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Educational Psychology in Practice

Vol. 26, No. 2, June 2010, 105122

Cognitive Behaviour Therapies and their implications for applied


educational psychology practice
Shami Raita, Jeremy J. Monsenb* and Garry Squiresc,d
a

Buckinghamshire County Council, Buckingham, UK; bKent Educational Psychology Service,


Gravesend, Kent, UK; cSchool of Education, University of Manchester, Manchester, UK;
dStaffordshire Educational Psychology Service, Coventry, UK
Educational
10.1080/02667361003768443
CEPP_A_477366.sgm
0266-7363
Original
Taylor
202010
26
Dr
jeremy.monsen@kent.gov.uk
00000June
JeremyMonsen
and
&
Article
Francis
(print)/1469-5839
Francis
Psychology
2010
in Practice
(online)

This paper critically considers the growing interest in the use of Cognitive
Behaviour Therapies to support children and young people presenting with a wide
range of social-emotional difficulties. This focus has emerged since the
prevalence of such difficulties in children and young people has increased over
the past four decades, and the application of such approaches is no longer seen as
being the sole preserve of specialist Child and Adolescent Mental Health Services
(CAMHS), counsellors or therapists. To develop a critical understanding of the
principles and core components of Cognitive Behaviour Therapies, two prominent
approaches are reviewed. These are Elliss Rational-Emotive Behaviour Therapy
(REBT), and Becks Cognitive Therapy (CT). The paper concludes with a
discussion of some of the ways in which Educational Pychologists can directly
and/or indirectly support the delivery of Cognitive Behaviour Therapies in their
work.
Keywords: Cognitive Behaviour Therapies; children and young people; socialemotional difficulties

Introduction
The psychological well-being of children and young people
Legislation within the UK is clear that the identification and management of the
psychological well-being of children and young people is no longer solely the remit
of Health Services, and that mental health is everybodys business (DfES, 2001;
Health Advisory Service, 1995). The Childrens National Standards Framework
Standard 9 clearly states that sustained improvements in the mental health of all children and young people is a core aim (DoH, 2004a). Furthermore, all adults who work
with children and young people are considered to have a responsibility for identifying
possible difficulties at an earlier stage and making sure that targeted support is in
place. There is increasing evidence (DfES, 2001) that schools are well placed to
recognise and identify potential difficulties and intervene early. Therefore, schools
could be viewed as being a major therapeutic environment where staff can closely
monitor, adapt and track specific programmes. Currently there is an increasing trend
to train Tier 1 workers who make up a sizeable proportion of the childrens workforce
(Aggett, Boyd, & Fletcher, 2006; Pettitt, 2003).

*Corresponding author. Email: jeremy.monsen@kent.gov.uk


ISSN 0266-7363 print/ISSN 1469-5839 online
2010 Association of Educational Psychologists
DOI: 10.1080/02667361003768443
http://www.informaworld.com

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S. Rait et al.

This shift in thinking inevitably places a greater focus on the type of input and
support that schools may seek from educational psychologists (and other providers)
and it is therefore timely for educational psychologists to explore and analyse
evidence-based preventative interventions that are likely to be successful in supporting children and young peoples psychological well-being.
Prevalence and definition of psychological difficulties
A report on child well-being by UNICEF (2007) found that of 21 industrialised
countries the UK fell in the bottom third of the rankings for five of the six dimensions
reviewed (material, educational and subjective well-being, family and peer relationships and behaviour and risks). The Department of Health (DoH, 2004a) describes
how between 10% and 15% of children and young people have a mental disorder that
would meet the criteria for a clinical diagnosis and a similar number of children have
less serious problems that would benefit from some structured input. In total, it
estimates that around two million children need intervention to improve their
emotional well-being, mental health and resilience (DoH, 2004a). This report
estimates that around 40% of children with a psychological difficulty are not currently
receiving any form of specialist input.
Although a clear definition of psychological difficulties may help in directing
appropriate intervention and resources (NHS Health Advisory Service, 1995), there is
a danger that terminology such as mental or psychiatric disorder may be stigmatising and suggests that the problem is entirely located within the individual rather
than looking more systemically at issues such as poverty, employment and access to
services. Weare and Gray (2003) highlighted that terms used will vary between different services; while Education may refer to presenting features as social-emotional and
behavioural difficulties, Health may view and label them as mental health problems.
They state that there is a need to achieve greater commonality of terminology between
services, recommending the terms emotional and social well-being and emotional
and social competence.
Early identification and prevention
Fonagy, Target, Cottrell, Phillips, and Kurtz (2005) suggest that child psychiatric
disorders become more complex and resistant to intervention with time and recommend early effective interventions. Their critical review of treatments/interventions for children and adolescents found that Cognitive Behaviour Therapies
(CBTs) produced positive outcomes, particularly with children who fell within the
mild to moderate range of psychological difficulties. Moreover, in the National
Institute for Health and Clinical Excellence (NICE, 2005), guidance suggests that
children and young people presenting with moderate to severe depression should
initially be offered a specific psychological therapy such as individual CBT or for
mild depression, group CBT, preferably within an outpatient or community based
setting such as a school.
Cognitive Behaviour Therapies (CBTs)
CBTs are eclectic groups of techniques that combine strategies from cognitive and
behavioural psychology. Sapp (2004) provides a comprehensive overview of a range

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of traditional (for example, behavioural therapy, hypnotherapy and systematic desensitisation) and non-traditional (Adlerian, transactional analysis and reality therapy)
cognitive behavioural approaches. Although the need to be eclectic within the broad
cognitive-behavioural umbrella is suggested, caution is raised about the danger of
haphazardly attempting to integrate opposing theories and strategies without a clear
conceptual rationale for doing so.
Graham (2005) provides both a narrow and a broad definition of CBTs. The
narrow definition focuses on specific therapies, which state that individuals feel and
behave the way they do because of what they think and therefore it is necessary to
change or modify these thoughts if emotional health is to be maintained. The broader
definition, however, includes a family of models that fall under the umbrella of
Cognitive Behaviourial Approaches, such as Solution Focused Therapy, parenting,
social skills and anger management interventions. As the definitions are not precise,
educational psychologists will need to make a judgment as to where along this
continuum, between the narrow and broad definition, a particular CBT intervention or
programme may be operating.
Albert Ellis was the founder of CBT within the field of clinical psychology,
whereas Aaron T. Beck is a prominent figure for Cognitive Therapy (CT) within the
area of psychiatry. These two main schools of CBTs were selected for critical
review due to their influence in developing an empirical base with children and young
people. A brief overview of the main aspects of each of the two therapies, Elliss
Rational-Emotive Behaviour Therapy (REBT), and Becks Cognitive Therapy (CT) is
presented in the Appendix, Table A1.
Elliss Rational Emotive Behaviour Therapy (REBT)
Ellis founded REBT in 1955 (Ellis, 2003) and was the first of the major Cognitive
Behaviour schools. Ellis (2005) studied philosophy and was particularly influenced by
some of the ancient philosophers who emphasised the view that any psychological
disturbance reflected an individuals belief about a disturbing event, rather than the
event itself. REBT is based on six theoretical concepts (see Appendix, Table A2) and
proposes the ABC model to understand this relationship. Ellis explains that individuals have numerous beliefs. thoughts or ideas about activating events, and that the
beliefs have a powerful influence over the cognitive, emotional and behavioural
consequences or responses. Therefore, beliefs can be seen as directly causing,
creating and maintaining consequences or responses. REBT is mainly interested
in individuals rational beliefs, which are helpful, and irrational beliefs, which are
unhelpful and lead to self-defeating behaviours and emotions. The assumption made
is that people are born with self-defeating tendencies and that they have the choice of
either utilising more helpful emotions such as disappointment, frustration, or
unhelpful emotions such as anger, depression or jealousy. It is suggested that
whatever emotions are chosen depends on an individuals belief system.
REBT hypothesises that individuals will continue with their negative cognitive
distortions and seeks past causes and reasons for their irrational beliefs. Therefore,
individuals are encouraged to consider how looking at the impact of their beliefs in
the present is likely to be more beneficial. It aims to teach individuals to specifically
label and describe emotions and to conclude whether they are rational or irrational
using a range of techniques (see Appendix, Table A3), which aims to weaken the
irrational beliefs (Ellis & Dryden, 1999). REBT is not seen as an easy solution and it

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is acknowledged that it requires a great deal of commitment and hard work by the
individual to positively change their thoughts, behaviours and feelings in order to
minimise their distress.
Some of the limitations of REBT include the lack of information or exploration of
how a belief system develops and whether there are any critical periods related to
the development of irrational or unhelpful beliefs. There is no mention of the internal or external risk or protective factors that might be at play in the beliefs held
by children. Additionally, accessibility of this approach for children and young people
with specific learning needs or differing cultural norms is not addressed. The REBT
techniques require a high level of cognitive and verbal ability, which involves identifying, exploring, reflecting and articulating on the negative impact of holding onto
an irrational belief. This level of cognitive skill is unlikely to be fully developed in
children and the emotional disturbance of a problem may make therapy even more
inaccessible (Barnes, 2000).
Becks Cognitive Therapy (CT)
Becks CT arrived some 10 years after Elliss REBT. Beck gradually formed his ideas
and thinking around CT during the 1960s. He carried out research on dreams and from
this work developed a cognitive model of depression. Beck was influenced by the theory
of evolution and considers that a range of cognitive structures, such as depression and
anxiety disorders, may have served a survival purpose in early human development.
CT is based on information processing theory and emphasises the way in which
individuals process, code, store and manipulate information from the environment
(Beck, 1979). Beck describes five cognitive distortions, where an individual makes
errors in thinking (see Appendix, Table A4) and looks at ways of repairing an individuals faulty styles of processing information. As with other CBTs, it aims to question
individuals distorted thinking using a scientific approach of testing these beliefs and
using techniques (see Appendix, Table A5) that encourage individuals to be coinvestigators in conducting behaviour and cognitive experiments. Unlike REBT, individuals are encouraged to consider how they arrived at their negative thoughts,
through the exploration of themes derived from counselling sessions (referred to as
guided discovery).
One of the limitations of CT is the lack of information and evidence on how faulty
styles of processing information develop and whether any part of the processing stages
are more critical than others. For example, could information received be successfully
coded and stored but then fail at the stage it is used in the real world. This is an
extremely complex area and there is no mention of the vital role of memory and
language development. Although CT encourages clients to be co-investigators and set
up experiments that can be tested in the real world, it does not address the fact that
children and young people often have limited control in the real world, particularly
within the context of the school and home environment. Therefore, a weakness of CT
is the lack of exploration and guidance of how and when significant adults, peers and
siblings could contribute to the therapeutic process.
Summary
When analysing the influences and philosophies of the two prominent CBTs, it is
apparent that although conceptually there are differing views as to the theory behind

Educational Psychology in Practice

Figure 1.

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Summary and analysis.

psychological difficulties (irrational beliefs versus faulty information processing)


there is a high level of commonality in the way they have been constructed and
delivered, as outlined in Figure 1. These similarities have been accounted for by the
long standing communication links that both Ellis and Beck have kept with each other
until Elliss recent death (Sapp, 2004).
Both REBT and CT can be seen to have challenged the orthodoxy and primacy of
the psychotherapeutic model in attempting to address client presenting problems in
present-orientated and pragmatic ways. Both emphasise the individuals ability to
choose to think and act differently and teach the theory so that it becomes a life skill.
The therapies are used with a range of ages, backgrounds and psychological difficulties (obsessive compulsive, anxiety, depression, anger and so on). The models can be
seen to be experimental, used worldwide and continually evolving as new reflections
and research emerges (Beck, 2005; Ellis & Dryden, 1999).
Figure 1. Summary and analysis.

Evidence basis for CBTs


The six criteria developed by Sapp (2004) are used as a framework to summarise the
effectiveness and efficacy of the two therapies chosen for discussion. These are:
comprehensiveness (explaining human development and the reason for any
divergence), precision and testability (identification of criteria and impact of all
variables), parsimony (ease with which the theory can be explained), heuristic value
(interest shown by others), applied value (application in the real world) and empirical validity (use of valid research instruments).

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Comprehensiveness
Neither REBT nor CT explore reasons for any divergence in detail or cover the areas
of developmental psychology, attachment theory or cognitive development. They do
not consider other areas of human functioning that may be impacting on an individuals irrational or unhelpful beliefs or faulty processing, such as economic, social and
cultural needs.
Precision and testability
Although both have encouraged evaluation, REBT and CT have been particularly
robust in specifying and identifying the theoretical concepts and techniques used (see
Appendix, Tables A2 and A3).
Parsimony
Both REBT and CT can be seen to be parsimonious, as they do not contain any unnecessary concepts and avoid and minimise any potential complexities. This may be a
feature that contributes to their growing popularity. Weinrach (1995) comments that
practitioners will often choose an intervention that is easy and enjoyable to use rather
than one that is necessarily effective.
Heuristic value
Both REBT and CT have stimulated a wide range of interest and research. CT was one
of the first to use manualised treatments and as a university based practitioner, Beck
was keen to ensure that CT was empirically investigated. It is this rigour that has
contributed to its current popularity, acceptance and growing interest by other
researchers (Fonagy et al., 2005). Ellis (2003) is mindful of the lack of robust studies
in the field of REBT and notes that as the Institutes focus was on the training of
clinicians to develop their practice, any interest by them on researching outcomes was
not a priority. However, in recent years the emphasis has changed and more efficacy
research is slowly emerging on REBT.
Applied value
Both approaches have been used with a range of ages, cultural groups and levels of
psychological difficulties (Durlak, Furnham, & Lampman, 1991; Gonzalez et al.,
2004; Radtke, Sapp, & Farrell, 1997; Sapp, 2004).
Empirical validity
The conclusions which can be drawn from single case studies are limited, many
researchers have used meta-analytic methods to assess the strength of various interventions. Meta-analysis is a quantitative procedure, where the difference between the
means of the experimental and control group is divided by the standard deviation to
calculate the effect size of the intervention, which is independent of the measures
used. By pooling the results, an overall effect size can be obtained.
A comparison of the meta-analysis studies conducted by Gonzalez et al. (2004),
and Durlak et al. (1991) was undertaken to draw out conclusions regarding the

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evidence base for REBT and CT. The selected meta-analyses studies used the
following inclusion criteria: all specifically addressed REBT and CT; the majority
(85%) of studies delivered CBT to children (518 years of age) presenting with social,
emotional and behaviourial issues; all provided effect sizes and at least 50% of the
CBT was delivered in a school setting. Table 1 provides a comparison of the studies.
The meta-analysis conducted by Durlak et al. (1991) identified eight separate CBT
components, such as problem solving and attribution training, which resulted in a
unique combination of 42 treatment components. They found no significant correlation between changes in cognition and behaviour, so although a child was able to say
how a confrontation could be avoided there was difficulty translating this into actual
practice (i.e. into the real world context). These findings have enormous implications
Table 1.

Comparison of meta-analysis studies for REBT and CT.

Meta-analysis study

Gonzalez et al. (2004)

Durlak et al. (1991)

Description of CBT

REBT

CT

Years searched (total years


covered)

19722002 (30 years)

19701987 (17 years)

Number of studies
analysed

19

64

Age range (percentage of


518 year olds)

Any school aged child under


18: (100%)

Mean age 13 years or younger:


(100%)

Presenting difficulty

With or at risk of social


emotional and behavioural
difficulties (SEBD)

SEBD; 37.5% clinically


significant difficulties

Sample size

1021

Approximately 2624 (mostly


boys aged nine)

Study design (percentage


using control groups,
CG)

Some used random


assignment and normative
measures (100% used CG)

38 used random assignment; 53


at least one normative
measure and 43 a placebo
(100% used CG)

Timing of sessions

6 to 35 hours

Average of 9.6 hours or 12


sessions

Background of therapists

Mental health and non-mental


health professionals (MHP)

No information re skill level of


CT therapists.

Percentage of CBT
delivered in school
setting

100%

65%

Overall effect size (ES)1

0.51 for ages 1418


0.18 for ages 1014
0.70 for ages 610

0.92 for ages 1113


0.55 for ages 711
0.57 for ages 57

Additional information

Largest impact on disruptive


behaviours (ES: 1.15)
ES less by MHP (0.36) than
non-MHP (0.54)

Unique combination of 42
techniques
No significant relationship
between cognitive processes
and behaviour

1
Cohens d (as cited in Fonagy et al., 2005) guidelines for interpreting the effect size (ES) is as follows:
0.20 small, 0.50 medium and 0.80 large.

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for the way in which practitioners decide on which CBT techniques to use and how
the success or benefits of a CBT intervention should be measured.
The meta-analysis conducted by Gonzalez et al. (2004), found a large effect size
(ES = 1.15) for children presenting with disruptive behaviour; however, it was
suggested that this result may have been a reflection of the weak outcome measures
used, such as frequency counts. In this meta-analysis 100% of the therapy took place
within a school setting where in some cases teachers were involved in the direct delivery of the therapy. For this reason, these studies are likely to be of particular interest
to educationalists and worthy of further focused attention and research.
The meta-analyses undertaken by Durlak et al. (1991) and Gonzalez et al. (2004)
provided the most detailed breakdown of the effect size for the various age groups. It
appeared that the success of a CBT was not dependent on the age of the children and
presumably their level of cognitive functioning. Durlak et al. (1991) concluded that
the five to seven year olds (ES = 0.57) may have benefited more because they were at
a stage where they were developing the capacity to use language to mediate their
behaviour and this interacted positively with the intervention, as well as them having
fewer ineffective strategies to unlearn. Gonzalez et al. (2004) suggested that the small
effect size (ES = 0.18) shown by the 10 to 14 year olds might have been due to their
skills at avoiding or undermining the therapy and presenting with difficulties that were
more entrenched and difficult to shift.
Limitations and future research
From these analyses it is clear that there is insufficient information available relating
to demographic characteristics, follow-up data, quality of the therapy, and the skill
level of the therapists. Fonagy et al. (2005) suggests that one of the key problems with
meta-analysis is that it often concludes effectiveness of a treatment over no treatment
as originators of intervention programmes are often responsible for the measurement
techniques and evaluations. Therefore, it is suggested that there is a need to go beyond
a reliance on an individuals responses to questionnaires.
The evidence base for CBT currently lacks the robustness of well-conducted,
randomised-controlled trials of children and young people, certainly within the UK
and Europe. However, the use of randomised-controlled trials for evaluating therapeutic interventions has been severely criticised as being an inappropriate methodology
(Morrison, Bradley, & Westen, 2003; Westen, Novotny, & Thompson-Brenner,
2004a, 2004b). Research reporting evidence-based outcomes tends to originate from
studies where single specific areas have been targeted, such as depression (Harrington,
2005) and anxiety (James, Soler, & Weatherall, 2005) and which appear to fall at the
milder end of the spectrum. Though an emerging evidence base is appearing, with
positive outcomes for children seen in school settings by an educational psychologist
using CBT (Squires, 2001), these are not always sustained for all children (Ehntholt,
Smith, & Yule, 2005; Luk et al., 2001).
The recent resurgence of interest in CBT within the field of educational psychology has largely arisen from the Governments agenda that highlights the responsibility
of all practitioners to work together to support the mental well-being of children and
young people (DfES, 2001). Educational psychologists have always worked closely
with colleagues in Health and Social Care utilising a range of approaches, including
cognitive behavioural frameworks in their work with children, schools and families
(DfEE, 2000; MacKay, 2002). CBTs provide a time limited, problem/solution focused

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and skills-based approach that has a theoretical base with emerging evidence highlighting its effectiveness (NICE, 2005).
Although REBT and CT are popular, a range of limitations was identified in
their application with children and young people. The therapies neglect to fully
explore and explain the underlying processes, developmental stages and critical
periods that may contribute to and maintain emotional problems experienced by
children and young people. Neither of the therapies seriously considers the accessibility of their approach with children and there is an assumption that the techniques
used with adults are easily transferable to children and young people. Practitioners
and researchers have been testing this assumption and finding that more creative
approaches can lead to successful outcomes when working with children (Doherr,
Reynolds, Wetherly, & Evans, 2005; Quakley, Coker, Palmer, & Reynolds, 2003;
Quakley, Reynolds, & Coker, 2004) or young people with learning difficulties
(Bason, 2008).
Supporting the delivery of CBTs
A review by Farrell et al. (2006) on the functions and contribution of educational
psychologists notes that although a limited amount of time (about 2%) is currently
spent on one-to-one therapy, such as CBT, there is potential to broaden the scope
of work in this area. The debate over the use of CBTs with children and young
people is complex and therefore, in their practice, educational psychologists will
need to consider the limitations as well as the benefits of the CBTs on offer and
the prerequisite skills required not only by children and young people but also
themselves. Bolton (2005) concluded that the developmental level required for
CBT was likely to be related to whatever level was involved in creating the problem in the first place. Therefore, it is suggested that the emphasis should be firmly
placed on the assessment of the particular case, where the focus is on what kinds
of thinking processes are generating and maintaining the presenting problem(s). If
a particular cognition is involved then it should be addressed, if not it should be
left alone.
Due to limited resources and time constraints, it is highly unlikely that educational
psychologists will be in a position to offer regular intensive direct CBT to individual
children and young people, although some, such as MacKay (2002), argue that this
may well form an increasing element within an applied educational psychologists
portfolio. The problem is that there are a range of other providers of such services and
often they are more cost effective. It is vital that a much wider and more critical debate
is needed about the role and purpose of applied educational psychologists within
multi-practitioner/agency teams before a clear position can be presented on the extent
of educational psychologists adopting a more therapeutic role (Ecclestone & Hayes,
2008).
Educational psychologists do have a unique working knowledge of school
systems, priorities and constraints and how these impact on the way in which children
learn and behave, which places them in an ideal position to support school staff who
may be more directly involved in the delivery of CBT programmes. At a whole school
and preventative level, educational psychologists can promote the development
and implementation of more universal and non-selective cognitive behaviour interventions such as the Social Emotional Aspects of Learning (SEAL) and Healthy
Schools (Hallam, Rhamie, & Shaw, 2006). These types of intervention programmes

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are particularly powerful as they are non-stigmatising, easily accessible and more
acceptable to parents/carers than when they are targeted at specific individuals or
groups (Bailey, 2005).
At a whole class or group level educational psychologists can support schools in
identifying and assessing the needs of a group of children and recommending appropriate CBT focused interventions such as social skills and behavioural self-regulation
programmes, which could initially be co-delivered with school staff. Squires (2001),
a practicing educational psychologist, delivered a six-session CBT intervention in a
mainstream setting, to groups of six to nine pupils (aged between 1013 years), who
presented with disruptive or withdrawn behaviours. The study reported improvement
in teacher ratings of behaviour and pupil ratings of self-control. Squires recommended
that educational psychologists provide more input at this preventative level, as it was
cost effective, reduced the need for Statements of Special Educational Need, and
was resource efficient, as it enabled more children to be supported, maximising
educational psychology time and input.
At an individual level, educational psychologists using structured hypothesistesting could support staff to devise and formulate case profiles or formulations, highlighting the various influences on cognition and behaviour, such as the social context
and life circumstances (Monsen & Frederickson, 2008). With more complex cases
educational psychologists can systematically explore with staff hypotheses around
why a childs cognitions and behaviours may be resistant to change, even though the
CBT applied appears to be well delivered and matched for the specific need
(OConnor & Creswell, 2005; Monsen & Frederickson, 2008).
School as a therapeutic environment
Ellis (2003) believed that the future of REBT and CBT in general rested within the
field of education, where the classroom was seen as a base that could provide a
therapeutic climate and promote the prevention of future psychological difficulties.
Kurtz (2004) notes that it is unhelpful if children have to wait too long to be seen
by specialist Child and Adolescent Mental Health Services (CAMHS), and that it
can be counter-productive, as children and families may be less willing to take up
the service when it is offered and during that time difficulties may increase and
become more entrenched. In addition, a model of clinic based intervention makes
numerous, often class-based assumptions about clients cognitive, material (can
they get themselves to the clinic, can they attend regularly and can they get time
off work?) and motivational resources to engage in a therapeutic alliance. Therefore, pragmatically, schools and educational psychologists need to be fully engaged
in supporting children and young peoples emotional health within the school
setting.
Farmer, Burns, Phillips, Angold, and Costello (2003) found that almost 70% of
children and young people receiving intervention for psychological difficulties do so
at school and there is growing evidence of this input. Weare and Gray (2003) examined the way in which five Local Education Authorities in the UK supported the
development of childrens emotional and social competence and well-being and found
that although all were doing good work in this area only one had prioritiesed this area
of work. Furthermore, they identified a range of initiatives being used that included
circle time, peer buddy systems and a specific CBT programme called FRIENDS
(Barrett, Webster, & Turner, 2000).

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Training and supervision


Schools see a role for educational psychologists in providing training on a wide
range of issues, including counselling (DfEE, 2000). The National Society for the
Prevention of Cruelty to Children (NSPCC, 2006) gathered the views of over 4400
children (1116 years of age) in 2004 on who they could talk to about problems.
The most popular choice was friends and family, followed by teachers. Therefore,
training and supervision to school staff is likely to encourage dialogue and interactions that incorporate key principles of CBT which may help reduce levels of
distress and increase confidence to request specific support. Additionally, the
NSPCC (2006) survey reported that almost a quarter of children said that they would
welcome input from adults outside of the school environment, which has implications for the way in which educational psychologists raise awareness of their distinctive contribution in this area of work. Educational Psychology Services may need to
consider how their service could be made more accessible, not only to children in
schools but also to those within the local community, through venues such as youth
centres and extended schools.
Derisley (2004) notes that although there is limited research in the area of clinician
competency with regards to the delivery of CBT, it is found to play an important role
in terms of outcomes. There is an increasing amount of therapeutic training being
provided for new entrants to the profession of Educational Psychology at several institutions in the UK, with attempts being made to evaluate the implementation and
impact for trainee educational psychologists (Squires & Dunsmuir, 2008). Therefore,
practicing educational psychologists may need to establish what additional training is
required if they are to provide specific support in the area of CBT. Educational
Psychology Services may want to consider whether they view CBT emerging as a
distinctive specialism alongside others, such as behaviour, autism and early years or
whether CBT is a generic tool that can potentially inform a range of educational
psychologist work, or both. This latter interpretation would see the CBT model and
techniques being used to support educational psychology work through direct casework with a small number of more complex difficulties, indirect casework supporting
others who are working with more children who are less complex, helping school
managers thinking around how the CBT model can inform organisational practice,
and the use of CBT in consultation and in supporting adults managing their own
emotional reactions when working with children and young people with challenging
behaviour.
Multi-professional/agency delivery of CBT
The emphasis on multi-practitioner/agency working, the emotional well-being of children and the cost effectiveness of interventions have led to a number of jointly funded
projects. There has been a growth in the number of educational psychologists becoming involved with CAMHS work (DfEE, 2000). School-based CBT is likely to be
more successful and effective if undertaken jointly with school staff, educational
psychologists and other allied external agencies such as CAMHS, as it would enable
follow-up and if needed more in-depth specialist therapeutic input. There is now an
increasing emphasis on supporting children with psychological issues within more
comfortable and accessible environments, such as the school rather than clinic. As a
result it is becoming more apparent that the roles, responsibilities and remit of the
work of CAMHS staff and educational psychologists need to be re-apprasied. This

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may involve mapping the involvement of both services along the tiered model of
delivery (Pettitt, 2003), which could ensure that gaps and overlap in service provision
are minimised so that the best outcomes for children and young people can be
achieved. Developing networks across universal, targeted and specialist practitioners
could strengthen inter-agency/professional working relationships.
The need for increased applied research
It is known that children with disabilities have an increased risk of psychological
health difficulties and that there are differences in the prevalence of psychological
problems across different ethnic groups. However, there is little research evidence on
the types of CBT that may be of benefit to those children with specific learning needs,
and across differing cultural norms (DoH, 2004b). The influence of significant adults
and peers in the life of children is not considered in any depth and there is no guidance
as to the type of contribution they could make to therapy effectiveness (Kendall &
Choudhury, 2003).
If a credible case is to be made for recommending specific CBTs over other interventions it is vital that educational psychologists engage in robust applied research
that identifies the benefits and limitations of alternative interventions and strategies.
More studies are needed that evaluate the effectiveness and efficacy of the delivery of
CBTs within natural settings such as the school, where the complexities of childrens needs can be fully explored. Educational psychologists are in a prime position
to explore and research these neglected areas in their work with children, young
people and families.
Reviewing research is an essential way of monitoring and evaluating the outcomes
of particular strategies and interventions, and is currently considered by educational
psychologists to be an under utilised skill (DfEE, 2000). Educational psychologists are
well placed to analyse, synthesise and critically examine the CBT research literature
and advise on the gaps and limitations of research findings. They are also well positioned to design studies that can evaluate the quality, impact and cost effectiveness of
a CBT programme. With the development of commissioning services there may be a
greater demand for educational psychologists to carry out research on behalf of
commissioners, who are seeking answers as to which resources and interventions they
should be purchasing.
Conclusions
Finally, CBT for children and young people is growing in popularity: however, further
local applied research is required in a number of areas. These include considering the
varying influences of internal and external risk and protective factors on the development of specific emotional difficulties experienced by children and young people, and
the benefits and limitations of various CBTs. NICE (2006) published their guidance
on the use of Computerised Cognitive Behaviour Therapy (CCBT) for adults with
depression and anxiety, and as technology is particularly appealing and attractive to
children, the effectiveness and efficacy of using child-friendly CCBT is worthy of
investigation. Recent research evidence in the field of neuroscience outlining the
cognitive neural development of adolescents is exciting and likely to provide invaluable information as to the future techniques and focus of CBT with children and young
people (Blakemore & Choudhury, 2006).

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This paper reviewed two prominent CBTs (REBT and CT) and concluded that
although they were based on different theories (irrational beliefs versus faulty
processing) there were many conceptual similarities in the way they were
constructed and delivered, including the emphasis on internal control and a solution
focused oriented framework. Despite a range of limitations in their application,
there is evidence that CBTs are more effective when targeted at the milder end of
the spectrum of psychological difficulties such as anxiety and depression (that is,
targeted support). The growing interest in child-focused CBT has resulted in a range
of materials and structured workbooks (Barrett et al., 2000; Stallard, Udwin,
Goddard, & Hibbert, 2007). This increase in the availability of child-friendly materials can help staff in schools to deliver a CBT programme with more confidence. In
these cases, educational psychologists are in an ideal position to support staff to
understand the theoretical model and core principles that underpin programmes, so
that when required a programme can be adapted in a coherent and theoretically
robust way. A distinct supervision role for educational psychologists could be
evolved here.
When identifying the benefits of a particular CBT approach, educational psychologists need to be aware of the underlying conceptual framework being used and the
evidence of its success with the age range and type and severity of the difficulty.
Future applied research exploring the use of CBT needs to take place with the UK
population of children and young people, where a range of learning needs and cultural
influences can be identified and explored. Studies need to be robust, with randomly
controlled trials and where in-depth demographic characteristics and information is
gathered, so that significant factors that impact on the outcomes of CBT can be better
understood, evaluated and addressed. More follow-up is required so that any medium
to long-term benefits can be highlighted and costed. Although educational psychologists may not regularly be directly involved in delivering one-to-one CBT, they are in
a unique position to support others, through school-based projects, consultations,
supervision, training and applied research.
The DoH (2004b) states that a variety of therapeutic skills is needed to support the
psychological difficulties faced by children and young people, including behavioural,
cognitive, interpersonal, pharmacological and systemic. Both Ellis (2003) and Beck
(Bloch, 2004) imply that the terms REBT or CT may become redundant in the future,
where the preferred concept may simply be Child Focused Psychological Interventions (CFPI), with all the most powerful strategies, techniques and processes from the
different cognitive behavioural stables being integrated both conceptually and practically. For this reason it may be appropriate for educational psychologists to begin to
systematically evidence what the most powerful ingredients are for children and
young people receiving CBT.
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Appendix
Table A1.

Overview of CBT.

Founders

Influences and original


applications
Theory

Rational Emotive Behaviour Therapy

Cognitive Therapy

Albert Ellis
Clinical Psychologist
Mid 1950s.
Philosophy and Couple/Sex Therapy.

Aaron Beck
Psychiatrist
Early 1960s.
Science and Evolution,
Depression.
Informational Processing
Theory.
Change faulty styles of
processing information.
Collaborative.

Emphasis of therapy

ABC Theory (Activating Event;


Belief and Consequences).
Dispute irrational beliefs.

Role of therapist

Active-directive.

Table A2.

REBT: concepts.

Concept

Explanation of concepts

Irrationality

An individuals condemnation of the self, others and the world:


I must do well and be loved by all or I am no good; the
environment must be perfect.
Individuals have two goals: that of survival and being happy.
Rational beliefs, behaviours and emotions are required to help
individuals achieve their desired goals.
Individuals aim to achieve long-term happiness through achieving
their goals in a personally meaningful and humane way.
An individuals ability to consider the interests of others in
achieving their goals as well as their own.
The individuals human worth, even if there are errors of
judgment. It emphasises the interaction between biological
factors, social context and structures, free will and choice.
1. To think irrationally.
2. To work on changing irrational thinking.

Rationality

Hedonism
Enlightened self-interest
Humanism

Two biologically
determined tendencies
Table A3.

REBT: techniques.

Techniques

Explanation of technique

Logical disputes

Helps the individual identify the flaw and illogical elements of


the irrational belief.
Explore the evidence for their irrational beliefs.
Help the individual identify what the negative impact in
practical terms would be of holding on to the irrational
belief or beliefs, as well as the emotional and behavioural
consequences of sticking to the irrational belief.
Presents the individual with a rational belief that meets their
needs in a positive way.

Empirical disputes
Functional disputes

Rational alternative disputes

Four disputing interventions: didactic (teaching), socratic (asking questions about the irrational
belief), metaphorical (applying the irrational belief to an area well known by the individual)
and humorous style (carefully using humour to expose and reduce the irrational belief).

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Table A4.

CT: cognitive distortions.

Cognitive distortion

Explanation of cognitive distortion

Personalisation
Dichotomous thinking

Individual takes responsibility for events that are out of their control.
A polarised or absolute view is stated, for example, everything is
good or bad.
Negative aspects are focused on rather than the positive or neutral.
Individual arbitrarily reaches a negative conclusion without any
evidence.
Individual maximises the negative and minimises the positive from
limited information.

Selective abstraction
Arbitrary inference
Overgeneralisation

Table A5.

CT: techniques.

Techniques

Explanation of technique

Decatastrophising

Use of a what if question. This is related to a perceived traumatic


event and the individual is supported through the suggestion of a
range of strategies of how to cope.
Individuals are encouraged to re-examine and re-interpret events by
considering other possible causes.
Helps individuals to redefine the problem so that they can act in a
different way to address the difficulty.
Helps individuals to move away from their own problem and to
consider it from an objective perspective and carry out a
behavioural experiment to test out the faulty information
processing.
Individuals are given specific tasks to try outside of the sessions, with
a particular focus on how their thoughts influenced their feeling.
Individuals are initially asked to validate their thoughts and then
taught to test their beliefs in the real world.
Aims to desensitise the individual to the distorted cognitions.
Individuals are encouraged to role-play in a safe environment so that
they can then use this in real situations.
Individuals are distracted from the negative and distorted cognition
by focusing attention on other actions, for example, work, play,
imagery and so on.
Individuals are encouraged to set up and schedule in routines that will
reduce negative emotions. These activities are also monitored and
tracked for their effectiveness.
Individuals are encouraged to take on increasingly more tasks in a
stepped way to address impaired cognitions.

Reattribution
Redefining
Decentering

Homework
Hypothesis testing
Exposure therapy
Behavioural rehearsal
Diversion

Activity scheduling

Graded task
assignment

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