Cognitive-behavioral and attachment based family therapy for anxious children and adolescents

1. Cognitive-behavioral and attachment based family therapy for anxious children and adolescents ADAA, March 2008 Lynne Siqueland, Ph.D. Children’s Center for OCD and Anxiety Guy Diamond, Ph.D. Center for Family Intervention Science/CHOP University of Pennsylvania Medical School siqueland@pobox.com

2. Interplay anxiety and adolescence • Adolescence is a time of recalibrating the balance of attachment and autonomy. • Anxiety complicates this normal process. • Anxiety reinforces avoidance and dependency which undermines the exploration of independence and competency • Parents to find balance between challenging and helping

3. Goals of ABFT for depression Depression in adolescence is characterized by interpersonal problems in cohesion, responsiveness, criticism, conflict • Once adolescents are able to express their attachment related feelings and demands in more directly and in a regulated manner, and parents respond in caring, respectful manner, this process can generalize to issues beyond the attachment relationship. • Parents are then positioned to support, guide and protect their adolescents re: dating, peer relations, school, etc.

4. Role of family intervention • Not necessary for all families- assess and address as relevant • Other targets of treatment above symptom relief not always addressed by CBT but important for development • Interactional processes that impede CBT treatment

5. Cognitive-Behavioral Skills 1. Identify physical symptoms of anxiety and relaxation training 2. Identify and modify anxious or depressive self-talk- cognitive restructuring 3. Problem-solving vs. avoidance 4. Self evaluation and reward 5. In vivo practice with anxiety hierarchy

6. Education and engagement • Explain what anxiety is (body’s alarm system backfiring) • Give it a name, draw a picture of it • Think about what you hate about it • Think about what you want to be doing instead. Chansky, T. Freeing your child from anxiety

7. Case conceptualization • Presenting problem • Physiological symptoms • Mood • Behavior • Cognition • Interpersonal

8. Case conceptualization • History and development • Cultural context • Cognitive structures and predispositions • Behavioral antecedents and consequences

9. Session structure • Mood or symptom check in • Homework review • Agenda setting • Session content • Homework assignment • Eliciting feedback

10. Relaxation training Coping modeling Role play Contingent reward Individualized performance-based practice (in vivo exposure) Graduated sequence of tasks Repetition to mastery Pleasant event scheduling Homework Basic Techniques

11. Modifications for adolescents:cognitive formulation • Be specific about cognitive formulation or model • Review in first session with parents and adolescent. • 3 components physical, cognitive and behavior • Be clear about the reason for introduction of each skill with adolescent

12. Physiological reactions to anxiety and relaxation techniques Identifying physical reactions facial & bodily expressions- identification and errors monitoring through daily log and observation Techniques for relaxation diaphragmatic breathing, calming counts progressive muscle relaxation- personalize music or tape visualization- candles, stairs, falling leaf

13. Strategies for identifying thoughts • Daily diary and 3 column technique • Cartoons, stories about other teens, imaginal exposure about things you tell yourself • Cognitive replay- review of past situation • Cognitive forecasting- imagining future events • Offering hypotheses • Down arrow technique- emotional significance- then what? from Wilkes, Belsher, Rush, Frank & Assoc. Cognitive therapy for depressed adolescents

14. Situation Thought Feeling Action

15. Anxious and depressive thinking Anxiety • Overestimate likelihood of bad outcome • Overestimate how terrible would be if happened • Focus on danger (safety, criticism, embarrassment) Depressed • Think in self critical ways (worthless, helpless) • See lives in negative ways and believe situations cannot change • Negative view of future- always this way and never get better

16. Anxiety Tricks • Their first reaction self-talk is typically about the most awful thing instead of most likely that could happen in a situation • Being in danger vs. feeling afraid • Always think twice- don’t trust 1st reaction-is that your final answer • Feelings vs. facts • “what ifs” vs. “what elses” • Future vs. present Chansky, T. Freeing your child from anxiety

17. Socratic dialogue Goal: to promote understanding of beliefs • Elicit & identify automatic thought • Tie automatic thought to feeling and behavior • Link thought-feel-beh sequence together with an empathic response • Obtain collaboration from child on 1-3 and agree to go forward • Socratically test the belief

18. Discussion of thinking errors 1. Identification types of errors 2. Explore and label themes (safety or threat, focus on self, evaluation by others) 3. Double standard technique 4. Pro-con evaluation 5. Contradictory evidence 6. Logical analysis- identify inconsistencies 7. Time projection- consequences of thoughts over time from Wilkes, Belsher, Rush, Frank & Assoc. Cognitive therapy for depressed adolescents

19. Cognitive challenges Are you expecting the worst? Or making it worse than it is Are you sure this is really going to happen?- how likely? Are you jumping to conclusions?- what is the evidence? Are there other ways to look at the situation? Is this thought helpful? Can you expect to be perfect in everything you do? How horrible would it be if the worst thing happened? Best outcome? Most likely outcome? So what?

20. Challenging thought content • Decatastrophizing • Test of evidence • Advantages/disadvantages • Reattribution • Responsibility pie

21. Problem solving steps 1. Identify the problem 2. Brainstorm possible solutions or responses 3. Think about consequence of each response especially inappropriate response 4. Identify your goal 5. Evaluate and choose the best 1-2 solutions 6. Evaluate the results of solution

22. FEAR acronym 1.Feeling frightened 2.Expecting bad things to happen 3.Actions and ideas that will help 4.Results and reward

23. Depression related interventions • Pleasant activity scheduling • Activation vs. withdrawal • Think can’t but can • Improve mood • Assertiveness • Family conflict

24. Tolerating affect • Surfing anxiety* • Learning to tolerate strong affect instead of fearing it • Don’t fight it • This is only a feeling • Identify what you are meant to be doing • Internal to external (interpersonal or grounding) *Chilled: The Cool Kids Anxiety and Depression Program Schnieing, Lyneham, Wignall and Rapee (2006). Center for Emotional Health, Macquarie University Sydney, Australia.

25. Strategies into action • Behavioral experiments- generate and test predictions • Problem solving what can and cannot change • Understand problem (who and what) • How could I change the situation • Change my reaction for what cannot change (teacher you hate)

26. Core beliefs • Not trying fear of failure or disappointment • Letting people walk all over you • Not looking after yourself • Withdrawing from others or not trying to make friends • Not taking risks due to low self confidence • Giving up on things • Being too dependent or needy with others • Chilled: The Cool Kids Anxiety and Depression Program Schnieing, Lyneham, Wignall and Rapee (2006). Center for Emotional Health, Macquarie University Sydney, Australia.

27. Two types of exposures • Facing fears in a step by step fashion to test out the accuracy of thoughts and the ability to cope with possible anxiety experienced. • The family also provides a context for expressing one’s views and feelings, dealing with conflict, negotiating relationships, and self assertion.

28. Social skills • Anxiety gets in the way of demonstrating good social skills or person under-estimates their skills • reduce anxiety • address perceptions and cognitions • Anxiety partly related to social skills deficits • (trouble reading social cues, opportunities for practice) • affective education • role play, coaching, and progressive steps

29. Modifications CBT for adolescents Often more resistant to homework- focus in session Use language of choice Distinguish personality style from anxiety Discuss avoidance or “fake” quality of role play Hierarchy established by adolescent more out of session Focus on goals for independence in future

30. Modifications for adolescents: using the language of choice • “right now you do not have a choice- in some ways you are controlled or limited by your way of thinking- consider alternatives so you have some control or choice in the matter.” • “Would you like to be able to choose when you think about things rather than thinking or obsessing all the time? Try new way you can always go back to the old .” • “You could make your own choices, to better define who you are, rather than be defined by anxiety”

31. Modifications for adolescents:language of choice • “Alternative thoughts may be easier to both conjure up or hold on to when calm.” • “Let’s figure out how to resolve this when you are calm. Right now we know who wins in the moment- the old familiar thoughts.” • You can always keep the old way in back pocket. Instead you can experiment- notice the conflicts, as you challenge them you may be able to integrate more.

32. Modifications for adolescents:separating anxiety & personality Be aware of not challenging the adolescent’s uniqueness unnecessarily While it is helpful to normalize some feelings or experiences, many adolescents feel their situation, feelings and thoughts are different. Therapist should tentatively offer alternatives and suggestions – what about, could it be, is it possible

33. Modification for adolescents: separating personality and anxiety • “Challenging things is really interesting and is something that you enjoy but challenging is different from being stuck in the repetitive old patterns or concerns.” • “Your personality is to care about other people and to value their opinion. This is one of your strengths- your personality is not to be anxious or self-conscious. Don’t want to change your sense of caring or sensitivity to others because these are positive qualities which you value. We want to address discomfort that holds you back or keeps you from your goals and interests”

34. Modifications for adolescents:avoidance of analysis • Many adolescents are avoidant to the point of hesitancy to practice skills in session. Focus on how being unwilling to practice leaves you unprepared for situations which raises your anxiety. Role play as in vivo • Avoidance sabotages the likelihood that it will go well. • Avoid anxiety by not wanting to review past experiences. “It’s over, I don’t want to dwell on it. Now is time I feel fine and want to have fun. Again can’t learn from experiences

35. Modifications for adolescents: Homework compliance Hesitant to commit thoughts to paper because it • makes the thoughts seem “more real” • worry about getting it right • complain the task is too analytical compared to living in the moment Can use diary format or tape recorder instead

36. Modifications for adolescents:Homework compliance • Wilkes et al (1994) suggest making homework assignments brief and simple and then completing the rest in session. • have adolescent jot down once each day situation, emotion and automatic thought • therapist and adolescent in session, label the distortion and generate alternative thoughts.

37. Modifications for adolescents:Establishing in vivos • Adolescent as an active collaborator and take the lead on setting manageable goals or steps. • Adolescents are less motivated by rewards. • The adolescent may be even more hesitant about doing an in vivo with the therapist • Most relevant in-vivos are naturally occurring (being invited to a party, a trip to mall) or can be created (e.g. adolescent agrees to call a friend on the phone, chat with a classmate in homeroom).

38. Why add family based treatment? Risk for disorder Children of parents with an anxiety disorder are at risk. • 7 times more likely to have disorder than control • 2 times than depressed parents • emotional distress, poor social adjustment, anxiety and fears • 65% of children (18-59 months) were behaviorally inhibited & somatic problems - early precursors (Manassis et al., 1995)

39. Why add family based treatment? Risk for disorder Children with anxiety disorders are likely to have parents who suffer with anxiety disorders 83% lifetime (40%) 57% current (20%)

40. Observation of family interaction Family Enhancement of Avoidant ResponsesFEAR effect (Barrett et al., 1996) Children with anxiety disorders • children and parents perceived more threat to ambiguous situations • generated more avoidant responses • avoidant responses increased following discussion with parents

41. Family treatment approaches • Barrett et al (1996) treatment involves teaching parents: • To reward courageous and coping behavior • To extinguish excessive anxious behavior • Coping skills for their own anxiety • Communication and problem-solving skills

42. Efficacy of family treatments % children no diagnosis Barrett et al (1996) individual CBT CBT-family End of treatment 57% 84% 12 month follow-up 70% 96% Barrett (1998)group CBT group CBT-family 64% 85%

43. Is CBT-family treatment better for all families? Percent children with no diagnosis end of treatment Child CBT Child CBT + parent anxiety mgt Without parental anxiety 82 80 With parental anxiety 39 77 Cobham et al (1998)

44. Psychological autonomy • solicits child's opinion, not simply a reaffirmation of parents' opinion • tolerates differences of opinion • acknowledges and demonstrates respect for child's views • avoids judgmental or dismissive reactions to child's views • encourages child to think independently • uses explanation and other inductive techniques

45. Observation of family interaction Children with anxiety disorders and control families(Siqueland et al., 1996) • Children reported less warmth or acceptance • Rated by observers as less granting of autonomy • No differences by parent report

46. Treatment structure of CBT + family Session 1 - parents & adolescent - focus on family interaction style Session 2 - adolescent alone- alliance & goals Sessions 3- 6 alone with adolescent Cognitive behavioral techniques (relaxation, cognitive restructuring & problem-solving) Session 3-6- concurrent parents alone – beliefs, parenting & marital conflict Sessions 8-16 adolescent, parents or conjoint- focus in vivo exposure & family interaction

47. Family targets of treatment • Modeling anxious behavior • Encouraging avoidance • Modeling anxious interpretations of events • Autonomy and competence • Expression of conflict or differences

48. Attachment Working internal models of self, world and particularly relationships • Self as competent • Family as a secure base • Family as able to tolerate independent exploration • Family can tolerate potential conflict, independence and affect • At adolescence, more often negotiated around goal conflicts and through conversation (Kobak)

49. Family component Assess and address as relevant 1. helping parents to encourage adolescent's coping and mastery rather than allowing avoidance, taking over for, or directing. 2. modifying parents' expectations of adolescent's ability to function independently in academic, social and interpersonal arenas. 3. identify and discuss the role of parent's own anxiety or depressive symptoms may have on helping adolescent

50. Family component 4. encouraging increased tolerance for the expression of different viewpoints, feelings and experiences within the family, especially negative affect of anger and sadness 5. focus on problem-solving and open negotiation of conflict rather than avoidance 6. if marital conflict involves major differences in parenting- working with parents alone to negotiate a compromise position on managing anxious behavior