[Katharina_Manassis]_Cognitive_Behavioral_Therapy

Clinical Challenge

Think about how you would engage Josh, a 15-year-old depressed teen, in a discussion of treatment expectations. Josh was referred to you by his family doctor for CBT, and his parents have ensured he attends by threatening to remove his computer from his room if he does not. He protests that there is nothing wrong with his brain and blames his teacher for a “lousy year at school.” Josh says the only thing he still enjoys in life is playing “Dungeons of Doom,” an online video game. He reports that his mother took him to a therapist previously, and he has no interest in talking about “feelings and junk” because it changes nothing. He says, “No offense, but therapists are pretty useless.”

1.What would you say to Josh?

2.What (if anything) would you say to Josh’s parents?

References

Beckner, V., Vella, L., Howard, I., & Mohr, D.C. (2007). Alliance in two telephoneadministered treatments: Relationship with depression and health outcomes.

Journal of Consulting and Clinical Psychology, 75, 508–512.

Chu, B.C., Choudhury, M.S., Shortt, A.L., Pincus, D.B., Creed, T.A., & Kendall, P.C. (2004). Alliance, technology, and outcome in the treatment of anxious youth.

Cognitive and Behavioral Practice, 11, 44–55.

Chu, B.C. & Kendall, P.C. (2004). Positive association of child involvement and treatment outcome within a manual-based cognitive-behavioral treatment for children with anxiety. Journal of Consulting and Clinical Psychology, 72, 821–829.

Creed, T.A. & Kendall, P.C. (2005). Therapist alliance-building behavior within a cog- nitive-behavioral treatment for anxiety in youth. Journal of Consulting and Clinical Psychology, 73, 498–505.

Howard, I., Turner, R., Olkin, R., & Mohr, D.C. (2006). Therapeutic alliance mediates the relationship between interpersonal problems and depression outcome in a cohort of multiple sclerosis patients. Journal of Clinical Psychology, 62, 1197–1204.

Kaufman, N.K., Rohde, P., Seeley, J.R., Clarke, G.N., & Stice, E. (2005). Potential mediators of cognitive-behavioral therapy for adolescents with comorbid major depression and conduct disorder. Journal of Consulting and Clinical Psychology, 73, 38–46.

Kazdin, A.E. & Weisz, J.R. (1998). Identifying and developing empirically supported child and adolescent treatments. Journal of Consulting and Clinical Psychology, 66, 19–36.

Kendall, P.C. (1994). Treating anxiety disorders in children: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 62, 100–110.

Kendall, P.C., Flannery-Schroeder, E., Panichelli-Mindel, S.M., Southam-Gerow, M., Henin, A., & Warman, M. (1997). Therapy for youths with anxiety disorders: A second randomized clinical trial. Journal of Consulting and Clinical Psychology, 65, 366–380.

Kendall, P.C. & Southam-Gerow, M.A. (1996). Long-term follow-up of a cognitivebehavioral therapy for anxiety-disordered youth. Journal of Consulting and Clinical Psychology, 64, 724–730.

Krupnick, J.L., Sotsky, S.M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., & Pilkonis, P.A. (1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 64, 532–539.

Shirk, S.R. & Saiz, C.C. (1992). Clinical, empirical, and developmental perspectives on the therapeutic relationship in child psychotherapy. Developmental Psychopathology, 4, 713–728.

Wilansky-Traynor, P., Manassis, K., Sanford, M. (submitted). Parental involvement and youth participation in a cognitive behavioral group treatment for depressed adolescents.

Manualizing a therapy has a number of potential benefits. When a therapy has been manualized, the manual provides a framework for the therapy, so there is less variability in how the therapy is done from one practitioner to the next (Wilson, 1996). This is helpful in psychotherapy outcome research, where is important to standardize therapy in order to do a valid evaluation. Standardization can also facilitate communication between professionals. Thus, when someone says “I did Coping Cat with this child” (a common anxiety-focused program by Philip Kendall, 2006), the listener has some idea of the concepts that the practitioner taught or tried to teach the child. Manuals may have the further benefit of focusing therapy on key techniques, to ensure these are learned and practiced frequently. Repetition in a variety of contexts both within sessions and between sessions is likely to result in the child’s long-term use of new coping strategies (Kendall & Southam-Gerow, 1996), and this repetition is more likely to occur when a manual is followed.

Clinician judgment and skill are required in the implementation of manualized, evidence-based treatments (McNeill, 2006; Wilson, 1996). Therapeutic flexibility in the use of manuals has been advocated by some authors (Kendall, Chu, Gifford, Hayes, & Nauta, 1998), but it was not found to relate to treatment outcome in a large study of anxious children (Kendall & Chu, 2000). This study, however, focused on well-trained therapists in an academic center who had regular supervision, and results might have differed in a community practice. Perhaps more challenging is the question: when is a deviation from the manual considered “therapeutic flexibility,” and when is it considered poor treatment adherence? For the inexperienced therapist, this can be a difficult distinction to make. In describing flexibility, Kendall and colleagues (1998) emphasize individualizing the use of manuals by selecting those strategies or exercises that will aid the therapist in achieving goals with a given child. Thus, some strategies may be excluded and others expanded upon, depending on what the child needs in order to grasp and apply key concepts. Flexibility may also involve taking into account cultural differences between the client and the author of the manual, for example, by modifying examples in the manual to make them more relevant to the client’s cultural context and using culturally valid measures of outcome (Huey & Polo, 2008).

Before applying these ideas to your work, though, here is a list of some common, disorder-specific CBT manuals for children. The list is by no means exhaustive, but it highlights some manuals that have undergone empirical evaluation, are in the public domain, and are often used in child CBT. Child manuals are constantly being updated, and some have separate therapist manuals, so it is worth checking http://www.workbookpublishing.com (where many can be found) to ensure you get the most current and complete version. For disorders not addressed in this list, you may want to look up a recent CBT outcome study on the topic and then contact the authors regarding the manual they used. Most authors are willing to share their insights

and/or materials as long as you respect their authorship and do not distribute the materials further.

Anxiety-Focused Manuals

•Flannery-Schroeder, E. & Kendall, P.C. (1996). Cognitive behavioral therapy for anxious children: Therapist manual for group treatment. Philadelphia: Workbook Publishing.

•Kendall, P.C. (2006). Coping cat workbook (3rd ed.). Philadelphia: Workbook Publishing.

•Kendall, P.C., Choudhury, M., Hudson, J., & Webb, A. (2002). “The C.A.T. Project” workbook for the cognitive-behavioral treatment of anxious adolescents. Philadelphia: Workbook Publishing.

•March, J. & Mulle, K. (1998). OCD in children and adolescents: A cogni- tive-behavioral treatment manual. New York: Guilford Press.

•Rapee, R. Cool kids. http://www.psy.mg.edu.au/MUARU/books/prof. htm.

Depression-Focused Manuals

•Charma, D. (1997). Treating depressed children: A therapeutic manual of cognitive behavioral interventions. New York: New Harbinger.

•Langelier, C. (2001). Mood management: A cognitive behavioral skillsbuilding program for adolescents; skills workbook. New York: Sage.

•Stark, K.D. & Kendall, P.C. (1996). Taking action: A workbook for overcoming depression. Philadelphia: Workbook Publishing.

•Stark, K.D., Simpson, J., Schnoebelen, S., Hargrave, J., Molnar, J., & Glen, R. (2007). “ACTION” workbook: Cognitive-behavioral therapy for treating depressed girls. Philadelphia: Workbook Publishing.

•Stallard, P. (2002). Think good—feel good: A cognitive behaviour therapy workbook for children and young people. London: John Wiley.

Manuals Focused on Externalizing Problems

•Child Development Institute (2002). S.N.A.P.: Stop now and plan program. Toronto: Child Development Institute.

•Kendall, P.C. (1996). Stop and think: Workbook for impulsive children

(2nd ed.). Philadelphia: Workbook Publishing.

•Nelson, W.M. (1996). Keeping your cool: The anger management workbook. Philadelphia: Workbook Publishing.

Putting It into Practice

Manuals sometimes provide a false sense of security, particularly for the inexperienced CBT practitioner. It is tempting to believe that doing what is in the manual is all that is required for therapeutic success. This assumes, however, that the practitioner is using the best manual for the child in question, that modifications are made when the child or family is not ideally suited to the

treatment program, and that basic therapeutic skills that are needed to keep the child and family engaged and motivated throughout the program are not sacrificed for the sake of “following the manual.” Those assumptions are not always met.

A common analogy has been used to describe this problem: a manual is not a cookbook. Let us suppose, for a moment though, that it is. As any cook with even limited experience will tell you, following recipes does not ensure a delicious result. If you are baking a cake, for example, your oven may be a bit hotter than average on the top rack. Putting your cake there may burn it. The eggs you buy may be slightly larger than average, resulting in too much liquid in the mix if you do not make adjustments. Familiarity with these factors allows you to make minor modifications that are needed, but that familiarity only comes with experience. It also helps if you do not start with the most complicated, multistep recipe. A simple one is more likely to turn out well for the novice baker. If you have never baked before, it may help to get advice from a more experienced neighbor, or even bake the first cake together. Adding ingredients to the recipe or substituting one ingredient for another is probably not advisable until you have developed some confidence with the basics. You will also not find certain things in the recipe, because it is assumed you are aware of them. For example, it will be assumed that you know you need a large mixing bowl and a pan in the shape of the cake you are making, that you know to preheat the oven, and that you have obtained the recipe from a trusted source with expertise in baking cakes (as opposed to cookies, casseroles, or other products).

Let us take each sentence in the “bake a cake” analogy above, and think about how this might translate into using “recipes” (manuals) in child CBT.

One translation might be:

•Know the environment you work in and how it differs from “research conditions” (see Chapter 2). Make adjustments accordingly.

•Know the children you typically see, and how they differ from typical research subjects (see Chapter 2). Make adjustments accordingly.

•Start with a case that is relatively uncomplicated and close to an “ideal candidate” for CBT (see Chapter 3).

•Do not hesitate to get supervision or peer support, especially on the first few cases.

•Addition or substitution of ideas in the manual should not be done until you are confident with that particular model. Even so, it is not always advisable (see below).

•Do not neglect therapeutic common sense for the sake of following a manual. For example, take some time to build rapport with the child, even if the manual does not tell you to do so.

•Find a manual that is as specific to the child in question as possible (good match in terms of diagnosis, age, cognitive level, etc.) from a

source specializing in child CBT (as opposed to adult CBT or child therapy of another sort).

Attempts have been made to describe the best use of manuals more systematically. A number of authors have proposed checklists of “treatment adherence” that allow therapists to review for themselves whether they are adhering (literally, sticking) to the treatment described in the manual closely enough (for example, DeRubeis & Feeley, 1990). Before getting to those, however, some discussion about how to select the right manual for your client is in order.

Manual Selection

Some people may wonder, “Why use a manual at all?” After all, shouldn’t an experienced therapist know how to provide CBT without referring to a text? The answer is “yes and no.” While it is true that one may do what is in the manual more easily or automatically with experience, it is still worth checking consistency with the manual on a regular basis. It is simply human nature to gravitate toward the familiar, and if one is familiar with therapeutic approaches other than CBT (as most therapists are), one tends to drift into those approaches unless there is at least periodic checking of the manual.

In selecting a manual, go with a reputable source. Manuals that have been evaluated in randomized studies and that come from centers specializing in child CBT are preferred. One excellent source of CBT manuals for many childhood disorders and age groups is http://www.workbookpublishing.com. This site features manuals by Philip Kendall and colleagues at Temple University in Philadelphia, one of the foremost research groups in this field. A number of adaptations of this work have also been done. For example, Coping Cat (Kendall’s classic child anxiety manual) has been adapted in Australia as Coping Koala, in Canada as Coping Bear, and so on. Usually, these adaptations are done in university-based clinics or research centers, so check these resources in your area if you want a manual that is reputable and culturally specific.

Select a manual that is as specific as possible to the client(s) you are seeing. Look for a good match in terms of diagnosis, age, and cognitive level. For example, do not assume that a manual developed for grade school children is suitable for teens or vice versa. If there is a discrepancy between age and cognitive level (for example, in a child with intellectual delay or significant learning disabilities), this can pose particular challenges, because the language and examples in the child manual may seem “babyish,” but the teen manual is too cognitively complex for the youth to master. In this case, my preference is usually to work with the child manual, but edit it ahead of time to make the examples and language sound “older.” It is easy to replace references to “children” with “people,” for example. Similarly, cute cartoon characters can be used as mascots for the program, without expecting the youth to take them too seriously.

If the child or youth has several diagnoses, decide which one is best to address first (as described in Chapter 4) and look for a manual for that one. It may not address all of the problems, and this should be discussed with the client and family, but it will provide a good start. It is usually better to build confidence by focusing on one problem and dealing with it successfully, rather than trying to address several problems at once and not taking the time to really solve any one of them. There are also a number of common elements across manuals (for example, improving the client’s problem-solving skills) that may have positive effects on the diagnoses that are not targeted directly.

If you are planning to do a CBT group, look for a group-specific manual. Individually focused manuals may cover the same content, but that content is not always presented in a way that is engaging for groups and takes advantage of group processes. For example, recognizing physical sensations associated with anxiety can be done individually by having the child look at a drawing of a human body and identify the body parts where he or she has experienced discomfort when anxious. In a group, this exercise is much more effective when one group member’s body outline is traced and hung on the wall. The other group members then take turns marking where in the body they experience anxiety using different colored markers. Thus, the group works together to produce an impressive anxiety-ridden figure, and everybody discovers (from their peers) at least one new way to recognize anxiety.

Adherence

A colleague of mine coined a wonderful term several years ago: “pseudo-CBT.” I knew immediately what he meant. All too often, we see children whose families claim they have had CBT, but on closer inquiry it turns out they have not. What they have usually received is some form of eclectic therapy that includes a few CBT principles, but without the structural elements of true CBT. For example, they will describe relaxation strategies or positive thinking strategies, but cannot name specific situations that these were applied to. Alternatively, they will describe learning strategies for certain situations, but never being assigned tasks between sessions to practice them. Sessions with no formal structure, where the client talked about his or her feelings about various things, and suggestions were made as to how to handle those feelings also do not constitute CBT.

What are the key elements needed for a therapy to be considered CBT? First, there must be a defined session structure. Once past the first session (where rapport-building is often prioritized), this structure looks something like the following:

1.Review homework the child has done since the last session, and positively reinforce either doing it or attempting to do it.

2.Set agenda for the current session (including therapist and client elements), and ensure the child is in agreement with this.

3.Teach a new CBT skill (usually one spelled out in a manual or book specific to the client’s disorder), including questions to ensure the child understands it.

4.Practice the new skill in the session with positive reinforcement for doing so.

5.Assign homework based on the new skill.

6.Check that the child understands the homework assigned.

7.Allow a few minutes for the child’s part of the agenda (most children choose to either play a game or talk about something that interests them).

Some authors also advocate creating a “bridge” to the previous session before introducing new material, for example by asking the client to recall what was helpful (or not) about that session (Beck, 1995). Personally, I find keeping notes about what was discussed in the session in addition to the exercises in the manual facilitates session-to-session continuity for the therapist. “Bridging” questions may improve continuity for the child though.

The homework is sometimes given a more pleasant name (for example, a “Show That I Can” task in Coping Cat), or just called “real-world practice” (a term often more acceptable to teens). It includes one or, at the most, two specific tasks that incorporate the skill(s) learned in the session. It does not include anything that has not been tried at least once with the therapist in a session. It need not be a written task, as long as it allows practice of the skill(s) learned in the session. Some children and teens actually find homework based on implementing a new skill more relevant and acceptable than writing about thoughts and feelings.

Lack of homework completion by clients is common, and therapists address the issue in different ways. One can explore reasons why it was not done and address these, give incentives to increase motivation to do homework, or allow a natural consequence. A natural consequence involves doing the homework at the beginning of the session, with the result that the time for unstructured discussion or play (element #7 of the structure described above) is reduced. This approach also ensures that the child understands the homework material, and offers a helpful review if he or she does not. Some authors also advocate exploring automatic thoughts that might interfere with homework completion (Beck, 1995) (for example, “What thoughts went through your mind when you remembered you had homework to do?”). If anxious or depressive thoughts interfered, this could be a nice in vivo cognitive exercise to address these thoughts, but only in an adolescent or older child who is able to access automatic thoughts in this way.

Beyond the session structure described above, the only other common element on most adherence checklists is a reminder to check for consistency between the content in the manual and the content that has been covered with the child. As described below, some modification of content is possible while still maintaining good consistency.