This chapter focuses on the observations that variations in adrenal steroid levels, particularly cortisol, contribute to psychopathology and major depression in particular. The associations are complex due to clinical heterogeneity together with physiological and genetic variations, influencing corticoid production, function and activation by environmental adversities. There is evidence that genetic differences in adrenal function, the impact of chronic early adversity, excess corticoid production or exogenous corticoids each contribute to the risk of depression, delay in clinical recovery and relapse. Further, psychiatric illnesses, mainly but not exclusively depression, may induce changes in corticoid activity. Elevated corticoids can affect psychological function, in particular reduced memory acuity for recall of and emotional responses to life experiences.

We want to emphasise the importance of psychoeducation (PE) as an active intervention in clinical BPI practice. As noted already, PE was originally considered as a passive aid to medical treatments rather than an active therapeutic agent. For example, it is highly likely that PE enhances adherence and collaborative working in any intervention through explaining the implications of treatment to the patient. This is undoubtedly a useful mediating process but in BPI practice we want the therapist to utilise PE from the perspective that it acts as a therapeutic change element of treatment. For BPI practice, PE is the conversational delivery vehicle for information about how to understand mental states, engage in adaptive activities and habilitate and use new understandings and strategies to promote well-being and resilience in the face of future adversities. Whilst the focus is directly on the adolescent, such PE can also be delivered to important others such as family, carers and teachers, with the consent of the YP.

This chapter describes the clinical methods that most likely make the best use of the clinical tools described in Chapters 3 and 6. First, we describe the three BPI domains of psychoeducation, social and personal prescribing and habilitation that constitute the framework of BPI.

The Notion That The Teenage Years Have Any Particular Value In Social, Cultural Or Biological Terms Does Not Appear In Any Literature Until The Fifteenth Century. Before Then, Received Wisdom Was That Infancy And Childhood Were Followed By Adulthood And All That Goes With Being A Grown-Up Individual In Any Society. The Word ‘Adolescence’ Came From The Latin Word Adolescere, Meaning ‘To Grow Up Or To Grow Into Maturity’. Although Ongoing Maturation During The Teenage Years Is Clearly Suggested, There Appears To Be No Formal Adoption Of The Concept In Any Society Until The Early Twentieth Century. In 1904 The First President Of The American Psychological Association, Greville Stanley Hall, Was Credited With Coining The Term ‘Adolescence’. In His Study Entitled Adolescence, He Described This New Developmental Phase, Which He Hypothesised Came About Due To Social Changes. Some Of This Hypothesis Resonates Clearly With Today’S Viewpoints, Although Much Is Also Now Known To Be Incorrect.

In the previous chapter we outlined a brief history of psychotherapies since the medieval period and noted that we are now in a scientific phase that is particularly focused on establishing valid clinical effects for talking cures.

In Chapters 5 and 6 we outlined the BPI framework together with clinical principles and methods. In Chapters 7 and 8 we translate these into practical BPI practice. You will have read about the concepts and techniques in prior chapters but now you get the chance to consider them through the clinical practice lens. These two chapters can serve as clinical guides and underpin the clinical manual and protocol that was used in the IMPACT study.

To recap, there are three key practice principles of BPI.

We have noted that, in our view, when undertaking any psychotherapy there should be supervision and reflective practice throughout one’s career. Senior therapists can be as much in need of discussions about their cases as newly qualified practitioners. Until we have much improved our understanding of what intervention works for which patient and how, we recommend supervision as a key clinical tool in learning the skills and techniques of BPI. Of course, we do not yet know which of these tips is responsible for clinical effectiveness. Therefore, regular fortnightly supervision with a senior, more experienced colleague is sound practice. Table 9.1 describes key general components that should activate a discussion with your supervisor.

In Chapter 1 we described the emergence of the concept of adolescence in the early twentieth century and how it represented a new and developmentally sensitive period of ongoing mental maturation. We also noted that the talking cures were fast gaining a foothold in developed societies and adolescents were beginning to be a focus of these interventions, this being due to the clear-cut increases in mental health difficulties and emergent mental illnesses in the second decade of life. The theories and techniques of the psychotherapies were, until the 1970s, relatively uninfluenced by the emergence of the concept of adolescence and its implications for mind-brain maturation. This implies that very little of what we know about adolescents and their mental states has been taken into account when devising a talking treatment for young people.

Brief psychosocial intervention was first used as a non-manualised reference treatment for depressed adolescents receiving the antidepressant fluoxetine with or without CBT. Both the treatment groups received the forerunner of BPI, specialist clinical care, as their general clinical support. The surprise was that CBT provided no added value over fluoxetine and specialist clinical care by the end of the study, which was only a short-term outcome of some 28 weeks [1]. This was the first finding that specialist clinical care provided by psychiatrists and mental health nurses to depressed adolescents may be as clinically effective as specialised psychological treatments such as CBT.

An interesting consequence of this study was to ask: what exactly did the therapists do when delivering specialist clinical care and how was it delivered?