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9 Manualized Cognitive Behavioral Therapy: An Adolescent With Anxiety and Depression Pamela Lusk

■ PERSONAL EXPERIENCE WITH COGNITIVE BEHAVIORAL THERAPY

I had an exceptional psychiatric nursing rotation on a small adolescent unit at a private psychiatric hospital in the late 1970s during my bachelor of nursing degree program. My psychiatric nursing instructor and the psychiatric inpatient treatment team, which included a psychiatric clinical nurse specialist, were inspiring. I found working with this population to be the most interesting rotation of my nursing education, and I knew when I graduated that my goal was to practice psychiatric nursing with older children and adolescents. Soon after graduation, I was hired as the adolescent team nurse at a psychiatric hospital for children and adolescents. I loved my work there and became increasingly interested in learning more and expanding my role in this specialty area of psychiatric nursing.

A few years later when exploring options for graduate school, I found a master’s degree program in psychiatric nursing that prepared students to conduct psychother- apy with adults during the first year and, with faculty approval, to specialize in con- ducting psychotherapy with children and adolescents during the second year of the program. After starting the program, I was approved for the second year in the child and adolescent specialty and was able to register for courses in child psychotherapy and developmental psychology in the university’s clinical psychology graduate program. During my second year of specializing in children and adolescents, half of my time was spent working on an inpatient children’s unit where I was supervised by a psychiatrist with a psychoanalytic play therapy background and the other half of my time was spent working in the community with adolescents where I was supervised by a clinical psy- chologist, who was an expert in developmental psychopathology and the author of our developmental psychopathology textbook. After graduation with my master’s degree in psychiatric nursing, I became certified as a child and adolescent psychiatric clinical nurse specialist. Since then, I received a post-master’s degree in a psychiatric-mental

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health nurse practitioner program and became certified as a psychiatric mental health nurse practitioner (PMHNP). For the past 15 years, I have practiced as a PMHNP at a variety of primary care settings where I have integrated behavioral health into primary care. Currently, I am the PMHNP at a large pediatric medical practice and see children and adolescents from our practice as well as those who are referred from other commu- nity agencies and practices for behavioral healthcare.

Ten years ago, I decided to go back to graduate school for a doctorate in nursing prac- tice (DNP) degree. While reviewing the literature on evidence-based psychotherapy for adolescents with depression, my topic for my clinical scholarly project, it became very clear to me that cognitive behavioral therapy (CBT) had the strongest evidence of sup- port for the first-line treatment of adolescents with anxiety and depression. At that time, I only had a rudimentary understanding of this therapeutic approach. Consequently, I attended an introductory training in CBT and began to use the approach with teens I was working with at a community mental health center. Experiencing great outcomes with the teens I saw for depression, I decided to obtain further training. I completed the Beck Institute training in CBT with children and adolescents in 2011. I have attended additional trainings at the Beck Institute since that initial training and continue to learn more with each course. In a primary care setting, most of my referrals are for teens experiencing anxiety and depressive symptoms that are significantly impairing their functioning at school, home, or in social situations. CBT is an evidence-based approach indicated for this population with these types of problems.

■ FOUNDER OF COGNITIVE BEHAVIORAL PSYCHOTHERAPY

Aaron Beck (1921–) and Albert Ellis (1913–2007) are recognized as the fathers of CBT. Aaron Beck, an American psychiatrist and professor emeritus in the department of psy- chiatry at the University of Pennsylvania, found in his work as a psychoanalyst in the 1960s that his clients with depression had automatic negative thoughts about certain situations they encountered. He discovered that the content of these thoughts fell into three categories that he eventually called the cognitive triad of depression: negative ideas about oneself, negative ideas about the world, and negative ideas about the future (Beck, 2011). Beck found that he could lessen the depressive symptoms of his clients by helping them identify and evaluate these negative thoughts and develop alternative, more prob- able thoughts. By doing so, clients were able to think more realistically, feel better emo- tionally, and behave more functionally. CBT soon after became a model of psychotherapy with principles and strategies for implementation and eventually many outcome studies to support the approach (Beck, 2011). Since that time, Beck and his colleagues have found CBT to be efficacious in treating a wide variety of disorders in addition to depression including anxiety disorders, bipolar disorders, personality disorders, psychotic disor- ders, and substance use disorders, among others. In addition, CBT has been shown to be very effective in working with children and adolescents (Beidas & Kendall, 2014).

Albert Ellis, an American clinical psychologist, was first trained as a psychoanalyst like Aaron Beck. Ellis became dissatisfied with aspects of the psychoanalytic method and developed Rational Therapy in the 1950s. His approach focused on helping clients understand their self-defeating irrational beliefs (rational analysis) that led to upset- ting emotional consequences and behaviors and then develop more rational constructs (cognitive reconstruction) and functional behaviors. His well-recognized ABCD model specified that it is not the activating event that causes the upsetting emotions, but the irrational beliefs (self-talk) about the event.

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• A is the Activating Event • B is the Self-Talk or Irrational Beliefs about the event • C are the Upsetting Emotional Consequences • D is the Disputing of the Irrational Idea

During his life, Ellis authored over 75 books for professionals as well as the lay public. He founded The Institute for Rational Living in 1959 to train other therapists and to pro- vide therapy for clients in the community. In 1993, he changed the name of his therapy to Rational Emotive Behavior Therapy (REBT). His institute continues to thrive in New York City and is now known as The Albert Ellis Institute: The Home and Headquarters of Rational Emotive Behavior Therapy.

■ PHILOSOPHY AND KEY CONCEPTS OF CBT

CBT is a structured, short-term, present-oriented psychotherapy, which is well received by adolescents and their parents. Adolescents are, according to Piaget’s theory of cogni- tive development, in the formal operations stage—the stage in which the young per- son gains the ability to think abstractly and draw conclusions about information. Using one’s cognitive abilities to problem-solve and identify coping strategies in therapy fits well with this cognitive developmental level described by Piaget. Erikson’s psychoso- cial theory of development emphasizes mastery of developmental tasks. For the ado- lescent, the task is identity versus role confusion, which is the ability to understand oneself and others, the ability to see oneself as a unique and integrated individual, and the ability to have success in relationships with others (Adler-Tapia, 2012). Adolescents are very interested in exploring where they fit in the world; thus, the self-exploration required in CBT is appealing to them.

In CBT, the therapist works with clients on cognitive restructuring, problem- solving, and behavioral activation. Cognitive restructuring refers to identifying, evaluating, and modifying faulty thoughts and beliefs that are responsible for negative mood states. Adolescents are curious about their thinking and beliefs of others. They develop skills in challenging beliefs and coming up with creative ways to solve problems. When they apply CBT skills to their own cognitions, clients learn to solve their own prob- lems. Behavioral activation is the identification of activities that are pleasurable and then increasing these activities in their life. This allows teens to express their individual preferences and choices for activities, develop skills in those activities, and increase time in those activities that are fun and interesting for them. They often learn to experi- ence these activities as “being in the zone”—a time where usual worries don’t intrude (Adler-Tapia, 2012).

■ DEFINITION OF MENTAL HEALTH AND PSYCHOPATHOLOGY IN CBT

CBT is based on a cognitive theory of mental health and psychopathology. CBT believes that mental health is the result of sound information processing that manifests itself in realistic and accurate thinking, which leads directly to appropriate emotions and adap- tive behaviors. In contrast, psychopathology is the result of faulty information process- ing that reveals itself in distorted and dysfunctional thinking, which leads directly to negative emotions and maladaptive behaviors (Beck, 2011).

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■ THERAPEUTIC GOALS IN CBT

CBT is an evidence-based short-term psychotherapy. Typically, clients attend weekly sessions over a period of several months and will then be able to independently use the strategies learned in the therapy sessions. The goal of CBT is for clients to develop thought patterns that allow them to live a more functional and satisfying life. As each session is tailored to meet the needs of individual clients, the goals vary. For example, teens may have a need to develop more friendships, speak in front of class without performance anxiety, or overcome symptoms of depression. Goals are examined to determine the thought patterns, emotions, physical reactions, and behaviors that are associated with specific problems and to then develop new thought patterns that result in more functional behaviors (Beck, 2011).

■ PERSPECTIVE ON ASSESSMENT IN CBT

In CBT, assessment is a collaborative process of joint discovery between the client and the therapist. The client identifies the problem believed to be important and the ther- apist helps the client determine the thoughts, emotions, physiological reactions, and behavior relevant to the identified problem. The therapist also seeks additional informa- tion about the problem such as when and where it occurs; the frequency, intensity, and duration of symptoms; and the specific triggers for the problem.

■ THERAPEUTIC INTERVENTIONS IN CBT

According to Beck, there are 10 CBT principles to guide the therapists’ interventions (Beck, 2011). These are as follows:

• CBT is based on an ever-evolving formulation and conceptualization of the client’s problems in cognitive terms.

• CBT requires a sound therapeutic alliance. • CBT emphasizes collaboration and active participation by the client as well as the

therapist. • CBT is goal oriented and problem focused. The client is viewed as a detective finding

the solutions to the problems. • CBT emphasizes the present and is a here-and-now approach to therapy. Parents and

teens find that exploring issues that are part of the teen’s life now are less intimidat- ing and more relevant.

• CBT is educative and aims to teach clients the skills to be their own therapist, which is important in relapse prevention.

• CBT aims to be time-limited (four to 14 sessions). For teens, I use the COPE (Creating Opportunities for Personal Empowerment) for Teens program, which is a seven- session, manualized approach to treatment.

• CBT sessions are structured and include a check in, agenda setting, homework review, session work, summary, feedback, and assigning homework. Knowing how each session will be organized decreases anxiety for teens. It is predictable and they know what will be asked of them.

• CBT teaches clients to identify their automatic self-critical or negative thoughts, evaluate the truth of the thought (is it entirely true or partially true and is there an

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alternate explanation), and change the dysfunctional thought to a more accurate, use- ful thought.

• CBT uses a variety of techniques and teaches a variety of skills to change thinking, mood, and behavior. Some of these include relaxation strategies, mindfulness, and thought stopping.

Strong research evidence exists to support the effectiveness of CBT treatment man- uals with depressed and anxious teens. The use of manuals assures that each client receives the same intervention. Treatment manuals have sometimes been criticized as an impersonal, cookbook approach to therapy; however, a study of manual-based treat- ments found that they are not inflexible, impersonal, or uncreative; rather, they con- tinue to require clinical skill in their flexible implementation (Beidas & Kendall, 2014). Training is also available to orient therapists to specific treatment manuals.

In my practice, I use the teen manual COPE when working with adolescents. COPE, developed by Bernadette Melnyk in 2003, is a Seven-Session Cognitive Behavioral Skills Building Program, presented in a colorful, developmentally appropriate manual (Melnyk, 2003). It is a highly structured manual that I have been trained in to use. Each teen is evaluated for the ability to think abstractly in order to use the COPE manual for teens. Using the COPE manual allows me to provide a workbook to the teen at the beginning of therapy. The teen then takes ownership of the workbook and uses it for reference during our sessions, as well as after our sessions have been completed. Meta- analysis research of effective psychotherapy for adolescents with depression has identi- fied 12 necessary components of therapy, which are included in the COPE CBT manual for teens. These are as follows:

• Achieving measurable goals and competency • Adolescent psychoeducation • Self-monitoring • Relationship skills and social interaction • Communication training • Cognitive restructuring • Problem-solving • Behavior activation • Relaxation • Emotion regulation • Parent psychoeducation • Improving the parent–child relationship (McCarty & Weisz, 2007).

There have been 17 intervention studies using the COPE treatment manual, which are listed on the COPE training website at www.Cope2thrive.com. Other CBT manuals are available for teens. One that is especially valuable is the Adolescent Coping With Depression Course (CWD-A) (Clarke & Lewinsol, 1989), which is useful in treating ado- lescents with depression (Rohde, Lewinsohn, Clarke, Hops, & Seeley, 2005).

■ CASE STUDY

Background

Stephanie, a 16-year-old high school junior with dark, free-flowing, shoulder length curly hair, came to our pediatric practice with her mother. She was dressed in a loose,

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flowing cotton top and pants that were consistent with her description of herself as an artist. She was referred from an urgent care practice where she was recently seen for gastrointestinal (GI) distress, depression, and anxiety. Her Patient Health Questionnaire-9 (PHQ-9) for adolescents revealed a score of 22, indicating severe depression. Stephanie, seen individually and together with her mother, stated very clearly that she wanted help for her depression and anxiety. Stephanie lived with her mother, stepfather, and younger brother in a home in a nearby small town in Arizona. Her parents divorced 10 years ago. Her mother, a junior high school teacher, is very supportive of Stephanie, especially of her interests in art and yoga. Although Stephanie believes her depression and anxiety began a few years ago, she did expe- rience two recent losses, which may have increased the intensity of her symptoms. These losses were the death of her biological father from an alcohol-related illness and the estrangement from her best friend Angie who left her behind for a new boy- friend and new friends. Stephanie views herself as an artist and hopes to continue studying art in college. She achieves good grades (A’s and B’s) and is in advanced art classes. She has a new boyfriend and a group of friends, but misses her closest long-term friend Angie. Stephanie’s GI symptoms, for which she has had numer- ous workups, revealed no definitive cause for the symptoms. Her mother was very concerned about Stephanie’s symptoms of depression followed by anxiety, especially a recent panic attack. I shared with Stephanie and her mother that adolescent treat- ment studies indicate that CBT has the strongest evidence as a psychotherapy for adolescent depression and anxiety, while for the most severe depression and anxiety disorders, the combination of CBT and antidepressant medication provide the most robust treatment. Both Stephanie and her mother were interested in starting CBT without medication as soon as possible. Both felt she would benefit greatly from talk therapy. Stephanie is very interested in psychology and enjoys discussions of self-improvement and self-help topics. I showed Stephanie and her mother the CBT COPE manual for teens (Melnyk, 2003) and provided an overview of this approach to treatment. They agreed for Stephanie to be seen individually by me with her mother reviewing the sessions and homework pages between sessions. In the CBT approach with teens, it is very helpful for parents to follow along with the skills being taught in order for the cognitive restructuring, behavioral activation, and problem-solving approach to be reinforced at home.

I have used the CBT COPE manualized program teens for 10 years and I present each of the topics in the manual in 30-minute visits (Lusk & Melnyk, 2011). I present the material to the client word for word in order to ensure fidelity to the interventions and flexibility in individualizing the examples. The Teen COPE 7 Session CBT manual has the following session topics:

• Session 1: Thinking, Feeling, and Behaving: What Is the Connection? • Session 2: Self-Esteem and Positive Thinking/Self-Talk • Session 3: Stress and Coping • Session 4: Problem-Solving and Setting Goals • Session 5: Dealing With Your Emotions in Healthy Ways/Effective Communications • Session 6: Coping With Stressful Situations • Session 7: Putting It All Together for a Healthy You!

Because the manual presents the content in clear, concise, well-illustrated lessons with the subsequent homework assignment in a “fill in the blank” format, the session can easily be completed in 30-minute visits, which is the recommended session time for teens. This time period is age appropriate for the teens I see and still allows time for the teen or parent to bring up pressing concerns. The fast pace of the 30-minute session

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keeps the interest level high and is long enough for the attention span of most teens. The structure of the session provides a continuity that reduces anxiety for the client. It progresses in the following order:

1. Check in—the teen brings up any pressing concern and a PHQ-9 for adolescents is administered. The PHQ-9 assesses for suicidal ideation and other symptoms of depression.

2. Homework—a review of the homework from the last session takes place. 3. Lesson content—the content for the weekly lesson is reviewed. 4. Summary of content—the content for the weekly lesson is summarized. 5. Feedback—feedback is provided by the client and the therapist. 6. Homework—a plan for the next session is made by reviewing the required home-

work pages. Homework (also called an action plan) extends the session and gives the client an opportunity to reinforce what was covered in the session and to continue working on self during the week.

Transcript of Therapy Sessions

Each of the seven sessions will be presented with an overview of the skill and a brief transcript of the dialogue between Stephanie and me.

COPE Session 1: Thinking, Feeling, and Behaving: What Is the Connection?

I gave Stephanie her COPE manual and she was eager to get started.

APPN: I’d like to start by having you fill out the PHQ-9.

Stephanie: OK.

APPN: Your score decreased to a 14, which indicates moderate depression. So, let’s do a check-in about your past week.

Stephanie: I met a guy at school named Mick and we have been spending time together. I feel better about myself since this happened.

APPN: That may be the reason why your test number decreased.

Stephanie: Yes.

APPN: The content for this week is an overview of the Thinking, Feeling, Behaving Triangle. Often in our lives something happens that is an anticipatory event or trigger. The trigger event happens, and we may have an automatic negative or not helpful thought. These thoughts happen reflexively, quickly, before we even have time to think things through. For example (reads from COPE manual), Sarah, a student in art class, has a classmate walk by her table and say, “Your art project is weird.” Sarah’s automatic thought is “I can’t do anything right.” Following her thought is a feeling of sadness and discouragement and a behavior of not putting any more effort into that art project or in fact any schoolwork for the rest of the day. She walks down the school hallway changing classes with her head down, not interacting with anyone. So, how you think affects how you feel and how you behave. (I show her the following visual)

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How you think

affects how you feel

and how you behave.

APPN: Do you understand this, Stephanie?

Stephanie: Yes.

APPN: Then, let’s go to the next example in the workbook of the teen named Darcy. Darcy gets good grades, but the teacher has just handed the test papers back and Darcy got a D. Darcy thinks, “I really blew the test this time, but I will study hard for the next test and do well and bring the grade up.” How do you think Darcy feels? Fill in the feeling Stephanie.

Stephanie: I guess Darcy feels just fine.

APPN: What do you think about Darcy’s subsequent behavior?

Stephanie: I think she probably just goes on with her day—no problems.

There is a brief discussion in the manual about how we can reprogram our brain from negative thoughts to more realistic, positive thoughts, resulting in feeling better and behaving more positively. Then, the teen is asked to identify a trigger with auto- matic thoughts and then subsequent feelings and behaviors.

APPN: So, can you identify a situation that happened for you this week that was difficult?

Stephanie: It’s still hard for me to see my best friend Allie being with her new boy- friend and new group of friends at lunch.

APPN: What thought do you have when you see this?

Stephanie: “I’m not good enough to be in that group of kids. Allie is spending her time with people that are cooler than me. I’m not good enough to be in that group.”

APPN: What feelings do you have after having these thoughts?

Stephanie: Sadness and disappointment in myself.

APPN: What do you do?

Stephanie: I guess I walk around with my head down, go to the other side of the cafeteria, and sit by myself and read.

APPN: Although you can’t change how other people think or what they say, you can choose how you react to them.

I review the Thinking, Feeling, Behaving Triangle and the next session skill, which is positive self-talk.

APPN: Positive self-talk is one way to begin to change your negative thinking. Here are some examples in the manual:

• I am a good friend. • I did that well. • I’m not going to give up.

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• I’m going to stay calm. • This won’t last forever. • I am in control of my feelings. • I’m going to try harder next time.

APPN: Which of these positive self-statements resonate with you?

Stephanie: “This won’t last forever” and “I have some other good friends.”

APPN: That’s very good. So, if you use these self-talk messages, your feelings and your behavior will change.

Another CBT skill taught in this first session is “staying in the moment.” An activity of clapping and following the cadence of the APPN who claps first provides an experi- ence of concentrating totally on what one is doing, and thereby not regretting the past or worrying about the future. With this activity, both the teen and APPN are trying so hard to keep the clapping cadence followed, there isn’t time for problematic thoughts or worries.

APPN: OK Stephanie. Let’s review all of the content covered—triggers, auto- matic negative thoughts, the Thinking, Feeling, Behaving Triangle, pos- itive self-talk, and staying in the moment.

Stephanie: (Reviews and summarizes the content)

APPN: I’d like to review the situation you provided earlier in the session when you saw Allie with her new boyfriend and new group of friends and thought, “I’m not good enough to be part of that group and felt sad and disappointed, and isolated yourself at lunch.” What positive state- ments might you tell yourself?

Stephanie: “I have other friends that I fit in with, that have been friends for a long time. I fit in well with them and they are my cool artistic friends. We have a good time.”

APPN: Let’s spend a few minutes on you and I giving each other feedback.

Stephanie: I like the CBT model and think I understand it.

APPN: You have picked up the CBT model very quickly and are very forth- right and self-aware. It’s going to be fun to work through the manual with you and with all your cognitive strengths.

Stephanie: This makes sense and will be helpful for me. I like psychology.

APPN: Terrific. Let’s review the homework pages for you to fill out in the man- ual before our next meeting. First, I want you to write on an index card two positive self-statements and say those statements out loud 10 times a day.

Stephanie: (she writes) I am good at art.

In the waiting room, I check in with her mother and suggest they review the home- work pages together so Stephanie can explain the CBT approach we are using. It is a positive part of CBT when parents also learn the process and can provide their own examples of triggers, automatic negative thoughts, and their learned strategies for coping.

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COPE Session 2: Self-Esteem and Positive Thinking/Self-Talk

Stephanie arrived for Session 2 with her manual in hand. First, I administer a PHQ-9, which is done at each session, and her score was 7, much lower than before and indicat- ing her symptoms are now in the mild range of depression. I also asked about suicidal thoughts, which she did not have.

APPN: Let’s review your homework.

Stephanie: (Shows the APPN her homework. In the manual, Stephanie had identified examples from her week where she had autonomic negative thoughts and sub- sequent feelings and behaviors. She was also able to identify times she was able to catch the negative thoughts, question if the situation was all negative, and identify a more realistic, useful interpretation.)

APPN: Tell me about a negative thought you had this week.

Stephanie: My brother and I were fighting and I said to myself, “We never can just have a peaceful evening.” I realized quickly that is not true and caught myself by saying, “Sometimes we fight, but many times we have a good time together.”

The content of Session 2 begins with the explanation of self-esteem—how the teen views and feels about self. The manual focuses on the fact that self-esteem comes from within and that positive self-talk can change the way we see ourselves.

APPN: The manual here lists signs of poor self-esteem. Can you relate to any of these examples for yourself?

Stephanie: Yes. Two of them sound like me—not trying things for fear of failure and being worried too much about what oth

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