[Katharina_Manassis]_Cognitive_Behavioral_Therapy

shrugged his shoulders in response to open-ended ones. He had never before seen a therapist. He described an attempt by a teacher to engage him in a game with his peers, but felt he had been “pushed” to do so and was then excluded and ridiculed by his peers because he was not familiar with the rules of the game. He said his shyness became worse after that incident.

After providing this description, I discussed diagnosis (most likely social anxiety disorder), invited suggestions from the audience regarding intervention, and then elaborated on Tom’s successful treatment with CBT. Tom was seen individually, with considerable concurrent work with his parents to help them to better understand his difficulty and to appropriately support his attempts to change. Despite his father’s initial disparaging remarks about Tom, he became much more supportive once told there were specific things he could do to facilitate social contact for his son. For example, practicing soccer skills with his father made it easier for Tom to play on a team of sameaged peers without risking humiliation. Tom’s mother recognized that she had inadvertently encouraged some of his social avoidance because she often worried about him being hurt. After several months of work with Tom and his family, he was still socially reticent, but regularly participated in activities with his peers and was able to initiate contact with them with his parents’ encouragement. With support from his teacher, he had also practiced answering questions in class and even entered the school public speaking contest.

The morning seemed to be off to a good start. Next, a member of the audience was invited to present her case to me. Her question was: is this child a suitable candidate for CBT, and do you have any other recommendations? She presented the case of Vicky.

Vicky was a 14-year-old girl who had not attended school for two years, after being embarrassed by a teacher about a poor mark on a test. There had been two previous attempts at therapy with Vicky, but she had “fired” both therapists, and her parents believed that this occurred because neither “really understood” their daughter. After an episode of self-harm behavior (superficial cutting of her forearm), Vicky was hospitalized and diagnosed with “multiple anxiety disorders and possible mood disorder.” Medication had been recommended, but Vicky refused to take it. Since then, Vicky reported that her mood was better, but she “panicked” if her parents tried to escort her to school. Nevertheless, she still went to the mall with her friends several times a week, sometimes during the school day. Her mother did not want to curtail this activity, as she feared her daughter becoming more depressed if she was isolated from her peer group. When the presenter had encouraged Vicky’s parents to become more firm in their approach to her school avoidance, they reported that Vicky had threatened suicide. The parents had stopped their efforts to return her to school at that point. They were now considering home schooling for Vicky.

Having heard this story, I made recommendations, but they had nothing to do with CBT! Difficulties in the family system, behavioral issues, and the

possibility of an underlying learning problem all needed to be explored and addressed. Then came the inevitable (and legitimate) question from the audience: “Dr. Manassis, isn’t CBT the best evidence-based treatment for anxiety disorders in children and youth? Why are you not recommending it in this case?” I answered the question by going over all the factors that made Vicky a poor candidate for CBT (lack of motivation, family’s inability to set limits, poor engagement in previous therapy, uncontrolled acting out behavior, long duration of avoidance of school, and so forth). This response resulted in a second question, though: “If CBT is not the evidence-based treatment of choice in this case, what is?”

My attempt to answer that second question became the inspiration for this book. In the next few years, as I taught and supervised community practitioners trying to apply CBT under less-than-ideal conditions with challenging cases, I gradually found some answers. This book is an attempt to share those answers—to help decide when CBT can be helpful to children, when it can be helpful with some modifications, and when it has little hope of succeeding.

Is This Book for Me?

When I shared the title of this book with colleagues, I was often asked, “What do you mean when you say community practitioner?” My answer is: anyone who has not had expert training in CBT and hopes to practice it outside an academic center. The disciplines of the people in this position I have met and trained have included social work, child and youth counseling, family practice, pediatrics, pediatric nursing, child life, and trainees in all of these areas. Psychiatry residents or psychiatrists who were trained at a time when CBT was not part of the curriculum have also participated, as have psychology interns and students. Many of my trainees have worked on multidisciplinary teams where CBT was their assigned “piece” of the treatment plan. Some have been independent practitioners. Some have been quite knowledgeable about CBT but lacking in experience. For others, CBT concepts were new and outside their usual scope of practice. All were dedicated to providing the best care possible to their young clients.

This book focuses on children with anxiety and depression, as these are the diagnoses where CBT is currently considered the initial treatment of choice (Compton, March, Brent, Albano, Weersing, & Curry, 2004), where the effect sizes (average degree of improvement in study participants) are largest (Butler, Chapman, Forman, & Beck, 2006), and also where most of my own practice has focused. While CBT has been used in other childhood disorders (for example, externalizing disorders), it is usually preceded by or combined with other treatments in these disorders (medical treatment or behavior management without a cognitive component), and child impulsivity can be problematic in implementing CBT strategies with children who have these disorders. References to manuals for these disorders are included in Chapter 5.

What Is Cognitive Behavioral Therapy (CBT)?

To begin, a brief definition of CBT is in order to ensure a common, basic understanding of this form of therapy and challenges associated with it in community practice. Cognitive behavioral therapy is a form of brief, structured psychotherapy based on the premise that thoughts, feelings, and behaviors affect each other in reciprocal ways (Kendall, 1993). For example, negative thoughts often engender negative feelings and vice versa. Fearful thoughts, on the other hand, often increase anxious feelings and anxiety-related avoidant behaviors. Angry thoughts can contribute to angry feelings and aggressive behavior. Because changing unpleasant feelings directly can be difficult, CBT aims to do so indirectly by having the client change the associated thoughts and behaviors. Numerous randomized controlled trials in children and adults attest to the ability of CBT to reduce emotional symptoms and their associated diagnoses, especially for anxious and depressive symptoms, relative to nonintervention or (in some studies) alternative intervention (reviewed in Compton et al., 2004).

As cognitive theory has continued to develop, some authors have written about integration between CBT and other therapies (Alford & Beck, 1997). They point out common therapeutic elements among therapies, for example, the ability of psychodynamic therapy to aid desensitization to certain social anxieties. Conceptual similarities also exist, for example in the similarity between cognitive schemas or beliefs about relationships (in CBT) and core conflictual relationship themes (in short-term dynamic therapy). What distinguishes CBT from other therapies, however, is (1) the highly structured nature of sessions and (2) the discussion of therapeutic elements as explicit strategies with the client (Alford & Beck, 1997). Thus, although the therapist is in charge of preserving the session structure, the therapeutic encounter between therapist and client is highly collaborative and transparent. These distinct elements are often the most challenging to learn when starting CBT, so they are emphasized in this book and in most CBT manuals.

What Is the Problem with CBT in Community Practice?

As illustrated in the two very different cases at the start of this chapter, CBT is not beneficial for everyone. In community practice, there are many children and families for whom it is not ideal, or it is not ideal in the absence of other interventions (Weersing & Weisz, 2002). Trying CBT in these cases can result in discouragement for the child, the family, and the practitioner. Why is this dilemma so common?

Too often, CBT is either touted as a panacea for every mental health problem, or cynically considered an “ivory tower” treatment that only works in research centers. Neither of these extreme positions is accurate, but it is easy to see how they can develop. Pressure to make psychotherapy more

“scientific,” the quest for more time-efficient treatments, and the myth that “one size fits all” (that all children in a given diagnostic category can be treated the same way) have all contributed to broad, sometimes indiscriminate use of CBT in children’s mental health settings. Often with inadequate training and support, community practitioners are told to “do CBT.” They find themselves struggling to make their clients fit CBT manuals that were designed for research populations, and that were never intended to be used as “cookbooks” or to replace clinician judgment (McNeill, 2006). When CBT fails under these circumstances, the cynical “ivory tower” position emerges.

Addressing the Problem: The Focus of This Book

CBT can be used effectively in community settings, but doing so requires more information than what is found in most child CBT manuals. That is where this book comes in. In fact, the content can be thought of as “child CBT: what is not in the manuals.” There are new approaches to CBT that may address some obstacles to treatment success in the community (see Chapter 10), but most of this work has been done with adults, and typical child CBT manuals do not describe it in detail.

Understanding the differences between children seen in research centers and community clinics, differences between academic and community environments, and the challenges of applying CBT manuals to different children and families are useful starting points. In this book, adaptations that address these differences will be described for each stage of assessment and therapy. Combining CBT with other modalities, working with challenging families, and dealing with obstacles to therapeutic progress are other important aspects of community practice that will be discussed.

The book can be used in more than one way. Practitioners who are starting to use CBT with their clients may wish to read it from cover to cover to gain an overview of the joys and challenges of what lies ahead. It can also be used as a guide for supervisors of new practitioners or as a guide for peer supervision groups, because much of it was written initially to address issues arising in my own supervision of others. In this case, reading about a chapter a week and completing the worksheets and clinical challenges at the end of each chapter will promote active learning and bring the material to life. The first few chapters emphasize assessment, contracting, and starting therapy, the next few the middle stages of therapy, and the last few issues around termination and therapeutic obstacles. Finally, if there is an issue that comes up frequently in your clientele (for example, most have cognitive limitations or most have family problems), you may wish to skim the entire book but then come back and read thoroughly those chapters that are most relevant to your clients.

Sample modules (units focused on a particular CBT concept or skill), which focus on imagery, are included later in the book for anxious children with cognitive limitations. These modules were written because such children

commonly present for treatment in community settings, and existing manuals are often particularly difficult to use with this population (see Chapter 7). They have been pilot tested with several children, but not empirically evaluated yet. There are also some children who have no cognitive limitations, but respond preferentially to imagery rather than words, probably because there are different learning styles and imagery tends to be more appealing to visual learners (Slater, Lujan, & DiCarlo, 2007). Most existing manuals, however, rely more on words than imagery. References are included for existing manuals that are readily available for other populations.

Chapter Organization

Each chapter integrates information from empirical studies with my own clinical experiences and those of my supervisees to illustrate an aspect of adapting CBT to community practice. CBT is an empirically validated treatment, but many research questions remain unanswered. To clarify the empirical basis of the information in this book, each chapter contains a section near the beginning entitled “What Is Known.” What is not known about the topic of the chapter will also be indicated in this section, so that the reader can clearly distinguish between ideas that have been tested and reported in published studies and those that have not.

The largest section of each chapter is titled “Putting It into Practice” and focuses on applying these ideas to your practice. Case examples from my practice and those of my supervisees are used to illustrate key points.

Near the end of each chapter is a worksheet with exercises that allow you to think about the principles described in relation to your clientele. For those who are not yet working with a client in CBT, a hypothetical “Clinical Challenge” is provided to stimulate your thinking. One possible set of answers to these clinical challenges is provided later in the book, but try to think them through without looking at the answers first.

References to publications about the topics addressed in each chapter are included throughout, to allow you to study a given topic in more detail if you wish.

The Value of Sharing Ideas with Peers

Having worked with groups of community practitioners from diverse settings, it has become clear to me that “more heads are better than one.” In other words, discussing with colleagues the topics of this book and how they relate to your work may be very useful. Colleagues may have a fresh perspective on your work, provide useful feedback, and help you apply the principles outlined in this book to your unique clientele and setting. It is also advisable to obtain supervision from a colleague with CBT experience for the first few cases if this modality is new to your practice.

Much of the practical content of this book is the direct result of my attempts to supervise community practitioners and adapt child CBT to their clients. Some of these practitioners also participated in an outcome evaluation study of a CBT teaching program. The results and suggestions which emerged from that study further influenced the book’s content and organization. Clearly, I am indebted to those who participated in the study and thank them for the opportunity to work together and to share ideas.

To begin the book, reasons for the difference between success in academic settings (called “efficacy”) and success in the community (called “effectiveness”) are described along with some lessons learned from an outcome study recently completed in my center that relate to this question. We then examine ways to begin “leveling the playing field” to allow successful cognitive behavioral treatment of children in the community.

References

Alford, B.A. & Beck, A.T. (1997). The integrative power of cognitive therapy. New York: Guilford Press.

Butler, A.C., Chapman, J.E., Forman, E.M., & Beck, A.T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17–31.

Compton, S.N., March, J.S., Brent, D., Albano, A.M., Weersing, R., & Curry, J. (2004). Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: An evidence-based medicine review. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 930–959.

Kendall, P. (1993). Guiding theory for therapy with children and adolescents. In P. Kendall (Ed.), Child and adolescent therapy. New York: Guilford Press.

McNeill, T. (2006). Evidence-based practice in an age of relativism: Toward a model for practice. Social Work, 51, 147–156.

Slater, J.A., Lujan, H.L., & DiCarlo, S.E. (2007). Does gender influence learning style preferences of first-year medical students? Advanced Physiological Education, 31, 336–342.

Weersing, V.R. & Weisz, J.R. (2002). Community clinic treatment of depressed youth: Benchmarking usual care against CBT clinical trials. Journal of Consulting and Clinical Psychology, 70, 299–310.