Cognitive Behavioral Treatment...
Research - RKT
An Idea to help Anxiety...
The journal article is entitled...
A Model of Therapist Competencies for the Empirically Supported Cognitive-Behavioral Treatment of Child and Adolescent Anxiety and Depressive Disorders
Elizabeth S. Sburlati • Carolyn A. Schniering •
Heidi J. Lyneham • Ronald M. Rapee
Published online: 26 January 2011
Springer Science+Business Media, LLC 2011
May they help kindle ideas to help anyone with Anxiety and the stigma of being labeled through Cognitive Behavior Therapy.
Richard Kerry Thompson
RKT
Mr. T
A Model of Therapist Competencies for the Empirically Supported Cognitive-Behavioral Treatment of Child and Adolescent Anxiety and Depressive Disorders
Elizabeth S. Sburlati • Carolyn A. Schniering • Heidi J. Lyneham • Ronald M. Rapee
Published online: 26 January 2011 Springer Science+Business Media, LLC 2011
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Abstract
Abstract
While a plethora of cognitive-behavioral empirically supported treatments (ESTs) are available for treating child and adolescent anxiety and depressive disorders, research has shown that these are not as effective when implemented in routine practice settings. Research is now indicating that is partly due to ineffective EST training methods, resulting in a lack of therapist competence. However, at present, the specific competencies that are required for the effective implementation of ESTs for this population are unknown, making the development of more effective EST training difficult. This study, therefore, aimed to develop a model of therapist competencies for the empirically supported cognitive-behavioral treatment of child and adolescent anxiety and depressive disorders using a version of the well-established Delphi technique. In doing so, the authors:
(1) identified and reviewed cognitive-behavioral ESTs for child and adolescent anxiety and depressive disorders,
(2) extracted therapist competencies required to implement each treatment effectively,
(3) validated these competency lists with EST authors,
(4) consulted with a panel of relevant local experts to generate an overall model of therapist competence for the empirically supported cognitive-behavioral treatment of child and adolescent anxiety and depressive disorders, and
(5) validated the overall model with EST manual authors and relevant international experts.
The resultant model offers an empirically derived set of competencies necessary for effectively treating children and adolescents with anxiety and depressive disorders and has wide implications for the development of therapist training, competence assessment measures, and evidence-based practice guidelines for working with this population. This model thus brings us one step closer to bridging the gap between science and practice when treating child and adolescent anxiety and depression.
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Specific CBT Techniques
Specific CBT Techniques
Specific CBT Techniques are those cognitive behavioral techniques that have proven efficacy for treating child and adolescent anxiety disorders and depression (Roth and Pilling 2008). As seen in Fig. 1, these techniques are divided into five categories, based on whether they aim to
modify thoughts (Managing Negative Thoughts), behaviors (Changing Maladaptive Behaviors), mood and arousal (Managing Maladaptive Mood and Arousal), general skills (General Skills Training), or the family environment (Modifying the Family Environment) and are further
described in Tables 2, 3, 4, 5, 6, respectively. It can be argued that a number (if not all) of these techniques could be placed into one or more other categories, as most techniques tend to have more than one aim and impact on multiple maintaining factors. For example, behavioral
experiments have been placed into the managing negative thoughts category because its usual stated aim is to provide the individual with a chance to test out their negative
thoughts and predictions. But it could as accurately be placed into the Changing Maladaptive Behaviors category, as it generally involves encouraging the child or adolescent
to enter avoided situations.
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Table 2
Table 2 - Descriptions of Specific CBT Techniques from the managing negative thoughts category
Cognitive restructuring
Cognitive restructuring
Cognitive restructuring for anxiety and depression is a technique where the child or adolescent is asked to identify his or her negative, unrealistic or unhelpful thoughts, evaluate evidence for and against these, and generate a more positive, realistic or helpful thought based on this evidence (e.g., March and Mulle 1998; Ost and Ollendick 2001; Pincus et al. 2008).
While for most children and adolescents, cognitive restructuring will center around negative automatic thoughts, the therapist might consider applying these techniques to deeper level cognitions including underlying assumptions and core beliefs when the child or adolescent is capable of doing so (Brent and Poling 1997) - A.N.T.
Behavioral experiments
Behavioral experiments
Behavioral experiments involve the client identifying, testing out, and evaluating the validity of predictions about avoided situations (e.g., Brent and Poling 1997)
Thought substitution/ self-talk
Thought substitution/self-talk
Thought Substitution, also known as ‘Self-Talk’, asks the child or adolescent to identify negative, unrealistic or unhelpful thoughts and without entering into evidence finding procedures seen in cognitive restructuring, simply generate a more positive, realistic, or helpful thought to replace it with (e.g., Kendall and Hedke 2006; March and Mulle 1998).
This is more useful than cognitive restructuring with younger children who lack the ability to engage in cognitive processes involved in evidence finding.
Positive imagery
Positive imagery
Positive imagery asks the child or adolescent to identify negative images that they experience and replace these with positive ones (e.g., Deblinger and Heflin 1996)
Thought stopping/interruption
Thought stopping/interruption
Thought Stopping, also known as ‘Thought Interruption’, asks the child to catch themselves having a negative thought and to use a strategy helpful for them to stop this thought (e.g., Clarke et al. 1990).
These strategies can include saying ‘‘stop’’ out loud or internally, flicking a rubber band on ones wrist, or setting aside worry time (e.g., Clarke et al. 1990)
Thought acceptance
Thought acceptance
Thought acceptance is aimed at having the child or adolescent recognize that their thoughts may or may not be true and to cultivate and encourage a non-attachment to the thought (March and Mulle 1998).
This technique is akin to techniques such as cognitive defusion in Acceptance and Commitment Therapy, which do not ask the individual to alter the nature of the thought (as in traditional cognitive restructuring), but rather alter their engagement in or relationship with the thought
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Table 3
Table 3 - Descriptions of Specific CBT Techniques from the Changing Maladaptive Behaviors category
Interoceptive exposure
Interoceptive exposure asks the individual to confront feared and avoided somatic sensations (Pincus et al. 2008)
In vivo exposure
In vivo exposure asks the child to confront feared and avoided situations, objects, or events (e.g., Beidel et al. 1998)
Imaginal/narrative exposure
Imaginal/narrative exposure
Imaginal/narrative exposure asks the individual to confront feared and avoided mental events including images and traumatic memories (e.g., Deblinger and Heflin 1996).
All three forms of exposure (interoceptive, in vivo, and imaginal/narrative) should be gradual, endured, repeated, and rewarded (e.g., Rapee et al. 2006)
Response prevention
Response prevention
Response prevention aims to curtail the young person’s engagement in problematic behaviors which can serve to maintain anxiety, such as excessive hand washing or checking in the case of OCD (March and Mulle 1998)
Behavioral activation
Behavioral activation
Behavioral activation is a technique that increases a depressed individual’s engagement in daily activities and goal-directed behaviors (e.g., Brent and Poling 1997).
This is aimed at bolstering the degree of positive reinforcement and reducing the amount of punishment experienced in the environment and promoting mastery experiences for the depressed individual.
Pleasant events scheduling
Pleasant events scheduling
Pleasant events scheduling is a feature of behavioral activation and aims to increase the individual’s engagement in activities that they enjoy or that they enjoyed before developing depression (e.g., Clarke et al. 1990)
Self-evaluation and self-rewards
Self-evaluation and self-rewards
In self-evaluation and self-rewards, children are taught to realistically evaluate their performance and reward themselves for efforts made (e.g., Clarke et al. 1990; Kendall and Hedke 2006; Rapee et al. 2006). This is aimed at providing youth with positive reinforcement for desirable behaviors in order to encourage further engagement in these.
Training in realistic self-evaluation can also assist with altering excessively high expectations or negative views of oneself that are typically seen in youth internalizing disorders
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Table 4
Table 4 - Descriptions of Specific CBT Techniques from the managing maladaptive mood and arousal category
Emotion identification, expression and regulation
Emotion identification, expression, and regulation
Emotion identification, expression, and regulation refer to teaching the child or adolescent to identify different emotions in themselves and others, accept and express a variety of different emotions, recognize when their emotions are becoming negative and to engage in activities aimed at moderating and regulating negative emotions (e.g., Brent and Poling 1997; Cohen et al. 2006; Kendall and Hedke 2006; Rapee et al. 2006).
Activities that may help with regulating emotions might include, for example, seeking social support, listening to music or reading a book, and maintaining a present focus (e.g., Brent and Poling 1997; Curry et al. 2005; Rapee et al. 2006)
Progressive muscle relaxation
Progressive muscle relaxation
Progressive muscle relaxation is aimed at reducing muscle tension associated with anxiety or depression by teaching the client to systematically tense and release muscles in the body (e.g., Clarke et al. 1990; Kendall and Hedke 2006). When working with children, imagery may facilitate the child’s use of PMR.
For example, the child can pretend to be a robot in the tensing phase, and then a rag doll in the releasing phase (Kendall and Hedke 2006).
Applied tension
Applied tension
Applied tension is a technique used with adults or adolescents who have a specific phobia, blood injection injury type and experience a dramatic decrease in their blood pressure when confronted with blood, injections, and/or injuries (e.g., Ost and Ollendick 2001).
Applied tension asks the individual to tense their muscles when confronting feared objects in an attempt to increase their blood pressure by encouraging to prevent the fainting response (Ost and Ollendick 2001).
Breathing retraining
Breathing retraining
Finally, breathing retraining is aimed at countering the anxiety-related hyperventilation or over-breathing response that some individuals with panic disorder experience (e.g., Pincus et al. 2008).
Breathing retraining asks the individual to slow down and deepen his or her breathing so as to moderate the amount of oxygen inhaled (Pincus et al. 2008)
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Table 5
Table 5 Descriptions of Specific CBT Techniques from the general skills training category
Problem-solving skills
Problem-solving skills
Problem-solving skills are provided in an effort to give those individuals with problem-solving skills difficulties more effective ways of engaging in problem-solving.
This technique typically involves:
(1) asking the young person to define the problem,
(2) generate a list of possible solutions to the problem,
(3) evaluate the advantages and disadvantages of each solution,
(4) choose one or a combination of several of these solutions,
(5) implement the solution, and
(6) evaluate its effectiveness at overcoming the problem
(e.g., Rapee et al. 2006)
Interpersonal engagement skills
Interpersonal engagement skills
Interpersonal engagement skills refer to the young person’s effective engagement of others in social interactions using age-appropriate verbal and non-verbal behavior.
This skills technique involves training the young person to make appropriate use of body language and voice quality, understand social cues, perform greetings and introductions, start and maintain conversations, listen to and remember what conversational partners have said and skills for joining and leaving group conversations (e.g., Beidel et al. 1998; Rapee et al. 2006)
Friendship skills
Friendship skills
Friendship skills aim to teach the child or adolescent age-appropriate skills for making and maintaining healthy friendships (e.g., Beidel et al. 1998).
This involves discussion around appropriate places to meet friends, the use of interpersonal engagement skills to hold an initial conversation, inviting the child to meet up again in an appropriate setting, and reading social cues to determine the other child’s level of interest. Further discussions centre on the importance of consistent contact with friends, and appropriate ways of treating others in friendships.
Communication and negotiation skills
Communication and negotiation skills
Communication and negotiation skills involve teaching the child or adolescent effective ways of communicating with others, and negotiating outcomes with others when their opinions differ (e.g., Curry et al. 2005).
This can include teaching the young person to engage in active listening and reflection of the conversation partner’s opinions, empathy, patience, and respect. If parents are involved in treatment, then some of these areas may also be covered in Family Communication and Conflict Resolution techniques (e.g., Curry et al. 2005) described in Table 6
Assertiveness skills
Assertiveness skills
Assertiveness skills training aims to teach youth how to carry out age, culture, and context-appropriate assertive behaviors.
Broadly speaking, these assertive behaviors include both verbal and non-verbal behaviors related to communicating one’s opinions, thoughts, needs, and feelings in a manner that is open, honest, and direct, and most importantly, respects the rights of the self and others (e.g., Curry et al. 2005; Rapee et al. 2006)
Dealing with bullying skills
Dealing with bullying skills
The aim of dealing with bullying skills is to provide children and adolescents with effective and adaptive ways of dealing with bullying (Rapee et al. 2006).
Examples of ways children and adolescents may be able to deal with bullying include talking to someone about the bullying, ensuring peers are surrounding them, acting in a more confident way and developing clever and non-accusatory comebacks to bullying (e.g., Rapee et al. 2006)
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Table 6
Table 6 Descriptions of Specific CBT Techniques from the modifying the family environment category
Table 6 - Specific CBT technique Description
Family communication and conflict resolution
The aim of family communication and conflict resolution is to improve the nature of the parent-child relationship for those families that are experiencing difficulties in this area.
This is done by teaching both the parent and the young person about the negative communication styles that often occur in families of youth with depression, and how to engage in effective listening, negotiation, and conflict resolution strategies (e.g., Curry et al. 2005)
Parental expectations management
Parental expectations management
The aim of parent expectations management is to work with the parent and the child/adolescent to identify domains in which parental expectations may be excessively high or low and to negotiate more age-appropriate expectations of the individual (Curry et al. 2005).
This is particularly useful with parents of depressed adolescents, who tend to hold unrealistically high expectations of their teenager (Curry et al. 2005)
Parent intrusiveness and overprotection management
Parent intrusiveness and overprotection management
The aim of parent intrusiveness and overprotection management is to work with the parent to identify situations where he or she may be overly intrusive or protective of their child and to learn how to promote age-appropriate independence (e.g., Rapee et al. 2006).
This is particularly useful for parents who tend to overprotect their child or adolescent and provide excessive reassurance
Parent contingency management
Parent contingency management
The aim of parent contingency management is to teach parents how to reinforce appropriate and desirable behaviors and to punish inappropriate and undesirable behaviors.
For example, parents of anxious youth may be taught to distinguish between anxious and non-anxious behaviors, how to reinforce non-anxious behaviors and to ignore anxious behaviors (Rapee et al. 2006).
For depressed adolescents, parents may be taught to provide greater levels of reinforcement for age-appropriate activities, given the low levels of positive reinforcement found in the families of depressed adolescents (Curry et al. 2005).
Parents may also be taught to reinforce not only their child or adolescent’s success in engaging in positive behaviors but also their effort in trying to engage in positive behaviors
Parent emotion management
Parent emotion management
For parents who experience high levels of anxiety or depression the therapist can teach the parent to use the same CBT strategies taught to their children to intervene on their own anxious or depressed cognitions, emotions, and behaviors (e.g., Rapee et al. 2006).
If the anxiety or depression experienced by the parent is of a clinical nature, however, the therapist should consider referring the parent to a different professional to gain individual therapy for his or her own concerns
Parent modeling of adaptive behavior
Parent modeling of adaptive behavior
Given that children learn both adaptive and maladaptive behavioral patterns from parents, it can be useful for parents to be able to identify and alter maladaptive behaviors (e.g., avoidance of a feared stimulus)
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In summary
In summary, by offering a framework for the development of dissemination and clinical training programs, therapist competence assessment measures, and EBP guidelines, this core competency model provides an innovative approach to bridging the gap between science and
practice in the treatment of children and adolescents with anxiety disorders and depression. Certainly, as the field moves toward the development of dimensional models of psychopathology (e.g., Widiger 2005) and the use of transdiagnostic treatments (e.g., Weersing et al. 2008), this model with its integrative approach will continue to provide a conceptual framework for operationalizing clinical competencies needed by therapists treating children and adolescents with internalizing disorders.