[Katharina_Manassis]_Cognitive_Behavioral_Therapy

Relapse Prevention

Judith S. Beck (1995) and other CBT authors have emphasized the importance of considering strategies for relapse prevention. Strategies for adults are further described in her book. When working with children, we often facilitate the continuing use of CBT strategies in various ways. These can include:

•Having the child designate a “special place” to keep his or her workbook, so it is not lost and can be accessed easily if needed.

•Having the child and parents schedule times to continue practicing relaxation or other CBT strategies so these are not neglected.

•Emphasizing the role of parents as “coaches” throughout therapy, as they learn more about supporting their child’s progress. When therapy ends, they continue coaching their child in the use of CBT strategies, essentially picking up where the therapist left off.

•Anticipating times of high stress (for example, starting a new school year, moving to a new house) and encouraging parent– child communication and review of coping strategies at such times. The family can then decide whether or not the review of strategies is sufficient to manage the stress. If not, they are advised to call back for a “booster” session, preferably before the child feels overwhelmed.

Returning for More CBT

Children do sometimes need to come back for a further course of CBT, either because of a new life challenge or a new developmental stage. Societal expectations of independent behavior increase as children get older, and coping strategies that are helpful for younger children are not necessarily appropriate for adolescents. If this happens, find out first what new challenges are contributing to the child’s symptoms, and address any unnecessary stresses or need for added support. For example, if the family has recently separated, a support group for children of separated or divorced parents may be more appropriate than further CBT. If the child is anxious about having lunch at school, but has been taunted or bullied in the lunchroom, ensure better supervision there to reduce this stress. After these common sense interventions, see if the symptoms resolve or remain, and proceed with further therapy only if symptoms remain.

To address remaining symptoms, begin with a review of coping strategies the child has previously learned or previously used. Determine why these are insufficient or no longer effective. Sometimes, the child no longer remembers how to do them properly (for example, remembering to breathe deeply, but doing it too quickly for relaxation to occur). Sometimes, the strategies need to be updated. Cognitive strategies learned at elementary school age are often no longer effective in adolescence, as the young person begins to reason in more

abstract ways than previously. A more sophisticated approach is needed and often welcome at this age.

It is important not to see children who resurface in your office as therapeutic failures. Few children have a perfectly smooth developmental course after CBT. In many cases, parents can help them master the occasional setback. In some cases, a session or two with the therapist to review previously learned skills is enough to get the child and parents back “on track.” If more is needed, contract for a further course of therapy. There is no shame in offering a “refresher course” to those who are still struggling.

Remember also that there is a cognitive bias inherent to doing therapy: people who get better stop seeing us, so eventually we see mainly those who do not get better. As a result, we get the biased impression that few of our clients are improving and begin to doubt ourselves. Correct the bias once in a while; you have probably forgotten most of the people out there you have helped!

Concluding Therapy Worksheet

• Preparation:

Have you recently reminded the child and parent of how many sessions are left?

Yes No

If not, do so and address any concerns they may have in relation to this prospect.

Client concern(s):

Plan to address concerns:

Other preparation:

• Graduation:

Check the manual you are using for any “graduation exercises” or other interventions to aid successful conclusion of therapy.

If absent, will do:

(See suggestions in this chapter)

•Reducing reliance on the therapist: Plan:

•Relapse prevention: Plan:

Clinical Challenge

You have been working with Nicholas, a 12-year-old boy with social anxiety, for the past 11 weeks, and he has made excellent progress. Concurrently, you have worked with his parents on different strategies for increasing their son’s exposure to and mastery of social situations with good effect. You remember (and your progress notes confirm this) that you discussed the timing and conclusion of therapy at least three times with Nicholas’ parents at various points in the therapy, including the previous week. At that time, everyone agreed that nothing further was needed, apart from additional “real-world practice,” which the parents would facilitate. The parents agreed to only call back in the event of a setback. This is your final session, and Nicholas says he is looking forward to inviting a friend over to play his new video game, the reward he has earned by working so hard over the previous three months. Nicholas’ mother turns to you and says “So, when would you like to see us again?” How do you respond?

References

Beck, J.S. (1995). Cognitive therapy: basics and beyond. New York: Guilford Press. Clarke, G.N., Rohde, P., Lewinsohn, P.M., Hops, H., & Seeley, J.R. (1999). Cognitive

behavioral treatment of adolescent depression: Efficacy of acute group treatment and booster sessions. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 272–279.

Emslie, G.J., Mayes, T.L., & Ruberu, M. (2005). Continuation and maintenance therapy of early-onset major depressive disorder. Paediatric Drugs, 7, 203–217.

March, J.S., Mulle, K., & Herbel, B. (1994). Behavioral psychotherapy for children and adolescents with obsessive compulsive disorder: An open trial of a new protocoldriven treatment package. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 333–341.

Shefler, G. (2000). Time-limited psychotherapy with adolescents. Journal of Psychotherapy Practice and Research, 9, 88–99.

the next professional, unrealistically hoping for an easy answer to their child’s problems.

2.Once Vicky’s parents are more cooperative, I would pursue a gradual, behavioral approach to school reentry. There is some evidence that this is more likely to succeed if she concurrently takes an antidepres- sant-type medication to reduce her anxiety (Bernstein, Borchardt, Perwien, Crosby, Kushner, Thuras, & Last, 2000), so I would pursue this as well. I would contact Vicky’s teacher and any other adults involved at the school to explain the rationale for this approach and elicit their cooperation in implementing it. Note: while suicidal threats should never be dismissed, Vicky’s appear to be designed to manipulate her parents, as she has no other evidence of depression and a rather active social life at the mall. Therefore, I would matter- of-factly indicate that gradual school reentry will occur regardless, and have her escorted there if needed.

3.Vicky is ready for CBT when she is making a daily attempt to attend school (leaving the house and approaching the school building at minimum), and is genuinely motivated to conquer her fears and reestablish regular school attendance. Her parents must be able to support the treatment plan, as discussed above.

Chapter 2: Tom

1.Most impairing problem: Based on the case description, I am fairly certain that Tom’s main problem relates to anxiety or to depression. His lifelong anxious temperament, distress about being “different” from his peers, and lack of behavior problems are all very consistent with an anxiety disorder. Before interviewing Tom, I might have also thought about Asperger’s syndrome or mild autism, given the degree of his social isolation. His appropriate responses to other children, good eye contact, desire for more friends, and painful awareness of being “different,” however, make an autism spectrum diagnosis unlikely. Note that difficulty responding to open-ended questions is quite common among socially anxious children.

2.Contextual factors: Although his medical history appears noncontributory, I would still like Tom to have a physical checkup with his family doctor if this has not been done recently. Even children with a lifelong history of anxiety sometimes experience exacerbations in response to illness or medication. I would also inquire about any caffeine consumption, exercise routines, and sleep routines and provide appropriate advice about these. From Tom I would want to know if there have been any other recent stresses at school or in his

184Cognitive-Behavioral Therapy with Children

10.Individual CBT would be preferable to start, because Tom’s high social anxiety might make a group seem overwhelming and, thus, make it difficult to learn CBT strategies in a group environment.

11.There are no contraindications to CBT in this case.

Chapter 3: Jerry

1.Some people would say that Jerry’s obsessive compulsive disorder (OCD) is the most impairing problem, because it results in a potentially serious medical problem: skin breakdown on his hands. One might also consider the degree of family conflict the most impairing problem, though, because it is threatening to derail existing treatment and is likely making Jerry more anxious and thus exacerbating his OCD. Furthermore, because Jerry is not of age, medical decisions will be made by his custodial parent. Until custody is clear, one cannot change much in the management of this case. Finally, the family conflict is making it very difficult to ascertain the truth: does Jerry really have the diagnoses his mother says he has?

2.There are no easy or quick fixes in this case. A first step, however, might be to locate a practitioner with expertise in custody and access assessments. To assist this practitioner, one could obtain further history regarding Jerry’s symptoms, particularly from people outside the family who might have witnessed them (for example, school teachers or previous doctors), and regarding previous treatment. It is not always possible to determine the truth with certainty in these cases, but a good history is a necessary prerequisite for any treatment, even if that treatment must be delayed until custody is clear.

3.While awaiting the result of the custody assessment, one could begin some supportive therapy with Jerry, as long as it was clear that this would have no bearing on the custody issue. Jerry is struggling with teasing, sexuality concerns, and other early adolescent issues in addition to his horrible family situation. He could use a good listener. Establishing a good therapeutic relationship may also make him more amenable to CBT in the future, if this is indicated.

4.Everyone in this family is motivated to start somewhere else, as everyone has a different perspective on what the “real” problem is. As mentioned, I would vote for starting with Jerry’s concerns until the parental conflict is resolved. The only caveat would be to maintain a good relationship with Jerry’s family doctor to ensure that the skin damage to his hands is treated appropriately until a more definitive treatment is decided upon.

Chapter 4: Josh

1.I would ignore the “useless” comment, but indicate that, since we are spending the hour together anyway, we might as well discuss some things that interest him. If it would make him more comfortable, we can minimize “feelings talk,” though I cannot promise to eliminate it entirely (I sometimes joke that it is one of my “bad habits”). Let us start with, what does he enjoy about “Dungeons of Doom”? I would listen intently and try to understand the game as best I can. If I could connect the game to some other aspect of life that he values, I would. If not, I might ask if Josh has experienced the kind of enjoyment he gets from the game anywhere else (perhaps before the “lousy year at school”)? Could he see himself getting back to that enjoyment, or some part of it? How does he think that could happen? What would he need to do? What would his parents need to do? What would I need to do? If possible, I would begin to formulate some treatment goals focused on his answers. Behavioral activation is an important aspect of recovery from depression, so I would not mind beginning with concrete, behavioral goals and avoiding extensive discussion of thoughts and feelings for now. Hopefully by the end of the session we can agree on one behavioral goal, or at least on meeting again to discuss his goals further. Later, probably in a subsequent session, we can discuss the connections between thoughts, feelings, and behaviors (the basic principles of CBT), but in the context of trying to reach his goals. If paying attention to his feelings and thoughts can help him cope in a situation he previously enjoyed, Josh is less likely to consider this a “useless” exercise than in his previous therapy.

2.The discussion with Josh’s parents would follow the outline in this chapter on CBT treatment expectations, but with a cautionary note. Their son is very defensive, and it is not yet clear whether he will engage in this therapy. Nevertheless, you will try to engage him in therapy. If he continues to see you, they must recognize that a few initial sessions may be needed to develop rapport with him and find treatment goals that he can agree to before actually doing CBT. Thus, the time frame for therapy may be slightly longer than usual. The limits of confidentiality are also important to emphasize in this case, because you want the option of involving the parents if Josh is at risk (for example, if he becomes suicidal), but otherwise allow much of the therapy content to remain private to increase Josh’s level of trust.

Chapter 5: Jenny

1.Since Jenny is a 10-year-old with generalized anxiety disorder and no other significant diagnoses, I would use the Coping Cat CBT manual