Jeremy S. Peterman, Cara A. Settipani, and Philip C. Kendall
Introduction
Cognitive behavioral therapy (CBT) is a collaborative undertaking that presupposes participant engagement, “collaboration” being seen to consist of working together toward a common goal, and “engagement” referring to one’s investment and involvement in the treatment. Collaboration is central to therapy with youth. It has been associated with less attrition, positive treatment outcomes, and a more favorable therapeutic alliance (Chu et al. 2004; Creed and Kendall 2005). Collaboration can be said to create the foundation of the alliance, fostering trust and increasing the child’s motivation. Engagement, or involvement, is of particular importance because youth typically do not refer themselves to treatment and may not see their situation as problematic. Accordingly, CBT therapists working with youth engage the child with a goal of making therapy both relevant and enjoyable. Often the CBT therapist uses engagement strategies such as rewards, stories, metaphors, drawings, games, and other interactive methods. Strategies of engagement are also tailored for adolescents.
Key Features of Competencies and Behavioral Markers
Ability to collaboratively set and adhere to the session goals or agenda
Agenda and goals are potentially influenced by the parent, the youth, the therapist, and the treatment manual. Thus a negotiation regarding the goals and the agenda is needed between the involved parties, including the youth. Importantly, collaboratively setting goals has been found to relate to a stronger therapeutic alliance, as perceived by the child (Creed and Kendall 2005). Within this collaborative model, the therapist takes the role of a “coach” (Kendall 2012). As a coach, the therapist explains to the child that her role includes some teaching, some practice, as well as providing encouragement and support throughout. The coach is equipped with specialized knowledge about ways to treat the presenting concern and to reach set goals. Equally relevantly, the therapist emphasizes that the child contributes important knowledge about himself, his family, and his experiences and that parents may contribute complementary knowledge. Within collaboration, the therapist highlights that she, the child, and (depending on the treatment manual or the circumstances) the parents work together as a team, each bringing valuable expertise that can be integrated. It is important to keep in mind these complementary roles when setting the agenda and determining goals, and to ensure that each party has a balanced influence on goals and tasks. For example, the therapist can check in with all parties at the end of each session to discuss opinions on progress toward goals.
When using an empirically supported treatment for youth internalizing disorders (Kendall and Hedtke 2006; Stark et al. 2007), much of the therapy agenda will be outlined in the treatment manual. Adherence to the core components of the manual is important, but treatment is also tailored to the individual child; the principle for this is “flexibility within fidelity” (Kendall and Beidas 2007; Kendall, Gosch, Furr, and Sood 2008). Manuals are not to be used in “cookie cutter” fashion, but rather as guides. For example, implementing exposure, behavioral activation, and cognitive restructuring is central to the treatment of anxiety and depression, yet the content and application of these tasks will vary depending on the child’s idiosyncratic presentation. By allowing a child to influence the choice of the topic from which he is to learn or practice a new skill, the therapist can ensure that the session is engaging and, through a judicial selection of the options offered by the child, that each session contributes to the overall goals.
Ability to communicate the rationale for each specific CBT technique
Taking the time to explain CBT activities conveys the message that the therapist wants the youth to understand the importance of the intervention rather than blindly follow an authority’s orders. Discussing the rationale exemplifies collaboration and motivates the child to “buy in,” thereby increasing compliance during in-session and homework tasks. When discussing CBT with youth, it is important to avoid jargon and to use developmentally appropriate language. The use of metaphors can make CBT accessible to young children and provides a simple way to understand complex concepts (Friedberg and Wilt 2010). For example, when introducing mood-regulating strategies – such as relaxation, coping thoughts, or behavioral activation – the therapist could say: “In the upcoming sessions we’re going to go through a tool box with lots of different tools you can use when you are feeling upset. Different tools can be used for different situations, just as a screwdriver and a hammer are used for different things. I can help provide you with several possible tools, and then we can decide what works best for you.”
In the Coping Cat treatment for youth anxiety (Kendall and Hedtke 2006), the therapist uses the metaphor of a fire alarm to explain somatic reactions in anxiety. For example, the therapist may say:
Similarly, stories and appropriate therapist self-disclosure are other methods to explain the CBT rationale and to improve the therapeutic alliance. The therapist should determine if the rationale has been understood by asking youth, in a fun and nonconfrontational way, to explain it back to the therapist or to parents, or by eliciting feedback to assess whether the information was communicated clearly and effectively.
Prior to presenting a rationale to a child, a therapist needs to ensure her own comfort with explaining the relevant details. This can be achieved through practice, by explaining each rationale to people unfamiliar with the treatment, and through analysis of video recordings of sessions focused on a child’s reactions and evidence of comprehension.
Ability to elicit and respond to feedback
Delivering feedback can be empowering for the child (Friedberg and McClure 2002) and can illustrate that the therapist and the child are working as a “team.” Furthermore, eliciting feedback allows for a more individualized protocol. For example, when constructing a fear hierarchy, it is important to have the child contribute items to the list. Once the hierarchy is established, the therapist can elicit feedback about what makes each item harder or easier (for example social anxiety exposure tasks can involve girls or boys, younger or older children, large or small groups of people); and this will assist in a further application of the skill.
The timing of feedback is important. The end of a session provides a natural time to inquire about feedback, but feedback can also be elicited before, after, and during therapy tasks. The purpose of this feedback is to gather objective evidence regarding what can be learnt from skill implementation, for example by contrasting anxiety before or during and after an exposure, and to compare the child’s comprehension or experience of the skill with the intended goal. This latter feedback can be used to identify and address potential ruptures in the session before the agenda – or progress – is derailed. Therapists should also be cognizant of the child’s nonverbal feedback. A sudden mood shift, change in body posture, cessation of regular eye contact, or eye-rolling are signals that the therapist should pause and check in with the child. Responding to these nonverbal cues with questions such as, “I noticed you’ve been looking away for the past minute or so, what’s going on,” or “what I just said seemed to upset you, tell me how you’re feeling” makes the child feel attended to and provides the therapist with valuable information to guide the next therapeutic interaction. The therapist needs to adjust therapy tasks in response to feedback, in a way that guarantees continued progress toward skill development and goals, while also ensuring that the child remains engaged.
Ability to facilitate in-session collaboration
In addition to working on direct collaboration between child and therapist through goal or agenda setting, by communicating rationales, and by utilizing feedback, incorporating parents into the collaboration has benefits. These include improvement in the internalizing symptoms, greater family participation, and less frequent cancellations (Hawley and Weisz 2005; McLeod and Weisz 2005). The role taken by the parent is determined by the selected manual, the setting of the therapy, and that parent’s willingness to be a part of it. All collaboration may occur with the direct involvement of the child or through parent–therapist discussions, conducted independently of the child. The latter are crucial when the matters discussed may be embarrassing or punitive for the child. When working with the parent independently, it is crucial to frame for the child how you will protect his privacy, what the purposes of the discussions are, and how you will use the information you gather.
Kendall (2012) proposed three ways in which parents can contribute to therapy for youth. Parents can be consultants, collaborators, or co-clients. The “consultant” parent provides input on treatment concerns and goals and on progress over time, as well as a different point of view on the success (or otherwise) of skill practice and generalization. “Collaborative” parents help facilitate a “transfer of control” (Silverman, Ginsburg, and Kurtines 1995): for children, the therapist is gradually phased out and parents take charge, to help their child cope (e.g., a parent responds to a child’s apparent worry about a school performance by guiding the child to use coping self-talk). With adolescents, the therapist transfers her control to the adolescents themselves, allowing the parents to take a supportive role on request (e.g., when the adolescent requests the parent to facilitate a pleasant event by providing transport). To enable a successful transfer of control, the therapist may include the parent in some sessions during the treatment: in this way she can exchange therapist knowledge and skills with that parent. For instance, at the end of a relaxation training session, the youth would teach the parent, under the therapist’s guidance, how to do deep breathing and progressive muscle relaxation; or the therapist would dedicate session time to teach the parent relevant skills, independently. Finally, the parent may be a “co-client” in situations where the direct targeting of parenting behavior is necessitated by a manual (e.g., training in family conflict resolution) or by the fact that the parent’s behavior impacts on the child’s progress (e.g., the parent’s anxiety discourages the child’s completion of exposure tasks). Each of these roles can be used to facilitate collaboration with the therapist and child to support treatment progress.
Ability to implement specific CBT techniques flexibly
“Flexibility within fidelity” represents another competency. CBT procedures are optimal when presented flexibly and in sync with the youth’s presenting problem, needs, preferences, cultural background, level of emotional and cognitive development, and current mood. For example, Friedberg and Gorman (2007) proposed that clients who are older, motivated, high in hopelessness, afraid of negative evaluation, and more stable (e.g., not in crisis) or who have a high tolerance for frustration may benefit from increased collaboration and less direction and structure. All CBT strategies can be tailored to the needs of the client. For example, therapists may personalize relaxation recordings to reflect visualizations that are meaningful to the client; they may present “thinking traps” and other cognitive restructuring methods via visual or verbal methods in response to the client’s preferred learning style; they may adjust the content in problem solving to reflect issues salient to the child’s recent experience; and they may introduce visual aids, such as a fear hierarchy or a mood thermometer, which can be decorated according to the child’s interests (e.g., Harry Potter themed visual aids). A discussion of modifications recommended for specific disorders and for the developmental level appears later in the chapter.
