9Manualized Cognitive Behavioral Therapy: An Adolescent With Anxiety and DepressionPamela 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
Copyright Springer Publishing Company. All Rights Reserved. From: Case Study Approach to Psychotherapy for Advanced Practice Psychiatric Nurses DOI: 10.1891/9780826195043.0009
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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
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.
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.
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?
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 others think of me.
APPN: Now, there is a list of signs of positive self-esteem. Can you identify with any of these?
Stephanie: Yes. I have no trouble standing up for what I believe in with peers.
APPN: Practicing positive self-talk is a very effective way to build self-esteem. Can you list five people or things you are thankful for?
Stephanie: I am thankful for my family, especially my supportive mother and my new boyfriend who just introduced me to his family. I am enjoying my art projects this semester. They are going to be part of an art exhibit at the local college.
APPN: That is terrific.
Stephanie: Sometimes, when I feel pressure about the art show, I find myself say-ing things like, “I’ll never get my projects finished in time” or “My proj-ect will be lame compared to my classmates.” Then, I feel hopeless and don’t want to do anything. I have been catching myself though and substituting, “I will get my projects finished in time and they will be good.”
Further content for Session 2 focused on identifying habits and learning how to change unhealthy habits focusing on stages of change: (a) make a decision to change; (b) set the goal; (c) believe you can do it, because anything is possible when you believe;
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and (d) take action one step at a time. Stephanie told me that she smoked cigarettes in the past, but stopped smoking completely. Stephanie then summarized the ses-sion by reviewing the Thinking, Feeling, Behaving Triangle and I reiterated the point: “Although you can’t change how other people think or what they say, you can choose how you think and how you react to them.” Stephanie fully understands the concept of cognitive restructuring and is enjoying catching automatic negative or catastrophic, hopeless thoughts. We ended the session with giving mutual feedback and reviewing the homework pages for the week, which focused on identifying positive and negative habits and plans for change. She also added to her index card: “I am a good friend.”
COPE Session 3: Stress and Coping
This session is one of the most helpful for most teens. It focuses on teaching teens to rec-ognize symptoms of anxiety—how anxiety is experienced physically, emotionally, and behaviorally. It is noted that during the initial psychiatric evaluation, Stephanie spoke of having panic attacks as well as a history of GI symptoms with negative diagnostic tests. These presenting symptoms indicated to me that Session 3 would be particularly help-ful in providing strategies for Stephanie when experiencing high levels of anxiety. In week 3, I did a quick check-in and administered the PHQ-9, which remained at a score of 7. I then reviewed Stephanie’s homework.
APPN: Can you describe an event that happened this past week where you changed your thinking from negative to positive?
Stephanie: My parents and I were having a major conflict. Mom thinks my grades are dropping. I responded angrily that I have so many obligations, school, babysitting, needing to spend time with my friends and my new boyfriend, and that I am so overwhelmed. I said, “I never can get everything done.” I realized I was so exhausted and irritable that I told Mom that I needed to take time in my room to regroup and then I would make a workable plan to get caught up with my two classes in which I received lower grades.
APPN: Let’s review the Thinking, Feeling, and Behaving Triangle with your thought, “I will never get everything done, feeling exasperated, and stomping around, but then quickly catching the thought, and modify-ing that to “I’m exhausted right now. I will think straight after some time in my room." (Reviews the situation and subsequent thoughts, feelings, and behavior)
Stephanie: When I went to my room and regrouped, I came up with a plan to get my grades up in the two courses telling myself to take one step at a time and then I felt hopeful.
Following this, the manual introduces the topic of stress with the following COPE definition: “Stress is when you do not have the ability or skills to deal with things that you see as frightening or unpleasant (like taking a test that you didn’t study for or missing your curfew). Stress can also be helpful; for instance, when it helps you finish an assignment before the deadline, but too much stress, not handled in healthy ways, can contribute to bad health in both your body and mind” (Melnyk, 2003, p. 21). There is a list of the 13 most common causes of stress and worry for teens. These include whether you are liked by your peers, pressure from parents, school and grades, feelings of anxiety or depression, and what you will do when finished with school.
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APPN: What are your common stressors?
Stephanie: School and grades, feelings of anxiety and depression, and pressure from my parents are my greatest causes of stress.
APPN: In all my years of delivering this session, nearly every teen—about 99%—has chosen “pressure from parents” as a top cause of their stress. This seems to be universal—young teens, older teens, rural, from urban areas, all feel the expectations of their parents as stressful, so you are not alone.
The next section of content is a list of 11 physical responses to stress. The list includes fast or pounding heart rate, breathing fast, anger, restlessness, headaches, stomach aches, and feeling tired all the time.
APPN: What are your physical responses to stress?
Stephanie: Stomach aches, fast heart rate, and breathing fast.
The next section identifies emotional signs of stress, like feeling irritable, feeling anx-ious, feeling hopeless, feeling burned out, and so on.
APPN: What happens to you emotionally when you feel stressed?
Stephanie: I feel anxious, hopeless, irritable, and at times burned out.
The next section is a list of behaviors associated with stress and includes examples such as arguing with parents, bad grades, smoking, overeating, and drugs/alcohol.
APPN: What behaviors associated with stress do you have?
Stephanie: Oh definitely, arguing with my parents, especially my mother.
The emphasis in the session then moves to identifying healthy coping with the stresses of life including a list of possible healthy coping strategies. The list includes these suggestions:
• Talking about how you feel• Exercising• Seeking out family and friends for support and help• Writing thoughts and feelings in a journal• Turning a negative thought in response to a stressor into a positive one• Using positive self-talk (I can do anything that I set out to do, I can remain calm)• Doing relaxation techniques like deep breathing or guided imagery• Taking small steps when working toward a goal or starting something new
The teen identifies how he or she currently copes and then identifies ones from the list that might work well in the current life situation. These behavioral strategies are then reinforced. In CBT, the B stands for behavioral activation, which focuses on increas-ing one’s participation in the activities he or she enjoys and works for him or her as a coping strategy. Behavioral activation is critical for improving depressive symptoms and improving anxiety symptoms.
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APPN: Is there anything from the list that would work for you? You can iden-tify any healthy strategy that works for you and that does not cause harm to you or others.
Stephanie: I love yoga, but since I have been so overwhelmed with school assign-ments, family obligations, and my boyfriend and friends wanting to spend time together, I have not been going to my yoga studio. I will think about putting yoga back into my week and figure out how often I can go.
APPN: Is there anything else?
Stephanie: Well, I prefer doing my artwork and using self-talk, deep breathing, and of course yoga.
The rest of the session includes a list of clinical symptoms from the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) of depressive disorders and anxiety disorders. Reviewing these symptoms pro-vides an opportunity for anxiety and depression psychoeducation and to teach the teen that they are treatable medical conditions. Thoughts of death and suicide are also explored with a list of resources for the teen as well as any friend in need. Session 3 con-tent ends with practice of abdominal breathing.
APPN: OK. Let’s summarize and give some mutual feedback.
Stephanie: OK. But I want you to know that I am having some bad dreams and have awakened with worries about not meeting my deadlines.
APPN: I would like for you to track how often you have these bad dreams with increased anxiety in the morning.
Stephanie: I can do that. (She summarizes the session and gives feedback.)
APPN: The homework for the week is to identify a most stressful situation and then identify how you thought, felt, and behaved. Then, identify the coping strategies that worked and those coping practices that you would like to add to your list of strategies for coping with stress.
Stephanie: OK. I will do that.
APPN: Also, for homework, I would like you to make a chart of how often you are able to repeat your positive self-statements on your index card and also a chart of how many days you utilize your coping strategies.
Stephanie: OK. I am also going to add to my index card: “I am capable of doing what I need to do once I make up my mind to do it.”
Session 4: Problem-Solving and Setting Goals
Stephanie arrived for Session 4 with her homework pages filled out. She had been feeling a high level of stress during the past week related to school deadlines, especially because several of her advanced art projects for the art show were taking longer than expected to complete. Her thoughts were: “I can’t possibly get this done like I planned and wanted.” Her PHQ-9 score was more elevated to 13, which is a moderate level of depression. She was feeling conflicting pressure from parents and her boyfriend. Her parents wanted her to
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keep her grades up and so did she, but she also wanted to spend time with her boyfriend. During the check, she spoke about the difficulty of getting her art work done.
Stephanie: I was having a hard time getting my art work done this week realizing that I could not possibly get them done as I had planned.
APPN: I wonder what happened when this was realized?
Stephanie: Well, I realized that I needed to modify my multistage project to a sim-pler plan.
I used my self-talk and also met with my art teacher and explained that I would have to do a simpler plan.
APPN: And . . . .
Stephanie: I told myself that the simpler art project is fine. It is still beautiful and still shows my idea and artistic creativity, even if not the grand design. It is good art and it is doable in my time frame. But, sometimes, I am unable to say these positive thoughts.
APPN: What happened then?
Stephanie: I admit I sometimes say that I messed up and didn’t complete the awe-some project. Then, I feel sad about not doing the larger, awesome proj-ect. But it doesn’t last long. I am able to go back to the positive thoughts and not have the sad feelings.
We then continue with the focus of Session 4, which is problem-solving and setting goals. This topic is of great interest for Stephanie for she is in her last few months as a high school junior and post high school plans were weighing heavily on her mind. The lesson asks if the teen dreams about what he or she wants to do as an adult and what kind of things are needed to do to achieve those dreams? This helps the teen identify things to do now in order to move toward reaching the goals and dreams. The manual has an example of a 13-year-old boy who has a goal of becoming a teacher and the client is asked to identify what he can do now to prepare to become a teacher. Stephanie easily comes up with ideas for the 13-year-old.
APPN: Now. Can you write down a long-term dream for yourself?
Stephanie: OK. I would like to go to college to study forestry as my major and also participate in all of the art clubs and take art courses so I can keep up with my art work. I have decided that art is not the best day job career plan, but forestry would allow me greater employment opportunities. We live in a state with several National Parks and forests surround us. Forestry is a difficult major, but a field of study with much promise. I love being outdoors and providing education to people about the natu-ral resources in the area.
APPN: What can you do in the next 1 to 2 years? Can you write down weekly tasks and goals to achieve your dream?
Stephanie: Yes. I know I need to continue to make good grades in my junior and senior years of high school.
APPN: Are there any barriers such as people, events, or situations that you might encounter that might prevent you from reaching your dreams and goals?
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Stephanie: The cost of college. I don’t know how I will afford college. I don’t even have a car yet, so I can’t get a good job to start saving money.
APPN: And what could you do to overcome these barriers?
Stephanie: Apply for scholarships. My mom knows how to apply for them. I can meet with her and begin to realistically plan to overcome the cost bar-rier. I don’t want to burden my family with my financial needs, so I have not brought up my worries.
The last part of the session includes four steps of problem-solving and addresses the following questions:
• What is the problem?• What is the cause?• What are all the possible solutions and the pros and cons?• What is the best solution?
Some example situations from teens are presented in the manual and the client is asked to go through the four steps of problem-solving to help the teen in the manual examples figure out the best solutions. Stephanie is exceptional at problem-solving, so solving the situations were fun for her.
APPN: But how about problem-solving your conflict?
Stephanie: Yes. I am feeling conflicting pressure from my parents and my boy-friend. My parents want me to keep my grades up and so do I, but I also want to spend time with him.
APPN: This is a good problem to work on during the week using the four steps of problem-solving for your homework.
Stephanie: Will do.
Stephanie is very capable of solving this for herself, and when we review the home-work pages, she smiles confidently stating that this is the type of challenge she enjoys. As with other teens, the challenge of using their cognitive skills to figure out problems leads to a feeling of accomplishment and pride.
The session ends with a summary and feedback and the words: Success happens when:
• You start achieving your goal by taking small steps• You overcome barriers to your goal by problem-solving• You build on your strengths and BELIEVE in yourself
Session 5: Dealing With Your Emotions in Healthy Ways/Effective Communications
By this time in the CBT program, the effort on the part of the therapist has been teaching the principles of CBT, walking the client through the areas where he or she expresses struggle, and choosing the coping strategies that fit best. In the last two sessions, the teen assumes the major part of coming up with his or her own strategies for dealing with common and possible future problematic situations. The teen practices the skills and becomes very good at identifying targets and the associated automatic negative
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thoughts. The teen has learned how to challenge the automatic thoughts with Socratic questions such as, Is this entirely correct? Or is it only partially true? Are there other explanations? Once the teen learns the basic concepts of catching his or her unhelpful automatic negative or self-critical thoughts, the teen is able to evaluate the thoughts with the CBT lens, and modify them to be more realistic. The teen then becomes more in charge and gains mastery of his or her thoughts and well-being. The teen strengthens the skills of self-talk and uses strategies to cope with stress and anxiety. The teen uses problem-solving skills and goal setting skills. Stephanie is at the point where she identi-fies her usual negative thoughts such as, “I will never finish the art project” or “If I don’t do my original project plan, this isn’t worthy of entry into the exhibition.” She is able to catch these thoughts quickly and often laughs as soon as the all or nothing statements are spoken and modifies these thoughts to more realistic, accurate statements such as “I will get the modified art project done for the exhibit” or “I am totally capable of quality work.” She now has an appreciation of how the process takes a great deal of practice during the week. With the next three sessions teens are honing the skills they learned and giving thought to future challenging situations.
Session 5 begins with a check-in; administration of the PHQ-9, which was back down to 7 indicating mild depression; and a review of her homework.
APPN: So, let’s take a look at your homework.
Stephanie: You remember my conflict last week of wanting to both spend time with my boyfriend and also keep up my grades.
APPN: Yes. Go on.
Stephanie: Well, I had a heart-to-heart talk with my boyfriend and came up with some solutions. We decided that during the school week, our time together will be study dates. We are both happy with this plan to be able to keep up with our assignments while also enjoying being with each other. My mom was impressed that I came up with this plan, and for the first day or two the study dates worked out well.
APPN: I too am impressed with the plan you came up with to solve your problem.
The next part of the homework page asks the teen what she is thankful for today and to write down two or three good things about herself. The homework reminds her to add to the positive self-statements on the index cards. The content in this session relates to additional ways of dealing with stress and introduces the technique of mental imagery.
APPN: Mental imagery is a healthy way to cope that involves imagining that you are in one of your most favorite places or doing one of your favor-ite things. Close your eyes and think of a place that is pleasant for you, a peaceful place, a place of no worries. Be in this place—take in the smells, the sights, the temperature of being. This is the time to simply enjoy being at your peaceful pleasant place.
After the experience, the point is made that she can close her eyes and return to her peaceful place at any time. This is a favorite skill for teens. They realize that when anxi-ety increases, a trip to this peaceful place can be made and it results in relaxation. The importance of practicing going to the special place is emphasized. As with all the skills, practice is critical and makes the skill become part of the teen and available when needed.
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The next part of Session 5 focuses on regulation of emotions. Emotional regulation is a positive way to gain control over sadness, anxiety, fear, jealousy, and anger—healthy, normal emotions that everyone has, but that need to be regulated when they are too strong. The subsequent behaviors of what the teen does with the emotions is most important. A list of self-control strategies is presented, so that the teen can choose the strategy that best fits. The manual includes the following:
• Positive thinking• Positive self-talk• Counting to 100 or reciting the ABCs• Deep breathing• Walking away and finding a quiet place to practice a relaxation technique (e.g.,
breathing, imagery)• Talking with a friend or adult who will listen and support you• Going for a walk or run or bike ride.
APPN: Talking about what you will do next time you experience a stressful sit-uation will help you use the self-control strategies you choose. Healthy choices are under your control, and as you practice them, they will become easier and easier. So, from this list of healthy coping strategies, which ones do you choose Stephanie?
Stephanie: Spending time with a friend and quiet time in my room with my art supplies.
APPN: Other strategies in the manual include listening to your favorite music, exercise, taking time with a friend, relaxation techniques, writing in a journal, reading a positive book, watching a funny movie, singing, hav-ing quiet time, and doing hobbies. Do any of these fit?
Stephanie: Yes. Listening to music and writing in my journal.
APPN: Terrific. You have a number of strategies. It is important to practice and rehearse your self-control strategies when you are calm—so when something happens that annoys you or makes you feel angry or anx-ious, you will be ready to deal with it in a healthy way.
There is also a section in Session 5 that describes effective communication (tone of voice, word choice, active listening, body language). Even though Stephanie is an excellent communicator and is very good at these skills, we still go over them for the CBT program as presented in the manual needs to be fully completed for fidel-ity; thus, all the portions of the program are read, even those that aren’t needed as much by an individual client. I always read the manual word for word, then rein-force the individualized examples the teen has provided. Thus, that is what I did with Stephanie. We ended the session with a summary, feedback, and a review of the weekly homework.
APPN: The homework for the week is to identify a situation during the week when you feel anxious and/or angry and discuss how you coped with the situation. You are then to reflect on how you might have coped in other healthy ways in the particular situation. (Stephanie will also record how many times she practices going to her peaceful place.)
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Session 6: Coping With Stressful Situations
Stephanie’s homework was reviewed.
APPN: I am always so impressed with the time you put into filling out the homework pages. Can I make a copy of some of your homework pages to use as an exemplar to share with my students?
Stephanie: Of course. I am proud of my work and pleased that you will show it to students. (She gave permission for this example—as did her mother.)
Exhibit 9.1 is an example of one of Stephanie’s homework pages, which she gave permission to use for this chapter.
The content for Session 6 begins with a review of a trigger followed by the Thinking, Feeling, Behaving Triangle.
APPN: What event occurred this week that led you to use the strategies that we have talked about in this program?
Stephanie: I had a stressful time with my art work that wasn’t turning out the way I had hoped.
APPN: What did you do?
Stephanie: I first did my positive self-talk and then went to my peaceful place. That worked and I was able to get back to my art.
Completed homework assignment.
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The rest of Session 6 consists of questions about how the teen can apply the COPE lessons. Some examples are the following:
• How do you express your feelings when you are hurt or disagree with another per-son? (Use “I” statements instead of accusing the other person or calling him or her a name.)
• How do you ask for help or for what you need? (Asking for help is not a sign of weakness for everyone needs help at times in his or her life.)
• How to say “no” to others (When you don’t give into peer pressure you are less likely to get into trouble, less likely to get into a dangerous situation, be seen as a positive leader rather than a follower, and serve as a role model for other teens.)
We end the session by summarizing the content, giving mutual feedback, and review-ing the weekly homework, which is to give examples of the questions provided and to specific situations in his or her life. And, they are also asked to add another positive statement to the index card.
Stephanie: (smiles and adds to her card) I do a great job on my COPE homework!
Session 7: Putting It All Together for a Healthy You!
This final session is a review of the COPE program. After a check-in, administering the PHQ-9, which was now down to 4 (minimal or no signs of depression), we began the session:
APPN: Over the past few weeks you have learned how to handle some difficult situations by thinking more positively and coping in healthy ways. Can you describe a situation that occurred this past week that you think you handled differently because of the things you learned through the COPE program?
Stephanie: I’ve learned that when I am faced with something stressful and start to think negatively, I can turn the negative thought into a positive one to feel better and act in a positive way.
APPN: Can you describe a situation where you “turned around” your negative thinking to a positive thought?
Stephanie: Well, my situation with my art. When I start saying negative things about it, I just turn it around to a positive message.
APPN: Terrific. I would like to go over the important review points:
• Positive thinking is up to YOU!• When you think and talk positively, you will feel happier—remem-
ber to say your positive self-statements every day!• Stay in the present moment to lessen your worries.• Focus on what you have, not what you don’t have.• You cannot change other people. You can only change how you react
to them.• You can change a habit or reach a new goal through practice.• You can make a decision to change.• Set a goal and picture yourself reaching it.• Believe you can do it.• Take action one step at a time.• Ask yourself what is the best solution?• Act on the best solution.
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Stephanie: Those are really good points to remember.
APPN: To deal with stress, practice the things that help you, like relaxation techniques, write in a journal, talk to someone, or exercise. When you are angry, practice your self-control strategies, like counting to 10, blow-ing your anger away, listening to music, or exercising. Communicate effectively and ask for help when you need it. Remember, anything the mind can conceive and believe, it can achieve. You can continue to think positively for a healthier you! Congratulations! You did it! Stephanie, you did it! You completed the manual!
Stephanie felt great about completing the COPE CBT program. As I reviewed our ther-apy process, I initially provided psychoeducation and taught the CBT process of cogni-tive restructuring. In each session, new skills were taught and practiced. The theme of positive self-talk and recognizing individual strengths via the index card of positive self-statements was a focus during all seven sessions. In the fourth session, the respon-sibility for the session moved from my teaching to encouraging Stephanie to do the work. She identified her dysfunctional thoughts, and caught the thoughts, evaluated the thoughts, and modified and changed the thoughts to more accurate, positive, help-ful thoughts. Stephanie would quietly laugh when she caught herself stating negative thoughts such as, “I will never finish my art project” or “That isn’t good enough—my high goals have to be met or it is nothing.” She was very quick at catching the automatic negative thought and this was quite impressive. She informed me about the strategies and skills that worked best for her in coping with anxiety, dealing with stressful situa-tions, and self-regulating her strong emotions. She shared her dreams and set short- and long-term goals to achieve these dreams. She now knows strategies to address barriers she might encounter on her way. Stephanie has excellent cognitive abilities and enjoys using her mind to solve problems.
It took Stephanie approximately 16 weeks to complete the seven sessions. This is usual, for many teens and families have many competing obligations (e.g., school breaks, illnesses, activities) and cannot come in weekly. A 16-week course of therapy is great to both finish a time-limited therapy and allow for the practice of new ways of thinking, feeling, and behaving as well as new skills and strategies. This time frame was perfect for Stephanie.
By the end of our work together, Stephanie’s GI symptoms and panic attacks had not reoccurred. Her grades were good and her PHQ-9 was low (was 4). She felt positive and hopeful and confident that she had done the hard work of CBT and mastered this form of cognitive restructuring and problem-solving. She still struggles with getting back to yoga on a regular basis. We agree to meet periodically for “booster” follow-up sessions. Stephanie became very engaged in therapy and would always bounce into the sessions with her homework carefully done. She related warmly and showed me photos of her art projects. She has been a joy to watch as she met the challenges of each session and grown in self-confidence. She is hopeful about her future and aware of her strong capabilities.
ADDENDUM from a follow-up booster visit: Stephanie is now a high school senior. She talked with a guidance counselor and found out that if she attends the local com-munity college for her first 2 years, she will be able to attend her last 2 years at the State University with their exceptional forestry program on full scholarship. It is a special scholarship program put together by the two colleges in order to encourage students to stay in the state and contribute to the state. This is a great relief for Stephanie and
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it has decreased her senior stress level. Stephanie is working part time after school. Her grades are good. Over the summer, she and her boyfriend had some difficult times and spent some time apart, but now are back together and doing fine. Her mother is supportive of her busy schedule with work and school and tries to ensure she gets some down time. Stephanie’s efforts are recognized by her family. She remains hopeful about her future. She continues to use her coping strategies. We continue to meet every 3 months for booster sessions and any time she requests an appointment. I am always so happy to see Stephanie bounce into the office and share her great art projects.
1. What are the pros and cons of using a CBT treatment manual with adolescents? Discuss fidelity with flexibility.
2. What is an automatic negative thought that you “catch” yourself saying to yourself in times of stress?
3. CBT requires collaboration and active participation from the teen. If you are working with a naturally quiet teen or an angry, resistant teen, what strategies might you use to increasehis or her participation in the sessions?
4. With the content of the sessions just described, and skills taught, what do you think adolescents might take from their therapy into their young adult/adult years?
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Melnyk, B. (2003). COPE (Creating opportunities for personal empowerment) for teens: A 7-session cognitive behavioral skills building program. Columbus, OH: COPE2THRIVE, LLC. Retrieved from https://www.COPE2Thrive.com
Rohde, P., Lewinsohn, P. M., Clarke, G. N., Hops, H., & Seeley, J. R. (2005). The adolescent coping with depression course: A cognitive-behavioral approach to the treatment of adolescent depression. In E. D. Hibbs & P. S. Jensen (Eds.). Psychosocial treatments for child and adolescent disorders. Empirically based strategies for clinical practice (pp. 219–237). Washington, DC: American Psychological Association. Retrieved from https://psycnet.apa.org/record/2005-00278-010