Chapter Two
The process of cognitive behaviour therapy

Cognitive behaviour therapy (CBT) is founded on a guiding principle of collaborative empiricism whereby the clinician and young person work together to discover new understandings and ways of coping. This is achieved through a process of guided discovery where the young person is encouraged to experiment and to be open and curious about their cognitions. This helps the young person to develop a new relationship with their cognitions and to question the meanings they ascribe to events. The process is positive and empowering as the young person discovers new cognitive skills and processes.

Therapeutic process

CBT occurs within the context of a strong therapeutic relationship built upon warmth, empathy, and understanding (Beck et al. 1979). The relationship is open, honest, and non-judgemental with the young person and clinician actively working together.

A number of specific aspects of the therapeutic relationship have been identified as important. Creed and Kendall (2005) noted the significance of collaboration, where the young person and clinician work together as a team, with mutually agreed goals, and where the young person is actively involved in the intervention. Clinician flexibility and creativity are also important. This involves making sessions engaging and active through presenting ideas and concepts in multiple formats such as games and role plays, appropriately adapted to the interests of the young person (Chu and Kendall 2009). Similarly, clinicians who are warm, positive, and empathic develop better relationships with young people than those who are aloof or patronising or push them to talk about uncomfortable emotions (Russell, Shirk, and Jungbluth 2008). Establishing a good therapeutic relationship is associated with better engagement, increased motivation, and superior outcomes (Chiu et al. 2009; McLeod and Weisz 2005; Shirk and Karver 2003; Karver et al. 2006; McLeod 2011).

Another aspect of the therapeutic process which is important for CBT is the development of collaborative inquiry where young people ‘become scientific investigators of their own thinking’ (Beck and Dozois 2011, p. 400). The promotion of a reflective and investigative approach requires careful attention since young people are often more familiar with being provided with information and answers rather than discovering their own solutions. Finally, the need to adapt CBT to the developmental level of the young person has been emphasised by many writers (Stallard 2003; Friedberg and McClure 2015) and has been reflected in different versions of CBT programmes for children and adolescents (Barrett 2005,2005). This requires CBT to be pitched at a level which is consistent with the young person's cognitive, emotional, verbal, and reasoning ability.

Stallard (2005) has defined the key elements of the therapeutic process with young people by the acronym PRECISE.

1. P – Partnership: This emphasises the collaborative nature of CBT and the importance of the therapeutic partnership whereby the young person has an active role in securing change.
2. R – Right developmental level: The clinician carefully attends to the young person's developmental level in order to ensure that the intervention is consistent with their cognitive, linguistic, memory, and perspective-taking abilities. Pitching the intervention too high will result in the young person failing to understand the model whilst pitching it too low may be perceived as patronising.
3. E – Empathy: Focuses on developing and maintaining a relationship based on warmth, genuine concern, and respect. This is fostered through important interpersonal skills such as active listening, reflection, and summaries.
4. C – Creativity: Identifies the need to be flexible and creative in conveying the concepts of CBT in ways that match the young person's interests and experiences.
5. I – Investigation: A curious, open, and inquisitive approach is encouraged where thoughts, feelings, and behaviours are subject to objective evaluation through Socratic dialogues and behavioural experiments.
6. S – Self-efficacy: The process should encourage self-reflection and discovery. This empowers the young person to develop a better understanding of their cognitions and to discover ways in which these can be processed in more helpful ways
7. E – Engagement and enjoyment: Finally, the process should be enjoyable and engaging so that the young person's interest, commitment, and motivation are maintained.

CBT is based on a strong empathic relationship which encourages openness, curiosity, and self-discovery.

Phases of CBT

The clinician will guide the young person though a number of phases each with a different primary aim. The length of time spent in each phase will vary according to the young person's needs.

Relationship building and engagement

Thus is the initial phase of CBT where the primary focus is upon developing the therapeutic partnership and engaging the young person in the process of change. This phase is particularly important since young people rarely seek help in their own right. Typically, they are identified by others and as such may not recognise or acknowledge any problems and may initially appear unmotivated or disinterested (McLeod and Weisz 2005; Creed and Kendall 2005; Shirk and Karver 2003).

Engagement can be developed through interpersonal skills such as active listening and empathy. Active listening conveys interest and demonstrates that the clinician respects and understands the young person whilst empathy shows that they understand how they feel. The relationship is strengthened through an open and non-judgemental stance where the young person's difficulties and potential ambivalence are validated and acknowledged.

The young person's motivation to engage in CBT can be enhanced by focusing on how they would like their life to be different and the targets they would like to achieve. The miracle question from solution-focused brief therapy can help the young person to focus on the future rather than remaining stuck with their problems in the present moment (de Shazer 1985). The miracle question asks the young person to think how and what would be different if they no longer had a problem:

Imagine that whilst you slept tonight a miracle happened and all your problems were sorted. When you awake tomorrow, what would you notice that would tell you that life had suddenly got better?

Once some degree of commitment to securing change is established, clear goals need to be agreed and defined. The SMART acronym helps to ensure that goals are specific, measurable, achievable, relevant, and timely. A good goal should be specific, e.g. ‘to call my friend Joe twice per week’ rather than general and vague ‘to be more sociable’. When goals are specific, it is easier to know what needs to be achieved whilst establishing concrete criteria, e.g. ‘twice per week’ allows the young person to objectively measure their progress. Motivation will be enhanced by successful achievement of meaningful goals. Goals should not be so large that they are difficult to achieve and should relate to relevant and important aspects of the young person's life. Finally, to maintain motivation, goals need to be achieved within a realistic time frame.

Engaging and motivating the young person is a pre-requisite to the subsequent stages of CBT. The therapist therefore presents as open, understanding, positive, and hopeful as they elicit commitment from the young person to ‘give it a try’.

Psycho-education

Psycho-education involves providing the young person with information and primarily focuses upon three main areas.

First, the young person is socialised into the process of CBT and in particular the concept of collaborative empiricism. The collaborative nature of the relationship is explained with the clinician providing a structure and framework for the young person to use to reflect on their own experiences. The active role of the young person in testing ideas and undertaking experiments to discover what happens and works for them is highlighted. The need to suspend judgement and to adopt an open and curious approach is stressed and the importance of the young person's contributions highlighted.

Second, the young person is socialised into the cognitive model. Information is provided about the link between events, thoughts, feelings, and behaviours. The central role of cognitions in determining how they feel and what they do is stressed. This provides the rationale for CBT, i.e. to understand their thoughts and to change the relationship with them by either questioning or accepting them. Through the development of more helpful cognitive processes, the young person will feel better and be able to confront challenging situations and deal with their problems. Finally, the effectiveness of CBT in alleviating many emotional problems is highlighted. The clinician remains optimistic and hopeful, but is unable to guarantee that CBT is always successful or suits everyone.

These first two aspects of psycho-education occur during the initial stages of the intervention, although they will be regularly revisited during...