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JOURNAL OF SOCIAL WORK PRACTICE, VOL. 17, NO. 2, 2003 Surviving the swamp: using cognitive behavioural therapy in a social work setting STUART MATTHEWS, ANNA HARVEY & PAMELA TREVITHICK Summary This paper explores the attempts of an adolescent support team working for South Gloucestershire Social Services, to integrate Cognitive Behavioural Therapy (CBT) into its practice. We explain how we, as a team, undertook a year-long course of study in CBT and discuss the advantages and difficulties we encountered. Then, beginning with a case study, we draw out the limitations of trying to use CBT in a social work setting. We focus specifically on how the complications of wider family systems will often compromise individual therapeutic work with young people and conclude that a more pragmatic approach to CBT is required in social work, rather than attempts to replicate work carried out in the clinical setting. Introduction This paper looks at the application of a cognitive behavioural approach within social work. We begin by charting the journey taken by our local authority social services team in relation to a year-long course of study in Cognitive Behavioural Therapy (CBT). We then focus on two themes. Firstly, how the team reacted to this sustained period of training, and secondly we highlight some of the difficulties we continue to encounter in our efforts to integrate and to apply what we have learnt in our CBT training to our work with young people and their families. A case study is used to illustrate some of common difficulties we encounter. Context South Gloucestershire’s Adolescent Support Team was created in early 1999 following the closure of the county’s last children’s home. The team’s main objective is to prevent young people entering the care system by offering support to families at times of crisis. Packages of support include direct work with young people, family work and, increasingly, group work. This includes parenting skills and women’s groups. Support to foster carers and children who are looked after is also provided. The team is made up of both qualified and unqualified social workers, coming from a range of social backgrounds but with a common interest in and commitment to young people. As a team, we felt we were doing a good job when we embarked on the training. We all had skills and experience that enabled us to engage quickly with most of the young people with whom we worked, and the ability to give difficult messages to parents about changes they could make to Correspondence to: Stuart Matthews, South Gloucester Social Services, Adolescent Support Services, 43 The Park, Kingswood, South Gloucester BS15 4BL, UK. Email: [email protected] ISSN 0265-0533 print/ISSN 1465-3885 online/03/020177-09 DOI: 10.1080/026505302000145680 # 2003 GAPS 178 S. MATTHEWS, A. HARVEY & P. TREVITHICK their parenting styles and family cultures. We all had, through education, training and our own reading, a knowledge and understanding of various theoretical approaches used within social work but this was not uniform across the team and most of our decisions and actions were based on the ‘practice wisdom’ we had accumulated over the years. The dominance of ‘practice wisdom’ over theory is a common experience in social work, made worse by the ‘fads and fashions’ that preoccupy social work (Sheldon, 1995, p. 6). Over time, we began to see that we had, in fact, a poor understanding of theory. As our awareness increased, a corresponding desire developed in the team to improve the theoretical basis for our decision-making and our work with young people. We recognised that this would give us greater confidence as practitioners and better serve our clients—an ethos we were actively seeking to nurture in the team. As a result of our team discussions, and with the active support of our manager, it was decided that we should focus our training needs on Cognitive Behavioural Therapy (CBT) or, in social work terminology, a cognitive-behavioural approach (Hudson & Sheldon, 2000, p. 63). We had some familiarity with CBT. Many of the team were already using cognitive behavioural techniques gleaned from books we had read, or short training courses we had attended, but none of us felt we had the full picture—the understanding of why or how these interventions worked. What we did know was that it was a theory and an approach with a strong evidence base, something which we, as individual practitioners, wanted to explore, and a perspective that is supported by South Gloucestershire, as well as the Department of Health. The training experience Following our decision to focus on CBT, the team enrolled in a post-graduate certificate in counselling (cognitive behavioural), which was taught in-house over an academic year by a lecturer at the University of Wales College, at its Newport site in South Wales. We met for three hours every second Thursday with reading set in between. Assessment involved two 2,500 word essays and a tape-recorded session with a client. The course covered the cognitive behavioural model, case formulations and specific techniques and approaches. In addition, consideration was given to the use of treatment plans for particular difficulties and disorders. The teaching format involved traditional didactic methods, the use of video and audiotapes, and case discussions. The year ended with a day spent at the university in Newport, where we presented a seminar to other students outlining our experiences trying to implement CBT in the social work environment with adolescents. Although often referred to as one distinct therapeutic or practice approach, it is worth noting that Cognitive Behavioural Therapy is a generic term. As Hudson and Sheldon point out, the therapy is made up of ‘two overlapping sets of techniques, their attendant psychological theories and bodies of empirical research’ (2000, p. 63). The training we received had a strong bias toward the cognitive element of this combination. This in itself is not a problem, but does raise important issues if the training veers towards either the cognitive or behavioural aspects of the approach, because this will result in noticeably different ways of working. The training we received proved to be enormously interesting and stimulating. However, we did not account for the impact that this training could have on us, as individuals and as a team. In our enthusiasm to learn, we did not realise how our emotional engagement with the process would affect us. Over the course of the training, several team members experienced a sense of personal upheaval as we grappled with trying to understand what was happening to us, and to do this in a new way. This was both enlightening and exhausting, but a particularly important experience because it enabled us to appreciate more fully the impact of work on service users, a dimension that is easy to overlook when working with people in crisis. COGNITIVE BEHAVIOURAL THERAPY IN SOCIAL WORK 179 Running parallel to the impact that we experienced as individuals was the collective impact the training had upon the team. We found ourselves in a new environment, one where our intellectual and practice abilities were being exposed, in ways we had not anticipated—exposed in ways that meant that our skills and abilities could be contrasted and compared. This felt uncomfortable and was an element that was not picked up on or processed at the time. As a result, those who ‘did well’ felt unable to enjoy their success, and those who did less well felt embarrassed or discouraged. In any team, there are individuals with different levels of ability, motivation and selfawareness and this fact is reflected across social work as a profession as a whole. What occurs to us now is that social work practice is rarely, if ever, analysed or understood in a team context. Therefore differences are not overtly addressed, yet the impact of these differences can be critical—as social workers, service users and managers will all testify. Teams made up of a range of ‘mixed ability’ will always exist, with attendant strengths and weaknesses. It is therefore important for this fact to be recognised and for this group dynamic to be given careful consideration before any kind of team training is embarked upon, particularly where this is a more intensive or exposing experience. As a team we were able to work through these difficulties. Preparing for them in advance, however, would have been valuable and would have saved considerable energy in the long run. It would be challenging and exciting if managers could create a climate that allows for, and works with, the differences that exist within teams—this could have important benefits both for individual team members and the organisation. A further difficulty we faced in our training was coming to terms with the degree of theoretical information we were being presented with, and expected to learn. Our preconceptions of the course before we embarked on it had been, perhaps naively, that we would be taught how to ‘do’ CBT. The expectation that we might also have to understand why CBT worked—its theory— seemed somewhat alien to many of us. Indeed, our common complaint at the beginning of the course was that it was not practical enough, and was not relevant to the young people who made up our client group. The idea that it was ‘down to us’ to adapt the training and approach was not one that came easily. Although our teacher did take steps to make our training relevant to work with children and young people, the approach we covered, particularly in the early part of our training, was focused on work with adults. This raises an important issue. Any training has to fit into the needs of practitioners and anyone considering training would do well to ensure the programme of study is going to be relevant to their work before thinking to set up training of this kind. South Gloucestershire has a strong commitment to training and to supporting its staff in their professional development but matching training to staff needs is not always easy, particularly if staff are not clear what it is they need to know. The difficulty linking theory and practice, and finding good training, was not new to us but in the past this dilemma mainly focused on the lack of theory—something that was not lacking in our CBT course. As a team, one of the shortcomings of our experiences with external training has been that many trainers deliver the mechanics and techniques of certain approaches rather than giving a theoretical framework on which to hang those approaches. This produces a particular kind of dependency on those trainers who pursue this standpoint: if we need to understand more, and no reading lists are provided, this means that we have no option but to invite further training in the hope that this might unravel our confusions. It is as if we were being constantly given directions but never the map. As Whittington notes (2000), a more a-theoretical approach to training is likely to follow a ‘technical model’, rather than an approach that encourages ‘critical thinking’ (Gambrill, 1997, pp. 125–156) or a more reflective and creative approach to practice, and to learning and teaching. Training cannot answer all our confusions and given the kind of work we do, with disturbed adolescents and equally troubled parents, we are always likely to be up against impossible problems, as Schön notes: 180 S. MATTHEWS, A. HARVEY & P. TREVITHICK There are those who choose the swampy lowlands. They deliberately involve themselves in messy but crucially important problems and, when asked to describe their methods of inquiry, they speak of experience, trial and error, intuition, and muddling though (Schön, 1991, p. 43). We know how to muddle through, but given the nature of the ‘swamp’, we need more than directions, which is what we now have in the consultancy we have set up for our group-work. This links theory and practice, directions and the map, based on a psychosocial perspective. The advantage of any theory and skills-based approach is that it enables us to understand and link the relationship between concepts and techniques and, therefore, to adapt our practice more effectively to the complex environment that is characteristic of work with children and families. For any team who may be contemplating a similar training experience, we think it is important to think about the impact that the training might have on individual staff members, who may require additional support. Where the training exposes individuals’ intellectual, academic and practice abilities, this needs to be recognised at the time, processed and capitalised upon. Through the use of a case study we hope to demonstrate how we attempted to apply our training to practice. Following this we will explore how we experienced the process of integrating CBT into our work and identify some of its common strengths and weaknesses. Case study Joanne, a white 15 year old, was referred to social services after she was charged with criminal damage at her home and detained in police custody overnight. Her mother, Sue, and father, Tim, and her younger brother and sister, were very reluctant for Joanne to return home as she had a history of poor anger management that sometimes led to frightening episodes of physical and verbal abuse. As a temporary measure it was agreed that Joanne would stay with Pauline, her older half sister, and undertake some intensive work to bring her anger under control with a view to her returning home within four weeks. Alongside this work, Joanne’s younger siblings were given the opportunity to express their feelings about recent events at their home and, in particular, about Joanne’s angry behaviour. Support was also offered to Sue and Tim. At this time, Joanne’s motivation to change her behaviour was high. She clearly demonstrated a capacity for selfreflection and her parents were being supportive. Therefore CBT seemed an appropriate initial intervention to assist the family. To begin with Joanne was offered two sessions a week for four weeks. The initial focus was to look at what triggered Joanne’s fury and the extent to which she had the capacity for self control and to formulate a simple case conceptualisation. A case conceptualisation or formulation (the two terms are used interchangeably) is a way of seeing a client’s difficulties in a sequential and interrelated way. At its most basic it draws together their thoughts, feelings, behaviours and physiology resulting from a critical incident, whilst in its fullest form it charts the root of these in early experiences, core beliefs and assumptions. Case conceptualisations are seen as being fundamental to any CBT intervention—they are a constantly evolving piece of work that both inform and drive the therapy. Joanne engaged fully with this process using the cognitive triangle (a representation of the links between a person’s thoughts, feelings and behaviours following a critical event or trigger) and began to keep thought records to note her strongest negative automatic thoughts, or ‘hot thoughts’ with a view to looking at these reactions. Joanne was having regular contact with home and the situation, on the surface, looked promising. However, as time passed, it became increasingly clear that Sue and Tim’s ambivalence to the idea of Joanne returning home was not abating in any way. Indeed, what was evident was COGNITIVE BEHAVIOURAL THERAPY IN SOCIAL WORK 181 their capacity for discounting any positives about Joanne’s progress in managing her anger. It also became evident that Sue was actively withdrawing any responsibility for ‘triggering’ situations and was very reluctant to recognise how her parenting style had, often, supported Joanne’s behaviour. These tensions, along with the fact that Joanne was feeling increasingly isolated from her family and friends, over took the work that was being done. Joanne’s motivation lessened without familial encouragement, and she initially became very low emotionally and then deeply angry, resulting in a violent confrontation with Sue after her mother refused to lend her money. Joanne did not return home and our role shifted abruptly from therapeutic to crisis work. Instead of implementing cognitive behavioural techniques within subscribed boundaries time was spent chasing after a deeply distressed teenager who had become a risk to herself as well as to others. The priority changed because we needed to find somewhere for Joanne to live and also to maintain some kind of meaningful contact with her family, despite the polarisation that subsequently ensued between Joanne and her mother. Linking theory and practice Traditionally social work has drawn upon systemic and developmental theories with special attention being paid to attachment theory (Fahlberg, 1996; Howe, 1995; Brandon et al., 1998; Cairns, 2002) in order to help people unravel the complexities of their lives. These approaches, coupled with practitioners’ practice wisdom, have been applied to young people whose needs are categorised under particular emotional and behavioural headings. Our team encounters such difficulties routinely and, in common with other professionals, must assess, intervene and review regularly in an attempt to improve the circumstances and life chances of our young service users. This of course is greatly complicated by a lack of resources, a lack of cohesiveness between various agencies and, historically, inadequate social work theory. In recent years considerable efforts have been made to counteract these shortcomings and new texts have emerged (Adams et al., 2002; Trevithick, 2000) and the drive towards more evidence-based practice is symptomatic of attempts to explicitly link theory to practice. South Gloucestershire Social Services is one of the authorities that adheres to this more rigorous approach and therefore supported the team’s training because one of the strengths of CBT is that it claims a strong empirical base. Understanding how other theories could sit alongside CBT and inform our practice was an important lesson to learn. Developmental theories have clearly had a role in helping us to assess a young person’s awareness of their internal world and to access their thoughts in ways that help us to determine the suitability of certain cognitive aspects of CBT to help them. The link between CBT’s concept of ‘schema’ or ‘core beliefs’ that form an ‘internal model’ of the world seemed to mesh strongly with our understandings of attachment theory. Together they added a further tool to our repertoire in helping to explore and explain this often complex area to young people and their families. Using CBT with children and young people Children bring to the therapeutic process particular challenges due, in part, to their age and emotional and physical immaturity: limited reasoning skills; difficulties with conceptualising and a poor sense of deferred gratification (Bee, 1997; Ronen, 1998). Traditionally this has meant that behaviour, not cognitions, has been the focus of the intervention. However, as the model of CBT with children continues to develop the picture is altering. According to Ronen, it has ‘become an umbrella term for different treatment techniques that can be offered in many different sequences and permutations’ (1998, p. 2). A major characteristic of this change is the adjustments of some 182 S. MATTHEWS, A. HARVEY & P. TREVITHICK methods and techniques to individual problems, while taking individual differences into account. Thus it is imperative at the initial assessment stage that social workers consider and work with a wide range of variables: age, gender, cognitive stage, emotional development and, significantly, in contrast to adult therapy, the role of the family system (Ronen, 1998). This considerable data helps inform the worker as to whether a problem exists, who should be treated (as this model extends beyond the individual) and what techniques should be selected and adapted to best meet the child’s unique needs and abilities (Graham, 1998). In Joanne’s case, working to a cognitive behavioural model was not viable because it was not possible to exercise enough control over the variables at play in her circumstances. As Herbert (1998) points out, changes seen in one environment, such as a therapy session, will not necessarily follow an individual into another environment, if that environment still contains strong stimuli likely to trigger an unhelpful response. This is particularly so if the initial changes are at a behavioural rather than at a cognitive level. Psychodynamic theories tell us that people work from their histories and systems theory tells us that a threat to the status quo will always be challenged. In Joanne’s case it proved impossible to use CBT because of the problematic relationship history between her and her parents and because of the function that Joanne fulfilled in her family. Until there was a willingness to expose and to work through these components, Joanne could not hope to address the difficulties she had with anger in any sustainable way regardless of the individual therapeutic approach used with her. In essence, the training that we received, although of a high standard, did not prepare us for the complexities inherent in social work. Few authors have addressed this area and the issue remains one that requires further investigation and consideration. Lane (1998) writes with authority of the importance of including the system around the adolescent in any work in order to maximise the chance of success and minimise the chance of remission, but when working with crisis, this option is often elusive. It must be recognised that without the support of a young person’s family, and possibly school as well, the chance of a successful intervention using CBT will be minimal. CBT has its genesis in a clinical setting, where individuals receive treatment on a one-to-one basis for specific problems and, for the most part, it continues to be practised by therapists in this particular environment. Although clinical practice is the norm, there are those who positively promote the idea that social workers practice theory, approach and position in the community render them ‘eminently qualified for direct child intervention, and that CBT is an appropriate, feasible and exciting approach that the social worker can use’ (Ronen, 1998, p. 43). This proposition, appealing as it is, is not without its difficulties as the case study shows. The greatest challenge we continue to encounter when trying to apply CBT in practice is the complex and competing needs and demands of the families that we work with. Frequently parents/carers and their young people are polarised when we begin to work with them, and often the adults have poor motivation to try any other approaches believing that they have ‘done everything’ and ‘nothing works’. At its most dogmatic, this belief subsequently leads to requests for accommodation and withdrawal of emotional support. Given that CBT with young people requires significant engagement with family members the lack of commitment from parents and carers to the process creates a hurdle that has to be overcome before work can commence with any reasonable chance of success. Closely aligned to this is the motivation of the young people themselves. Children and young people are rarely key players in determining whether they take up a service or not. Most often a service is imposed. This difficulty is not insurmountable but it may require considerable effort to overcome. In our team much time and attention is invested in establishing relationships with service users that are as democratic as possible. This dovetails well with the principle of empowerment inherent in CBT but it can also militate against the work if the young person chooses to opt out. One dilemma we continue to come across at this stage is COGNITIVE BEHAVIOURAL THERAPY IN SOCIAL WORK 183 whether our attempts to influence and counteract this desire to opt out can be experienced by young people as oppressive. Another difficulty that we continue to come across is that when motivation is assessed to be sufficient and we are about to begin to use CBT we often find, much to our frustration, that a fresh crisis erupts in the family and we are left to resort to ‘fire fighting’, and to losing our original momentum. In Joanne’s case the need to find accommodation entirely overtook the work that was being done in her one-to-one sessions and illustrates very well the difficulties we face. In essence, familial crisis coupled with entrenched family dynamics, frequently hijacks the practice of CBT and as a result at times this has left us feeling discouraged and lacking confidence in our skills. In situations where our work with young people has clearly been unsuccessful, perhaps all we can hope is that the experience of working on a one-to-one basis with a social worker has been a positive one and that the young person has felt valued and listened to. What further complicated our efforts to use CBT and practice in an anti-oppressive way is the conflict that exists between confidentiality and statutory responsibilities, which can sometime overshadow the interests of the child (Bourn, 1998). For example, if a young person’s behavioural difficulties and negative belief system has been shaped by their experience of abuse, workers are required to forward this information. Many young people are acutely aware that this kind of disclosure will lead to further investigation and this knowledge in itself can act as a brake on the therapeutic process, thus preventing an accurate case conceptualisation forming and skewing the work and strategies put forward. If child protection procedures have been instigated this in turn can set up an almost untenable situation where it is very difficult to work with a young person’s cognitions in the face of the intrusive impact of child protection procedures and the mandate to not ‘lead’ the young person in any way. While young people should be made aware of the exceptions to confidentiality, they remain in emotional isolation if they know that the experiences and pain that they need to speak about is the very thing they must not say in order to maintain some control of their disclosure. In terms of CBT, and in fact other social work approaches, this remains a dilemma that has yet to be resolved. Reflections We, as a team, recognised the importance of the link between theory and practice. We knew why we chose CBT as an approach and we came to the training, supported by management, with enthusiasm and commitment. This was not enough. Despite our positive expectations and best intentions, within a year of our implementing CBT we were floundering. Gradually we began to ask ourselves why and to review the whole process. This proved to be a cathartic experience both individually and collectively. Workers began to talk about the way that they found the training experience difficult, their loss of confidence in practice and the loss of morale this engendered. The CBT training featured significantly in a team development day and from talking, staff began to feel re-energised about the topic. What we discovered was that we had established our own ‘vicious circle’. The trigger was a lack of success, we had begun to think that we ‘couldn’t do it’ and this led to feelings of inadequacy and anxiety. As a result, we had begun to use CBT less and less. Through exploring our experiences and the evidence that supported our beliefs, we began to challenge these feelings and to establish alternative perspectives and belief about our work and ourselves. This renewed confidence has resulted in a plan to revisit our training and to provide a firmer framework of support and development for those team members who want to continue to use CBT in their work. Our advice to any team embarking on similar experience would be to do this sooner rather than later. After finishing our training we failed to set up a system to maintain the 184 S. MATTHEWS, A. HARVEY & P. TREVITHICK momentum of our learning. We practised our newly learned skills as individuals in isolation from each other and any reference to CBT was usually informal, as opposed to a part of a structure. We also recognise that utilising a cognitive behavioural therapist on a consultancy basis, perhaps as a part of team supervision, would have been hugely beneficial in the early months of our practice and we would highly recommend this approach to any team considering a similar route. The detailed analysis of our experience also highlighted more global factors, significantly, that we had focused on the training element of CBT with scant regard for the environment we were to practise in. With hindsight this appears foolish, yet we know that the reality of much social work is to ‘hit the ground running’ and we, like others, assumed we would manage. In reality, environment is absolutely critical to the successful application of CBT. We now recognise that very few families will meet the selection criteria for this therapy in its purest form. To identify those who do requires a change to our current referral system and this is presently being reviewed. For those families where CBT seems inappropriate, elements of it can still be used positively. Despite the difficulties we experienced there were many positive outcomes from the process under discussion. While we have not all been transformed into fully functioning Cognitive Behavioural Therapists, we do now have a shared point of reference, a common language and a solid foundation for decision-making. The realisation that we now, unconsciously, use the language and ideas of CBT more and more in our work dawned on us slowly. The benefits of this are significant. Having shared a detailed understanding of a theory, particularly one as well evidenced as CBT, we are in a position to approach cases from a consistent angle. It has given us a benchmark from which to review other ideas and approaches and it has given us greater confidence in our work with other agencies. The adaptability and accessibility of CBT techniques means that it can be used on an ad hoc basis, providing the practitioner has the theoretical understanding of why he or she is employing a particular technique with a client. Looking back on our two-year journey with CBT this last point seems obvious. We have seen the benefits of introducing an angry teenager to the use of self talk as an anger management strategy over a game of pool, or helping stressed parents to identify the cognitive distortions they are employing when focussing only on their children’s negative behaviour. These benefits were not immediately apparent to us. Our training, which derived from a counselling perspective, influenced us to regard CBT as being valid only in its purist, clinical form. In effect, we have travelled from this purist perspective to a pragmatist one, increasingly confident in the service we now offer. We have the directions and the map and, hopefully, the capacity to do good work in social work’s ‘swampy lowlands’. The writing experience As practitioners we are neither encouraged nor expected to write about our work. It is considered to be the domain of academics and unfortunately it is our experience that few practitioners consider themselves capable of writing, let alone contemplate the act itself. Our experience of training in CBT and attempting to implement it in our work, however, seemed too important not to share with colleagues. The process of writing has been long and not without its difficulties but ultimately it has been a rewarding and informative experience. The analysis and thinking required to put our story to paper has brought up issues that otherwise we would have remained oblivious to, particularly in the complex arena of group dynamics. We hope other practitioners will feel inspired to also write of their work, their successes and difficulties and would welcome correspondence from anyone wishing to know more about our work or wanting to exchange thoughts and ideas. COGNITIVE BEHAVIOURAL THERAPY IN SOCIAL WORK 185 Acknowledgements The authors would like to thank Nick Thorne (Training Manager, South Gloucester), Peter Parry (Team Manager), Phillip Lewis (Team Co-ordinator), colleagues at 43 The Park, Judith Thomas (UWE) and Nigel Sherriff. References ADAMS, R., DOMINELLI, L. & PAYNE, M. (2002) Social Work: Themes, Issues and Critical Debates, second edition (Basingstoke, Macmillan). BEE, H. (1997) The Developing Child, eighth edition (New York, Harper Collins). BOURN, D. (1998) Intervention to protect the child in: K. CIGNO & D. BOURNE (Eds) Cognitive-Behavioural Social Work in Practice (Aldershot, Arena). BRANDON, M., HININGS, D. & SCHOFIELD, G. 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