In this episode of Practice Matters, host Rachel Handley is joined by Dr. Eleanor Leigh, Clinical Psychologist and Associate Professor at the University of Oxford to discuss social anxiety disorder in young people. Eleanor shares her journey into this field, highlights the challenges of recognising and treating social anxiety in young people, and offers hope through emerging evidence-based interventions, including tailored cognitive therapy for adolescents.

Resources Mentioned:

• OXCADAT Resources: Free therapy resources, manuals, and videos for cognitive therapy.
• CAMY Website: Learn more about Dr. Leigh's research group focused on young people's mental health.
• Overcoming Social Anxiety and Building Self-confidence: A Self-help Guide for Teenagers (Helping Your Child)

Papers mentioned:

Carruthers SE, Warnock-Parkes EL, Clark DM. Accessing social media: Help or hindrance for people with social anxiety? Journal of Experimental Psychopathology. 2019;10(2). doi:10.1177/2043808719837811.

Evans, R., Chiu, K., Clark, D. M., Waite, P., & Leigh, E. (2021). Safety behaviours in social anxiety: An examination across adolescence. Behaviour research and therapy, 144, 103931. https://doi.org/10.1016/j.brat.2021.103931

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This podcast was edited by Steph Curnow

 

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 we're joined by Dr Eleanor Leigh and we'll be talking about social anxiety disorder in children and adolescents. Eleanor is a clinical psychologist, an Associate Professor at the University of Oxford and Honorary Associate Professor at University College London. Her research and clinical work is focused on improving our understanding and treatment of adolescence anxiety disorders. Her particular expertise is in social anxiety and she's widely published in the area and has done some really fantastic work deepening our understanding of the application of cognitive therapy in this population. Welcome to the podcast, Eleanor.

Eleanor: Hi, Rachel. Thanks for having me.

Rachel: It'd be really great. just as a starting point to hear what got you interested in this area, how did you get into looking at social anxiety in young people?

Eleanor: So I was very lucky to do my clinical psychology doctorate many moons ago at the Institute of Psychiatry at King's, and I had my final placement at the Centre for Anxiety Disorders and Trauma, and which sort of specialised in the treatment of anxiety problems in adults using cognitive approaches, which have been set up by David Clark and Anke Ehlers. And I remember being really nervous about being there because there's a great reputation. And I got there and I had the most amazing supervisor in Debbie Cullen. And I had this really exciting six months of going deep into a therapy and feeling like I was delivering treatments that seemed to make a real difference. I was treating adults with Post Traumatic Stress Disorder and Social Anxiety Disorder. And I found it just really fulfilling and I thought, wow, this is amazing. And then I went and did a placement in a service for young people with anxiety problems, which was equally dynamic and exciting. But also made me really aware of how much kind of further behind the curve the research was, and treatment development was, with children and young people. And I'm sure we'll come on and talk about this in a little bit, but I was particularly struck by how the treatments for young people with social anxiety, which seemed to be the bread and butter that was coming through the clinic, just weren't as useful or helpful. And that was, I suppose, the real catalyst for where I've gone. And where my career has taken me so far.

Rachel: So you had this experience of seeing stuff that really worked, that was really satisfying, but then also seeing this gap in the market, if you like, this area that we were under helping folk with. And it makes sense that this was the bread and butter of what you were seeing because adolescence can be an excruciatingly self-conscious time for many, but not all young people. And I guess lots of young people must suffer from social anxiety, but what do we know about how many actually suffer from this as a disorder? What the sort of typical age and onset and course of social anxiety is at this stage of life?

Eleanor: Yeah, I think you've just pulled out two really important things. One is about what tends to happen to most of us in our teenage years, and the other is about thinking about the scale of the problem of social anxiety. Maybe if we just start off by thinking about what happens in the teenage years.

I don't know, Rachel, about you, but when I think back to my kind of progress into being a teenager, I have like a particular memory that I find excruciating, which is of going shopping. I always tell this when I'm doing teaching, of going shopping with my mum, and I remember asking her to walk slightly ahead of me so we could pretend that we weren't actually together because I didn't want to be seen by my friends hanging out with my mum. My dearest mother, though, still carried on and bought me a really nice pair of jeans, despite my like abominable behaviour. And I suppose what this really makes me think about in retrospect is how we all get very self-conscious during the adolescent years, and there are all these changes going on with our kind of social, emotional, cognitive processes in adolescence, and that's all I suppose in the service of trying to help young people shift away from their family unit and towards their peer group, learning how to make, break and repair relationships because that's what we need to do to be able to become independent adults, functioning ourselves.

Rachel: So what you're saying is it's normal that my teenage sons want to spend all their time in their bedroom and not with me.

Eleanor: I know, painful as it is, and I've got a, my daughter is moving into the adolescent phase, and I can feel her pulling away as I endlessly try and hug her, I realise that this is a very normal thing. And so what we see, the research seems to suggest that there is this very predictable uptick in social worries as you sort of pre adolescence move into the teenage years and that's based on both parent report and child self-report. For most kids what we then see is that sort of just eases down naturally without any particular intervention.

Rachel: So I can really identify with that. I remember my teenage years feeling like a long tunnel of feeling dull and boring and generally socially unacceptable. But you're saying that part of this is normal as a process of kind of individuating, separating from our parents, wanting kind of work things out, feeling awkward, feeling uncomfortable, self-conscious, but how does it develop into a problem that impacts people like social anxiety?

Eleanor: Yeah, and I think, so this is a really critical point, isn't it? It's that for most people, all of these processes are recurring and increase in susceptibility to peer influence, self-consciousness, and there's this kind of perfect storm that sets the stage for social anxiety or social concerns. But why is it that some young people will then go on to have this kind of much more distressing and problematic social worries compared to others. And I suppose there are a few answers to that. Most likely there are going to be genetic vulnerabilities. And so some young people temperamentally, but more sort of behaviourally inhibited, tend to hold back, tend to be those kids who take a bit longer to engage in a party or play or a game or something novel. But there's also likely to be sort of particular experiences that some young people have been through that might make them more likely. So we know that, for example, from twin studies it seems to be this combination of genetic factors, but also non shared factors. So environmental factors. So things most likely to do with what's happened to that young person that's not in their family home. So peer experiences might be the kind of best candidate we could consider. And one of my colleagues did a really lovely meta-analysis looking at the relationships between peer problems and social anxiety in young people and found really clear indication of a two way link. But so it does seem to be that problematic peer relationships and peer victimisation in particular, contributes to social anxiety over time.

Rachel: So it's a significant problem then for young people is it? I mean, how many young folk actually do develop this as a disorder as opposed to a normal self-consciousness?

Eleanor: Yeah, exactly. So estimates vary but lifetime prevalence rates suggest it's between sort of five and 8%. But when you think about that sort of around 90 percent of cases will have their onset before early adulthood, before about the age of 20 ish. So most cases will first occur in that kind of adolescent period. So if you think about an average classroom of about 30 kids, you could expect to see a couple of kids, one to two kids in the classroom. Yeah. And if you speak to clinicians, it is the most kind of common problem coming through the doors.

Rachel: So it’s a really significant problem. We see it really frequently in services, thinking back to where you started with saying there was this gap in treatment for it and evidence-based treatment and treatments that really helped. How well recognised do you think it is now generally in services or generally in the population and how easy is it for young people to get evidence-based treatment now?

Eleanor: I think recognition has improved probably for all mental health problems. I think there's been great strides in how we talk about mental health and how we recognise it. And with the development of mental health support teams in schools, I think there has also been a great improvement. I think there's something particular about social anxiety that brings with it some challenges in terms of the stigma and shame that young people would often feel about their difficulties, which can be a kind of inbuilt obstacle to young people asking for help. And so many young people, I think, who are socially anxious will feel like it's not that they have a problem that could be treated. It's that there's something wrong with them inherently as a person. It's sort of, it's a sense of social anxiety. A bit like depression is sort of disorder of oneself. The other thing that I think can impact on detection rates is that many people in the system, parents, families, or teachers will see it as a normal part of being a teenager that many young people will grow out of. It's just the kind of awkwardness of being-just like we were speaking about a moment ago, Rachel. And yet we know that there are levels of social anxiety, which really get in the way and are really debilitating and actually don't go away on their own. And that's the other thing. When young people, are intensely socially anxious, they will get caught in cycles which mean that actually the social anxiety is perpetuated, and we see from longitudinal studies that social anxiety is one of the most chronic of the common mental health conditions.

Rachel: And it sounds like it can be quite difficult doing this sort of peeling apart what's normal developmentally from a sort of disorder pathway. How difficult is that to do? How do you know, right, okay, this is no longer just this kind of teenage normal development, and it's actually spilling into something that needs an intervention right now. How do you decide that when someone presents in clinic?

Eleanor: I think it's such a good question. And there are lots of different views on the utility and rights and wrongs of diagnosis. But I think at the core, what we want to do is talk to the young person, talk to the family and understand from their perspective the way that social anxiety is impacting on their happiness, on their well-being, on their ability to do the things that we know they should and could be doing. And I think that's one of the other really key aspects of thinking about intervening in adolescence is that there are these absolutely critical milestones that young people will be moving through, and that we know that problems like social anxiety can really impact on. For example, some big studies in Sweden have suggested that social anxiety disorder can really impact on kids’ academic attainment. So young people who are seeking clinic treatment for social anxiety disorder were less likely to progress through to tertiary education like university and they tended to do less well in their final year exams. And that's not because of IQ, it's not because of ability, it's because likely a range of things, but social anxiety will make it hard to put your hand up in class and ask the question and have that kind of query resolved. It will make you less likely to do well in that presentation which might be part of your final assessment. But also, some work that I've done with colleagues indicates that it also might affect how able you are just to concentrate on what the teacher is saying. Because instead, all of your attention, as we were saying earlier, is preoccupied on, oh my gosh, is someone going to ask me a question? I feel like I'm really red and I'm looking really silly. Instead of something to do with Henry VIII, or something to do with photosynthesis, or whatever else is on the topic.

Rachel: So both in terms of the prevalence at this age and the onset being a huge statistic, isn't it? 90 percent of folk having their onset at this stage in life, and in terms of the impact it has on people and the longevity of that disorder and the huge impact that can have on the trajectory of their lives, it sounds like it's really important to try and stem this tide to get in there at this stage.

Eleanor: Absolutely, and I’m always minded that I give this very bleak kind of picture, and it is a really impairing disorder, but I also think for any clinicians or researchers thinking about working in the adolescent space, it's also a really exciting opportunity to think about how do we deliver an effective treatment in a timely way? Because that can really nudge young people in a different direction. So, I think a smaller, sort of tighter intervention can have a bigger effect at these early stages is my kind of optimistic take on it.

Rachel: Well, we're all about hope here and that's what these treatments offer, isn't it? And David Clark was recently on the podcast and talked through the Clark and Wells model of social anxiety, which you might, as you might expect, he's pretty familiar with having developed that himself. And it seems that has a lot of relevance to adolescents. And I know that you've been applying that model for many years and adapting that model. I wonder, given what you've started to say about what's distinct, or additional factors in young people if you could talk us through a model of social anxiety as applied to young people.

Now we're a podcast, so you can't use boxes or arrows or any other visual aids, so this is your challenge. Can you tell us what a formulation of social anxiety looks like in adolescence without any of those aids?

Eleanor: Rachel, it's still early in the morning. I haven't even finished my first coffee, but I will try. And I will also feel very glad to come in the wake of David because I think anyone can probably go and listen to his amazing description of the model. I will try and do my second best, I think. One of the things just to say that I found so interesting in the work that I've done with David thinking about how the model might apply to young people, it's just how many parallels and similarities there are to how many findings we replicated in young people, as were found in adults.

And so just thinking about it, a young person with, who's socially anxious, will be going into a classroom. Going into the lunch hall, for example, and there'll be a sense of something's going to go wrong, something bad's going to happen. That kind of threat signal is going to be coming up. It's going to be an anticipation of social demands that a young person feels unable to manage. And when they go into that lunch hall and they see the table they're going to join, they sit down, they’ll start thinking everyone's looking at me, perhaps I've got nothing to say, and they're all going to think I'm the kind of boring one. So the whole kind of range of negative thoughts that will be different for each young person will be running through their minds. And as a result of all of those kind of negative thoughts that will impact and create a cycle of effects on what young people pay attention to, what they picture in their mind's eye and what they tend to do. So the first thing that will often happen is something to do with their attention. And if we think about attention a bit like a spotlight, you and I will be in a conversation and I'll be thinking about you, Rachel, I'm focused on you. and then sometimes thinking, what am I going to say next? But generally I'm absorbed in the to and fro of our chat. Whereas a young person who's socially anxious, that spotlight will be absolutely on themselves and on how they're coming across and that has negative consequences, it has a knock on effect. It means that, firstly, they aren't attending to how the other kids are, what they're doing on the lunch table. They're not noticing that the person opposite them is smiling, perhaps that someone else is not even paying any attention to anyone, they're eating their ham sandwich.

And so then the next part is that they are not attending to the other people, but they're attending to themselves. They're attending to their physical feelings. And internal information. And that is what becomes the source of information about how they're coming across to other people. So feeling sweaty in the armpits becomes information that actually I must look sweaty in my armpits. Feeling red in my cheeks means I must look like I'm blushing. And then the other source of information are those mental images and impressions. So picturing in one's mind's eye the kind of worst case scenario of how one looks. One young girl told me that she looked like a kind of red blushing tomato and that's a clear image. But obviously the worst case negative distorted sense of how she looks. But other young people have described more impressionistic like, sense of how they come across. So one young girl said it was like she was a kind of a lump, like a stone in the room. So everyone else was moving around and she was just this lump that no one was interested in.

And because these images or impressions tend to be seen from the outside in, so as if you can see yourself, they feel quite believable, feel plausible. And so again, these are used as further information for how one's coming across. And so this kind of self-focused attention and these internal images become data or information and it's how one processes oneself as a social object. And then of course, because people are concerned about messing up, because they have these horrible senses of coming across badly, it will trigger a whole range of safety behaviours, things people will be doing to try to prevent or mitigate those kinds of horrible concerns. And these will vary. They will be the classic sort of avoidant behaviours, looking down, speaking less but also those more sort of sophisticated strategies of trying to come up with good stories, having a joke ready that always lands, asking lots of questions, laughing along to every joke. And these may be sort of work in the moment at some level, but they keep those fears going. And they also have a whole range of other negative consequences like they can actually directly cause the feared symptoms, they increase that self-focused attention. And really importantly, they can actually impact on the social interaction. That's the social setting, because if you're not looking at someone and not asking questions, that's giving a pretty clear signal about whether or not you're interested, even though it's the opposite to what's intended.

Now, at this point, I might just pause if that's okay, Rachel, and just comment briefly on some of the findings we've had in relation to young people and this model because that's the sort of, that's the core aspect of the model, I suppose, as we might be thinking about it with adults.

Rachel: It sounds very familiar in terms of that adult model. I'm really curious to hear what pieces might be a bit different or might be additional to that.

Eleanor: Yeah, so just in terms of what we know from our work with young people, firstly, there's some really interesting findings that we’ve picked out in relation to safety behaviours. One of my colleagues did some really nice work looking at the types of safety behaviours and how they might vary across development. And so we seem to have these kind of two clusters of safety behaviours, these avoidant safety behaviours and impression management safety behaviours. And when we looked at this in young people, we sort of replicated that. So we seem to find these two factors. But what was really interesting is that we seem to find, when we looked at younger adolescents, so the kind of Year 7s, the just starting high school, compared to our college students, so 16 to 18s, we seem to find that younger kids used relatively more of the avoidance safety behaviours compared to impression management safety behaviours. So I think what's interesting about that is that it makes sense because probably when you're trying to use impression management safety behaviours, they're sort of more cognitively sophisticated. You have to be thinking about what the other person might be thinking about you in order to this is going to be a good story.

Rachel: So in terms of cognitive development, younger kids might not quite be there yet. Is that right?

Eleanor: Yeah, so that's what we seem to see at a kind of group level. But then this is very interesting when we think clinically because the other part of the finding about safety behaviours is that both types of safety behaviours make you feel more anxious, they perpetuate those negative beliefs about yourself, but it seems to be that it's the avoidance safety behaviours that are particularly problematic in terms of that contaminating effect on other people.

So impression management behaviours affect you if you use them, but they don't seem to affect the interaction. Whereas in contrast, avoidance safety behaviours also affect the interaction. So when we sort of zoom out and imagine our year seven students starting secondary school in lots of quite complex social environments, feeling very nervous, but tending to use more of these sort of avoidance strategies hunkering down, they're going to be more vulnerable to having that kind of negative impact on their social environment. And then if we add another layer and think, what are the peer processes going on normatively? Well, normatively there's this whole hypersensitivity to peer rejection. There is this kind of really febrile environment socially. All the kids are worried about being rejected at this time. So then if you're this young person with social anxiety, bringing in their worries and being very avoidant, that may well be picked up particularly negatively by a peer. And so one gets locked in these cycles very early, that can then be quite hard to break.

Rachel: So the environment seems to confirm your fears, where the environment is one that's all about fitting in. You only have to watch a group of teenagers walking down the road to see they're all wearing the same trainers, the same haircut, the same clothes. It’s all about conforming in many ways, isn't it?

Eleanor: Yeah, it's so interesting. I feel like I've been this kind of, not a bird watcher, but a sort of watcher of teens for a while. Because you're absolutely right, there are these sort of tribes, these groups, and at first glance they all look identical. But then there are these very subtle differences between them. And actually, so one might be wearing their grey trackies at a particular length, the other's wearing like black trackies, and they've got very similar Nikes, but one's got a green tick and the other's got a blue tick, there are just these sort of little differences. And when I speak to my young people in clinic, they'll often talk about trying to get it right. And just sort of often mimicking or doing the same thing as my peers, but then being criticised or rejected for that because they haven't quite got it correctly because they copied too much. They haven't got the social rules right because they've just been so desperate to fit in.

Rachel: And it sounds exhausting trying to fit in all the time, trying to manage your impression. I know that certainly adults who speak about a long life of social anxiety talk about that a lot, don't they? It's just so draining and exhausting always trying to come across well.

Eleanor: Yeah, absolutely. And we've just done some work with looking at quite a big data set, with a large community sample, and that's really borne out with that data in that what we see is that, over time, social anxiety is associated with persistence of depression symptoms, but also it seems to be associated with suicidal ideation over time through a pathway through depression symptoms. And in fact, that's what we often find is that it's depression that will bring young people to clinic. I think that's the same problem with adults as well. It's often not the social anxiety. And I think it's that, what young people and what most of us, many of us want more than anything is social connection. And that's what brings us most pleasure and most meaning in our lives. And that's no different for a young person with social anxiety, and actually it's acutely true for teenagers. And yet, kids who are socially anxious just fundamentally don't feel like they're acceptable and feel like if they show themselves then they will be rejected.

Rachel: So you have summarised that beautifully. Is there anything we've missed in terms of additional sort of factors that influence young people in terms of our social anxiety formulation?

Eleanor: I suppose the other dimension that we've been thinking about in addition is thinking about the kind of parent system. So I mentioned earlier that young people as they're moving through adolescence or it's a process of individuation, but of course, the majority of young people will be still living in the family home and parents will still have considerable sway and influence over their day to day lives and over their decisions that are made around them. And it's quite interesting in the kind of evidence around the relationship between parents and young people anxiety is not hugely compelling. It seems that if there is an association between parental behaviours and beliefs and young people anxiety, it's pretty modest, and the dimension that seems to be most relevant is that of sort of being overprotective or over intrusive. As parents, and I feel like I'm learning this all the time, we don't just put on our parent hat, like, we come to parenting with all our own concerns, worries, beliefs, like, I feel like I'm constantly doing it wrong.

Rachel: I'm convinced it's worse if you're a psychologist.

Eleanor: I know, because you do it and then you realise you've done it wrong, I think, probably, something like that. Yeah, so parents will bring with them their own anxieties and we think that those parents who are particularly worried about their child, like my child's is not going to be able to cope with their social, new social environment, my child's going to get treated badly by their peers. That may well encourage a sort of over control, over involvement in their child's social world in a way that potentially is developmentally inappropriate. And I suppose that can impact in a range of ways. It can mean that young people are less willing to try things and test out ideas. But it can also mean that young people are more susceptible to unkind reactions from others. Because I remember a young person whose mum would take them to the gate every day and pick them up, even though that just wasn't happening anymore in year seven. So that young person was then sort of singled out somewhat for some unkind treatment by their peers. So in some cases, it can be useful to think about the role of parents as potentially a sort of feature of that's keeping the social anxiety cycle going. Of course, when we're thinking therapeutically, parents will also very often be an absolutely critical resource and support to help the young person develop confidence. But sometimes, inadvertently, parents despite the best will in the world, can be getting caught up in the cycle a little bit.

Rachel: So thank you so much for describing that. That really helps put it in context an helps us think about those factors which are really specific to young people. Is the treatment for social anxiety and CBT specifically for social anxiety with young people effective? Is equally effective as it is for adults? You started out by saying there was lots of developmental work to do there. Is it there yet? Is it equally effective in the real world as in treatment trials? How's it working?

Eleanor: So CBT is a broad church, and maybe we'll do a brief history lesson for CBT for anxiety in young people. But for a long time, whilst treatments were being developed for kind of particular anxiety problems in adults, in children and young people, it was a different approach that was being taken where CBT for all kinds of anxiety was one intervention. And so these treatments tended to focus on anxiety, sort of a generic model of anxiety, and then there'd be psychoeducation and anxiety management skills, and then there would be graded exposure based on habituation model. And probably one of the best well known ones of those is Coping Cat or the Adolescent CAT Project, but there've been a whole, there's a kind of now very wide family of these that vary in terms of like, with parents, without, in groups, one to one, via digital delivery and so on.

And broadly, there've been so many treatment trials with this intervention and broadly, when you look at loss of primary diagnosis, or when you look at reduction on a broad measure of anxiety, the outcomes seem to be good. So effect sizes are around 0. 8, which is really great. But what's been exciting is that as there've been so many treatment trials, data accrues and that allows us to begin to ask really important questions around what are the kind of moderators of treatment outcome? What things predict who does well in these treatments and who doesn't? And a really consistent finding from these studies is that the presence of social anxiety disorder, is a kind of significant predictor of poorer outcomes. So we did a meta-analysis of this a few years ago, led by a really fantastic colleague of mine. And what we found is that young people with social anxiety disorder were about 50 percent less likely to recover from these broad-based CBT interventions. So about, I think, well, about 55 percent of those with other anxiety problems recovered from broad based CBT. Only about 35%, with social anxiety recovered. And this is a finding that's been replicated by various other groups. So there's a really nice paper out, a couple of weeks ago by our colleagues in Norway. And they found this seems, this effect persists up to about 4 year follow up.

Rachel: Wow. So that's a really big discrepancy between those groups, isn't it? 55 down to 35%,

Eleanor: Yes, so this is this is what's so brilliant about bringing findings of lots of trials together, being able to ask these really important nuanced questions like what works for whom. Those kind of broad-based CBT interventions are probably good for lots of anxiety problems, it just seems there's something particular about social anxiety that means that those kind of exposure-based techniques aren't so helpful. And then when we think back to what we were talking about a moment ago, in terms of the sort of social anxiety Clarke and Welles model, this starts to make sense, doesn't it? Because if a young person is repeatedly facing social situations, but still very much caught up in their head doing safety behaviours, then it's going to be very hard for them to learn anything new, learn that actually they came across just fine. And so what this suggests is that we need to do something with those attentional and behavioural processes in the moment to help young people make the most of those learning opportunities, and to discover that they don't need to hide, they come across just fine as they are and that's where we've been moving in the last few years thinking about the applicability of cognitive therapy, which is the treatment that David and others developed to target those core processes in the social anxiety model. And we've been adapting that for young people.

And we're obviously not the only group. So others have been involved in doing similar evaluations and we're still at a sort of early stage, but findings are really promising. For example, Jo Magne Ingul in Norway, who undertook a trial comparing one-to-one face to face cognitive therapy to group based Coping Cat or a version of Coping Cat to an attentional control, found that individual cognitive therapy outperformed group Coping Cat and outperformed attention placebo up to six months follow up, which is really exciting. I mean, there are questions around, well, you've got a one-to-one treatment compared to a group treatment and maybe a kid with social anxiety doesn't want to be in a group treatment so there are some questions, but it is really exciting preliminary findings. And then we've run a preliminary trial, we actually took a bit of a leap, so we decided to test the treatments, not just as cognitive therapy, but delivered in digital format, so an internet delivered version.

Rachel: Which intuitively makes a lot of sense if we're talking about a digital generation.

Eleanor: Well it's very interesting. So Chris Hollis has done lots of really, MindTech has done a really nice review looking at this and actually preferences are mixed I think amongst young people towards digital treatment. So I think we do need to think about choice for young people as well as for adults.

But what digital therapies provide, which I think is really crucial, given the sort of constraints on services, is the opportunity to deliver rich, high content therapies in a brief format. So with no loss of all the kind of core treatment elements, which is so important. And what we found with that trial that came out last year, it was a waitlist-controlled trial, we found, that about 77 percent of young people had recovered at the end of treatment compared to 14 percent in the waitlist, and then when we looked at six months follow up that had increased to about 90%. So young people did really very well.

Rachel: Wow. That must have been really exciting.

Eleanor: Yeah, it was really exciting. I was also really delighted that we tested an internet delivered treatment because it's during covid. Yeah, it felt really exciting, and it was sort of the preliminary demonstration of the sense that we'd got from our early development work of the potential for the treatment. But obviously, really big questions are now there ready to be tested. So are there specific treatment effects that we can demonstrate? So in other words, is internet delivered cognitive therapy, which we've called OSCA for young people, Online Social Anxiety Cognitive Therapy for Adolescents. Is that better than an active comparator or treatment as usual?  And also in our first trial, treatment was delivered by me as a kind of someone who lives and breathes social anxiety. And we really want to be able to find out what are the outcomes like when it's delivered by clinicians working in routine services, who are doing a whole range of other things with their day to day working life, not just social anxiety research.

Rachel: So we want to know it's not just an Eleanor effect?

Eleanor: Yes, exactly.

Rachel: Although I imagine being with you Eleanor would just be very therapeutic in and of itself, but fantastic results. I mean, thinking about even just what you were saying about good, more generic treatment across disorders. We were looking at sort of 55 percent recovery rates, weren't we? And you're not talking about 77 percent at the end of treatment, going up to 90 percent later. So there's must be some of the best treatment response rates we're seeing across the board in young people.

Eleanor: Yeah, I think we need to remember this is a small trial. It's preliminary so I think it's now about increasing our sample size, feeling greater confidence in our results and then starting to think about implementation and rollout and improving access to the treatment if our findings are supported.

Rachel: And are there any sort of diversity factors we need to be aware of there? So do we know yet is the research there to tell us that this treatment- and I hear what you're saying is preliminary results from small trials- but do you have a hunch around this treatment being equally accessible to everyone? Or do you think there might be cultural or other issues that might make it more difficult for some people?

Eleanor: Yeah it's a really good question. In terms of cultural diversity so we actually recruited through, it was primarily, it was in the South of England but from lots of South London secondary schools we were working with. We had quite a diverse sample, primarily female, and I'd like to boost our mix of genders in our next trial. We've also been working with the Born in Bradford project, looking at is our internet program acceptable to people from different parts of England and also people from different ethnicities that weren't captured in our first trial.

I think the big area for us which we're currently working on with colleagues in Bath, and with some of us here in Oxford, is thinking about neurodiversity. I think is the kind of big area which I do have more questions about, is the treatment as it stands going to be helpful or are there things that we need to adapt? So for example, recent work we did was looking at the kind of construct overlap between safety behaviours. So these are those things, the kind of things people do to try and keep themselves safe, in relation to their social worries on the one hand, and then camouflaging and masking behaviours on the other, which are things young autistic people will do in order to hide or conceal aspects of their autistic identity or autistic selves. And what we find is that, that these camouflaging and safety behaviours can often look the same from the outside, despite having functional differences. So this is an area where, for example, we might want to think about, are there in our clinical techniques things we need to do a little bit differently? Because it may be that although camouflaging and masking are associated with stress and burnout, they're quite protective and important for judicious use in certain contexts for a young person, or at least we need to know when and if a young person chooses to use them or not.

Rachel: Thats so interesting and such important work because we know that social anxiety is really raised along with other anxiety problems in those folk that are on the autistic spectrum.

Eleanor: So we know like 50 percent of young autistic people will have social anxiety disorder. It should be something that clinicians are seeing routinely and so the other dimension of it, I suppose, is thinking about all different autism specific processes or traits that might interact with social anxiety. So sensory sensitivity, for example. And so we're doing some work at the moment which is hoping to get at this question. So we're going to start with, as well as some observational experimental studies, we're also beginning a multiple baseline case series design just to learn some lessons before we hopefully move into a bigger evaluation of what would this treatment look like if we evaluate it.

Rachel: Fantastic. And given what you've been saying about thinking about so closely developing the interventions, whilst looking very closely at the mechanisms that are underpinning the presenting problems and the perpetuating factors. Can you tell us a little bit about sort of the nuts and bolts of what treatment looks like, typically what do you do in therapy with a young person?

Eleanor: Yeah, I now feel like I'm a digital native and I spend a lot of my time doing internet delivered treatment, but why don't I talk about the kind of more traditional way of doing it, which I think might be more familiar to listeners. This is a phrase that David used once, and now it kind of echoes in my head, but he says, treatment sticks like a limpet to the model which, I don’t know if that means anything to you, but I find that really helpful. So if you, if one has a good understanding of the model, then the treatment flows from that because everything one does in treatment is in service of targeting those maintenance processes.

What treatment looks like is, we will start by thinking with the young person about their own social anxiety and developing a personalised version of that Clark and Welles model with them. It's almost like a snapshot of when they are anxious in a social situation, what tends to happen to their thoughts, to their attention and to what they do to keep themselves safe. How do they tend to picture themselves in the moment? We might also just check in on those kind of processes that are around it. So is there worry and rumination? Are there issues around high self-criticism that we might want to think about? What about the peer environment, parental factors, just holding those but always think about the core aspects of the model which we're going to be really focusing on. So that's the sort of first step.

It can often be helpful to ask a young person to do another few models over the week so that as all social situations are different, particularly sort of performance situations compared to a social interaction. The next step is the self-focused attention and safety behaviours experiment. This is all following, hopefully if people know the adult treatment, it's following a very familiar predictable course. So the next step is the self-focused attention and safety behaviour experiment, which is that experiential exercise where we want young people to discover for themselves the unhelpful effects of being internally focused and using safety behaviours. So one of the criticisms that would be historically be levelled at, I was thinking about cognitive therapy for young people as well, but it's all talking and surely young people aren't going to like that. And actually cognitive therapy is learning through action. That's how I see it. And that's why I think it's such a great match for young people because here in session two, we have this experiment where really people find out for themselves, Oh, so this thing that I thought was helpful is really not working for me. And I don't think very often one gets a sort of penny drop moment in with therapeutic procedures whereas I think this is one of those techniques that really is can be pivotal, so we do that in session 2. Very often young people, which I think is more of an issue with young people compared to adults, will say yeah but it was an adult I was talking to, they were friendly, this is not how it works at school. So we really need to think about that bridge to okay let's test these ideas in your everyday life. Let's see if these principles hold when you're at school, when you're at your football club, when you're going to drum. And then this then sets the stage for the next clinical technique which is video feedback so young people can watch back with that kind of careful preparation in advance that Emma Warnock-Parkes has written so beautifully about in her paper with David. And really helping young people to see themselves in a more objective and positive light. And then following that we give some systematic training in getting out of one's head and getting better at engaging in the external environment, social environments, so that young people can gather real information, real data from the outside world about how they're coming across rather than relying on their feelings.

And then that sort of sets the stage for behavioural experiments. And that's really where we go, testing out one's fears in social situations whilst dropping safety behaviours, getting out of one's head in order to really hopefully learn that young people are acceptable, that they are liked, that they are fine just as they are without safety behaviours. That's the message that we want to convey and help them to discover about themselves.

Rachel: So it sounds a world apart from that sort of generic exposure type treatment you were talking about that often got delivered to young people in the past, because that just gave people the opportunity to learn and learn again that actually this feels awful in my head, to be exposed to those awful images and that felt sense that they had of themselves. This is quite different, isn't it?

Eleanor: It is and it's really interesting. Some other groups have done some really lovely work where they've sort of taken the generic approach and they've tried to add in elements of attention training or of imagery work and see whether that is better than the generic sort of standard broad-based treatment. And they don't seem to find these effects. So I wonder whether there's something about being very model driven and really bringing in those kind of core techniques early on that seems to be very helpful. So I think the kind of key things I'd be thinking about for clinicians is just making sure that you develop that model early and that is what's driving the techniques subsequently, and also that one doesn't hold back from doing, for example, the self-focused attention and safety behaviour experiment, which I think does make therapists a bit nervous and I think there can be a tendency to leave that till a bit later, spend longer on psychoeducation, but I think it's really valuable to do it very early on. And I think, in fact, that's sort of something that David and Adrian discovered, when they were testing out the treatment, some time ago.

Rachel: And I'm conscious that when we were speaking earlier, you mentioned that teenagers can be quite cruel about difference. They can pick up on these things. We tend to hope when we're running these experiments that people are going to come back with really positive data. Is there a risk when you're sending a young person off to their environment to experiment and behaving? Maybe not in this kind of net within those narrow tram lines, they might believe they have to behave that actually they might have some of their worst fears confirmed.

Eleanor: Yeah, this is an absolutely critical point, and this is a question I think I get asked at every training that I do, and it is certainly a reality and a difficulty. So our job as therapists is to try to ensure that young people go and do experiments and discover something helpful and positive for themselves that's also more objectively accurate, I suppose, but it's about making sure they make helpful discoveries about themselves. We need to think about, in that initial assessment, what is their social context? What are their peer relationships like? Even that is not easy to find out, so I've got an amazing PhD student at the moment who's trying to get at this question of the links between social anxiety and peer relationships. And she's going to be using something called social network analysis to try to strip out that layer of, well if you've got social anxiety you actually are more likely to rate people being unkind to you, you're going to inflate these associations. So she's trying to get at this question using different study techniques. So I suppose tracking back, what I mean by that is thinking about even asking a young person about their social relationships when they're socially anxious, it's quite hard to unpick what is it that's perception and what is it that is how people relate to them. I think if a young person with social anxiety perceives a certain environment that they're in as victimising or bullying, that's how you read it. That's how you take it. And then what I would normally do is think, let's try to in the first instance produce or help form some alternative social settings that feel safer, that feel more benign in which they can undertake those behavioural experiments and start to test out some of their ideas.

And then whilst we're doing that, also just very gently trying to start unpicking some of the mechanisms we think link social anxiety and peer problems. What happens when you go into a social situation and you're using those kind of avoidant behaviours and not looking up? What might be the message that someone else is picking up? So just starting to pull out and test out the ideas around actually, there might be some things that a young person who's socially anxious does in social situations that might elicit less friendly reactions.

Rachel: How do you go about creating those opportunities to interact with those more benign situations? It's a long time since I was trying to decide what to do with my social life as a teenager, where do you start? Do you go hang out with them, Eleanor? Do you go in the bowling alley?

Eleanor: I think I'd make that worse. It's definitely about in vivo experimentation, for sure. If you're spending a whole session in the clinic room, I think one should be going out and doing behavioural experiments together, so that's part of it. The other part of it is, what I tend to do is, very much engage with parents as a resource. Where, who, which of the friendship, is it cousins? Is it, for example, can we get them connected to a drama group? Can we get them connected to a dance group? Joining those groups that feel more manageable. It’s very much a kind of, there's some practical work that's often done there with parents or carers or people in the system to support that. Another way of doing it is get engaging with a member of school staff, finding those lunchtime clubs that might be more manageable, for example, and a kind of safer setting. So it's sometimes getting those kind of key adults around to scaffold, to support environmental shifts so that behavioural experiments can happen.

Rachel: And that leads nicely to thinking about that other piece that you mentioned that's a little bit different for adolescents, so the parental interaction. How do you engage parents? Do you engage directly with parents around that? Do you engage through the young person? How does that look in your therapy where it's necessary to address that?

Eleanor: Thinking about how we work with parents, it's different with each young person. In terms of working with parents, it can vary from almost never seeing the parent, to them to spending some time directly doing some one-to-one work with a parent. And that will be determined by a range of factors, the kind of developmental age or stage of a young person, the preferences of a young person, the ability of a young person to engage independently with therapy or the extent to which they need help.

And then thinking about whether there is a reason to engage with a parent because we think there might be parental behaviours that are kind of part of or feeding into the difficulties. In terms of that kind of last strand, which I think is where your question was going, I would always exercise a bit of caution around intervening with parents because, what we tend to see is that anxious parenting behaviour is often in response to parenting an anxious child, it's a sort of dyadic process, it's not one way or the other. And I think by really focusing initially on the young person, hoping to get some symptom relief, and then seeing actually what happens to how the parent is engaging. We often see just spontaneous resolution of those parenting behaviours when a young person feels better. If that doesn't ease, even though the young person is engaging in therapy, and we're also seeing, for example, a parent allowing avoidance of behavioural experiments. Perhaps there's a little bit of parental avoidance that is impacting on the child's experimentation then it might be, that might be some signals to think about working with parents.

And there it's quite light touch typically, maybe 20 minute phone call and some kind of back and forth emails. And it's absolutely using the principles that we have been using with a young person. The first step is often about helping a parent to spot their own beliefs and concerns about their young person's ability to cope, the potential threat that they're facing socially. Identifying that belief, but then also getting a sense of where that's come from, understanding the parent's perspective, because parents will often be feeling blamed. They feel like they are to blame, we all feel a sense of responsibility for our children. And so that's probably particularly the case when your child is receiving a treatment. So thinking about walking alongside a parent. Saying, of course, let's make sense of where these concerns come from, that your daughter's going to get bullied. It's often from somewhere really understandable. I was really socially anxious as a child and I had a horrible time, or they were bullied in primary school and I don't want it to happen again to them. Understanding the story in the background. Well, that makes absolute sense that you have that belief and that you feel like that. Now let's look at how that belief impacts on how you relate to your child and what you do. So you start to move to thinking about, well, because I'm concerned that they're going to get bullied, for example, I will walk them to school. I don't allow them to use social media, or I track their social media. And we look at them and then we look at the pros and cons of those behaviours, the intended, the unintended consequences. And that then sets the stage for some, often some kind of research work that we encourage parents to do. Benchmarking. What are other parents doing in their cultural group, in their community, in their age range? Working out for them what is actually probably where they should be compared to where they are. And then behavioural experiments. So let's test out those ideas and see, find an alternative and it can be helpful to engage a young person sometimes in those moments so that they know what's coming and, it depends I think on, from a case by case basis how much you involve the young person in the parent work.

Rachel: And it does sound like a really understanding, respectful process where, there's nothing more basic and human is there for us as parents to want to protect our children from harm, but also tapping into that piece of what we want most of them is to flourish. And those two things, the way we go about those two things don't always marry up.

Eleanor: No, and I think often parents are busy, often they have many competing demands, and parenting can often just be driven by quite quick emotional habits. And so it's helping a parent explicitly think about the pathway through to what they're doing and is that how they choose or want to do it and giving them that space to test out doing things a bit differently.

Rachel: So Eleanor, that's been a really helpful description of how the model might be applied, how it looks very much like what we might expect in terms of sticking like a limpet to the model, but also thinking about these additional factors that are play a really important part in how you might need to address those more broadly, the sort of systemic factors that are supporting or maintaining the problem. In your vast experience of teaching this work, supervising, applying the therapy with young people, where do therapists get stuck? What are your most frequently asked questions or trickiest issues that come up?

Eleanor: I think we might have just been speaking about it actually. I think the most challenging thing is, particularly in the kind of work with young people, is thinking about the reality of that social environment. I was talking about this with colleagues the other day in that there's something very specific about the school environment which is not only all these adolescents having all their social concerns and feeling kind of sensitivity to peer reward and peer rejection, but it's also like a locked system, so to speak. So as adults, we have agency, often we have much more choice about how we interact with our environments, our workspace. Not everyone will feel that to a certain, to a greater extent, but that is much more so than young people who need to be in school all day. And so then I do think it becomes a challenge to think about how do we help young people make positive discoveries about themselves when their social environment can be quite unkind. And actually one of the things that we've recently developed are virtual classrooms. So these are sort of filmed classrooms of differing sizes and it's a way for young people to test out and do behavioural experiments and video feedback, giving speeches or reading aloud or just sitting in a classroom that generates the feeling of being in a classroom, but in a slightly safer setting. So then you have a kind of staggered way to then move to experimenting in a real classroom, which potentially does feel more challenging.

Rachel: I love this idea, but I've got to check out- is there someone throwing something at all times? Another child in these videos, because if the stories that come out from my kids schools, if you believe that it wouldn't be authentic otherwise.

Eleanor: We did, we asked, we got a range of classroom scenes. So some we've got some good students in quotes, and then we've got some other scenes where we've got disinterested students. So they're all looking over their shoulders and whispering and passing notes. So we've tried to get a range.

Rachel: the teacher tested, brilliant. And what about another question or issue I hear people talking about is sometimes about starting off on the right foot in terms of diagnosis or problem presentation. So with young people, as I understand it, there's often quite a lot of comorbidity or sometimes it's hard to say what the main problem is as it still emerging or there's seems to be more sort of nonspecific anxiety around this. Is that a thing that people struggle with?

Eleanor: Yes, absolutely. and I would say, I mean, social anxiety brings with it a risk of a whole range of other anxiety problems and depression. It's rare to see social anxiety in isolation. And certainly, I think that problem of sort of specification of anxiety disorder is even harder in pre adolescence and it gets a little bit easier, as kids move into the teenage years. And I think that was very much the motivation historically for those kind of broad based approaches, because it was often tricky to identify the primary problem. But I think, I suppose there's a few strategies that can help us to do that and to tease out if there is a social anxiety that seems to be the kind of core problem, then how we do that. And part of that's about using good measures which I think is something that we still need to improve our use of in child and adolescent mental health services. So thinking about making sure we have a comprehensive battery of good, valid, reliable measures for young people to complete at the beginning, so that we can actually quantify and understand the kind of picture of their problems. And I think that's particularly important, I suppose, thinking about social anxiety where sometimes young people wouldn't say that their main problem was about other people and how they came across, but on a questionnaire it comes out really clearly and that then opens the door to ask these questions.

And then the other thing is about, if there are a range of problems, which there typically are when a young person has social anxiety in the mix is thinking about asking questions around if we could treat your social anxiety and you weren't worried about how you came across to other people, what effect would that have on the other difficulties we've talked about so far? How are the, we've got these different problem areas that we've talked about. How do you think they relate to one another? Which would be the thing that would have the biggest impact on you if we could target that? And I think, there is value in focusing in a single-minded way on a particular problem to gain traction, because I think otherwise there can be a risk of therapist and young person getting lost in the, not seeing the wood for the trees, so to speak.

Rachel: So a useful response to complexity can often be to simplify?

Eleanor: Yeah. And there are different approaches to that, aren't there? I think it's about thinking, my approach has been to think about mechanisms. So what do we understand are the modifiable processes that seem to be driving this young person's problems and how can we target those effectively and acceptably for them?

Rachel: and they may be in common across the different issues that they're dealing with.

Eleanor: Yeah.

Rachel: You've talked about how you've been working really hard to harness the digital world in your work. I'm wondering for young people though now, what impact life lived online is having on them. And we read about it all the time in the newspapers, any parent I speak to is always obsessing about how much time their kids are spending online and which social media apps they're using and when and how often and with whom. Are you seeing in data, in clinics and presentations, an impact on young people of this online life?

Eleanor: So this is a big question and I feel like perhaps it might be one that you could do a whole podcast on.

Rachel: Great. We'll have you back

Eleanor: No, well, I don't think I'm an expert in any way. I think that the research is a little bit messy. And what seems to emerge from, there've been a number of umbrella reviews and so on. What seems to emerge from the studies that have been done is that there does seem to be an effect. In general, it seems to be that there is it’s a negative effect, but on the whole, it's pretty modest. So someone who's been a real trailblazer in this area is Amy Orban up in Cambridge, and she's done some really interesting work, mainly in the kind of wellbeing space rather than the kind of, the kind of more severe end, I suppose, of the spectrum. But she has found, for example, that young people who tend to use more social media than others there are some links with poorer wellbeing across certain domains, but also when young people tend to use more social media compared to when they would usually, that then is linked to a slight decline in wellbeing. So that's, I think, really interesting. She also seems to find two particular sensitive periods, which I think probably needs replication. But for, and it's different for girls and boys. So there's, in the early phase of adolescence, it seems around 11 for girls and 14 for boys. Think about when puberty might be happening. So very interesting. And then there's a subsequent sensitive period, which is coincides for girls and boys of around 17. In other words, a time when social media, the strength of the association seems to be a little bit stronger. So that's there in terms of looking across the population. I think potentially it's different when we think clinically and Emma Warnock-Parkes, just to mention her again, has done some nice work thinking about how social anxiety, safety behaviours and so on might translate online. And really what we see is that what young people, individuals, tend to do in real life, so to speak, will move and migrate on the online interactions. So people who are socially anxious will tend to do more passive scrolling than interaction. They will be posting less. They'll spend a lot of time preparing posts before they do it. So these are things that you can see sort of analogue parallel, so to speak. And this makes sense, when we talk to young people about their social world, they don't see a distinction between a real world and a social world. And many of the people that they interact with overlap. I suppose what's potentially different is the rate at which people, you can connect with people, they can react in kind or unkind ways. And one can quantify, literally, with one's likes how well you've been received and that's so potentially it could be that you, it amplifies any effects received about social rejection or acceptance.

Rachel: That makes sense. A human behaviour is human behaviour wherever it occurs, but it may be amplified in certain contexts, in certain, medium, that's really interesting to, to see what comes of further of those studies as we learn more about that.

Eleanor: Yeah, and I have to say, like, although I mentioned all of that with Amy Orban I still, as a parent am very reluctant to, and I'm always having debate, I'd say debates with my daughter about, whether or not she can have a phone.

Rachel: This is good. I can quote the expert to my kids. We know that CBT isn't just a process of clinically applying techniques and tools, we bring ourselves as therapists with all our assumptions and life experience. And we spoke earlier about how many of us may have had negative experiences ourselves in childhood, in social situations, sometimes I feel, albeit working clinically with adults who are presenting with various different anxiety disorders and other presentations, it feels like everyone was bullied when they were a kid, everyone's got a story about what was going on. You start to wonder who were the bullies, but, I guess we might have to challenge some of our own assumptions, some of our own preconceptions about how childhood, adolescence and peer interactions in that period work, or maybe some of our own standards or beliefs about what's acceptable, what's not. Does that play out do you think in therapy?

Eleanor: I think what's really interesting is, and I've been learning about this recently and thinking about it quite a lot, is our language around bullying, teasing. What I find really interesting is that we've just been doing qualitative interviews with young people who have experienced difficulties with peers and social anxiety, and we decided not to use the word bullying. Because when you ask young people if they've been bullied, most of them will say no. And then you ask, then you list a whole range of behaviours and they'll tick many of the things that we would think absolutely constitute bullying. And I think there's something particularly for those individuals who have had or are socially anxious, to tend to minimise unkind behaviours from other people, internalise and take on the blame and responsibility for those behaviours. And I also think that you mentioned like, who are the bullies? I also think there's not always completely clear lines about how, you know, relationships are very complicated things. And there are often times when people can go between both sides of that bully/victim dynamic and times when one can be a bystander as well. So I think it's also partly about thinking how do we ask people these questions to get good data and also how, what methods do we use to try to interrogate the associations between peer relationships and various mental health outcomes going beyond self-report, which is just going to inherently be problematic when we're looking at these sorts of associations.

Rachel: And it sounds like it might be important to explore some of my own assumptions as a therapist about what is going on in this peer interaction. As you said, if people have had those negative experiences, they may have internalised those have thought that it's something about them and they may therefore also minimise the young person's experience or think that it's all about them learning some more social skills rather than testing the veracity of their perception of themselves.

Eleanor: Yeah, absolutely. And I think the other thing is when we work with young people is remembering that I mean, it's hard, it's trying to tap back into how it feels and how it felt when you were young, but also just coming from a position of you need to tell me, you're the expert on all of it. You tell me what it's like for you and what your school is like. Coming from a position of curiosity, I think, and while you can try and tap into what it was like as a teenager for yourself, also just saying, you need to tell me this bit. We need, we can't, I can't do this on my own. I might know this stuff about CBT, but you know what it's like in your school and in your, in your kind of landscape for now. So let's come together to try and boost your confidence and help you feel better.

Rachel: And we often learn as much from our patients and our work, don't we as our patients learn from us. I think it's one of the joys of doing this work. You get to see the inner workings of people's lives and their thinking and how that plays out. Have you learned from the young people you've worked with, how has that work made a difference to you and your life, do you think?

Eleanor: Oh my gosh, that's a good question. And lots of things are coming to my head at the moment. Firstly, and the first thing I was thinking is like, it's just been, it's such a privilege all of it. But that, I mean, that sounds a bit of a nicety, but it does genuinely. I always feel so privileged that people trust one enough to do the work together. And I think, that is a role one shouldn't underestimate the importance of.

I've had a really nice experience. Recently we have, so with Emma Warnock Parks and David Clark and we were commissioned to write a self-help book in the Overcoming series for young people with social anxiety. And we were really lucky to have a young person with a lived experience of social anxiety join us as a co-author. And that has been a fantastic experience in how to write properly for young people. So she would go through and say, this is patronizing. This is patronizing. You don't need to speak down to teenagers. And she just guided us to think about making sure that we had an authentic voice that was respectful to young people, but also always thinking about accessible language, and that's a hard balance to find. And I was really grateful to have her on our team guiding us. And the other thing she talked about, which was so interesting is the importance of weaving throughout our book, this notion of speaking to oneself with kindness, trying to counter self-criticism throughout, because she said she experienced, and actually many of the young people I've worked with, just that kind of self-critical voice that seems a really common thread.

Rachel: Yeah. So what can look like stroppy and difficult behaviour from an adult perspective, actually, when you get dig underneath that, there's often so much self-doubt and self-criticism isn't there for young people that's going on and that's maybe coming out in a way that doesn't help.

Eleanor: Absolutely. And make sure you make me think that, I think one of those cognitive techniques that has been talked about is asking patients to have a second thought if they've had a kind of negative automatic thought, if they're depressed and actually we as clinicians need to do that as well, take a second thought, particularly when working with adolescents is that stroppy reaction actually an anxiety driven response, for example.

Rachel: And I'm guessing that as a mother of a 12-year-old, when you're being marched down the street, three paces behind her on a clothes shopping trip, you may have some compassion and want to buy that pair of nice jeans for her.

Eleanor: If I have half the compassion and loveliness of my mum that she had towards me, then I'll be doing okay. So I just got it. Yeah, exactly that.

Rachel: As we move towards the end of the podcast, Eleanor, I wonder if you can tell us a little bit more about some of the exciting horizons in your research. You've mentioned so many different things that are going on. You sound like a very busy person, with fingers in lots of pies, but it sounds like it's a really exciting burgeoning field. What, what's happening? What are the next big steps?

Eleanor: Yeah, so we're really delighted that the NICE early value assessment in their recommendations of digital CBT for anxiety and depression in young people gave a provisional recommendation for our OSCA online treatment last year, which was fantastic, really great. They also published some evidence generation plans. So sort of clear, description of the evidence they would like to see down the line in order to provide full recommendation and actually that aligned quite neatly with our existing plans. So we are about to start a randomized control trial comparing OSCA to treatment as usual, which we've operationalised as graded exposure based CBT, delivered by clinicians working in routine children and young people's mental health services. So that will be with 220 young people and that's going to be starting very soon. So that's really exciting.

And then another track of work is looking at understanding the treatment for autistic young people with social anxiety and then another big strand of work is implementation and thinking about making sure from the beginning we're thinking about how best to roll out and implement OSCA in services so it's acceptable to clinicians except service managers so that's another important part of the work.

Rachel: And so for people listening who are really eager to learn more about this and they, they don't want to wait for a dissemination study 10 years from now, they want to know what they can do right now to learn more about this, to implement this and to help the young people that are sitting in front of them overcome this really challenging problem. Where can they learn more? What can they do?

Eleanor: Yes so there are lots of ways really so there's a couple of websites that people might find helpful, so the first which is OXCADAT Resources and that is where people once they've registered it's a free resource and people can find lots of videos and therapy resources and our questionnaires that we use to support to guide and support our therapy can all be accessed. So that is, I think, and there's our manual is on there as well. And another website is for our group, focused on young people's mental health. And that's, our group is called CAMY, so Cognitive and Behavioural Approaches to Mental Health in Young People. And I can give you the link to, to share, afterwards. And that just gives an introduction to our team members and what we're doing at the moment. And then the other thing, if people are interested, is our young people's self-help book will be out, I think in a couple of weeks, published by Hatchette and it's in the Overcoming series.

Rachel: Fantastic. We'll put all those links in the show notes so people can get to those directly. Okay. In true CBT fashion, we like to summarise and think about what we're taking away from our session. So, I wonder if there is a key message that you would like to leave folk with regarding this really important work.

Eleanor: So I think what I would say is social anxiety many people feel is a hard problem to treat, but it's actually, I think one of the most rewarding problems to treat. And it's very likely that you will, if you're working with young people, it will be something that you see. And if we can deliver a good treatment early, we have this amazing opportunity to really shift a young person's trajectory and their journey. They might be going on to university when they weren't going to go to university, getting that job in a cafe when they weren't going to, choosing to leave home. These kinds of moments in life that really can make a difference. And it's well, the evidence really is pointing to the potential value of considering using cognitive therapy for this problem in young people.

Rachel: That really does sound like a very hopeful place to leave it. I know you said at the beginning, make it sound so huge and difficult, but to know that these treatments are available, that we can stem that tide is really exciting. Amazing to hear about your work and all the work that's ongoing. Thank you so much for talking to us today, Eleanor.

Eleanor: Thanks so much, Rachel. Lovely to speak to you.

Rachel: And to our listeners, thank you so much for joining us until the next time, please look after each other and look after yourselves.

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