JOURNAL OF SOCIAL WORK PRACTICE, VOL. 17, NO.

2, 2003

Surviving the swamp: using cognitive

behavioural therapy in a social work setting

STUART MATTHEWS, ANNA HARVEY & PAMELA TREVITHICK

Summary This paper explores the attempts of an adolescent support team working for South
Gloucestershire Social Services, to integrate Cognitive Behavioural Therapy (CBT) into its practice. We
explain how we, as a team, undertook a year-long course of study in CBT and discuss the advantages and
difficulties we encountered. Then, beginning with a case study, we draw out the limitations of trying to use
CBT in a social work setting. We focus specifically on how the complications of wider family systems will
often compromise individual therapeutic work with young people and conclude that a more pragmatic
approach to CBT is required in social work, rather than attempts to replicate work carried out in the
clinical setting.

Introduction
This paper looks at the application of a cognitive behavioural approach within social work. We
begin by charting the journey taken by our local authority social services team in relation to
a year-long course of study in Cognitive Behavioural Therapy (CBT). We then focus on two
themes. Firstly, how the team reacted to this sustained period of training, and secondly we
highlight some of the difficulties we continue to encounter in our efforts to integrate and to apply
what we have learnt in our CBT training to our work with young people and their families. A case
study is used to illustrate some of common difficulties we encounter.

Context
South Gloucestershires Adolescent Support Team was created in early 1999 following the
closure of the countys last childrens home. The teams main objective is to prevent young people
entering the care system by offering support to families at times of crisis. Packages of support
include direct work with young people, family work and, increasingly, group work. This includes
parenting skills and womens groups. Support to foster carers and children who are looked after is
also provided. The team is made up of both qualified and unqualified social workers, coming from
a range of social backgrounds but with a common interest in and commitment to young people.
As a team, we felt we were doing a good job when we embarked on the training. We all had
skills and experience that enabled us to engage quickly with most of the young people with whom
we worked, and the ability to give difficult messages to parents about changes they could make to

Correspondence to: Stuart Matthews, South Gloucester Social Services, Adolescent Support Services, 43 The
Park, Kingswood, South Gloucester BS15 4BL, UK. Email: happy@stuman.fsnet.co.uk

ISSN 0265-0533 print/ISSN 1465-3885 online/03/020177-09 # 2003 GAPS

DOI: 10.1080/026505302000145680
178 S. MATTHEWS, A. HARVEY & P. TREVITHICK

their parenting styles and family cultures. We all had, through education, training and our own
reading, a knowledge and understanding of various theoretical approaches used within social work
but this was not uniform across the team and most of our decisions and actions were based on the
practice wisdom we had accumulated over the years. The dominance of practice wisdom over
theory is a common experience in social work, made worse by the fads and fashions that
preoccupy social work (Sheldon, 1995, p. 6).
Over time, we began to see that we had, in fact, a poor understanding of theory. As our
awareness increased, a corresponding desire developed in the team to improve the theoretical
basis for our decision-making and our work with young people. We recognised that this would
give us greater confidence as practitioners and better serve our clientsan ethos we were actively
seeking to nurture in the team. As a result of our team discussions, and with the active support of
our manager, it was decided that we should focus our training needs on Cognitive Behavioural
Therapy (CBT) or, in social work terminology, a cognitive-behavioural approach (Hudson &
Sheldon, 2000, p. 63). We had some familiarity with CBT. Many of the team were already using
cognitive behavioural techniques gleaned from books we had read, or short training courses we
had attended, but none of us felt we had the full picturethe understanding of why or how these
interventions worked. What we did know was that it was a theory and an approach with a strong
evidence base, something which we, as individual practitioners, wanted to explore, and a
perspective that is supported by South Gloucestershire, as well as the Department of Health.

The training experience

Following our decision to focus on CBT, the team enrolled in a post-graduate certificate in
counselling (cognitive behavioural), which was taught in-house over an academic year by a
lecturer at the University of Wales College, at its Newport site in South Wales. We met for three
hours every second Thursday with reading set in between. Assessment involved two 2,500 word
essays and a tape-recorded session with a client. The course covered the cognitive behavioural
model, case formulations and specific techniques and approaches. In addition, consideration was
given to the use of treatment plans for particular difficulties and disorders. The teaching format
involved traditional didactic methods, the use of video and audiotapes, and case discussions. The
year ended with a day spent at the university in Newport, where we presented a seminar to other
students outlining our experiences trying to implement CBT in the social work environment with
adolescents.
Although often referred to as one distinct therapeutic or practice approach, it is worth noting
that Cognitive Behavioural Therapy is a generic term. As Hudson and Sheldon point out, the
therapy is made up of two overlapping sets of techniques, their attendant psychological theories
and bodies of empirical research (2000, p. 63). The training we received had a strong bias toward
the cognitive element of this combination. This in itself is not a problem, but does raise important
issues if the training veers towards either the cognitive or behavioural aspects of the approach,
because this will result in noticeably different ways of working.
The training we received proved to be enormously interesting and stimulating. However, we
did not account for the impact that this training could have on us, as individuals and as a team. In
our enthusiasm to learn, we did not realise how our emotional engagement with the process
would affect us. Over the course of the training, several team members experienced a sense of
personal upheaval as we grappled with trying to understand what was happening to us, and to do
this in a new way. This was both enlightening and exhausting, but a particularly important
experience because it enabled us to appreciate more fully the impact of work on service users, a
dimension that is easy to overlook when working with people in crisis.
 COGNITIVE BEHAVIOURAL THERAPY IN SOCIAL WORK 179

Running parallel to the impact that we experienced as individuals was the collective impact the
training had upon the team. We found ourselves in a new environment, one where our intellectual
and practice abilities were being exposed, in ways we had not anticipatedexposed in ways that
meant that our skills and abilities could be contrasted and compared. This felt uncomfortable and
was an element that was not picked up on or processed at the time. As a result, those who did
well felt unable to enjoy their success, and those who did less well felt embarrassed or
discouraged. In any team, there are individuals with different levels of ability, motivation and self-
awareness and this fact is reflected across social work as a profession as a whole. What occurs to
us now is that social work practice is rarely, if ever, analysed or understood in a team context.
Therefore differences are not overtly addressed, yet the impact of these differences can be
criticalas social workers, service users and managers will all testify. Teams made up of a range
of mixed ability will always exist, with attendant strengths and weaknesses. It is therefore
important for this fact to be recognised and for this group dynamic to be given careful
consideration before any kind of team training is embarked upon, particularly where this is a more
intensive or exposing experience. As a team we were able to work through these difficulties.
Preparing for them in advance, however, would have been valuable and would have saved
considerable energy in the long run. It would be challenging and exciting if managers could create
a climate that allows for, and works with, the differences that exist within teamsthis could have
important benefits both for individual team members and the organisation.
A further difficulty we faced in our training was coming to terms with the degree of theoretical
information we were being presented with, and expected to learn. Our preconceptions of the
course before we embarked on it had been, perhaps naively, that we would be taught how to do
CBT. The expectation that we might also have to understand why CBT workedits theory
seemed somewhat alien to many of us. Indeed, our common complaint at the beginning of the
course was that it was not practical enough, and was not relevant to the young people who made
up our client group. The idea that it was down to us to adapt the training and approach was not
one that came easily. Although our teacher did take steps to make our training relevant to work
with children and young people, the approach we covered, particularly in the early part of our
training, was focused on work with adults. This raises an important issue. Any training has to fit
into the needs of practitioners and anyone considering training would do well to ensure the
programme of study is going to be relevant to their work before thinking to set up training of this
kind. South Gloucestershire has a strong commitment to training and to supporting its staff in
their professional development but matching training to staff needs is not always easy, particularly
if staff are not clear what it is they need to know.
The difficulty linking theory and practice, and finding good training, was not new to us but in
the past this dilemma mainly focused on the lack of theorysomething that was not lacking in our
CBT course. As a team, one of the shortcomings of our experiences with external training has
been that many trainers deliver the mechanics and techniques of certain approaches rather than
giving a theoretical framework on which to hang those approaches. This produces a particular
kind of dependency on those trainers who pursue this standpoint: if we need to understand more,
and no reading lists are provided, this means that we have no option but to invite further training
in the hope that this might unravel our confusions. It is as if we were being constantly given
directions but never the map. As Whittington notes (2000), a more a-theoretical approach to
training is likely to follow a technical model, rather than an approach that encourages critical
thinking (Gambrill, 1997, pp. 125156) or a more reflective and creative approach to practice,
and to learning and teaching. Training cannot answer all our confusions and given the kind of
work we do, with disturbed adolescents and equally troubled parents, we are always likely to be
up against impossible problems, as Schon notes:
180 S. MATTHEWS, A. HARVEY & P. TREVITHICK

There are those who choose the swampy lowlands. They deliberately involve themselves in
messy but crucially important problems and, when asked to describe their methods of
inquiry, they speak of experience, trial and error, intuition, and muddling though (Schon,
1991, p. 43).
We know how to muddle through, but given the nature of the swamp, we need more than
directions, which is what we now have in the consultancy we have set up for our group-work. This
links theory and practice, directions and the map, based on a psychosocial perspective. The
advantage of any theory and skills-based approach is that it enables us to understand and link
the relationship between concepts and techniques and, therefore, to adapt our practice more
effectively to the complex environment that is characteristic of work with children and families.
For any team who may be contemplating a similar training experience, we think it is important to
think about the impact that the training might have on individual staff members, who may require
additional support. Where the training exposes individuals intellectual, academic and practice
abilities, this needs to be recognised at the time, processed and capitalised upon.
Through the use of a case study we hope to demonstrate how we attempted to apply our
training to practice. Following this we will explore how we experienced the process of integrating
CBT into our work and identify some of its common strengths and weaknesses.

Case study
Joanne, a white 15 year old, was referred to social services after she was charged with criminal
damage at her home and detained in police custody overnight. Her mother, Sue, and father, Tim,
and her younger brother and sister, were very reluctant for Joanne to return home as she had a
history of poor anger management that sometimes led to frightening episodes of physical and
verbal abuse. As a temporary measure it was agreed that Joanne would stay with Pauline, her
older half sister, and undertake some intensive work to bring her anger under control with a view
to her returning home within four weeks. Alongside this work, Joannes younger siblings were
given the opportunity to express their feelings about recent events at their home and, in particular,
about Joannes angry behaviour. Support was also offered to Sue and Tim. At this time, Joannes
motivation to change her behaviour was high. She clearly demonstrated a capacity for self-
reflection and her parents were being supportive. Therefore CBT seemed an appropriate initial
intervention to assist the family.
To begin with Joanne was offered two sessions a week for four weeks. The initial focus was to
look at what triggered Joannes fury and the extent to which she had the capacity for self control
and to formulate a simple case conceptualisation. A case conceptualisation or formulation (the
two terms are used interchangeably) is a way of seeing a clients difficulties in a sequential and
interrelated way. At its most basic it draws together their thoughts, feelings, behaviours and
physiology resulting from a critical incident, whilst in its fullest form it charts the root of these
in early experiences, core beliefs and assumptions. Case conceptualisations are seen as being
fundamental to any CBT interventionthey are a constantly evolving piece of work that both
inform and drive the therapy. Joanne engaged fully with this process using the cognitive triangle
(a representation of the links between a persons thoughts, feelings and behaviours following
a critical event or trigger) and began to keep thought records to note her strongest negative
automatic thoughts, or hot thoughts with a view to looking at these reactions.
Joanne was having regular contact with home and the situation, on the surface, looked
promising. However, as time passed, it became increasingly clear that Sue and Tims ambivalence
to the idea of Joanne returning home was not abating in any way. Indeed, what was evident was
 COGNITIVE BEHAVIOURAL THERAPY IN SOCIAL WORK 181

their capacity for discounting any positives about Joannes progress in managing her anger. It also
became evident that Sue was actively withdrawing any responsibility for triggering situations and
was very reluctant to recognise how her parenting style had, often, supported Joannes behaviour.
These tensions, along with the fact that Joanne was feeling increasingly isolated from her family
and friends, over took the work that was being done. Joannes motivation lessened without
familial encouragement, and she initially became very low emotionally and then deeply angry,
resulting in a violent confrontation with Sue after her mother refused to lend her money. Joanne
did not return home and our role shifted abruptly from therapeutic to crisis work. Instead of
implementing cognitive behavioural techniques within subscribed boundaries time was spent
chasing after a deeply distressed teenager who had become a risk to herself as well as to others.
The priority changed because we needed to find somewhere for Joanne to live and also to
maintain some kind of meaningful contact with her family, despite the polarisation that
subsequently ensued between Joanne and her mother.

Linking theory and practice

Traditionally social work has drawn upon systemic and developmental theories with special
attention being paid to attachment theory (Fahlberg, 1996; Howe, 1995; Brandon et al., 1998;
Cairns, 2002) in order to help people unravel the complexities of their lives. These approaches,
coupled with practitioners practice wisdom, have been applied to young people whose needs are
categorised under particular emotional and behavioural headings. Our team encounters such
difficulties routinely and, in common with other professionals, must assess, intervene and review
regularly in an attempt to improve the circumstances and life chances of our young service users.
This of course is greatly complicated by a lack of resources, a lack of cohesiveness between various
agencies and, historically, inadequate social work theory. In recent years considerable efforts have
been made to counteract these shortcomings and new texts have emerged (Adams et al., 2002;
Trevithick, 2000) and the drive towards more evidence-based practice is symptomatic of attempts
to explicitly link theory to practice. South Gloucestershire Social Services is one of the authorities
that adheres to this more rigorous approach and therefore supported the teams training because
one of the strengths of CBT is that it claims a strong empirical base.
Understanding how other theories could sit alongside CBT and inform our practice was an
important lesson to learn. Developmental theories have clearly had a role in helping us to assess a
young persons awareness of their internal world and to access their thoughts in ways that help us
to determine the suitability of certain cognitive aspects of CBT to help them. The link between
CBTs concept of schema or core beliefs that form an internal model of the world seemed to
mesh strongly with our understandings of attachment theory. Together they added a further tool
to our repertoire in helping to explore and explain this often complex area to young people and
their families.

Using CBT with children and young people

Children bring to the therapeutic process particular challenges due, in part, to their age and
emotional and physical immaturity: limited reasoning skills; difficulties with conceptualising and a
poor sense of deferred gratification (Bee, 1997; Ronen, 1998). Traditionally this has meant that
behaviour, not cognitions, has been the focus of the intervention. However, as the model of CBT
with children continues to develop the picture is altering. According to Ronen, it has become an
umbrella term for different treatment techniques that can be offered in many different sequences
and permutations (1998, p. 2). A major characteristic of this change is the adjustments of some
182 S. MATTHEWS, A. HARVEY & P. TREVITHICK

methods and techniques to individual problems, while taking individual differences into account.
Thus it is imperative at the initial assessment stage that social workers consider and work with a
wide range of variables: age, gender, cognitive stage, emotional development and, significantly, in
contrast to adult therapy, the role of the family system (Ronen, 1998). This considerable data
helps inform the worker as to whether a problem exists, who should be treated (as this model
extends beyond the individual) and what techniques should be selected and adapted to best meet
the childs unique needs and abilities (Graham, 1998). In Joannes case, working to a cognitive
behavioural model was not viable because it was not possible to exercise enough control over the
variables at play in her circumstances. As Herbert (1998) points out, changes seen in one
environment, such as a therapy session, will not necessarily follow an individual into another
environment, if that environment still contains strong stimuli likely to trigger an unhelpful
response. This is particularly so if the initial changes are at a behavioural rather than at a cognitive
level. Psychodynamic theories tell us that people work from their histories and systems theory tells
us that a threat to the status quo will always be challenged. In Joannes case it proved impossible
to use CBT because of the problematic relationship history between her and her parents and
because of the function that Joanne fulfilled in her family. Until there was a willingness to expose
and to work through these components, Joanne could not hope to address the difficulties she had
with anger in any sustainable way regardless of the individual therapeutic approach used with her.
In essence, the training that we received, although of a high standard, did not prepare us for
the complexities inherent in social work. Few authors have addressed this area and the issue
remains one that requires further investigation and consideration. Lane (1998) writes with
authority of the importance of including the system around the adolescent in any work in order to
maximise the chance of success and minimise the chance of remission, but when working with
crisis, this option is often elusive. It must be recognised that without the support of a young
persons family, and possibly school as well, the chance of a successful intervention using CBT
will be minimal.
CBT has its genesis in a clinical setting, where individuals receive treatment on a one-to-one
basis for specific problems and, for the most part, it continues to be practised by therapists in this
particular environment. Although clinical practice is the norm, there are those who positively
promote the idea that social workers practice theory, approach and position in the community
render them eminently qualified for direct child intervention, and that CBT is an appropriate,
feasible and exciting approach that the social worker can use (Ronen, 1998, p. 43). This
proposition, appealing as it is, is not without its difficulties as the case study shows.
The greatest challenge we continue to encounter when trying to apply CBT in practice is the
complex and competing needs and demands of the families that we work with. Frequently
parents/carers and their young people are polarised when we begin to work with them, and often
the adults have poor motivation to try any other approaches believing that they have done
everything and nothing works. At its most dogmatic, this belief subsequently leads to requests
for accommodation and withdrawal of emotional support. Given that CBT with young people
requires significant engagement with family members the lack of commitment from parents and
carers to the process creates a hurdle that has to be overcome before work can commence with
any reasonable chance of success. Closely aligned to this is the motivation of the young people
themselves. Children and young people are rarely key players in determining whether they take up
a service or not. Most often a service is imposed. This difficulty is not insurmountable but it may
require considerable effort to overcome. In our team much time and attention is invested in
establishing relationships with service users that are as democratic as possible. This dovetails well
with the principle of empowerment inherent in CBT but it can also militate against the work if the
young person chooses to opt out. One dilemma we continue to come across at this stage is
 COGNITIVE BEHAVIOURAL THERAPY IN SOCIAL WORK 183

whether our attempts to influence and counteract this desire to opt out can be experienced by
young people as oppressive.
Another difficulty that we continue to come across is that when motivation is assessed to be
sufficient and we are about to begin to use CBT we often find, much to our frustration, that a
fresh crisis erupts in the family and we are left to resort to fire fighting, and to losing our original
momentum. In Joannes case the need to find accommodation entirely overtook the work that was
being done in her one-to-one sessions and illustrates very well the difficulties we face. In essence,
familial crisis coupled with entrenched family dynamics, frequently hijacks the practice of CBT
and as a result at times this has left us feeling discouraged and lacking confidence in our skills. In
situations where our work with young people has clearly been unsuccessful, perhaps all we can
hope is that the experience of working on a one-to-one basis with a social worker has been a
positive one and that the young person has felt valued and listened to.
What further complicated our efforts to use CBT and practice in an anti-oppressive way is the
conflict that exists between confidentiality and statutory responsibilities, which can sometime
overshadow the interests of the child (Bourn, 1998). For example, if a young persons behavioural
difficulties and negative belief system has been shaped by their experience of abuse, workers are
required to forward this information. Many young people are acutely aware that this kind of
disclosure will lead to further investigation and this knowledge in itself can act as a brake on the
therapeutic process, thus preventing an accurate case conceptualisation forming and skewing the
work and strategies put forward. If child protection procedures have been instigated this in turn
can set up an almost untenable situation where it is very difficult to work with a young persons
cognitions in the face of the intrusive impact of child protection procedures and the mandate to
not lead the young person in any way. While young people should be made aware of the
exceptions to confidentiality, they remain in emotional isolation if they know that the experiences
and pain that they need to speak about is the very thing they must not say in order to maintain
some control of their disclosure. In terms of CBT, and in fact other social work approaches, this
remains a dilemma that has yet to be resolved.

Reflections
We, as a team, recognised the importance of the link between theory and practice. We knew why
we chose CBT as an approach and we came to the training, supported by management, with
enthusiasm and commitment. This was not enough. Despite our positive expectations and best
intentions, within a year of our implementing CBT we were floundering. Gradually we began to
ask ourselves why and to review the whole process. This proved to be a cathartic experience both
individually and collectively. Workers began to talk about the way that they found the training
experience difficult, their loss of confidence in practice and the loss of morale this engendered.
The CBT training featured significantly in a team development day and from talking, staff began
to feel re-energised about the topic. What we discovered was that we had established our own
vicious circle. The trigger was a lack of success, we had begun to think that we couldnt do it
and this led to feelings of inadequacy and anxiety. As a result, we had begun to use CBT less and
less. Through exploring our experiences and the evidence that supported our beliefs, we began to
challenge these feelings and to establish alternative perspectives and belief about our work and
ourselves.
This renewed confidence has resulted in a plan to revisit our training and to provide a firmer
framework of support and development for those team members who want to continue to use
CBT in their work. Our advice to any team embarking on similar experience would be to do this
sooner rather than later. After finishing our training we failed to set up a system to maintain the
184 S. MATTHEWS, A. HARVEY & P. TREVITHICK

momentum of our learning. We practised our newly learned skills as individuals in isolation from
each other and any reference to CBT was usually informal, as opposed to a part of a structure.
We also recognise that utilising a cognitive behavioural therapist on a consultancy basis, perhaps
as a part of team supervision, would have been hugely beneficial in the early months of our
practice and we would highly recommend this approach to any team considering a similar route.
The detailed analysis of our experience also highlighted more global factors, significantly, that
we had focused on the training element of CBT with scant regard for the environment we were to
practise in. With hindsight this appears foolish, yet we know that the reality of much social work
is to hit the ground running and we, like others, assumed we would manage. In reality,
environment is absolutely critical to the successful application of CBT. We now recognise that
very few families will meet the selection criteria for this therapy in its purest form. To identify
those who do requires a change to our current referral system and this is presently being reviewed.
For those families where CBT seems inappropriate, elements of it can still be used positively.
Despite the difficulties we experienced there were many positive outcomes from the process
under discussion. While we have not all been transformed into fully functioning Cognitive
Behavioural Therapists, we do now have a shared point of reference, a common language and
a solid foundation for decision-making. The realisation that we now, unconsciously, use the
language and ideas of CBT more and more in our work dawned on us slowly. The benefits of this
are significant. Having shared a detailed understanding of a theory, particularly one as well
evidenced as CBT, we are in a position to approach cases from a consistent angle. It has given us
a benchmark from which to review other ideas and approaches and it has given us greater
confidence in our work with other agencies. The adaptability and accessibility of CBT techniques
means that it can be used on an ad hoc basis, providing the practitioner has the theoretical
understanding of why he or she is employing a particular technique with a client. Looking back on
our two-year journey with CBT this last point seems obvious. We have seen the benefits of
introducing an angry teenager to the use of self talk as an anger management strategy over a game
of pool, or helping stressed parents to identify the cognitive distortions they are employing when
focussing only on their childrens negative behaviour. These benefits were not immediately
apparent to us. Our training, which derived from a counselling perspective, influenced us to
regard CBT as being valid only in its purist, clinical form. In effect, we have travelled from this
purist perspective to a pragmatist one, increasingly confident in the service we now offer. We have
the directions and the map and, hopefully, the capacity to do good work in social works swampy
lowlands.

The writing experience

As practitioners we are neither encouraged nor expected to write about our work. It is considered
to be the domain of academics and unfortunately it is our experience that few practitioners
consider themselves capable of writing, let alone contemplate the act itself. Our experience of
training in CBT and attempting to implement it in our work, however, seemed too important not
to share with colleagues. The process of writing has been long and not without its difficulties but
ultimately it has been a rewarding and informative experience. The analysis and thinking required
to put our story to paper has brought up issues that otherwise we would have remained oblivious
to, particularly in the complex arena of group dynamics. We hope other practitioners will feel
inspired to also write of their work, their successes and difficulties and would welcome
correspondence from anyone wishing to know more about our work or wanting to exchange
thoughts and ideas.
 COGNITIVE BEHAVIOURAL THERAPY IN SOCIAL WORK 185

Acknowledgements
The authors would like to thank Nick Thorne (Training Manager, South Gloucester), Peter Parry
(Team Manager), Phillip Lewis (Team Co-ordinator), colleagues at 43 The Park, Judith Thomas
(UWE) and Nigel Sherriff.

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