Exploring novel approaches to youth mental health

In 2013, the NHS trust I worked for did away with the traditional transition at 18 years from Child and Adolescent to Adult Mental Health Services. A Child and Family service was created to work with those up to 14 years, and a new Youth Service working with those aged between 14 and 25 years (see Wilson et. al., 2018, for an account). The main drivers behind this change included the extending and increasingly fragmented phase of adolescence in today's society, and research suggesting most mental health difficulties start before 25 years of age (Kessler et al., 2005).

Having started work in the new Youth Service, my colleagues and I had to ensure the service properly met the needs of young people. We began by considering two models. The first was the developmental model: we reasoned that the Youth Service must support a successful progression through the adolescent phase of life into adulthood; supporting the development of self-efficacy, self-identity, and positive, supportive relationships with peers and families. The second model we considered was the diagnostic model. We were aware that the diagnostic model did not apply in the same way to mental health as it did in other branches of healthcare, because there was no evidence to support the existence of any underlying cause for any mental disorder. This meant that the distinction between 'ill' and 'well' represented an arbitrary line bisecting the normal population along a continuum of wellness. Our experience of soaring referrals of young people to mental health services demonstrated the shift of this arbitrary line to include ever-increasing numbers in the 'ill' category.

For young people, the diagnostic model is especially problematic. It can undermine the efficacy of young people, giving them the impression that they are suffering from an illness over which they have little control. It also provides lifelong labels, right at the time when young people are forming a sense of identity, labels already associated with high levels of stigma (Patton, 2016). The diagnostic model also minimises the influence of wider systems in their lives, being defined in DSM5 as 'a disorder that is located within an individual'. Fundamentally, it's a model of illness, providing no information about health or wellbeing.

Dilemmas

This left us in the Youth Service with a significant dilemma. The two models of most importance to our service were in direct conflict with each other. This dilemma was highlighted by the frequent invitations my colleagues and I received to talk about youth mental health to other agencies, including GPs, schools and colleges. I was a clinical psychologist, fairly fresh out of training, so I should have been well versed in all the content, statistics and ideas I'd need. But when considering where to start, I realised that my training had equipped me to begin only with the diagnostic model: 'this is anxiety, this is depression, here are the symptoms, the prevalence, and the treatments'. But this wouldn't be youth mental health. Going into schools and colleges to talk about all of the potential 'illnesses' that young people might experience didn't seem a particularly helpful way of guiding them towards health, wellbeing, happiness, or fulfilment. This was especially problematic as we, as health professionals, were being invited out of traditional health settings into community settings, and there was a risk of encouraging even more young people to view themselves as ill.

Unlearning the language

Around this time, I attended workshops with the clinical psychologist and speaker Lucy Johnstone and an event on positive psychology, both of which increased my discomfort about relying so heavily on an illness model. So, what could I do instead?

The solution was not actually as complicated as we supposed; we just began somewhere else. Rather than starting with disorders, their prevalence, and their treatment, we started with the psychology of emotion. We aimed to understand each emotion, look at its causes, the impact it has on the individual, when it functions in a helpful way, and when it is less helpful. I was embarrassed to discover that 10 years of study to qualify as a clinical psychologist had not equipped me to properly explain what anger was, or the function of sadness. I wasn't sure anybody had ever mentioned happiness.

The psychological community had already undertaken a great deal of research into emotions, but I was surprised by how well it all linked with cognitive behavioural theory. We began to deliver cognitive behavioural therapy (CBT) within this understanding of emotions, rather than the more traditional diagnostic approach. We stopped talking about anxiety disorders and started talking about fear; we stopped talking about depression, and started talking about sadness. This changed how people understood their emotions: they were no longer symptoms of an illness to get rid of, but an understandable and universal emotion, which could be understood and responded to. Of course, this is the position of many psychologists everywhere, but it felt liberating to have it built into the fabric of the approach to CBT.

Making this shift in clinical practice took some work: we had to unlearn the language of diagnosis and teach ourselves a different language through which to view people and their difficulties. Our treatment waiting list became littered with phrases like 'miserable and almost completely isolated' or 'problems with emotion regulation, particularly anger'. Shifting our language and reference point had a significant impact, in turn, on our work. Personally, I felt released from the expectation that I should be an expert in 'illnesses' and now could be another human with a particular understanding of emotion. I stopped expecting young people to 'get better' and started to view my role as somebody who could help them navigate the emotional challenges of their adolescence and early adulthood.

As a result, I frequently provided less ongoing intervention and more guidance. On many occasions young people left single sessions with a clear sense of what they needed to do to bring about change, something I felt that a diagnosis and subsequent intervention would have undermined. Some of my longer-term interventions were also interesting, helping young people to understand how emotions worked and how they might helpfully respond to them (instead of giving a diagnosis of autistic spectrum disorder or emerging borderline personality disorder).

Many young people and their families found this approach helpful, and told me what it meant to them:
'You can see where the feelings are coming from, the result of the feeling, and how it feeds back on itself. Because it's logical, it's easy for me to see how it fits with what's going on in my head.'
'When you're sad, you just think about being sad, you don't see it with the thoughts and behaviours and see how it all goes together.'
'It's nice [to understand things in this way] because it means that I'm essentially normal, I am supposed to respond like this.'

As a result of this kind of feedback, my colleagues and I developed a series of six 'Psychology of Emotions' workshops, an educational package designed to help young people apply the science of emotions and CBT to their difficulties. It was enjoyable illustrating the function of fear using videos of free-climbers and Pingu, and the function of anger with Basil Fawlty. Most importantly, the tone of our approach completely shifted: we talked about our emotions, rather than your illness, and family members and friends were invited to attend and participate along with everybody else. Talking about emotions brought people together and provided a shared language to discuss experiences, instead of isolating people diagnosed with a disorder. We had succeeded in developing an intervention that could be used without encouraging people to view themselves as ill. Almost 600 young people were invited to these workshops and we showed that attending could help them better understand themselves and make positive changes as a result, all without reference to illness or disorder (Howells et al., 2019).

We went on to develop a youth specific IAPT service that worked with people aged between 16 and 25. We aimed to provide intervention grounded in emotion rather than illness, to provide easy access to understanding about emotions and effective intervention and guidance. There were many successes of this approach, but also tensions with the targets of IAPT, which is a predominantly diagnostic, adult-focused model (Howells et al., 2020).

Powerful experiences

I now deliver CBT very differently to adolescents, young adults, and adults. I call it Emotion Regulation CBT (ER-CBT) and its principles are consistent with traditional CBT, but it is grounded in emotion science rather than illness and disorder. Being an emotionally-focused approach, I am more comfortable with demonstrating how to regulate emotion in session. When people are struggling with fear, I make them scared; when people are struggling with anger, I make them angry. These are powerful experiences, teaching people that emotions are a normal part of human life and within their control. People often don't think it is possible to produce intense feelings in session, but I remember one young man getting so angry he had to take off his shoes because his curled toes would not fit into them! To increase the intensity of his anger I had encouraged him to change his attention, his muscle tension, and his breathing; the same techniques decreased it again so that by the end of the session he had calmed down and replaced his shoes. The whole approach is written up in a treatment manual with examples and illustrations, which has received positive feedback (Howells, 2018).

The process of re-learning how to deliver therapy from a different standpoint has been fascinating and I have appreciated applying academic psychology to clinical populations. My future plans are to continue to invite colleagues and my students to consider alternatives to diagnosis, and to further develop research around ER-CBT. As Peter Kinderman says (e.g. The Psychologist, February 2020) we really do have alternatives and I am pleased to be a part of the community actively offering something different.

- Dr Lawrence Howells is a Clinical Psychologist and Lecturer at the University of East Anglia.
[email protected]

Illustration: James Hayes

Key sources

Kessler, R.C., Berglund, P., Demler, O. et al. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593-602.
Howells, L. (2018). Cognitive behavioural therapy for adolescents and young adults: An emotion regulation approach. Routledge.
Howells, L., Rose, A., Gee, B. et al. (2019). Evaluation of a non-diagnostic 'Psychology of Emotions' group intervention within a UK youth IAPT service: a mixed-methods approach. Behavioural and Cognitive Psychotherapy, 48(2), 129-141.
Howells, L., Simmons, C., Gee, B. & Clarke, T. (2020). Evaluation of a Youth-Specific IAPT Service: Successes and Tensions. Manuscript in preparation.
Wilson, J., Clarke, T., Lower, R. et al. (2018). Creating an innovative youth mental health service in the United Kingdom: the Norfolk Youth Service. Early Intervention in Psychiatry, 12(4), 740-746.