Cognitive Behavior Therapy (CBT) (page 2)

— NYU Child Study Center
Updated on Jul 9, 2010

How does CBT treatment typically proceed?

Phase I—This involves psychoeducation; the therapist teaches children and their families about anxiety and the cognitive behavioral model of treatment. The techniques that will be practiced in therapy are introduced as "tools" that the child will acquire to "boss back" the anxiety symptom and reclaim areas of their lives that the anxiety currently disrupts.

Phase II—This involves collaborative work between the child and therapist as they "map out" the child's anxiety symptoms, generate an exposure hierarchy, and begin supplementing EX/RP (exposure/response prevention) during subsequent sessions. The child is put in activities that expose him to the feared object or situation and prevents him from performing the avoidance he uses to reduce the anxiety. Although the exposure deliberately arouses anxiety, it does so in a controlled and gradual way.

For example, Sam, described above, would be asked to touch a doorknob. This act is called an exposure, because it exposes him to his fear of contamination and creates anxiety. The response prevents him from washing his hands, the act that reduces his anxiety. The anxiety levels get higher temporarily and then subside. This exposure is repeated several times and then followed by more challenging exposures.

The child and therapist work as partners against a common enemy—anxiety—which enhances the trust a child may have in the therapist as exposures get underway. Typically, therapy sessions are used for exposures that the child is trying for the first time, and then independent sessions are planned for home so that the child can further master the skills and continue to "shrink" the symptom.

Phase III—The therapist prepares children and their families for the cessation of active treatment. The likelihood of an eventual reemergence of symptoms is discussed explicitly, both to normalize the experience as well as to encourage children to take on more independence in planning and executing remaining exposures. In the last few sessions, therapists work carefully with children to develop a plan for relapse prevention, emphasizing that the same skills the children have mastered in therapy are those that they can use on their own whenever the need arises. Moreover, booster sessions are scheduled so that therapists and children can reconnect at regular intervals to address any problems or simply to check in and celebrate continued good health.

Effective EX/RP leads to 'habituation.' When the child repeats the same act over and over again and sees that nothing happens, they build up a tolerance and anxiety levels go down. Treatment sometimes leads to a near- or total attenuation of symptoms. Most of the time anxiety disorders have a chronic waxing and waning course. Symptoms may reoccur during times of stress, fatigue, or physical illness—and sometimes just out of the blue. This does not mean that the child will experience a complete relapse. Rather, a reemergence of symptoms can serve as a signal to children that it is time to revisit the skills they learned in therapy and implement them as needed.

It is in this way that CBT teaches adaptable coping skills that children will be able to use for the rest of their lives. For instance, the ability to recognize problems that are getting out of hand then develop thoughtful plans to solve them is a general skill that children will find they can apply to a host of situations. This in turn will promote feelings of confidence and self-efficacy that can enhance positive development and good mental health throughout childhood and beyond.

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