Episode 21 Play, Mental Health and CBT; An interview with Claire

Welcome to this week's episode of Pondering Play and Therapy. Claire, a clinical service lead for CAMHS (Child and Adolescent Mental Health Services), joins the podcast to discuss childhood mental health, CBT, and the different services that can be accessed through CAMHS. Claire also discusses the different types of services and interventions that are offered, including inpatient, clinic, and early intervention services. 

In her role, Claire works within a multidisciplinary team that includes psychologists, social workers, drama therapists, and occupational therapists. They collaborate to support children and families facing mental health challenges. One of Claire's key areas of expertise is Cognitive Behavioral Therapy (CBT), where she works directly with individuals and supervises fellow clinicians.

CAMHS access can often feel like it's impossible to obtain a service, with its high pressure and complex cases. So, how did Claire end up in this demanding field? Join us as we ponder her journey, the challenges of working in CAMHS, and the unique ways she supports both children and her team.

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Transcript

Play, Mental Health and CBT, and Interview Claire a CAMHs service lead

Philippa: [00:00:00] Welcome to this week's episode of Pondering Play and Therapy with me, Philippa. And this week, my guest is Claire, who is a clinical service lead for CAMHS, which is the Child and Adolescent Mental Health Service, where she, ensures that CAMHS are providing the best mental health care that they can for children and adolescents, typically from the age of six, to 18.

Claire works in, a multidisciplinary team, which means that she works with lots of other professionals that are also supporting children and families where mental health is a concern. And these can be psychologies, social workers, drama therapy, SOTs. There's quite a wide variety, which we'll probably hear a little bit more about.

But Claire's particular, area of interest is cognitive behavior therapy, often known as [00:01:00] CBT, where she works with individuals, but also provides supervision to other clinicians. So Claire, CAMS, is often given a bad rep sometimes. It can be quite tricky working in CAMS because there's so much pressure. So how did you end up in CAMS? Because I'm guessing it's not where you, where you started really. So what led you to being in CAMS? 

Claire: Well, that's, that's quite a big question. I very first started off in care when I was about, it must have been about 15 and I got a part time job in a nursing home, elderly nursing home. I can't tell you exactly what drew me to that position, I knew somebody was already working there and I just thought that sounds like a actually quite a nice job to do, caring for the elderly, and I knew it entailed all sorts of care. [00:02:00] So engaging with them and personal care as well.

So I just thought I'd give it a go. And I did that all the way through, just finished my GCSE. So I did that alongside with my A levels and still continued it as far as I could whilst I was going through university as well, because that was the thing that led me to go on to do my nurse training. And I think what stood out most For me, it was taking the simple things for granted.

So why do we make a bed? Why do we make a bed properly? Because, obviously, the elderly can't do it for themselves. And you want them to be comfortable. You want them to have their little toes free at the end of the bed. And it's just making sure that there was attention to detail. And it was making, day to day life, comfortable for people who couldn't necessarily do it for themselves.

And that actually led me to go on, to become [00:03:00] a learning disability nurse. Because it was working with people of all ages who couldn't necessarily do the things that we take for granted in everyday life. And I wanted to support them with accessing the things that we take for granted. So I got through my university years, got my qualification, and then started my journey as a learning disability nurse it was quite a rough journey in some respects, some aspects of it I absolutely loved, the diversity in the people that you meet, it was adults, it was young people, and equally the professionals that you meet along the way, there was just so much to learn, but it was really daunting as well as a newly qualified nurse. Eventually. I suppose the turning point for me was that I also saw quite a bit of malpractice. [00:04:00] So I did see some practice along the way that wasn't okay. And I had to address that, which was tough, but obviously as a nurse, that's what you do. And I think really it disheartened me in the world of care and I questioned whether or not I This was for me or not. I couldn't make a big enough change. There was stuff going on. It wasn't within my power to, to address a part where I could address it, but it was really, really difficult. And I just thought this isn't for me. It's not what I expected. And I thought, right, that's it. I'm going off to be an air stewardess.

I've got to do something completely different. And I was just at this junction where I'd spent. So much of my life thinking about care training and I just didn't know what to do after that point, a friend of mine then pointed me in the direction of a job, which was being [00:05:00] advertised. in child and adolescent mental health and it was an inpatient service, for young people with quite severe mental health needs. 

Philippa: You didn't take the easy route Claire then because, inpatients is quite it wasn't like, let's start it at the low end. And, I'll do a little bit of psycho ed in schools or something, which is classed as tier one, when you think about childhood mental health, that's tier one.

That's the prevention stuff, isn't it? That's like, let's give people some skills, let's support people around them. Inpatients is what is classed as tier four. And that is the, that is when everything else, failed to make, to support the child or the family or the, the mental health is so significant that they need to be in a hospital and often under the mental [00:06:00] health act, which I guess will surprise people.

So you went Straight in at the top. You went straight in at that, let's get out of here. Let's make it as hard as I can for myself learning this new, area of care. 

Claire: Yes, but do bear in mind though that, the client group that I'd worked with before, it was again, the most severe end. So these were adults with severe learning difficulties and challenging behaviors as well.

So it didn't feel too foreign in that sense, but equally I'd never worked. in child and adolescent mental health before. So it was completely brand new. But I thought, why not? Different area, but equally, it still had that mental health feel to it or learning disability feel to it in terms of severity. I'd give it a go. And equally, I will say, at that point, Children were never my client group [00:07:00] of choice either. So yes So I gave it a go, 

Philippa: Can we just stop there? Just tell us a little bit about a tier four service because people listening to this will be quite surprised that children can be detained under the Mental Health Act.

Yeah. It's something that you, you don't think about, that children and adolescents need that level of care, and that level of support. So can you just tell us a little bit about, a Tier 4 service in a hospital? 

Claire: Yeah, so like you've already alluded to this is where we have young people who are suffering from what we'd call a diagnosable mental health disorder. So it may be that they've already had some early intervention, so they've already been in contact with services. [00:08:00] They've already had some previous support for many different reasons, and difficulties still persist. And this could be for, like I say, a number of reasons, and some of that may be genetic elements.

Some of it may be environmental. Usually we find that there's a combination of lots of things going on for the young person, but interventions which have been provided in the community just haven't been successful. And usually when we think about detaining a young person, it is the very, very last resort.

But we're thinking about their safety, the safety of others. And that's for a period of time where we get to keep them safe. We get to assess them. We get to be with them every minute of the day, to observe and to engage with them, to understand a bit [00:09:00] more about what's going on. What's been going on and how the disorder, whatever that might look like, how it presents for them as well.

But we usually find that there is quite a high level of risk and a high level of harm that can potentially occur, but it's linked to the mental health. disorder itself. 

Philippa: Okay, and I said, that children are detained. Are they always, or can you access a Tier 4 service where you're not under the Mental Health Act?

Claire: I usually find that happens with some of the older. So if we're thinking about adolescents, there are occasions where you may find usually around 16 and 17 that they may choose to go in informally. Obviously they will have the necessary professionals around them to help them to make an informed choice, but that can happen.

And they may make a decision that actually I will go [00:10:00] in for a period of time informally, so they're not under the Mental Health Act and they can leave at any point, but they recognize that they need that additional support. For the other side of things, for the majority of the young people, usually we will have had an assessment with your, consultant or a recognized consultant that, will provide mental health act assessments.

We have other professionals who are also aligned specifically for this as well, that will make a decision about a young person's mental health and whether they are best placed in an inpatient service or whether they're still, sometimes it can get confusing. We can see risk. And that sets panic in people, but actually if we can reduce that panic and we can put a group of professionals around the young person, the family, and ease that, we can start to [00:11:00] think about how we would support them in the community.

It doesn't always have to be a tier four, but that is the very, very last resort. 

Philippa: And what age range children and young people in these kind of hospitals, are they as young as seven, eight, nine or is there a, is there an age limit where you think actually this is where it needs to be.

Claire: I have known young people of 13, and I think I've probably even gone as low as 12. Now, it just depends. There's no hard and fast rule as I'm aware. You will find that there is an age range within hospitals and it's usually about 13. Upwards age range. My personal opinion about this. I think one has to tread very carefully when we are working with 13 and 14 year olds because there's so many needs that are there.

And again it's about ensuring that we're wrapping the care around the young person and family, supporting [00:12:00] them in the community because it can create more harm than good. Going into an inpatient service. We want to keep that family unit together but where that mental health need takes precedence, and there's very clear lines that the family and the work that we can provide can't change that then we'd look at that route, but ultimately it's thinking about the family network and it's thinking about how we can support the family, maybe on their own and the young person on their own and bringing them together as well. 

Philippa: Okay, so you started your child and adolescent mental health, career in, in a hospital in this service and you went in as a staff nurse so 

Claire: yeah 

Philippa: And tell us about how you worked there and where and how you left there what happened?

Claire: So I started off as staff nurse And rightly so, I, I didn't know a great deal about young [00:13:00] people or mental health, but I got to work with a really great group of people that were very experienced. And I just tried to learn as much as I could from them and also from the young people and families as well, it wasn't always an easy job but sometimes there were really good bits where we could see a young person's journey coming in where maybe they wouldn't engage at all. Where unfortunately, and again, this might be difficult think about, but sometimes we'd have to place our hands on young people to safely hold them or to restrain them as the word would be. Under the remit of, we'd think about conflict resolution because sometimes their ability to think through things. There was a lot of emotion there. They'd be very angry and sometimes we'd need to keep them safe [00:14:00] and safe in respect of them, not hurting themselves. So we'd have to hold them to keep them safe. And it's difficult. It's difficult to have to hear the distress of a child. But it's getting to know them and understand that distress also comes from a very deep place inside as well. And that's why they're there and from staff nurse, I worked up to senior staff nurse. Then I worked to deputy and then I went on to become ward manager. So yeah I think it was about, I was there for about six or seven years in total. And I got to experience other care facilities as well. So we also had an inpatient eating disorder unit. And, it was a massive, massive journey for me, but it was a real eye opener and I'm so glad that I did it because I I've not looked back from there and child and adolescent mental [00:15:00] health is everything that I do now.

Philippa: So from there you almost then came into the community so you did the tier four and saw the extremes and then moved to what is classed as tier three service is that right? So yeah it's still significant mental health difficulties, but those difficulties are now in the community and they're now being supported with a team of people in a CAMHS setting within a designated area.

Claire: Yes. Yeah. 

Philippa: Yeah. 

Claire: And I think part of that was to see the other side of the coin, really. I'd work with young people and families and in the most difficult crisis situation you could experience. And I guess this was branching out and thinking about, what happens before we get to this point? What are services offering?

What is the therapeutic care that they [00:16:00] talk about? There's all of this. lingo, those kinds of words. Oh, yes, it's therapeutic intervention, this, that and the other. And I thought what does that actually consist of? What care is provided and what can be provided before we ever get to the position of having to have young people detained under the Mental Health Act?

So that took me on my next journey, which was for I think it was a couple of years because I ended up having my daughter after that. And that was in a city working in Nottingham. So that was almost what they would class as a tier 3. 5. So it's in between. were on the verge that we could end up with hospitalisation.

But equally, it was a little bit more tricky than, and there was also more risk than perhaps what would be managed within a CAMHS team. [00:17:00] So it was that little bit of a grey area in between. So we were targeting young people and families that were perhaps in the most hard to reach areas. There were There was a criteria for two elements.

So we had to have the mental health presentation and the mental health difficulties, but equally they may also have a learning disability or difficulty there may be autism that's there. They may be young offenders, or there may be sexual offenders as well. So there was a, a good mix of what presented, but equally they were classed as hard to reach young people, but There was quite a bit of risk and the mental health need as well. And I got to work with a fantastic team who I did a lot of shadowing with because I was very new to it and I got to, Observe what therapy looked like, [00:18:00] therapeutic ways of working, and equally to see what it was like in the lives of people in the community, which was a real eye opener because you work with so many different families from all sorts of backgrounds.

 Yeah, and it was a real, it was a real privilege to be able to work in people's homes. Sometimes it was difficult. But it was seeing other people's lives, that you may not have experienced, or even thought of in your own day to day life. 

Philippa: Okay, so when you talk about mental health difficulties, can you just tell us what you mean by that? What does that mean? 

Claire: Mental health difficulties, how see it now,

It can be a multitude of things. If we look at it on its own, it could be young people suffering from low mood or depressive [00:19:00] symptoms. 

Philippa: So what does that mean, low mood, that they're a bit sad because they've got to go to school?

Claire: Well, sometimes it can be, but in its worst case scenario, and if we're thinking about the worst case scenario, the young people we're supporting CAMHS. I can think about a young person and when we talk about low mood, yes, it can be sad. It can be feeling quite miserable. You're not really going out with your friends. So those are like those early indicators that we would expect our colleagues before CAMHS to be supporting with. And equally that's normal.

Not every day is a great day. And sometimes it's just helping people to understand that yeah, it's okay to have these sad periods but when we think about the young people that we work with in CAMHS, we're talking about young people that are completely disengaged from the social world. They have disengaged from school.

School's become so difficult for them in a social [00:20:00] context. They can't engage with their friends anymore. They don't go out with their friends anymore. It's really hard for them to engage even with their family at home. Their diet has decreased significantly. There's very little interest or anything in day to day life which motivates them.

The preference is to stay in bed, have the curtains drawn, and sometimes the sleep pattern is totally out of sync, so they will prefer to sleep throughout the day and be awake at night. There are also thoughts that come with this in respect of, what's the point in me even being alive. And there's a helplessness and a hopelessness there's no thought to the future because they don't see a future. And that is what we'd class as depression. If we're thinking about some of the other. Elements of mental health. We think about things like [00:21:00] PTSD. So, trauma, post traumatic stress disorder. So that can also present as well. And that can be a single case where something like a road traffic accident's happened.

Or we can think about trauma in the context of somebody, their life journey. So they've been through traumatic events very young in life and that has continued throughout the years. So those are the interventions that we would provide there and certainly would be a role within CAMHS. Some of the other presentations.

We think about social anxiety. Now, I think it's important to think that there's a difference here so we can be anxious in social situations. Absolutely. And there is a, for want of a better word, complete normality around that. So no one, or some people quite often don't want to stand up in front of a mass group of people and [00:22:00] speak out loud.

That's completely normal. And sometimes we can feel anxious when we're with our friends. We can feel anxious at school in those social situations, but it doesn't necessarily impact upon our day to day life too much. And as we get older, those anxieties tend to ease a little bit as we develop and gain maturity. When we talk about social anxiety, these are young people who have very specific beliefs about how they may look, how they may sound, and what people think about them in social situations, to the point that worst case scenario, They disengage, they don't go to school anymore, and they don't leave the house because walking down the street is just too traumatic, too scary, and too difficult for them.

And that's your social anxiety. [00:23:00] The other one that we sometimes find is panic disorder. When we think about some of these, they are quite closely linked with feelings of anxiety. So if we think about panic disorder, it's not uncommon to have those moments where we might feel panicky. We might feel a little bit stressed in situations. Suddenly the heart rate's increased and we feel a bit flushed. And we might consider that as being a mild panic attack. But when we're talking about. Planet disorder. This is when those experiences, those physical sensations are experienced to the point of increased heart rate, tight chest, feeling sick, sweating, dizzy, and following that, there is a belief that you will die.

And there is a real strong belief that you will die. That obviously it [00:24:00] perpetuates, if you worry about having those physical sensations because you think that because of those sensations you're going to die, then you're going to fear that, which means that the likelihood of you having those symptoms and bringing them on, it's quite a high probability.

And that's what we class as panic disorder. Some of the other ones that, People may have heard of a little bit more OCD, which is obsessive compulsive disorder, which reflects repetitive behaviors and compulsive behaviors. And I think sometimes people will say, Oh yeah, I have a little bit of OCD which again, absolutely right.

Because there's a part of this that is completely normal. We all like our little routines and certain ways, not a problem. But OCD is Exceptionally debilitating every moment of every day to the point that we are checking [00:25:00] repetition in our behavior or we may have fears around germs and with those fears of getting germs again we may think that we're going to die from it so we are continually doing behaviors that will try and get rid of those germs and the other one is intrusive thoughts as well. So we may have quite disturbing thoughts or tricky thoughts. It just depends because it's different for different people. But these thoughts that sneak into our mind again, because it's anxiety driven, the thoughts are very, very distressing. They're not pleasant thoughts. Unfortunately, anxiety does not ever give us any nice thoughts. It can usually be about our loved ones, whether it's hurting people, and it's usually, OCD usually attacks people that are the most kindest, conscientious people in the world and it [00:26:00] preys on that as well and the other one, and again, I'm just thinking about some of the things that we might treat in the world of CBT, the final one, phobias as well.

So we know that there's a multitude of phobias some of the more, more common ones that we might see. in CAMS might be sickness, sickness phobia, dog phobias, spider phobias we've had some more of the unusual ones such as balloons and sensory ones such as buttons as well. So you can get all sorts of a mixture really.

But Those, that's a flavor of some of the things that we look at in terms of CBT, but equally we do work with young people where there are difficulties in the family network as well so there may be a lot of emotional dysregulation seen within the young person, which may be seen as, Oh, it's anger. Oh, it's this, it's that, or it's misbehavior. But actually. [00:27:00] It's the young person not having necessarily those skills to manage that internal regulation that's going on inside. It's quite complex, but we have to unpick that to understand and to try and build up those skills for the young person, but equally we work through the family to help the young person.

And that's particularly prevalent with our younger ones as well. We work with a lot of young people in care, and again, a lot of, presentations where we may see anger, we might see dysregulation, but we're working with young people that haven't had the necessary parental support to help them to build that resilience and to develop those skills to help regulate themselves.

So again, we work with those young people as well and not to mention where there's comorbidities such as young people with ADHD and young [00:28:00] people with autism as well. 

Philippa: Gosh, it sounds like there's such a variety of support and care offered for a wide range of disorders it sounds like when I was listening to you that They come to the CAMS tier three service when these things are having significant impacts on their daily life. So you might be experiencing some of these things and might need support and guidance and professional support. It's not professional input, but it's when it gets, when it's really impacting a young person or family's lives.

So they're not attending school and they can't leave the room and they're not doing the self care or that there's high levels of fear or there's risk of real impact to self and, those things, from the thoughts or the experiences I have that they're coming to tier three, that maybe there's interventions that happen.

[00:29:00] Before then to try and prevent the tier three services that rise. 

Claire: Yes, so we have, broadened our reach into schools now. So some schools do advocate, our mental health in schools teams as well. So these are teams allocated to schools in different areas and they provide earlier intervention. So it's the early intervention, where maybe a young person is experiencing some of those difficulties.

So when we said before low mood, it's not depression, but we can see that there's a change in how they're feeling. They're experiencing low moods. They might be a bit tearful. Or equally, they might be angry. Depression isn't always about crying so it's that first line intervention. And they will use CBT based interventions and they have a multitude of different tools in the toolbox as well, but there are [00:30:00] short interventions.

So it may be six to eight sessions and sometimes That can be enough and they do some fantastic work, but when that isn't enough and we recognize that actually the problem is persisting or there's something, it's a bit like an onion. You've peeled off a few of the layers and actually we need to peel off more of the layers to get down to the center of what's happening. So They provide the early intervention and then if things are still persisting, if the difficulties are still persisting, or they are finding that actually there's more than meets the eye here, then they will refer to us as well. And we can do some more of that. More intense work and I think sometimes there's a little bit of a misconception in the fact that sometimes families feel that they're getting a bit of a disservice by going [00:31:00] to mental health in school teams and actually want to go to cams.

We want the the proper intervention and they see it as a stepping stone. But actually, when coming to camp to camps, what we ask of parents and young people, it's really difficult. This is not. easy work to do. So if we can do it, the simplest, the quickest and the least intrusive way possible, we're going to go down that route first because they don't do dissimilar work to what we do.

It's just at a more gentler and a more informal kind of informal level. You don't take a sledgehammer to crack a walnut. And if that's enough, absolutely fine but if it's not, then we can build upon that. So the stuff that they've already done is. invaluable. Absolutely. And we will start to just build upon what they've already learned and done as an [00:32:00] early intervention. 

Philippa: I think that's really helped give a real good picture of services. So you talked about CBT, which is your specialist really, although you've got an overview of all these things, you're a specialist intervention in CBT, which is cognitive behavior therapy. And everybody does CBT, Claire, don't they?

Claire: Oh, yes. So everybody does CBT. Oh, we'll just do a little bit of CBT here. Just, it's just a little bit about how you think and change your behavior. Just change the way you think and everything will be fine and also there has been a huge drive, not just for CBT, but in terms of, What we provide as a service in CAMHS, the interventions that we provide to young people and families, they have to be evidence based.

And what I mean by that is, you don't just pluck some tools out of midair [00:33:00] and say, Oh, we'll give this a try. We want to know that the intervention that we're providing has actually been tried and tested. It's got a scientific component to it. It's been adapted to meet the needs of Adults and children are very different.

So equally, we want to know that the intervention is adapted to meet the needs of young people because their development is very different. And we also need to know that there's good research out there that says, you know what, this works because of X, Y, and Z. Or you want the opposing research that says, actually, this is a load of rubbish because this, and this is better for this.

And that's what we mean by evidence based. We need to look at what works, what doesn't, what the conclusions are because what works for one presentation or mental health disorder does not necessarily mean it works [00:34:00] as well for another mental health presentation. But what we do know is CBT does work for a lot of things. As a result, there has been a huge drive to increase the accessibility of people going and training in cognitive behavior therapy. Now it's nothing new. It's been around for, goodness knows how many years. But because it's evidence based, it's been around for such a long time, and the evidence tells us that it works for treatment outcomes.

There's been a huge push to get people through and trained I guess there's a couple of things to consider, and that is that We could go, we can train to be a cognitive behavior therapist, but the outcome from this is very different based on your experience. So for me, I was really lucky to have worked in CAMHS for a good [00:35:00] number of years. So I had that experience. I'd learned from other people. I had seen the practice out there. So I was able to bring CBT into my world for the young people that I work with, which is then, now I hope there's no cognitive behavior therapists on here, because if you're a purist, you'd probably be really cross with me.

I adapt my CBT practice to meet the needs of young people and families. So I don't always work to a pure model. And two reasons there. Firstly, because working with young people and families, it's complex. It really is. And you have to adapt to meet their needs. And secondly, I very, very rarely see a young person come into CAMHS for the treatment of one disorder.

So, seeing a young person come in to be treated for social anxiety, it's [00:36:00] like gold dust. It's hardly ever seen, because there's other factors that need to be addressed there as well. Whether it's working with the family, or it's thinking about other elements of their life. It's so multifaceted. And I can't just say, right, well, we'll just work on the social anxiety and off you go. There's so much more to it, which is why young people may stay in our service that little bit longer. But just going back to the CBT element, people see it as being really stuffy and I think quite dry. 

Philippa: Well if the cap fits, then you have to wear it, don't you? 

Claire: So before I go on to that little bit, so yes, there's a lot of people that are coming through with CBT qualifications.

Philippa: So can we just talk about the qualifications? Because there are six week courses out there that say you can do CBT in a six week [00:37:00] course. Is, am I now a CBT therapist? Or we do, some online module is that what the training guides? 

Claire: No, they made it more accessible in the sense that, that there is a year long training.

So in that year, possibly slightly over, it is, throughout the entire year, where you have obviously your lectures, you go in, you train, you learn, etc. And then the other part of that is having a live caseload. So what I mean by that is you're actually working with young people who require support. So they actually get a really fantastic service because As I'm working with a young person, I am looking at the most up to date information.

I'm looking at, exactly what the plan is going to be for their care. I get supervision. internally with the [00:38:00] university for three hours. I get in supervision externally from our trust for a good hour and a half every week and then in between you're obviously doing the the more academic bits as well.

So actually if you are working on social anxiety, for example what does the research say? And you do your work upon that case study. So obviously we keep it, depersonalized, no names or anything. So I will say it's a case study, but obviously it is a young person there. So that we're learning. as we go along.

So it's live and it's absolutely, I can't rate it enough. It's absolutely fantastic simply because you get to work directly with young people and families. You're putting theory into practice when it doesn't work, you're exploring it, you're learning from it and you've got so much [00:39:00] support around you as well to really understand what you're doing.

So six days, three day courses. No, this is an entire year. I absolutely busted a gut on it. I really did. And anybody who's done this course, it is no, me it's a real toughie to do, but, so worth it because it breaks you down as a practitioner to build you back up in the world of CBT from not yours. Your textbooks of how you treat something, but how do you engage with somebody? How do you meaningful, how do you make that time meaningful with a young person in session and engage them in the process and work in the process? As a journey together, how do you go on that journey together where you're not the expert, the young person's the expert on what's going on for them.[00:40:00] 

You are the expert with toolbox. One can't do it without the other. So it's absolutely fantastic and breaking down. your understanding of how to therapeutically engage somebody. As I say, can't rate it enough.

Philippa: So what is CBT? Tell us a little bit about what, for somebody who doesn't really understand or they've just heard the term or CBT. So like you say, you think, Oh, I just asked them to stop thinking the negative thoughts to know, notice the negative thoughts, then don't think about them. And then they'll stop having that, is that really what it is? 

Claire: I guess. Some of the answers in the title. Cognitive relates to thinking.

Behavior relates to our behavior so those are the two main areas that you will work on because that will produce a different outcome and it also affects the way that we feel about things. However, it's about understanding what's going [00:41:00] on I think what I love about it is there's something that's happening.

We are thinking very negatively about something we are finding it really difficult to engage in life, but just those day to day skills, it's becoming harder and harder. And we need to understand what's going on and there's a couple of reasons. And I think one is to know how we're going to address this through treatment, but equally to take the fear out of it, because people come and when you talk about mental health, that has a scary connotation to it anyway.

But if you're the person that's always having these thoughts and You're having all of these negative experiences and you're thinking, what's going on for me? Why do I feel like this? Why am I different to everybody else? Then I think part of that job is normalizing and that's why I quite like [00:42:00] working with the young people and the parents as well, because they've got a different experience.

They're adults. But a lot of what we experience is normal, for want of that better word again, that actually when we have those sneaky intrusive thoughts, we all get them. The brain is a weird and wonderful machine, and it thinks independently to us. The brain is attracted to anything that is. It's bizarre, weird, wonderful, wacky, and it almost has that kind of life of its own.

So a big part of cognitive behavior therapy is the psychoeducation element of it. And it's learning what's going on for me. Why am I thinking this? Why am I experiencing this? What's going on in my body because I'm getting these horrible sensations and I don't get it. I don't get it. So we [00:43:00] take the fear out of it by understanding it, but on that journey, we try to tease out, what's going on here? So we start off with something as simple as a problem list. In the here and now, what do you feel are the biggest problems for you? And it can be absolutely anything, as long as you feel that it's a problem. And we draw it out. And the young person will put down little bits and bobs. Sometimes they might not put nothing down. It just depends where we're at and we start to make links that actually, okay, so we're not going to school anymore. And we're not really talking with our friends anymore. We feel quite sad most of the time. And we also feel anxious, so we're not going out. And it's helping to understand what's impacting on which area.

And if you think about when we feel low and when we feel anxious, those two [00:44:00] can actually present at the same time. So we can have anxiety and we can be low in mood. But it's a journey to think about which is the biggest problem for you right now and that anxiety, how does it affect friendships, let's think about that.

And when you're feeling low, how does that affect the difficulties that you're experiencing with your family? Well, actually, when I feel low, my family come into my room, they're talking to me and I don't want them to be there. So I shout at them, I scream at them, and they end up feeling bad for that. But actually what we need to understand is that's perfectly normal. And then externalize the problem. Because you are not the problem. Depression or low mood is the problem. You're not the problem. Anxiety is the problem. You weren't born with anxiety. It's the anxiety that's impacting upon you. And it's [00:45:00] designed To, crush every bit of good that happens in your life.

That's what anxiety does. It's an absolute bully. So again, it's externalizing it and thinking, This isn't you. You don't want this. But it doesn't like it when you achieve. It doesn't like it when you're using your time and being out with your friends. Depression. Depression is this protective bubble around you.

It doesn't want you to socialise. Because when you socialise, how does that feel? I like you, my friends. Exactly. Depression doesn't like that. And it will do everything in its power to stop you from enjoying life, fulfilling life, and progressing forward. So, it's the education part of it. It's the normalising it, because we will have bad thoughts, all sorts of stuff happens, that actually it's normal, [00:46:00] and it just takes that fear out of it.

The next part is externalising it. This isn't you, this is me. depression or this is anxiety or it's the OCD and it's a bully. So again, if we can separate the issue from the young person, that really helps as well. And it helps the family to see the problem and become a little bit more protective to try and draw the child out of it, because anxiety seeps into the family network.

It not only controls the young person, anxiety controls the family as well. It's very, very powerful. After those bits, Then we can go on to what we call behavioral experiments. So once we understand how it presents for the young person, we may incorporate the family as well. We think about, right, what do we do to tackle this now?

Because, [00:47:00] okay, for example, we may have intrusive thoughts, but the idea of intervention is not to stop the intrusive thought, even though the young person wants it to stop. What we're going to do We're going to incite it because what we're going to do is not be fearful of it anymore because a thought is just a thought.

And we can think whatever we want, doesn't mean we're a bad person, doesn't mean I could think about, Oh, many a times I've thought about throwing my laptop out the window when it's not working or fast enough, but it doesn't mean I'm going to do it. However, For some people who have intrusive thoughts, they believe that by having that thought they are a bad person.

That by having that thought they will act upon it. And it's our job of working together to help them to go on a journey to find out that actually by [00:48:00] having that thought It's okay, because a thought is just a thought. It doesn't define who I am, and it doesn't mean I'll act upon it. And that requires us to test out some of the theories.

That's very scary. That's scary for adults. It's scary for young people. And that's why When we do a lot of the psychoeducation and the learning about what's going on and we go on that journey together, some people get a bit frustrated because it's like, well, when, when are we getting to the point of intervention here?

I'm not seeing any improvement. You have to remember, if I'm going to ask somebody to do an activity which brings on feelings of increased heart rate and panic, And by doing that, they believe that they're going to die. If I'm going to ask them to do that, they need to be able to [00:49:00] trust me and trust in what we're working on.

And that comes from understanding it, giving them the confidence of what's happening, giving them as much information as possible so they can test it out in their own head, because me telling them, you're not going to die. It's immaterial. They're not going to believe me. But we need to test it out because they might be right. So we have to test those bits out. We have to get the evidence for it. But if I'm going to ask them to do something that's going to make them feel quite uncomfortable and to create distress, all of that preliminary work and the work on externalizing it and giving them a focus to life could be much better than this. And it doesn't have to be this way. We've got to embed that first, for that final stage, and then we do the behavioural experiments. And it's a [00:50:00] bit like a science experiment, so we set them up, what do we think is going to happen, what are we challenging, how are we going to do it, what are the variables in there, and then we get learning from it and doesn't matter if it goes well, doesn't matter if it's, they get stuck with it or whatever, it's all invaluable learning. So I don't know whether I've given you a short answer there, I don't know if that's, giving you a flavor of a journey. Yeah, 

Philippa: it sounds really interesting, for somebody like me who doesn't really work in the brain at all, works I'm much more in the body and there's a lot less thinking, a lot less talking, it's more about feeling, it's more about, what's going on. So that's really helpful the title of this podcast has got play in it. So how does play fit into CBT or doesn't it? Can't you play in it with CBT? 

Claire: So this goes back to [00:51:00] your stuffy CBT therapist. So yes, it does. And you've got to remember We're working with children and we're working with young people who have ADHD, young people who have autism.

So there needs to be treatment adaptations in how we do this so, like I've said, there is a fear that presents when young people come to us. And the best way to ease that fear is to bring the humor into the room and to bring that element of play so it doesn't feel scary the other point would be that there is some learning to do here as well. So there is that psychoeducation part. Nobody wants to sit there being told stuff, and just pointing to a diagram of your heart rate increases, this happens that happens. So it [00:52:00] can be potentially very dry. So I think the first thing for me is, it's that journey together. So it's how you set that up in the sense of we're going on an expedition.

I've got some tools in my box that might be quite helpful to you, but you have all of this wonderful information in your head. And I need to get your information and you need to know which tools you need out of my box. So it's just setting up the groundwork of what we're going to be doing and I'm not the expert.

in this arena. I'm not, they are and it's about going on that journey together. So instantly you're setting up the framework around this. And it's the same with your behavioral experiments as well. We're going to be scientists this week. We're on the hunt for information. So they may go away and they do certain tasks and we look at what information they need to gather.

We're detectives this week. Next week, we might be [00:53:00] scientists. Drawing out as well some bits can be quite heavy going. So say, for example, if we are doing, about fight and flight. So how the body responds when we're anxious, when we're scared and all the rest of it. We like to have movement in the room. And it just makes the space so much different. So for example, we could be working on a massive sheet on the floor, where the young persons lie down. They've lain down and we draw around them. So the parent might draw around them. I might draw around them. They might draw around me. So we've got the body there. Now we're going to think about how those physical elements of when fight and flight kicks in, how it affects the body. So we draw it on there. It could be on a whiteboard. It could be anywhere and that can be really good in terms of drawing out the heart, thinking about the breath, we can color bits in, and it's getting movement into the session.

[00:54:00] And that can be really good for some of our young people with ADHD as well. And they quite like that. We draw things out. In the session as well, when we write down a little bit of an agenda at the beginning, and we draw out our formulation and the formulation bit helps them to understand that when this problem presents, what does it do? And every time they get into a tricky patch, Or they experience that difficulty, they can put it into this little diagram and they can say, Oh, yeah, I know what's happening. So when that thought came in there, it affected me that way. It did this, it did that. And again, it just helps ease that fear, but we draw it out.

And we don't know, does it go this way? Which colour are we using? We draw a massive diagram out and again, it just keeps them engaged in it, but equally, it makes it their work and then they can bring it together, they can put it together in their [00:55:00] little booklet. They can Do all sorts of things with it. Now when we're externalizing the problem, so we're trying to separate the young person from the anxiety, or the young person from the low mood, or young person from the obsessive compulsive disorder sometimes they name it and again, it just pushes it away from then, and I remember one person when we were doing, the OCD and the anxiety bit there, they referred to it as a squishy mushroom, and they drew out this mushroom, and it was all squishy when we described it.

And we were able to do some visualization work with that, but actually, when they became. A little bit more empowered and they were talking back to it that actually no I'm not going to do this just because you say it. We do a little bit of role playing session. So what are we going to say and we have a little bit of a whisper and then we can have a bit of a picture.

And I might [00:56:00] show up to the picture of what I would say to it and then they might say, well actually no I'm not doing this today because I'm going to go out and play with my friends. So it's that role play that we have in there. Well, and it's the visualization that actually what are you going to do to this mushroom?

So when it's there again, and it's whispering in your ear and you can hear it saying, she goes, I'm going to stamp on it show me how you're going to stamp on that squishy mushroom. And then we do it in session and we have a good stamp on it. Now, obviously those are just a few flavors of what we might do, but CBT is really good for metaphors as well. So little stories along the way and this is, there's a whole load of literature about metaphors and little stories about how, people live in fear of things because they don't necessarily know anything different and how people have been held back, from doing [00:57:00] something greater. And there's a wonderful array of short stories that go with it. Just to help that understanding that when we're living in fear, it doesn't have to be this way. It's just the fact that we don't know anything different. And that could be really good, a just ending a session on, so they can take that story away with them and again, it's about reducing the fear around it. The other one would be, and this perhaps isn't The play element of it, but, if we're working on phobias, then we have to pull in different resources as well. So, we have had dogs in clinic before, I've had to go and capture spiders. Now, it isn't necessarily the play, because this is their fear, but at the end of it, when we are handling the little spider in the shoe box and we're able to stroke the dog at the end of it.

It's just being creative in what [00:58:00] we do. But without a doubt, play for me in these sessions, it breaks down fear it, for example, again, with the fight or flight, We can have a little scenario whereby, okay, so when you leave clinic today and those doors open downstairs, if you suddenly feel the ground starting to shake, big thuds underneath your feet, and suddenly the T Rex comes up from behind the buildings and obviously, I'm not going to do it here, but in session we've got that imagery going on with it as well. What would you do? Would you stand and fight? And some, usually the little boys, yeah, I'm going to get a stick and I'm going to fight him, okay, so that's your fight response. Other people, flight. So then you can question, okay if you're going to fight him, do you think a stick's going to be big enough here? And then think about it, what do you think you're going to be gobbled up? And it's oh, I might be [00:59:00] gobbled up. Okay, so what do you think you best do in this situation? Run. Oh, yes, we're gonna run and we're gonna run off. So it's just I guess bringing those little stories in there It's making it light hearted because what I am asking people to do in session is really really difficult the best way to engage is through that lightheartedness.

The best way to learn is to have that element of play in there and to be part of it, they need to be a part of that session in some way, whether I'm getting them to write an agenda on the board and to keep me on track fear is the biggest thing that helps to overcome this. And what I would say is that it doesn't matter whether you are 10 or whether you are 16.

Sometimes I still draw in the big T Rex analogy. And [01:00:00] They love it. Just because you're 16 doesn't mean you're old enough not to have that fear. Because actually when you're older, there is a little bit more of a reality that comes with this. So even a bigger need to almost bring it back down to its simplest level, have some play in there, and then link it back to some of their real life scenarios.

Philippa: And it sounds like it also builds connection as well. So the play is helping you, within the therapy, but it's also building that connection, that playfulness of you and them together, that you're in your whole brain, aren't you, when you're playing. So you're connecting with all of them and not just with the fear or not just with their worry. And then you'll be enabled to take them from that connection to that worry, or that fear, or that, that thing. But that connection is, it is being enabled through play. [01:01:00] 

Claire: And that was the biggest thing that I learned from doing the CBT element. Um, and I don't think I appreciated, I knew it was important, but I didn't appreciate just how important it was.

And they will say that therapy is 80 percent the relationship. And 30%, or 20% even and 20% is just the textbooks, the somatics around it. And absolutely, and I think that was the biggest thing that I learned from doing CBT. Obviously there's more to it as well. But to have that engagement, even when it doesn't go right, or those experiments don't go right is absolutely fine, but.

The joviality of it, the lightheartedness does connect you and it does build that relationship and the young person and the family, they need to be able to feel that they [01:02:00] can trust you. Like I say, if you're going to ask them to do some really, really challenging things and it's produced some of the most wonderful outcomes, and you can tell in the session as well, a session that's gone well, and a session that goes well isn't one where you've completed x, y, and z.

Now we can move on to the next bit. It's where you both work together. It's where you both got loads of question marks over stuff and you just don't know and you can both have that silence in the session while you're wondering and you're actually both thinking it's not an uncomfortable silence and they come up with the ideas that it always amazes me.

The, when we're, when doing intervention, what young people come up with and they'll say, well, actually, shall we try this? When I say what kind of tasks do you think would be helpful to inform the next session? What just thinking about what we've done today, they will come [01:03:00] up with the ideas. And it's absolutely brilliant when that happens because they're owning it. They're thinking about it. They are there in the moment and that is the best thing you could ever feel when you're doing that work and intervention. 

Philippa: Oh, that's fantastic, Claire. I think that's a really good place to start to wind this up, but I'm guessing if there's parents or carers listening to this and feel like they might need a bit of support or guidance, where is the first place for them to go?

What would you advise them to do? 

Claire: I would think about, linking in with your school first. Majority of schools do have, for us it's mental health in schools teams, for other areas it might be called something different, but it's just thinking what support is there to start off with and that is a really good way of just gently introducing your child into the [01:04:00] therapeutic arena and not scaring them off.

And if that's enough, fantastic. Now, if your school doesn't have access to that, there will be other, organizations specific to your area again, and they'll be more independent, but they'll be linked in somewhere along the lines. But there will be individual providers within your area and school will know of them that you could link in for some low level intervention, so you could do it that way. And equally if there are further concerns, that's when we would expect those professionals to then link in with ourselves if they weren't seeing the progression that they were hoping for, or if they think, well, actually, no, we definitely need CAMHS at this point. Equally, CAMHS have a self referral, I [01:05:00] think it's most areas, certainly we do, but there's nothing to stop parents to make a self referral to CAMHS, don't be put off, because we might say yes, absolutely appropriate for us, but if it isn't appropriate for us, we don't just leave people, we will guide you back to the right path that we think would be most beneficial at that moment in time.

Philippa: That's wonderful. And then for clinicians or practitioners, if they wanted to go on and do the tr the training in CBT, do they need to contact a university? Is there a website? Where would they find out more about, becoming an accredited CBT therapist? 

Claire: Yeah it's through iapt please don't ask me. What that stands for, cause I can't remember. And I should do improving access to psychological therapies. There we go. Remembered it. So this was under the IAPT initiative, but if [01:06:00] you do link him with universities, then you will see whether or not they do have access to, CBT, under the IAPT initiative. It does need to be young person focused though there are slight variations that are there but what I would say to anybody is have that experience with the young people first, if you've got the experience, then this is a great add on, but I would always say to anybody, there's been a huge push for people to engage in therapeutic training. Absolutely. And it should be there. When I started initially in CAMHS, I didn't have a specific therapy, but I made it my business to get the right supervisor who could help me to learn more about the different presentations that presented in young people in mental health you can develop, don't rush into, therapy.[01:07:00] 

The therapy has to fit for you as a practitioner and you have to feel its benefit. CBT works for me for a multitude of reasons and I think it's that structure element, the formulation and everything. People go on to do the IACT in terms of systemic family work and systemic family therapy. The therapy has to fit for you.

because you are selling this and engaging people into it. If you don't believe in the intervention, why should young people and families believe in it and do it? 

Philippa: Yeah, that's perfect. That's a really great place for us to end, Claire. Thank you so much for your time today. I'm sure people are going to get a load out of this podcast.

Thank you for having me. That's okay. Thank you.