A Clinician's Guide to CBT for Children to Young Adults
A Companion to Think Good, Feel Good and Thinking Good, Feeling Better
2. Edition December 2020
320 Pages, Softcover
Wiley & Sons Ltd
ISBN:
978-1-119-39631-4
John Wiley & Sons
Further versions
A powerful and insightful clinical resource for CBT practitioners who work with children and young adults
The newly updated and thoroughly revised Second Edition of this companion to Think Good, Feel Good and Thinking Good, Feeling Better delivers guidance for clinicians using the author's seminal workbooks. This companion work builds upon the workbook materials by offering readers instruction on all aspects of the therapeutic process and a wide range of case studies highlighting specific therapies in action.
A Clinician's Guide covers topics including parental involvement, key cognitive distortions in children, formulations, challenging thoughts, guided discovery, and the use of imagery. The author also includes a chapter focusing on common potential problems that arise in therapy and strategies to overcome them.
The book highlights the underlying philosophy, process, and core skills of employing CBT with children and young people. Readers will appreciate the competency framework, which describes the CORE philosophy, PRECISE process, and the ABCs of specific techniques. The book also includes:
* Additional materials and handouts for use in therapy, including psycho-educational materials for children and parents on common problems, like depression, OCD, PTSD, and anxiety
* Downloadable, multi-use worksheets for use in the clinician's therapeutic sessions
* Practical, real-world case examples that shed light on the techniques and strategies discussed in the book
* A systematic approach to the use of cognitive behavioural therapy to treat common psychological problems
Perfect for professionals and trainees in child and adolescent mental health, like psychiatrists, clinical psychologists, educational psychologists, community psychiatric nurses, and occupational therapists, the book also belongs on the shelves of non-mental health professionals, including school nurses and social workers, who regularly work with children in a therapeutic setting.
About this book xiii
Acknowledgements xv
Online resources xvii
1 Introduction and overview 1
CBT as an intervention 1
CBT as a preventative intervention 2
CBT with younger children 3
CBT with children and young people with learning difficulties 4
Technologically delivered CBT 5
Involving parents 6
The competencies to deliver child-focused CBT 7
Assessing competence 8
Cognitive Behaviour Therapy Scale for Children and Young People 9
CORE philosophy 13
Child-centred 14
Outcome-focused 15
Reflective 16
Empowering 17
2 PRECISE 19
The therapeutic alliance 19
Partnership 21
Eliciting the young person's and parents' understanding and views 22
Encourages the young person to participate in decision making 23
Involves the young person and parents/carers in planning the intervention 24
Encourages the young person to provide feedback about sessions 25
Right developmental level 25
Ensures an optimal balance between cognitive and behavioural techniques 26
Uses simple, clear, jargon-free language 27
Uses a variety of verbal (direct and indirect approaches) and non-verbal techniques 28
Appropriately involves parents/carers/others 28
Courtney has anger outbursts 30
Empathy 30
Conveys interest and concern using active listening, reflection, and summaries 30
Acknowledges and responds to emotional responses 32
Demonstrates an open, respectful, non-judgemental, caring approach 33
Empathises with parents 34
Creative 35
Tailors the concepts and methods of CBT around the interests of the young person 35
Uses a range of verbal and non-verbal methods 36
Creatively uses a range of methods 37
Utilises the preferred media of the young person 38
Investigation 39
Creates a process of collaborative inquiry 39
Fully involves young people in the design of experiments 40
Helps young people and parents/carers to consider alternative explanations 41
Encourages reflection 42
Self-efficacy 42
Identifies and highlights strengths and personal resources 43
Encourages identification of helpful skills and strategies 44
Develops personal coping strategies 44
Reinforces use of new skills 45
Enjoyable and engaging 45
Uses an appropriate mix of materials, activities, humour 46
Maintains an appropriate balance between task and relationship-strengthening activities 46
Attends to the young person's interests and incorporates them into the intervention 47
Presents as positive and hopeful 48
PRECISE in practice 48
Ella's obsessional thoughts 48
Joshua's negative thinking 49
3 A: Assessment and goals 51
Undertakes a full assessment of the presenting problem 51
Compliments assessment with routine outcome measures (ROMs) 53
Negotiates goals and the dates when progress will be reviewed 55
Identification of goals 56
Prioritisation of goals 57
Whose goals? 57
Inappropriate goals 58
Uses diaries, thought bubbles, and rating scales 59
Sarah feels faint 59
Tick charts 60
Thought bubbles 60
Visualisation 61
Stories 62
Rating scales 63
Pie charts 63
Theo's washing 64
Assesses motivation and readiness to change 64
Pre-contemplation 65
Contemplation 67
Preparation 67
Action 68
Maintenance 68
Relapse 68
4 B: Behavioural 69
Uses behavioural techniques to facilitate therapeutic change 70
Developing hierarchies 70
Graded exposure 72
Response prevention 74
John is worried about germs 75
Problems when undertaking exposure 75
Young person avoidance 75
Clinician avoidance 76
Anxiety does not come down 76
Is the young person focusing on their anxiety? 77
Are parents/carers appropriately involved? 77
Uses behavioural techniques such as activity rescheduling and behavioural activation 77
Activity rescheduling 77
Alison feels down 78
Behavioural activation 79
Problems when undertaking behavioural activation 80
I didn't feel like doing it 80
I did it, but I don't feel any better 81
I did it, but so what? 81
It's not important 81
Provides a clear rationale for using behavioural strategies 82
Identifies and implements reward and contingency plans 82
Models, uses role play, structured problem-solving approaches, or skills training 85
Model how to cope 85
Role play 87
Problem solving 88
Skills training 89
5 C: Cognitions 91
Facilitates cognitive awareness 92
Cognitive content 92
Levels of cognitions 92
Freya worries about making a fool of herself 93
Uses thought records and bubbles 96
Identifies functional and dysfunctional cognitions 98
Unhelpful thoughts 99
Helpful thoughts 99
Identifies common cognitive biases ('thinking traps') 99
The negative filter 100
Blowing things up 100
Predicting failure 101
Being down on yourself 101
Setting yourself up to fail 101
Facilitates thought challenging and perspective taking 102
What is the evidence? 102
The 4Cs 103
What would someone else say? 103
Jaz falls out with her friend 104
Facilitates continuum work using rating scales 104
Uses techniques such as mindfulness, acceptance, and compassion 105
Mindfulness 105
Compassion 107
Acceptance 109
Kindness 110
6 D: Discovery 111
Facilitates discovery and reflection through use of the Socratic dialogue 111
The Socratic dialogue 113
What makes a good Socratic question? 116
Mike is worried about his cat 118
Common difficulties 120
Alternative perspective taking and attending to new or overlooked information 122
Perspective taking 122
Responsibility pies 123
Joshua's accident 123
Attends to overlooked information 124
Analogical comparisons 124
Systematically testing the assumed relationship 125
Marla worries she will pass germs to others 126
Behavioural experiments and prediction testing 127
Cognition- and prediction-testing experiments 127
Planning a behavioural experiment 128
Prediction-testing experiments: Caleb thinks he is a failure 129
Active experiments: Laura's social anxiety 130
Information gathering experiments: Adam's formulation 131
7 E: Emotions 133
Develops emotional literacy by facilitating the identification of a range of emotions 133
Helps to distinguish between different emotions and identifies key body signals 135
Body signals 135
Feeling diaries 135
William feels sad 136
Emotional logs 137
Isabella feels down 137
Relaxation, guided imagery, controlled breathing, and calming activities 138
Progressive muscle relaxation 139
Calming imagery 141
Aisha's calming image 141
Diaphragmatic (controlled) breathing 142
Change the feeling 143
Physical activity, letting feelings go, emotional metaphors, and imagery 144
Physical activity 144
Let the feeling go 144
Emotional metaphors 145
Emotive imagery 145
Anthony's humorous image 146
Self-soothing, mind-games, and mindfulness 146
Self-soothing 146
Mind games 147
Mindfulness 147
Talk with someone 148
8 F: Formulations 149
Provides a coherent and understandable rationale for the use of CBT 149
Linking thoughts, emotions, and behaviours 151
Mini-formulations (two- or three-system models) 151
Rhiannon is unhappy and scared 152
Maintenance formulations 154
Naomi cuts herself 154
Four-system formulations 155
Abdul's anxiety 156
Remember the strengths 157
Provides an understanding of important past events and relationships (onset formulations) 158
Mary's anxiety 161
Includes parental/family factors in formulations 163
Sally's anxiety 163
Activities and goals/targets are clearly linked to the formulation 165
Common problems 167
Difficulty identifying thoughts or feelings 167
Is it important to distinguish between different levels of cognitions? 168
I can't seem to put this together in a formulation 168
I'm not sure if the formulation is right 169
I can't seem to find all the information to complete the formulation 169
9 G: General skills 171
Prepares and brings the necessary materials and equipment to the meeting 171
Manages the young person's behaviour during sessions 172
Ensures that sessions have an agenda and clear goals and are appropriately structured 174
General update 175
Outcome measures update 175
Home assignment review 175
Session topic 176
Home assignment 176
Session summary and feedback 176
Ensures good timekeeping so that all tasks are completed 177
Sessions are appropriately paced, flexible, and responsive 178
Responsive 180
Gary is worried about germs 180
Prepares for endings and relapse prevention 181
Relapse prevention 181
10 H: Home assignments 185
Negotiates home assignments 185
Assignments are meaningful and related to the formulation 188
Assignments are consistent with the young person's developmental level 189
Assignments are realistic, achievable, and safe 191
Refers to goals when planning assignments and to rating scales when reviewing progress 193
Harry wants to get fitter 193
Fatima's unhelpful thoughts 194
Assignments are reviewed and reflection encouraged 195
11 Putting it together 199
Anxiety 200
Effectiveness 200
Rationale informing the intervention 200
Core components of CBT interventions for anxiety disorders 201
Parents 202
Important cognitions 202
Depression 203
Effectiveness 203
Rationale informing the intervention 204
Core components of CBT interventions for depression 205
Parents 206
Important cognitions 206
Obsessive-compulsive disorder (OCD) 207
Effectiveness 207
Rationale informing the intervention 208
Core components of CBT interventions for OCD 209
Parents 210
Important cognitions 210
Post-traumatic stress disorder (PTSD) 210
Effectiveness 210
Rationale informing the intervention 211
Core components of CBT interventions for PTSD 211
Parents 212
Important cognitions 213
When it doesn't go right 213
Is the young person motivated to change? 215
Sam's costs of change 217
Are the young person and their family engaged with the intervention? 219
Jade is anxious and depressed 221
How has the intervention been delivered? 224
12 Resources 229
The Chain of Events 230
The Negative Trap 231
Four systems 232
How did this happen? 233
Session rating scale 234
Scales of change 235
Anxiety intervention plan 236
Depression intervention plan 237
OCD intervention plan 238
PTSD intervention plan 239
Motivation 240
Engagement 241
Intervention delivery 242
Reflective practice 243
The Cognitive Behaviour Therapy Scale for Children and Young People (CBTS-CYP) 244
Beating anxiety 259
Fighting back depression 264
Controlling worries and habits 270
Coping with trauma 275
References 279
Index 291
Acknowledgements xv
Online resources xvii
1 Introduction and overview 1
CBT as an intervention 1
CBT as a preventative intervention 2
CBT with younger children 3
CBT with children and young people with learning difficulties 4
Technologically delivered CBT 5
Involving parents 6
The competencies to deliver child-focused CBT 7
Assessing competence 8
Cognitive Behaviour Therapy Scale for Children and Young People 9
CORE philosophy 13
Child-centred 14
Outcome-focused 15
Reflective 16
Empowering 17
2 PRECISE 19
The therapeutic alliance 19
Partnership 21
Eliciting the young person's and parents' understanding and views 22
Encourages the young person to participate in decision making 23
Involves the young person and parents/carers in planning the intervention 24
Encourages the young person to provide feedback about sessions 25
Right developmental level 25
Ensures an optimal balance between cognitive and behavioural techniques 26
Uses simple, clear, jargon-free language 27
Uses a variety of verbal (direct and indirect approaches) and non-verbal techniques 28
Appropriately involves parents/carers/others 28
Courtney has anger outbursts 30
Empathy 30
Conveys interest and concern using active listening, reflection, and summaries 30
Acknowledges and responds to emotional responses 32
Demonstrates an open, respectful, non-judgemental, caring approach 33
Empathises with parents 34
Creative 35
Tailors the concepts and methods of CBT around the interests of the young person 35
Uses a range of verbal and non-verbal methods 36
Creatively uses a range of methods 37
Utilises the preferred media of the young person 38
Investigation 39
Creates a process of collaborative inquiry 39
Fully involves young people in the design of experiments 40
Helps young people and parents/carers to consider alternative explanations 41
Encourages reflection 42
Self-efficacy 42
Identifies and highlights strengths and personal resources 43
Encourages identification of helpful skills and strategies 44
Develops personal coping strategies 44
Reinforces use of new skills 45
Enjoyable and engaging 45
Uses an appropriate mix of materials, activities, humour 46
Maintains an appropriate balance between task and relationship-strengthening activities 46
Attends to the young person's interests and incorporates them into the intervention 47
Presents as positive and hopeful 48
PRECISE in practice 48
Ella's obsessional thoughts 48
Joshua's negative thinking 49
3 A: Assessment and goals 51
Undertakes a full assessment of the presenting problem 51
Compliments assessment with routine outcome measures (ROMs) 53
Negotiates goals and the dates when progress will be reviewed 55
Identification of goals 56
Prioritisation of goals 57
Whose goals? 57
Inappropriate goals 58
Uses diaries, thought bubbles, and rating scales 59
Sarah feels faint 59
Tick charts 60
Thought bubbles 60
Visualisation 61
Stories 62
Rating scales 63
Pie charts 63
Theo's washing 64
Assesses motivation and readiness to change 64
Pre-contemplation 65
Contemplation 67
Preparation 67
Action 68
Maintenance 68
Relapse 68
4 B: Behavioural 69
Uses behavioural techniques to facilitate therapeutic change 70
Developing hierarchies 70
Graded exposure 72
Response prevention 74
John is worried about germs 75
Problems when undertaking exposure 75
Young person avoidance 75
Clinician avoidance 76
Anxiety does not come down 76
Is the young person focusing on their anxiety? 77
Are parents/carers appropriately involved? 77
Uses behavioural techniques such as activity rescheduling and behavioural activation 77
Activity rescheduling 77
Alison feels down 78
Behavioural activation 79
Problems when undertaking behavioural activation 80
I didn't feel like doing it 80
I did it, but I don't feel any better 81
I did it, but so what? 81
It's not important 81
Provides a clear rationale for using behavioural strategies 82
Identifies and implements reward and contingency plans 82
Models, uses role play, structured problem-solving approaches, or skills training 85
Model how to cope 85
Role play 87
Problem solving 88
Skills training 89
5 C: Cognitions 91
Facilitates cognitive awareness 92
Cognitive content 92
Levels of cognitions 92
Freya worries about making a fool of herself 93
Uses thought records and bubbles 96
Identifies functional and dysfunctional cognitions 98
Unhelpful thoughts 99
Helpful thoughts 99
Identifies common cognitive biases ('thinking traps') 99
The negative filter 100
Blowing things up 100
Predicting failure 101
Being down on yourself 101
Setting yourself up to fail 101
Facilitates thought challenging and perspective taking 102
What is the evidence? 102
The 4Cs 103
What would someone else say? 103
Jaz falls out with her friend 104
Facilitates continuum work using rating scales 104
Uses techniques such as mindfulness, acceptance, and compassion 105
Mindfulness 105
Compassion 107
Acceptance 109
Kindness 110
6 D: Discovery 111
Facilitates discovery and reflection through use of the Socratic dialogue 111
The Socratic dialogue 113
What makes a good Socratic question? 116
Mike is worried about his cat 118
Common difficulties 120
Alternative perspective taking and attending to new or overlooked information 122
Perspective taking 122
Responsibility pies 123
Joshua's accident 123
Attends to overlooked information 124
Analogical comparisons 124
Systematically testing the assumed relationship 125
Marla worries she will pass germs to others 126
Behavioural experiments and prediction testing 127
Cognition- and prediction-testing experiments 127
Planning a behavioural experiment 128
Prediction-testing experiments: Caleb thinks he is a failure 129
Active experiments: Laura's social anxiety 130
Information gathering experiments: Adam's formulation 131
7 E: Emotions 133
Develops emotional literacy by facilitating the identification of a range of emotions 133
Helps to distinguish between different emotions and identifies key body signals 135
Body signals 135
Feeling diaries 135
William feels sad 136
Emotional logs 137
Isabella feels down 137
Relaxation, guided imagery, controlled breathing, and calming activities 138
Progressive muscle relaxation 139
Calming imagery 141
Aisha's calming image 141
Diaphragmatic (controlled) breathing 142
Change the feeling 143
Physical activity, letting feelings go, emotional metaphors, and imagery 144
Physical activity 144
Let the feeling go 144
Emotional metaphors 145
Emotive imagery 145
Anthony's humorous image 146
Self-soothing, mind-games, and mindfulness 146
Self-soothing 146
Mind games 147
Mindfulness 147
Talk with someone 148
8 F: Formulations 149
Provides a coherent and understandable rationale for the use of CBT 149
Linking thoughts, emotions, and behaviours 151
Mini-formulations (two- or three-system models) 151
Rhiannon is unhappy and scared 152
Maintenance formulations 154
Naomi cuts herself 154
Four-system formulations 155
Abdul's anxiety 156
Remember the strengths 157
Provides an understanding of important past events and relationships (onset formulations) 158
Mary's anxiety 161
Includes parental/family factors in formulations 163
Sally's anxiety 163
Activities and goals/targets are clearly linked to the formulation 165
Common problems 167
Difficulty identifying thoughts or feelings 167
Is it important to distinguish between different levels of cognitions? 168
I can't seem to put this together in a formulation 168
I'm not sure if the formulation is right 169
I can't seem to find all the information to complete the formulation 169
9 G: General skills 171
Prepares and brings the necessary materials and equipment to the meeting 171
Manages the young person's behaviour during sessions 172
Ensures that sessions have an agenda and clear goals and are appropriately structured 174
General update 175
Outcome measures update 175
Home assignment review 175
Session topic 176
Home assignment 176
Session summary and feedback 176
Ensures good timekeeping so that all tasks are completed 177
Sessions are appropriately paced, flexible, and responsive 178
Responsive 180
Gary is worried about germs 180
Prepares for endings and relapse prevention 181
Relapse prevention 181
10 H: Home assignments 185
Negotiates home assignments 185
Assignments are meaningful and related to the formulation 188
Assignments are consistent with the young person's developmental level 189
Assignments are realistic, achievable, and safe 191
Refers to goals when planning assignments and to rating scales when reviewing progress 193
Harry wants to get fitter 193
Fatima's unhelpful thoughts 194
Assignments are reviewed and reflection encouraged 195
11 Putting it together 199
Anxiety 200
Effectiveness 200
Rationale informing the intervention 200
Core components of CBT interventions for anxiety disorders 201
Parents 202
Important cognitions 202
Depression 203
Effectiveness 203
Rationale informing the intervention 204
Core components of CBT interventions for depression 205
Parents 206
Important cognitions 206
Obsessive-compulsive disorder (OCD) 207
Effectiveness 207
Rationale informing the intervention 208
Core components of CBT interventions for OCD 209
Parents 210
Important cognitions 210
Post-traumatic stress disorder (PTSD) 210
Effectiveness 210
Rationale informing the intervention 211
Core components of CBT interventions for PTSD 211
Parents 212
Important cognitions 213
When it doesn't go right 213
Is the young person motivated to change? 215
Sam's costs of change 217
Are the young person and their family engaged with the intervention? 219
Jade is anxious and depressed 221
How has the intervention been delivered? 224
12 Resources 229
The Chain of Events 230
The Negative Trap 231
Four systems 232
How did this happen? 233
Session rating scale 234
Scales of change 235
Anxiety intervention plan 236
Depression intervention plan 237
OCD intervention plan 238
PTSD intervention plan 239
Motivation 240
Engagement 241
Intervention delivery 242
Reflective practice 243
The Cognitive Behaviour Therapy Scale for Children and Young People (CBTS-CYP) 244
Beating anxiety 259
Fighting back depression 264
Controlling worries and habits 270
Coping with trauma 275
References 279
Index 291
PAUL STALLARD is Professor of Child and Family Mental Health at the University of Bath and Head of Psychological Therapies (CAMHS) for Oxford Health NHS Foundation Trust. He is a clinical psychologist who has worked with children and young people for 40 years using Cognitive Behaviour Therapy (CBT). He is also an active researcher and has been involved in many studies exploring the use and effectiveness of CBT with children and young people.
