Ethical and Cultural Issues in CBT Treatment with Children - Essay Example

Ethical and cultural issues that could arise when working with children and adolescents and Introduction Children and adolescents are a special group in the society. This is because they have unique needs which are different from those of the adults or the general public. These cultural differences are brought about by age differences since the young and the old, most probably, grew up in different cultural surroundings (Derisley, 2004). To that end, the ethical, professional and cultural issues that may arise for a professional dealing with these special categories of minors may differ from those that may possibly arise from dealing with adults. In psychotherapy, just like in any other area of treatment, children and adolescents should be accorded specialised treatment, one that is tailored to suit their unique cultural perspectives (Barrett, Duffy and Dadds, 2001). Cognitive behavioural therapy (CBT) has, especially, been found to be effective in children in treating psychosis and related mental health conditions. Even though these treatments are effective, their effectiveness would have been optimized had they been tailored towards children and adolescents instead of applying the general guidelines that were designed for adult interaction. As a result, more studies are being conducted on the use of cognitive behavioural therapy on children and adolescents (Spence and Donovan, 1998). This paper examines what cognitive behavioural therapy is and what are its benefits. It goes ahead to explicate how it is used with children and adolescents. Lastly, the paper discusses some of the ethical and cultural issues that may arise when dealing with children and adolescents. Cognitive Behavioural Therapy Cognitive behavioural therapy is a combination of cognitive therapy and behavioural therapy (Roth and Pilling, 2008). It is a major psychotherapy approach that has, of late, become very popular in the treatment of mental illnesses and conditions. Dummett (2010) observes that CBT, as an approach, is used to correct dysfunctional emotions and undesirable, potentially harmful, behaviours. CBT is goal oriented and is applied following systemic procedures (Spence, Donovan and Brechman-Toussaint, 2000). In this psychotherapy approach, the therapist and the client jointly identify the problem, illness or condition and then identify ways to overcome them. Goals are, therefore, identified and then systematic procedures instituted and which, if followed to the latter, may lead to the achievement of the objective of the therapy. Therefore, the therapy procedures and goals may differ according to the individual undergoing the treatment and the dysfunctional emotion or behaviour that is being treated (Beck, 1979). Stallard (2002) asserts that this aspect of being problem focused and action oriented is what has made CBT highly applicable in the field of psychotherapy. This is because it acknowledges the fact that people are different and that the traditional symptom-based general treatment may not be effective in psychotherapy. However, CBT and the general healthcare approach have significant similarities. They are both evidence-based approaches that rely on symptom-based diagnoses to offer treatment (Tarrier and Calam, 2002). CBT, however, goes a step further to consider the individual traits of the client in order to offer treatment, a practice that is not prominent in the general healthcare approach. Furthermore, clients utilizing CBT are included in decision making whereas those in the general healthcare approach are, typically, expert-led in that they are bound to accept the treatment prescribed by the doctors (Spence and Donovan, 1998). CBT has extensively been used in treating mental health conditions such as anxiety disorders, mood disorders, eating disorders, substance abuse, and personality disorders such as obsessive compulsive disorder among others (Stallard et al, 2007). CBT manages to achieve this treatment by making the presumption that if the maladaptive thinking in an individual can be altered for the better then the behavior and affect of the individual would also change (Beck, 1979). CBT further presumes that this change is directly proportional; the extent of the change in maladaptive thinking would produce an equal change in the same direction of the behaviors. CBT draws heavily from the cognitive model of emotions. This model explains that a person’s behavior and emotions are determined by the thoughts the person entertains (Tarrier and Calam, 2002). These thoughts are usually triggered by an action. The reaction of the person to that action, in terms of the behavior and the emotions that would be adopted, heavily rely on the thoughts that would be entertained of that action. Figure 1 gives an illustration of this relationship between the trigger, thoughts, emotions and behaviours of an individual. The hypothesis is that is the client perceives the action positively; they have positive thoughts which translate to positive behaviours and emotions (Wheldall and Merritt, 1991). For, example, if a teenage boy decides to approach a girl for a date and gets a negative answer, it is up to the boy to decide how he thinks about it. If the boy thinks of it as a personal rejection, chances are that he would develop personality issues and experience a dip in confidence levels. This is at the thought level. At the behavior level, the individual may become reclusive or even an outright antisocial or outcast. The boy may also become emotionally void and never approach a woman in life again. The thought level is, therefore, the most crucial level in the cognitive and behavioural therapy as it is the root of a reaction (Wheldall and Merritt, 1991). Figure 1: The cognitive model used in CBT (Source: Wheldall and Merritt, 1991) CBT, based on the aforementioned model, treats individuals by changing their thinking. Negative thinking such as overgeneralizing the situation, catastrophising an event or even downplaying a positive of an action and instead magnifying its negative are some of the things CBT addresses during treatment (Roth and Pilling, 2008). CBT enables the clients to replace these maladaptive thinking and behaviours with more positive, progressive ones. CBT commonly applies exposure therapy for individuals with anxiety disorders (Barrett, Duffy and Dadds, 2001). Through this therapy, an individual is gradually introduced into the subject that arouses the anxiety until the individual gets used to it. Cognitive processing therapy is another form of CBT where individuals are taught to consciously think about an issue in a positive way thus influencing behaviours and emotions positively (Dummett, 2010). The other forms of CBT include dialectical beavioural therapy, stress inoculation therapy and acceptance therapy. Cognitive Behavioural Therapy with Children and Adolescents CBT has been widely and extensively been used with children and adolescents (Stallard, 2002). This is because they are a special group that is still in the formative stage. These individuals, probably, have not yet formed an opinion about themselves about what the kind of individuals they want to become in life; they are still discovering themselves. CBT goes to the root of their thinking, correcting maladaptive behaviours and dysfunctional emotions (Barrett, Duffy and Dadds, 2001). According to Derisley (2004), CBT with children and adolescents can used in treatment programmes to address anxiety disorders, posttraumatic stress disorders, obsessive compulsive disorders, suicidal tendencies, school rejection, sexual abuse, conduct disorder, and depression. CBT interventions in children and youths may exist in the form of self-instructions, relaxation measures, developing of adaptive coping skills and techniques and goal setting. The choice of the form to be used is determined by the condition being treated and the individual’s characteristics (Spence and Donovan, 1998). Depression is a major issue in children and adolescents in the UK. CBT is, thus, mostly used to address depression issues among children and adolescents in Britain. In the UK, research suggests that the school going children have a prevalence of 1% to 2% to suffer depression (Roth and Pilling, 2008). In adolescent, the prevalence rate rises to between 3% and 8% then it more than double when the individual progresses into young adulthood with the prevalence levels recorded at 20%. The studies also concluded that girls have a higher prevalence than boys. For children the depression episodes in children subsist for an average of 3 to 6 months while in adolescents it averages 5 to 8 months (Roth and Pilling, 2008). The case of the use of CBT over other psychosis treatment for children and adolescents such as the use of drugs is strengthened by the high recurrence rates of depression bouts among individuals in these age groups. The depression recurrence risk in children is placed at between 30% and 70% while in adolescents it is placed at between 11% and 33% (Dummett, 2010). To minimize these recurrent rates, it is imperative that the root causes of the dysfunctional emotions and maladaptive behaviours be addressed; there is no therapy that addresses them better than CBT. The growing need for CBT treatment among children and adolescents in Britain has brought with it many challenges. The major challenge is that there are not enough cognitive behavioural therapists. There are many psychiatrists who are suited to handling the psychological issues of children and adolescents but fewer are able or skilled at applying CBT treatment (Roth and Pilling, 2008). CBT practitioners are different from psychiatrists in that they do not seek to provide solutions but rather provide a guide to discovery often through the application of Socratic dialogue to promote self-help (Stallard, 2002). Due to the scarcity of professional CBT practitioners, CBT treatment has also become scarce. However, the government is committed to see to it that it is available to all who would like to use it. As a result, many practitioners are now deserting other psychotherapeutic modalities for CBT (Stallard et al, 2007). This has brought with it some professional, ethical and ethical issues which ought to be addressed if the practice is to continue being as effective as earlier established. Cultural Issues Cultural issues in psychotherapy are those issues that emphasize the differences or uniqueness of an individual (Derisley, 2004). The major cultural issues, therefore, relate to the age factor. CBT is meant to help individuals across all age groups. But due to cultural differences between the young and the old, CBT treatments should not be standardized but rather adjusted based on the individual’s age. One of the cultural issues that could arise when dealing with children and adolescents is the cohort effect (Dummett, 2010). This is the effect that emphasizes the different in reaction to a CBT treatment programme because of the differences in the times that one grew or grows up in. Age, here, is seen as critical in shaping an individual’s thought processes and even the values being upheld (Barrett, Duffy and Dadds, 2001). For instance, children that were brought up in the mid 19th Century are said to be more decisive than those in the later part of the century. The former are also more likely to be cooperative because in the society they grew up in, deviance was not tolerated. Right now, with the increase in knowledge on human rights, the level of deviance and social miscreants has increased rapidly (Wheldall and Merritt, 1991). Today’s population of children and adolescents is not very helpful in collaborating with therapists in developing and using CBT tools for their own good. These children would rather suffer depression and be reclusive provided they have their own technological gadgets with them (Dummett, 2010). Today’s children and adolescents have better maladaptive techniques such as continuous watching of televisions and spending hours on end on a social networking site where they create their own little imaginary world to escape from the harsh realities of life. In as much as these techniques are helpful in the short run they are not in the long run because they do not treat negative thinking but just provide an alternative way of escapism (Roth and Pilling, 2008). As a CBT practitioner, interacting with today’s children and youths can be tricky if one does not understand the cultural surroundings that they grew up in and which have been heavily influenced by technological advancements. I tend to think that it should not be a surprise if this group of individuals fails to attach much importance in the CTB treatment programmes and even skip some of the programmes’ sessions. The other cultural issue is that, contrary to popular belief, CBT with children and adolescents may be easy to apply because they do not have an established role unlike the old (Tarrier and Calam, 2002). The social role of an individual determines one’s thinking and this may, in turn, influence the easiness or difficulty in adapting to the proposed CBT measures (Derisley, 2004). Issues like depression and posttraumatic stress disorders become easier to address in children because they do not have preconceived ideas and negative schema that bring about extensive cognitive bias. Lastly, children and adolescents are quick to learn unlike adults. They are yet to develop the rigidity in thinking associated with older people. They, thus, take less time to learn and retain cognitive therapy unlike the older generation. Therapists are encouraged to increase the pacing in children and adolescents (Stallard et al, 2007). Therapists should also use visuals and verbal tools to improve the retention capacity of the clients. Professional and Ethical Issues These are issues that relate to the operational aspect of delivering CBT treatment. Some of the issues that could arise when dealing with children and adolescents here include issues to do with the administration of exposure, provision of rationale behind decisions to the clients, use of reward systems with children so as to secure their cooperation, spicing up the treatment to make it interesting and determining the time to terminate the CBT programme in case of an unforeseen eventuality (Spence, Donovan and Brechman-Toussaint, 2000). One of the issues that may arise when dealing with children and adolescents is determining the rate of exposure. Exposure therapy is a form of cognitive behavioural therapy that is used to treat anxiety disorders and is extensively used with minors. It involves introducing an individual gradually into the phobia that causes the anxiety until the individual masters his fears and overcomes it (Stallard, 2002). The issue arises in determining the gradual rate. Children may not be mentally strong, if the gradual exposure exceeds it becomes a rapid shock which eventually ends up magnifying the fear instead of reducing it (Derisley, 2004). A good example is where there is a student who gets nervous whenever he anticipates to be asked a question in a classroom setting. If the teacher does not know how to gradually introduce the student into answering questions by asking him simple questions sparingly, the student may start to think of himself as a useless student who is incapable of answering any question. However, if the teacher starts by asking simple questions then the student changes the thoughts about him and gains a boost in confidence. The negative thoughts are eventually eradicated. The other issue is the explanation of rationale to the client. Questions abound as to whether it is professional not to explain the rationale behind a decision (Stallard, 2002). The theory of reciprocal determinism stresses the fact that it is important that the rationale behind decisions be given to the person affected by the decision (Wheldall and Merritt, 1991). Ordinarily, adults participate in defining the dysfunctional emotions and maladaptive behaviours and design ways to counter them. Children and adolescents may not have this level of cognitive ability. They may fail to effectively evaluate their situations. Consequently, self-help may not be achieved (Spence and Donovan, 1998). On the other hand, if the therapist goes ahead to provide those solutions to the problem encountered then the aspect of jointly developing the solutions, which is core to CBT, is lost. Therapists are, therefore, torn in some situations on whether they should go ahead and impose solutions or not. Another ethical issue relates to the use of rewards to secure cooperation from children and adolescents. Most of the children and adolescents undergoing the CBT treatment do not do it out of their own volition (Tarrier and Calam, 2002). Most of them have been directed to participate in the programmes. It is, therefore, highly probable that some might withhold their cooperation. The ethical issue here is whether it is right to induce them into participating and whether this inducement can influence their choices (Dummett, 2010). Loosely related to this issue is making of the treatment interesting through the use of reminders and appropriate language. Therapist should take care not to compromise on the quality of the treatment in a bid to make the treatment interesting (Barrett, Duffy and Dadds, 2001). Another ethical issue that may arise is whether to become emotionally attached to the clients or not. Children and adolescents demand special care from therapists. It is imperative that a therapist is able to draw the ethical line on the extents to which he can get involved in a clients life (Derisley, 2004). For example, there was a boy I interacted with who was my client. The boy had a complex personality disorder which made him unable to converse with people of the opposite sex. Whenever he was in a position to do so, he would feel agitated and anxious and would finally end up foregoing the opportunity. This problem had started when he was a young boy. The boy had spotted a girl with whom he wished to go on a date with. Without disclosing the details about the object of his affection, the boy approached me for guidance on how to go about it. The root cause of the problem was evident; the boy had confidence issues which propelled dysfunctional emotions and maladaptive behaviours. The CBT is a systematic process that involves a holistic approach to a problem and this takes even up to a year to treat (Stallard et al, 2007). But here was a boy who wanted urgent answers. I decided to help, against my better judgment. We sat and devised a plan that was supposed to secure the dream date. The next day, the boy executed the plan to the latter but he received a negative answer. The boy, expectedly, took the rejection personally and ended up depressed even further. The self-critical thoughts he was having intensified. In retrospect, I think it is not wrong for therapists to be emotionally attached to clients, but the treatment they design should not be compromised by the emotional attachment. The same guidelines should be applied to adults seeking or undergoing CBT treatment programs. It is ethical for adult clients to have a romantic relationship with their therapist, but it is not professional. In both cases, the ethics line is crossed once the emotional attachment compromises objectivity (Dummett, 2010). Oftentimes, the children and adolescents would be financially impoverished. Therapists may, therefore, find themselves in a caregiver role with no pay to look forward to (Barrett, Duffy and Dadds, 2001). Working with clients in financial straits may sometimes alter the goal of the CBT therapy. The focus may easily change from treating dysfunctional thoughts to social problem solving. An example here is of a girl who is suffering from depression due to taking care of her terminally ill mother. This girl has no income and relies on food stamps from the government and handouts from well wishers. If this girl is to be taken through a CBT treatment the focus would most likely be, first, on how to provide the girl with material needs, only after then would the focus be on mental peace and adaptive practices (Stallard, 2002). Therapists would be torn on which aspect should be given preference because in as much as the therapists would like to focus on dysfunctional emotions, it is also imperative that the CBT treatment program be conducted in the context of the children and adolescent’s families and physical environments they exist in (Derisley, 2004). It takes a good professional to strike a good balance between focusing on an individual and placing the problem in a context for the treatment programme to be effective. In conclusion, CBT treatment programmes are growing in popularity. CBT is based on the cognitive model which places thoughts as the root cause of an individual’s being. The thoughts are often triggered by an action and the thoughts, in turn, influence behaviours and emotions (Wheldall and Merritt, 1991). CBT treatment programs are designed to address dysfunctional emotions and maladaptive behaviours. CBT treatment programs should be specifically tailor-made for specific individuals and should be systematic. Children and adolescents are a unique group of individuals who, of late, have come to adequately benefit from CBT as a psychotherapy approach. They have their own special needs and characteristics that are culturally propagated. There are, thus, many professional, ethical and cultural issues that therapists should consider when administering CBT treatment with children and adolescents. These issues include the cohort effect, difference in mentality between the young and the old, emotional attachment with clients, working with financially impoverished clients and many other considerations. Professionals dealing with children and adolescents should design interventions taking into considerations all the aforementioned issues (Derisley, 2004). References Barrett, P., Duffy, A., and Dadds, M.,2001. Cognitive–behavioural treatment of anxiety disorders in children. 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