Evidence Based Practice?

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I recently came across a review of trials for school-based interventions for adolescents aged 10 to 19 who displayed symptoms of depression and anxiety.

45 studies were reviewed of mainly CBT based interventions which I would assume would be short to medium term though this is not specified. What is found is that immediately after the intervention that there was a small reduction in symptoms for depression and a moderate one for anxiety. However, there was no evidence that the impact on anxiety lasted beyond the immediate intervention and no longer than 6 months for depression. The review suggested that more research was required as to the long-term impact of interventions. Interestingly, it did not seem to be questioning the efficacy of the provision. Personally, it does not seem adequate to offer something that only works when the child is provided with the input. I am not against helping children feel better for a little while but hope we might be able to do better. I do have three suggestions from experience of how provision may be thought about differently.

1. That we provide longer term interventions, the establishment of a relationship can take several sessions and with the standard 6 to 12 meetings one has barely started work when one must stop. The evidence appears to show the work has some impact but perhaps not long enough to really take hold. This can create a revolving door of input where the child bumps between feeling better and worse and repeated referrals are made where children can end up with what I call ‘intervention fatigue’, where they have had lots of short term interventions and end up feeling with good evidence that ‘nothing works’ and it gets harder and harder to engage them. It would be more useful and efficient to offer one intervention of 6 months or a year than 3 or 4 of 6 to 12 weeks.

2. A one size fits all approach is problematic. A practitioner in a school will offer the model they have been trained in however this may miss issues particularly of trauma. If you are looking at the symptoms rather than the history and background one might overlook issues of Trauma and Aces which would need a process that attends to the emotional and relational impacts and beyond the thoughts which are layered on top. Otherwise, the internal processes and neural pathways which have probably operated for many years on an unconscious basis will overwhelm the thinking cortical brain.

3. As well as attending to historical context and relationships one needs to attend to these in the now, particularly for adolescents who look beyond the family home for relationships the current context is important. If one just sees and works with the child without including parents there may be no improvement as their context may remain the same and the thing they are anxious or depressed about has not changed. We talk about Contextual Safeguarding perhaps we also need to think about Contextual Mental Health and with adolescents group work can be used to think about community and cultural issues.

We have a wide range of interventions and models available for working with children and young people and their various needs including psychotherapy, play based therapies, family therapy, group therapy and more cognitive provision. If we are being truly evidenced based one must look at the limitations of CBT as identified in this study and think more widely about what is best suited to a child and their situation.

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