Flexibility Within Fidelity

Flexibility Within Fidelity
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  Flexibility Within Fidelity  PHILIP C. KENDALL, P H .D., A.B.P.P., ELIZABETH GOSCH, P H .D., A.B.P.P., JAMI M. FURR, M.A.,  AND  ERICA SOOD, M.A. The American Academy of Child and AdolescentPsychiatry, the American Psychiatric Association, andthe American Psychological Association emphasizethe importance of evidence-based practice. The centraltheme for all three groups is the integration andimplementation of the best available research withinthe provision of optimal clinical services. Consistent with this mission, research has evaluated the efficacy andeffectiveness of a variety of interventions for a range of mental health problems. Based on criteria detailed by Chambless and Hollon, 1 a treatment is considered to be‘‘empirically supported’’ when it has been shown to beefficacious for a particular disorder in controlled clinicaltrials across multiple research settings.Manual-based protocols for psychiatric treatmenthold great promise for increasing evidence-basedpractice. This column addresses concerns regarding manual-based treatments and contends that many of these concerns arise from misperceptions about how these treatments are optimally implemented in practice. We illustrate the flexible application of manualsthrough the examples drawn from the Coping Catprogram, a cognitive-behavioral therapy (CBT) for anxiety problems in youths that has been found tobe efficacious. These examples underscore the im-portance of implementing manual-based treatments within the context of a child-centered, individualizedapproach to facilitate the child’s involvement in thetreatment process.CBT for anxiety disorders in youth has received a great deal of empirical attention. CBT emphasizes therelations between thoughts, feelings, and behavior anduses cognitive restructuring, problem-solving strategies,relaxation exercises, and, of great importance, graduatedexposure tasks to help the child master and managedistressing anxiety. Results from randomized con-trolled trials suggest that children assigned to CBT aresignificantly more improved after treatment comparedto those assigned to a waitlist condition. 2  Y  4  Approxi-mately 50% to 65% of children no longer met criteria for their principal anxiety disorder after 16 weeks of CBT, 3,4 and gains have been reported to be maintainedseveral years after the completion of treatment. 5  Y  8 Using the established criteria for determining whether a treatment is empirically supported, 1 several reviewshave concluded that CBT is an efficacious treatment for youth anxiety. 9  Y  11  Although several versions of CBT for youth anxiety have been developed and evaluated empirically, thecore components of each treatment are akin to oneanother. This article focuses specifically on the Coping Cat program as one example of CBT for youth anxiety.The Coping Cat program is a manual-based CBT for children, ages 7 to 13 with generalized anxiety disorder,separation anxiety disorder, and/or social phobia. 12,13 The treatment is divided into two segments, each of  which consists of approximately eight 1-hour sessions.The first segment focuses on skills training, whereasthe second segment emphasizes exposure tasks that placethe child in/expose the child to anxiety-provoking situations. To facilitate the learning and recall of severalskills, the Coping Cat program presents the steps of anxiety management throughtheuse of anacronym (theFEAR plan). The ‘‘F’’ step of the FEAR plan, ‘‘Feeling Frightened?,’’ involves identifying bodily reactions thataccompany anxiety and gaining an awareness of andcontrol over physiological and muscular anxiety through  Accepted March 3, 2008 Dr. Kendall, Ms. Furr, and Ms. Sood are with Temple University; Dr. Gosch is with the Philadelphia College of Osteopathic Medicine.Correspondence to Dr. Philip C. Kendall, Department of Psychology, Temple University, Weiss Hall, 478, 1701 North 13th Street, Philadelphia, PA 19122;e-mail: 0890-8567/08/4709-0987  2008 by the American Academy of Child and Adolescent Psychiatry.DOI: 10.1097/CHI.0b013e31817eed2f  E V I D E N C E - B A S E D P R A C T I C E  John D.Hamilton, M.D., M.Sc. Assistant Editor   WWW.JAACAP.COM  987  J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 47:9, SEPTEMBER 2008  progressive muscle relaxation. The ‘‘E’’ step of theFEAR plan, ‘‘Expecting bad things to happen?,’’involves identifying anxious self-talk and modifying self-talk by considering alternative ways of viewing anxiety-provoking situations. The ‘‘A’’ step of the FEAR plan, ‘‘Attitudes and Actions that can help,’’ involves theuse of problem-solving to redefine the problem, identify  ways to address the problem, and develop a plan tocope with any unwanted distress. Finally, the ‘‘R’’ stepof the FEAR plan, ‘‘Results and Rewards,’’ involvesevaluating and rewarding one’s efforts.Empirically supported manual-based treatments,such as the Coping Cat, offer promise as a means toincrease evidence-based practice. Most manuals deline-ate a treatment framework based on treatment andsession goals, describe therapeutic activities and strate-gies to meet these goals, and provide guidelines tomanage treatment challenges. 14 These componentsfacilitate the training of therapists (available materialsinclude a DVD entitled  CBT4CBT   [Computer-BasedTraining to Be a Cognitive-Behavioral Therapist for anxious youth]), provide a means to evaluate treatment,enable comparisons among treatments, and lendthemselves to dissemination.Despite these advantages, resistance to manual-basedtreatments has been encountered. Many criticisms reston the assumption that manuals are designed toimplement a small number of specific procedures in a rigid, routinized manner. Critics argue that manualsinhibit therapists’ creativity, are insensitive to individualneeds, and negatively affect the client  Y  therapist relation-ship. Addis and Krasnow  15 found that 45% of cliniciansthought that manuals ignored the unique contributionsof therapists and 33% thought that using manualsdetracted from the authenticity of the therapeuticinteraction. Nauta, working in the Netherlands, notedthe risk of therapists providing didactic instructionfrom manual-based protocols in a manner thatencourages client passivity, decreased participation,and loss of client interest. 14 Furthermore, commentsmade in casual conversation suggest that cliniciansbelieve that manuals cannot address the complex clientproblems and interpersonal interactions encountered inclinical practice.These criticisms could be valid if manuals wereapplied inflexibly with little attention to the therapeuticrelationship. Critics may overestimate the rigidity of manuals. Misconceptions may be associated with a failure to address treatment process or relationshipissues. However, creativity and clinical skill play a major role in the proper implementation of manual-basedtreatment, and flexibility within fidelity is encouraged. 16 Several manuals explicitly call for therapists to beflexible within the context of a positive alliance withclients. Manuals are not meant to be implemented in a ‘‘cookie cutter’’ fashion, with all patients being treatedexactly alike. Research on the therapeutic processsuggests that rigid adherence to a protocol under conditions of strain in the therapeutic alliance isassociated with poor outcomes, 17 and a more collabora-tive approach is associated with a more favorabletherapeutic relationship. 18  When properly implemen-ted, manuals act as a guide, with the therapist taking into account the client’s needs and addressing therapeutic alliance issues as they arise. For example, when a client brings a particular concern to a session,the therapist does not ignore the issue to focus onthe manual-based topic/procedures, but addresses theclient’s concern while using the therapeutic goals of the treatment to guide the process.Studies of manual-based treatments indicate highratings of client satisfaction and therapeutic alliance. With reference to the Coping Cat program, childpatients reported satisfaction and assigned favorableratings to their relationships with their therapists(Kendall et al., unpublished data, 2007). In a study of treatment at a community mental health center, clientsrated the therapeutic relationship as superior in manual-based treatment programs compared to standardtreatment. 19  Also, some studies found that the positiveeffects of a manual-based treatment for a specificdisorder can generalize to other problem areas. 20,21 To address ‘‘flexibility within fidelity’’ for manual-based treatment, we discuss how creativity andflexibility can be applied in the Coping Cat program. We have found that child-relevant strategies usedduring the skill-building and the exposure task portions of treatment lead to greater child involve-ment and a stronger alliance, both of which can beassociated with beneficial outcomes. 7,11,22  Y  24  Weselected our examples to underscore the importanceof a child-centered, individualized approach to facil-itate the child’s involvement in the treatment process.This discussion addresses and illustrates ‘‘flexibility  within fidelity’’ for several of the FEAR steps thatconstitute the skill-building segment of CBT and KENDALL ET AL. 988  WWW.JAACAP.COM J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 47:9, SEPTEMBER 2008  for implementing a key component of CBT, the ex-posure tasks. FLEXIBILITY WITH RELAXATION  A strategy to help children manage anxiety is toprovide a way for them to soothe their physiologicalarousal. Relaxation training can follow progressivemuscle relaxation scripts such as those by Koeppen 25 for young children and Ollendick for older children(unpublished, 1978). We often provide a tape/CD withdirections for relaxation exercises to help the childpractice at home. However, not all children findrelaxation useful. Some become anxious when focusing on their bodies and benefit from exposure to theexercises themselves. These same youths may need to‘‘rethink’’ (cognitive restructuring) their bodily sensa-tions. Younger children may prefer imagery or breathing exercises rather than progressive muscle relaxation. For young, active, or cognitively impaired children, short-ened versions of these exercises are suggested. Whenasked what they remembered about the FEAR planseveral years after completing the program, childrenoften answered ‘‘take a deep breath.’’ This simple self-instruction may be the nugget that some children takefrom the array of relaxation exercises presented to them.The rationale for relaxation can vary. Some childrenaccept the idea that they can learn to calm themselvesand decrease their anxiety through relaxation. Othersseem to require evidence, such as hearing stories aboutprofessional sports figures, movie stars, or peers who usethe exercises (i.e., relaxation) to calm themselves. Theseexamples are best drawn from the child’s interests andexperiences. For example, an adolescent who was an avidgolfer only became keen on relaxation after learning thatTiger Woods used similar exercises to focus during hisgolf game. Another child more enthusiastically embraced imagery when it included scenes from  Star Wars  , his favorite movie. Relaxation is the manual-basedgoal, but implementation within fidelity can beaccomplished flexibly. FLEXIBILITY WITH THE ‘‘E’’ STEP  Another component of the treatment requireschildren to identify their anxiety-evoking cognition(i.e., anxious self-talk) and develop more adaptive,realistic cognition (i.e., coping self-talk). We usecartoons with empty thought bubbles to help childrenrecognize self-talk (e.g., expectations, automatic ques-tions). The cartoons can be those found in the Coping Cat workbook  13 or made to fit the child’s interests (e.g.,sports, television characters). Some children benefitfrom role-playing exercises in which the therapist ‘‘stopsthe action’’ to identify the child’s self-talk while thechild is acting out a situation that evokes anxiety.Children can also begin to identify self-talk whileplaying common games, particularly those that may elicit performance fears or competitiveness.Once the anxiety-eliciting self-talk has been identi-fied, children engage in exercises to challenge thesethoughts. These exercises vary by child. Some childrenfind common ‘‘thinking traps’’ helpful in examining their self-talk. Some benefit from cost  Y  benefit analyses,projecting into the future about possible outcomes, or realistically considering a worst case scenario. Adoles-cents may resist challenging beliefs and often find anacceptance-based approach helpful in decreasing theintensity of their distressing self-talk. Some children,particularly young children or those with cognitivelimitations, cannot readily identify their self-talk andmay have difficulty challenging their maladaptivebeliefs. These children may find a few key self-instructions (e.g., ‘‘Just do it!’’) helpful for coping  with anxiety-provoking situations. We have created‘‘coping key chains’’ (laminated coping statementsand actions that are strung on a key ring) to provideconcrete reminders of self-instructions for children touse when anxious.For some children, talking about their thoughts may evoke change, whereas others require experiencing actual situations that disconfirm their belief. For example, one separation anxious child expected thatsomething terrible would happen to his mother whenshe went out and he would never see her again. He wasnot able to relinquish his belief despite reviewing theevidence, recognizing that it was unlikely, and crafting an argument against the belief. He was able to decreasehis anxiety by accepting that something negative may happen to his mother and by experiencing theseparation while tolerating the emotions and their decline during the course of repeated exposures. FLEXIBILITY WITH THE ‘‘A’’ STEP ‘‘Attitudes and Actions that can help’’ (the ‘‘A’’ step)involves problem solving. Anxious arousal can be seen as EVIDENCE-BASED PRACTICE  WWW.JAACAP.COM  989  J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 47:9, SEPTEMBER 2008  a problem, and like other problems, a person can comeup with a plan to try to address it. Anxious youths useavoidance (i.e., a response that is thought to preventa negativecondition but in factdoes not affect the negativecondition) as a primary problem-solving approach. If something is seen as a problem (e.g., causing anxiousdistress), then it is avoided. The ability to view situationsdifferently and to develop strategies is a key component of treatment. To develop nonavoidance problem-solving skills, the therapist and the child collaborate to identify a problem and to brainstorm several potential solutions. Atthe beginning of solving a problem, the goal is to generateas many potential solutions as possible without evaluativecomment (and the problem need not be one related toanxiety). After several possible solutions are identified, thetherapist and child ‘‘kick around’’ the merits and possibleoutcomes of each.Creativity and flexibility are important in problemsolving. Problem solving can be presented as a game/activity, leading to greater child involvement. 25 For example, the therapist and child can work individually to brainstorm ideas, each trying to identify the greater number of solutions or be the first to have five ideas. Alternatively, the child can record potential solutions ona dry erase board and provide ratings of each solution inthe form of drawings (e.g., happy faces, sad faces). Thetherapist and child can also role play or draw pictures of characters (or themselves) engaging in each potentialsolution. Therapists adhere to the overall goals of the session (e.g., discuss problem solving; practiceproblem solving in anxiety-provoking situations), butthe means through which these goals are accomplished vary across patients. As noted earlier, skeptics of manual-based treatmentshave argued that reliance on a manual could lead thetherapist to ignore the communications and experiencesof the client. We have found that the communicationsand experiences of the child client are easily andreadily attended to while solving problems. Examples of problems to be solved are provided in the Coping Catmanual and workbook, but therapists are encouraged toadd examples that are relevant to the child. For example,if the child reports feeling nervous on the bus to school,the child and therapist can generate potential solutions(e.g., I can take deep breaths; I can sit with someone Iknow; I can listen to music) and can explore thepotential outcomes of each solution. Similarly, a child who forgets his or her workbook at home or arrives lateto a session can problem solve with the therapist toidentify actions that may eliminate or reduce thisproblem in the future (e.g., I can leave my workbook inthe car). Within the framework of problem solving, thetherapist addresses a client’s unique experiences whileadhering to the goals of the manual-based treatment. FLEXIBILITY WHEN CREATING A FEAR HIERARCHY  After skill building, the therapist and child (withparent input) collaborate to draft an individualized fear hierarchy (i.e., hierarchy of anxiety-provoking situa-tions). The hierarchy lists the situations that evokeanxiety for the child, beginning with low-anxiety situations (placed toward the bottom of the hierarchy)and moving up to high-anxiety situations (placedtoward the top of the hierarchy). These situations willgradually be faced by the child as part of the exposuretasks. For some children, particularly younger ones, theconcept of differential levels of anxiety may be difficult. Although a fear hierarchy template is provided in theCoping Cat workbook, it is up to the therapist andchild to determine how best to create the hierarchy. If the child prefers a hands-on approach, then the therapistcan draw a ladder (or pyramid) on a large sheet of paper and write potential exposure tasks on index cards, andthe child can physically place the cards onto the ladder.The relative difficulty of each is discussed in relation tothose already placed on the ladder and the location of each can be shifted as new cards are added. The use of a computer permits cutting and pasting parts of thehierarchy in a collaborative fashion (i.e., a CD versionof the Coping Cat, ‘‘Camp Cope-A-Lot’’ 26 uses a child-driven interactivity to arrange the hierarchy). As part of the activity and to provide visual cues, the child/therapist can add magazine cutout pictures expressing differential degrees of anxiety next to the corresponding levels of the hierarchy. The number of levels included onthe hierarchy can vary based on the child’s age anddevelopmental abilities. For some youths, the levels may be limited to easy, medium, and difficult, whereas for others, the hierarchy may consist of five or six levels of relative difficulty. FLEXIBILITY WITH EXPOSURE TASKS  After creating a hierarchy, the therapist and childselect and plan an initial exposure task. Thisexposure task is a situation in which the child KENDALL ET AL. 990  WWW.JAACAP.COM J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 47:9, SEPTEMBER 2008  faces an easy-to-medium fear and has the opportunity to master the situation and experience success. Whenplanning exposure tasks, the therapist strives to ensurethat the task is developmentally appropriate.Before engaging in an exposure, it is helpful toexplore with the child the ways in which he or shemay have stayed away from (i.e., avoided) anxiousarousal. This information helps plan future exposuresthat are meaningful for the child and taps into variousforms of avoidance (e.g., cognitive, physical). A child with generalized anxiety disorder may engage in worry to cognitively avoid experiencing anxiety in a givensituation and physically avoid situations that arethought to be linked to feared outcomes. For example,an adolescent worried that her physical symptoms(e.g., shaking legs, wringing hands, red cheeks) wereapparent to others and indicated that she was weak and unsuccessful. She worried about the impact of her physical symptoms and avoided making eyecontact and speaking in class/public. As part of her exposure task, she practiced answering questions infront of others while tolerating the physical symptoms.In later exposure tasks, she purposefully focused onher physical symptoms, allowing them to presentoutwardly. This client worked toward acknowled-ging these symptoms as a part of who she is andunderstanding that these symptoms may not com-pletely go away. Her exposure tasks were opportunitiesto not only practice what she had avoided but also topractice experiencing her arousal and not letting itinterfere.For both imaginal and in vivo exposure tasks,subjective ratings of distress (SUDS) are gatheredbefore, during, and after the exposure. In cases in which it may be intrusive, it is acceptable to wait untilthe child has completed the task to obtain a SUDSrating. SUDS ratings are child relevant and are best when in a system that is meaningful to the child (e.g.,faces ranging from scared to happy). An adolescent may modify the feelings thermometer. For example, oneadolescent created his own SUDS rating scale thatranged from ‘‘cool’’ to ‘‘nervous’’ (i.e., cool, dork, geek-dork, geek, nervous). To help make an exposure task a positive experience for the child and to demonstrate thechild’s success during an exposure task, the therapist andchild can graph the SUDS ratings (e.g., taken eachminute), and the visual aid allows the child to see thatdistress diminishes.For children with limited cognitive abilities or of a younger age, modifications can be made to the exposuretasks to increase the probability that the child willremain engaged in and benefit from the experience. 27 For example, a concrete plan to use during the exposurephase can be developed, which may include one generalcoping thought (e.g., I can do it) and a simplifiedproblem-solving step (e.g., take deep breaths) followedby a strong reward. To provide a visual reminder of hisor her success in being brave in the face of fear,photographs can be taken of the child facing each of hisor her fears and can be made into a collage. Potentialexplanations of the mechanisms involved in exposuretasks for the reduction of anxiety in youths are describedelsewhere. 28 WHEN DOES FLEXIBILITY BECOMENONADHERENCE? Implementing a manual-based treatment within thecontext of a child-centered, individualized approach canfacilitate the client’s involvement in the treatmentprocess. Some adaptations to a manual, however, may extend beyond flexibility into nonadherence. To discern whether an adaptation to the manual constitutesflexibility versus nonadherence, several considerationsmerit attention (discussion here is practice focused: within a randomized controlled trial, all of therandomized cases would be analyzed.) First, consider  whether the stated goals of each session are being met. An individualized adaptation of the methods through which a child learns anxiety management strategiesconstitutes flexible implementation; a failure to addressone or more of the anxiety management strategiesconstitutes nonadherence. Second, conceptualizationsof the child’s difficulties are framed within a cognitive-behavioral perspective. A clinician who uses a devel-opmentally appropriate explanation and approach todemonstrate the relations between thoughts, feelings,and behavior is adhering to the manual, whereas a clinician who emphasizes the role of unconsciousimpulses and desires is not. Third, the treatment isaction oriented rather than passive. Clinicians encouragechildren to face their fears and parents to facilitate their child’s exposure to anxiety-provoking situations. A clinician who accommodates (or reinforces) a child’sanxiety orencourages a parenttodo so isnotadheringtothe treatment. Fourth, clinicians abide by the principles EVIDENCE-BASED PRACTICE  WWW.JAACAP.COM  991  J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 47:9, SEPTEMBER 2008
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