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Educational Psychology in Practice

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

Cognitive Behaviour Therapies and their implications for appliededucational psychology practice

Shami Raita, Jeremy J. Monsenb* and Garry Squiresc,d

aBuckinghamshire County Council, Buckingham, UK; bKent Educational Psychology Service,Gravesend, Kent, UK; cSchool of Education, University of Manchester, Manchester, UK;dStaffordshire Educational Psychology Service, Coventry, UKTaylorandFrancisCEPP_A_477366.sgm10.1080/02667361003768443EducationalPsychologyin Practice0266-7363 (print)/1469-5839 (online)Original Article2010Taylor&Francis262000000June2010DrJere [email protected]

This paper critically considers the growing interest in the use of CognitiveBehaviour Therapies to support children and young people presenting with a wide

range of social-emotional difficulties. This focus has emerged since theprevalence of such difficulties in children and young people has increased overthe 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 prominentapproaches are reviewed. These are Elliss Rational-Emotive Behaviour Therapy(REBT), and Becks Cognitive Therapy (CT). The paper concludes with adiscussion of some of the ways in which Educational Pychologists can directlyand/or indirectly support the delivery of Cognitive Behaviour Therapies in theirwork.

Keywords: Cognitive Behaviour Therapies; children and young people; social-

emotional difficulties

Introduction

The psychological well-being of children and young people

Legislation within the UK is clear that the identification and management of thepsychological 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 chil-

dren and young people is a core aim (DoH, 2004a). Furthermore, all adults who workwith 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, schoolscould 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: [email protected]


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106 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 support-

ing 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 relation-

ships and behaviour and risks). The Department of Health (DoH, 2004a) describeshow 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 theiremotional well-being, mental health and resilience (DoH, 2004a). This reportestimates 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 isa danger that terminology such as mental or psychiatric disorder may be stigma-

tising 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 differ-

ent services; while Education may refer to presenting features as social-emotional andbehavioural 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 recom-

mend early effective interventions. Their critical review of treatments/interven-tions 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 shouldinitially 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


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Educational Psychology in Practice 107

of traditional (for example, behavioural therapy, hypnotherapy and systematic desen-

sitisation) 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. Thenarrow 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 ofCognitive 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 youngpeople. 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 psychologicaldisturbance 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 individu-

als have numerous beliefs. thoughts or ideas about activating events, and that the

beliefs have a powerful influence over the cognitive, emotional and behaviouralconsequences or responses. Therefore, beliefs can be seen as directly causing,

creating and maintaining consequences or responses. REBT is mainly interestedin individuals rational beliefs, which are helpful, and irrational beliefs, which are

unhelpful and lead to self-defeating behaviours and emotions. The assumption madeis 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 cognitivedistortions 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 irrationalusing a range of techniques (see Appendix, Table A3), which aims to weaken the


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108 S. Rait et al.

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 tominimise 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 inter-

nal or external risk or protective factors that might be at play in the beliefs heldby 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 identi-

fying, exploring, reflecting and articulating on the negative impact of holding ontoan 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 andanxiety 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 individ-uals 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 co-

investigators in conducting behaviour and cognitive experiments. Unlike REBT, indi-viduals 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 faultystyles of processing information develop and whether any part of the processing stages

are more critical than others. For example, could information received be successfullycoded 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 setup 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 andsiblings could contribute to the therapeutic process.

Summary

When analysing the influences and philosophies of the two prominent CBTs, it is


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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 thelong standing communication links that both Ellis and Beck have kept with each other

until Elliss recent death (Sapp, 2004).Figure1. Summaryandanalysis.

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 tochoose 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 difficul-ties (obsessive compulsive, anxiety, depression, anger and so on). The models can be

seen to be experimental, used worldwide and continually evolving as new reflectionsand research emerges (Beck, 2005; Ellis & Dryden, 1999).

Evidence basis for CBTs

The six criteria developed by Sapp (2004) are used as a framework to summarise theeffectiveness 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 empir-

Figure 1. Summary and analysis.


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110 S. Rait et al.

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 individ-

uals irrational or unhelpful beliefs or faulty processing, such as economic, social andcultural 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 unnec-

essary concepts and avoid and minimise any potential complexities. This may be afeature 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 hascontributed 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 wasnot 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 ofpsychological 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 inter-

ventions. Meta-analysis is a quantitative procedure, where the difference between the

means of the experimental and control group is divided by the standard deviation tocalculate 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),


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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 aunique combination of 42 treatment components. They found no significant correla-

tion 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 yearscovered)

19722002 (30 years) 19701987 (17 years)

Number of studiesanalysed

19 64

Age range (percentage of518 year olds)

Any school aged child under18: (100%)

Mean age 13 years or younger:(100%)

Presenting difficulty With or at risk of socialemotional and behavioural

difficulties (SEBD)

SEBD; 37.5% clinicallysignificant difficulties

Sample size 1021 Approximately 2624 (mostlyboys aged nine)

Study design (percentageusing control groups,CG)

Some used randomassignment and normativemeasures (100% used CG)

38 used random assignment; 53at least one normativemeasure and 43 a placebo(100% used CG)

Timing of sessions 6 to 35 hours Average of 9.6 hours or 12sessions

Background of therapists Mental health and non-mental

health professionals (MHP)

No information re skill level of

CT therapists.Percentage of CBT

delivered in schoolsetting

100% 65%

Overall effect size (ES)1 0.51 for ages 14180.18 for ages 10140.70 for ages 610

0.92 for ages 11130.55 for ages 7110.57 for ages 57

Additional information Largest impact on disruptivebehaviours (ES: 1.15)

ES less by MHP (0.36) thannon-MHP (0.54)

Unique combination of 42techniques

No significant relationshipbetween cognitive processes

and behaviour

1Cohens d(as cited in Fonagy et al., 2005) guidelines for interpreting the effect size (ES) is as follows:


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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 deliv-ery 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. Itappeared 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 havingfewer 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 withmeta-analysis is that it often concludes effectiveness of a treatment over no treatmentas 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 therapeu-

tic 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 fromstudies 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 psychologistusing 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 psychol-

ogy 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 andyoung 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


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and skills-based approach that has a theoretical base with emerging evidence high-

lighting 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 accessi-bility 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 educationalpsychologists 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 willneed 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 prob-lem in the first place. Therefore, it is suggested that the emphasis should be firmlyplaced 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 andoften 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 schooland preventative level, educational psychologists can promote the development

and implementation of more universal and non-selective cognitive behaviour inter-

ventions such as the Social Emotional Aspects of Learning (SEAL) and Healthy


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114 S. Rait et al.

are particularly powerful as they are non-stigmatising, easily accessible and more

acceptable to parents/carers than when they are targeted at specific individuals orgroups (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 appro-

priate 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 recommendedthat 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 hypothesis-testing could support staff to devise and formulate case profiles or formulations, high-

lighting 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 aroundwhy 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 environmentEllis (2003) believed that the future of REBT and CBT in general rested within thefield 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 itcan 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 timeoff work?) and motivational resources to engage in a therapeutic alliance. There-

fore, 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) exam-

ined the way in which five Local Education Authorities in the UK supported the

development of childrens emotional and social competence and well-being and foundthat 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


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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 interac-

tions that incorporate key principles of CBT which may help reduce levels of

distress and increase confidence to request specific support. Additionally, theNSPCC (2006) survey reported that almost a quarter of children said that they would

welcome input from adults outside of the school environment, which has implica-

tions for the way in which educational psychologists raise awareness of their distinc-

tive contribution in this area of work. Educational Psychology Services may need toconsider 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 rolein terms of outcomes. There is an increasing amount of therapeutic training being

provided for new entrants to the profession of Educational Psychology at several insti-

tutions 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 orwhether CBT is a generic tool that can potentially inform a range of educationalpsychologist work, or both. This latter interpretation would see the CBT model and

techniques being used to support educational psychology work through direct case-

work with a small number of more complex difficulties, indirect casework supporting

others who are working with more children who are less complex, helping schoolmanagers 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 chil-

dren 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 becom-

ing involved with CAMHS work (DfEE, 2000). School-based CBT is likely to be

more successful and effective if undertaken jointly with school staff, educationalpsychologists 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 aresult it is becoming more apparent that the roles, responsibilities and remit of the


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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 provisionare 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 inter-

ventions 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 chil-drens 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 educationalpsychologists 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 posi-

tioned to design studies that can evaluate the quality, impact and cost effectiveness ofa 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, furtherlocal 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 develop-

ment 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 withdepression 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 invalu-able information as to the future techniques and focus of CBT with children and young


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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 faultyprocessing) 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 mate-

rials can help staff in schools to deliver a CBT programme with more confidence. Inthese 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 psychol-

ogists 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 UKpopulation 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 psycholo-gists 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 Interven-tions (CFPI), with all the most powerful strategies, techniques and processes from the

different cognitive behavioural stables being integrated both conceptually and practi-cally. For this reason it may be appropriate for educational psychologists to begin to

systematically evidence what the most powerful ingredients are for children andyoung people receiving CBT.

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Appendix

Four disputing interventions: didactic (teaching), socratic (asking questions about the irrationalbelief), metaphorical (applying the irrational belief to an area well known by the individual)

Table A1. Overview of CBT.

Rational Emotive Behaviour Therapy Cognitive Therapy

Founders Albert EllisClinical PsychologistMid 1950s.

Aaron BeckPsychiatristEarly 1960s.

Influences and originalapplications

Philosophy and Couple/Sex Therapy. Science and Evolution,Depression.

Theory ABC Theory (Activating Event;Belief and Consequences).

Informational ProcessingTheory.

Emphasis of therapy Dispute irrational beliefs. Change faulty styles ofprocessing information.

Role of therapist Active-directive. Collaborative.

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; theenvironment must be perfect.

Rationality Individuals have two goals: that of survival and being happy.Rational beliefs, behaviours and emotions are required to helpindividuals achieve their desired goals.

Hedonism Individuals aim to achieve long-term happiness through achieving

their goals in a personally meaningful and humane way.Enlightened self-interest An individuals ability to consider the interests of others in

achieving their goals as well as their own.

Humanism The individuals human worth, even if there are errors ofjudgment. It emphasises the interaction between biologicalfactors, social context and structures, free will and choice.

Two biologicallydetermined tendencies

1. To think irrationally. 2. To work on changing irrational thinking.

Table A3. REBT: techniques.

Techniques Explanation of techniqueLogical disputes Helps the individual identify the flaw and illogical elements of

the irrational belief.

Empirical disputes Explore the evidence for their irrational beliefs.

Functional disputes Help the individual identify what the negative impact inpractical terms would be of holding on to the irrationalbelief or beliefs, as well as the emotional and behaviouralconsequences of sticking to the irrational belief.

Rational alternative disputes Presents the individual with a rational belief that meets theirneeds in a positive way.


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122 S. Rait et al.

Table A4. CT: cognitive distortions.

Cognitive distortion Explanation of cognitive distortion

Personalisation Individual takes responsibility for events that are out of their control.

Dichotomous thinking A polarised or absolute view is stated, for example, everything isgood or bad.

Selective abstraction Negative aspects are focused on rather than the positive or neutral.

Arbitrary inference Individual arbitrarily reaches a negative conclusion without anyevidence.

Overgeneralisation Individual maximises the negative and minimises the positive fromlimited information.

Table A5. CT: techniques.

Techniques Explanation of technique

Decatastrophising Use of a what if question. This is related to a perceived traumaticevent and the individual is supported through the suggestion of arange of strategies of how to cope.

Reattribution Individuals are encouraged to re-examine and re-interpret events byconsidering other possible causes.

Redefining Helps individuals to redefine the problem so that they can act in adifferent way to address the difficulty.

Decentering Helps individuals to move away from their own problem and toconsider it from an objective perspective and carry out a

behavioural experiment to test out the faulty information

processing.Homework Individuals are given specific tasks to try outside of the sessions, with

a particular focus on how their thoughts influenced their feeling.

Hypothesis testing Individuals are initially asked to validate their thoughts and thentaught to test their beliefs in the real world.

Exposure therapy Aims to desensitise the individual to the distorted cognitions.

Behavioural rehearsal Individuals are encouraged to role-play in a safe environment so thatthey can then use this in real situations.

Diversion Individuals are distracted from the negative and distorted cognitionby focusing attention on other actions, for example, work, play,imagery and so on.

Activity scheduling Individuals are encouraged to set up and schedule in routines that willreduce negative emotions. These activities are also monitored andtracked for their effectiveness.

Graded taskassignment

Individuals are encouraged to take on increasingly more tasks in astepped way to address impaired cognitions.


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