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

ADAA, March 2008Lynne Siqueland, Ph.D.

Children’s Center for OCD and AnxietyGuy Diamond, Ph.D.

Center for Family Intervention Science/CHOPUniversity of Pennsylvania Medical School

siqueland@pobox.com

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

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.

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

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

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

Case conceptualization

• Presenting problem– Physiological symptoms– Mood– Behavior – Cognition– Interpersonal

Case conceptualization

• History and development

• Cultural context

• Cognitive structures and predispositions

• Behavioral antecedents and consequences

Session structure

• Mood or symptom check in

• Homework review

• Agenda setting

• Session content

• Homework assignment

• Eliciting feedback

Basic Techniques

• 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

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

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

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

Situation Thought Feeling Action

Anxious and depressive thinking

Anxiety• Overestimate likelihood of bad outcome• Overestimate how terrible would be if happened• Focus on danger (safety, criticism, embarrassment)DepressedThink in self critical ways (worthless, helpless)See lives in negative ways and believe situations cannot

changeNegative view of future- always this way and never get

better

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

Socratic dialogueGoal: to promote understanding of beliefs

1. Elicit & identify automatic thought

2. Tie automatic thought to feeling and behavior

3. Link thought-feel-beh sequence together with an empathic response

4. Obtain collaboration from child on 1-3 and agree to go forward

5. Socratically test the belief

Discussion of thinking errors1. 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 timefrom Wilkes, Belsher, Rush, Frank & Assoc. Cognitive therapy for depressed adolescents

Cognitive challengesAre 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?

Challenging thought content

• Decatastrophizing

• Test of evidence

• Advantages/disadvantages

• Reattribution– Responsibility pie

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

FEAR acronym

1. FFeeling frightened

2. EExpecting bad things to happen

3. AActions and ideas that will help

4. RResults and reward

Depression related interventions

• Pleasant activity scheduling

• Activation vs. withdrawal• Think can’t but can

• Improve mood

• Assertiveness

• Family conflict

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.

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)

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.

Two types of exposures

o Facing fears in a step by step fashion to test out the accuracy of thoughts and the ability to cope with possible anxiety experienced.

o The family also provides a context for expressing one’s views and feelings, dealing with conflict, negotiating relationships, and self assertion.

Social skills

Anxiety gets in the way of demonstrating good social skills or person under-estimates their skills

• reduce anxiety

• address perceptions and cognitionsAnxiety partly related to social skills deficits (trouble reading social cues, opportunities for practice)

• affective education

• role play, coaching, and progressive steps

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

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”

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.

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

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”

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

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

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.

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).

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)

Why add family based treatment?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%)

Why add family based treatment?Why add family based treatment?

Observation of family interactionObservation of family interaction

Family Enhancement of Avoidant ResponsesFamily Enhancement of Avoidant ResponsesFEAR effect (Barrett et al., 1996)FEAR 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

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

% 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%

Efficacy of family treatmentsEfficacy of family treatments

Is CBT-family treatment better for all families? 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)Cobham et al (1998)

Psychological autonomyPsychological 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

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

Observation of family interactionObservation of family interaction

Treatment structure of CBT + family

Session 1 - parents & adolescent - focus on family interaction styleSession 2 - adolescent alone- alliance & goals Sessions 3- 6 alone with adolescentCognitive 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

Family targets of treatment

• Modeling anxious behavior

• Encouraging avoidance

• Modeling anxious interpretations of events

• Autonomy and competence

• Expression of conflict or differences

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)

Family component

Assess and address as relevant1. 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

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

Family issues in adolescent depression

• Adolescent feels not listened or specifically criticized

• Adolescent feels not understood or accepted in own right

• Ongoing anger and unresolved conflict

• Past attachment rupture that has not been talked about or addressed.

Reattachment Task

• Adolescent disclosure of core conflicts

• Parental acknowledgement and respect

• Mutual responsibility and commitment to change

Reattachment: Expanded Model

• Therapist initiates• Adolescent anger/explore details • Adolescent vulnerable emotions• Adolescent attributional assessment• Parent confides own role• Adolescent ambivalence• Relational reframing• Forgiveness

Session 1 interventionsSession 1 interventions

• Ask each family member’s view of the problem-philosophy about the reason for anxiety

• Ask how each member feels and what each member does when child is anxious

• What works and what does not work• How does child feel about the parent’s reaction

Session 1 interventionsSession 1 interventions

• If it arises in session, can ask parent about their own anxiety or depression and how they cope or do not cope with it.

• Provide rationale for CBT and skills to be taught• Introduce dilemma for parents of knowing how much

to push and how much to help• At end of session try and summarize theme of family

interaction

Establishing goals for family treatment

• Parents balance helping and challenging

• To teach the adolescent to self soothe

• To develop the adolescent’s self & social competence

• Need for change for current development and future

Engaging families

• Join with parents about difficulty of parenting anxious child

• Normalize experience and discuss other families

• Be aware families are hesitant to admit difficulties or frustrations

• Identify impact of anxious child on family functioning

• Clarify should have same expectations of this child with modifications

Engaging parents

• Identify dilemma of accommodating to child and then getting angry

• Okay to want change for themselves

• Discuss child’s need for structure and consequences

• Check if family gives child independence or responsibility (chores)

Session alone Adolescent

• What do you want from and for your life?• What wishes and dreams do you have for yourself?• It’s time to take responsibility for where your life is

going. It’s okay to feel afraid• You need to show your parents how to do it or help• What gets in the way of you being independent?

Set individual and family oriented goals

Family targets

• Family beliefs

• Family behaviors

• Family interaction

Parent session

Ask parents beliefs about parenting:

• Match child’s emotional style and own

• What do you think good parent is?

• How do you decide how to parent?

• How were you (parent) parented?

• How does how you were parented affect how you parent your child?

Family of origin issues

• Own parents as good or bad model

• If parent was anxious as child, how did their parent help or hinder coping

• Legacy from parents about expression or management of emotions

• Elucidate message being sent by parent actions in present family

Parental fears

• Anxiety is threatening and to be avoided

• It is terrible to upset my child

• My child is too fragile to expect much or to push

• Expectation that parent has to fix situation

Various points of interventionVarious points of intervention

• first session – explanation of anxiety or family pattern identified

• parent session- parenting beliefs

• helping create new conversations/interactions

• “sabotage” of or no support of in-vivo exposure

• parental psychopathology

• marital conflict

Family targets for intervention

Family beliefs/behavior Technique

ideas of safety and threat awareness

encourage avoidance challenge

promote perfectionism cognitive restructuring

limit autonomy or difference indiv tx/ inter

limit expression of emotion enactment

Adolescent’s contributionAdolescent’s contribution

• Do you like that your parents take over for you?

• Do you like when your parent handle things for you so you don’t have to?

• Do you sometimes act as if you can’t do things for yourself when you can?

• I wonder if you could do it with a little help

• Do you want to be able to do it yourself?

Psychological autonomy

Concerns about autonomy are often concerns about expression of feelings

• Don’t upset your mother or father

• Going to be out of control- messy

• Going to dwell in it

• To ask for help, to be needy is weak

Psychological autonomy

Concerns about autonomy are often concerns about relationships

• expression of differences or conflict in the family will damage or lead to the loss of their intimate relationships

• open negotiation and communication is blocked • physical and psychological independence is perceived

as a threat to closeness

Parent-adolescent conversation

• Prepare adolescent- to tell parent what needs and does not need in a respectful way

• Prepare parent- to elicit input and listen

• Enactment of a different type of conversation and different kind of help

Autonomy and competence task• Encourage the adolescent to take the risk and express what he or

she wants or needs in terms of a change from parents. • Coach the adolescent to stand up for him or herself and not

acquiesce or sacrifice him or herself in order to protect their parents.

• Or if the adolescent is not ready to assert his or her independence more directly, we encourage the adolescent to share with the parents his or her fears or worries about independence

• The main shift for parents is to focus on a different kind of

parenting: from over protecting to promoting competency. We help parents give permission for autonomy and tolerate expressions of differences, conflict and independence.

Psychological autonomyPsychological autonomy

• Look for clinical examples in session or examples from home

• Model different way of interacting- ask adolescent first, validate their view

• Gently note and challenge examples of taking over

• Look at language used and give feedback about how might be perceived

• Or ask adolescent to help give feedback- hard to speak up or try

Psychological autonomy Problems arise during in vivos

• Parents may question adolescent’s motivation or ability

• May suggest concerns about danger, safety or failure

• Parent doesn’t find time or is unable to complete in vivo

• Parent may not be able to do in vivo because of own discomfort or adolescent’s

Defining helpDefining help

• Let adolescent ask for help

• Adolescent can define kind of help needed

• Different kind of help – adolescent coping CBT skills

• What do you think you could do or say that would help you feel calmer

Defining helpDefining help

• Therapist can help parents sit with adolescent in distress

• Wait until adolescent calms self

• Best help is not helping- faith in adolescent’s ability

• Make sure request not dropped or avoided

Parent psychopathologyParent psychopathology

Parent identifies with adolescent because of similar distress

Parent unable to reassure adolescent that world is safe

Parent feels overwhelmed by own anxiety- anxiety is too painful and to be avoided

Parent physically unable to do the in vivo because of own limitations- no model for adolescent

Parents issues dominate session or family life

Parent psychopathologyParent psychopathology

• Frame for parent what need to be able to do for adolescent

• Start from place may be able to overcome concern to help adolescent

• Therapist and spouse as support

• Evidence that parental difficulty impeding adolescent

Parent psychopathologyParent psychopathology

• Treatment for parent to help adolescent

• Treatment for parent for self because deserves less pain & better life

• Parent as model to adolescent of taking care of self and family

• Adolescent treatment as model for how treatment works and possible recovery

Marital conflictMarital conflict

• Need for an agreed upon way of managing anxiety that both can feel comfortable with

• Often one parent identifies with adolescent

• Discuss issues of polarization to compensate for other spouse

• Can have stronger parent take lead with other’s support

Marital conflictMarital conflict

• Need for parents to be united in goals and consequences

• Parents cannot agree on parenting because don’t agree on anything

• Difficulty compromising with spouse

• Adolescent and problem serves purpose of uniting couple or keeps parents apart