Cognitive-Behavioural Assessment And Therapy With Adolescents

Janet Zarb

• Publisher: Routledge
• Year: 2014
• Topic: Psychology
• eBook ISBN:
  9781317772156
• Subtopic: Clinical Psychology
• Index: Psychology

Presents a therapeutic approach that addresses the behavioural, Motivational, And Cognitive Aspects Of Adolescents. The Text Explains The cognitive-social-learning orientation, presents an assessment format and describes various cognitive restructuring and behavioural coping-skills interventions.

PART I THEORY AND METHODS

1 A Cognitive-Behavioral Approach with Adolescent Clients

Theoretical, Empirical, and Practical Considerations

DOI: 10.4324/9781315803647-2

The purpose of this book is to present a cognitive-behavioral approach to assessment and therapy specifically adapted for adolescent clients and their families. For pragmatic reasons, adolescence will be defined as the years from 11 through 19, following the onset of puberty. While it may be argued that many adolescent psychological disorders resemble adult disorders, nevertheless, adolescent problems present a distinct set of behavioral and cognitive components, reflecting the adolescent developmental stage.

The terms “cognitive-behavioral therapy,” “cognitive learning therapy,” or simply “cognitive therapy” have been applied to a variety of procedures, with the common distinguishing feature of simultaneous endorsement of the importance of the role of both cognitive and behavioral processes in shaping and maintaining psychological disorders, and the application of empirically-based cognitive and behavioristic procedures to alter dysfunctional response patterns. Therapy interventions are designed to reduce the frequency of the client’s maladaptive responses and to teach new cognitive and behavioral skills until there is a significant decrease in unwanted behaviors and an increase in more adaptive behaviors.

Features and Assumptions of Cognitive-Behavioral Approaches

Cognitive behavioral approaches for adult clients, as outlined by clinicians such as Beck and his colleagues (Beck, 1976; Beck, Rush, et al., 1979; Beck & Emery, 1985). Meichenbaum (1977), Kendall and Hollon (1979), and others rely on two major types of interventions: cognitive-restructuring interventions and behavioral coping-skills interventions. A cognitive-behavioral therapist considers exclusive focusing on only behavior or cognition or affect to be too restrictive, and therefore concentrates on all three areas simultaneously. The therapist focuses on the nature of the client’s behavioral repertoire (i.e. competencies and deficits) and on accompanying cognitive processes. The client’s cognitions are viewed as part of a complex repertoire of skills, which also includes problem-solving ability and other coping skills, self concept, and interpersonal strategies.

Three important assumptions underlying cogntive-behavioral approaches to psychotherapy have been supported by research over the past decades: (1) that cognitions mediate behavior, (2) that a relationship exists between cognitions and emotional arousal so that the way in which a person labels or evaluates a situation, on the basis of his or her expectancies and assumptions, affects that persons emotional reactions to it, and (3) that particular patterns of maladaptive cognitions are characteristic of specific psychological disorders (Bandura, 1977; Beck, 1976; Ellis, 1962, 1977; Ellis & Grieger, 1977; Goldfried & Davidson, 1976; Goldfried & Goldfried, 1980; Kendall & Hollon, 1979; Mahoney, 1974, 1977; Meichenbaum, 1977).

Cognitive behavioral approaches to family therapy are based on assumptions that family distress stems from a combination of cognitive factors such as family members’ distorted or unrealistic appraisals of each other, as well as from dysfunctional interpersonal behavioral exchanges between family members, such as deficits in communication or problem-solving skills (Epstein, Schlessinger & Dryden, 1988).

The cognitive-behavioral clinician seeks to identify the meaning system that the client brings to therapy, which would in turn explain the client’s inner dialogue. Cognitions (which include perceptions of reality, beliefs, values, causal attributions, and recurring themes) are elicited and recorded by the therapist, to be used as the raw material in subsequent therapy sessions. A major objective of cognitive therapy is to help clients to gain new perspectives on their problems. Clients are taught how their cognitions can help to explain the etiology and maintenance of their maladaptive emotional and behavioral responses. They are also taught that cognitive change is of central importance in the therapy process. Once clients have grasped these points, they are more likely to be motivated to engage in therapeutic interventions (Meichenbaum, 1976).

The course of therapy alternates between interventions designed to correct faulty cognitions, and interventions designed to increase behavioral competencies. The first of the two major categories of interventions, the cognitive restructuring therapies, are designed to help clients to discover and detect their maladaptive cognitions, to recognize their negative impact, and to supplant them with more appropriate and adaptive thought patterns. Two of the original cognitive restructuring approaches described in the literature are Ellis’ Rational Emotive Therapy (Ellis, 1962) and Beck’s Cognitive Therapy (Beck, 1976). Ellis viewed the client’s internal dialogue as a reflection of irrational belief systems, while Beck viewed the client’s thoughts and images as reflections of faulty thinking styles which had to be examined and corrected if the client was to get better.

Coping-skills therapies are a collection of procedures that place their emphasis on helping the client to develop a repertoire of skills that will facilitate adaptation in a variety of stressful situations. An underlying premise is that emotional disorders, such as depression and anxiety, are partially related to a client’s failure to develop the necessary skills to cope with what he or she, or others in his or her environment, consider to be routine duties and tasks, or appropriate behaviors. Skill training is designed to foster the client’s sense of self adequacy and efficacy.

Coping-skills interventions include procedures such as activity scheduling, assertiveness training, problem-solving training, and self-control skill training. These interventions are comprised of both behavioral and cognitive components, although they tend to be predominantly behavioral in focus. Various forms and components of many of these procedures were originally introduced by behavior therapists.

In cognitive-behavioral approaches, targeted problem behaviors are specified precisely in operational terms, while seminal cognitions related to the problem behaviors are identified, since they function as stimuli in controlling the dysfunctional overt behaviors. Therapists select appropriate techniques and use their own creativity in devising ways of teaching the client more adaptive behaviors to be used in daily life. Therapists use devices such as modeling and behavioral and covert rehearsal during the therapy session to teach the client new coping skills. Principles of operant and classical conditioning, social learning theory, and cognitive mediation are incorporated into therapy interventions to produce changes in targeted dysfunctional behaviors and cognitions, as well as to shape more adaptive behaviors.

Analysis of maladaptive cognitive-behavioral sequences is carried out by therapist and client on an ongoing basis. As the contingencies of reinforcement that maintain unwanted behaviors are identified, therapy techniques are applied in order to alter these contingencies. Cognitive-behavioral psychotherapies are active and goal-oriented, incorporating educational methods such as agenda setting, structure, clarification, feedback, reflection, practice, and homework. The teaching component also involves therapist modelling of new ways of thinking and approaching problems. Continual evaluation of therapy in progress, along with evaluation of results, is also an integral part of the therapy process.

A collaborative and empirical working relationship is established between therapist and client. Clients are encouraged to try out newly learned behaviors in their day-to-day life on the premise that they will be less likely to resist suggestions for change if they can be pursuaded to experiment with new behaviors that will have more rewarding consequences.

The feedback component is crucial to insure that the client has understood the concepts and is sufficiently involved in the therapy process, especially with adolescent clients who may not have initiated the therapy endeavor. This is achieved by direct questioning by the therapist and by careful attention to nonverbal language and affective shifts.

Periodic evaluation of treatment success takes place throughout the course of therapy. Repeated measures, using some of the original assessment instruments or self-monitoring techniques, are employed to determine whether there has been a significant reduction in the frequency and severity of the client’s unwanted behaviors, cognitions and emotions. The therapist also seeks to evaluate clients’ perceptions of their own progress in terms of daily functioning in various problem areas.

In recent years, cognitive-behavioral approaches have been found to be effective in treating a variety of adolescent disorders, including depression, anxiety disorders, eating disorders, conduct disorders, and disorders of impulse control (Bedrosian, 1981; Block, 1978; Clarke, Lewinsohn & Hops, 1990; DiGiuseppe, 1988; Schrodt & Wright, 1986; Schrodt & Fitzgerald, 1987; Snyder & White, 1979). Characteristics of cognitive-behavioral therapy approaches such as the collaborative and empirical working relationship, the active, goal-oriented, problem-oriented approach, teaching of coping skills, and the emphasis on feedback have been found to be particularly well suited to address problematic aspects of therapy with adolescent clients (Schrodt & Fitzgerald, 1987).

The most effective approaches with adolescents tend to be those which are action-oriented at the start and geared to what the adolescent perceives as “the problem” requiring change. Generally, coping-skills interventions are introduced almost immediately to alter aspects of these perceived problems, so that clients will experience some improvement in symptomatology and therefore be more likely to become involved in their own self-directed programs of behavioral change. However, the therapist will need to strike the appropriate balance between emphasis on self-analytical, cognitive-restructuring techniques and the more action-oriented coping skills techniques. This will differ for each client, based on individual levels of emotional, intellectual, and motivational functioning.

Therapy techniques and homework assignments are simplified for adolescent clients. Interventions are broken down into smaller component steps, and the rationale behind each intervention technique is explained in simple terms. Often, it is helpful for adolescent clients to write down important points during the session, to insure understanding of concepts and procedures being taught.

Essentially, the same basic approach is applied to each symptom, whether cognitive or behavioral (Mahoney & Arnkoff, 1978):

1. The therapist elicits relevant data related to the symptom
2. Underlying assumptions and other cognitions related to the symptom are explored
3. Behavioral- and cognitive-intervention techniques are initiated, the underlying rationale explained, data are authenticated through cognitive techniques, and skills are taught and practiced during the session
4. Homework is assigned. The client is asked to practice or experiment with new behavioral or cognitive responses learned
5. Evaluation of therapy effectiveness

A Cognitive Social-Learning Theory Perspective on Adolescence

Cognitive-behavioral therapy approaches are consistent with a cognitive social-learning theory conceptualization of both normal and abnormal adolescent development. Social learning theory draws on concepts from a variety of psychological sources, and theoretical concepts are tested empirically. Essential theoretical constructs include the following: that behavior is controlled by its consequences and antecedent discriminitive stimuli, that complex behavior patterns are learned through imitation of observed models, and that learning and performance of behaviors are commonly mediated by cognitive processes.

Application of social learning theory to adolescence has been greatly influenced by the work of Albert Bandura (Bandura & Walters, 1959, 1963; Bandura, 1977). Particular emphasis is placed on the influence of reinforcement contingencies associated with social conditioning shaping different aspects of an adolescent’s personality and behavior. Social conditioning is under the influence of the parents’ childrearing practices, cultural and social expectations of family and peers, and the child’s exposure to influential models, especially parental models initially, and subsequently peer models to an increasing degree as the youngster approaches adolescence. With the onset of adolescence, parents and teachers often decline as important models, while the peer group and selected entertainment heroes become increasingly important as models, especially if parent-adolescent communication breaks down.

Bandura’s approach is an outgrowth of earlier behavioral and social-learning models, with some significant new developments. In the early sixties, some behaviorists began to acknowledge the legitimacy of private events as a focus of therapy. Ellis (1962) and Beck (1963) identified the role of irrational beliefs contributing to psychological disorders. Later, Bandura argued that the process of therapy is dependent upon cognitive mechanisms that are effectively activated through behavioral procedures. This initiated a conceptual integration of cognitive and behavioral perspectives.

This “cognitive” social-learning perspective differs from earlier behaviorist models in its interpretation of change processes in psychotherapy, while simultaneously sharing many of the same specific procedures. Whereas earlier behaviorists argued that behavior modification results from the direct effects of the reinforcement contingencies on the response, cognitive social-learning theorists would argue that the reinforcement procedures have not simply strengthened the response, but have produced a cognitive association between the response and its consequences, in the form of the individual’s own “rules” for future actions (Mahoney, 1980).

Whereas behavior analysis focuses mainly on overt behavior, and cognitive analysis focuses primarily on the causal role of maladaptive thought patterns associated with psychological disorders, cognitive social-learning theorists have sought to integrate the three regulatory systems of antecedent, consequent, and mediational variables into one theoretical framework (Bandura, 1977; Wilson, 1980). Mechanisms of classical and operant conditioning are presented in more cognitive terms, so that conditioned responses are no longer seen as automatic responses, but as self-activated responses based on learned expectations.

Reinforcements are no longer viewed as automatic strengtheners of behavior, but as sources of information and incentive governing behavior. Internal cognitive processes, which help to determine what is attended to by the individual, how it is initially processed, and whether it will be remembered, are viewed as mediating antecedent and consequent external events that influence behavior. The cognitive social-learning model is similar to phenomenological models of behavior in its emphasis on the role of subjective perceptions, but it differs from phenomenological models in its greater reliance on empirical assessment methods.

According to this perspective, the same principles of learning would be used to explain the development of both normal and abnormal adolescent behavior. The learning process involves cognitive mechanisms that operate through four basic forms of learning: direct associative learning, vicarious learning, symbolic instruction, and symbolic logic, all of which have implications for assessment and therapy (Bandura, 1977).

Direct associative learning (learning under the control of immediate external circumstances) results from parental disciplinary techniques and parental attempts to set down and enforce rules and regulations. Vicarious learning refers ...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Preface
• Part I Theory and Methods
• 1 A Cognitive-Behavioral Approach with Adolescent Clients Theoretical, Empirical, and Practical Considerations
• 2 The Assessment Approach and Data Collection Methods
• 3 Cognitive-Behavioral Coping-Skills Interventions
• 4 Cognitive-Restructuring Interventions for Adolescent Clients
• 5 Family Interventions
• Part II Application to Specific Adolescent Problems
• 6 Family-Related Problems
• 7 Peer-Related Problems
• 8 School-Related Problems
• 9 Adolescent Emotional Disorders: Depression and Anxiety
• Appendixs
• Appendix A Initial Presenting Problems Interview
• Appendix B The Family-Peer-School Behavior Interview
• Appendix C Family Behavior Checklists
• Appendix D Daily Activity Sheet
• References
• Name Index
• Subject Index