This week’s workshop, CBT for Children and Adolescents, included Kanan Kanakia, who traveled from Mumbai, India to attend the workshop. She has experience as a psychotherapist, special educator, counselor, and hypnotherapist which allows her to choose the best treatment path for her clients.
After learning about CBT, she wanted to get the actual feel of how to apply CBT and researched Beck Institute workshops, deciding “which better institute than here.”
“This workshop was exactly what I was looking for with the know-how and the application in real life and real circumstances.”
When asked about Dr. Torrey Creed, the workshop instructor, Kanan replied, “Oh, she’s amazing!” She presented real case examples of the topics she was instructing, which made the complex topics easy to grasp.
Kanan also had the opportunity to role play a tough client with Dr. Aaron Beck via Skype.
On my desk sits a stack of pictures that includes: “Evil Pink Monster,” “Bob, the angry wolf,” and “Enfado,” a small bird that breathes out long flames of anger. These pictures, all externalized images of emotion, play a crucial role in my clinical work with children. CBT is a problem-specific type of therapy, and as such, treatment goals reflect the identified problems, including those embodied in the monsters and birds on my desk. Kids think differently from adults, so it may not be surprising that CBT looks and works a little differently with children and adolescents.
Sara (not her real name) is the artist who created “Evil Pink Monster.” When she came into my office the other day, she wanted to make sure we included a recent “Pink Monster” episode in our agenda. Sara described an incident where she had acted verbally aggressive towards her sibling—an ongoing issue. When our work first began, Sara had explained to me that she was “just not a nice kid. I’m not one of those good kids, I’m just not.” As we delved deeper, it became clear that Sara had a great deal of difficulty regulating her emotions, and she often over-reacted to situations.
“The person is not the problem, the problem is the problem,” wrote narrative therapist Michael White. When a child thinks that she’s a problem kid because she always acts out in school or causes conflict at home, it’s harder to help her make changes. In that narrative, the problem is her. CBT involves reappraisal of the situation and a willingness to look at the problem through different perspectives. When the child feels as if she is the literal problem, it becomes harder for her to objectively view the situation and her reactions. In CBT with kids, this is where the process of externalizing the problem becomes very helpful. It’s amazing how much easier it is to tackle a situation when a kid doesn’t feel like she is the sole reason for the problem.
Here’s how it works: Sara, age 9, had struggled with her anger for quite some time. She entered into CBT with a clear sense that she was “messed up” and that she was at fault for causing stress in the family. Every adult in her life had asked her why she did the things she did, and tried to talk with her rationally about making different choices. The reality was that 9-year-old Sara didn’t have a good sense of why she acted the way she did, and she truly felt terrible about it. Sara and I worked on identifying the automatic thoughts she had when she was angry. These thoughts included: “It’s so unfair,” “This always happens—I always get blamed,” and “I hate them!”
As we wrote down Sara’s automatic thoughts and looked at her feelings (anger, frustration, sadness), we began to imagine what those thoughts and feelings would look like if they were an actual creature. Sara, an excellent artist, began to draw out some designs. (If Sara had been reluctant to actually draw the image, we would have narrowed down the type of creature [monster, wolf, etc.] and googled clipart versions to get ideas).
Sara and I kept talking about what we imagined her anger looked like while she drew, and she was able to verbalize the experience of her emotions and to voice her automatic thoughts. “Something mean, that makes everything seem like it’s worse than it is. He, like, gets in my head and tries to make me feel so bad and so mad. He’s an evil little monster.” Seeing a finger puppet on my desk, Sara picked it up and said, “This is it. It’s him.” Once we had a clear description and name for the monster (in this case, “Evil Pink Monster”) we had a new language for discussing the identified problem of her treatment—her difficulty controlling anger and regulating her emotions.
Sara had willingly come to therapy because she was unhappy with how little control she felt she had over her emotional responses, and because she felt guilty about how she acted. By externalizing her anger into a concrete image, she was able to view the problem more objectively. In this way it wasn’t all her fault; she wasn’t a bad kid; she just had an Evil Pink Monster inside that made things seem worse than they actually were.*
And now we needed to figure out how to battle the monster.
Traditional CBT techniques used to manage anger and regulate emotions now became more easily implemented into the therapy. As Sara and I began the process of identifying behavioral and cognitive patterns, we simply shifted the language to reflect situations where the Evil Pink Monster was likely to be triggered. In lieu of discussing behavioral patterns and automatic thoughts in traditional language, we discussed them through the lens of the Evil Pink Monster. As we rated the intensity of the anger response, we created our own 1-10 rating of how strong the Evil Pink Monster was at that moment (1 was Fuzzy Bunny strong and 10 was Godzilla Drinking Espresso strong). And as we began to incorporate imagery into self-calming strategies, we often imagined the Evil Pink Monster on the beach drinking from a coconut or relaxing in a swimsuit under a palm tree. The images in themselves were relaxing, but they were also funny, and the use of humor in coping strategies can often go a long way.
The process of externalization in CBT is frequently discussed in the OCD literature, but there is broader use for this technique. Just as anger can be externalized into an evil pink monster, so can sadness be understood as Eeyore from Winnie the Pooh or, as one child described it “the blue monster that follows me around.” A beautiful but anxious fourteen-year-old girl describe her social anxiety as a clown wearing plaid pants and braces. Her general anxiety was “the nasty storm cloud that always follows me around.” Externalization doesn’t take away the patient’s responsibility to address their problems, but it does provide a tool to take away some of the self-blame, allowing for greater objectivity and greater change.
Externalization is one of many techniques pediatric CBT clinicians employ to make the process relatable, meaningful, and developmentally relevant. Kids aren’t little adults, and their therapy looks a little different (and is often a lot more fun).
*To be clear, as a 9-year-old with no cognitive impairments, Sara could easily understand that we were using the monster as a symbolic representation of her anger. This technique would not be effective for children unable to differentiate between abstract and concrete ideas.
Learn more about CBT for Children and Adolescents at our upcoming workshop.
Adolescents whose parents have a history of depression are at risk for developing depression and functional impairment. The long-term effects of prevention programs on adolescent depression and functioning are not known.
To determine whether a cognitive-behavioral prevention (CBP) program reduced the incidence of depressive episodes, increased depression-free days, and improved developmental competence 6 years after implementation.
Design, Setting, and Participants
A 4-site randomized clinical trial compared the effect of CBP plus usual care vs usual care, through follow-up 75 months after the intervention (88% retention), with recruitment from August 2003 through February 2006 at a health maintenance organization, university medical centers, and a community mental health center. A total of 316 participants were 13 to 17 years of age at enrollment and had at least 1 parent with current or prior depressive episodes. Participants could not be in a current depressive episode but had to have subsyndromal depressive symptoms or a prior depressive episode currently in remission. Analysis was conducted between August 2014 and June 2015.
The CBP program consisted of 8 weekly 90-minute group sessions followed by 6 monthly continuation sessions. Usual care consisted of any family-initiated mental health treatment.
Main Outcomes and Measures
The Depression Symptoms Rating scale was used to assess the primary outcome, new onsets of depressive episodes, and to calculate depression-free days. A modified Status Questionnaire assessed developmental competence (eg, academic or interpersonal) in young adulthood.
Over the 75-month follow-up, youths assigned to CBP had a lower incidence of depression, adjusting for current parental depression at enrollment, site, and all interactions (hazard ratio, 0.71 [95% CI, 0.53-0.96]). The CBP program’s overall significant effect was driven by a lower incidence of depressive episodes during the first 9 months after enrollment. The CBP program’s benefit was seen in youths whose index parent was not depressed at enrollment, on depression incidence (hazard ratio, 0.54 [95% CI, 0.36-0.81]), depression-free days (d = 0.34, P = .01), and developmental competence (d = 0.36, P = .04); these effects on developmental competence were mediated via the CBP program’s effect on depression-free days.
Conclusions and Relevance
The effect of CBP on new onsets of depression was strongest early and was maintained throughout the follow-up period; developmental competence was positively affected 6 years later. The effectiveness of CBP may be enhanced by additional booster sessions and concomitant treatment of parental depression.
Brent, D. A., Brunwasser, S. M., Hollon, S. D., Weersing, V. R., Clarke, G. N., Dickerson, J. F., Beardslee, W. R., … Garber, J. (January 01, 2015). Effect of a cognitive-cehavioral prevention program on depression 6 years after implementation among at-risk adolescents: A randomized clinical trial. Jama Psychiatry, 72, 11, 1110-8.
Congratulations to Torrey (and team) on her recent publication in Current Psychiatry Reviews!
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 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.
Creed, A. T., Waltman, H. S., Frankel A. S. & Williston, A. M. School-based cognitive behavioral therapy: Current status and alternative approaches. Current Psychiatry Reviews, 11.
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.
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
This is a fantastic training opportunity for pediatricians who want to use cognitive behavior therapy to supplement medication management. [My supervisor] has been enthusiastic and patient and is a wealth of knowledge. It has added a wonderful dimension to my practice and I would recommend this for any practioneer who deals with behavior issues in kids.
Despite the abundance of research that supports the efficacy of exposure therapy for childhood anxiety disorders and OCD, negative views and myths about the harmfulness of this treatment are prevalent. These beliefs contribute to the underutilization of this treatment and less robust effectiveness in community settings compared to randomized clinical trials. Although research confirms that exposure therapy is efficacious, safe, tolerable, and bears minimal risk when implemented correctly, there are unique ethical considerations in exposure therapy, especially with children. Developing ethical parameters around exposure therapy for youth is an important and highly relevant area that may assist with the effective generalization of these principles. The current paper reviews ethical issues and considerations relevant to exposure therapy for children and provides suggestions for the ethical use of this treatment.
Gola, A. J., Beidas, S. R., Antinoro-Burke, D., Kratz, E. H. & Fingerhut, R. (2015). Ethical considerations in exposure therapy with children. Cognitive and Behavioral Practice. doi:10.1016/j.cbpra.2015.04.003
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