School-based cognitive behavioral therapy: Current status and alternative approaches

Congratulations to Torrey (and team) on her recent publication in Current Psychiatry Reviews!

Abstract

Cognitive Behavioral Therapy (CBT) is among the most studied EBPs with support for its efficacy across a range of presenting problems in youth, but broad uptake of traditional CBT in school-based settings has been slow. A review of CBT in schools is presented, which suggests that most school-based studies have examined the use of a protocol for a single research blog (4)disorder or presenting problem, delivered by an individual provider (e.g., teacher, counselor). Evidence supports the effectiveness of these interventions for targeted problems, but limitations of these practices may present barriers to broader implementation of CBT. A review of alternative strategies is then presented, which suggests an approach that may flexibly meet the needs of a broader range of students, capitalize on the unique characteristics of a school setting, and emphasize principles of resilience. Finally, the University of Pennsylvania Beck Community Initiative is presented to illustrate an integrated approach to CBT within schools that is case conceptualization-driven, milieu-focused, and resilience-oriented to apply these strategies in a school setting.

 

Learn more about the upcoming workshop CBT for Children and Adolescents, taught by Dr. Torrey Creed. 

 

Creed, A. T., Waltman, H. S., Frankel A. S. & Williston, A. M. School-based cognitive behavioral therapy: Current status and alternative approachesCurrent Psychiatry Reviews, 11. 

CBT for comorbid migraine and/or tension-type headache and major depressive disorder: An exploratory randomized controlled trial

Abstract

Numerous studies have demonstrated comorbidity between migraine and tension-type headache on the one hand, and depression on the other. Presence of depression is a negative prognostic indicator for behavioral treatment of headaches. Despite the recognised comorbidity, there is a limited research literature evaluating interventions designed for comorbid headaches and depression. research blog (2)Sixty six participants (49 female, 17 male) suffering from migraine and/or tension-type headache and major depressive disorder were randomly allocated to a Routine Primary Care control group or a Cognitive Behavior Therapy group that also received routine primary care. The treatment program involved 12 weekly 50-min sessions administered by clinical psychologists. Participants in the treatment group improved significantly more than participants in the control group from pre-to post-treatment on measures of headaches, depression, anxiety, and quality of life. Improvements achieved with treatment were maintained at four month follow-up. Comorbid anxiety disorders were not a predictor of response to treatment, and the only significant predictor was gender (men improved more than women). The new integrated treatment program appears promising and worthy of further investigation.

 

Martin, P. R., Aiello, R., Gilson, K., Meadows, G., Milgrom, J., & Reece, J. (January 01, 2015). Cognitive behavior therapy for comorbid migraine and/or tension-type headache and major depressive disorder: An exploratory randomized controlled trial. Behaviour Research and Therapy, 73, 8-18.

RCT of a Brief Phone-Based CBT Intervention to Improve PTSD Treatment Utilization by Returning Service Members

Worried about their reputation and career prospects, returning service members with PTSD may avoid seeking treatment. research blog (1)In a randomized controlled trial, the authors examined engagement in treatment and symptoms among veterans with PTSD who received a brief phone-based intervention to discuss why they had avoided treatment. Veterans who received a call entered treatment sooner and experienced more immediate reductions in PTSD symptoms than veterans who received usual care. By six months, differences between the two groups had faded, suggesting that adding a second phone call might be warranted.

Objectives

Many service members do not seek care for mental health and addiction problems, often with serious consequences for them, their families, and their communities. This study tested the effectiveness of a brief, telephone-based, cognitive-behavioral intervention designed to improve treatment engagement among returning service members who screened positive for posttraumatic stress disorder (PTSD).

 

Methods

Service members who had served in Operation Enduring Freedom or Operation Iraqi Freedom who screened positive for PTSD but had not engaged in PTSD treatment were recruited (N=300), randomly assigned to either control or intervention conditions, and administered a baseline interview. Intervention participants received a brief cognitive-behavioral therapy intervention; participants in the control condition had access to usual services. All participants received follow-up phone calls at months 1, 3, and 6 to assess symptoms and service utilization.

 

Results

Participants in both conditions had comparable rates of treatment engagement and PTSD symptom reduction over the course of the six-month trial, but receiving the telephone-based intervention accelerated service utilization (treatment engagement and number of sessions) and PTSD symptom reduction.

 

Conclusions

A one-time brief telephone intervention can engage service members in PTSD treatment earlier than conventional methods and can lead to immediate symptom reduction. There were no differences at longer-term follow-up, suggesting the need for additional intervention to build upon initial gains.

 

Stecker, T., McHugo, G., Xie, H., Whyman, K., & Jones, M. (January 01, 2014). RCT of a brief phone-based CBT intervention to improve PTSD treatment utilization by returning service members. Psychiatric Services (washington, D.c.), 65, 10, 1232-7.

Reducing Clinician Stress When Treating Traumatized, Suicidal Clients

Marjan G. Holloway, Ph.D., Beck Institute Faculty

 

Portrait

Marjan G. Holloway, Ph.D.

As an educator, I have noticed that two subgroups of clients are highly likely to activate anxiety and other types of emotional distress (e.g., professional burnout) among clinicians.  The first subgroup consists of traumatized clients and the second subgroup consists of suicidal clients.  When working with clients who are traumatized and suicidal, the potential for therapy-interfering emotions such as excessive worry and therapy-interfering behaviors such as avoidance on the part of the clinician notably increases.  These problematic emotional and behavioral reactions often stem from a series of maladaptive clinician cognitions, as described below.

  1. All-or-None Thinking (Example: “After months of therapy, nothing has changed.”)
  2. Catastrophic Thinking (Example: “If I ask too many questions about the traumatic event, the client will deteriorate, fall apart, and may even become suicidal.”)
  3. Labeling (Example: “This client is resistant to change – wants to remain a victim.”)
  4. Personalizing (Example: “As an incompetent therapist, it’s my fault that the client remains symptomatic.” )

We have all been there.  I recall my excitement after having received a new client referral in the early years of my practice.  This excitement quickly transformed to anxiety, indecisiveness, and self-doubt as I learned about this particular client’s history of multiple lifetime traumas and suicidal behaviors.  I was terrified to accept the case as a newly licensed psychologist and I frankly questioned my ability to work effectively with the client (even after years of solid clinical training).  Not surprisingly, I avoided taking the case.  To address my sense of responsibility and guilt, I started to call other community clinicians and colleagues in private practice to find a good referral source.  Very quickly, I discovered that other clinicians, regardless of their seasonality, were similarly not available to accept a “complex” trauma case who was also considered at high risk for suicide.  As I listened to the justifications provided by these clinicians, I had an opportunity to examine my own beliefs about the client.  I realized that these beliefs – along with my negative emotions – were dictating my decision to avoid.

During an upcoming 2016 Beck Institute Workshop on CBT for PTSD, I plan to review two evidence-based CBT interventions for trauma: Prolonged Exposure (PE; Foa, Hembree, & Rothbaum, 2007) and Cognitive Processing Therapy (CPT; Resick & Schnicke, 1996).  While each intervention has a different theoretical underpinning and technical approach, both emphasize the following:

  • The importance of having the client understand (i.e., “digest”) the traumatic event
  • The importance of having the client understand that the memory of the traumatic event, by itself, is not dangerous and therefore, not to be avoided

By repeated exposure to the memories associated with the traumatic event and/or repeated examination of the impact of the traumatic event, the traumatized client can gain a sense of control and mastery over the traumatic memories.

To date, there is no scientific evidence to suggest that asking about trauma-related and/or suicide-related content exacerbates psychiatric symptoms.  CBT clinicians can learn to effectively manage their own anxiety and emotional distress, while working with this highly vulnerable client population, by engaging in the following recommended activities:

  • Gaining continuing education in evidenced-based CBT for PTSD
  • Being mindful of their own therapist maladaptive emotions, cognitions, and/or behaviors
  • Seeking peer consultation and/or supervision, as needed
  • Listening carefully to the trauma/suicide narratives of their clients in order to construct meaningful cognitive behavioral conceptualizations for treatment planning
  • Paying close attention to self-care and early signs of professional burnout

Working with traumatized clients is certainly not easy.  However, we as CBT clinicians have the responsibility to intervene, rather than to avoid.  Prolonged Exposure and Cognitive Processing Therapy are two CBT-oriented treatment packages that are evidence-based.  Gaining familiarity and future competency in delivering these interventions will certainly prove to be beneficial to your clients and to you.

 

Recommended Resources

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide. New York, NY: Oxford University Press.

Ghahramanlou-Holloway, M., Neely, L., & Tucker, J. (2014). A cognitive-behavioral strategy for preventing suicide. Current Psychiatry, 13(8), 18-25.

Resick, P. A., & Schnicke, M. K. (1996). Cognitive processing therapy for rape victims. Newbury Park, Sage Publications.

 

Mobile Apps to Consider

PE Coach

Breathe2Relax

Provider Resilience

The New “Homework” in Cognitive Behavior Therapy

By Judith S. Beck, Ph.D., and Francine R. Broder, Psy.D.

 

Judith S. Beck, Ph.D.

Judith S. Beck, Ph.D.

We’ve stopped using the word “homework” in CBT. Too many clients take exception to that term. It reminds them of the drudgery of assignments they had to do at home when they were at school. So in recent times, we’ve switched. “Homework” is now called the “Action Plan.”

We like the label “Action Plan.” It conveys a sense of proactivity, of taking control.

Action plans aren’t optional. They are very carefully created, in a collaborative fashion. Therapists emphasize that most of the work in getting better happens between sessions. A significant part of each session involves helping clients figure out what they need to do outside of the therapy office to feel better and regain a good level of functioning. We tell clients:The New Homework Quote

Fran Web

Francine R. Broder, Psy.D.

That’s why we make sure that whatever is important for the client to remember about the session, including their Action Plan, is recorded, written down or entered as text or audio into an electronic device.

And that’s why, after we’ve finished collaboratively creating the Action Plan, we ask:

How likely are you to do this assignment(s) this week?

And that’s why we continue talking about potential obstacles that could get in the way when clients say they are 90% or less likely to complete the Action Plan.

Here is an example of a client who did not do his action plan, and this is how we worked on it.

A 28-year-old came to treatment to work on reducing depression, social anxiety, and worry about his irritable bowel syndrome.  During our session, he identified “getting into shape” as important to him and set up a specific action plan that included going to the gym he belonged to, two times during the week, for approximately 30 minutes.  Upon returning the following week and checking in on how it went, he stated he did not go.  When asked what got in his way, he stated he did not know.  He was asked to go back to an earlier time in the week, imagine himself about to go to the gym, and to notice the thoughts that were going through his mind.  Using imagery, he was able to identify his interfering thoughts.  Next, we used Socratic questioning, summarizing his conclusions in a two-column thought record.

 

The New Homework ChartThe Action Plan isn’t optional. A considerable body of evidence shows that clients who do homework have better outcomes than clients who do not. See, for example Conklin & Strunk (2015); Kazantzis, Deane, Ronan & L’Abate (2005). It’s up to therapists to help clients carefully design meaningful assignments with a good likelihood of success and to motivate clients to follow through.Finally, we used the two-column thought record to anticipate additional interfering thoughts that could get in the way of engaging in his action plan for the coming week.

 

Conklin, L. R., & Strunk, D. R. (January 01, 2015). A session-to-session examination of homework engagement in cognitive therapy for depression: Do patients experience immediate benefits?Behaviour Research and Therapy, 72, 56-62.

 

Kazantzis, N., & L’Abate, L. (2006). Handbook of homework assignments in psychotherapy: Research, practice, and prevention. New York, NY: Springer.

Brief Cognitive-Behavioral Therapy Effects on Post-Treatment Suicide Attempts in a Military Sample: Results of a Randomized Clinical Trial With 2-Year Follow-Up

Abstract

research blogObjective:The authors evaluated the effectiveness of brief cognitive-behavioral therapy (CBT) for the prevention of suicide attempts in military personnel.

Method: In a randomized controlled trial, active-duty Army soldiers at Fort Carson, Colo., who either attempted suicide or experienced suicidal ideation with intent, were randomly assigned to treatment as usual (N=76) or treatment as usual plus brief CBT (N=76). Assessment of incidence of suicide attempts during the follow-up period was conducted with the Suicide Attempt Self-Injury Interview. Inclusion criteria were the presence of suicidal ideation with intent to die during the past week and/or a suicide attempt within the past month. Soldiers were excluded if they had a medical or psychiatric condition that would prevent informed consent or participation in outpatient treatment, such as active psychosis or mania. To determine treatment efficacy with regard to incidence and time to suicide attempt, survival curve analyses were conducted. Differences in psychiatric symptoms were evaluated using longitudinal random-effects models.

Results: From baseline to the 24-month follow-up assessment, eight participants in brief CBT (13.8%) and 18 participants in treatment as usual (40.2%) made at least one suicide attempt (hazard ratio=0.38, 95% CI=0.16–0.87, number needed to treat=3.88), suggesting that soldiers in brief CBT were approximately 60% less likely to make a suicide attempt during follow-up than soldiers in treatment as usual. There were no between-group differences in severity of psychiatric symptoms.

Conclusions: Brief CBT was effective in preventing follow-up suicide attempts among active-duty military service members with current suicidal ideation and/or a recent suicide attempt.

 

Rudd, M. D. (January 01, 2015). Brief Cognitive-Behavioral Therapy Effects on Post-Treatment Suicide Attempts in a Military Sample: Results of a Randomized Clinical Trial With 2-Year Follow-Up. American Journal of Psychiatry, 172, 5, 441-449.

 

Effectiveness of Trauma-Focused Cognitive Behavioral Therapy in a Community-Based Program

New Study (1)Abstract:

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a widely used treatment model for trauma-exposed children and adolescents (Cohen, Mannarino, & Deblinger, 2006). The Healthy Coping Program (HCP) was a multi-site community based intervention carried out in a diverse Canadian city. A randomized, waitlist-control design was used to evaluate the effectiveness of TF-CBT with trauma-exposed school-aged children (Muller & DiPaolo, 2008). A total of 113 children referred for clinical services and their caregivers completed the Trauma Symptom Checklist for Children (Briere, 1996) and the Trauma Symptom Checklist for Young Children (Briere, 2005). Data were collected pre-waitlist, pre-assessment, pre-therapy, post-therapy, and six months after the completion of TF-CBT. The passage of time alone in the absence of clinical services was ineffective in reducing children’s posttraumatic symptoms. In contrast, children and caregivers reported significant reductions in children’s posttraumatic stress (PTS) following assessment and treatment. The reduction in PTS was maintained at six month follow-up. Findings of the current study support the use of the TF-CBT model in community-based settings in a diverse metropolis. Clinical implications are discussed.

Konanur S., Muller R. T., Cinamon J.S., Thornback K. & Zorzella K. P. (2015). Effectiveness of Trauma-Focused Cognitive Behavioral Therapy in a ommunity-based program. Child Abuse Negl. 2015 Aug 25. pii: S0145-2134(15)00242-2. doi: 10.1016/j.chiabu.2015.07.013.

CBT for adolescents with anxiety: Mature yet still developing

New Study (1)Abstract

Anxiety disorders are common in adolescents (ages 12 to 18) and contribute to a range of impairments. There has been speculation that adolescents with anxiety are at risk for being treatment nonresponders. In this review, the authors examine the efficacy of cognitive-behavioral therapy (CBT) for adolescents with anxiety. Outcomes from mixed child and adolescent samples and from adolescent-only samples indicate that approximately two-thirds of youths respond favorably to CBT. CBT produces moderate to large effects and shows superiority over control/comparison conditions. The literature does not support differential outcomes by age: adolescents do not consistently manifest poorer outcomes relative to children. Although extinction paradigms find prolonged fear extinction in adolescent samples, basic research does not fully align with the processes and goals of real-life exposure. Furthermore, CBT is flexible and allows for tailored application in adolescents, and it may be delivered in alternative formats (i.e., brief, computer/Internet, school-based, and transdiagnostic CBT).

Kendall, C. P. & Peterman, S. J. (2015). CBT for adolescents with anxiety: Mature yet still developing. The American Journal of Psychiatry, 172(6). pp. 519-530. http://dx.doi.org/10.1176/appi.ajp.2015.14081061

Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (prevent): A randomised controlled trial

New Study (1)Abstract:

Background:
Individuals with a history of recurrent depression have a high risk of repeated depressive relapse or recurrence. Maintenance antidepressants for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to medication. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce risk of relapse or recurrence compared with usual care, but has not yet been compared with maintenance antidepressant treatment in a definitive trial. We aimed to see whether MBCT with support to taper or discontinue antidepressant treatment (MBCT-TS) was superior to maintenance antidepressants for prevention of depressive relapse or recurrence over 24 months.

Methods:
In this single-blind, parallel, group randomised controlled trial (PREVENT), we recruited adult patients with three or more previous major depressive episodes and on a therapeutic dose of maintenance antidepressants, from primary care general practices in urban and rural settings in the UK. Participants were randomly assigned to either MBCT-TS or maintenance antidepressants (in a 1:1 ratio) with a computer-generated random number sequence with stratification by centre and symptomatic status. Participants were aware of treatment allocation and research assessors were masked to treatment allocation. The primary outcome was time to relapse or recurrence of depression, with patients followed up at five separate intervals during the 24-month study period. The primary analysis was based on the principle of intention to treat. The trial is registered with Current Controlled Trials, ISRCTN26666654.

Findings:
Between March 23, 2010, and Oct 21, 2011, we assessed 2188 participants for eligibility and recruited 424 patients from 95 general practices. 212 patients were randomly assigned to MBCT-TS and 212 to maintenance antidepressants. The time to relapse or recurrence of depression did not differ between MBCT-TS and maintenance antidepressants over 24 months (hazard ratio 0·89, 95% CI 0·67–1·18; p=0·43), nor did the number of serious adverse events. Five adverse events were reported, including two deaths, in each of the MBCT-TS and maintenance antidepressants groups. No adverse events were attributable to the interventions or the trial.

Interpretation:
We found no evidence that MBCT-TS is superior to maintenance antidepressant treatment for the prevention of depressive relapse in individuals at risk for depressive relapse or recurrence. Both treatments were associated with enduring positive outcomes in terms of relapse or recurrence, residual depressive symptoms, and quality of life.

Kuyken, Willem et al. (2015) Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): A randomised controlled trial. The Lancet (386) 9988, p. 63 – 73.

Bringing Technology to Training: Web-Based Therapist Training to Promote the Development of Competent Cognitive-Behavioral Therapists

New Study (1)Abstract:

In general, as well as part of dissemination and implementation science, there is the need to focus on training of mental health professionals in cognitive-behavioral therapy (CBT). Unfortunately, the usual training methods (e.g., workshops, seminars) and the availability of treatment manuals have not produced full uptake or quality practice. Web-based therapist training programs can improve and expand access to CBT training. Advantages of a web-based training approach allows for increased flexibility, accessibility, cost-efficiency, scalability, potential for both didactive and interactive learning, consistency in quality, and importantly, the potential for remote supervision/consultation. We provide a rationale for the use of technology in clinician training in CBT, highlight several promising programs, and describe the technology and research considerations in web-based training using the example of computer-based training in CBT for childhood anxiety disorders. We also discuss directions for future research, as well as the challenges that remain.

Khanna, S. M. & Kendall, C. P. (2015) Bringing Technology to Training: Web-Based Therapist Training to Promote the Development of Competent Cognitive-Behavioral Therapists. Cognitive and Behavioral Practice 22(3) p. 291-301. doi:10.1016/j.cbpra.2015.02.002