In this podcast Dr. Andrew Beck talks about the changes he has seen in CAMHS and how it is being affected by the COVID19 pandemic, why CBT is his intervention of choice, and the reasons he advocates behavioural activation to improve the mood children and families during the COVID19 pandemic.
Dr. Beck is the President Elect of BABCP, taking the position in July 2020 and he talks about his hopes for the future of the organisation including working in partnership with ACAMH.
Dr. Andrew Beck is President Elect of BABCP, taking the position in July 2020. He has worked as a Consultant Clinical Psychologist in CAMHS since 2006 and worked with children and adolescents for 30 years in a variety of settings. He has been Honorary Senior Lecturer at the University of Manchester since 2007 . He is a BABCP accredited CBT therapist and supervisor and has developed and run several CBT supervision courses and the first stand-alone CBT training course in India. He is a member of the BABCP Scientific Committee and is the former Chair of the Equality and Culture Special Interest Group of the BABCP. At BABCP Annual Conference, Bath 2019, he was elected as the next President of BABCP. He is author of Transcultural CBT for Anxiety and Depression (Routledge 2016) as well as many academic papers on CBT, supervision and work across cultures.
Interviewer: Hello, and welcome to the ‘In Conversation’ podcast series for the association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today I’m interviewing Consultant Clinical Psychologist Doctor Andrew Beck of East Lancashire Child and Adolescent Services. Andrew is also President-Elect of the British Association for Behavioural and Cognitive Psychotherapies.
If you’re a fan of our in conversation series, please subscribe on iTunes or your preferred streaming platform. Let us know how we did with a rating or review and do share with friends and colleagues. Andrew, thanks for joining me. Can you start by saying a little about yourself by way of an introduction?
Dr. Andrew Beck: Yeah, I’m a clinical psychologist. I work in a core CAMH’s in East Lancashire. I worked in Manchester and Tower Hamlets before that. Head of Psychology there. My specialism is in cognitive behaviour therapy. Though drawn systemic ideas as well and also got an interest in working with children who have neurodevelopmental problems, and as you said I’m President Elect to be the BABCP. So I’ve be President Elect for the past year and I’ve been a BABCP member for a long time and this July I’ll become the President for two years.
Interviewer: You’ve worked with children and adolescents for around 13 years, I believe. What prompted your interest in child and adolescent mental health.
Dr. Andrew Beck: Yeah, that’s a good question. I kind of fell into it really. I was around 19 years of age. Had left school without any real qualifications. Started doing some voluntary work. Kind of got pulled into applying for a job in a children’s home and found it really interesting and stimulating, but wanted to have more of an idea about how to help some of the young people that I was working with in the kids home and ended up going and doing a psychology degree and through that got interested in research and then eventually trained as a clinical psychologist and always kind of maintained that interest in working with children throughout my training period and then after qualification.
Interviewer: You’ve been in CAMHS since 2003. What changes have you seen within CAMHS in that time?
Dr. Andrew Beck: I mean, it’s been a fantastic time to be in CAMHS to be honest. So I first started working in CAMHS around the time when there began to be a real sea change in terms of investment in child mental health. So I was lucky enough to be around during that first wave of teams expanding, both in terms of the numbers of staff but also expanding the range of therapies that they could offer.
Get in earlier assessments for children and adolescents and then the move towards them. So adolescent Specialty Teams and it was an absolutely fantastic time and there was several years of year-on-year expansions. A real increase in the range of therapies on offer. An increase in our depth of understanding of child mental health, and I’m really lucky to have been involved in the second wave of that with the CYP-IAPT Programme which I think has done a lot to improve the range of therapies on offer.
Really skill up staff and a lot of really good staff in CAMHS but haven’t had access to a lot of therapeutic training and CYP-IAPT has really done that, and then this new wave of the mental health in schools programmes which is again increasing access, increasing the availability of evidence-based therapies for children and young people so it’s been a fantastic time really to bee involving in CAMHS and to be interested in therapies in CAMHS.
Interviewer: What changes though would you still need to happen, say in terms of helping clinicians better connect with their clients?
Dr. Andrew Beck: Yeah, that’s a really good question Jo. All the evidence that we see from the small scale studies that have been done suggest that kids from ethnic minority backgrounds are less likely to get referred to CAMHS, whether that’s for a neurodevelopmental assessments or for treatment of mental health problems, and I think one of the big challenges over the next few years is making sure that we give as good a service to our ethnic minority populations in the UK as we do to white majority service users, and I think there’s really a long way to go in terms of that.
We need to diversify our workforce and have work forces that look like the communities that we serve and then train existing staff in cross-cultural assessment and treatment. So I think that’s the biggest challenge now. We’re getting good evidence based treatments in place, but we need to make sure that they’re available to all the communities that we work with and I think that change has got to really come from Commissioners because services are under a lot of pressure.
Even despite the big investment services still don’t have the resources to treat the need that they currently have. That’s why we see long waiting lists. Children getting kind of sub-optimal amounts of treatment and therapy. So of course it’s really difficult for services in that situation to then step up and want to bring more people through the service.
So actually what we need is for Commissioners to take a, kind of, long hard look at the local data to see what’s going on in CAMHS Teams in terms of the ethnicities of people who are coming through and then to specifically ask CAMHS Services to improve the degree to which they work with local communities and bring those local communities through for treatments.
Interviewer: Andrew, as we mentioned at the start you are an Accredited CBT Therapist and Supervisor and you’ve developed many CBT training courses. Why is CBT your intervention of choice?
Dr. Andrew Beck: I think the first supervisor I ever had as a trainee was a cognitive behaviour therapist. So I think the first time I sat down in a room to learn how to be a therapist was using that approach. You know, I suppose we do tend to prefer the things that we’re first inspired by and, but what I liked about it was that it was pragmatic. It was fairly short term. It focused on service user goals and looked to make changes that service users identified as the ones they wanted to make, and then as I became, kind of, more interested in research evidence it was clear that there was a good, solid evidence base support in CBT for a wide range of problems and I would add a caveat to that though.
When you bring that kind of… those skills and interest into CAMHS you need to think systemically as well. So although CBT is my main model of orientation. I think it’s got a lot to offer in child mental health setting. We can’t ignore the systems around a child and their culture and their context. So in a way I think if you working in CAMHS you often find yourself doing CBT plus and the plus is taken into account and think about all those other things that impact on a child’s life, but it’s not to say that I don’t really value the therapeutic models and one of the things I like about working in CAMHS is that you’re part of an MDT and you work with systemic practitioners.
You work with art and play therapists. You work with people who are trained in interpersonal therapy and I think all those models also have a lot to offer us in terms of our thinking about child mental health and how we can help particular children who are struggling.
Interviewer: Andrew, you developed the first stand-alone CBT training course in India. I’m curious about this. How did this come about?
Dr. Andrew Beck: It was a really fantastic opportunity for me. I’ve been involved in CBT training in India… in England, sorry, through the IAPT Programme mainly. Some kind of colleagues in India who I kind of knew socially as much as anything else were really interested in setting up a CBT training course in Chennai in Tamil Nadu. Now there had already been a really good CBT training programme in Bangalore through Nimhans which is, there’s a National CBT Training Programme, but only a small number of people were able to access that and they had to be part of the faculty there to get onto that really high-quality CPT training course.
So what people wanted was something that people who weren’t part of that Network could access. So we worked with Care International which is a training provider in Chennai and the University of Chennai to get a short course that was modular. So people, myself or some colleagues from the UK could go for a week at a time and train people up into the various modules and help develop the skill set over there.
When I present that model, so I might do a couple of days training on OCD, for example. What the team did who had come on the training is think about how could they apply this in their own setting? So they did a lot of the adaptation themselves so that the specialists in child mental health who came along would work together as sort of mini teams as part of the training to think about how they’d adapt those ideas in the schools or in the hospitals that they worked in and likewise the people from an adult specialist would think about adapting it for their context and do a lot of the work around cultural adaptation as part of the training as they thought about these ideas and thought about how to apply them.
Likewise people working with children would think about well, how do we take these ideas down the developmental spectrum? You know, how do we work with kids at different ages in our context to make them applicable? Now what’s really nice about that course is that I don’t go over there and do the CBT training anymore because some of the people who did it early on are now more than capable of running courses themselves.
So it great that for a relatively small investment in time from people from the UK who had CBT expertise we’ve now got a really good group of therapists and trainers and supervisors in India who have been able to develop their own courses and get them up and running. So it was really good for me to be involved with that. I learned a lot about cross-cultural working. I was working with some of the brightest and the best mental health practitioners in India. You know, we had psychologists, psychiatrists, nurses, social workers come in.
I gained probably a lot more from that than I gave really as a trainer. It really helped develop my own thinking and it’s great to see that it’s got a life of its own now.
Interviewer: Did you bring back some ideas as well as those that you disseminated?
Dr. Andrew Beck: Yeah. Well I did and I think if I’d not, if I’d not gone over there and spent all that time thinking about cross-cultural adaptation I would never have ended up writing the book that I did on transcultural CBT. So although that was written for English, kind of British practitioners, actually the inspiration to write it came from me having to really work hard with my Indian colleagues to think about how those ideas developed in a western context fit across different cultures. So yeah, I got a lot of from that work and brought a lot back in terms of my own thinking.
Interviewer: We’re speaking during the 2020 COVID-19 pandemic and I know you’ve advocated behavioural activation as helpful in improving the mood children and families during the pandemic. Can you share some of the key principles of this and why it’s particularly useful at this time.
Dr. Andrew Beck: Yeah. It’ll be a pleasure. So, I mean, when I was training in CBT the model I used was very much cognitive and behaviour therapy for kind of childhood depression, but about five years ago I was lucky to attend some training that Professor Shirley Reynolds offered on using brief behavioural activation for depression and became very inspired by that. I’m very interested in this sort of evidence based approach to treat an adolescent depression, and when the pandemic started in the UK and a couple of days after lockdown I started thinking well, I’ve got kids. I’ve got a ten year old and a 14 year old kid.
They’re likely to be at home for weeks, if not months, and it has turned out to be a month what can I bring from my own kind of psychologically informed knowledge about child mental health that’s going to be helpful at home? So I looked to the work that Shirley people like Chris Martell had done on behavioural activation as a framework for that. Another that was developed for children who are depressed I thought it had a lot to offer just in thinking about time spent with kids in general. So what BAA suggests really at heart is that all of our moods are improved by the things that we do.
By the way that we spend our time and one way that BAA thinks about the activities we might do is to think about, it uses this acronym Ace, ACE. So in any particular tasks that we do does it give us a sense of achievement? Does it giver us closeness to others and does it give us enjoyment? So what you can do is think about how you spend your day and think about the tasks that you do or the activities that you do during the course of that day and ask, does this give me a good mix of achievement, closeness and enjoyment?
So an example of that might be, let’s say I’ve got a big pile of washing that needs folding and putting away. So I could do that and it would give me personally quite a high sense of achievement. It’s one of those things I kind of quite like doing, but if I did it on my own it couldn’t give me much closeness to others. I might get a moderate sense of enjoyment, but not a great deal.
So you can think well if I’m going to spend an hour doing that this morning it’ll have a slightly beneficial effect on my mood, but how about I got one of my children to do it with me. So that as we do it we can talk and how about I get them to pick the music we’re going to listen to while we do it and we can chat about the music while we’re doing it and both of us might enjoy that. So although I’ve got a task that might give me a sense of achievement to start with I can actually add some additional closeness and enjoyment to make that a genuinely mood boosting task for both of us, and I think if you’re looking at long periods of time with your children being sort of not occupied with school and not seeing their friends in the way that they would have done previously, using that way to plan the days to make sure that there’s a good mix for you and them of ACE activities.
Make sure that they are getting close to some of the people. That there are some really enjoyable either individual or family based activities planned in and to make sure people do get a sense of achievement is a good way of keeping everybody’s mood, kind of, going. Then everybody is mood well. Whether someone who has been depressed and is vulnerable to depression or someone who’s just dealing with the pandemic, but I’ve got a couple of things I’d like to add to that as kind of caveat.
So I think it’s a really useful model but something I’ve noticed as the pandemic has gone on is that even as a parent who takes those kind of things seriously it’s been tough to maintain them and there’s been days and sometimes days at a time when I found the activities have kind of slipped a little bit and I think all of our wellbeing has suffered then when we’ve fallen out our regular routines a bit. When perhaps bedtimes have got later. Family numbers have slept in a bit more.
Not spent as much quality time together and I do really appreciate how hard it is to sustain that over months and months at a time. You know, for most of us we’re going to be sustaining it right the way through until September.
Interviewer: Is it something in terms of abusing this idea of ACE? Should parents explain the concept to their children?
Dr. Andrew Beck: I mean, I always like to approach family dilemmas as collaboratively as possible. So I think most children from, yeah, nine, ten, eleven upwards would be able to get that idea of ACE activities and I think if parents sit down and explain it in a developmentally accessible way most kids would get that and understand the need to plan days a little bit. Now it’s interesting I think when I first…I mean I started writing something on, I think, like the second day of the lockdown and I think I was a bit over ambitious then in that I was thinking well, maybe we should plan a week at a time.
You know, that was the best way to do it and actually I’ve been putting this into practice with my own family, but also with the families that I work with as CAMHS practitioner and I’ve kind of changed my mind a bit about that now, and I if you’re planning one or two days ahead you’re doing pretty well and that’s probably a realistic amount of planning most families can do.
The other thing that I’ve really noticed in doing this work through the lockdown is obviously I kind of wrote that outline and came up with my ideas from a pretty privileged position. You know, I live in a big house. We’ve got, both myself and my partner are working. We’ve got money. We’ve got space. We’ve got resources to draw on and one of the things that’s really struck me during lockdown is how much you’ve got to think about bringing these ideas into play with families who are really struggling who are living in very crowded accommodation.
Who don’t have a lot of money. Don’t have a lot of resources. Parents who are perhaps struggling quite a bit themselves with mental health difficulties or financial pressures or even substance misuse problems, and I think in those kind of context you’ve got to be quite modest about how much you can plan and what would be considered to be a good day, but I still think that there’s something to be gained from that model, even with families who are really struggling to sort of plan some pleasant enjoyable activities that bring a sense of closeness and bring a sense of achievement into people’s days.
Interviewer: So where might one start if the family is in that situation where there isn’t money coming in, where the conditions are cramped and there were a lots of pressures. If one wanted to bring in that idea of ACE how could one do that in a fairly modest way when there just aren’t the kind of resources.
Dr. Andrew Beck: It’s a really good question, Jo. I think one of the things is to introduce the idea and just start off by asking parents and their child in the consultation as well to think about one thing they could change the next day that might just boost everybody’s mood, because families are incredibly resourceful and I tend to think that families who don’t have a great deal have learned to be pretty resourceful and will be able to come up with some solutions that as a therapist particularly one like me from a pretty privileged situation these days that I would struggle to come up with.
So I think having a facilitative discussion with families and getting them to reflect and getting them to think about just one thing that they might manage that next day is a really good step, and you may need to scaffold that a bit by saying, okay. So what might be the barriers? What might get in the way of you doing it? Is there anything I can do to help make that happen? I’ve also found, I mean, one of the really nice things about lockdown for me as a therapist is it’s got me more used to keeping regular contact with families through text for example, which a lot of services were bit funny about historically, but I could then the next day when we made a modest plan for one thing they might do just text and say how did it go?
What did you notice about how it impacted on everybody in terms of how you were getting on or your mood? What could you do this afternoon that might build on that or what could you add tomorrow? Even what you’ve learned about doing this that might just make life a little bit better then. So I think setting out with fairly modest aims, scaffolding discussions and then even, kind of, following up a little bit the next day with a text reminder and a prompt it might just help families to make a shift in a way that they’ll find genuinely helpful.
Interviewer: You’re implying from that that families do still have contact with CAMHS and I wanted to ask you about that. What impact has the pandemic had on CAMHS?
Dr. Andrew Beck: I think families who are already in the service on the whole are, my experience both within my own service and speaking to colleagues in other CAMH Service as is that despite a lot of care moving to remote care, either through video platforms on the phone that families who are already in the service are carrying on getting that.
I think some therapists have adapted to remote working better than others, but certainly a lot of therapists have really risen to that challenging CAMHS and drawn on a lot of the resources that are around on how to adapt your therapy for remote working and offered a good service, but my worry is that nationally the amount of referrals to CAMHS has gone down and I don’t think that’s because the need has gone down.
I mean, they’ll probably be a few kids who are struggling a bit less because school was a problem and when you take school out of the picture those kids may not need CAMHS referral as urgently as before, but equally there’s probably as many children for whom school is a massively beneficial place and has actually positively help their mental health.
So I’m not sure that the absence of school explains the reduction in referrals. I think it’s just families are a bit reluctant to contact their GP or other people who might have referred them to CAMHS and who are sitting on problems and struggling with them and not reaching out and getting the help that they might typically have got. My expectation is and I think a lot of services are gearing up for the idea that as the lockdown eases September time that we’ll see a massive increase in referrals into CAMHS as those families then begin to seek the help that they need, and also the children who are likely to struggle to return to school after a long break will need CAMHS input as well.
I mean, we’re lucky in the northwest where I work in that we’re one of the trailblazers for the mental health in schools initiative. So we’ve got a lot of staff currently in training and working in schools who will be able to pick up a lot of that work in September but I know that not every region has benefited from that so far. The idea is that everywhere in England will get that investment eventually. So I think CAMHS services that have been have got those partnerships into schools will probably manage, but but it is going to bring additional pressures onto other services.
Interviewer: I’m wondering if the pandemic might be an opportunity for better investment in Child and Adolescent Mental Health Services. What do you feel? Are you optimistic?
Dr. Andrew Beck: Before the pandemic there was this big investment in the mental health in schools programme anyway. So it’s been one of the few areas of the NHS where I think there’s been a genuine investment in spend rather than just, you know, not even keeping up with the pace of inflation. So I do think that investment was already happening and will continue to happen as it’s rolled out in different regions. I’ll be really surprised if the core financial packaging to CAMHS increases significantly.
I have read some estimates that at current funding levels we can meet somewhere between 35 and 40 percent of the need in the population. The school’s projects will increase that a little bit but I think we’ll always be somewhat underfunded for the tasks that we’re doing. What I think may improve though and genuinely improve as a result of the pandemic is that we’ve had to quite rapidly learn to work more flexibly as CAMHS services, and so services that might for example have really been reluctant to offer phone or video based appointments are doing that as a matter of course.
Services that might have been a bit reluctant to move to electronic patient records suddenly find that there’s a huge drive to do that because then staff can access records from home and provide a much better remote service. So I do think and I really hope that as CAMHS Services we’ve learned to be more flexible and that some of that flexibility will remain in the service after lockdown ends to the benefit of our families because for some families, I think this is the case in a lot of regions, getting to a CAMHS appointment is really tough.
Okay. You may have to take two buses to travel to a hospital that might cost £10 for a family of two or three which is a lot if you are struggling financially. So being able to more readily offer remote appointments might really benefit families in terms of access. So I do think we should see some genuine improvements in the service that we offer?
You know, I usually would happily have sort of six appointments on a day and really you feel energised by those and the move to being more creative and flexible and offer those as remote appointments has been pretty tiring and it took a lot of getting used to, but probably three months in I’m finding it less tiring and genuinely think I’m beginning to offer as good a service now as a remote therapist and a remote supervisor as I did in the room four months ago.
Interviewer: Is there a sort of self-care element then?
Dr. Andrew Beck: That’s a really good question. I think as practitioners we’re generally pretty awful at that, aren’t we, and a lot of the online resources around the move to remote working and the move to remote supervision have taken that into account and emphasised that need for for self-care as a practitioner, but also if you’re a supervisor for thinking about the well-being of the people that you’re supervising who are working remotely.
So I’ll just give a quick plug for there’s a podcast and a document that Professor Sarah Corrie and I did for the BABCP which is available for non-members on our website around supervision during the pandemic and we really emphasise that need for kind of looking after the emotional well-being of staff as an important part of that move to remote supervision. So as a supervisor you’re asking about it. You’re thinking about it and you’re acknowledging those additional challenges that come because if we’ve got, you know, an emotionally healthy workforce we’re going to have a better workforce in terms of patient outcomes.
Well look on BABCP as a Google search term and then there’s a whole set of pages on COVID resources and you’ll find the supervision resources there and you’ll be able to find a link to the podcast to Lucy Maddox.
Interviewer: Andrew, what else is in the pipeline for you that you’d like mention?
Dr. Andrew Beck: Well, I mean, take over the Presidency of BABCP really and I’m taking over from Paul Salkovskis who I’m sure everybody who’s worked in child mental health will know about Paul’s work. He’s a pretty tough act to follow to be honest. He’s an absolutely remarkable figure in terms of mental health and has been one of the genuine pioneers in terms of improving CBT as a trainer, as a supervisor, as a researcher, but also has done tons in the organisation around improving the way that we think about diversity in the way that we offer therapy.
So the big thing in the pipeline for me is stepping up into that role. Continuing the really good work that Paul has done around diversity, and of course this is something that all organisations need to be thinking more about at the minute and one of the really positive things I think that’s come out of the Black Lives Matters Campaign in the UK is it has put all organisations under the spotlight in terms of how they think about equality and diversity and I think that’s absolutely for the best that there is more scrutiny.
So BABCP we’ve made a good start around that but I think there’s more work to be done. What that probably means for me is more opportunities to train people on this topic. You know, for the past few years since the book came out I’ve done a lot of training for organisations around improving how people provide therapies to diverse communities.
So I’ll probably do some more of that. So certainly one of the things that I’d like to see over the next few years is, I think there’s a lot of shared interests between ACAMH members and BABCP members and we’ve had a really good history in the past of joint training events where our Child and Family Special Interest Group have come together with ACAMH to put on some joint CPD, and I would really like to see over the next couple of years to see that happening again, because I think our organisations do have a lot in common and there are many people who are members of both organisations or who are members of one but keep a close eye on what the other is doing because they see the value of what that organisation offers.
So I think I’d really like to see that. Personally I think the big challenge for me is I can’t see the sort of world of COVID changing a lot over the next year or two. So it’s continuing to think about how you can make family life genuinely enjoyable during these constraints.
Interviewer: Finally Andrew, what is your takeaway message for those listening to our conversation?
Dr. Andrew Beck: Well in terms of child mental health I think that provision of evidence-based treatments is immensely helpful and we’re moving towards getting those treatments more widely available, but there’s still a long way to go and that includes working with our minority communities to make sure that their mental health needs are met because historically I think they’ve been very poorly served, but also thinking about their challenge to come around the end in the pandemic lockdown and the return of children to school and looking after the mental health needs of kids who have been very isolated for quite a long time now and who may need additional support to get back to the the challenges of being at school or who may have had mental health needs that just haven’t been met because it’s been difficult for parents to get to speak to GPs and get referrals made.
So I think there is a fair task to do and meeting lots of unmet needs but we do have a pretty good idea about what’s going to help and we’ve got skilled mental health practitioners, both in CAMHS, third sector and in schools who can rise to that challenge. So I think that’s what I’d like people to take away from today.
Interviewer: Great. Thank you Andrew. Thank you so much. It was really interesting. For more details on Doctor Andrew Beck please visit the ACAMH website www.acamh.org and Twitter at ACAMH. ACAMH is spelt A C A M H and don’t forget to follow us on iTunes or your preferred streaming platform and let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.