Brief Cognitive-Behavioral Therapy for Anxious Youth

13 Pages·2013·0.4 MB·English

by  Rinad S. Beidas

CognitiveandBehavioralPractice20(2013)134-146
www.elsevier.com/locate/cabp
Brief Cognitive-Behavioral Therapy for Anxious Youth: The Inner Workings
Rinad S. Beidas, University of Pennsylvania
Matthew P. Mychailyszyn, Towson University
Jennifer L. Podell, University of California, Los Angeles
Philip C. Kendall, Temple University
Weprovideadetaileddescriptionoftheclinicalapplicationofbriefcognitive-behavioraltherapy(BCBT)foranxiousyouth.Arationalefor
thedevelopmentofBCBTispresented,followedbyadescriptionanddiscussionofthe8sessionsofthetreatment.Mike,a7-year-oldyouth
withanxietydisorders,isusedtoillustratetheinnerworkingsofimplementingBCBT.Caseconceptualization,sessiondetails,andpre-,post-
andfollow-up-treatmentinformationareprovided.Conclusionsregardingclinicaladvantagesandfuturedirectionsaremade.
T HEpresentpaperisacompanionpiecetothereport has been galvanized by epidemiological research suggest-
oftheinitialfindingsfrombriefcognitive-behavioral ing that in the general population, fewer than half of
therapy(BCBT;Crawleyetal.,2013-thisissue).Weprovide children with anxiety disorders receive care (Egger &
a session-by-session description of a streamlined 8-session Burns,2004).Further,inprimarycaresettings,morethan
versionofawell-established(Chambless&Ollendick,2001) two-thirds of children who meet criteria for an anxiety
empirically supported treatment (EST) for youths with disorderhaveneverreceivedtreatment(Chavira,Bailey,&
anxiety disorders (Silverman, Pina, & Viswesvaran, 2008). Stein,2004).Suchfindingsareconcerninggiventhat,ifleft
ESTs refer to interventions that have been evaluated untreated, childhood anxiety may develop into chronic
scientifically (e.g., a randomized controlled trial; RCT) anxiety,depression,andsubstanceabuse(Kendall,Safford,
andsatisfythecriteria outlinedinChamblessand Hollon Flannery-Schroeder,&Webb,2004).
(1998). Specifically, the Coping Cat program (Kendall & DespitetheneedtodisseminateandimplementCBTfor
Hedtke, 2006), an intervention that has been deemed childanxietyin communitysettings, thereisevidencethat
efficacious via multiple empirical investigations over the ESTs,asdesignedandevaluated,mayneedadaptationtofit
past two decades (Kendall et al., 1997; Kendall, Hudson, the context of these settings. For example, a recent study
Gosch,Flannery-Schroeder,&Suveg,2008;Walkupetal., found that community providers implementing CBT for
2008), was consolidated into an 8-session treatment and youthanxietyidentifiedthenumberofsessions(16)tobean
subsequentlyevaluated(Crawleyetal.). obstacleindeliveringthetreatment(Beidas,Mychailyszyn,
BCBTwasdevelopedprimarilyinresponsetoaneedfor et al., 2012). BCBT was developed with an eye towards
treatments whose dissemination and implementation are makingCBTforchildanxietymoreamenabletocommunity
morefeasibleinthecommunitygivenexistingbarriersto settingsbyreducingthelengthofthetreatment,andhasthe
care.Disseminationincludesthepurposefuldistributionof potentialtoreducecostsandincreaseaccesstoservicesby
relevant information and materials to providers whereas makingdisseminationandimplementationmorefeasible.
implementationreferstotheadoptionandintegrationof The Coping Cat treatment is a cognitive-behavioral in-
ESTs into practice (Lomas, 1993). The impetus for dis- terventionforyouthwithseparationanxietydisorder,social
seminationandimplementationofESTsforyouthanxiety phobia,and/orgeneralizedanxietydisorder,deliveredover
the course of 16 one-hour sessions. BCBT (Crawley et al.,
2013-this issue; Kendall, Beidas, & Mauro, 2012; Kendall,
Crawley,Benjamin,&Mauro,2012)retainsmostofthecore
Keywords:casestudy;briefCBT;anxiousyouth
elementsofthisEST.Likethe16-sessionCopingCat,BCBTis
1077-7229/11/134-146$1.00/0 divided into two main parts, with the first focusing on
© 2012 Association for Behavioral and Cognitive Therapies. psychoeducation (e.g., cognitive restructuring, problem
PublishedbyElsevierLtd.Allrightsreserved.
solving), and the second devoted topracticeof these skills
;
ContinuingEducationQuizlocatedonp.245. throughexposuretasks.However,BCBTisadministeredin
BCBT Case Study 135
eight60-minutesessions,withtheexceptionofSessions1and hisfirstgradeplayandattemptedtoavoidtheperformance.
4 which include an extra 30minutes for consultation with Mikealsoreportedworryabouthisfamily,specificallyabout
parents. BCBT includes approximately 40% less treatment the health of his parents. Mike had particular concerns
time when compared to the original treatment. BCBT abouthisownhealthandthehealthofothersaftervomiting,
materialsincludeatherapistmanual(Kendall,Crawley,etal., and reported interfering avoidance when classmates
2012), child workbook (Kendall, Beidas, et al., 2012), and vomited (e.g., Mike reported that he was unable to go to
parentcompanionguide(Kendall,Podell,&Gosch,2010). movietheatresbecauseheonceobservedapeervomiting
ThepresentpaperprovidesadescriptionofhowBCBT while at a movie). Mike's parents reported that Mike
is administered in practice with anxious youth. For each exhibitedworrymoredaysthannotoverthepastyear.Mike
sessionofBCBT,wesummarizethemaincontent,provide experienced somatic symptoms when worrying, including
session goals, and illustrate with a case example. The difficultysittingstill,difficultyrelaxing,stomachaches,and
interested reader is referred to Crawley et al. (2013-this irritability. Mike's worries caused difficulties at home and
issue)foradescriptionofthedevelopmentofBCBTaswell impairedhissocialfunctioninggivenhisrefusaltoattend
asareportoftheinitialfeasibilityandoutcomedata. birthday parties or go to friends’ houses. Based on these
symptoms and interference, Mike met criteria for a
Case Example: Pretreatment
principaldiagnosisofgeneralizedanxietydisorder(GAD).
Diagnostic Information
Inadditiontohisexcessiveworries,Mikeandhisparents
Mike1wasa7-year-oldCaucasianmalewholivedwithhis reported that he had difficulty separating from caregivers
biological parents, who were married, and his 10-year-old andaspecificfearofloudnoises(e.g.,firedrills,fireworks,
brother. Mike and his parents were referred by his toiletflushing).Mikeandhisparentsreportedthathewould
pediatricianduetoexcessiveworrying,anticipatoryanxiety, worry ahead of time when he knew that they would be
and difficulty with changes in routine. The pretreatment separating.Mikereportedthattherewerelocationsthathe
assessmentincludeddiagnostician-ratedmeasuresandself- wouldnotgotowithouthisparents(e.g.,afriend'shouse).
report questionnaires completed by Mike and his parents. Mikesaidthathewasworriedthat“arobbermightstealme”
Mike was evaluated using the Anxiety Disorders Interview whenhewasnotwithhisparents.Mikealsometcriteriafora
ScheduleforChildrenandParents(ADIS-C/P;Silverman& secondary diagnosis of separation anxiety disorder (SAD).
Albano, 2006), Pediatric Anxiety Rating Scale (PARS; The Additionally, Mike's parents reported that Mike demon-
Research Units on Pediatric Psychopharmacology Anxiety strated an extreme fear of loud noises (e.g., fire drills,
StudyGroup,2002),theClinicalGlobalImpression–Severity fireworks,thunder)thatlastedoverthepastfewyears.Mike
andImprovementScales(CGI-S &CGI-I; Guy, 1976), and avoided all loud noises, and if he heard one he would
Multidimensional Anxiety Scale for Children (MASC; becomeemotionallydistressed.Forexample,Mikerefused
March,Parker,Sullivan,Stallings,&Conners,1997). to flush the toilet after he used it because of the noise it
Asreportedduringthediagnosticinterview,bothMike made. Given the level of impairment and interference, a
andhisparentsstatedthatheworriedexcessively,aboveand specific phobia of loud noises was assigned as a tertiary
beyondthetypicalworriesexperiencedbychildrenhisage. diagnosis.
MuchofMike'sworrywasanticipatory;whenMikewasinthe In addition to the diagnostic interview, diagnostician-
moment, he typically did not experience these same high rated measures and self-report questionnaires were com-
levels of anxiety. Specific areas of worry reported by Mike pleted by Mike and his parents. Thorough assessment for
and his parents included uncertain situations, social other comorbidities, such as other internalizing disorders
performance, and the health of family members. His (e.g.,depression)andexternalizingdisorders(e.g.,opposi-
parents reported that Mike's most interfering worry was tionaldefiantdisorder),indicatedthatneitherMikenorhis
about uncertainty and changes in routine. For example, parentsreportedanyotherinterferingdifficulties.Screening
Mike had a very difficult time when he had a substitute for autism spectrum disorders and other psychiatric con-
teacheratschool.Inaddition,Mike'sparentsreportedthat ditions (e.g., selective mutism) also did not indicate other
Mikehaddifficultywithattendingassemblies,eatinginthe diagnoses. A review of hisdevelopmental history indicated
cafeteria,andgoingtofriends’housesduetotheunknown that Mike's mother did not experience any pregnancy or
natureofthesesituations.Mike'sparentsalsoreportedthat birth complications and that Mike met all of his develop-
Mike experienced anxiety when performing in front of mental milestones within the expected time periods. At
others due to his own standards for performance. For pretreatment,Mikemetcriteriaforthreeanxietydisorders,
example,Mikewasextremelyanxiousaboutparticipatingin was scored as “markedly ill” on the CGI-S, in the clinical
range on the PARS (above 11.5 on the 5-item scale;
Ginsburg,Keeton,Drazdowski,&Riddle,2010),andinthe
1Forpurposesofconfidentiality,nameandidentifyinginformation clinicalrangeontheMASC(above47;Rynnetal.,2006).See
havebeenchanged. Table1forpretreatmentratings.
136 Beidas et al.
Table1
Pre-,Post-,andFollow-upTreatmentScores
Diagnoses CGI-S CGI-I PARS MASC
Pretreatment GeneralizedAnxietyDisorder(5)⁎Separation 5 __ 14 86
AnxietyDisorder(4)SpecificPhobia(4) markedlyill
Posttreatment ADHD-InattentiveType(4) 2 1 2 67
Borderlinementallyill Verymuchimproved
1-yearFollow-up None 1 1 3 59
normal Verymuchimproved
Note. CGI-S=Clinical Global Impression Severity; CGI-I=Clinical Global Impression improvement (not measured at pretreatment);
PARS=PediatricAnxietyRatingsScale;MASC=MultidimensionalAnxietyScaleforChildren.
⁎
ClinicianSeverityRatingfromAnxietyDisorderInterviewSchedule.
BCBT: the Inner Workings feelings are associated with different physical expressions.
Finally, the importance of continued practice of skills
TheinnerworkingsoftheBCBTprotocolarepresented
outside of session through homework tasks is emphasized,
sessionbysession.First,wedescribecontenttobecovered
andSession1iswrappedupbyengaginginafunactivityto
ineachsession,followedbyadescriptionofMike'ssession.
rewardparticipationandcontinuebuildingthetherapeutic
relationship.
Session1:BuildingRapport,TreatmentOrientation,and
Inthesecondportionofthesession,thetherapistmeets
the First Parent Meeting
withtheparents.ThetherapistreviewsthelogisticsofBCBT
SeeFigure1forthemaingoalstobecoveredinSession1. andthenopensupthediscussiontoelicitinformationabout
InSession1,thetherapistmeetswiththechildforthefirst situations in which their child becomes anxious. The
60minutes,andtheparentsforthelatter30minutes.The therapistoffersspecificwaystheparentscanbeinvolvedin
overarching goal of time spent with the child is to orient theBCBTprogram,suchashelpingwithexposuretasksat
him/hertothetherapyexperienceandtoensurethatthe home.A key part ofthe firstsession with the parentsitto
childfeelshopefulandwillingtoreturnforasecondsession. identifytreatment“deliverables,”orthemeasuringstickby
Foranxiousyouthpredisposedtoaheightenedsensitivityto whichthetherapist,parents,andchildwilljudgeprogress.
social evaluation and other threatcues, the importance of Thisidentification isespeciallyimportantgiven the abbre-
takingthetimeandefforttohelpthechildfeelcomfortable viatedformatofthetreatment.Threetreatmentdeliverables
cannot be overstated. Rapport-building with a fun and isamanageablenumberthatcanbeadjusteddependingon
friendlyattitudeiscentraltoSession1.Puttingthechildat theneedsofthefamily.Itisimportantthatthesedeliverables
easepavesthewayfortheinitialtherapeuticcontent,suchas bespecific,concrete,andtangible.Forexample,atreatment
the normalization of anxiety and the notion that various deliverable for a separation-anxious child might be
Child portion (60 minutes) Parent portion (30 minutes)
1. Build rapport 1. Provide information about BCBT
2. Orient child to BCBT 2. Learn more about the situations in which
the child becomes anxious
3. Normalize anxiety
3. Offer specific ways the parents can be
4. Encourage child’s participation
involved in the program
5. Introduce the concept that different feelings
4. Provide parents with a copy of the Parent
have different physical expressions
Companion (Kendall et al., 2010)
6. Introduce the concept of an anxiety
hierarchy and the feelings thermometer
7. Assign an initial simple Show-That-I-Can
(STIC) task
8. Engage in a fun end-of-session activity
Figure1.MaingoalsofSession1.
BCBT Case Study 137
“sleeping alone in my bed” or “parents go out without Parent Portion (30Minutes)
child,”whereasalessidealtreatmentdeliverablemightbe In the parent portion of the first session, the therapist
“feelinglessscaredaboutseparatingfromparents.”Atthe providesadditionalinformationaboutBCBTwithregardto
end of the first session, the therapist provides a helpful howoftenshewillmeetwiththefamilyandtheroleofthe
parentcompanionguidetotreatment(Kendalletal.,2010) parents. Mike's mother reports some anxiety about
sothattheparentscanfollowalongandbeawareofwhatwill “pushing”Miketodothingsthat makehimnervous,and
happeninthetreatmentsessions. the therapist normalizes Mike's mother's inclination to
protect her son while also discussing how parents can
unknowingly reinforce anxious behavior by allowing
Child Portion (60Minutes) avoidanceandaccommodatinganxiety.
When Mike enters the therapy room, he displays Themajorityoftimeisspentdiscussingsituationsinwhich
nervous energy. He asks repeatedly, “What are we doing Mike becomes anxious, particularly the three main treat-
today?” and “Are we going to do anything scary?” The ment deliverables that the family is hoping to accomplish
therapistinvitesMiketomakehimselfcomfortableandto withtreatment.ThemaindeliverablesforMike'sparentsare
lookaroundandseeifthereareanygamesthathewould forMiketobeabletogotoplaydatesandbirthdaypartiesat
liketoplay.MikefindsConnect4.ThetherapistletsMike hisfriends’houses,beingabletoseparatefromMomwhen
knowthattheywillsavethelastfewminutesofthesession shetravels,andlearninghowtocopebetterwithchangesin
toplayConnect4together.ThetherapistthanksMikefor his routine such as driving on the highway. The therapist
coming and they play a “getting to know one another helps the parents identify tangible goals with
game”wheretheyaskeachothersomequestions. clear opportunities for evaluation, such as “going to a
After spending about 15minutes getting to know one birthdayparty”ratherthan“feelinglessanxious.”Attheend
another, the therapist introduces Mike to some of the ofsession,thetherapistprovidestheparentswithacopyof
logisticsofBCBT.Theywillbeworkingweeklyoverthenext theparentcompaniontreatmentguide.
8weeks,andwillbecollaboratingtohelpmanageanxiety.
Thetherapistusestheanalogyofafirealarmtointroduce
Session 2: Identifying Anxious Feelings, Self-Talk, and
theideathateveryonehasanxietybutthatinsomechildren
Learning to Challenge Thoughts
and adults, the anxious response is triggered even when
thereisnothingtobefearfulof(i.e.,falsefirealarmwhen Session2(seeFigure2forthemaingoals)beginsthe
there is no fire). The therapist asks Mike, “What do you processofintroducingthespecificskillsthatwillcomprise
thinkyouwoulddoifyoudidn'thaveanxietyandsawalion theplanforcopingwithanxiety.Afterreviewingthefirst
walking down the street?” Mike answers, “Pet it!” The homework assignment—or “Show That I Can” (STIC)
therapist uses this example as a way to normalize the task—thetherapistworkswiththechildonincreasinghisor
experience of anxiety and make clear that the goal of her identification of particular bodily reactions to feeling
treatment is not to “cure anxiety” but to reduce the false anxious. By pairing this focus with basic education about
alarms and be able to respond more appropriately to thephysiologyofthefear/stressresponse,thetherapisthas
anxiety. anotheropportunitytonormalizetheexperienceofanxiety
ThetherapistintroducestheCBTmodelbyencouraging fortheclient.InthecontextofBCBT,thisisknownasthe
Miketothinkthroughrecenttimeswhenhehasfeltacertain “F” step,where youths are taught toask themselves,amI
way(e.g.,happy)andwhattypesofthoughtshewashaving “FeelingFrightened”?Especiallyforyouthswhomaynotbe
during that time. They explore what happens in his body effective at realizing they are anxious, the therapist
whenhefeelshappy,andMikebeginstolearnthatvarious emphasizesthatthechild'sidiosyncraticsomaticresponses
feelings have different physical expressions in his body.
Finally, the therapist asks Mike, “How will we know that
1. Review the STIC task from Session 1
therapyisover,orwhatarethethreemainthingsyouhope
toaccomplish?”Mikesays,“Idon'tknow!”Thetherapistis 2. Discuss and identify the child’s specific somatic reactions to anxiety
3. Present somatic reactions as cues to increasing anxiety
readywithalistofsituationsthatcameupintheassessment,
4. Introduce the “F” step
and Mike states that he would most like the following
5. Introduce the concept of self-talk
deliverables: being in the dark alone, being able to go
6. Discuss self-talk in anxiety-provoking situations
somewhere loud where there are fireworks (i.e., baseball 7. Differentiate anxious self-talk from coping self-talk
game),anddrivingonthehighwaywithMomandDad.To 8. Introduce the “E” step
wrapup,thetherapistandMikeplayConnect4,aspromised, 9. Begin to construct a hierarchy of anxiety-provoking situations
and Mike leaves with a homework task to write about a 10. Assign STIC task
situationwherehefelt“good.”Mikeisinstructedtoidentify
histhoughtsandfeelingsinthissituation. Figure2.MaingoalsofSession2.
138 Beidas et al.
(i.e., their own personal body sensations in response to highwaytobringhimtotherapy.Thetherapist,introducing
anxiety)canserveasanearlycluethatanxietyispresent. theconceptthatourbodiesarehard-wiredtorespondto
ThesecondmainfocusofSession2istoassistthechildin anxiety in a certain way, uses coping modeling to self-
being able to identify the content of his/her thoughts. disclose her own anxious response (e.g., when she feels
Specifically,thegoalisfortheclienttobeabletorecognize nervous,shegetssweaty,herheartraces,andherstomach
thepresenceofanxiousself-talk,ortheparticularthoughts drops).ThetherapistasksMiketotryandrememberwhat
that reflect what one is worried will happen in a situation. happenedin hisbodywhenhe wasfeeling scaredonthe
Thisworkconstitutesthe“E-Step”inwhichthechildlearnsto highway. Mike says that when he feels scared, his body
becomeawarewhetherheorsheis“Expectingbadthingsto responds by giving him a “headache,” an“upsettummy,”
happen?”Oncethisisaccomplished,thetherapistprovides and“gettingredintheface.”ThetherapistandMikedrawa
coachingondevelopingmoreresourceful“copingself-talk,” picture of how their bodies look when they feel anxious.
whereanxiouscognitivebiasesarechallengedwiththoughts Theydiscussthatthesecanbecluesforsomedetectivework
thatpromoteresilienceratherthanfuelavoidance.Atthe that they are feeling anxious. Then, the therapist in-
endofsession,thetherapistandchildbegintocollaborate troduces the “F” step, which stands for “Feeling Fright-
to create a hierarchy of anxiety-provoking situations. ened?”
Next,thetherapistintroducestheideathatweengagein
Session 2 self-talkaswegoaboutourday,andthattherearedifferent
MikecomestosessionwithhisBCBTworkbookinhand, types of self-talk. She does this by bringing out some
eagertoshowhistherapistthathecompletedhisSTICtask. pictures with cartoon bubbles above the heads of the
ThetherapistandMikereviewthesituationthathewrote peopleinthepictures.First,theystartwithpicturesthatare
aboutinhisworkbook.Mikereportsthathefeltreallygreat non-anxietyprovoking,suchasapictureofthetherapist's
over the pastweek whenhe gotto go to the zoo with his dogstandinguponherhindlegs.Mike(jokingly)identifies
parentsandbrothers.Mikeidentifiesthathefelt“happy” thatthedogisthinking,“Iamhungry!”Aftergoingthrough
andthathewasthinking,“Thisiscool!”Thetherapisttakes a number of nonthreatening images, they move on to
extracaretouseverbalpraisetorewardMike'scompletion pictures that might elicit anxiety, such as a young girl
oftheSTICtaskbysaying,“Mike,Ilikehowyoudidyour campinginthedarkwithoutalight.Thetherapistsuggests
STICtaskandhowexcitedyouaretoshowittome!”She thatthewaythatwethinkimpactshowweactandfeel,and
givesMikeonedinosaurstickerinhisrewardsbank,located that two different people could have two very different
intherearoftheBCBTworkbook. thoughtsinthesamesituation.Sheusesapictureofaboy
Mikehasdifficultysittingstillandattendingtosession,so ice-skating to help Mike identify two possible contrasting
the therapist relies on using games to impart the thoughtstheboymighthave.Mikeidentifiesthattheboy
psychoeducational material for this session, including couldbethinking,“I'mgoingtofall!”or“Thisisfun”and
identifyinghowMikeexperiencesanxietysomaticallyand thatwouldheavilyimpactwhetherornothestayedouton
cognitively.TheystartoutbypickingatimewhenMikefelt theice.ThetherapisttalkswithMikeaboutcopingthoughts
anxious recently. Mike says the last time he remembers thathecouldhaveinanxiety-provokingsituations,suchas,
feelingnervouswaswhenhisdadneeded todriveonthe “Icandoit,”or“Theworldwon'tendifIfeelscared.”To
Figure3.Mike'shierarchyofexposuretasks.
BCBT Case Study 139
thathecanstillearnamini-stickerforcompletingtheSTIC
1. Review STIC task from Session 2
task now in session. Mike's apprehension lifts and he sits
2. Introduce the “A” and “R” steps
down with his therapist. They identify two situations over
3. Introduce problem solving
thepastweekwhenMikefeltanxious.Inthefirst,hisdad
4. Plan for next exposure
wasdrivingonthehighway.Mikeidentifiedthathehadan
5. Assign STIC task
upset stomach and that he felt really hot in his ears and
cheeks.ThetherapistasksMikewhathemighthavebeen
Figure4.MaingoalsofSession3. thinking in the situation. Mike says, “I don't know!” The
therapist provides Mike with a few possible thoughts that
otheranxiouskidsmighthave,andMikepicksonethatbest
complete the introduction of self-talk, the therapist pre- fits him: “that we might crash.” In the second situation,
sentsthe“E”step,or“ExpectingBadThingstoHappen?” MikereportsthathefeltnervousbecauseMomtoldhimshe
Towardstheendofsession,thetherapistteamsupwith wasgoingawayonabusinesstrip.Mikesaysthathefelthot
Mike to work on the hierarchy of anxiety-provoking andhadaheadacheandthathewasthinking,“Whatifshe
situationsforfutureexposuretasks.Mikeandthetherapist doesn'tcomeback?”or“Whatifsomethingbadhappensto
agree to the following hierarchy (rated from 0–8, with her?”ThetherapistmakessuretopraiseMike'shardwork
8 being the most anxiety-provoking exposure task). See identifyingbodyfeelingsandthoughtswhenheisnervous
Figure 3. Note the finalization of this hierarchy occurs in and,aspromised,providesamini-sticker.Thetherapistalso
Session 4 (this session just begins the process). The asksMikewhatmadeithardtodohishomework.Hesays,“I
hierarchy is largely based on the treatment deliverables leftitinmybookbagandnevertookitout.”Thetherapist
identified in Session 1 and includes tasks of gradually saves this situation for when they will talk about problem
increasing difficulty. At the end of session, the therapist solvinglaterinthesession.
assignsaSTICtaskforMiketocompleteoverthenextweek. The therapist introduces the idea that they have now
TheSTICtaskinvolvesidentifyinghisthoughtsandfeelings learnedhowtheirbodyandmindreactstoanxiety,andthat
intwodifferentsituationswhenhefeelsanxious. thenextstepistolearnaboutthespecificcopingtoolsthat
hecanuseinanxiety-provokingsituations.Thisisknownas
Session3:IntroducingProblemSolving,Self-Evaluation, the“A”step:“Attitudesoractionsthatcanhelp.”Theyreview
and Self-Reward (a)deepbreathinganditseffectoncalmingthebodydown
and(b)usingcopingthoughtstocombatanxiousthoughts.
SeeFigure4forthemaingoalstobecoveredinSession3.
One of the coping tools is problem solving. The therapist
DuringSession3,theclientcontinueslearningstepsofthe
collaborateswith Mikeaboutthestepsof problemsolving,
FEAR plan that will be used to cope with anxiety. Having
including identifying the problem, generating as many
worked on identifying his/her physiological response to
solutions as possible (even silly ones!), evaluating the
feeling anxious as well as the predictions about negative
solutions, and then trying/implementing the best option.
outcomes that are typically maintained, the focus shifts
Todothisina“real”way,shecomesbacktohishomework.
toward consideration of “Attitudes and actions that can
Theydiscussallthepossiblewaystosolveleavinghomework
help.”This“A”stepencompassesthecopingtoolsalready
inhisbookbagthewholeweek,generatingsolutionssuchas,
covered (e.g., coping self-talk) and introduces the skill of
“askMomtotakeitrightaftersession”;“leaveanotebythe
problem solving. Armed with strategies to challenge the
door”;“carryitaroundwithmeeverywhereIgo”;and“just
mind'scatastrophization,andflexiblybrainstormsolutions
notdotheSTICtask.”Afterdiscussion,theyagreethatasking
to difficult problems, the child is now equipped with the
Momtotaketheworkbookrightaftersessionisprobablythe
toolsnecessarytobegineffectivelymanaginganxiety.One
bestoption.
final important piece remains, however, to complete the
Next, the therapist introduces the final step of the
copingplan:The“R”steppromptsthechildtoconsiderthe
FEARplan,the“R”step:“Resultsandrewards.”Mikeand
“Resultsandrewards”offacingone'sfears.Thiscomponent
the therapistdiscuss whyrewards for trying ourbest and
encouragestheclienttoreflectontheexperience(e.g.,Did
rating our performance are important. The therapist
anxietydiminish?Waseyecontactmaintained?)ofbeingin
takes extra care to note that rewards are not for perfect
contactwith—ratherthanavoiding—anxiety,andtoreward
performance,acommonbeliefofanxiousyouth,butthat
oneself for effort (trying one's best) to cope in a difficult
rewardsarewayswepatourselvesontheback,evenifwe
situation.
don'thavetheperfectoutcomewemighthavehopedfor.
Session 3 Inthelatterpartofsession,thetherapistdiscussesand
Mike walks into the therapy room with his eyes cast then solidifies the hierarchy of anxiety-provoking situa-
downward and says, “I forgot to do my STIC task.” The tions with Mike, checking in to make sure the numbers
therapistthankshimforlettingherknowandletshimknow andrankingsareappropriate.Atthispoint,thetherapist
140 Beidas et al.
Child portion (60 minutes) Parent portion (30 minutes)
1. Review STIC task from Session 3 1. Provide information about the second half
of treatment (i.e., exposure tasks)
2. Finalize hierarchy of anxious situations
2. Provide parents an opportunity to ask
3. Review the idea of progressing from
questions and discuss their concerns
learning new skills to practicing new skills
3. Learn more about the situations in which
4. Review and apply the FEAR plan to a low
the child becomes anxious
anxiety-provoking situation
4. Offer specific ways the parents can be
5. Begin practicing using exposure in low
involved in the second half of treatment
anxiety-provoking situation
6. Plan exposure task(s) for Session 5
7. Acknowledge upcoming parent session
8. Assign STIC task
Figure5.MaingoalsofSession4.
asksMike,“Whatmightbeagoodfirstchallengeforusto from the therapist, the child is able to work through the
donext session?”Mike says,“Idon'tknow, they allseem implementation of the FEAR plan, receiving coaching as
kindahard.”Thetherapistpointsouttwoofthelowrated needed. Afterward, a brief parent session is conducted in
situations(beingaloneinthetherapyroom,beinginthe whichthetherapistprovidesinformationaboutthesecond
dark)andasksMikewhichonehewouldliketostartwith. half of treatment, learns more about the situations and
Mike chooses being alone in the therapy room for stimulithatmakethechildanxious,providesarationalefor
1minute. The therapist praises Mike for being brave. engaging in exposure work, and allows the parent to ask
TheycreateaFEARplantogetherinpreparationforthis questions. The therapist also takes this opportunity to
firstchallenge.Mikeidentifiesthatwhileheisaloneinthe mentiontotheparentsthattheywillbeneededtosupport
therapy room, he might feel hot and he might get a thechild'spracticeoftheFEARplanthroughexposuretasks
headache(“F”step).Also,hemightbethinking,“Whatif assignedasSTICtasks.
Igetstuckinhere(“E”step)?”Ifthathappens,hewilltake
deep breaths and remind himself, “I probably won't get
stuck (“A” step).” The therapist and Mike also problem Child Portion (60Minutes)
solvewhattodoifhedoesgetstuck(i.e.,bangingonthe To start the session, the therapist reviews Mike's STIC
door,callingoutforhelp).Finally,theyplanarewardfor task, which was to write down two anxiety-provoking
hisfirstexposuretask,which,asrequestedbyMike,wasto situationswithregardtohisbodyreaction,anxiousthoughts,
havechocolateicecreamtogether. and how he helped himself over the last week. Mike has
For his STIC task, Mike is to write down two completed his STIC task, and the therapist uses labeled
anxiety-provoking situations with regard to his body verbalpraise—“GreatjobcompletingyourSTICtask”—asa
reaction, anxious thoughts, and how he helped himself reward.Mikegetsasticker,anditistimetopicksomething
overthenextweek.HealsowillteachtheFEARplantohis fromtheprizeboxbecausehehasreceivedfourstickersto
parents. dateforhishardwork.Mikepicksatoycar.Thetherapist
checks in to make sure the hierarchy that they have been
working on is still reflective of Mike's fears. The therapist
Session4:ReviewingSkillsAlreadyLearned,Practicing thensuggeststhatthesessionisabridge—atransitiontothe
in Low-Anxiety-Provoking Situations, and the Second
next part of treatment, which includes exposure tasks
Parent Meeting (called “challenges” for the youth and families) using the
Having introduced the steps of the model for coping toolkithehaslearnedinanxietysituationswiththetherapist
withanxiety(i.e.,theFEARplan),treatmentshiftstoward ascoach.
practice in anxiety-eliciting situations. See Figure 5 for Next,MikeandthetherapistreviewtheFEARplanthey
the main goals to be covered in Session 4. Session 4 is createdintheprevioussession.Thetherapistchecksinto
a 90-minute session (60minutes with the youth and make sure that Mike is still committed to doing the
30minutes with the parents). An emphasis is placed on exposure he chose (being in the dark). While preparing
theprogressionofmovingfromthelearningofnewskillsto forthechallenge,thetherapistnoticesthatMikeishavinga
puttingthemtouse.Thefearhierarchyisfinalized(although toughtimeattendingtotheFEARplan,soshesuggeststhat
itcanbealteredlater),andalowanxiety-producingsituation theyinstituteapointsystem,wherehegetsapointforevery
ischosenforafirstexposuretask.Withguidanceandsupport 2-minuteintervalthatheisable to stayontask.Whenhe
BCBT Case Study 141
gets5points,heearnsanothersticker.Thishelpsredirect aboutthetreatment,discussconcerns,andprovidemore
Mike'sattention.Forthefirstexposure,Mikeagreestostay information about anxiety-provoking situations. The par-
inthedarkfor10seconds.Atfirst,hesays,“Idon'tliketodo entsreportbeingpleasedwithMike'sprogressandthatthe
scarythings!!”despitetheiragreementtodotheexposure. hierarchy is a good depiction of the desired treatment
However,withsomecoaxingfromhistherapist,heagrees deliverables. The therapist and parents discuss how the
totryitfor10seconds.TohelpmotivateMiketocomplete parents can facilitate use of coping skills in challenges
theexposuretask,thetherapistremindshimthathewillget conductedathome.Aparticularemphasisisplacedonhow
a reward immediately following the challenge. She also the parents can use positive reinforcement to encourage
remindshimthathehaslearnedlotsofnewskillsandthisis Mike'sparticipationinchallenges.Thetherapistassiststhe
achanceforhimtopracticethoseskills,andthatshewillbe parents in identifying a reward schedule to be used for
right there with him. While doing the exposure, the in-home challenges with rewards with high motivating
therapistelicits ratingsof hisanxietyon a scale from 0to powerforMike(e.g.,hisfavoritedessert,specialtimewith
8(where8isthemostfrightening).Mikesaysthatheisan hisparents).Thetherapistalsostressestheimportanceof
8fortheentire10seconds.Thetherapistasksiftheycould immediate rewards and lots of labeled verbal praise (i.e.,
trytheexposureforalittlebitlongertoseewhathappens. “Greatjobbeingsobrave!”).Usingtheexampleofbeingin
Aftersuccesswith10seconds,Mikeagreestotry30seconds, thedark,thetherapistcoachestheparentsinhowtheycan
then1minute,andthen5minutes.Eachtime,hisratings help support Mike when he completes this exposure at
start lower, and decrease within the exposure (intra- and home.Thetherapistalsoemphasizeshowimportantitisfor
inter-exposurehabitation).Forthelastexposuretask,Mike Miketocompleteatleastthreeexposuresbeforethenext
agreestobeinthedarkroomalone,furtherintensifyingthe session.
challenge.
Aftercompletingthefourexposuretasks,Mikeandthe Sessions 5 to 7: Practice With Increasingly
therapistcheckintoprocesstheexposuretasks,investigating Anxiety-Provoking Situations
if what Mike expected to happen actually happened, and
The main goals to be addressed in Sessions 5 to 7 are
discussinglessonslearned.Mikenotesthathefelthotand
detailedinFigure6.Buildingontheexperienceofhaving
like he had a headache at first, and that he was scared
usedtheFEARplancopingskillsinalowanxiety-inducing
somethingbadwouldhappen.Hehastheinsighttoobserve
situation, the remaining treatment sessions focus on
that his somatic symptoms decreased over time and that
implementing these skills in progressively more difficult
nothing bad happened. When asked about what he has
situations. Session 5 begins with a review of the child's
learned,Mikesays,“Itwasn'tasbadasIthoughtitwouldbe,”
experiencewiththefirstexposuretask,conductedathome
andthathis“scaryfeelings”godownthelongerheisinthe
withtheparentascoach.Fromthere,thechildisencouraged
situation. The therapist praises Mike for his bravery and
tobeginascendingtheanxietyhierarchybyengaginginan
makessuretofollowthroughontherewardtheyselected,
exposuretaskofmoderatedifficulty.Asbefore,thetherapist
chocolateicecream.Mikeandthetherapistdiscusswhatthe
ispresentforsupport,althoughencouragementofagreater
exposurewillbeforthenextsession,andtheyagreethatthey
amountofindependenceintheapplicationofcopingskillsis
will pick something from the medium category on the
emphasized. The session ends with planning for a moder-
hierarchy. Mike selects doing a scavenger hunt alone on
atelyanxiety-provokingexposureasaSTICtaskaswellasthe
different floors in the building. For his STIC task, Mike
exposuretasktobecoveredatthenextmeeting.Sessions6
agreestopracticebeinginthedarkbasement,somewhere
and 7 follow the same format as Session 5. In each
henevergoes,atleastthreetimesoverthenextweek.
subsequent session, the objective is to continue up the
hierarchybyfacingsituationsthatelicitmoreanxiety.
Parent Portion (30Minutes)
In the second parent session, the therapist reviews Session 5
information about the second half of treatment and To start, the therapist reviews Mike's STIC task, which
sharesMike'ssuccesswithhisparents.Thetherapistalso wastopracticeusinghiscopingskillsinthedarkatleast3
providestheparentswithanopportunitytoaskquestions times. Mike reports that he has been successful in his
practices,andevenaddedachallengethisweek,complet-
ingatotaloffourpracticesforhomework.Mikeisexcitedto
1. Review STIC task from previous session
tell his therapist that he went on the highway with his
2. Practice using exposure in anxiety-provoking situation parentsandusedhiscopingskillseffectively.Thetherapist
3. Plan exposure task(s) for next session uses labeled praise to reward Mike's hard work and gives
4. Assign STIC task himanextrasticker.
Mikeandthetherapistagreetocompletetheexposure
Figure6.MaingoalsofSessions5–7. task planned the previous week: Mike will go on a
142 Beidas et al.
scavenger hunt by himself on multiple floors of the completing three over the past week. Mike was able to
building—achallengerateda4.Priortothesession,the flush the toilet after going to the bathroom, go on the
therapist creates a scavenger hunt map and hides highway, and eat at a busy restaurant. The therapist
SpongeBob SquarePants stickers in different locations praisesMike'shardworkandgiveshimasticker.
(selected because of their high reward value for the Mike and the therapist prepare the exposure task
client).MikeandthetherapistformulateaFEARplanfor plannedthepreviousweek:goingtoamovie(ratedan8).
the exposure task and run through the scavenger hunt Mike and the therapist formulate a FEAR plan for the
togethertomakesurethatMikeknowshowtogetbackto exposure, and catch 20minutes of a movie of Mike's
theoffice.WhenMikereturns,hisfaceisflushedwithpride choosing. Mike reports that this is the hardest challenge
that he completed the scavenger hunt. Mike and the he is done yet, given his worry that he or someone else
therapistprocesshisexperience,payingspecialattentionto mightvomitatthemovies.Behavioralobservationsbythe
the mastery he is feeling. For next week, Mike and the therapist suggest high levels of anxiety as evidence by
therapistagreetogoonthesubwayfortheirchallenge.For frequentskin-pickingduringthemovie.However,Mikeis
homework, they agree that Mike will (a) go to a friend's able to stay in the situation until his anxiety goes down.
house,(b)sleepinhisownbedwhilehismotherisawayon Afterwards, Mike and the therapist process his experi-
business,and(c)driveonthehighwaywithhisparents.Mike ence.Mikeandthetherapistagreethatthetherapistwill
runs to his parents after the session and tells them all the setofffireworksforthefinalchallenge,averyhighlyrated
challengeshewantstodothisweek,andhisparentsconfirm fearforMike.Forhomework,theyagreethatMikewill(a)
thattheywillbeabletosetuptheplaydate. gotoandwatchawholemovie,(b)driveonthehighway,
and(c)gotoacrowdedplace.
Session 6
At the outset, the therapist reviews Mike's STIC tasks.
Session 8: Practicing in High-Anxiety Situations and
Mikereportsthathehasbeensuccessfulinhispractices,
Celebrating Success
completingthreeoverthepastweek.Mikewasabletogo
SeeFigure7forthemaingoalstobecoveredinSession
toafriend'shouse,sleepinhisownbedwhilehismother
8.Session8isthelasttherapysessionofBCBT.Afterhaving
was away, and go on the highway. The therapist praises
practiced coping skills across a number of situations with
Mike'shardworkandgiveshimasticker.
both the therapist and parents providing support, this
Mike and the therapist prepare the exposure task
sessionistohelpthechildsolidifygainsbypracticingone
plannedthepreviousweek:goingonthesubway(ratedan
last time in one of the harder (e.g., more anxiety
8).MikeandthetherapistformulateaFEARplanforthe
provoking) scenarios. It is recommended that this not be
challenge and head to the subway to ride the train back
themostdifficultsituation,butratheronethatthetherapistis
and forth. Because of the loud subway noises, Mike
relativelyconfidentthechildcanbesuccessful(thatis,we
reportsinitiallyfeelinghighlevelsofanxietyandsomatic
want the client to finish the program with a sense of
symptoms, which quickly subside. Afterwards, Mike and
mastery). Once completed, the therapist spends time
the therapist process the experience, paying special
reviewing and enthusiastically celebrating all that the
attention to the lesson learned about anxiety subsiding
child has accomplished. This celebration can be done
when he stays in the situation. Mike and the therapist
with parents, friends, or other family members, with the
agree to go to a movie for their second-to-last exposure.
child'spreferencesdictatingwhatwillbemostmeaningful.
Forhomework,theyagreethatMikewill(a)flushthetoilet
The therapist also underscores for both the child and
each time he goes to the bathroom, (b) drive on the
parents the importance of being proactive about relapse
highway,and(c)gotoacrowdedplace.
prevention,whichisachievedthroughcontinuedpractice
Session 7 ofskills.Itisemphasizedthattheworkdoneintherapyis
The therapist first reviews Mike's STIC tasks. Mike notastand-alonecureforanxiety,butratherafoundation
report that he has been successful in his practices, tobebuiltuponthroughregularandongoingapplication
1. Review STIC task from Session 7
2. Conduct a final exposure task in a challenging anxiety-provoking situation
3. Review and summarize the treatment program
4. Bring closure to the therapeutic relationship
Figure7.MaingoalsofSession8.
BCBT Case Study 143
of coping. Finally, during this session, the therapist Role of Parents
addresses the closure of the therapeutic relationship, As illustrated in Mike's case, parental participation in
letting the client know that it is now time for him or her treatmentcanbevaluablefortherapeuticsuccess.Parents
to go forth and independently be brave and face the are not co-clients, but are involved in treatment as
anxiety-engenderingchallenges. collaboratorsandcoaches(Kendall,2012).Parentsprovide
informationregardingtheirchild'sfunctioninginandout
of the home and serveascollaborators/coachesthrough-
Session 8
out treatment. Appropriate parental involvement may be
ThetherapiststartsbyreviewingMike'sSTICtasks.Mike
crucial given the abbreviated nature of BCBT, which
reports that he has been successful in his practices,
requiresthatmanyoftheexposuretasksoccuroutsideof
completingthreeoverthepastweek.Thetherapistpraises
the therapy session (within the home setting). If parents
Mike'shardworkandgiveshimasticker.BecauseMikehas
accommodate their child's anxiety by allowing them to
earnedanotherfourstickers,hepicksoutaprizefromthe
avoid exposures, orif they are underinvolved and do not
prizebox.Heselectsaglowinthedarkslinky.
facilitateexposures,itislikelythattheeffectsofBCBTmay
Mike and the therapist prepare the exposure task
be limited (more sessions would be needed for exposure
planned the previous week: being around sparkler fire-
tasks).Inourcaseexample,Mikewasabletocompletehis
works (rated an 8). Mike and the therapist formulate a
writtenSTICtasksonhisown.However,notall7-year-olds
FEAR plan for the challenge. The therapist lights the
maybeabletodoso.Insuchinstances,parentalassistance
sparklersandmodelssafebehaviorforMike,andthenMike
withSTICtaskscouldbeencouraged.Keepinmindthatitis
practices holding them as they burn down. Mike reports
importantthatparentsdonot“do”theSTICtasksforthe
feelingsomeanxietyandthatashisanxietysubsidesthathe
youth,butratherassistandfacilitatethechilddoinghis/her
startstothinkthisis“superfun.”Afterwards,Mikeandthe
own STIC tasks. For example, parents can help younger
therapistprocesshisexperience.
children by scheduling times for them to do their STIC
Mike and the therapist review and summarize treat-
tasks, and parents can also themselves be involved in the
ment to date. They make a big poster of all of his
actual STIC tasks. In Mike's case, his parents helped him
accomplishmentsoverthecourseofthe8sessions.Mike,
face his fear of separation from them by bringing him to
the therapist, his parents and siblings celebrate Mike's
anddroppinghimoffatplaydateswithpeers.Hisparents
accomplishmentswithapizzaparty,andeveryoneshares
didnotgoontheplaydatesbutfacilitatedMikefacinghis
how proud they are of him. The therapist makes sure to
fearsbygettinghimtoandfromfriends’houses.Parental
ask the parents and Mike if they feel like treatment has
involvement in treatment is tailored for each family to
achieved the deliverables they were seeking at the
encourageapproachratherthanavoidancebehavior.
beginning. They all agree that Mike has made huge
gainsbyincreasinghiscopingbehaviorandfacingfeared
Youth Compliance
situations bravely. Specifically, Mike has been able to
Youthcomplianceinthecompletionofexposuretasksis
achieve all treatment deliverables, including: going to a
critical to the success of CBT for child anxiety, including
friend's house, being in the dark alone, tolerating loud
BCBT.Mikewasquitecompliantincompletinghisexposure
noises,separatingfromhismotherwhenshetravels,and
tasks, although he needed some initial convincing when
toleratingchangesinroutine.Inthelastfewminutes,the
startingtheexposureportionoftreatment.Asillustratedin
therapistbringsclosuretothetherapeuticrelationshipby
Mike's case, some gentle coaxing (supportive encourage-
sharinghowwonderfulithasbeenworkingwithMikeand
ment) isoften all a child needs totry their first exposure,
his family, and encourages the family to continue doing
especially if the hierarchy of feared situations is appropri-
challenges,modeling,andreinforcingMikeforfacinghis
ately constructed (i.e., the first exposure task is relatively
fearstomaintaintreatmentgains.Thetherapistdiscusses
easy). In our experience, an appropriate reward can be
relapsepreventionandemphasizesthefactthatMikenow
enoughmotivationtoparticipateinthefirstexposuretask,
has skills with which to face his feared situations, even if
and success in the first exposure task often comes with
newsituationsarise.
mastery and a willingness do more challenges. Further,
giving the child a “choice” in the exact nature of the first
exposure task will help engender motivation. When these
Additional Considerations
twopointsareaddressed,werarelyfindachildunwillingto
As with the full protocol (i.e., Coping Cat program), engageinanexposuretask(especiallywhenthetherapistis
thereareissuestoconsiderwhenimplementingtheBCBT willingtonegotiateifthetaskfeelstoodifficultforthechild).
program,includingtheroleoftheparentsinthetreatment If necessary, an exposure task can be broken down into
and how to engender youth compliance with exposure smallerandmanageableparts,sothekeyistobecreativein
tasks. coming up with something challenging that the child is