Profile: Professor Shirley Reynolds Talks Child And Adolescent Mental Health

Professor Shirley Reynolds is a clinical psychologist, research and author. She has been the Director of the Charlie Waller Institute at the University of Reading, Head of the Department of Clinical Psychology at Norwich Medical School and President of the British Association of Behavioral and Cognitive Therapy (BABCP). She is also Founder and Director of CBTReach, delivering online training workshops in CBT. We talked to Shirley about the experience of training during such a pivotal time in clinical psychology, second chances, and the idea of giving psychology away for free.

Starting out

How did you end up in clinical psychology, and focusing on anxiety and depression in adolescents?

It happened partly by chance, and a collection of brilliant experiences. I chose the wrong A-level subjects – with no science – then annoyingly realized that I quite liked science. I recognized that psychology would give me an opportunity to do science, while combining it with my interest in people. Through clearing, I got into a psychology degree at Cardiff, and it happened to have a placement year, which I did at the Institute of Family Therapy. It was an amazing place, a fantastic early leader of family therapy in the UK, and they trained some great people. Evan as an undergraduate they gave me the same training they gave the social work students, which was hands on therapy, with a one-way screen and a full consulting team – it was brilliant.

In my fourth year, we had this great lecturer who talked about ‘giving psychology away’ – for free. Even then, he told us that there’s too many people that need psychologists, and that we would never meet the demand. He told us we had to be thinking about models of delivery: about how we deliver psychology and who we do it through. It was really inspiring, with big picture ideas. I was lucky to be taught by inspiring people who were way ahead of their time, who helped shape my thinking.

I got my first job as a nursing assistant on an adolescent unit, but then left to do a PhD at Southampton University with Professor Tony Gale. This was linked to my experience in family therapy. It was based on observing family interactions and trying to study families in their true ecology. We used to live with families for a week at a time. We used participant observation as our methodology, which was very exploratory and a bit crazy.

I was lucky that the postdoc working on the team was someone called Dr Arlene Vetere. She later became a very well-known systemic family therapy researcher.  It was a very exciting time in psychology and for me personally. I had no academic confidence at all, I’d never thought of having an academic career, and I’d never known any academics, apart from ones who taught me. I didn’t know how it worked, but everything I’d done had reinforced that I wanted to do clinical psychology, and nothing had happened to put me off, so I carried on.

What is it about the child and adolescent area that is fascinating for you?

I think it might be the sense that if you can get in early, there’s more hope. I have a sense of how influential it is to help people early in their trajectory. I know that my own early experiences were pivotal – I grew up in an area where people could go one way or the other, and I saw people go in all sorts of different directions, often with much worse long-term outcomes. I was always aware that there was a pivotal point where, if life didn’t go right for you, you might not get another chance. You need to be given that second chance. I’ve benefitted from second chances many times in my life, so I know how important they are.

I came from quite a political background, and grew up in a very working-class area. My parents were immigrants, and quite religious. I believed that if you were going to change anything, you needed to start at the roots. I don’t know if I was particularly conscious of any of this at the time, but I think that is probably where a lot of it came from. I can see how those different elements fit together now.

Changing times and perspectives

How have things changed in adolescent mental health during your career?

Obviously, there’s a lot more focus on and awareness of mental health, both generally and in children and adolescents. People have adopted a much more psychological way of thinking about most situations, even in the most informal conversations. That’s been a significant shift. We’ve also now got a better sense of what schools can do: how they can intervene, and shape children’s futures. It’s great to see significant government investment going into schools to support teachers, children and young people.

We’ve got evidence-based treatments for anxiety that we never had before. We understand more about how to treat anxiety. We know that exposure is the best treatment for anxiety disorders, and that you need to support people so that they don’t avoid the things that they are frightened of and create secondary problems. Given that anxiety is the most common mental health problem in children, and we know how to treat it, that’s probably the most significant breakthrough.

People didn’t know what anxiety was when I was younger. I was admitted to hospital when I was about eight, for stomach problems. I have no idea what was wrong, but it wasn’t anything physical, and once they’d realized that, the approach was just to keep me in hospital for observations for a few days, and then send me home. Now I’d expect there to be more curiosity about my background, about triggers for the symptoms, and the family and social context, and more interest in me psychologically.

I think the fundamental knowledge and the basics of learning theory were there when I was an undergraduate, but they weren’t applied in a systematic way, and we didn’t understand how these things linked together. There weren’t programs for parents to use with anxious children. Now you can go and buy an evidence-based book about child anxiety by Cathy Creswell and Lucy Willetts, or about adolescent depression by myself and Monika Parkinson. Parents have access to more information and evidence based support and might be able to support their child or teenager without ever going near a clinic.

How do you think your approach and perspective has changed over time?

My perspective has developed as my experience has accumulated in certain areas. I appreciate how important compatibility and connections are. Working at Reading University was great, because we had a lot of early career researchers and students in quite a big team. We were able to involve younger staff and students in our clinics and this was very helpful as they were closer in age to the adolescents than me or some other colleagues. If I go into an assessment with a young person it can feel that they’re talking to their grandma. As I’ve become older I’m much more aware of the implicit power differentials between clients and therapists and how hard it can be to overcome these.

The most common age of a depressed young person in our clinic was 15 years old. So if a 25 year old is their therapist, they still seem really old to 15-year-old, but not as old as their dad. They can have more credibility because they are closer in age. It can also be an issue the other way around – when i was a trainee, and aged about 25, I was constantly being asked if I had children, or how old I was when I worked with parents or in adult mental health services. This illustrates just how important it is have a diverse range of people working in mental health services who reflect the community that they work within in – in terms of age of course, but also ethnicity, sexuality and other aspects of ‘human’.

Essentially doing therapy well is about establishing an alliance with them. The most important point to remember is that it doesn’t matter how brilliant your therapy is: if people won’t stick with you, therapy will not work, because they won’t be there to receive it. As a therapist your very first job and top priority is to make that personal connection with them and to start to build a therapeutic alliance.

Teenagers are the hardest to get into therapy and to keep in therapy. This is often because they have been sent to therapy, or brought to therapy. They might feel annoyed and angry about this. Who can blame them? They don’t know you, and you’re older than them. That’s why sending in a younger trainee can be really helpful. You’ve got a lot of work to do, just to reach the base of a starting point and build an alliance. I understand that better now.

What are the biggest misconceptions and common challenges you encounter when supervising and training other clinicians?

I mainly supervise people around adolescent depression, and there are several challenges and misconceptions. I think people are sometimes a bit unaware about how dangerous depression can be. When I’m training people to do any kind of treatment with teenagers who are depressed, we always focus a lot on risk assessment, risk management, and how important it is to keep young people safe. That should be the first focus. We need to help trainee therapists understand that asking about young people about self-harm or about suicidal ideas or plans doesn’t increase the risk. Most people will be relieved if you ask them about these scary things. You might be the first person ever to ask them and by asking them you’re giving them permission to talk about it. If you don’t mention suicide or self-harm and show that it is ok to talk about young people will never know that it’s okay to say how they feel, and will never realize that it’s not just them. That’s really important.

It is crucial that you have a mechanism to follow through, after you’ve asked these questions. You have to make sure that you don’t ignore what young people tell you and that you can make a plan for the next step. It’s important to show young people that you are there, that you are listening, want to keep them safe and that it is ok for them to tell you about their scary thoughts and behaviors.

The other misconception is that depression is ‘crying’ and ‘being sad’. For teenagers, there are three core symptoms of depression, and any one of them is important. Feeling sad is one of them. The other two core symptoms of depression in young people are “irritability’ and ‘anhedonia’. Irritability is very important and often overlooked. ‘Anhedonia’, means feeling flat, uninterested, and not enjoying anything, as if everything is grey, empty, and unremitting. This means you can have a diagnosis of depression without feeling sad or crying. That’s a really hard thing to understand as a trainee, so we work a lot on that.

If you ask young people important questions about feeling irritable and about not enjoying things any more (anhedonia), you usually get far more of a response from boys. If you only ask ‘Are you feeling sad? Do you find you cry a lot?’, the answer is more often “No.” If this happens then you have closed down the conversation. Once you get a ‘No’ – it can be hard for a young person to get back on board. On the other hand, if you ask them if they ever get annoyed or if people are getting on their nerves, it’s much more likely that they’ll say “Yes.” Asking about what they used to enjoy (i.e., football, tennis) and whether they are enjoying it at the moment is another good angle. It opens up the conversation, rather than closing it down. It can be easier to admit to being irritable and to not enjoying things than being sad and crying.

Lots of young people won’t want to say they cry, even if they do. They have never met you before, and it can be hard to open up to a stranger. For a therapist, asking questions that young people can say yes to, listening to what they say and being able to tolerate how uncomfortable it is when people tell you they are thinking about suicide are all critical skills to develop.

Research – the chase, the collaboration and being in the right place

Many clinical psychologists never carry on with their research. What drives you to carry out all the research you’ve done? Why do you value it and what’s different about you?

I don’t think I am different to other clinical psychologists. I think if you fall into the right place and talk to the right people, you can get excited by the right thing at the right moment. I’m curious about what makes things work, and I want to make a difference, and I think that may be the common denominator that links together clinical psychologists who continue to do research. You can also be curious and make a difference in lots of other ways, for example by running a brilliant psychology service, or a school, or training people, so that would probably work for me just as well.

There’s something about looking at what’s happening in your clinical life, and then collaboratively tackling the puzzles and the things you don’t understand with other people that you get on with. That’s one of the joys of research. Sometimes you notice something in the data, and it suddenly sends you off down an unexpected line of inquiry, which I love. If you’re lucky, you have a really great team of PhD students, postdocs and various other people, with whom you can sit down and explore different elements of the problem. Then you can work at it, see it through, and come up with some kind of an answer, or not! Perhaps that might lead you down a different route. There’s something about that chase, and that pursuit, that’s very important.

I don’t think there’s anything different about me. I’m just really interested in the things that I want to follow, which come out of the clinical experience, whether you observe them in a therapy room or seeing what emerges from the data you collect from a randomized controlled trial of 500 people. Those elements fascinate me and get me excited.

What is it about carrying out research that motivates you the most? Is it the intellectual challenge of solving a question, or improving interventions?

It’s all of it, but always as a team thing that you do with other people. I don’t think I’d ever sit in a corner and figure it out by myself. If you were a mathematician, for example, you would have to do it all in your own head. I could probably do it, but it wouldn’t be as enjoyable. I love bouncing ideas around and building on ideas together. It’s very energizing and when it works well, a complete delight.

What are you working on at the moment which excites you the most?

I’m in a very strange position at the moment, as I’m not employed at a university, which is very odd for me! I still have PhD students and am enjoying working with them. I’ve also set up two things which are really exciting. The first is an online training and workshops organization called CBTReach, which I started with a colleague, Rod Holland (who has run the BABCP conferences for years), as a response to the pandemic.

It’s online only, so we can bring in international trainers and speakers from anywhere, and we’ve had Americans and Europeans and Brits contribute to it. We invite the best people, who we know are really good because we’ve been to their workshops before and have worked with them over the years. I’m really proud that we’ve been able to get world leaders in their areas. I help to host and facilitate the workshops with workshop leaders, including doing role plays with them or just generally acting as their stooge or sidekick. We’ve made it as interactive and friendly as possible within an online setup.

Online delivery of training isn’t my ideal scenario at all, but we have learned that this is now the preferred method of learning for a lot of people. It opens up training opportunities in terms of convenience, location and timing; you can fit training in without having to waste time traveling.  We give everybody a recording afterwards, so they can come back, watch it again, come and go as they please or pick it up later. We’re getting people from all over the world who otherwise wouldn’t be able to attend these events. It’s obviously a different experience to a real-life training course, but there is definitely value in it.

The second thing I’ve set up is a project is trying to find, curate and share the best free training and mental health resources that are available. People can have them for free, while knowing that they’re great quality. This has a different purpose compared to CBTReach. It’s for students, trainees, potential trainees and people who are just starting in their career, or who want to stay up to date with emerging ideas and research.

An important phase in Psychology

The time you were training must have been exciting in terms of the emergence and development of CBT. How do you think the practice of therapy, CBT and evidence-based practice has changed over your career?

It was absolutely exciting. I went to university in 1977, so it was long time ago. As I mentioned, in 1980-81 we were being told we’d have to start giving psychology away for free because there weren’t enough of us. It’s incredible to think about how true that has been. I picked that up and carried it with me.

Though we were taught many therapeutic approaches, I started with a family therapy mindset, and then went further and further down the CBT path as time went on. At first, I was very systemic and very family orientated and so I couldn’t get on board with CBT. Then I had these clinical placements with people like Paul Gilbert, who was already doing incredible things on shame, hierarchies, social rank theory and depression, and was very intellectually sharp and exciting. As I went through training, I shaped myself more into a kind of cognitive behavioral psychologist, just through exposure, and seeing the evidence.

Seeing things work like actually helping cure a child’s anxiety, or bedwetting, or helping an old lady with a phobia, is such a thrill, and it’s really straightforward. To see that you can give effective psychological treatment it away was a real insight. I’ve seen that emerge during my career. We don’t have to make it difficult, and it needs to be accessible.

Looking back in terms of how you were trained, versus how people are trained now, what do you think the biggest differences are?

We had much more autonomy. Somebody would refer a client to you, and you could pretty much do anything – for as many sessions as you liked, as often as you liked – as long as you were supervised. There were no manuals, nothing was prescribed, everything was entirely improvised. The world is so different now. Now it’s much more controlled, managerial and rigid.

I don’t have any issue with giving psychology away, and I’m a big fan of IAPT.  The IAPT model of psychological therapy services has meant that many many more people are able to access evidence based psychological therapies, close to home, and relatively quickly.   However, one problem with the IAPT service model is that training has been condensed – i.e. it is a lot shorter and more focused. This means that supportive management and supervision structures are essential. However, structures and management can stifle innovation and creativity, which some therapists find very limiting.

In the past, you could create what you wanted and innovate. If you were research minded, that gave you huge amounts of freedom. It would be quite hard to do that now in the same way. You’d have to look for really particular places that would allow that to happen – previously you could have done that anywhere. I would say to anybody who wants a research career now, to choose your first job very wisely. If that nugget of excitement and curiosity and energy isn’t supported in your first job, it’s probably going to get stifled. It’s really hard to hold the curiosity and energy and keep it alive. Think about whether somebody else will be helping you, and whether you will receive a mentor, supervisor, structure, or a surrounding system that will offer you that kind of support and encouragement to explore.

What excites you now?

What developments in psychological treatment, interventions or techniques do you think look promising at the moment?

There’s something fascinating called the two-chair technique which is catching on. When I worked in Sheffield back in mid 1980s, we did a lot of work with a man from the USA, Dr Les Greenberg. He developed the ‘two-chair technique’ as part of Gestalt therapy. At that time, it was seemed such a completely separate from CBT or psychodynamic psychotherapy, and it didn’t have a place in the mainstream therapies. However, now, people like Matthew Pugh, Tobyn Bell and others have found a way of making integrating this technique into CBT.  So although the two-chair technique seemed marginal it has now been grounded and adapted in a way that allows people to accept it and see the benefits.

People sometimes think about CBT as being too narrow, too closed, but it’s exciting to see its openness and ability to integrate new and helpful techniques, within a broader conceptual CBT framework. Chairwork is a really good example of thoughtful integration and that we’ll see much more of that in future. I don’t think things always have to change – but new approaches come around, and they have their time, and their place. I love that.

The other thing that I am finding interesting, especially for teens, is understanding the specific components of depression, rather than using a composite umbrella term that we think about, discuss and treat as a sort of generic ‘blob’. Treatments for CBT are typically quite generic, broad and nonspecific. However what we are discovering is that treatments that tackle the key symptoms a person is experiencing (or whatever is interfering with their life) are promising. If somebody’s got depression, but sleep is their biggest problem, you can start with an effective intervention for their sleep problems. Likewise, if anhedonia (loss of interest and pleasure) is a major problem for a young person it can be helpful to focus on addressing that and helping them to notice, experience and amplify pleasurable experiences.

What is your perspective on transdiagnostic approaches in comparison to diagnostic models?

In some ways, this is a contradiction to what I’ve just said, because I do think the diagnostic models can be helpful. I appreciate there’s massive backlash against diagnosis in mental health and I understand why people dislike the use of diagnoses. If you say, for example, that someone’s got ‘a personality disorder’, for example, it’s stigmatizing and negative, but diagnostic labels can also be freeing, and give people a sense of understanding themselves because they have the beginning of an explanation.

It is important to know if a child is anxious, depressed or both, because you target your treatments in different directions. Our own research has cast some light on the relationship between sleep and anxiety and depression in teenagers. Sleep problems are a feature of depression and anxiety, although are more common in depression. Interestingly, for young people who have anxiety, sleep problems are common during the week (i.e. on school nights) and less common at weekends. In contrast, for young people who have depression, sleep problems are reported every night of the week. This suggests that there is something slightly different going on. Therefore, the sleep problems and how you treat them might not be the same, because they aren’t coming from the same place.

I like a transdiagnostic approach – I’m very open to it. I don’t think that means we shouldn’t consider whether there’s a broader picture we need to understand as well, because there are different risk factors. If somebody is depressed, it’s much more important to ask them about suicidal thoughts. Anxiety is still important, but suicidal ideas are less likely to be an issue.   If you didn’t know that depression was in the picture, and you were only thinking about treating a young person’s sleep problems, you might not specifically ask them about suicidal thoughts and self-harm and miss something very important. I’m not wedded to one approach, they both have benefits. If you’re going to give psychology away, sometimes it is helpful to be a bit clearer.

What do you think lies ahead for treating anxiety and depression, and where will we be in 20 years’ time?

We will be much more likely to treat anxiety and depression in a broader context – it won’t just be a mental health thing. By then, mainstream medical, physical health treatments will be much more aware of the physical impact of anxiety and depression. That would be brilliant, because if they could have treated me that way at eight, when I was admitted for stomach problems, that would have been a different childhood. We are already starting to see this now.  COVID has had helped us understand that mental and physical health are closely linked. I hope that this understanding means we can get to the root of issues earlier, tackle problems sooner, and solve them faster.

If you could go back in time and give advice to yourself as a younger trainee, what would you say?

You’re going to meet everybody again. Always. So don’t piss anybody off. You’ve no idea how small this world is – I go to conferences, and I’m still seeing people I went to conferences with in 1982.

I’d also tell myself that you’ll always meet more interesting people. Even when you think you’re older, you’ll still meet people that you can learn from.

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	Cooper, K., Hards, E., Moltrecht, B., Reynolds, S., Shum, A., McElroy, E., & Loades, M. (2021). Loneliness, social relationships, and mental health in adolescents during the COVID-19 pandemic. Journal of Affective Disorders, 289, 98-104.
	Reynolds, S., Wilson, C., Austin, J., & Hooper, L. (2012). Effects of psychotherapy for anxiety in children and adolescents: A meta-analytic review. Clinical Psychology Review, 32(4), 251-262.