Beruflich Dokumente
Kultur Dokumente
Adolescents (CTRS-CA)
Robert D. Friedberg, Ph.D., ABPP, ACT
Center for the Study and Treatment of Anxious Youth at Palo
Alto University
September 2014
2. INFORMALITY
Rationale; Children and adolescents respond well to informal therapists (Creed & Kendall,
2005). Optimally, the therapist balances an authoritative, adult stance with an informal demeanor
when interacting with young patients. Clearly, clinicians want to avoid talking down to children
and talking to them in baby-talk like tones. Informality should not be confused with indulgence
or the absence of therapeutic limit setting. Neither should it be confused with a sense that CT is
not a serious undertaking.
However, good CBT therapists avoid a pompous, stuffy stance that is overly parental. The key is
create a relaxed therapeutic milieu where children are sufficiently comfortable to approach their
problems flexibly and experiment with new thought, feeling, and action patterns. Ideally, the
therapist is able to directly communicate a sense of genuine appreciation of the young patients
and their family members perspectives. Where limits are indicated, they are imposed
authoritatively rather than in an authoritarian manner. The therapist is also adept at
communicating his/her enjoyment in taking care of the patient and their collaborative work.
While informality may include play with younger children, good cognitive therapists may
achieve informality through discussions of hobbies, interests, and peer activities with adolescents
as well as judicious self-disclosure.
Background material:
CBT for the busy child psychiatrist (pp.58-60)
Creed & Kendall (2005)
3. Playfulness
Rationale: CBT is hard work but it does not have to be unpleasant (Friedberg et al., 2011,
Peterman et al. 2014a). Playfulness and fun enlists young patients in the therapeutic enterprise.
Fun enjoys a long-standing tradition in CBT spectrum approaches (Chu & Kendall, 2009;
Stallard, 2005; Stallard et al. 2014 ). Playfulness decreases childrens perception that CBT is
boring and dull. Moreover, playfulness fits well into the experiential nature of CBT. Playfulness
humanizes and normalizes psychotherapy (Wright et al. 2006, p. 34). Moreover, Borcherdt
(2002) noted that playfulness increases transparency, emotional tolerance, energy, and
therapeutic investment. Further, playfulness requires developmental sensitivity. Sburlati et al
(2011) noted that playfulness, creativity, and informality are developmental accomodations.
Adding fun and playfulness in session augments the reinforcement value of the therapeutic work.
Playfulness is key to making CBT real and relevant to young patients lives (Peterman et al.,
2014a, 2014b). While CBT is serious work that deals with sobering issues, CBT with children
and adolescents does not have to be applied in a heavy handed manner. Indeed, inaccurate beliefs
can be captured and modified in playful ways. Stories, rewards, games, metaphors, drawing,
music, and theatre exercises are used in playful CBT (Friedberg & McClure, 2002; Friedberg et
al. 2011; Peterman et al. 2014a, 2014b). However, playfulness with older children may include
verbal repartee and humor.
Background material
Clinical practice of cognitive therapy with children and adolescents (pp. 146-166).
Cognitive behavioral therapy for the busy child psychiatrist (pp. 58-60).
Peterman et al. 2014a; Peterman et al. 2014b
Desirable Therapist strategies
1. Creates a pleasant treatment milieu yet earnestly communicates the seriousness of
clinical work
2. Inspires a sense of curiosity in young patients by use of engaging, fun, and lively
experiential activities to identify as well as modify unproductive thought, feeling, and
action patterns.
3. Uses developmentally and culturally appropriate metaphors, games, stories, drawing,
music, games, theatre exercises, etc. to identify and modify unproductive thought,
feeling, and action patterns.
4. When indicated, administers contingent rewards to reinforce young patients
behavior.
4. CREDIBILITY
Rationale: The credibility domain is consistent with Shirk and Karvers (2006, p. 480) notion
that the clients experience of the therapist as someone who can be counted upon for help in
overcoming problems or distress. Garcia and Weisz (2002) discovered that doubts about
clinicians competence, perceptions that the therapist was not clear in explaining treatment
rationale, and/or were not helpful were related to the patient-therapist relationship problems.
Effective limit setting also instills a sense of credibility in young patients and their families.
Credibility is reinforced by therapist behavior. It is essential that therapists demonstrate their
credibility rather than trying to persuade patients they are credible.
Background material:
CBT for the busy psychiatrist (p.53)
Desirable Therapist Behaviors
1. Has an abundance of resources
a. I know this is hard and you want to change topics but lets try to hang in
there with this issue a little longer.
3. Avoids interrogating. Adheres to a hypothesis testing stance.
4. Gives young patients appropriate rest periods in session
3ASSIGNING AND PROCESSING HOMEWORK (see also Young & Beck, 1980)
Rationale: Homework is an indispensable way to generalize treatment gains to childrens natural
environments. Doing homework makes the abstract task of therapy concrete to young patients.
By assigning and reviewing homework in session, it becomes central to therapy. Finally, the
practice embedded in homework makes therapy less of a disposable commodity. Essential,
homework literally is a take-away product from the therapy session.
Background material:
Cognitive Therapy of Depression (pp. 272-294)
Clinical practice of Cognitive Therapy with Children and Adolescents (2nd ed), (pp 61-62;
Chapter 10) ,
CBT for the busy child psychiatrist (pp. 82-84),
Cognitive Therapy: Basics and beyond (Chapter 17)
Desirable Therapist Behaviors
1. When appropriate, considers calling homework something else (e.g. tool kit, STIC
tasks, challenges adventures, etc)
2. Ties Homework to Presenting problems
a. Line of questions
i. What do you do that a total loser would never do?
ii. What does a total loser do you would never do?
iii. How do other people in a total losers life treat them that
people in your life would never do?
4. Lays out the foundation for the childs inaccurate beliefs. The key here is that
the therapy allows an open guided discovery where the factual basis for the
childrens beliefs are not pre-empted.
a. What make you believe that ____?
b. What convinces you that _____?
5. Uses short, simple, open-ended questions especially with younger children.
a. How can you tell that _____?
b. In what ways, _____?
6. Varies the type of question asked. Adopts a flexible approach. Realizes that
not all questions have to phrased as a question (e.g Tell me about..)
(Overholser, 1993a)
7. Avoids presumption and assumption. Its OK not to know.
a. You keep saying I dont know. But there is so much going on inside
you. How can that be?
8. Engages in an organized coherent Guided Discovery process
9. Considers cultural contexts. Guided discovery is modified to fit patients
cultural contexts.
10. Demonstrates developmental sensitivity by including childrens idioms and
metaphors are ways to enhance the child-friendliness of the GD process.
working with hot cognitions, good CBT therapists maximize the emotional saliency of
sessions.
Background material:
Cognitive therapy for the emotional disorders, 6-131,
Cognitive Therapy for Depression, pp. 142-152, 163, 244-252
Clinical practice of cognitive therapy with children and adolescents (Chapters 2, 6, 7)
CBT for the busy psychiatrist (Chapters 2, 8, 9)
Cognitive Therapy: Basics and beyond (Chapters 2, 9, 10)
Desirable Therapist Behaviors
1. Use of classic cognitive therapy question and its variants at the moment of
mood shifts in session (e.g. What is going through your mind, right now?)
2. Mindfully considers of the content-specificity hypothesis
Mood state
Depression
Anger
Cognitive Content
Negative view of the self
Negative view of others/ones
experience
Negative view of the future
Hostile attributional bias
Confusing deliberate with accidental
Labelling the other person
Sense of unfairness
Violation of personal rules and
imperatives
Anxiety
Panic
Catastrophic misinterpretation of
normal bodily sensations
Fear of negative evaluation
Social Anxiety
3.
3. Techniques and procedures do not come out of the blue. Instead, they are
seamlessly connected to session content and are customized to individual
patients presentation/complaints.
4. APPLICATION OF COGNITIVE BEHAVIORAL TECHNIQUES ( See also
Young & Beck, 1980).
Rationale: This domain explicitly deals with therapists technical proficiency. Technical
proficiency reflects the proper use and implementation of specific procedures listed below. Good
CBT clinicians apply an effective dose when they use the procedures skillfully according to
stipulated guidelines and rubrics. Kendall and colleagues maxim of flexibility within fidelity is
especially apt here. Indeed, therapists need to respond to moment-to-moment interactions with
patients (Beidas et al. 2010). Practicing flexibility within fidelity allows customizing treatment
to individual without suffering theoretical drift.
Background material
Cognitive Therapy of Depression (pp. 27-32, 67-72, 104-271, 296-298)
Cognitive Therapy of Emotional Disorders ((pp.221-225, 229-232, 250-254, 282-299)
Clinical practice of cognitive therapy with children and adolescents (Chapters 8, 9,
11,12,13, 14)
CBT for the busy psychiatrist (pp. Chapters 5-10)
Cognitive therapy techniques for children and adolescents (Chapters 3-7).
Scoring:
The CTRS-CA is rated on a 7 point scale ranging from 0-6. A score of 6 should be reserved for
EXPERT level. 4 is the expected score for COMPETENT CBT practice and most skillful CBT
therapists will most likely achieve this level.
0- Therapist behavior indicating skill in this domain is ABSENT or NEARLY ABSENT as
defined in the item anchors and manual. Many major and minor flaws in implementation
are evident.
6- Therapist behavior indicating skill at an EXPERT level. The behaviors defined in the
item anchors and the manual are completely present throughout the session and applied
with EXCEPTIONAL COMPETENCY. Nearly flawless work in session.
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