Cognitive therapy compared with CBT for social anxiety disorder in adolescents: a feasibility study

Inclusion criteria

• Young people (aged 11–17.5 years at intake) whose primary presenting disorder was a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), diagnosis of SAD.

• If young people had been prescribed psychotropic medication, the dosage must have been stable for 2 months.

Exclusion criteria

• Young people who had previously received CBT for SAD were excluded if they had received more than four sessions in which key procedures of CT-SAD-A had been used (i.e. video feedback, attention training, memory work and multiple behavioural experiments).

• Young people with established autistic spectrum disorders [or suspected on the basis of Social Cognitions Questionnaire (SCQ)18; see Measures], learning disabilities, suicidal intent or recurrent self-harm (i.e. comorbid conditions that are likely to interfere with treatment delivery).

• Young people with a primary presenting disorder other than SAD.

The managers/clinical leads who were involved in managing the participating therapists on a day-to-day basis were invited to take part in qualitative interviews.

Ethics review

The study was approved by the NHS South Central – Oxford B Research Ethics Committee (REC reference: 16/SC/0315) and the University of Reading Research Ethics Committee (UREC 16/43).

Therapist training

CAMHS therapists were provided with a detailed treatment manual ahead of the training. They were also given a memory stick loaded with short video clips demonstrating many of the key steps in CT-SAD-A. Finally, they received a pack containing all worksheets needed to support CT-SAD-A. The training materials that were used in this study are freely available here: https://oxcadatresources.com.

Participating therapists completed a training programme comprising an initial 2-day workshop, focusing on the CT-SAD-A model and the key procedures involved in the first stage of therapy. Therapists were offered 6 months of weekly case supervision via Skype™ (Microsoft Corporation, Redmond, WA, USA) or telephone and a further 1-day workshop, which covered the key procedures used later in the therapy in more detail.

Supervision sessions involved a review of questionnaire measures, a detailed discussion of the previous treatment session, a discussion of any problems that had arisen and step-by-step planning for the next session. Videotaped treatment sessions were discussed on a regular basis in the supervision sessions.

Intervention: cognitive therapy for social anxiety disorder in adolescents

All young people received CT-SAD-A. Treatment was delivered in the CAMHS clinic in which the therapists usually worked, with behavioural experiments conducted in different environments, as required (e.g. in a shopping centre or a café). This therapy is based on Clark and Wells’ model of the maintenance of the disorder. 31 The treatment programme consists of 14 weekly sessions, each lasting 90 minutes, plus 2-monthly booster sessions and focuses on changing social anxiety-related beliefs and behaviours, with a particular emphasis on the four maintenance processes specified in the model. 31 These are (1) increased self-focused attention and observation (self-consciousness) and an associated decrease in observation of other people and their responses, (2) use of internal information (feelings and images) to make excessively negative inferences about how one appears to others, (3) use of overt and covert safety behaviours that prevent patients from discovering that their fears are unrealistic and interfere with the initiation and flow of social interactions, and (d) pre- and post-event processing (e.g. anticipatory worry and rumination). Given this, CT-SAD-A involves a number of components:33 (1) the development of a personalised cognitive model including the patient’s negative thoughts, self-images, focus of attention, safety behaviours and anxiety symptoms; (2) an experiential exercise to demonstrate the adverse effects of self-focused attention and safety behaviours; (3) video (and still photograph) feedback to correct negative self-imagery; (4) training in externally focused attention; (5) behavioural experiments to test patients’ negative beliefs by dropping safety behaviours and focusing attention externally on social situations and by also purposefully displaying feared behaviours or signs of anxiety (decatastrophising); (5) surveys to discover other people’s views of feared outcomes; (6) memory work (discrimination training and memory rescripting) to reduce the impact of social trauma experiences. The components of CT-SAD-A were well received by the adolescents in the case series. 29

Key adaptations were made to CT-SAD for working specifically with adolescents on the basis of previous experience from a development case series. 29 These were as follows: (1) working with peer victimisation (which is likely to involve school liaison) and (2) working with parents/carers. The degree of parental involvement varied from case to case. Typically, parents are involved at the start of treatment to learn about social anxiety and cognitive therapy and at the end of therapy to learn about their child’s relapse prevention plan and their role in supporting their child to stay well. Some parents will bring their child to sessions and will help to ensure that they complete their weekly measures. In some cases, therapists may speak with parents individually to identify and work with parental social beliefs that may interfere with their child’s progress in therapy. As described in Chapter 3, our PPI co-applicant and young people with relevant lived experience also gave feedback on their experiences of treatment, the treatment manual and the reviewed treatment materials to ensure it was appropriate and acceptable for adolescents with SAD.

Social anxiety symptom scales

Liebowitz Social Anxiety Scale for Children and Adolescents: self-report version

The Wilcoxon paired rank-sum test revealed a significant difference in LSAS-CA-SR scores from pre treatment to follow-up, with a large effect size. Scores dropped on average 66.80% over time, ranging from 3% to 100% (Figure 5). Ten participants, 83% of the sample, made a reliable improvement in their LSAS-CA-SR scores. Nine participants made a reliable and clinically significant improvement, based on a pre-treatment to follow-up change of at least 2 SDs from the original mean (a drop of 48.75 points).

FIGURE 5.

Individual patient LSAS-CA-SR scores at the following measurement points: pre assessment, mid-treatment, at the end of weekly sessions and at the follow-up assessment.

Revised Child Anxiety and Depression Scale: social anxiety subscale

RCADS social anxiety T-scores showed a significant and large decrease over the course of treatment. Before treatment, eight patients were on the borderline or in the clinical range based on their age and sex (T-score of > 65), whereas only one patient remained in the clinical range at follow-up (Figure 6).

FIGURE 6.

Individual patient RCADS social anxiety T-scores at the following measurement points: pre assessment, mid-treatment, at the end of weekly sessions and at the follow-up assessment.

Diagnostic profile

Table 6 shows the presence of diagnoses measured using the ADIS-C/P pre treatment and at follow-up for each participant. CSRs for SAD diagnosis at both time points are given in Table 5. CSRs for all other diagnoses are shown in Figure 7. Follow-up diagnostic data were missing for ID 11 and, therefore, they are not included in the following discussion (i.e. N = 11 for below).

FIGURE 7.

The ADIS CSR pre treatment and at follow-up scores. Scores of ≥ 4 indicate a positive diagnosis. a, Follow-up ADIS data missing for ID 11.

At pre treatment, all patients had a diagnosis of SAD. Only two patients had no comorbid diagnoses; GAD was present in eight patients and depression (either MDD or dysthymia) was present in three young people. There were five diagnoses of specific phobia pre treatment across four patients, with one patient diagnosed with two specific phobias. One patient had a diagnosis of post-traumatic stress disorder (PTSD) and one had a diagnosis of panic disorder. (This is detailed in Table 4. )

At follow-up, seven patients (63.64%) had lost their primary diagnosis of SAD. These same seven patients are also those patients who fell below the LSAS-CA-SR clinical cut-off at follow-up. Six patients lost their diagnosis of GAD, and three diagnoses of specific phobia were lost (one patient had two phobias at pre treatment and lost one of these at follow-up).

The number of depressive disorders in the sample increased from three to four by follow-up. Of the four patients who retained their diagnosis of SAD at follow-up, one had lost their diagnosis of depression, two had retained their diagnosis of depression and one had acquired a new diagnosis of depression. One patient lost their diagnosis of SAD, but had become depressed at follow-up.

Revised Child Anxiety and Depression Scale depression scores

There was a large and significant drop in RCADS depression subscale scores over time (Figure 8). For nine patients, depression scores were below the suggested threshold (T < 65) at follow-up. ID 4 continued to show elevated symptoms of depression at follow-up and also developed a new diagnosis of depression over the course of treatment (see ADIS data in Table 6) while losing their SAD diagnosis.

FIGURE 8.

Individual patient RCADS depression T-scores at pre assessment and at the follow-up assessment.

Revised Child Anxiety and Depression Scale generalised anxiety disorder scores

There was a large and significant drop in GAD scores over the course of treatment, with all patients scoring below threshold at follow-up (Figure 9).

FIGURE 9.

Individual patient RCADS GAD T-scores at pre assessment and at the follow-up assessment.

Parent-reported Revised Child Anxiety and Depression Scale

For the group as a whole (n = 11), parent ratings on the social anxiety, depression and GAD subscales of the parent RCADS were initially elevated (see Table 5) and reduced significantly by follow-up. Individual data for RCADS social anxiety subscale T-scores are presented in Figure 10. This indicates that all parents except ID 12 rated their child as making at least some improvement in their social anxiety symptoms.

FIGURE 10.

Parent RCADS social anxiety subscale T-scores pre treatment and at follow-up.

Social participation and satisfaction

The group as a whole showed large and significant improvements in their social participation (Figure 11). There was an improvement at trend level in ratings of social satisfaction for the group as a whole (Figure 12).

FIGURE 11.

Individual patient social participation scores at pre assessment and at the follow-up assessments.

FIGURE 12.

Individual patient social satisfaction scores at pre assessment and at the follow-up assessments.

Concentration in class

The group as a whole showed a small to medium improvement in self-reported classroom concentration from pre treatment to follow-up, although this was non-significant. As shown in Figure 13, four young people showed either no change (ID 10) or a deterioration in their concentration (IDs 4, 11 and 12). Patients ID 10, 11 and 12 are those young people who did not show a clinically significant improvement on the LSAS-CA-SR and, while ID 4 lost their diagnosis of SAD, they developed a new diagnosis of depression during treatment.

FIGURE 13.

Self-reported concentration in class at pre assessment and at the follow-up assessment.

Outcome rating scales

Although no significant improvements were detected on the ORS, a small effect (at trend level) was observed on the overall scale and social scale. The overall and social subscale ratings for each individual at pre treatment and follow-up are shown in Figures 14 and 15.

FIGURE 14.

Individual patient ORS: overall subscale scores at pre assessment and follow-up.

FIGURE 15.

Individual patient ORS: social subscale scores at pre assessment and follow-up.

Psychological process measures

Social Cognitions Questionnaire

Social Cognitions Questionnaire – belief

All patients reported some reduction in ratings of belief in their social cognitions, and the group as a whole showed a large and significant reduction in belief ratings on the SCQ (Figure 17). For all but three patients, these reductions were substantial (belief rating reduced by 88–100%). The same nine patients who showed these large reductions in the SCQ also showed a clinically significant improvement on the LSAS-CA-SR, as indexed by a drop of 48.75 points on the scale.

FIGURE 17.

Individual patient SCQ mean belief scores at pre assessment and at the follow-up assessment.

Social Behaviour Questionnaire

All but three patients reported substantial reductions in their use of safety behaviours at follow-up, as indexed by scores of 0.55 or below on the SBQ (range 0–3) (Figure 18). The same nine patients who showed large reductions in the SBQ also showed a clinically significant improvement on the LSAS-CA-SR, as indexed by a drop of 48.75 points on the scale.

FIGURE 18.

Individual patient SBQ scores at pre assessment at the follow-up assessment.

Social Attitudes Questionnaire

For the group as a whole, there was a large and significant reduction in negative social attitudes (mean SAQ) from pre treatment to follow-up (Figure 19). Only one patient (ID 10) showed a strengthening of their negative social attitudes, and they also retained their SAD diagnosis at follow-up.

FIGURE 19.

Individual patient mean SAQ scores at pre assessment and at the follow-up assessment.

Data completeness

Supervisor-completed economic logs, which included information on time spent by supervisors and therapists in workshops and weekly case supervision practice, had a 100% completion rate. Therapist-completed economic logs, which included time spent in delivering CT-SAD-A to patients and associated activities (e.g. preparation time), had rates of missing values that ranged from 50% to 67% for various treatment sessions across all patients. No data were recorded for any of the treatment sessions throughout the whole treatment programme for 4 out of the 12 patients.

Qualified supervisors’ and therapists’ time and costs

Three supervisors provided training and supervision to therapists during the training phase of the study. Day-long (7 hours) workshop training was usually delivered by two supervisors. Five day-long workshops were conducted during the duration of the study, because new therapists had to be recruited partway through the project. Weekly case supervision was generally led by only one supervisor who was occasionally helped by a second supervisor for part of the session. Sixty-two weeks of active case supervision were reported during the study. The time between case supervision weeks could be longer than a temporal week. Case supervision sessions were intended to be delivered to groups of four therapists at a time but, because new therapists were recruited at different times throughout the programme, multiple supervision sessions were delivered to a less than optimal number of therapists, and, on several occasions, a one-to-one case supervision session had to be offered. The mean number of therapists attending weekly supervision sessions was 2.8 (SD 1.27).

Table 8 shows that, during the whole training phase of the study, supervisors spent overall 4740 minutes (around 79 hours) on preparation and delivery of all of the training workshops, which would cost the NHS £4898. The mean time and cost per workshop were 948 minutes (SD 50.20 minutes) and £980 (SD £51.87), respectively. For the whole case supervision, supervisors spent overall 8621 minutes (around 144 hours) on preparation and delivery of all of the case supervision. As supervisors reported overall preparation and delivery time per week of active supervision (even if more than one supervision session may have occurred in a week), the mean time and cost of qualified supervisor time per supervision week were 139 minutes (SD 71 minutes) and £144 (SD £74), respectively.

Table 9 reports the mean time and cost of supervisor input per therapist attending each workshop and case supervision week. Results are stratified by time used for preparation and time used for delivery. Supervisors devoted on average 278 minutes (SD 157 minutes) (around 4.6 hours) to each therapist during the workshop training phase, which would cost the NHS £287 (SD £162) per therapist. The large cost was due to the long duration of each workshop (7 hours per day) and the relatively small number of therapists attending each workshop (two to six therapists per workshop day). The amount of qualified supervisor time per therapist was, on average, 50 minutes (SD 14 minutes) throughout the duration of the case supervision of the programme. The associated cost to the NHS would be £51.5 (SD £14.6) per therapist.

There were five full-day workshops; the mean number of therapists participating in each workshop was 4.4, the number of weeks of active supervision was 62, and the average number of therapists participating in each supervision week was 2.8.

To have an estimate of the overall cost to the NHS of training therapists to deliver CT-SAD-A, the amount of therapist time spent being trained and the associated cost needed to be estimated. Overall, 9240 minutes (around 154 hours) of therapists’ time was spent on workshop training (five full-day workshops to train a total of eight therapists), which would equate to a total cost to the NHS of £6468. Each therapist spent on average 420 minutes (SD 0 minutes) (7 hours) at each workshop for an NHS cost per workshop attended by a therapist equal to £294 (SD £0).

Table 10 presents descriptive statistics referring to therapists’ time and cost of participating in the weekly case supervision phase of their training. A total of 62 case supervision weeks were recorded, as often weekly case supervision occurred with more than one therapist. On average, each therapist participated in 24 (SD 12) case supervision sessions.

Overall, 12,540 minutes (around 209 hours) of therapists’ time was spent on case supervision sessions, which would equate to a total cost to the NHS of £8778. Each therapist spent in total 1791 minutes (SD 1107 minutes) (around 30 hours) on the whole case supervision sessions, which would equate to a cost to the NHS of £1254 (SD £775) per therapist. Each therapist spent on average 73 minutes (SD 40 minutes) at each case supervision session; the average NHS cost for a therapist to attend a supervision session would equate to £51 (SD £28).

Qualified clinician time and cost per adolescent treated

Tables 11 and 12 summarise the mean qualified therapists’ time per patient for each of the 14 treatment sessions and the two booster sessions, stratified by type of activity associated with each session, as reported by therapists. Data were reported for only half, or less than half, of the patients. Data on the associated costs are reported in Tables 13 and 14.

Based on the available data, the main cost driver across all sessions was the therapists’ face-to-face contact with the young person only, which amounted to a mean time of 81.02 minutes (SD 16.86 minutes) and would cost the NHS £56.71 (SD £11.80) per patient per session. Therapists also spent a considerable amount of time preparing for each treatment session; on average, 39 minutes (SD 21 minutes) per patient per session, which would cost the NHS £28 (SD £15). Therapists’ time spent on administrative tasks amounted on average across all treatment sessions to 33 minutes (SD 18 minutes), which would cost the NHS £22.91 (SD £12) per patient per session. The overall amount of time spent by therapists on each treatment session and associated activities was on average across all sessions equal to 177 minutes (SD 32 minutes), which would cost the NHS £124 (SD £22) per patient per session.

Finally, Table 15 reports the mean qualified clinician time and cost to the NHS of CT-SAD-A per adolescent treated, stratified by type of time use. Missing values in treatment sessions were handled as described in the Methods section, and clinicians’ training costs (workshops and weekly case supervision) were attributed pro-quota to each patient. Each adolescent treated required on average 5279 minutes (around 88 hours) of qualified clinicians’ time and would cost the NHS £4047 (SD £1003).

It has to be noted that, as therapists’ logs were not complete, we did not have any record of potential cancellation of sessions with the young person and, consequently, we could not account for the potential associated costs. To the best of our knowledge, this was not a recurrent event, but it is certainly a limitation of our results. However, on one occasion, one of the supervisors reported that the case supervision session with therapists was cancelled at the last minute because both therapists were unable to attend the supervision session. We did include the time that the supervisor had spent in preparing for that supervision session in our costs.

Finally, although in our analyses we focused on qualified clinician time and cost per adolescent treated, we acknowledge that other costs were incurred during the implementation of the treatment, such as costs of materials like memory sticks, binders, paper for information packs for therapists. All of those items were not accurately recorded in the clinicians’ logs and, therefore, were omitted from the analysis. Although every item of cost is important and should be included in any cost analysis and their omission is a limitation of our work, it is unlikely that those items would have represented key cost drivers.

Varied motives and experiences

Before starting CT-SAD-A, the idea of therapy was framed as potentially difficult and challenging. Young people described a range of expectations – for example, some were sceptical and ‘didn’t really think it was going to work’ (Julia), or felt that it ‘wouldn’t be any different’ (Julia) from previous counselling experience; some expected that they would be ‘sat in a room talking the whole time’ (Jennifer), whereas others thought they were going ‘to talk about er, [their] problems’ and ‘learn some like, er, er, um techniques for them’ (James). One young person acknowledged that the only experience they had of treatment was ‘things on TV . . . and those are quite a distorted image, so [they] had no clue [what to expect]’ (Jade), and another expressed ‘hope’ that the therapy would bring about improvements to their independence and confidence.

In the pre-treatment assessments, young people described their desire to reduce their levels of social anxiety. However, in the research interviews, many of the young people reflected on their motivations for engaging in this treatment or via this context. For example, some young people commented that they felt motivated by being part of a research trial in which they would be helping others, while other young people were motivated by the idea of a more interactive therapy:

I felt good doing it, because I felt like I was helping people.

Jade

Um, yeah, i–it was kind of good to know that it was all going to research, it wasn’t just, like, going towards me or anything, it was kind of going towards like a bigger thing.

James

Instead of just like, you know, saying ‘ahh I think I can get over it’, just actually doing them umm, that umm, yeah and umm that seemed like quite a reasonable idea.

Julia

A challenging, helpful and active experience

The therapy itself was generally represented as challenging but helpful. Most young people were able to identify and reflect on features that were helpful. The pacing was felt to be appropriate, and the repetition, practice and ‘building on’ progress were valued. For example, here, Julia reflects on how the rehearsal of strategies meant that they were subsequently easy to access:

It’s been good, because it was so repetitive in the treatment that I like can, it’s like, something that just comes to me naturally now it’s not, it’s not such a hard thing to do.

Julia

Some therapists had involved parents more actively in some aspects of the therapy, and this was also largely experienced as helpful and positive by the young people who were interviewed. For example, a number of young people reported that their parents would attend parts of sessions, which ‘kind of help[ed], like, in that respect, because it meant my mum could help carry it on with me after’ (Julia), or support them outside of sessions:

She was very involved because she had to be the one to stop doing a lot of things for me.

Jennifer

Using measures to decide where to focus and to track progress

Many of the young people reported that they found the measures difficult and described them as ‘really thick, dense and . . . seem[ed] really, really daunting’ (Jade). Some described them as ‘tedious’ (Julia), and many reported that they took ‘quite a long time’ (Julia) to complete. Nonetheless, for many of the young people, the use of measures during the therapy was experienced as helpful, and some described how the measures ‘kind of just became part of the treatment’ (Jasmine). The measures were seen as helpful in two ways. First, the measures provided a focus for treatment (e.g. choice of a behavioural experiment), as illustrated here by Julia:

It meant that we could focus on specific things that were harder than others and I think that was quite useful because I don’t think–, if–, I don’t think, without the questionnaire, it would have been so obvious the things that needed to be worked on.

Julia

Second, the measures were perceived as helpful, because they allowed young people to see their progress represented visually:

It was quite useful cos you could see, you could compare the different things, what I’d done each week to see what I was progressing in and what I wasn’t.

Jasmine

Identifying active ingredients

In terms of therapeutic mechanisms, it was striking that the young people were consistently able to identify distinct features of the interventions that they could discuss knowledgeably, and evaluate in terms of their utility. This is not always the case in studies of therapeutic experience. Behavioural experiments were generally reported as one of the most useful and important features of the therapy (e.g. ‘I definitely think the ‘training my attention’ and the ‘behavioural experiments’ were, like, key for me’; Julia).

The young people recognised and appreciated the importance of the therapy as an active process of doing, rather than as just a space for talking and reflection. This is concisely illustrated here by Jade:

I would go and interact with people outside, which I didn’t like doing, but it was really, really helpful [pause] because [pause] just talking about it wouldn’t have been enough.

Jade

Note that Jade says, ‘which I didn’t like doing, but it was really, really helpful’. Behavioural experiments were a key component of this activity, and, interestingly, they were also often represented as the most challenging part of the therapy: they were seen as difficult to do but worth doing. We can see how the balance skews towards the positive in Jade’s repetition of ‘really, really’. This was typical of how the young people evaluated their involvement in behavioural experiments:

I hated doing it, I absolutely hated it . . . but that was probably my favourite bit because it did the most for me.

Jennifer

I was so scared to do that as well, but it was nice to know at the end, like, I could do it. So I would say that was helpful, it was difficult at the time, but it was necessary I think.

Jennifer

I just didn’t like doing the things because I felt uncomfortable, but I see the, the whole point that we did it was to challenge the way I thought, and it did.

Jade

The complex response here underlines the importance of including qualitative methods in studies of acceptability and mechanism. Had our interviews been responding to a rating scale here, we might have been detecting the affective content of the appraisal (‘I hate it’) and missing out on the evaluative reflection, which recognises the benefits (‘it was my favourite bit because it did the most for me’).

Other memorable features were the attention-training exercise, and the self-focused attention and safety behaviours experiential exercise (two conversations with different instructions for focus of attention and safety behaviours) and related video feedback. Young people were less clear about how and why these components had been helpful, in comparison with the strong endorsements around behavioural experiments and measures. For example, the experience of the two conversations appeared to be mixed. Some young people seemed to have engaged with the learning behind the experiment:

I was expecting there to be a big difference with the two videos, like umm you know look really awkward in the first one and there wasn’t that much of a difference, so it made me realise I don’t look as anxious to other people as I may think in my head.

Jennifer

Others seemed less clear about the learning behind the exercise:

I recognised the safety behaviours, it was easier to try and not do them and it was good to take them out and focus on them.

Jasmine

Learning from and with the therapist

The role of the therapist in establishing a collaborative relationship around these components seemed to be important to the young people. This is generally evident in the language used to report on these activities, which tended to highlight the collective voice:

We looked at my umm, behaviours and stuff that linked to it and then the things that I found the most umm, like, scary to do and then, after we went through them, we decided on things we could do that could like, get over them, and then we cos we were it’s quite easy to go to like shops and cafes and stuff and we just gradually built it up to things that I found the worst.

Julia

We’d figure out umm, what we could do umm, and then we can go and ask someone to if they know what the time is in the street and then we’d go and test it out umm, and then go back and reflect on it and see how it actually was how I felt.

Jennifer

It was also illustrated by examples of therapist modelling and engaging in activities:

[Therapist] would stutter, er, then we’d see their reaction, but erm, yeah, he, he showed me that there wasn’t, people didn’t really care, to be honest with you if you stuttered.

James

One young person expressed concerns about being able to apply what she had learned during therapy. She sometimes struggled to see the relevance of the activities to her wider experiences, for example, in one behavioural experiment she ‘had to go around and ask people for the time which [she didn’t] think [she’d] ever need to do again’. This may have been a consequence of not having fully engaged with the model underlying the intervention. As a result, this young person struggled to generalise the things she’d learned in these activities to situations that she found herself in outside treatment:

It was quite hard, I think. [Pause] because [pause] I do things there [pause] but I–, I had to know how to adapt it [pause] which was hard, yeah.

Jade

However, this young person also experienced depression, and aspects of her problems with low mood appeared to interfere with the focus on social anxiety. She was advised to apply things she had worked on in the sessions to her experience with mood, but she struggled to do this:

I did ask during the treatment, um, do you know how ki–, how I could get help for depression and they said oh, and [Therapist] said, um, ‘You can use the same techniques’ but I didn’t really know how.

Jade

For her, it ‘felt like the ending [of the treatment] was very very quick’ and that she ‘didn’t get much closure’ (Jade). For example, she described weekly sessions, followed by one 2-week gap and a final session after a further month (close to that described in the protocol), and felt that these sessions ‘tapered off really quickly’. There was a general sense that the young person had been left slightly ‘behind’ the pace of the therapy or outside the understanding of the therapist.

The other young people were generally confident that they could identify what they learned and apply it. The importance of practice (outside the sessions) seemed to underline this for most of the young people. For example, one young person noted that ‘remember[ing] all of the things [they’d] learned and then just keep going over it and over it’ helped after the sessions had ended, as ‘then it didn’t seem like such a difficult thing not having a session every week.’ (Julia). Some young people mentioned that the ‘experiment sheets’ were really helpful for this:

Yeah I got given like experiment sheets to fill out and do the same things in between like say on my lunch break, umm, go and buy something myself from the shops cos I would never do anything like that umm and then I’d have to fill out these sheets and then bring them back to my next session.

Jennifer

Of course, we might reasonably expect the young people to vary in terms of their preferences and motives for engaging in different aspects of the treatment, as they do here. The strong preferential consensus about the active focus of treatment is all the more striking against the background of variation with regard to other aspects of the experience. For the most part, the young people were also very positive about the consequences. Some reflected on the ‘recalibration’ of their worries:

Some really big things I still find quite daunting. I don’t know if I’ll be able to do that, but I think, I kind of have a lot of the tools to kind of try and build up my confidence and stuff, so I think that will be useful.

Jasmine

Young people were often able to identify areas of significant functional progress that were important to them, too. For example, here, James describes several improvements since engaging in the therapy:

I used to go to the support area, [. . .] for about 3 hours a day every school day. I haven’t been in about a year . . . I’d never put my hand up to answer questions, I wouldn’t really go to lessons that much, er, but now I kinda answer questions all the time and talk to people and all that. [. . .] Performing was a big problem as well, but I, I do music now.

James

To summarise, young people appeared to find some aspects of the intervention challenging, but they reflected on the benefits (especially the functional improvements) outstripping the costs. They found the approach taken by their therapists to be open and non-judgemental, and the therapeutic process to be active. They identified the use of measures and behavioural experiments as being particularly helpful.

Keeping an open mind

The parents often shared ‘diffuse’ expectations about the therapy. They were unsure about what to expect, but they described their initial thoughts as hopeful or being ‘quite interested to see how it would [. . .] benefit’ their child. Experience of the problem and/or other interventions was framed as a ‘why not give it a try?’ opportunity by some parents:

No expectations, just; if it works, great, if it doesn’t, then, you know, at least we’re in the system and, um, we can get some help.

Pamela

It didn’t work so well with [the young person], but every child’s different, every child’s different, so yeah, give it a go, you’ve got nothing to lose.

Patricia

However, others were ‘really excited to be part of the study’, as they felt that there would be ‘a lot more audit, maybe, on [. . .] how the sessions were going’ (Phoebe) in comparison with experiences of standard services, prior to taking part in the study.

Noticing functional improvements

Parents were generally very positive about the impact of the intervention in terms of what the young person was now able to do. Some reported that it was ‘really helpful [. . .] very accommodating and [they] wish[ed] it was more available’ (Polly), or that the improvements that their child had made were ‘leaps and bounds very positive’ (Pippa). Parents noticed improvements in the young persons’ activities – particularly their engagement and involvement with friends, their autonomy and independence in communication, and their confidence in initiating activities outside the house. For example, one young person who had previously found it difficult to stay overnight at a youth event had, since the end of treatment, stayed at the event for an entire week and had further been selected to attend a 3-week event abroad:

He’d always liked the idea of going away for a weekend [. . .] but could never stay overnight [. . .] that was a big breakthrough for us, with him staying overnight [at event] [and now he’s] off [overseas] for three weeks next July.

Paula

These were incremental changes, which one parent described as ‘a very gradual process of, sort of, confidence’ (Pamela), and could not be pinpointed to a specific time in treatment. However, by the end of treatment, these improvements stood out as markedly different from the pre-treatment phase:

I don’t even know how to quantify how much better she is.

Polly

Parents reflected on the psychological changes that appeared to underpin these functional improvements. For example, one parent described their child’s ability to overcome difficult situations by shifting her focus of attention and drawing on learning from previous experiences:

When she went in for her theory test, you know, she was like, um, like she said ‘I took a deep breath, thought; right, I can do this, nothing is going to happen, it’s going to be fine’ and, you know, it’s those sort of things, like, that she, um, looks around her and her environment and takes it all in and knows that it’s, it’s OK.

Pippa

Appreciating the opportunity to be involved and informed

Parents appreciated the flexibility of the therapists. This was reflected in the flexibility of the session length, the appointment times, the information about the young person’s progress and the opportunity for involvement in the therapy. This last point was generally to do with understanding the therapy so that they could support and extend the young person’s progress outside the sessions. Some parents had a positive experience of feeling better equipped to support the young person outside sessions:

Lots of things that [. . .] she would tell me, I would um, the ideas of the stuff that I would try to, um, every time we went out, I would push her a little bit more to do little, little things and anything to help her along the way.

Pippa

Whereas, others felt more like they were ‘on the back burner’ and found it ‘a bit tough, not knowing what’s going on and just hoping that she was OK’. For example, Patricia felt less able to provide input between sessions because she was unaware of what was happening during sessions:

I think it would have been easier if maybe I kinda sat in on the first ones so I know what she was going through and then, if she wanted to talk about how it went, then I could say, you know, I could have had input because I knew, you know, that I had something to, to, yeah, base it on.

Patricia

There were varying degrees of involvement. For example, some parents felt that it was a ‘case of just keeping [them] in the loop and giving [them] a bit of evaluation of what is going on’, while others felt well informed but appreciated that the therapist was best placed to lead this:

We would have a little meeting for, sort of, 15–20 minutes and the things that [the young person] was willing to share, um, I was told about . . . I think, obviously [therapist] must have encouraged or made it part of the process to, to share those feelings with me, which of course is helpful.

Polly

Families varied in the extent to which they mobilised people around the young person. For example, Polly commented on having ‘lots of help’ throughout the therapy process and reported that she’d ‘talked to friends about it’ who had ‘listened, sympathetically’ (Polly). In contrast, Pamela chose not to involve others, reporting that it was ‘not the sort of thing [she] would tell [her] friends’, and that she ‘[hadn’t] really told [her] mum and dad the extent of it either’, because she thought ‘they’d be upset about it’, and the family ‘didn’t tell [the young person’s] little sister about it’, because they ‘didn’t feel she’d understand’.

Reflecting on relationships, roles and needs

Parents generally appreciated that the therapist was able to support the young person in ways that were not easily available to parents; they acknowledged that ‘it’s different when it comes from a parent somehow’ (Phoebe), but they wanted to be able to support the young person in ways that were consistent with what the young person was learning. There was an appetite for parental training, to provide this knowledge and to build confidence. For example, some parents found it ‘difficult to know what you should or shouldn’t be doing at home to help her and, um, or maybe what you’re doing that isn’t helping . . .’ (Pamela). Sometimes the therapist was appreciated, because they provided a new or different route for communicating with the young person.

Parents reflected on changes in their relationship with the young person. The time travelling to and from therapy was mentioned as a generally positive and shared experience by parents:

We would have that little bit of time in the car, just me and her, on the way, we’d chat about all sorts of stuff and I do, as [the young person] is a teenager, I don’t really get that time with her anymore, so actually it was quite nice, the sessions were quite nice in that respect . . .

Pamela

The sense that the problem was being addressed also provided relief from stress to the parents in some cases:

She’s not hitting rock bottom anymore . . . it does take the pressure off.

Patricia

However, others felt that they needed their own support:

I didn’t feel very supported as a parent, but I don’t know if that’s maybe something that I should have sought help for separately.

Pamela

Some parents also reflected on their own relationship with the therapist. In most cases, this was in the context of a contrast with the young people’s relationships with their therapist and the relative importance of these different relationships. For example, one parent reported that ‘[I]t’s not about me, it’s about him and, actually, he needs to be completely comfortable, um, with [the therapist] in order to maximise the benefits’ (Paula). Another mentioned that they were ‘solely focused on [the young person] and [they] didn’t really have the same relationship with [therapist] that she did’. (Pamela). However, another parent placed more importance on her relationship with the therapist and described the importance of the therapist giving the parent her own space to talk about her own concerns, reporting that ‘it kind of helped [her] to take some of the load off’ (Patricia).

The age of the young people’s siblings was varied, and siblings were not always involved in or informed about the problem. Some siblings were actively involved in supporting the young people; one parent speculated that ‘because [the young person’s sister]’s sort of observed how poorly he has been, she would just obviously recognise anything that would help him would be a good thing’ (Paula), and some siblings were reported to have found the young person’s reliance on their support difficult. Siblings sometimes had to ‘fill in the gaps’ in situations in which the young person’s social anxiety prevented them from doing something seemingly simple for themselves, such as asking for a table in a restaurant or going to the counter in a shop:

It’s been difficult throughout for her sister to understand . . . [the young person] couldn’t do it and her sister found that extremely frustrating.

Phoebe

Reflecting on the context of help-seeking

Parents did not express very strong views about the CAMHS context of the therapy. Parents did provide more discussion of this than the young people, but this was largely based on not knowing what to expect. One parent said that ‘not having dealt with any mental health service before . . . it was it’s all new and a bit scary’. (Pamela). The difficulty of accessing services was also a point of focus in some parents’ interviews. One parent described the referral process to CAMHS as ‘really lengthy’, and another felt that, had they not taken part in the trial, they ‘would have had to wait another year and [mum did not] know what would have happened’ (Polly). Others reported that their difficulty in accessing CAMHS lay in either themselves, or the young person’s school or college not knowing where to go for help:

I tried to get through to them at college when she was starting her apprenticeship, but I wasn’t getting much joy there.

Pippa

A number of the young people in the trial had a comorbid diagnosis of depression or experienced subclinical low mood. For some parents, the comorbid depression represented a barrier to engaging in the treatment:

Probably her underlying depression wasn’t you know, it wasn’t being treated at that time and I think that restricted her access to the CBT.

Phoebe

Others felt that, although the focus on social anxiety was helpful, there was some low mood left at the end of the treatment that was not then addressed:

I think, although it’s fixed the social anxiety, or helped with that, it hasn’t helped with her low mood . . .

Pamela

However, low mood was not a barrier for all of the young people who had mood problems at the start of therapy. For example, although one young person ‘was quite worried about it and thought, you know, “how’s this going to help me?”, because her mood was quite low as well’ (Pippa), her parent reported that this worry was not fulfilled, as she thought ‘it went very well . . . and, now, the end result, it was so worth it’ (Pippa).

Identifying active ingredients

Parents were able to identify features of the intervention that had struck them as important. These were generally framed in terms of their perceived helpfulness. As with the young people, the emphasis was often placed on the active components of treatment:

It’s very difficult to sit in a room for an hour and talk about yourself, I think, you know, to be able to go out and do those physical challenges, um, is probably a bit easier.

Phoebe

A number of parents commented on the fact that this approach was a better fit for the young person:

He felt that it was more around, it was more experiential and it was more, um, er, of a pragmatic, practical, um, treatment programme, rather than sitting and just talking about what he knew were issues . . . so, right from the outset, it felt different and, actually, never ever minded going.

Paula

Parents were aware that young people found some of the active aspects of treatment difficult:

[Therapist] took her out and did practical things with her, which I thought was very good, much to [the young person’s], didn’t like it, but it it helped her, you know. She probably thought that was the worst things for her to do, but actually doing it, it proved to her that it worked.

Pippa

Others emphasised the importance of having someone to talk to in a non-judgemental environment:

I think just talking to someone, as I said, regardless really of what the therapy is, I think that she could, well I, I can’t discount [the treatment] obviously, but I, I honestly think, just the process of talking to somebody in a non-judgemental environment . . . was invaluable.

Polly

Accepting the need for measures

The parents sometimes found their own measures difficult to complete (e.g. Polly) because of not having the information they needed to answer some of the questions about their child’s feelings. For example:

I would read them and think ‘how am I supposed to know the answer to any of this?’. So it’s all guess work and that felt, felt like, a bit like cheating.

Polly

Especially, like, as a parent, whereas she might not have told me a lot of stuff, I found a lot of it quite difficult to answer because I just didn’t know.

Pamela

However, they accepted them as important, describing that they felt like ‘if it helps with the research, it’s got to be done’ (Pamela). Some parents found the measures to be unproblematic for the young people to fill out. For example, one parent reported that, because it was something that could be done in the ‘home environment’, it ‘didn’t involve much challenge, so that wasn’t a problem for [the young person]’ (Phoebe). Others commented on how repetitive they were:

We were filling in the same sort of forms over and over and over, which was explained and, you know, understandable, but I mean, it did seem to be fairly repetitive.

Polly

Others noted that the young people’s questionnaires were ‘helpful’, because ‘you actually get to see it, of how she was feeling at that time and whether her mood was low or high’ (Patricia), even if they sometimes also commented that the young people found them ‘very tedious’ or (in one case; Patricia) overwhelming to complete. Some parents commented that an electronic means of capturing the data would have been preferable for them and/or their children, as this would have been more convenient for the young people to fill in and would have taken the pressure off busy family life, since they would not have had to remember to take them to sessions. For example:

I hadn’t already got them in the car, or she’s forgotten to bring them with her, I can’t stop, it would make me late . . . but you could e-mail them if you’ve still got your phone with you, which 9 times out of 10, you’re gonna have.

Patricia

Measures were accepted as integral to participating in research, with one parent reporting that, ‘with that being part of the trial, [the young person] could, you know, that to him was, made logical sense that every so often you’d have to evaluate what he was doing’ (Paula).

Parents appeared to find participation in the research acceptable. For some, the research was a mechanism for receiving an intervention that otherwise might have been unavailable or that would have required a long wait:

We probably saw it as a way that we might get some help quicker.

Pamela

One of the parents was keen on the additional monitoring (of progress) and transparency (about progress) that research involves, compared with treatment as usual:

Prior to that, we hadn’t really felt that there’d been, certainly not, not, er, fed back to us that there hadn–, didn’t seem to have been that much reflection and, well – ‘are we actually progressing and has there been any developmental progress?’, those kinds of things we thought would be, um, a lot more part of the, the core of the study, really, so we were quite excited.

Phoebe

The motivations of parents also included the benefit of helping others (e.g. Paula, Pamela), which was important when previous experiences had been unhelpful. For example, one parent reported that, although their main motivation was that they ‘just wanted someone to help’ their child, ‘if it helps other people in the, in the long term, then that’s great’ (Pamela). Another parent reported that their child was initially reluctant to access treatment for their difficulties, stating ‘I don’t need to, I’m fine’, but that they were able to ‘discuss it with him around it being a research trial’ and were able to ‘bag it as something different, um, and he was more than happy to do that’ (Paula). Research was also framed as more inclusive than treatment as usual, with one parent explaining that ‘it possibly gave me an avenue to contribute more than treatment, um, which I wouldn’t normally, or I hadn’t previously been asked from my perspective what I thought, um, how I thought [the young person] was doing.’ (Phoebe).

To summarise, parents were aware that young people found some aspects of the intervention challenging, but they noticed and valued the benefits (especially the functional improvements). They found the approach taken by their therapists to be open and inclusive, and they noticed and appreciated that the therapeutic process was an active one. They accepted the need for measures. They reflected on some of the relational impacts of treatment, and some felt that they would have liked to have received support for themselves as well.

Engaging and expert training

On the basis of their interviews, therapists generally appeared to find the training helpful. The therapists were very positive about the detail, format, focus and utility of the training (‘I think they were all great, I think there wasn’t one bad bit’; Caroline). The video clips illustrating particular treatment procedures were universally seen as ‘really, really useful’ (Carol).

The style of the training workshops was perceived to be very interactive, and therapists appreciated that the training was delivered by people who were acknowledged as experts in the field (e.g. ‘they are the bee’s knees’; Christopher). The appreciation of the trainers’ expertise and the interactive style of training was consistent. For example, Conner described how an advantage of ‘[B]eing trained by the person who, kind of, originated the protocol [was] that there was a much, kind of, closer knowledge of it’ (Conner). He went on to describe his appreciation of the blended teaching style, a point also made by Caroline:

Good mix of kind of didactic teaching and thinking together, some role plays, some getting out and doing behavioural experiments, experiencing them yourself, it was a really good mix I think.

Caroline

Challenging but supportive supervision

Therapists reflected on the ways in which supervision had been provided and how they had drawn on it. The use of supervision to support learning about and subsequently delivery of the treatment was largely positive. For example, Charlotte appreciated her supervisors’ ‘insightful comments’, and Carol reflected on how in supervision the ‘[A]dvice that you were given was massively helpful, so you really felt that you were developing your skills’.

Some aspects of this form of supervision were framed as ‘different’ from their usual or previous experiences of supervision. For example, focusing on therapy techniques in depth and using measures and videos to inform the session were indicative of distinctive attention to the treatment of a case (rather than as a forum for more general discussion of clinical issues). Generally, these differences were experienced as positive and constructive by our therapists, who noticed a shift towards ‘[F]ocusing very specifically on techniques and actual words so the minutiae . . .’ (Caroline). The videos, in particular, were an important learning mechanism for our therapists:

[Using videos is] much more powerful when you actually see the act– part of that session.

Christopher

We would watch videos in supervision, which was helpful, and then the feedback that came back was great, umm, going through the questionnaires was great. Yeah, I mean supervision was great.

Caroline

Supervision was thus framed as part of the wider learning opportunity provided by participation in the research and as being helpful in skill development and the growth of competence and confidence. This was one aspect of participation in the research that was attractive to the therapists:

I was kind of quite keen to umm, you know, see if there were things I could learn that might improve my practice.

Claire

Helps your professional development, checks that you’re doing the right thing.

Camilla

Therapists reflected that they had been motivated to participate in the research because of this opportunity to improve their skills. Learning from supervision was clearly understood as a component of this opportunity, as it provided clinical insights and informed the next steps in treatment planning. Here, Caroline and Claire both reflect on situations in which supervisory discussions helped them to plan their next sessions:

I guess I would always be keen for feedback on [when] I didn’t think I did that very well, how could I have changed that, how could I have done it, what would you have done in that situation, that kind of stuff. And then help planning behavioural experiments and umm, ones that would work practically, umm and then thinking about endings.

Caroline

I think supervision again was really, umm, necessary to help, ummhmm, you think about how you were going to umm structure the session and, and, and do the session.

Claire

Thus, we can see that supervision was framed partly as a mechanism for identifying what could have been done differently (areas for improvement) and partly as a mechanism for identifying what should be done next (treatment planning). Supervision in the project was often delivered with peers, rather than in a 1 : 1 format. Therapists generally liked the opportunity to learn from, and with, peers:

When it worked [with] the three of us, it worked brilliantly, and I preferred group supervision because of that richness.

Caroline

I think it’s useful to hear other people and how that is really, really key, especially if you’re struggling to do it all as well as you’d like to, you’re running out of time and you hear that they’re also doing that.

Camilla

Although therapists valued the ‘richness’ of learning alongside others and the benefits that came from their hearing about perspectives, some suggested that larger groups might have been preferable. Groups potentially offer the possibility of not always being in the spotlight, but that was not really provided in these smaller configurations. Charlotte reflected that:

It would have been nice if there was a couple more people, because it felt really intense with just two of us doing it.

Charlotte

However, one participant also felt that group supervision did not allow enough time to discuss their cases:

I would guess that I was just worried that I’d have enough time to discuss mine as well, but it was useful because you’re also hearing that somebody else is finding it difficult to fit it all in and practicalities of it as well.

Camilla

Thus, small groups would appear to have been a ‘best-fit’ compromise, striking a balance between the different preferences of the therapists. Some supervisees had not been able to meet their supervisor in person, and they felt that this would have been helpful: ‘it’s not the same as face to face to be honest’ (Christopher); ‘from a supervisee perspective and feeling, umm, kind of comfortable sharing your nightmare moments on video, it’s nice to have met somebody face to face’ (Caroline).

Less positive features of people’s experiences of supervision were generally related to one of two features. First, there were some early anxieties when they anticipated being on the receiving end of critical judgements about their competence. For example:

It was a bit nerve wracking and anxiety provoking when we first started . . . I thought supervision was done in a really, non-threatening way and I think, I think effort was put into that and I think it was appreciated.

Carol

I don’t think it made me seem like a particularly competent therapist at all.

Charlotte

As Charlotte’s quotation implies, these anxieties were not confined to the anticipation of scrutiny. Therapists also expressed some worries about the high standards that they wished to be able to meet and that they felt they would be measured against during supervision:

I found that quite difficult if I and, and that, that’s probably why one of the things I found it really difficult to do this and feel like I was doing it well which kind of like disappointed me and I always felt like ooo, I’m not doing this well.

Camilla

You’ve still got to deliver the video and stuff [yeah] and I think they put a lot of pressure on you to, to get it right.

Christopher

Second, therapists struggled with practical issues associated with access to supervision. This involved freeing up time, finding the time to prepare for supervision and making the technology work (‘I felt I needed to get this on camera’; Christopher). Freeing up time, and then protecting and using that time as planned, was a recurrent concern:

If I did particularly have a busy day if I had to split, you know if I’d had to slip something else in or I’d had to see like another family urgently or something umm and then it was on the back of the supervision session that was quite difficult.

Claire

[I needed to] have the questionnaires handed in, have the video uploaded, etc., all kinds of– and its weekly and it’s quite– and when you’re quite busy it’s hard to get it all ready.

Camilla

Issues with technology often compounded the sense of urgency and pressure that are captured in the accounts of Claire and Camilla above. Technological barriers included the ease and reliability of hardware and software, and the compatibility with people’s location and local systems:

It’s the technology, but, kind of, Skype was unreliable and that just made it kind of stressful, cos, when you’re kind of going into supervision and you got to spend 10 minutes trying to figure out how to actually get a clear line.

Conner

Every now and again where it would click off or something like that – yeah it was a pain yeah.

Christopher

These barriers were not insignificant: therapists expressed considerable frustration about technical problems and gave specific examples of the pressures on their time, such as ‘staying late trying to finish it all off’ (Claire) and arranging supervision on a non-work day (Caroline).

A useful and well-used manual

The manual (and training materials) were also appraised very positively:

I liked the way it was structured umm, and umm, having the manual there and everything so you knew exactly what you were doing.

Charlotte

The manual was really, obviously a brilliant resource.

Carol

Therapists used the materials in different ways. Some saw them as providing a grounding (‘I would have to go back to the manual if I was doing it again’; Camilla), and others saw them as a more integral part of growing their competence while delivering the intervention (‘I was constantly referring back to it’; Caroline). Alongside this, the use of video materials within the package was seen as particularly helpful. For example, Claire and Christopher both described how they used the videos to prepare for specific sessions, and how they had found this so useful that they hoped to be able to continue to incorporate the use of video materials into their future supervision.

There were a range of suggestions about additional materials that could be added to further enhance the resources. These included providing some form of checklist to help prepare for supervision (therapists felt that there was a lot to remember and bring) and including, in the training workshops, training in the use of all the equipment and software needed for recording and uploading sessions and accessing supervision. One therapist also suggested that it would be useful to have videos to show to the young people.

Developing competence

Therapists were confident that they understood that there was a ‘right way’ to deliver this intervention, but they were less confident that the work they were doing was always consistent with that. Some reported or described ways in which they experienced anxiety or pressure about meeting expectations. These examples were discussed in the context of therapists’ uncertainties about the degree of flexibility that was available to them. For example:

You kind of have to follow a very strict session pattern and it’s quite like clear instructions for each session.

Charlotte

I understand the need to get the research and to and to keep very purest in the research so that you can then perhaps go on and adapt some of the models.

Caroline

In applying their training, therapists appreciated the opportunity to focus on something specific (while framing this as a ‘luxury’ – ‘I think it was good, it felt like a luxury, actually’; Caroline) while also having the opportunity to develop their skills in ‘doing one thing really well.’ For example:

I quite liked it actually. I quite liked that you had a focus. Umm, and that was what you were working on and that you almost kind of didn’t get too distracted by anything else going on.

Claire

You’re just umm, doing social anxiety and you’re doing it slightly different, you’re getting umm, you’re using the formulation in a much more prominent way, right from the start.

Camilla

They looked forward to being able to take their new skills into their next roles, but, as we will see in the next section, they also worried about whether or not the flexibility required by ‘typical CAMHS’ work was at odds with doing so. The sense of developing both specific and transferable skills was common; however:

I think it has changed my practice a lot umm, not just with social anxiety, but I think with other treatments thinking about fidelity to the model umm behavioural experiments and how to develop a model umm, the attention training, the video feedback I think umm, not only in social anxiety cases where I feel a lot more confident and skilled in helping young people.

Claire

Identifying active ingredients

Therapists were able to identify features of the intervention that were particularly salient for their clinical work. These were generally framed in terms of helpfulness, but some features seemed to resonate more strongly than others. As with young people, behavioural experiments were singled out as a particularly important part of treatment. For example, they were ‘probably the most helpful’ aspect of the intervention (Camilla), ‘quite transformative’ (Conner) and ‘obviously a completely key part of it [that] the young people found [. . .] really helpful and were then able to go away and then put it into practice’ (Carol).

The requirement to ‘get’ out of the therapy room was generally incorporated well into the treatment sessions, even though therapists reported some practical barriers to this as ‘one of the biggest challenges’ of the trial (Claire), in terms of limitations of location and time to organise and complete the session within the session length. The benefits of the behavioural experiments were represented in terms of them being ‘more active’ than the therapists’ usual ways of working:

I was probably much more active than the CBT I was using before, I was probably much more passive [how do you mean?] Umm so right from the beginning you’re adding behavioural experiments [oh OK yeah] where I probably wouldn’t have done that before.

Claire

Another important feature was video feedback, which was described as ‘a very powerful part of the treatment’ (Claire), helping to ‘bring [. . .] alive the things we were talking about so that they could see it, rather than, just sit there and describe it’ (Conner).

Attention training was framed more ambiguously – therapists felt that it was difficult to implement and that the benefits were less tangible than for some of the other components. It was not ‘as helpful as some of the other techniques’ (Caroline), and therapists found it ‘hard to gauge how much a young person actually takes that on board’ (Conner). It could be difficult to implement too (Charlotte). One therapist did report more positively about attention training:

I always wondered how they were going to respond to this. Umm, just because it’s something that seems really different from the previous sessions and it sort of slowed, the pace has slowed down. Umm, but actually everyone seemed to engage well with it.

Carol

Affinity with the model

Some therapists appeared to endorse the model more confidently and consistently than others:

It is a great model, I love it, I love it from a theoretical and technical point of view, erm, I love its application and how much success you can get with it.

Conner

So, I would have been using Clark’s model anyway – social anxiety, but it was the, it was me applying it in the way that I think it was meant to be applied.

Carol

For others, it was one of the attractions of joining the trial, to be:

. . . trained in a model for social anxiety for young people. Umm, and then obviously being one of the therapists delivering the model.

Caroline

Some of this is reflected in variations in what therapists say about their confidence in the model, but much of it is illustrated more indirectly, through the way in which people talked about the model. For example, one therapist described the research as an opportunity to ‘tighten up’ (Caroline) on perceived inconsistencies in their CBT practice; another stated that ‘I kind of didn’t always really draw out the cognitive element of the learning enough. I think that was what supervision helped’ (Conner), and thus saw themselves as moving towards increasing consistency with the model:

[Developing] more of a sense of competence around was, of the cognitively driven element of that and targeting [pause] beliefs with behavioural experiments and selling that way of working to the young person.

Conner

By contrast, another therapist described sharing the young people’s doubts about engaging in some aspects of the activities or described times when they quickly abandoned a particular strategy because it did not appear to be working. Others expressed concerns about their grasp of some of the components (e.g. attention training, as we have seen). Some of these worries resurfaced in the desire for further confirmation that they were ‘doing it right’ or in requests for considerably more flexibility around complex cases: ‘the main thing is that it has to be a lot more flexible working with children’ (Charlotte).

Worrying about the number of measures

Concerns about the number of measures were related to both the intervention and the research. It was not always clear to therapists which measures were integral to the intervention and which were specific to its evaluation. For example, Claire described the ‘sheer number’ of measures as ‘overwhelming’ at the start. Here, Christopher describes his own initial concerns:

Oh my God this is what we’re gonna have to do every case, every client which is not true, but I don’t know if that was made explicit.

Christopher

Therapists also tended to frame their worries about the measures in terms of their perceptions of the young people’s experiences of completing the measures; they worried that the young people would find the measures boring or not helpful. Camilla, for example, felt that her clients were ‘a bit resistant to completing them’, because they found them to be ‘quite a chore’. Similarly, Carol felt that the young people found the measures to be ‘a bit of a pain.’ As we have seen, these concerns were not shared with us in the interviews with the young people.

There were also therapist concerns about the workload associated with managing the data, for example uploading the measures:

In real sort of you know day-to-day work, you haven’t got the capacity, no, that you can do the uploading and the interpreting and it’s err you know and if you’re doing four, five, six people a day you–you’re gonna struggle with that.

Christopher

Some measures were singled out as being particularly helpful in treatment. Most therapists preferred the anxiety-specific measures, which ‘felt much more relevant’ (Claire). The weekly measure of social cognitions (SCQ) was agreed as being one of the most useful, along with the less frequently used social behaviours measure (SBQ). The LSAS-CA-SR was talked about in terms of its use in treatment:

. . . kind of [to] do a comparison from week to week of what had changed and we’d pick things up.

Caroline

Some therapists did reflect on how they would make more use of the measures in their future work because of how useful they had been (e.g. Claire); others felt that the burden of including the measures was not acceptable to them because of the additional administrative load. It was evident that, for most of the therapists, the use of measures was one of the strongest distinctions from ‘normal working’.

In summary, the therapists were very positive about the training and the model. They found the process of developing competence through delivery and supervision challenging, but also constructive, acceptable and achievable. They framed the therapy as an active form of intervention and singled out behavioural experiments as a key component. Their confidence in other components of the therapy was more varied. They expressed concerns about the volume of measures involved and about the viability of delivering the therapy as part of routine CAMHS work. They identified features that they would incorporate into their future work, including the use of measures within treatment and the use of video in supervision.

Worrying about releasing staff time

Despite their support, they all expressed some concerns about being able to implement the intervention and research in the current CAMHS context (‘the reality was very, very tricky’; Marian). These concerns were generally framed in terms of the perceived pressure on staff, and specifically, the structural barriers to freeing up their time:

I did think it was going to put the staff members under pressure, if anyone piped up and said yes please, I’d like to be involved.

Margaret

There’s no way we could free them up for more than that time in the team, because they already had existing caseloads.

Monica

It was clear that some of these concerns pre-dated the managers’ agreement to be involved in the trial. The focus of their initial concerns was largely about the time needed by the therapists and the impact of protecting time for a specific client group (‘There is always a waiting list for CBT’; Margaret). At the outset, this took the form of uncertainties about what was involved and about what to expect. It was suggested that more explicit and precise information about the time needed at the outset would have been helpful. It was difficult for managers and therapists to anticipate what it is like to participate in research, and they emphasised the need for realistic information. For example:

[It’s important to be] really explicit up front because I suppose, we’ve learned from IAPT [Improving Access to Psychological Therapies] training, for example, that it’s often the amount of time people say is needed bears no resemblance to reality.

Monica

I don’t think it was ever set down clearly how much time the trial was supposed to take so my understanding is that was supposed to take half a day a week, but I think that wasn’t the same understanding as the people who were running the trial or the people who were involved in the trial who thought that they should just carve out as much time as it needs.

Marian

However, the managers’ worries about time appeared to expand as the process went on. This coloured the way in which they talked about every aspect of the project: the training phase (‘Oh my God this is much bigger than I ever anticipated’; Margaret), the therapists’ use of supervision, the research-specific aspects and the delivery of the therapy itself.

Freeing up staff to deliver the therapy and receive training and supervision was seen as a challenge, even when time was allocated for this (‘They had time allotted in their job plans for the trial and they were excited about the trial’; Marian). It was not always clear whether it was the managers or the therapists themselves who were responsible for negotiating (and working to) realistic job plans:

[Therapists should] make sure it’s actually job planned in before they embark on it, not after when they realise ‘oh my God I’ve, it’s a, I’m not able to do the job and the trial at the same time you know it’s too much’.

Margaret

I was really keen to umm, kind of, negotiate for therapists, a realistic amount of time to do it] in their job plans.

Monica

Some managers were more concerned than others about their ability to meet the requirements of the research (e.g. one felt ‘massively relieved’ when they heard the trial was closing). Concerns by this point had expanded to include the identification of appropriate cases, the impact of the work on therapists, the secondary impact on waiting lists and managers’ perceived lack of acceptability of the intervention to young people. For example, one manager expressed doubts about whether or not there were young people in CAMHS who were ‘suitable and motivated and ready for a very, very kind of disorder-specific intervention’ (Monica). Another expressed concerns about the acceptability of the measures for young people, stating that ‘it actually had an adverse effect on the child’s anxiety because of all the measures that were needing to be done’ (Margaret). The context and origins of these concerns were unclear.

Struggling to identify suitable cases

The identification of cases was perceived to be problematic, because (much as above, with the therapists), the availability of suitable cases was felt to be limited in Tier 3 CAMHS. For example, Monica described how it was ‘quite tricky’ to find cases that matched the study requirements. As a consequence, managers expressed concerns about ‘less serious’ cases ‘leapfrogging’ the waiting list. This was framed as an ethical issue:

It feels wrong, doesn’t it, if you’ve got these people phoning up and you’re saying I’m really sorry you’re waiting and they’re desperate to be seen umm, and then the other people are being seen quickly who don’t have the same severity of difficulties.

Marian

The availability of cases varied across sites. One of the managers interviewed did not report finding cases problematic, had a ‘readymade case load’ and felt that this ‘is a very relevant service for people to do this sort of trial in’.

Managing staff workloads

Managers shared their concerns about the impact of the work on the therapists’ other commitments. Margaret described how ‘it nearly sinks them’, and Monica worried about her staff’s capacity to cope with the workload but ‘didn’t feel that I could be asking on their behalf or saying “actually they need to stop doing it” ‘.

Managers were aware that therapists had to meet the standards required for participation in the research. They were represented as being under considerable pressure to perform:

They were worried about the demands on them.

Marian

It’s quite tough that I think.

Margaret

Technical problems were perceived as undermining therapists’ confidence – ‘you look rubbish in front of children and families’ (Margaret). Consequently, there was a call for more training around the practical issues associated with the treatment and research (such as recording and uploading videos). This call underlines the challenges of including technological components in the implementation of an intervention. The research team did provide support to the therapists (i.e. they provided step-by-step written guidance on how to use all the technology – including video cameras and Skype – and face-to-face support where needed), but it was still difficult for the therapists to manage these aspects of the trial in their day-to-day work.

In another example, the postponement of other commitments to accommodate supervision was framed as ‘cancellation’ of ‘core’ work:

People felt such obligation to be part of this treatment trial that they cancelled their prior clinical commitments which are a key part of their job.

Marian

Managers struggled to support the delivery of supervision, owing to the perceived pressure that therapists may have felt to meet the demands, in terms of both performance and expectations on their time, although one commented that they weren’t ‘. . . involved in any of that’ (Margaret). For example:

I think also the fact that the supervision was coming from such experts and the training was coming from experts made them feel umm, slightly more worried about how whether they couldn’t ‘you know’ meet the demands.

Marian

Extra stuff I suppose that hadn’t been factored in like umm, you know watching, watching videos or reading protocols or whatever, that, that they couldn’t fit into the half a day or whatever it was that we’d negotiated and I don’t think people were able, necessarily able or, or, or willing to kind of do it in their own time.

Monica

Concerns were also raised about the therapists’ perceived stretching of their usual professional boundaries to attend supervision (e.g. attending at times when they would not usually work) and whose responsibility it was to protect this:

. . . in a way it’s my, you know, who’s responsibility is it to say that that shouldn’t have happened?

Marian

Doubts were raised about whether or not the intervention was appropriate for CAMHS clients but not universally. Margaret, for example, reported that ‘I do not think we have a problem with that. We get lots of children with social anxiety’, while Monica expressed doubts about whether or not there were young people in CAMHS who were ‘suitable and motivated and ready for a very, very kind of disorder-specific intervention’ (Monica).

However, on the whole, the delivery of the therapy itself was not a huge concern for managers (‘People that had the treatment umm, got on well and they made a lot of progress’; Marian), except in the context of the impact on waiting lists (as above) and backfilling therapist time.

Problems with backfill

The limited utility of excess treatment costs meant that ‘there wasn’t anybody [else] to do the work’ that the therapist was not doing, because ‘you can’t actually do anything with little tiny bits of money’. This was a significant factor in the managers’ preoccupying concern with therapist’s time and capacity:

It wouldn’t have felt so difficult because all those people [. . .] who’d been waiting on the waiting list and then got triaged as not suitable for the trial could have had somebody else to see.

Marian

Managers expressed relief that the research was brought to a premature close, despite sharing in the disappointment of their therapists, who had ‘gained a lot in terms of the skills and supervision’ (Marian):

[I] felt really disappointed for the research team umm, and also for the clinicians I suppose on, because you know the clinicians had been really enthusiastic about it.

Monica

I thought ‘great, some of our patients who are really needy and risky can be seen now’.

Marian

To summarise, managers were sceptical about the viability of both the research and the intervention. They were concerned about the pressure on staff and used ‘time-as-a-limited-resource’ as the main means of framing this problem.

When we consider the combined perspectives across the two samples, it is notable that managers appear to overestimate the difficulty of therapists delivering the treatment. Therapists do notice the burden of the additional work, but they also accept and value the intervention and the opportunity to develop their skills. However, interestingly, they also mirror their managers in apparently overestimating the burden of the outcome measurement on the young people with whom they work.