Sally, 16 years old, was referred to CAMHS by her GP for low mood and anxiety. She had self-harmed by cutting but was not having any suicidal thoughts.
Read below what we did for Sally, as told by her cognitive behavioural therapist.
What did you do first for Sally?
She was seen in an urgent appointment (to assess her needs) and received four support sessions with a clinician who identified she would benefit from Cognitive Behavioural Therapy (CBT).
Sally remained with this clinician whilst awaiting her first CBT appointment.
She was also referred to the Consultant Child & Adolescent Psychiatrist to discuss the possibility of medication.
Why did Sally think that she had anxiety?
I was allocated to work with Sally using CBT. Sally was clearly low and very quietly spoken. Sally informed me that she lacked confidence and there were certain social situations in which she struggled to engage e.g. talking up in class.
Sally had also witnessed domestic violence within the family and her younger brother had been sexually abused.
Using an approved questionnaire to check on symptoms and level of risk, (completed by Sally) it was identified that she had separation and social anxieties. These measures would be repeated throughout the work to track treatment progress.
What did you do?
The first few sessions were important in getting to know Sally and finding out important information. In particular due to her shyness and lack of confidence, it was important she was given time to settle down into the therapeutic relationship so that the best outcome for her recovery might be achieved.
Acknowledging the past experiences of Sally was an important element of the therapeutic approach – a space in which she felt heard and understood so that she could be open and trust that confidence would be respected.
We always let young people know that we keep confidentiality but would also need to share things if we felt they were at risk of abuse in some way.
What resources did Sally use?
Resources of handouts and worksheets are commonly used in a CBT approach. The purpose of these resources is to further educate young people in keeping well and to gather additional information so that the appropriate goals are worked on.
Sally completed a problem list which identified poor sleep, lack of confidence and her belief of being an irritation to others. A specific goal, mutually agreed, was that Sally would work towards reducing thoughts that she was an irritation to others.
Various resources were used together with a work booklet on being assertive and using the CBT model to identify thoughts, feelings, behaviours and body sensations linked to the unhelpful thoughts.
What did Sally change?
Sally became more aware of the impact of her self-critical thoughts on her well being and began to make changes that she felt she could achieve as small steps towards her goal.
Various strategies were rehearsed and put into action by Sally in and outside of the therapy sessions. Sally found role playing (in session) what she would say in certain scenarios very helpful. A visualisation of what being confident would be like for her was also seen as a big step for Sally in changing her beliefs.
What difference did that make?
Positive affirmations and using newly learnt assertive skills enabled Sally to be heard and get her needs met. Her confidence grew and she was able to make decisions without fear of offending others – family relationships improved.
Sally also had a fear of rejection, therefore it was kept in mind to acknowledge respect for Sally’s thoughts and feelings, linked to decisions she made within the therapeutic space.
Sally was able to work on her sleep problems by using the self-help material given to her and checking in every session as to her progress and any concerns she might have in this area. Food and sleep affecting her mood were discussed to educate Sally in the importance of these in her well being.
Did Sally have medication?
During the work together, Sally was prescribed medication to help her mood. This proved very successful and gave enough ‘lift’ for her to improve her motivation.
In each session risk was monitored by careful questioning around Sally’s current well being. This was further monitored by use of an outcome measure to promote discussion at the beginning of sessions around well being. A further measure was used at the end of each session to check that Sally felt heard, understood, that her issues were covered and that overall the session met her needs.
When attending a medication review, Sally’s mother reported that she (and others) had noticed much change for Sally and how improved their relationship had become.
Sally also presented as a more upright and ‘open’ individual within the therapy session. She now had her hair back (showing her face) and no longer spoke in a whisper.
Does Sally feel better now?
At the end of the therapy measures used (as at the beginning) evidenced that Sally had reduced her separation and social anxieties to below the cut-off, which meant she resolved her problems to a manageable level.
Sally scored the attainment of her goal as 8/10 and was happy with the result, knowing she would continue to be confident in making changes for herself.
Identifying what did or did not work for her was crucial to her success and trusting her ability to make her choices which further boosted her self-esteem.
As a result of 8 sessions, Sally :
• got a new job – she was unhappy in her current one
• improved her sleep
• made friends at her new college
• was able to say ‘no’ when she didn’t want to do things – instead of just pleasing others all the time.
Children and Family Health Devon
Single Point of Access Team
1a Capital Court
Sowton Industrial Estate
Exeter EX2 7FW
t: 0330 0245 321