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Managing Negative Thoughts, Part 1: Cognitive Restructuring and Behavioral Experiments
Sarah Clark, Gemma Bowers, and Shirley Reynolds
Introduction
Negative thoughts are characteristic features of depression and anxiety and within the CBT model are seen to play a role in maintaining these conditions. This means that they are a key target for change. This chapter outlines ways of working with children and adolescents that help them manage and reduce their negative thoughts. The use of thought diaries, thought challenging, and behavioral experiments is described in relation to working with both children and teenagers across the anxiety disorders and depression.
Key Features of Competencies
Cognitive restructuring
The core principle of cognitive behavioral therapy (CBT) is that one’s emotions and behaviors are influenced by cognitions or the meaning that we attach to certain events. Helping individuals find alternative meanings or ways of thinking about events is central to changing the associated emotions and behaviors (see Chapter 8 for more detail on the theory behind CBT). However, young people often come to therapy expressing a desire to change how they feel rather than to change what they are thinking. The idea of changing their thoughts is usually not at all familiar. Therefore it is important to spend time explaining the basic CBT model and rationale. Time spent on this and on helping to develop, together with the young person, a basic formulation of his/her problems is vital and must occur before any work to challenge cognitions can begin. A description of the steps required for cognitive restructuring will be given below.
Identifying cognitions
Children and adolescents, like adults, can benefit from having some help with identifying their thoughts and finding a way to talk about them.
Talking about a recent situation in which the child or young person experienced a distressing emotion or an unwanted behavioral reaction can be a very helpful way of identifying his/her negative automatic thoughts. It can also help to socialize him/her to the CBT model and make him/her start to develop a basic formulation of the maintenance cycle (see below). In many instances, especially with younger children, including parents in this process can also be valuable, as parents may be able to offer suggestions as to what the young person was reporting at the time, while developing their own understanding of how thoughts, feelings, and behaviors are linked and how their own behaviors may be acting to maintain the young person’s difficulties.
Case example
Emily, a 14-year-old girl with social anxiety, attended weekly CBT appointments with her mother. She described feeling very uncomfortable at school, particularly in group activities or in lessons with people she described as acquaintances (rather than close friends or strangers). In order to develop a basic understanding of Emily’s experiences at school and to socialize her to the CBT model, a basic maintenance cycle was collaboratively constructed with her (see Figure 12.1). Emily’s mother also contributed to the development of the maintenance cycle by reminding her of things that she had told her about the situation being discussed.
Figure 12.1 Emily’s maintenance cycle.
As illustrated above, Emily, like many young people, identified a range of thoughts and feelings that she experienced. One of the challenges for us, as clinicians, is to identify which thoughts match with which emotions, and consequently with which behavioral responses. For example, if the young person is reporting feelings of anxiety, we would expect the associated cognitions to have themes of anticipation of harm, whereas feelings of sadness are more likely to be accompanied by thoughts of loss (actual or impending) or self-criticism. Trying to challenge a cognition that is not linked with the target emotion is likely to have little if any effect on reducing that emotion. Although Emily reported experiencing both worry and upset in the situation described in Figure 12.1, the content of her thoughts might best be categorized as related to potential social harm coming to her; her thoughts are therefore likely to be more strongly associated with anxiety than with sadness or feeling upset.
Young people often have their own words for certain emotions, and it is important not to assume that their interpretation of emotional words is the same as our own. Spending time talking through a list of common emotions can be very helpful, particularly when working with younger children. Asking where they feel certain emotions in their body, or asking them to draw on a picture of the human body and coloring in where they feel certain emotions can help the therapist and the child identify together the different emotions that the child is experiencing – quite apart from the fact that it offers a fun and engaging task early in therapy. Asking young people to rate the intensity of their different emotions can also be helpful: it may contribute to identifying the most salient emotion. Then the therapist may consider which thoughts link with this particular emotion. Images such as a feelings’ “thermometer” or building blocks that show higher and lower levels of emotion, can help children and young people understand that feelings and emotions can vary in intensity (hot versus cool, high versus low) and are useful ways of helping the young person start focusing on his/her own emotions and start monitoring how (s)he changes in different situations, with different people, and in the course of a day.
It is also important to remember that many young people will find it easier to describe images than to describe thoughts. Asking questions such as “What was going through your mind?” or “What did you see in your mind’s eye?” encourages young people to report images as well as verbally based thoughts. More specific questions, such as “Did you notice any pictures in your mind?” or “Can you draw what was going through your mind?” can be valuable. When Emily was asked if she had any images in her mind during the situation she described above, she evoked an image of everyone at school standing in a group, looking down on her. In her image, everyone else was much bigger than her, and they were all laughing at her. When she described this image, she became visibly upset, in a way that she had not when describing her thoughts. This image, therefore, seemed important to add to the maintenance cycle formulation.
Sometimes, even when therapists are creative and draw on many different methods to elicit thoughts from their clients, children and teenagers – and adults, too – struggle to identify what was going through their mind during a given situation. Here it is often helpful to encourage them to keep a record of their experiences outside of therapy sessions. This is because it is generally easier to access thoughts and images when you are as close to the situation as possible. In CBT, diaries and worksheets are often used between sessions, to record thoughts and images. These help the young person keep track of what was happening at the time – that is, of what the situation was – and of how they felt, how strong that feeling was, and what they noticed was going through their mind. There are numerous thought diaries designed for use with young people (see, e.g., Stallard 2002). However, particularly when working with adolescents, it is important to discuss with them how they would like to record their thoughts. For many, recording their thoughts on a mobile phone or on a dictaphone may be preferable to completing a paper version of a thought diary and may feel less like a school homework task. An example of a thought diary completed by Emily is shown in Table 12.1.
Table 12.1 Emily’s thought diary: Part 1.
| Situation | Feelings | Intensity of feeling | Thoughts | Distress caused by thought |
| Sitting in a French lesson | Worried Upset | 90% 80% | People are looking at me They are talking about me They will tell everybody else what they are saying about me Nobody will like me I won’t have any friends | 75% 80% 80% 85% 90% |
Apart from what goes on outside of therapy sessions, there are also important emotional shifts that occur during therapy. These give much more immediate access to the child’s ongoing thoughts and images, and therefore it is very important for therapists to be aware of changes of emotion and to be prepared to explore what the young person notices is going through his/her mind at such times. If the therapist is helping young people link thoughts and feelings within sessions, any thought-recording homework task is likely to be much more successful.
When the thoughts and images that are associated with the target emotion have been identified, it is important to spend time with the child or young person to acknowledge and recognize the emotional impact of these negative cognitions. This helps to validate the young person’s experience and makes him/her feel understood and “heard.” Moving on to challenging thoughts too quickly can feel dismissive to young people and may imply – or be understood as – a form of indirect criticism. Time should be given to discussing the thoughts they are experiencing in the context of their experiences and to accepting that, given their specific experiences, it is understandable that they might think the way they do.
For Emily, it was important to consider the events that precipitated the onset of these worried thoughts and feelings. She described finding the move up to high school difficult because she was separated from her close friends and remembered experiencing high levels of anxiety. At about the same time, Emily’s older brother, with whom she had previously had a close relationship, started going out more with his peers and spending less time with Emily. He also started teasing Emily about her taste in clothes and music and regularly referred to her as “weird.” Within the therapy session where this was discussed, the clinician and Emily spent time exploring how difficult this had been for Emily and how natural it was that she should tend to believe her older brother’s opinion of her. The clinician and Emily also acknowledged that, if Emily believed what her brother was saying about her, then it was understandable that she might think others were thinking similar things about her. This was even more understandable in the specific context, which was that she has started a new school and did not have the support of close friends.
Following this process of acceptance and validation, the next stage is to consider which one of the thoughts identified would be appropriate and effective to work on. A common mistake in CBT is for therapists to try to challenge thoughts that, for some reason, are difficult to shift. For example, it is not possible to challenge facts (e.g., “My mum is dead”) or questions (e.g., “Why me?”). However, questions can be turned into statements that may be challengeable; this can be done by asking questions such as: “What does it mean that this has happened to you?” Similarly, with careful questioning about the impact of events (such as a parent dying, or being bullied at school) and the meaning these events have for the young person, thoughts that are challengeable can be identified (e.g., unrealistic thoughts that have developed as a result of the event). It is also difficult to challenge central beliefs, such as “I am worthless,” early on in therapy, as these beliefs tend to be more global and rigid. Working on such beliefs too early in therapy can be overwhelming for the young person, and any shift is likely to be very small – if it occurs at all. Therefore selecting a thought that can be more easily challenged is likely to be helpful in the first instance and will instill a sense of hope in the young person that CBT might be a useful process for him/her.
While it is important to understand and validate the reasons why a young person might be experiencing certain thoughts, it is also important to help that person develop a sense of distance from these thoughts and an understanding that thoughts are transient and fluid rather than being facts. This process was referred to by Beck, Rush, Shaw and Emery (1979) as “decentering.” A useful technique here can be asking the young person if there was ever a time when (s)he didn’t experience these thoughts in similar situations. Or “Before you felt anxious, what would have gone through your mind in this situation?” “What would your best friend/your brother/your mum think in this situation?”
Through a process of decentering, it is likely that the young person’s belief in his/her thoughts will be diminished or shaken and his/her thinking about the target situations will become more flexible. Being able to stand back from negative automatic thoughts can be very powerful. Once a sense of distance from the thought has been created and the young person has developed an understanding that thoughts are just thoughts rather than being facts, that person is much more likely to engage with the process of thought challenging and with the development of alternative thoughts and perspectives. Given that thoughts have been previously considered to be powerful and to represent reality and “truth,” the ability simply to accept that thoughts are not reality is an important shift.
Young people usually find it relatively easy to identify the evidence that supports their thoughts and to draw upon it. This process sometimes leads to their feeling even more anxious or depressed, since they focus on the evidence for the thoughts that are related to the target emotions. It is therefore important to provide young people (and their parents) with psycho-education about the fact that this is a common reaction prior to commencing this task. As a therapist, it is essential to offer a great deal of empathy during this process and to build a sense of validation – a sense that, given these experiences and this evidence, it is understandable that the young person developed such thoughts.
Finding evidence against the disturbing thought can be much more challenging. Often young people cannot think of any evidence that goes against a thought or idea they have believed in so strongly. Elaborating on, and developing, the questions that were used at the decentering stage can be useful at this point: it may help the young person gain a wider perspective.
In addition to working directly with the young person, it can be helpful to invite the parents to make suggestions about evidence that does not support the target thought. A useful homework task might be for the young person to collect evidence during the week that does not support the thought, or to ask friends for their views and opinions.
Once the evidence for and against the thought has been collected, it is important to support the young person to develop a new, more balanced thought. Again, parents may be useful by suggesting alternative thoughts on the basis of the available evidence. Once an alternative thought has been constructed, the young person should be asked how much (s)he believes the new thought and how intense his/her target emotion gets when thinking this thought. The second section of Emily’s thought diary, which reviewed the evidence for and against the thought “I won’t have any friends,” is shown in Table 12.2.
Table 12.2 Emily’s thought diary: Part 2.
| Evidence that supports the thought | Evidence that does not support the thought | Alternative thoughts | Mood rating now |
| My own negative thoughts about what I look like | I have a group of good friends | Sometimes people could be thinking bad things about me or think something I’m doing is weird but I won’t be left without any friends | Worried (10%) |
| Upset (20%) | |||
| My brother’s comments that I look weird | I’ve always had friends even though I’ve done things that people might have thought were weird | (Belief = 75%) | |
| Hearing people at school make nasty comments about how my friend looks | My friend, whom I heard bad comments about, still has friends and people that like her |
Although cognitive restructuring can be a very powerful and useful process, young people often report that they understand logically that their old thoughts are not 100 percent true and that there is evidence that does not support them, but they explain that this exercise has not caused a significant shift in their emotions. It is therefore essential that this process is followed up by a process of testing out the new thought or of continuing to gather evidence to support it (this can be used in future cognitive restructuring tasks, if appropriate). Encouraging young people to think of ways in which they could test out the thoughts through behavioral experiments is likely to lead to a much larger emotional shift than a pen-and-paper exercise would.
Once the child (and the parent) is (are) familiar with a coherent formulation, the foundations are laid for designing a behavioral experiment. The formulation is vital for establishing the reasons to carry out the behavioral experiment, which are (i) to increase the motivation for testing out an alternative behavior; and (ii) to set up a context for the meaningful interpretation of the experiment’s outcomes, once it has been carried out. This process is most effectively (and efficiently) conducted by focusing on the maintenance cycle (as already described). By drawing out the maintenance cycle in a circular format, the child – and, where appropriate, the parent(s) – can reflect on the circularity of the safety behavior(s). The child can then be encouraged to use his/her own problem-solving abilities to break the cycle. This transfer, to the child, of the responsibility for change at such an early stage can help reduce apathy or lack of confidence, which can be common reactions at the beginning of therapy, when the child and the parent are desperate for a “quick fix” from the therapist. It also encourages confidence and self-belief – that is, young people’s belief that they themselves can improve things, and therefore can continue to do so after therapy has ended:
Therapist:
The child has three options: thoughts, feelings, or safety behaviors, to which the therapist can respond accordingly:
Child:
Therapist:
This response may be more common in younger children, who are more likely to believe they can have control over their thoughts. It is now the therapist’s role, while validating their suggestion, to introduce an alternative option. In doing so, the therapist is already modeling the CBT approach of open-mindedness and the consideration of other possible answers to a seemingly obvious question. At this point the Pink Elephant experiment can helpfully show that, when we try to stop thinking about something, our minds paradoxically think even more about the unwanted thought. The Pink Elephant experiment involves the therapist inviting the child (and the parent) to close his/her eyes and try to clear his/her mind. The therapist then asks him/her to spend the next minute (or less, depending on the child’s age and attention span) thinking of anything (s)he would like to, apart from pink elephants. In most cases, the child will laugh after the first few seconds, quickly realizing that the more (s)he tries to avoid a thought, the more fierce and intrusive it becomes. Indeed, children with a more vivid imagination may even make comments such as “the elephants are multiplying … and they’re all flying around in circles.”
These reflections can serve as a good introduction to behavioral experiments: the Pink Elephant experiment provides an experiential opportunity of putting a belief to the test – in this case, the belief that we can stop our thoughts – and of noting the similarities between pink elephants and unwanted thoughts. In the rare case where a child denies any “pink elephant” thoughts, it may be useful to ask the parent to reflect on their own experience, or to overtly drop in the words “pink elephant” into the middle of sentences throughout the remainder of the session, to highlight the difficulty and annoyance of trying to “get rid” of the thoughts. Additionally, the findings recorded in a useful piece of research carried out by Crye, Laskey, and Cartwright-Hatton (2010) can be shared with older children and teenagers. Crye and colleagues found that, among young people aged 12 to 14, 77 percent reported that they had intrusive and unwanted thoughts, thus highlighting how “normal” it is to have unwanted thoughts.
Realizing now that thoughts may not be the easiest place to start breaking the maintenance cycle, the child may suggest:
Child:
Therapist:
At this point, it is again helpful to ask the child to think of a recent example of their anxiety or depression showing up, and to reflect on how hard it would have been to stop the feeling. Directing the child to a recent example can help to elucidate the point that, just as with our thoughts, it is very hard to stop or change our feelings on demand:
Therapist:
If the child struggles to come up with an example, a useful analogy to use here is that of our feelings on a rollercoaster. That is, while you may be able to suppress the overt expression of a feeling, the feeling itself cannot be prevented, as it is a near-automatic response to the environmental trigger.
By this stage the child will gradually be realizing that there is only one other place where the cycle can be broken:
Child:
Therapist:
At this point it can be shared with the child that this is indeed the weakest part of the cycle, and an arrow can be drawn on the maintenance cycle to show how “doing something different” can help to determine whether the thoughts and beliefs are indeed as accurate as currently believed (Figure 12.2). The aim is to begin to invite curiosity in the child about the trustworthiness of his/her thoughts. This sets up the reason for devising the first behavioral experiment.
Figure 12.2 Emily’s formulation, showing a possible exit route.
Depending on the duration and severity of his/her anxious or depressive thoughts and feelings, the child may find it difficult to think of a time when (s)he did not use his/her safety behaviors. (S)he may not remember a time when (s)he did not have a problem with anxiety or low mood; (s)he may not be able to imagine dealing with things differently. However, there may be exceptions – times when safety behaviors have not been used; and the therapist can help find information about these “exceptions” by discussing situations where environmental factors have prevented the child from using his/her safety behaviors – for instance being on holiday or at school, being distracted, being with certain people, and so on.
Typically the child or young person will feel daunted and alarmed at the prospect of removing his/her safety behaviors. Safety behaviors do provide short-term relief from distressing symptoms and have become habitual and comforting. Therefore the idea that they would not be available to use is frightening and may be resisted by both children and parents. It is important to remind the child and the parent(s) that the therapy will continue to be guided by them, will be going at their pace, and that, while it is necessary to challenge their thoughts, this will not be done by “jumping in at the deep end.” An honest explanation of what a behavioral experiment is must be shared, both in order to socialize the child and the parent(s) to this part of the model and to enable informed consent (which, again, will increase the child’s feelings of mastery over the therapeutic interventions thereafter).
It can be helpful to draw out a basic graph to show how safety behaviors are successful and effective at reducing distress in the short term, but that behavioral experiments are much more effective at reducing distress from unwanted thoughts in the long term (Figure 12.3). The graph shows how, at the peak of anxiety (A), the use of a safety behavior will often reduce the anxiety quickly to a near-normal level (B), but, because it does not “fix” (get rid of) the anxious thought, the levels of anxiety will soon reach their peak again whenever the thought reappears. Alternatively, the dashed line shows how refraining from using the safety behavior (i.e. “doing something different” via a behavioral experiment) will result in a more gradual decrease in anxiety (C), but one that is much more likely to last; each time the thought reappears, the initial level of anxiety decreases (D).
Figure 12.3 The effect of safety behaviors and behavioral experiments on anxiety.
Once the child is in agreement to start using behavioral experiments, it is useful to set a long-term agenda to plan his/her experiments in a way that feels challenging, yet not out of his/her “comfort zone.” Loosely speaking, this may be referred to as graded exposure: beginning with the least challenging tasks and working up to the most challenging (see Chapter 14 for more details on exposure). It is useful to place this long-term plan in a context of specific short-, medium-, and long-term goals – again, in order to help the child create motivation for change and provide tangible reasons for carrying out the behavioral experiments.
A useful task to set as an initial piece of homework is for the child to pin up their maintenance cycle somewhere at home. The aim is for him/her to start trying to “observe” his/her thoughts, feelings, and behaviors just as they happen, using this cycle as a reference point. This helps the child to gain a “bird’s eye view” of his/her maintenance cycle when it is in action. Consequently the child will become able to notice when they are ‘at risk’ of using a safety behavior, slow down this ‘usual’ response to their anxious/ depressive thoughts and feelings, and disengage from the process of using safety behaviors (which are likely to have become more and more automatic over time). This means that, even before (s)he begins to carry out behavioral experiments, the child is able to increase the period between the onset of an anxious or negative thought and the start of the safety behavior. This gives him/her more time to make a choice to “do something different.”
If the therapist refers to the formulation together with the child and revisits the child’s goals in therapy, this will enable an informed decision about the most effective type of experiment to carry out. For example, a child with depression who has a number of negative beliefs about him-/herself may find it useful to gather information (e.g., from school reports) before moving on to more challenging, proactive experiments.
Depending on the child’s level of willingness and enthusiasm to carry out a behavioral experiment, the therapist may wish to model the process by devising, with the child, an experiment designed to test out one of the therapist’s own thoughts. The child may well enjoy designing an experiment that really challenges the therapist, giving the therapist permission to return the challenge in good humour at a later date. This can be a good way of introducing different types of experiments, which, in themselves, will require varying levels of bravery.
Careful and thorough planning is key to an effective behavioral experiment. That is, the details of the experiment must be discussed in depth and recorded in order that the experiment can be carried out accurately and effectively. The analogy with a “curious scientist” can be used here to explain to older children and teenagers the aim of “testing out” a theory: the therapist explains that, when a scientist does not know the answer to a question, his/her task is to devise ways of gathering information that would help him/her work it out. This analogy can make the child improve the quality of his/her experiment; it may also make the task feel less threatening and unfamiliar. Most children of middle school age and older have had the experience of carrying out experiments at school. This can then be used to facilitate the planning of future experiments and more ad hoc thought challenging in the future: “What would the curious scientist in you say?”
It is useful to carry out the first behavioral experiment with the child in a session, to make sure that the experience is positive and that the child understands the procedure and its rationale. Later on in therapy, behavioral experiments can be used as homework tasks. Some children may be more willing to complete homework than others. It is therefore useful to discuss with the child the best way to incorporate the homework into their day, and how on school days this process might be different from incorporating it at weekends. To encourage maximum feedback, the worksheet below (Figure 12.4) can help the child to briefly summarize predictions about the experiment, increase the likelihood of his/her carrying out the experiment (by minimizing potential barriers), and provide a space for the child to note his/her findings along the way. It also encourages him/her to carry out the experiment more than once between therapy sessions, on the premise that “practice makes perfect.” All this provides useful information about the effect, on the child’s troubling thoughts and feelings, of not using the safety behavior. This effect can be plotted on a graph over the course of therapy (if this is appropriate for the child’s age and ability); and any patterns can be noted along the way (e.g., behavioral experiments may be easier to carry out at certain times of day or in certain places).
Figure 12.4 Behavioral Experiment Worksheet. Adapted from Greenberger and Padesky (1995).
Involving parents can both assist the process and hinder it. Again, the formulation is key in determining the extent of parental involvement in the experiments. Parents may opt for having minimal input by acting in a “support from the sidelines” role; by offering encouragement while not getting involved in the actual experiment; or by offering their own alternative responses to similar situations. A more involved input may take the form of a “dual experiment,” where the parent simultaneously carries out his/her own behavioral experiment in order to test out his/her own beliefs in relation to the child’s behavior. The former kind of input may be more useful in situations where developing confidence and independence is important (e.g., with children experiencing low self-esteem or separation anxiety), whereas the latter may be particularly useful in situations where the parents themselves may be involved in maintaining the behaviors (e.g., by offering reassurance in obsessive compulsive disorder). It may also be useful, particularly with younger children, to devise a reward system upon completion of the experiment: a system that rewards new, non-avoidant behaviors, and therefore increases the motivation for further behavior change.
To maximize the impact of experiential learning, it is vital to “make sense” of the behavioral experiment after it is completed. Ideally this should be done immediately after, when the most accurate reflections can be recovered. A simple prompt sheet can be given as part of the behavioral experiment homework (Box 12.2), or the notes made on the behavioral experiment worksheet can act as prompts at the next session. The child can then be encouraged to compare previous safety behaviors and thoughts to updated behaviors and thoughts, again referring back to the maintenance cycle and to the goals originally set by the child. This then invites the child to move on to the next behavioral experiment.
Competence in Treating Anxiety Disorders and Depression
Most evidence-based treatments for children and adolescents have focused on anxiety disorders; the treatment of depression in children and adolescents is relatively under-researched. Depression is rarely seen before adolescence, and around three quarters of those diagnosed with it are girls. Young people who are depressed often have comorbid mental health problems such as anxiety disorders, eating disorders, self-harm, and conduct problems (National Institute for Health and Care Excellence 2005). Therefore the presentation of depression in young people can be extremely varied and complex. Young people with depression show low mood, low levels of energy and motivation, pessimism, and disengagement from social and educational activities. All CBT is based on the development of the therapeutic alliance (see Chapter 6), and this is the first priority in CBT for depression.
Cognitive restructuring with young people who have anxiety disorders typically focuses on perceptions of threat or harm coming to the self or to loved ones. Threats can be social (“they will ignore me, everyone will think I’m weird”) as well as physical (“I’ll be so frightened I’ll stop breathing”). Behavioral experiments to test these thoughts can include trying out new behaviors and seeing how other people react (e.g., do they ignore me?), carrying out informal surveys to ask people their opinions about the perceived threat, researching the medical literature to find out if it is possible to stop breathing through fear, or checking out beliefs with “experts.”
In depressive disorders, negative automatic thoughts are often associated with failure (“I’ll never pass my exams, I’m stupid/useless”) or loss (“no one will like me; I’ll be alone”). The key characteristics of depression coalesce around the cognitive triad: negative thoughts about the self, the world, and the future (Beck et al. 1979). Young people who are depressed are more likely to attribute any success or positive outcomes to luck or to other people, or to assume that such results are “random.” For example, a compliment about a young person’s behavior or performance (“You did that really well”) may be minimized by attributing it to kindness in the other person (“They’re just saying it to be nice”), or to a fluke or luck, rather than to a real skill or ability in the young person. In contrast, such a person is likely to attribute negative life events, for instance failures, to his/her own faults (“That just shows how rubbish I really am”). Cognitive restructuring should therefore examine alternative causal pathways for both positive and negative events, which balance internal global and stable attributions for negative events with external, specific, and unstable attributions for positive events.
Competence in Treating both Children and Adolescents
Cognitive behavior therapy relies upon the ability of the client and his/her therapist to be able to stand back from ongoing experiences and to notice and attend to the thoughts and the feelings that are being experienced. In other words, it is necessary to be able to think about your thinking. This ability of metacognition develops during childhood and adolescence and into adulthood (Cartwright-Hatton et al. 2004). It is influenced by our environment as well as by the increasing complexity and sophistication of our cognitive structures, and therefore therapists need to be able to work in a flexible way to meet the skills and developmental stage of their young clients.
CBT with children often relies more heavily on the behavioral than on the cognitive components. However, there is evidence that young children are able to identify thoughts and feelings and to discriminate among thoughts, feelings, and behaviors if they are given appropriate and child-friendly tasks. Ways of making the task more accessible to children include using puppets or toys, using drawings, cartoons, and especially thought bubbles. This ability has been observed in children of 6 and 7 years, who have high levels of behavioral or emotional problems and, therefore, are at risk of mental health difficulties (Reynolds, Girling, Coker, and Eastwood 2006). This suggests that many young children do have the fundamental metacognitive abilities to engage in CBT work. However, despite this basic understanding, children tend to find it easier to identify what they did in response to a certain situation, and even how they felt at the time; it is often more difficult for them to identify what they were thinking at that time. Therapists therefore need to be able to relate things to concrete incidents and to use simple and direct language when working with children and adolescents.
Children are also influenced by their social networks: their family, school, and peer group. Younger children tend to be more influenced by their parents, whereas older children and adolescents become more concerned about their peers and the external world. The involvement of parents in CBT can be helpful and will be discussed later (see Chapter 19). However, for adolescents, the involvement of parents may require careful negotiation. Adolescents often wish (and need) to develop autonomy from their parents and may be in conflict with them. Parents, on the other hand, may resent being excluded from therapy, may inadvertently contribute to the maintenance of difficulties, and frequently have their own mental health needs, which impact on the child. Where possible, the role of the family in maintaining difficulties should be explicitly considered in the formulation, and this information should highlight if, how, and when parents and other family members are involved in treatment sessions. Where the parents are not directly involved in treatment, it is often helpful to arrange occasional “catch-up” sessions in which the young person and the therapist jointly provide feedback to the parents.
Common Obstacles to Competent Practice and Methods to Overcome Them
There are likely to be a number of setbacks in therapy, which must be problem-solved if improvement is to be made. Just as we would guide the child back to his/her formulation if they faced a difficulty, a return to the formulation is likely to be helpful for the therapist in resolving barriers to progress in therapy.
Perhaps the most common difficulty is a lack of motivation – manifest for instance in not completing homework tasks, refusing to complete behavioral experiments, or missing appointments. This is an alternative example of avoidance, which can quickly be elucidated as a form of safety behavior in the maintenance cycle. The child must acknowledge that it is his/her choice to decide whether the anxiety or depression (s)he is experiencing is disabling enough to warrant change. This decision can be made by establishing the pros and cons of change by comparison to the pros and cons of continuing with current coping mechanisms. Additionally, modeling proactive behavior in sessions, either via role-play where the therapist and child swap positions or via an in vivo behavioral experiment, can serve to increase motivation by showing that change is often not as difficult as it was predicted to be.
Another difficulty that may arise is a difference of opinion between parent and child as to how much the parent should be involved in these therapeutic tasks. Again, a revision of the formulation will help to determine just how effective parental involvement will be. Ultimately the therapist must help the child and his/her parent to come to a compromise that enables the child to feel in control of the therapeutic interventions while the parent does not feel abandoned or replaced by the therapist. Some children may wish for parents to come to the first session, in order that they understand the rationale and procedure of the therapy, while others may like their parents to come to the first or last five minutes of the sessions, to remain “in the loop.” Maintaining parental involvement to some extent may also help the family to adapt to the changes that may come about during the course of therapy. In successful cases, for example, children may quickly find that they have more time on their hands, and parents may feel less “needed” by their children; and there is also the potentially accelerated transition to autonomy and independence that may accompany a reduction in anxious or depressed symptoms.
One of the harder problems in therapy may arise when a behavioral experiment does not go to plan. This is usually the result of poor planning or of the child’s not carrying out the experiment as planned. Using the prompt sheet (Box 12.2), the difficulties can be discussed and understood. Thereafter the behavioral experiment can be replanned and carried out, perhaps in vivo or with additional help from a parent, if necessary.
Conclusion
Negative and anxious thoughts are normal in children, as well as in adults. It is the interpretation of such thoughts that can lead to psychological distress. Problematic interpretations can be challenged by using techniques designed to broaden the perspective and to invite in new information. This can be done via conversation, via paper-and-pen cognitive restructuring exercises, or, more proactively, via behavioral experiments. The role of the family in such interventions can be useful, although the extent of involvement of family members must be agreed by all involved and in line with the information gained from the formulation – and particularly from the maintenance cycle. Children can then be guided in building a repertoire of skills that help them cope with negative and/or anxious thoughts as these crop up, thereby enabling a long-term strategy for managing difficult thoughts and feelings throughout their life.
References
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