Chapter 10
Aligned 2016 CACREP StandardsStandard 2.F.5.a. Theories and models of counseling
Standard 2.F.5.f. Counselor characteristics and behaviors that influence the counseling process
Standard 2.F.5.j. Evidence-based counseling strategies and techniques for prevention and intervention
Standard 2.F.8.b. Identification of evidence-based counseling practices
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In Chapter 8, on adolescent neurophysiological and social development, we learned that subcortical development outpaces cortical development during adolescence. Adolescents therefore experience intense emotions without the circuitry yet to fully process and regulate them (Casey, Jones, & Hare, 2008; Tyborowska, Volman, Smeekens, Toni, & Roelofs, 2016). We also learned that the nucleus accumbens within the striatum develops faster than the prefrontal cortex. The nucleus accumbens is a key structure in the dopaminergic system, and dopamine production increases significantly during adolescence (Galván et al., 2006). This helps us understand why adolescents have stronger motivational drives toward reward seeking and risk taking (Baker, Bisby, & Richardson, 2016). Issues such as identifying emotions, managing intense emotions, and anticipating the long-term consequences of short-term rewards are perhaps best addressed through cognitive behavior therapy (CBT).
There are now a proliferation of CBT theories, interventions, and protocols. Perhaps the most popular at the time of this writing are third-wave CBTs that incorporate aspects of mindfulness practice, such as acceptance and commitment therapy, dialectical behavior therapy, and mindfulness-based cognitive therapy, among others. These approaches assist adolescents with experiencing and accepting their emotional experiences without rejecting them or attempting to avoid them. Some pioneers of these approaches reject the notion that these therapies are forms of CBT (e.g., acceptance and commitment therapy; Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013), though there are common themes in how the approaches are applied.
A neuroscience-informed CBT (nCBT) model also exists. The nCBT model differentiates interventions based on a person’s response to threats in the environment (Field, Beeson, & Jones, 2015). Initial interventions target a process known as Wave1, whereby rapid activation of the hypothalamic-pituitary-adrenal and sympathetic-adrenalmedullary axes results in the secretion of cortisol and adrenaline that prime a person for action outside of conscious awareness. Once a person becomes aware of their activation during a process called Wave2, subsequent interventions seek to help the person make sense of their experiences (Field et al., 2015).
The nCBT model was developed after multiple failed attempts to help children change their cognitions in response to threats in their environment. Children typically became activated before they could change their thinking patterns, at which point their ability to think rationally was impaired. In nCBT, the adolescent first implements techniques such as mindfulness along with therapeutic lifestyle change, biofeedback, and neurofeedback (which we explore in Chapter 11). These techniques both help the adolescent prevent unnecessary sympathetic activation and assist them in coping with sympathetic activation automatically when activation does occur.
In this chapter, we propose a three-phase model for implementing cognitive behavior interventions that is grounded in third-wave mindfulness-based CBTs and nCBT (Beeson, Field, Jones, & Miller, 2017; Field et al., 2015). We apply the CBT model to the case of Brooke, which was introduced in Chapter 9.
CBTs are fairly directive approaches. At the beginning of the counseling process, the client collaboratively forms goals with the counselor to address the current problem. From there, the counselor teaches new skills to the client, such as coping strategies and cognitive restructuring of negative cognitions. The counselor and client then identify action plans (i.e., homework) to be completed in between sessions with the goal of reviewing and reinforcing progress. Making progress toward goals helps to foster self-efficacy, or the client’s belief in their ability to make progress and complete tasks.
Identifying goals can be complicated when working with adolescents. In many cases, children and adolescents are brought into counseling by third parties, such as school counselors and parents or guardians. They therefore often present as mandated clients rather than self-referred clients. When working with adolescents who do not particularly want to attend counseling (to put it mildly), it can help to identify and align with goals that the adolescents already possess. In inpatient and residential settings, it is common for adolescents to have the primary goal of being discharged from the facility and ending mental health treatment as quickly as possible! In such cases, the counselor could build rapport through a statement such as “It’s clear that you don’t want to be here and want to leave as soon as possible. I’m wondering if you would like my help with that. I could help you identify the kinds of behaviors that would demonstrate you are ready to be discharged and help you work toward those. I also think it might be helpful if we figured out what you’d need to do to avoid coming back here again.” In short, working with rather than against client resistance is a very useful technique for establishing counseling goals.
Psychoeducation is a core component of CBT and involves providing information to clients with the goal of helping them develop a better understanding of their current issues. Sharing neuroscience information with clients is called neuroeducation (Miller, 2016). The technical nature of neuroscience terminology requires a slightly different approach to delivery than is typical for psychoeducation. In Chapter 12, we provide a three-step procedure for delivering neuroeducation to child and adolescent clients.
The nCBT model contains one example of how to integrate neuroeducation into CBT. During the first few sessions of nCBT, the counselor provides information to the client about brain processing models called Wave1 and Wave2 (Field et al., 2015). These two processes describe how people typically experience threat response. In Wave1 processing, the person is unaware of their neurophysiological response to threats in the environment. Any preconscious identification of threat through sensory input (e.g., sounds, smells) or implicit (i.e., preconscious) memories results in messages being sent quickly from information processing structures within the brain (i.e., the thalamus) to glands within the endocrine system to release hormones that prepare a person for action to respond to the threat. This can result in neurophysiological consequences of adrenaline and cortisol secretion, such as increased heart rate. During Wave2 processing, the person eventually becomes aware of their neurophysiological activation and decides how to respond next. Wave2 thoughts and actions generate subsequent neurophysiological responses (e.g., accepting one’s current experience and engaging in deep breathing and activating para-sympathetic activation to reduce stress response, or becoming angry at oneself for being activated and sustaining one’s current degree of activation). Neuroeducation can help clients understand why they are struggling to control their neurophysiological responding (automatic threat responses) and methods for reducing neurophysiological activation when it occurs (e.g., acceptance of experience, deep breathing).
Many adolescents enter counseling in distress. They are experiencing significant symptoms that they are looking to better manage or resolve. Symptoms such as anxiety, depression, flashbacks, panic attacks, and sleep disturbance are aversive experiences that people wish to quell. Often goal setting initially focuses on reducing or managing these symptoms. The interventions below can help adolescents cope with their current symptoms.
During counseling, people may be unaware of the context for their distressing symptoms. They may not know how often their symptoms occur, how long they last, what precipitates their occurrence, and so on. An initial task in coping with these symptoms is thus helping clients begin monitoring their behavior more closely. Tracking these experiences is useful to conducting a behavioral chain analysis, which connects antecedents and consequences to the behaviors and symptoms a person is experiencing.
Tracking behavior can itself be a mechanism of change. When we pay more attention to our habits (e.g., diet, spending), we tend to change them by default. The same principle works for mental health symptoms. Adolescents who begin to track behaviors such as self-injury, substance use, and suicidal ideation tend to experience reductions in these behaviors as a result.
Self-monitoring interventions are common across CBTs. When using self-monitoring interventions, we recommend asking adolescents to bring in their diaries to discuss during sessions so they can review their progress. Reviewing a diary often yields more specific information than asking an adolescent at the start of a session to review their week. Over time, the adolescent learns to recognize patterns (e.g., rejection fears prompt self-injury, screen time at night impairs sleep duration) and can adjust accordingly by using different coping skills.
Alongside self-monitoring, identifying strategies for coping with mental health symptoms is very useful to symptom management. Many adolescents struggle with problematic forms of coping and can benefit from review and training in different coping methods. When providing coping skills training, a few principles are useful.
Most coping skills training needs to initially identify and address coping attempts by the adolescent that are problematic or maladaptive, such as self-injury, substance use, withdrawal from others, and so on. As we learned from Chapter 6, on behavior modification, it is critical to identify the function of a behavior before introducing a replacement behavior. There are a variety of reasons why an adolescent might engage in a specific behavior. For example, an adolescent might consume alcohol because they like the experience of getting intoxicated (i.e., hedonic sensation seeking) or may become intoxicated to reduce anxiety and stress. Replacement behaviors for problematic drinking behavior will thus differ by the function of the behavior. The dialectical behavior therapy skills training module on distress tolerance features a review of the function of coping behaviors (e.g., distraction, self-soothing, improving the moment).
We recommend that counselors ask about adolescents’ current coping strategies before teaching new ones. We have found that it is a lot easier for adolescents to increase the use of coping skills they already possess than to learn new skills. Reinforcing existing skills also helps adolescents build self-efficacy (i.e., belief in their ability to master problems).
When introducing new coping strategies, it can be helpful to have a list of potential strategies for the adolescent to choose from (see Reflection Question 10.1). Counselors can develop handouts to review with the client. The nCBT model (Beeson et al., 2017) contains several considerations for coping skills. Skills should be portable, accessible, socially acceptable, available for repetitive practice, and salient or attractive to the adolescent. For example, listening to music is fairly portable, accessible, available for repetitive practice, and in most cases socially acceptable (except when one is talking to someone else or in class). In contrast, soaking in a bath is not as easily accessed or available for repetitive practice. Repetitive practice is important so that the adolescent learns to use the skill in stressful situations automatically.
Alongside coping skills training, mindfulness practice can be a very useful strategy for managing and coping with distressing symptoms. Meta-analyses have substantiated the effectiveness of mindfulness for addressing anxiety and depression (Hofmann, Sawyer, Witt, & Oh, 2010; Khoury et al., 2013). Mindfulness is a practice derived from Eastern traditions such as Buddhism that fosters awareness of the present moment and acceptance of one’s thoughts, feelings, and physiological sensations (Hofmann et al., 2010; Tang, Hölzel, & Posner, 2015). Mindfulness appears to be as effective as CBT and, as mentioned earlier, is often integrated into more recent models of CBT (Khoury et al., 2013). For example, mindfulness is a core component of acceptance and commitment therapy, dialectical behavior therapy, and mindfulness-based cognitive therapy. Mindfulness practice can assist adolescents in identifying their thoughts and feelings, acknowledging and accepting them without judgment, and allowing these experiences to eventually pass rather than ruminating on them.
Daily mindfulness practice has strong neurophysiological impacts. A meta-analysis on mindfulness practice found changes to the activity and structure of the anterior cingulate cortex, which is associated with attentional control (Tang et al., 2015). Mindfulness also strengthens prefrontal cortex control over limbic structures such as the amygdala and thus enhances capacity for emotional regulation (Tang et al., 2015). Mindfulness also appears to increase gray matter density in the hippocampus and structures associated with the default mode network and self-referential awareness (Hölzel et al., 2011; Tang et al., 2015).
We now apply the practices of self-monitoring, coping skills training, and mindfulness to the case of Brooke (see Case Vignette 10.1). Thom uses first-person narrative to describe the counseling process.
Once the adolescent’s symptoms have stabilized, the counselor can work through deeper underlying causes of the symptoms through cognitive restructuring. During cognitive restructuring, the counselor works with the adolescent to identify and transform cognitive distortions and irrational beliefs so that they become more adaptive, realistic, and rational. In CBT, a person’s core self-beliefs are called schemata. Schematic thoughts such as “I am unlovable” are believed to precipitate and perpetuate automatic thoughts, emotions, and behaviors that are associated with depression (Beck, Rush, Shaw, & Emery, 1987).
When exploring an adolescent’s thought patterns, it is important to inquire about their life context. Thoughts such as “Everyone is out to get me” and “The world is a cruel place where people act primarily for self-preservation” might be typical and expected of an adolescent who has been raised in a dangerous community where violent acts occur regularly and criminal acts (e.g., stealing, theft, drug dealing) are common survival behaviors. In such an environment, the adolescent may need to be wary of the motives of others. Seeking merely to restructure these cognitions would miss the point. Instead, what the adolescent would need most is an example of a caring relationship that demonstrates interest, respect, and validation in which the adolescent can develop trust and vulnerability without fearing reprisal. The counseling relationship is thus at times an important restructuring technique in and of itself.
Some thinking patterns are distorted and require the counselor to use more active restructuring methods. In third-wave CBTs, the counselor emphasizes the client’s mindful awareness of these thought patterns when they occur and moves toward nonjudgmental acceptance of those patterns while also balancing them with counterthoughts.
We now return to the example of Brooke (see Case Vignette 10.2) to demonstrate the application of this technique. Thom uses first-person narrative to describe the counseling process.
As this case illustrates, the counseling relationship is central to all counseling approaches, including CBT. Disclosure of deeply personal thoughts and feelings such as self-disgust and shame following sexual assault can only occur when the adolescent has developed a deep trust in the counselor and in the therapeutic process. It is therefore important that the counselor attend to the relationship first and foremost when applying CBT techniques. Brooke needed to feel heard, understood, and validated initially. When Thom provided cognitive restructuring, he reinforced the fact that Brooke’s experiences of self-disgust and shame made sense and should be acknowledged and accepted as part of her experience rather than rejected. By validating these experiences, Thom avoided sending the message to Brooke that she just needed to “think positive,” which is often perceived by clients as disingenuous. Through this validation of her experience, Brooke came to understand and accept her self-experiences, which then modified her schematic beliefs. Consider Reflection Question 10.2.
Even though adolescence is known for increases in peer-focused socialization, parent-child interaction remains important during adolescence (Guyer, Silk, & Nelson, 2016). Parental warmth appears to have beneficial effects for the development of the striatum and limbic system during adolescence (Morgan, Shaw, & Forbes, 2014; Whittle et al., 2014). Parental warmth also protects against an adolescent’s rumination and internalized self-criticism during periods when the parent is upset about another matter in the environment that is unrelated to the adolescent (Lee, Siegle, Dahl, Hooley, & Silk, 2014). Adolescents remain sensitive to the opinions of their parents and guardians, and caregiver appraisal and criticism of their behavior is still emotionally salient (i.e., important) to them. Furthermore, parental warmth is also associated with an adolescent’s ability to respond adaptively to peer criticism. Warm parenting, described as supportive and noncritical, has been associated with attenuation in striatum activity in response to peer rejection, whereas critical parenting attenuates activity of the striatum in response to peer acceptance (Guyer et al., 2015; Tan et al., 2014). This means that warm and supportive parenting assists an adolescent in better regulating their emotions through appreciating peer acceptance and adapting to peer rejection. Parenting thus has a crucial role in supporting an adolescent’s emotional regulation relative to peer relationships, which themselves are so crucial during adolescence.
Reducing unnecessary parental criticism is an important cognitive behavior intervention during adolescence. In a study by Lee and colleagues (2014), adolescent brain activation during maternal criticism of neutral events such as the weather was associated with increased subcortical limbic activity, such as activation of the insula, and reduced activation of the dorsolateral prefrontal cortex and anterior cingulate cortex. This suggests that adolescents struggle with regulating their emotions when exposed to parental criticism.
Several CBTs that have been developed for adolescents contain parent modules. We propose 10 principles for integrating parent and guardian involvement into CBT for adolescents based on our practice experience: (a) Remain neutral and unbiased, (b) Respect the uniqueness of each family system, (c) Respect the dignity of each family member, (d) Identify and work within existing power structures, (e) Acknowledge multiple perspectives and perceptions of the same event, (f) Closely observe interactions between family members, (g) Facilitate improved interactions between family members, (h) Explain homeostasis, (i) Ensure that all relevant family members attend sessions, and (j) Avoid surrogate parenting.
Family counseling can often bring with it power struggles as various family members jostle for position. It is quite common for members of a family to seek to recruit the counselor to their perspective and position. The counselor must therefore be wary of such efforts and attempt to be as neutral as possible. Taking sides with a parent or guardian will marginalize a child or adolescent and vice versa. Taking sides also removes an opportunity for the family to work through their problems without an outsider deciding for them. Remaining neutral is especially important when a family member is not present in session. Counselors should work hard to avoid aligning against family members whom they have not yet met.
Many children and adolescents are brought into counseling as the identified patient (Gehart, 2017). In systems theory, this term is used to denote that the child or adolescent is shouldering the blame for dysfunction that is occurring in the family system (i.e., the child or adolescent is not solely responsible for their family’s dysfunction). During the first few sessions, the counselor must therefore work to establish neutrality by requiring the parents to participate in the initial sessions (see Chapter 1 for more information). This sends an important message to the child or adolescent that the counselor does not necessarily believe that they are the problem within the family system.
Every family is unique and has its own set of rules and norms (Gehart, 2017). Families are complex systems, and it is important to bracket assumptions and withhold clinical judgment until you have gotten to know the rules and norms of the family. Work hard to avoid imposing your own values and beliefs on what you believe is functional and optimal. This is an especially important principle for working with parents. Differences in parenting choices are not necessarily dysfunctional or problematic. For example, imagine a spectrum of parental discipline from harshly punitive on one end to permissively placating on another. The extremes of this spectrum are unhealthy. The disciplinary approach of most parents will reside somewhere toward the middle. If a parent is more strict or lenient than you might be, this does not necessarily mean the parent is not responding appropriately.
Counselors should be thoughtful when sharing information in front of all family members. When the counselor is providing parent education, children should typically be excused from the conversation. Parents may become embarrassed or defensive when being educated about parenting in front of their child, and the child may also feel bad for the parent being given feedback.
Although counselors should attempt to be neutral, they should also follow Salvador Minuchin’s advice to work with the existing power structures of the family to make changes (Gehart, 2017). For example, the family will likely not adhere to assignments such as out-of-session tasks (i.e., homework) if the parents or guardians do not approve of them. In addition, parents or guardians may have goals and expectations for counseling that need to be addressed at the beginning of the process.
Family members will perceive the same family event differently. This is normal and can be expected. The family should eventually learn to respect the multiple perspectives within the family, which can best be taught through the counselor’s own ability to manage and respect multiple perspectives during sessions.
To understand the functioning of a family, we strongly recommend closely observing interactions during sessions. Counselors can internally ask themselves questions such as “What are the seating arrangements, and is there a significance to them?” “Who controls the dialogue?” “How does each family member respond to the other members of the family in regard to body language and verbal communication?” Facilitating an enactment (Gehart, 2017), such as replaying a recent conflict in session, can be helpful for observing the dynamics of family interaction.
A primary goal of family intervention during CBT is to help each family member develop active listening skills so that each member of the family feels heard and understood. As we have mentioned in prior chapters, parents must make the transition during adolescence to becoming active listeners rather than problem solvers, and so developing these skills is particularly important for ongoing relationship building between adolescents and their caregivers. CBT’s focus on skills training is tremendously useful for helping parents or guardians and adolescents develop active listening skills. We recommend a specific procedure to facilitate caregiver-child active listening training.
CBT is predicated on the importance of making necessary changes that enhance a person’s functioning and quality of life (Beck et al., 1987). Making changes within a family system is often a challenge. Family systems tend to resist change and seek to maintain current homeostasis (i.e., adherence to established rules and roles). Homeostasis can hamper an adolescent’s attempt to change their thoughts and actions. We have observed that families often become more open to change once they become aware of this tendency. Small changes in family interactions can often result in much larger changes, so working through resistance is important to building momentum for larger change.
In our experience, it is common for family members to insist that they cannot attend family sessions. Often these family members are a key part of the adolescent’s problems, and their lack of attendance will stymy the work. When this occurs, the dialogue can quickly devolve to complaining about the family member who is not in the room. Even discussing how best to address issues with the family member is largely unproductive. It is therefore crucial that counselors emphasize that family counseling will only be successful if all relevant family members attend sessions.
Counselors can possess many biases about the parents they are working with and may at times feel the allure of aligning with the child or adolescent against the caregiver. There are two main dangers to aligning with youth against their caregivers. First, the schism between the adolescent and caregiver will widen, and the rupture will worsen. Second, the counselor will likely become increasingly pulled into a caregiving role, such as managing the child or adolescent’s feelings toward the caregiver rather than helping them express their feelings directly to the caregiver.
In situations when the child is clearly upset about their relationship with the parent, the best course of action is to try to repair the relationship between the caregiver and child (as best as possible). The active listening procedure described previously is an excellent technique for gradually repairing caregiver-child ruptures. It is also important to recognize when parental behaviors are creating problems and are in need of intervention and to provide parent education without the child or adolescent present.
Counselors should withhold judgment when caregivers make mistakes and assist caregivers in using these mistakes as learning experiences. Parenting does not have to be perfect. A parent or guardian’s response after a mistake is more important than the mistake itself. If a parent becomes reactive and regrets their actions, apologizing to the adolescent and asking for forgiveness can demonstrate important modeling for how to repair a rupture. In short, adolescents do not need to learn how to be perfect. Adolescents learn vicariously through their parents and guardians and need to learn how to repair mistakes they have made. The counselor’s ability to bracket their biases and help the caregiver repair ruptures is thus crucial to forging closer caregiver-child relationships.
We now apply these family intervention principles to the case of Brooke (see Case Vignette 10.3). Thom uses first-person narrative to describe the counseling process.
Adolescents experience faster development of subcortical systems associated with emotional experiencing and reward prediction than cortical systems associated with emotional regulation and predicting long-term consequences of short-term actions. As adolescents gain more sophisticated self-awareness and verbal abilities associated with both cortical and subcortical development, they may benefit from insight-oriented approaches that help them cope with stressors and symptoms and restructure root problems such as distorted schematic thoughts. Family counseling approaches are important to consider when providing CBT to adolescents who are experiencing barriers to family support or problems that emerge from family dynamics. Finally, neuroscience is already being formally integrated into CBT models. In this chapter, we integrated concepts from nCBT to demonstrate nCBT approaches.