Cognitive Behavioral Therapy for the Busy Child Psychiatrist and Other Mental Health Professionals

Rubrics and Rudiments

Robert Friedberg, Jolene H. Garcia, Angela A. Gorman, Laura Hollar Wilt, Adam Biuckians, Michael Murray, Robert D. Friedberg

• Publisher: Routledge
• Year: 2012
• eBook ISBN: 9781136822018
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

Cognitive Behavioral Therapy for the Busy Child Psychiatrist and Other Mental Health Professionals is an essential resource for clinical child psychologists, psychiatrists and psychotherapists, and mental health professionals. Since 2001, psychiatry residency programs have required resident competency in five specific psychotherapies, including cognitive-behavioral therapy. This unique text is a guidebook for instructors and outlines fundamental principles, while offering creative applications of technique to ensure that residency training programs are better equipped to train their staff.

One

Introduction The Whys and Wherefores of This Book

Cognitive behavioral psychotherapy (CBP) approaches with youth is steadily gaining empirical ground, clinical recognition, and widespread use (Brent & Birmaher, 2002; Graham, 2005; Kazdin & Weisz, 2003; Kendall, 2006; March, 2009). Cognitive behavioral spectrum approaches for depression (Brent & Birmaher, 2002; Brent et al., 1997, 2008; Treatment for Adolescents with Depression Study [TADS] Team, 2003, 2004, 2005, 2007; Weisz, Southam-Gerow, Gordis, & Connor-Smith, 2003), anxiety (Flannery-Schroeder & Kendall, 2000; Kendall et al., 1992, 1997; Kendall, Aschenbrand, & Hudson, 2003), obsessive-compulsive disorder (March & Franklin, 2006; March & Mulle, 1998; Piacentini, March, & Franklin, 2006; Pediatric OCD Treatment Study [POTS] Team, 2004), posttraumatic stress disorder (PTSD) (Cohen, Deblinger, Mannarino, & Steer, 2004), anger management (Lochman & Wells, 2002a, 2002b), and pervasive developmental disorders (Attwood, 2004; Myles, 2003) demonstrate empirical support. Finally, psychiatry has embraced CBP. In fact, March (2009) predicted that “psychiatry will move to a unified cognitive-behavioral intervention model that is housed within neurosciences medicine” (p. 174).

CBP includes social learning theory, classical conditioning, and operant conditioning paradigms (Hart & Morgan, 1993). Additionally, CBP blends various techniques into a coherent whole. There is quite a wide spectrum of CBP-based approaches to childhood problems. Indeed, many CBP techniques exist. Unfortunately, without an organizing theory and paradigm, the disparate tools float in a disembodied manner. This haunting phenomenon caused several authors (Ronen, 1997; Shirk, 1999) to lament the lack of theoretical coherence in child psychotherapy. Kendall, Chu, Gifford, Hayes, and Nauta (1998) argued that CBT with children is guided by its theoretical rationale rather than any specific technique. Accordingly, we adopt a theoretical focus point in this book. More specifically, Aaron T. Beck’s cognitive therapy (CT) forms the theoretical core to the many different interventions outlined in this book. Due to the flexibility and theoretical robustness of Beck’s CT, it has been referred to as the integrative psychotherapy (Alford & Beck, 1997).

While the empirical findings produced by the research on cognitive behavioral therapy with children are meritorious and exciting, community practitioners too commonly neglect them. The difficulty translating protocols to practice is problematic and is currently receiving a great deal of attention (Aarons, 2004; Addis, 2002; Chorpita, 2003; Flannery-Schroeder, 2005; Garland, Hurlburt, & Hawley, 2006; Kendall, 1998; Weisz, 2004; Weisz, Doss, & Hawley, 2005; Weisz & Jensen, 2001; Weisz, Jensen-Doss, & Hawley, 2006). The empirical literature base that supports cognitive behavioral therapy with children is methodologically rigorous and yields significant efficacy results. These promising results led to calls for empirically supported or at least empirically informed practice. However, many practitioners feel left out and alienated by this movement (Southam-Gerow, 2004; Weisz, 2004). They remain skeptical of translating research protocols to clinical practice. Indeed, efforts at disseminating effective treatment to the community have been well intentioned but largely unsuccessful (Addis, 2002; Carroll & Nauro, 2002; Chambless & Ollendick, 2001).

Indeed, perhaps researchers and clinicians are concerned with different questions (Weisz, 2004). In general, academic researchers are concerned with randomization, experimental design, grant funding, large numbers of patients, between group variance, and within group variance. On the other hand, clinicians represent local practitioner scientists who are doing a series of single case studies (n = 1) on a daily basis. They consume research but are primarily concerned with issues of direct patient care, patient satisfaction/attrition, time and cost efficiency, and reimbursement. Clinicians are often under burdensome productivity demands and are deluged by bureaucratic requirements, forms, and paperwork (Southam-Gerow, 2004; Weisz, 2004).

This text is tailored to helping real-world cognitive behavioral therapists meet their goals with a variety of patients. The sad reality suggests that few psychiatric practitioners feel competently equipped to deliver innovative cognitive behavioral approaches. Put quite simply, the circumstance is like developing a cancer treatment that few oncologists apply. Thus, the treatments need to be simply explained, engagingly presented, and effectively disseminated so child psychiatrists and other mental health clinicians can feel confident using them with children.

BREAKING THINGS DOWN TO PRACTICE ELEMENTS: MODULAR CBP

My (RDF) interest in teaching and helping others probably began when I was a boy in New Jersey living above my grandparents in a duplex. My grandmother, Rose, who had to leave school in the sixth grade to care for her brothers and sisters, would encourage me to teach her what I knew. She wanted to learn everything from chemistry (e.g., “H2O means water, Nana”) to playing Scrabble and trying to ride a bike. When preparing her lessons, I tried to break things into simple and entertaining forms. I came to recognize that understanding and change propelled through learning is best realized through interactive dialogue. Consequently, the book provides complex information in a highly interactive format.

Most professionals who are familiar with cognitive behavioral therapy know about a manual-based approach to psychotherapy. Manuals are in fashion in randomized clinical trials where treatment efficacy is studied. Manuals specify the precise content and operationalize the procedures. Additionally, most manuals outline a specific sequence to the procedures and interventions. In randomized clinical trials, manuals often include adherence checks that ensure the interventions are properly employed. Finally, most manuals include a discrete and limited number of sessions.

Academic and clinical cognitive behavioral therapists generally agree that manuals are starting points rather than end points, should be flexibly applied and embedded within a case conceptualization (Persons, 1989, 2008). Additionally, it is incumbent on clinicians to breathe life into a manual by creatively adapting the procedures to the individual child (Kendall et al., 1998). This text partners with clinicians to deliver lively cognitive behavioral therapy.

Like many other recent CBP texts (Chorpita, 2006; Friedberg, McClure, & Garcia, 2009), this book adopts a modular approach to treatment. A modular approach groups the many CBP techniques into meaningful interrelated conceptual categories such as psychoeducation, self-monitoring, behavioral techniques, cognitive restructuring, rational analysis, and experiment/ exposure procedures. For example, psychoeducation contains instructional material that orients patients to CBP, teaches them about their diagnosis/disorder, and provides self-help resources. Self-monitoring provides a baseline assessment and points the way toward self-directed change. Behavioral procedures focus on modifying the point-at-able actions as well as their antecedents and consequences. Cognitive restructuring involves self-talk intervention, which alter the content of maladaptive cognitions. Rational analysis is characterized by a set of sophisticated logical reasoning techniques targeting the process or way children form conclusions. Experiments and exposures are based on experiential learning and encourage children to put their acquired skills to use in real-life contexts.

The chapters are sequenced in the same order they should be applied. Treatment begins with case conceptualization. Second, you need to mindfully adopt a therapeutic stance that boosts productive outcomes. Self-monitoring baseline and assessment lights the way toward your desired goals. Then, you orient the patient to the approach via psychoeducation and typically begin with simple behavioral techniques. Interventions then progress from the cognitive intervention pods to the experiments and exposure procedures.

Modules make use of practice elements (Chorpita, Daleiden, & Weisz, 2005a). Chorpita et al. noted that practice elements are identified by a particular content and different elements may be sequentially or simultaneously administered. In this scheme, a practice element can be used in a single session or in repeated sessions.

A modular approach to cognitive behavioral therapy seems to be nice bridge between manuals and typical care. Modular CBT distills discrete techniques from the manuals and organizes these sundry techniques into conceptual categories (e.g., modules) based on shared elements (Chorpita, Daleiden, & Weisz, 2005a; Curry & Wells, 2005; Rogers, Reinecke, & Curry, 2005). Chorpita, Daleiden, and Weisz (2005b) defined modularity as referring to “breaking complex activities into simpler parts that function independently” (p. 142). In a modular approach, categories are conceptually related to one another and connected by a shared theoretical rationale.

The title of this book, Cognitive Behavioral Therapy for the Busy Child Psychiatrist and Other Mental Health Professionals: Rubrics and Rudiments, is purposefully telling. In the following chapters CBP is broken down into its simplest practice-friendly elements. Care is taken to make the material clear, comprehensible, and engaging. Between chapters the material is presented sequentially beginning with case conceptualization and ending with experiments and exposure. Chapters 2 through 4 place the various procedures (Chapters 5 through 10) in context. Case conceptualization leads off emphasizing the pivotal role case formulation plays in treatment and delivery. Chapters on therapeutic stance and session structure teach you how to create productive ambient conditions for various interventions. Chapters 5 through 10 are stocked with both theoretical background information and clinical guidelines that shepherd you through psychoeducation, self-monitoring, behavioral techniques, cognitive restructuring, rational analysis, and experiments/exposure procedures. Chapter 11 applies CBP to medication checks. Your own performance worries are discussed in Chapter 12 and various techniques for managing anxiety are suggested.

Each chapter from Chapters 2 to 12 is separated into rudiments and rubrics. Rudiment is referenced as a first principle, element, or fundamental (Webster’s Ninth New Collegiate Dictionary, 1991). Rubric is traditionally defined as “an established custom or procedure” (Webster’s Ninth New Collegiate Dictionary, 1991). Accordingly, the rudiments or theoretical rationales of each chapter are presented initially to set the stage for the rubrics or procedural guidelines. After the basic theory is introduced, you learn the procedural guidelines for intervening.

WHAT IT TAKES TO BE A COMPETENT CBP THERAPIST

A certain aim for this text is to propel you toward becoming a more competent cognitive behavioral psychotherapist with children, adolescents, and their families. Sudak, Beck, and Wright (2003) identified crucial components central to obtaining competency in CBP including case formulation, developing collaborative therapeutic alliances, maintaining session structure, monitoring progress, identifying thoughts and feelings, using cognitive behavioral techniques as well as strengthening treatment generalization and relapse prevention.

Competence includes the acquisition and application of knowledge techniques, and clinical acumen coupled with a contextual understanding of people (Barber, Sharpless, Klosterman, & McCarthy, 2007). Barber et al. (2007) explained that “nested within the contextual nature of competence is an appreciation and comfort with issues of diversity at the surface (e.g., diversity of gender, ethnicity, or psychopathology) as well as deeper senses of the term (e.g., diversity of values or knowledge)” (p. 494).

A former colleague at Wright State University School of Professional Psychology (WSU SOPP), Dr. James Dobbins, taught me (RDF) that people’s context is vitally important to understanding and proper intervention. Context shapes people’s specific beliefs, feelings, and actions as well as their core worldviews, schemata, rules for living, and basic philosophies. Whenever you read a journal article or textbook, hear a lecture, view an educational video, and receive supervision, be mindful of the person’s context. It will add valuable perspective.

Freeman (1990) addressed competency in CBT by distinguishing between technicians, magicians, and clinicians. Technicians rely on tools in a kit and have minimal interest in underlying theories or empirical findings. Technicians are similar to the cartoon character, Felix the cat, who relies on his wonderful bag of tricks. Magicians, on the other hand, are not keen about skill training and attribute therapeutic change to the personal qualities of the therapist. Clinicians integrate theory, research, and specific clinical skill training into their development. A good cognitive behavioral therapist is a clinician! Therefore, while we provide many rubrics, we are careful to embed the techniques in a theoretical understanding, cultural context, and empirical basis.

Learning CBP with children and adolescents requires declarative, procedural, and self-reflective knowledge (Bennett-Levy, 2006; Binder, 1999). Declarative knowledge involves the facts associated with theories, empirical findings, and technical procedures associated with CBP. Declarative knowledge also includes knowledge about how people work and operate in the world. Bennett-Levy (2006) refers to this as declarative interpersonal knowledge. This information helps you to predict and manage children’s, adolescents’, and families’ interpersonal reactions to treatment. Moreover, this declarative knowledge facilitates empathic attunement to patients; it helps you know “where they are coming from.”

Procedural knowledge puts declarative information into motion through clinical practice. Clinical plans, rules, and strategies are represented in procedural knowledge. For example, clinical algorithms that stipulate when and how to intervene are good examples of procedural knowledge. Procedural knowledge guides you toward decisions about what intervention to make for which children under certain circumstances at a particular time (Bennett-Levy, 2006).

Self-reflection is a third type of knowledge. Bennett-Levy (2006) defines self-reflection as a “metacognitive skill which accompanies the observation, interpretation, and evaluation of one’s own thoughts, emotions, and actions and outcomes” (p. 60). Bennett-Levy claims self-reflection contributes to what is commonly referred to as clinical wisdom. The reflective system makes use of self-monitoring and self-observation. In order to reflect, Bennett-Levy states you have to focus on your experience, compare it to your declarative and procedural knowledge base, and decide on whether to continue your current course of action.

Declarative, procedural, and self-reflective knowledge are all addressed in the following chapters. Not surprisingly, the book, like any text, is heavy on the declarative knowledge. The empirical and theoretical basics form the foundation for each chapter. However, the treatment rubrics specifically provide you with how and when guidelines. Practicing the techniques with actual patients will cement your procedural understanding. Experiential application transfers learning from the page to the present (Bennett-Levy, 2006; Safran & Muran, 2001). In this way, the “fancy book learnin’” in the chapters get put into action rather than remaining inert (Binder, 1999).

Self-reflection is initially fostered in Chapter 3 and formally elaborated in Chapter 12. Self-reflection involves psychotherapists identifying, focusing on, and processing their own reactions during CBP (Milne, 2008). Not surprisingly, this self-reflection results in a “deeper sense of knowing of CT practices” (Bennett-Levy, Lee, Travers, Pohlman, & Hamernik, 2003). Accordingly, Chapter 12 identifies common beliefs and emotional reactions beginning therapists encounter during their work and multiple methods to manage these experiences.

Scientific-mindedness and the capacity for abstract reasoning are key ingredients in a recipe for a good cognitive behavioral psychotherapist (Dobson & Shaw, 1993; Padesky, 1996). Abstract thinking and inductive reasoning are pivo...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Acknowledgments
• Authors
• Chapter 1 Introduction: The Whys and Wherefores of This Book
• Chapter 2 Case Conceptualization
• Chapter 3 Therapeutic Stance
• Chapter 4 Session Structure
• Chapter 5 Psychoeducation.
• Chapter 6 Self-Monitoring
• Chapter 7 Behavioral Techniques
• Chapter 8 Cognitive Restructuring and Problem-Solving Interventions .
• Chapter 9 Rational Analysis
• Chapter 10 Behavioral Experiments and Exposure
• Chapter 11 Incorporating Cognitive Behavioral Therapy Concepts Into Medication Management
• Chapter 12 Improving as a Cognitive Behavioral Psychotherapist
• References
• Index