Programmes with cognitive behavioural therapy are effective in reducing symptoms of anxiety and depression in young people. But that is only the case if therapists do apply the effective elements in those interventions. That does not happen often enough yet, says Professor of Clinical Psychology Maaike Nauta, project leader of the Consortium Anxiety and Depression in Young People.
For the study, meta-analyses, single case studies and microtrials were used to investigate the effectiveness of elements from interventions. This revealed that cognitive behavioural therapy (CBT) is an effective way of helping children and young people with anxiety and depression symptoms, says Nauta. ‘All interventions that work with CBT can therefore be used on the condition that these contain the most important elements of CBT. Such core elements are exposure (practising through exposure to the situation that elicits the anxiety, ed.), behavioural activation, cognitive restructuring, relaxation exercises, and solving problems. In the case of anxiety symptoms, exposure is essential for treatment just like behavioural activation is essential for treating depressive symptoms.’
The use of modelling (impersonating and participating) and relapse prevention also make some difference to the effectiveness of treating anxiety symptoms. For the treatment of depression, involving the parents in the treatment and working by challenging thought patterns are important, states Nauta. ‘However, the effects of the specific elements are small compared to the overall effectiveness of the CBT. They are almost like cherries on the cake. So therapists really do need to work with the programmes that contain CBT.’
And that is where the problem lies, as the results of two surveys make clear. The answers given reveal that few therapists precisely follow the treatment protocols of the programmes. Sometimes, this is because they do not know the protocols and sometimes because the strict sequence is experienced as too much of a straitjacket. In the case of young people with anxiety symptoms, only 50% of therapists apply exposure in the treatment. Some therapists are scared that exposure will cause harm, explains Nauta. ‘This means that acquiring experience and peer support are very important.’
'Some therapists are scared that exposure will cause harm.'
For the study, Mariken van Onna supervised therapists at Karakter (academic centre for child and youth psychiatry) which treats children and young adults with severe anxiety symptoms. All of them were trained in CBT and therefore in exposure, she says. Yet, they were nevertheless uncertain about whether they sufficiently mastered the technique. ‘During the weekly peer support sessions, we noticed that together we became better in practising our profession by examining how we could apply exposure in the situation of children and young people. Therapists started to talk less and do more and discovered together with children and young adults that exposure is effective. They gained more self-confidence.’ Nauta: ‘So for the therapists, the application is also a sort of exposure!’
The sessions during this research took one-and-a-half hours instead of the usual 45 minutes and were given more often per week, states Van Onna. ‘With an entire week between the treatment sessions, you have to keep on trying to get the young patients in the active state. Intensity and a strict plan with several therapists also helps the therapist to stick to the agreements. And because of the longer sessions, it is easier to practise at locations outside of the treatment centre. We practised at the blood transfusion centre, in a library and in a HEMA (retail chain store).’
The research clearly demonstrates how you could also treat more severe complaints but provides no information about the effect of increased intensity or a longer treatment session, because this concerned single case studies. The intensity of the treatment is especially effective in the case of young people with severe symptoms, according to Van Onna. Nauta adds: ‘At the Durfpoli (Dare clinic) we demonstrated that practising two or three times can be enough to overcome the anxiety for spiders or dogs, for example.’
For the five most effective elements from the CBT – exposure, behavioural activation, cognitive restructuring, relaxation exercises and solving problems – separate modules have been made. In the depression study, it was tested whether the effectiveness of the treatment was influenced by the sequence these modules were used in. 'That was not the case', says Nauta. 'Also for the treatment of anxiety, it made little difference whether the exposure happened during the actual session, elsewhere as homework or by practising with the parents. Neither did it matter exactly which combination of elements was used in the case of the fear to speak in public.'
'The therapist can now consider the case of each young person and discuss which effective element seems to be most useful to start the treatment with.'
Therefore, the choice of intervention makes little difference, as long as the most effective elements are contained in the programme, emphasises Nauta once again. ‘The therapist can consider what is needed for each young person and discuss what seems to be the most useful element to start with, and hence customise the treatment to the patient’s needs.’ Due to the freedom that working with modules offers, therapists will hopefully adopt this way of working more quickly. After all, this method is, less constrictive than the treatment protocol. In this approach, they can make use of the five modules. An explanation of these modules together with illustrative videos will soon be available in Dutch on the website of the Dutch Association for Cognitive Behaviour ( Vereniging voor Cognitieve gedragstherapie (VGCt)).
‘The CBT treatments we now have are mainly effective in the treatment of mild and moderate symptoms’, concludes Nauta. ‘For severe symptoms, additional or more intensive treatments are needed. The approach for this still requires more research. That makes it even more important to treat young people with symptoms at an early stage', says Van Onna. ‘Then you can overcome a developmental stagnation sooner with fewer risks and lower costs in the long term.’ An effective approach requires peer support, training, sufficient treatment time and the availability of practice material.
In the consortia Effectiveness of Psychosocial Interventions Youth, researchers and youth care organisations are exploring new possibilities for seven larger substantive themes related to growing up and parenting. The research provides knowledge about which (aspects of) interventions can best be used when, for who and by which persons. The key elements of interventions with proven effectiveness are the starting point for these interventions. Through innovative impact studies, the consortia provide answers to questions such as: What actually makes an intervention effective? Are there effective factors that can be found in all interventions? How can the care provider exert an influence on the impact? And: which interventions or aspects of these are cost-effective? Realising impact studies in an appropriate form is a challenge. Each consortium takes a different approach, but they work together to ensure that their approaches are well aligned with each other. The research from the consortia must improve the interventions and enable professionals and municipalities to choose an effective approach. The outcomes will make it possible to improve the effectiveness of professional practice and provide better help to children and families.
The consortia Effectiveness of Psychosocial Interventions Youth are working on these seven themes:
In the consortia, key elements of interventions will be investigated. But what exactly are those key elements? Key elements are the things that a care provider can do to teach desired behaviour to young people or their parents, guardians or carers. Or to diminish undesirable behaviour. This is given various names in the literature (e.g. components, elements, ingredients, kernels and techniques). We have chosen the term “key element” because this is used by most of the consortia and ties in well with the literature. As it is often not yet clear whether the element actually works, we ought to use the term “potentially effective key elements”. However, that is quite a mouthful. A collection of these key elements defines an intervention. Structural elements also play a role in defining an intervention. For example, the sequence, frequency and intensity of the key elements involved.
The research from the Consortium Anxiety and Depression has been set up to obtain more knowledge about effective key elements in the treatment of children and young people with anxiety and mood problems and the use of these elements in professional practice. The ultimate aim is to improve the care for this group of children and young people. Many other treatment programmes developed (55 in the databank of the Netherlands Youth Institute) usually consist of a combination of different key elements from combined behavioural therapy (CBT).
With the help of a taxonomy, it was first examined which key elements occur in each treatment programme and for whom the treatment programme is intended, and what its intended effect is. Subsequently, meta-regressions and meta-analyses of individual patient data were performed to determine for whom in particular the interventions were effective and which treatment elements are associated with a better result. The most important elements were tested in various microtrials. These targeted experiments investigate one specific element, for example the sequence, the added value or the content or form of this element. With the help of two surveys, the use of the elements in professional practice was investigated. Professionals and (representatives of) clients contributed ideas to the design and realisation of the trials and the best way to present the information from the studies.
The first project outcome was an overview of the key elements in the available treatment programmes. Subsequently, different approaches were used to examine which treatment elements appear to be effective and in which manner these should be deployed. The surveys revealed that, in practice, the treatment programmes as well as the key elements are not used often enough. The modules for the treatment of specific anxieties (Durfpoli) and for a group treatment at schools for (social) anxiety and depression, will be made available for use to encourage the use of effective key elements. Scientific and professional publications are now being written about the research results. Using the knowledge about how and when which key elements can best be used will improve the professional practice of youth care.
Tekst Veronique Huijbregts. Portret Maaike Jeroen Schaaphok. Portret Mariken Martin de Bouter. Fotografie header Studio Oostrum.