ways of doing it. And there's like an umbrella of trauma focused CBT modalities. They all seem to do the same sort of thing. If you drop the avoidance, think about this trauma in some way, things will get better. That fear is a huge one for therapists. So, so a lot of the time, actually, I don't work so much with young children, young people anymore. I'm mainly working with the negative automatic thoughts that therapists have around this stuff. That's what I'm working on a lot of the time. And so I go away and do trials for eight years and try to try and get evidence that will hopefully help therapists. feel better, about this. So, so yeah, that, that the kind of the kinds of fears that somehow they're going to make things worse, which isn't, isn't borne out. Obviously if you're starting to unpack material, it's really difficult. People may well get tearful. They may well get upset. They may well have a panic attack. They may will feel really rough for a period. But it doesn't overwhelm them, typically you don't see, people giving up at that point. Often, they're really proud of themselves that they've been able to get there. And they realise that, okay, they feel rough for 10, 15 minutes. They feel tearful, upset, emotional. But then things calm down, they realise they're safe now and that they actually got through it. And that, that's a huge thing. So, so all these fears around the corner, what the damage or something that's going to happen is, is a big deal.
I'd love it if therapists do work with a panic attack case first before they do PTSD to see if people can get really, really scared and you don't die, and nothing catastrophic happens. So, there's lots of, lots of fears. We always often have lots of discussions around this, you know, what's the harm and am I doing? And I think that then feeds into kind of, well, am I doing the techniques right? Am I doing reliving in the right way? And should you, you know, how should you order the work, which memory should you work on? And people can get quite bogged down in the minutiae. And I think it's because underlying this is like, if I do something wrong, I'm going to somehow harm this child, the young person. And I think, I think there's lots of flexibility about some of these things. And as I said earlier. You, you, you can't make children do anything, really. They are going to dip their toe into some of these activities, whether it's trauma narrative work, or reliving work, or in vivo exposure work, whatever, they're going to sort of dip their toe in. And even in vivo work, they'll have their own clever ways of managing their distress. They'll use their own safety seeking behaviours, or they'll shut their eyes, or they'll be doing something clever to get through it. But gradually they'll sort of be, you know, as they trust you a bit more and as they start to trust themselves a bit more and this realise they can handle these things, they'll be testing things. So they'll be immersing themselves more into this reliving or narrative work or in vivo exposure or whatever.
What other FAQs? Oh, dissociation. Everyone's terrified about dissociation. That's always a big thing. And I just try and normalise that I don't think dissociation is such a big thing to be worried about. It's a fairly normal part of panic and fear. It's a fairly normal part of having dissociative flashbacks, and flashbacks are inherently dissociative. There's a dissociative quality to them, but yeah, we know they settle down as you do this kind of work. So I'm just trying to calm people down,
Rachel: again, the anxiety underpinning that I guess is about, about doing harm. And of course, doing harm is a really, or doing no harm is a really important professional responsibility, isn't it? But I guess in a lot of spheres in our work, we're very comfortable with the idea that if emotion is present, we're probably talking about the things that really matter and we probably need to have emotion present to do good work and cognitive therapy, but somehow in PTSD, that can take on another layer of, of fear and anxiety, can't it, for a therapist?
Richard: Yeah. I, you have to kind of think about the counterfactual, I guess, the kind of, well, if you don't do this work, what will happen? The child, young person will just carry on having these memories popping out at a regular or irregular basis in an unpredictable, perhaps an unpredictable way And it really disrupts them. And they end up, they carry on believing that, well, it's my fault that my mum got badly injured when I was a child, you know, children have these thoughts that persist for years or decades, really, do we really want that to carry on and obviously it could be, hard, and, yeah, there will be some emotion when we confront some of these thoughts and some of these memories, but, the alternative is we let them carry on believing these things or having these horrible memories , for a long time and that's, that's really awful.
Rachel: So we don't, again, coming back to your earlier point, we don't want to withhold treatment that is actually going to be helpful for people. And I guess the distress isn't always just an issue for the patient, is it? And one of the things we're eager to talk about on this podcast is looking after ourselves as therapists, and childhood trauma can be very distressing to hear about and the work can open a window into some of the darkest acts of humanity and the devastation that that causes.
Now, you have four very lovely kids, whether that's further evidence of your love and enjoyment of children or a certain kind of insanity, we might never know. However, that this can also dial up the impact of the stories we hear as therapists, can't it, having, having our own kids or connecting to kids in our lives- we can relate really personally to the needs and vulnerability of children at the same age as our own. And therapists themselves aren't immune to the experience of trauma themselves of all types. They may have had those experiences in their own history. What advice can you offer to therapists in this area when they're working with trauma themes and issues with personal resonance or that they find particularly distressing or overwhelming?
Richard: Yeah, really good question. I guess we have to accept that the world is not a nice place. I mean, your average CBT therapist is fairly engaged with the world and isn't in denial about how there are awful things in the world.
The thing that gets under my skin the most, or bothers me the most, is some of the ideas we've already talked about, the idea that children don't always get therapy. There was one trial we did where we got 29 children in the trial. There was going to be a 30th case. This was the last case, I thought, we'll stop on this case. There was a young, a teenage girl, young teenager, who'd seen something really horrible. And I thought, this, this, this teenage girl, she was smart. She was really on it. I did a sort of baseline assessment and she had PTSD. And so I thought she's going to come into this trial and if she doesn't get better during the waiting list period, she'll get better with therapy for sure, because she was on it.
And then for, I never really quite knew why, but the family never got back to me, despite some fairly persistent efforts on my part to reach out and, say, yeah, look, we'd love to work with your child in this project. And they never got back to me. And that's one that's hung with, stayed with me more than anything else. That's the kind of thing that bugs me more. I think, yeah, bad things happen and it's grim. But we can make these things memories. We can put them in the past. That's a normal thing. That's how humans have survived for millennia. That's a normal thing. And we can encourage that and support that. That's our role. It's a good thing.
But the hard thing with children, teenagers is they don't always come through. to therapy and that there are sometimes these barriers there, so that's probably the thing that bugs me the most.
Rachel: The ones that get away, the ones that don't get the treatment.
Richard: Yeah. Yeah. When you think how many sort of mental health professionals there are in the UK now. So, I mean, just being honest, that's the thing that bugs me both most. I mean, again, when I think about my children, yes. Something grim could happen to them, couldn't it? And having four children, you mentioned that, I mean, I'm four times more vulnerable, I don't know, yeah, one of them’ s going to have something bad happen to them at some point. I mean, that's just inevitable. They're going to get ill or something grim, you know, but we, life has to go on. I guess one of the things that being a parent has taught me is to sort of enjoy each day. I mean, when you're there sort of changing nappies and so on, you just learn to enjoy being with them doing their daily activities, they're sort of just getting through mealtimes and just being, being with each other and those sorts of things are probably the things that keep me going.
And something may well happen bad at some point, the next day will come afterwards, or it won't, that's life and we have to get on with it.
Rachel: And it sounds like you draw a lot of hope from the fact that that's not the end of the story. Actually there is something we can do to intervene, to help to put lives back on, or even on a, a new and more positive trajectory.
Richard: Yeah, I've certainly seen young people, I mean, who I've written off in my own mind. I've picked up on some of the kind of messages and I've gone, Ooh. This, this teenager, they're too tricky, their needs are too great. And then when you realise, when you unpack what's going on, you think, hang on, this is a young person who's just no one. There's a case I often refer to in training I do of a teenager when she was only about 12, 13, she was subjected to a rape and it was, it's pretty hard to hear, I don't know if you'd call it retraumatisation, but the environment afterwards wasn't great because no one really recognised the horror of what she'd been through and gave her support. And then me and a colleague sort of worked with this young, she was now a young woman by the time we were working with her. And, actually it was one of the easiest cases I've ever worked with, but this, this girl's life had fallen apart. She'd got into all kinds of trouble, she had all kinds of needs. And, yeah, it was, it was like a nine-session case where we really worked on this PTSD from this attack. And she did really, really well but everyone had kind of written her off as being too awkward and too difficult. And she had people focus on the complexity and not the kind of, well, here's a young person with PTSD What can we do about that?
So she's a client I refer to if anyone's been to sort of training I've done, she's the client who, when I first asked her to talk about this horrible trauma at the end, she's smiling because, which is not what people, obviously people don't expect that people expect to be in floods of tears and stuff but ofcourse no one had actually just given her the space to talk about what she'd done. So this is why, that's why it's such a strong theme in what I've been saying today. Sometimes if you just give children, as hard as it is, giving them that space to work through what they've been through is, is just hugely beneficial. It certainly was in that case. So yeah, I've seen people do really well.
Rachel: There can be a tremendous relief in being heard and being validated.
Richard: Oh, absolutely. Yeah. Yeah.
Rachel: it sounds like you may have learned a fair amount from the young people you've worked with as well. We often hope that they will benefit from our experience, but certainly my experience of being a therapist is that I often learn as much from the patients as they learn from me. Are there examples of things that you've learned from young people or how that's, the work has made a personal difference in your life or the focus of your work?
Richard: Oh, well, look, I sort of regularly ruminate on what I've done and what the mistakes I've made. And, and how gracious some of my clients have been in continuing to work with me. I think that one I just mentioned is stuck with me a lot because just, I was just so conscious of my own expectations being so low and rather than sort of actually believing in hang on, we've got a pretty good model here that is pretty powerful, and it worked really well. yeah, that sort of stayed with me. And yeah, so all kinds of things over the years of comments. I've said something a bit glib, or I've got it wrong in some way and people have corrected me and I've always been grateful for it.
One, I do struggle with, sometimes it is, it is a really interesting issue, how you deal with parents and families. Because, you know, in one sense we want to give families, the young person, some space away from their family to have like a, they're freer to talk about things.
So sometimes people will say, we don't mind about upsetting you. You're not my mum. So, so I'm going to dump all this on you and you have to go, okay, fine. And that's no, and that's okay. That's our job and that's fine. But then sometimes, you know, sometimes there is obviously more complicated things going on. It's how, how do we involve the parents in this? And sometimes, there might be explicit messages they're giving the child, or it's obvious that there's the parents are handling a lot of stuff themselves. And so then how do we, you know, there is a real, there's a real tension there and how we deal with this.
But one mum stands out, she was just, well, I always thought she was a bit frosty towards me and my, and our colleague, and it was my colleague did the bulk of the work with this particular young person. And at the end, the mum just gave us this really powerful account of she'd found it really hard, basically letting a stranger talk in detail to their child. She felt like she'd failed as a parent and it was, it was really tough to let a stranger talk to her child. and not being able to help themselves and having to sort of put, really not, well, not really trust actually, but just having to rely on this person, and when you didn't, I don't think she really trusted my colleague. My colleague was an excellent therapist, really fantastic and worked really hard with this young person. And the young person did really well. And at the end the mum then said at the end, it was, it's really hard to say, but I'm just so grateful. The work done was brilliant. And I'm really glad, really, really, really glad we did this.
So, the mum had taken a huge chance on us and had really felt uncomfortable. and perhaps, so, so I guess the reflection there for me was perhaps, perhaps we could have done more to just help the mum through that process and sort of, sometimes we're able to do that, perhaps I sort of shied away, perhaps I was being a bit avoidant myself because mum seemed a bit kind of frosty with us, perhaps we should have given her more space and time to talk about what was going on for her was a pretty, it wasn't just a trauma. It was then getting help for my child is a painful, difficult thing.
Rachel: that sounds really important, just remembering the huge leap of faith people make at any stage when they come to therapy. And as you say not necessarily put their trust, but take a chance on us and, and build trust throughout that and a huge privilege actually to be entrusted with those stories.
Richard: Yeah, it's a huge privilege, isn't it, to do any, any piece of work. There's something in particular about PTSD. I mean, I guess, like, we've got these really lovely models. And we do have boxes and arrows. We have some fantastic boxes and arrows in PTSD. I mean, you can sit down and trace the Ehlers and Clark model happily, couldn't you, for hours. The arrows and the boxes there are brilliant.
But it is you, it is you being a human being with another human being and, and not rejecting them, sticking, hearing some tough, tough stuff. That is an element of what we're doing that is, I think you can train for it to some extent, but there's something raw, there is a rawness about that. You can't convince it and then a child or young person will know, if you're just going through the motions.
You have to, you've got to be like Dr Pimple Popper. You know, the doctor, the dermatologist in the US? She has these YouTube channels, and she's called Dr Pimple Popper. Rachel, you don't know this?
Rachel: I don't know this. I can't believe my children haven't, haven't found this on YouTube.
Richard: They're going to be horrified at your lack of awareness. There's this, this dermatologist called Dr Pimple Popper, and she has all these videos of her in the clinic, popping these horrible things. Ghastly substances come out of people's skin in ways that you can't begin to understand, Rachel, so you've watched a few of these videos. and, but there's huge relief when it's out. And this is a metaphor I use. We're just like Dr Pimple Popper, like if people are stuck with horrible stuff, inside them and it's our job to help just get it out.
And it's not very pleasant, but when it's out, it's out. And this is one of the lovely things about PTSD. Typically, when someone gets over PTSD, they don't, it doesn't come back. It's not like depression, we're trying to reduce the risk of relapse. Typically, PTSD, when something's resolved properly, it doesn't tend to come back. And that's a really lovely thing. And so this is why the Dr Pimple Popper metaphor is quite good. That's our role. It's a bit grisly. So she has to wear like eye goggles and stuff and, and all this kind of stuff. Sometimes you get spray, but we don't get that much spray, I don't think, but, in our work. But it's similar. It's grim, but it's got to be done and, and it's wonderful when it's over.
Rachel: you see that the relief, the clear skin, the hope that comes after.
Richard: Yeah, when things, when things heal, I mean, sometimes, and of course, sometimes people think they don't actually, it's interesting that they don't always heal brilliantly, sometimes things are better and they can get on with life and they can manage, actually, I think we can get quite a lot, really quite a lot of healing in children and young people with PTSD.
Rachel: And I think a really important part of your message today, Richard, that, that helps those, you know, therapists out there listening to this do care, don't they? And that's often what drives their anxiety about doing this, the very treatment that will help because they don't want to do harm. But a really important part of your message is that actually this treatment does work. It does help. So if people want to work more in this area and, train further and build their confidence. How can they, how can they develop that? What are the opportunities to get involved? What have you got in terms of resources, papers, books that you would recommend to folk?
Richard: Right. So, what we've done is produce some materials that are hosted by something called the UK Trauma Council. So you can, if you want to sort of see some of these elements of cognitive therapy for PTSD sort of in practice, then there's some wonderful videos on there. There's wonderful young person who's acting as a client and then a fantastic psychologist and therapist, Sarah Miles is the therapist and she's the one who got bullied into actually doing the video. But a whole team of people, really excellent people helped divide, devise these videos. And so there's some fantastic resources there. So that's easy to find. That's on the UK Trauma Council website. So if you just want to see a bit more about what this looks like in practice, that might be one place to go.
Yeah, so there's several of us, several of us that do, do sort of training at the moment, Rachel Hiller is leading an implementation science project. I'm trying to get more training out there. I do trainings. What other resources are there? I mean, in terms of books, I mean, there's Patrick Smith's book.
There's, I mean, I would really look closely at the Judith Cohen, Anthony Mannarino, Esther Deblinger book on trauma focused CBT for children and young people. And there's a huge amount of experience there and that's a really good book. And their work really came out working with sexually abused children on the east coast of the US. So, I mean, they're really dealing with some tricky cases, right? That's a serious book, oh, look, I mean, I'm still, I think many of us are quietly devastated about the loss of Hannah Murray last year, who was just, you know, just such a huge advocate for cognitive therapy for PTSD and just produced a fantastic book on working with complex PTSD with Sharif El-Leithy. That's a book written with adults in mind, but certainly if you're working with teenagers, and some older children, there'll be elements of that book that are really helpful. I mean, obviously you've always got to adapt to everything, anything to the sort of where your client is at. But there's some just wonderful, wonderful material in there. So I'd really look at those things. I mean, I think we could probably do better at getting more material out. So I suppose watch this space and I'm hoping we can get more material out to you.
Rachel: That's fantastic. And we'll put links and references to, to all of those pieces in the show notes. So people can click on those after they've listened to this. And what about, horizons in your research or the field or the world of PTSD and cognitive therapy for PTSD. What, what are the, what's the next big challenges, the next exciting developments do you think?
Richard: Well, the slightly sad story I suppose to start off with this is that PTSD is not an uncommon condition. Now, it might be for many young people that it goes away on its own after a period, but it looks like there's a good chunk of children and teenagers who have persistent PTSD. And of course, if anyone who's working in adult services will know this, that like, you see PTSD popping up all the time in adult services in different ways, shapes and forms with different comorbidities. So it's, it's, it's a big issue. So what we need to do is reach out more to people. Now, how can we reach out and, help more children? And so there's all kinds of therapists and practitioners in the UK now. So can we. get them working with trauma, comfortable and confident and competent working with trauma and PTSD. That's a big challenge, a big thing. As we've been talking about, so building people's confidence that they can do it. I don't think you need to be some sort of super therapist, really. I don't, I, or, have some sort of uniquely special skills. I don't see why most therapists can't do this kind of work.
So, so that's, that's one big effort. Can we just change the sort of confidence and competence levels of other therapists and practitioners in the UK. But then there's other things, can we use, technology more? So, there's some exciting evidence coming out from a project that Patrick Smith led down at King's where we can reduce the amount of direct therapist contact and where young people who've been involved in a single incident trauma, quite nasty traumas. This is a project, it's called Optic, that Patrick led during COVID. And it was a perfect COVID trial because it was all about doing therapist assisted, but internet delivered therapy. So, all the resources, all the sort of psychoeducation and understanding what PTSD is, huge amounts of work were all done online. So there's loads of really good resources, videos and animations to sort of get lots of points across. And then lots of technology that children and teenagers, particularly teenagers can use to make sense of their traumatic experiences. And so it's still therapist assisted. So it's still a therapist in the background to support you and have meetings, but shorter meetings. And this showed really good sort of results as a feasibility study. And so we're looking to scale that up, there's all kinds of things like that, where I think we're just starting to scratch the surface, but I think we are going to have to use technology to reach the hundreds of thousands of children around the world who are suffering in this way.
Rachel: So it sounds like a really key challenge is dissemination, getting this, getting this therapy out there and getting it to people who need it all over the world in all those different situations we've spoken about. So Richard, this has been, been so interesting. We've covered a lot of ground in CBT, we like to summarise, right? And think about what we're taking away from each session. So in time honoured fashion, what, what key message would you like to leave folk with regarding working with PTSD and kids using trauma focused cognitive therapy,
Richard: Yeah, PTSD can be understood in children and young people. We, we have a pretty good idea of what drives it. And it responds well to treatment. And then why not, why not offer, why not offer that treatment? There's no reason why you shouldn't, that I'm aware of, really. Obviously, we have to be sensitive and careful in how we proceed, but, confronting these memories, making sense of them. It’s something that children can do and they get the huge benefit from. So let's offer it. Let's offer this kind of treatment.
Rachel: it works. And I'm writing down Dr Pimple Popper.
Richard: Please do. I mean, I hope you won't come back to me so traumatised by some of these videos, but, some of them are a bit grim, but, it's, it's that sort of short term pain for long term gain idea. It's a bit gross at points, but you get through it.
Rachel: Thank you so much, Richard. It's been really fascinating. I thank you for being with us. I've really enjoyed this conversation. I'm sure folk listening will have learned loads from it. And to all of you out there listening, thank you as always for the work that you do, the often difficult, challenging work that you do, but full of hope as we've heard today and until next time, look after yourselves and look after each other.
Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team at [email protected]. That's [email protected]. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that new episodes are automatically delivered to your library and do please share the podcast with your therapist friends and colleagues.
