Tag CBT

What is Cognitive-Behavioral Therapy?

stressed boyCognitive-behavioral therapy (CBT) is often the talking treatment of choice for juvenile anxiety, depression, and various kinds of problems that result from poor stress coping. The word “cognitive” refers to strategies that deal with thoughts and thinking. The word “behavior” refers to strategies that deal with behavioral choices. This blog entry will review some of the major strategies that often comprise CBT.

Externalizing the problem: kids and teens develop a name for their anxiety, depression, or the primary problem area. As Stephen King once wrote: “Monsters are real, and ghosts are real too. They live inside us, and sometimes, they win..” Youth are taught that their symptoms of anxiety and depression no more constitute their personhood than symptoms of diabetes or asthma define the personhood of someone suffering from those conditions. Moreover, youth are taught to recognize how their internal enemy attacks them and what specific and effective countermeasures they can deploy.

Behavioral activation: this strategy involves arranging to do fun things on a regular basis. When youth are depressed or stressed out they often get into a rut where they wait for a good mood to do something fun. This CBT strategy teaches a youth that s/he can manipulate his or her mood by forcing himself or herself to do something that stands to be pleasurable. Youth are also taught that fun activities that are novel, social and involve physical activity tend to be the most effective (e.g., to avoid getting into a rut with fun activities as well).

√ Physiological calming: this is a term for learning how to relax muscles in theboys praying back to back body and to belly breath. Most youth overestimate their ability to relax their bodies. In CBT they learn strategies for becoming super relaxed. Moreover, they learn that a relaxed body and anxiety are like oil and water: they just don’t mix. Some practitioners also employ methods for measuring a youth’s success (e.g., through the use of biofeedback).

√ Coping or happy thoughts: this strategy involves developing a list of true and adaptive thoughts that promote positive feelings. Kids are taught that they can swap out uncomfortable thoughts just like they can swap out uncomfortable jeans.

√ Thought testing: this is a strategy for determining whether a painful thought is true or not. Anxiety and depression attack thinking and cause a youth to believe painful thoughts that are not true. This technique is very helpful for helping youth to determine what painful thoughts are real (and which can be subject to problem solving) and which represent their internal enemy’s lie (and are to be disempowered).

Teen girl√ Problem solving: this strategy is useful when a problem is distressing a kid or teen. When suffering from anxiety or depression problems can become super magnified and overwhelming. This very powerful strategy disempowers over reactions and produces adaptive coping responses.

√ Exposures: this strategy involves having anxious youth deliberately put themselves into developmentally appropriate situations that make them anxious, in a measured and gradual way, so that they can use their CBT tools to accomplish mastery and to dominate their internal enemy.

It’s common for parents to be taught how to coach and reinforce the CBT techniques. Moreover, multiple strategies can be done together as a family (e.g., physiological calming, problem solving). The CBT might also include other techniques for specific problems affiliated with anxiety or depression (e.g., response prevention for OCD). Moreover, sets of related strategies than be imported into the CBT depending on the problem(s) the youth has. For instance, social skills training can be used for youth who struggle making and maintaining friends, behaviorally oriented family therapy can be used for defiant youth who refuse to practice their CBT techniques and strategies from positive psychology can be used to produce experiences of happiness and meaning (e.g., the use of gratitude, personal strengths, acts of kindness).

The research supporting the efficacy of CBT is well developed and suggests that mom and daughterparents would do well to consider making this treatment available for any child or teen who suffers from anxiety,  depression or an assortment of problems involving poor stress coping. To find a qualified provider near you click here.

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Treating Anxiety in Youth: CBT, Medication or Both?

anxious teenAnxiety disorders in youth are common; between one fourth and one third of teens develop one by the end of adolescence. Examining treatment issues with this population, the landmark Child/Adolescent Anxiety Multimodal Study (CAMS) just published its 24 and 36 week outcomes (i.e., article dated 3/2014). This multisite study, that included 488 children aged 7 to 17 (average age of 10), compared cognitive behavioral therapy (CBT; a talking therapy) to sertraline (SRT; an SSRI medication), to both together (COMB), to pill placebo in the treatment of Generalized Anxiety Disorder, Social Phobia and Separation Anxiety Disorder. (Youth with other anxiety disorders, or with co-occurring problems such as depression or pervasive developmental disorders, were not included.) I will first review some key findings and then suggest some take home points for clinical practice.

• At 12 weeks, or the immediate conclusion of the study, this is the percentage of children who were rated to have a positive treatment response across the four conditions: COMB: 81%, CBT: 60%, SRT: 55% and pill placebo: 28%. At that point in time the combined treatment was determined to be moderately superior to the other three conditions.

• At no point in the study were there statistically significant differences between the CBT and medication treatment conditions.

• At week 24, the superiority of combined condition over medication alone and anxious childCBT shrank (COMB: 81%, CBT: 69% and SRT: 68%).

• At week 36, the superiority of the combined condition over medication alone and CBT shrank further (COMB: 83%, CBT: 72% and SRT: 70%).

• For both of the preceding two points, the magnitude of the differences at week 36 varied across the various outcome measurements.

• Quoting the authors: “…only 5% of youth receiving COMB and only 15% to 16% of those receiving monotherapy failed to achieve responder status at any point during study participation.” And, “although COMB appears best for prompt benefit, all 3 treatment conditions appear beneficial at 6 months.”

Take home points for clinical practice

therapy etchingThese results support what I, and many of my child clinician colleagues, have tended to recommend in the treatment of youth suffering from one of the aforementioned anxiety disorders. These recommendations are as follows:

• If wanting the most aggressive approach, consider medication therapy and CBT.

• If concerned about adding a psychoactive agent to a developing brain when there may be viable alternatives, consider starting with CBT alone unless the anxiety symptoms are in a severe range (e.g,, a child cannot get to school), to see if the talking treatment will be sufficiently effective.

• If a child is taking a medication, consult with the prescriber about the possibility of tapering off the medication once the CBT skills have been learned.

• It would usually not make clinical sense to treat a child with medication alone, though unusual circumstances could suggest otherwise (e.g., CBT is refused or not available).

• The CBT protocol used in this study was the “Coping Cat” program. However, other established CBT programs for children would likely also have value.

• The authors note that their results are similar to the results found in treatment therapy with teenstudies of juvenile depression. This suggests that similar clinical guidelines may also apply in the treatment of youth suffering from juvenile depression.

To read the abstract for this study, click here.

For a referral for mental health care, click here.

For an article on affording mental health care, click here.

I’d like to offer a closing thought for those parents who have a child or teen suffering from an anxiety disorder: in my clinical experience this is one of the most treatable kinds of problems that a kid can have. So, I strongly encourage you to take your child or teen to a mental health professional who can delivery quality care (for a more thorough review of what good mental health care looks like, please see Chapter 10 of my parenting book). After all, why have your baby suffer needlessly?

Tune in next week when I will post an article that describes cognitive behavioral therapy.

Mom Arrested for Giving Her Daughter Xanax: CBT Can Help to Avoid Such Sad Stories

According to a story this week in the North Platte Telegraph, a mother in Nebraska was arrested for intent to deliver a controlled substance after she gave Xanax to her 15 year-old daughter (the story indicates that daughter later gave it to a friend). I know no more about this story than what is contained in the above link. But I find myself wondering how much each of the following factors contributed to this unfortunate arrest:

√ The pharmaceutical industry markets directly to the public. The marketing budget of this industry far exceeds the public education budget of any mental health association that tries to teach the public about how psychological pain can be understood and relieved.

√ Studies vary but between one in ten and one in four youth suffer from an anxiety disorder (e.g., this graph, from the National Institute of Mental Health, demonstrates the high rates in teenagers).

√ Between 2/3rds and 90% of these kids receive no care. And, even when they do receive care they’ve often been suffering for years first and/or the care is truncated (my blog post discussing some of these issues regarding teens can be found here).

√ Many people, including primary care physicians and teachers, do not know what cognitive behavior therapy (CBT) is or that it is the number one researched talking therapy for relieving anxiety in children and teenagers.

This author knows of not one authoritative association or legitimately published researcher who recommends that anxiety disorders be treated by medication alone, in any human, at least when the afflicted person is able and willing to take part in talking therapy. Moreover, many kids successfully treated with CBT do not need medication to help manage their anxiety-based symptoms.

Cognitive behavioral therapy, which is a time-limited intervention, involves learning a collection of strategies for manipulating emotions and thoughts. Some of these strategies involve recognizing and adjusting thoughts (i.e., the “cognitive” part of the term), while others involve adjusting behaviors (the “behavioral” part of the term). In the case of anxiety treatments there are often two phases. In the first phase the child or teen learns the cognitive and behavioral strategies for defeating anxiety. (In my practice I’ll teach anywhere between five and ten strategies depending on the youth’s problems and situation.) In the second phase the youth then deliberately puts herself or himself into those developmentally appropriate situations that tend to evoke anxiety (e.g., getting on a school bus instead of being transported to school) and uses the techniques to conquer the anxiety. The work is finished once the youth is able to defeat all such fears. Often at termination both the youth and her or his parent(s) cannot believe how far she or he has improved in a relatively short period of time.

These treatments can be delivered to a child by himself or herself (with intermittent parent sessions so that the parent(s) are in a position to coach the strategies once the treatment is over), in groups of youth or together with family members. To identify a mental health professional who might be available to deliver this treatment in your area, click here. Below I have also listed links to three related blog entries.

Affording Mental Health Care

Signs that a Kid Needs Mental Health Services

Seven Common Myths About Counseling

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