Stop and think: the application of cognitive-behavioral approaches in work with young people
Peter Gabor and Carol Ing
This paper begins with a general overview of cognitive-behavioral approaches. A more detailed description of one influential approach, cognitive-behavior therapy (Meichenbaum, 1977), is then presented. Finally, the applicability and application of cognitive-behavioral approaches in work with children is considered and discussed.
OVERVIEW OF COGNITIVE-BEHAVIORAL APPROACHES
Negative cognitions result from the uncritical acceptance of irrational standards in the form of “shoulds” or “musts” (Ellis, 1967). Generally these standards confuse wants with needs, desirable with necessary, and unfortunate with catastrophic. For example, many people believe that they need love and approval from all significant people in their life, even though that is an unrealistic expectation. They may want love and approval from these people, but they do not actually need them in the sense that they are indispensable to a happy life. Alternately, negative thinking may take the form of distortions in evaluating events and situations or in reasoning to conclusions. Such distortions may consist of “all-or-nothing” thinking, overgeneralization, magnification, minimization, or catastrophizing (Freeman & Greenwood, 1987). For example, a preadolescent who does not succeed in completely staying within the lines while coloring a picture may tear up the page in anger, judging it totally worthless. Or a junior-high-school student who is unable to win the approval of one of his teachers may over generalize and magnify the situation, thinking, “My teachers all hate me.”
The principal objective of cognitive-behavioral interventions is to change such irrational thinking, thereby reducing or eliminating its negative consequences: interfering or disturbing feelings and self-defeating or unproductive behaviors. Cognitions are regarded as covert behavior and are modified using such behavioral techniques as operant conditioning, modeling, and behavioral rehearsal (Corey, 1986; Meichenbaum, 1977). These approaches do not take a medical-model perspective and are thus not concerned with curing clients; rather, the goal is to help clients cope more effectively with their life situations.
The role of the counsellor in cognitive-behavioral therapy is somewhat different from that inmost other therapeutic approaches (Ivey, Ivey, & Simek-Downing, 1987). Most striking is that the concept of relationship is de-emphasized in cognitive-behavioral therapy; the counsellors role is primarily that of teacher. Cognitive-behavioral approaches emphasize the teaching of thinking and behavioral skills. Relationship is only important to the degree that it facilitates this objective. Thus, counsellors tend to be very active and didactic in their approach, using a variety of teaching techniques. Most importantly, they do not hesitate to challenge their clients’ thinking, logic, or conclusions. This is very different from many other approaches, in which one objective is to accept and reflect the client’s perspective. Far from providing such validation, cognitive-behavioral counsellors take issue with those attitudes, opinions, and feelings that they see as illogical, and urge their clients to abandon them.
Cognitive-behavioral interventions have been applied to a wide variety of child and adult populations in the treatment of a broad range of problems. These approaches, unlike many other approaches currently in use, have been extensively evaluated. Although, given space limitations, it is not possible to describe this evaluation literature, cognitive-behavioral approaches have been found to have strong empirical support.
A prominent and increasingly influential approach is cognitive-behavior therapy (CBT), an umbrella term for a number of related approaches, such as cognitive restructuring, cognitive behavior modification, and stress inoculation. Based heavily on the work of Meichenbaum (1977, 1985), CBT relies more heavily on behavioral approaches than RET or cognitive therapy, but also continues to emphasize the importance of cognition in the therapeutic process. However, in CBT the relevant cognitions are conceptualized as self-statements.
Meichenbaum’s approach is “grounded on the assumption that what people say to themselves directly influences the things that they do. The role of inner speech is given primary importance” (Corey, 1986, p. 230). CBT shares with RET the view that distressing emotions and performance problems are the result of irrational thinking. However, this approach helps clients focus on their inner dialogue while experiencing disturbing feelings or performance problems, and has the goal of changing these self-statements and providing self-help techniques in order to help clients better cope in such situations.
Specifically, Meichenbaum uses a three-phase approach, as described below:
1. Self-observation: Clients are taught skills of self-observation to become more aware of their thoughts, feelings, physiological reactions, and behaviors.
2. Promotion of change: Clients learn to exchange negative inner dialogue for more constructive self-statements and also learn more adaptive behavioral skills.
3. Consolidation of change is concerned with ensuring that changes are consolidated and generalized and that relapse is avoided. To prevent relapse, attention is paid to teaching clients coping skills that can assist them to manage for themselves in similar troublesome situations in the future (Corey, 1986; Meichenbaum, 1985).
The Cognitive-Behavior Therapy Process
1. Provide the client with a rationale for an overview of
2. The counsellor helps the child to describe the problem
situation and identify his or her thoughts at the time.
3. The client is asked to evaluate his or her thoughts as
facilitating or self-defeating.
4. At this point the counsellor introduces the concept of
coping thoughts and helps the client develop some “smart” thoughts that are more
5. Preparations are made to implement these new coping
thoughts. A number of behavioral or cognitive techniques may be involved at this
stage, in addition to substituting coping thoughts for self-defeating ones.
Essential elements of the statement modeled above are (1) to help Adam recognize when he is making self-defeating statements and to use these as a cue to begin coping thoughts; (2) to help Adam dissipate some of the tension and stress through deep breathing; (3) to substitute coping thoughts for self-defeating ones; and (4) to teach Adam to reinforce himself verbally for using positive internal dialogue. After the counsellor modeled the process, the role play was repeated with Adam playing himself. The role play was repeated several times, until Adam had mastered the key aspects of the statement.
6. Implement the skills in an actual situation.
Considerations in Using Cognitive-Behavioral Approaches
with Children and Adolescents
Perhaps the most important factor to bear in mind in working with children and adolescents is that they are seldom self-referred but have usually been referred by an adult (Prout, 1983; Worchel, 1988). As a consequence, they may not be willing participants in the therapeutic process and may not even acknowledge that a problem exists. Under such circumstances, the first step is to establish a relationship and to obtain some agreement to examine and work on problems or concerns (Hughes, 1988; Worchel, 1988). This is, of course, important in any helping relationship but is particularly crucial when using cognitive-behavioral approaches. These approaches are essentially collaborative, and their success depends largely on clients’ willingness to examine their beliefs and ideas and the assumptions underlying those beliefs and ideas. Involuntary clients, participating reluctantly or even grudgingly, are unlikely to enter into a meaningful self- examination.
Although relationships are considered to be of secondary importance in cognitive-behavioral approaches, it is important to get the relationship off on the right foot by putting the young person at ease, explaining what to expect, and easing his or her apprehensions (Prout, 1983). It is also important to move gradually into the process by dealing with non-threatening issues and by allowing the young person to initially define concerns (Hughes, 1988).
Perhaps the most effective means of building a relationship is through the use of empathy statements (Thompson & Rudolph, 1988). These responses convey that the counsellor understands the concerns expressed. While such responses are effective in relationship building, they also validate, to a degree, the young person’s perceptions. Hence, these responses are often inconsistent with the challenging and disputing responses called for by cognitive-behavioral interventions. The counsellor is thus caught in a dilemma: She wants to build a relationship with her young client, but she does not want to validate irrational thinking. There is no easy way out of this bind. Ultimately, the counsellor will have to challenge and dispute irrational or negative beliefs and self-statements. However, challenging prematurely may cause the young person to “shut down” or withdraw from participation in the helping process. As challenges are most effective in the context of a strong relationship (Egan,1988), counsellors working with young people cannot afford to ignore the relationship-building phase of therapy, even if that means postponing challenges.
As their name implies, cognitive-behavioral approaches place considerable emphasis on the thought component of human functioning. Indeed, as has been shown, the modification of thoughts, beliefs, and philosophies is often accomplished through the application of logical analysis. Needless to say, this process requires a high level of cognitive ability on the part of the client. In work with children, however, counsellors are faced with the problem that the cognitive abilities of young people are often limited and depend greatly on the level of cognitive development reached (Thompson & Rudolph, 1988).
Piaget’s work provides a widely used guide to the cognitive development of children. According to Piaget, children between the ages of 7 and 11 are in the concrete operations stage of cognitive development and have limited abilities with abstract concepts. Most are unable to clearly relate events to each other and have trouble considering hypothetical situations (Thompson & Rudolph, 1988). Only around the age of 9 do most children develop the ability to step outside of themselves and reflect on their own thoughts and actions (Hughes, 1988). At 11, young people enter the formal operations stage of cognitive development (Worchel, 1988). During this stage, children acquire the ability to think in the abstract, to recognize hypothetical problems, and to engage in logical, scientific experimentation and problem solving. However, they are limited by their experience and will sometimes reach unrealistic conclusions (Worchel, 1988). Evidently, young people who have reached this developmental level are more likely to be able to understand and follow the logic of cognitive-behavioral approaches and are cognitively more ready to examine and evaluate their own thoughts and behavior.
When one is using cognitive approaches, it is essential to be aware of the cognitive developmental level of the young client and to match techniques to that developmental level. Because not all children reach cognitive developmental milestones at the same time, and because many children receiving child welfare services are delayed in their development, it is important to assess the level of development of each client. In the case of children who have not yet reached the formal operations stage, it becomes important to adapt the interventions to their cognitive abilities.
The most important adaptation is to provide visual aids and, where possible, concrete referents. These aids can include pictures, puppets, and skits.
Generally speaking, the verbal skills of pre-formal children may be somewhat limited, so the complexity of questions needs to be reduced, and it is important that the counsellor’s vocabulary be simple and jargon free. Children’s ability to communicate (especially to describe complex events and ideas) may also be limited by their small vocabulary, but communication can be facilitated through such media as role play, games, and drawing.
A third consideration is the context within which the child’s problems occur. Although cognitive-behavioral approaches are basically problem oriented and child centered, it is important to keep in mind that children react to their environment and have relatively little power or opportunity to eliminate or prevent environmental causes of problems (Prout, 1983). What is perceived as problematic functioning may, in fact, be a relatively normal reaction to a stressful or problematic situation.
In such circumstances, should helping efforts be exclusively aimed at bringing about changes in the young person? Should the objective of helping be to change some aspect of the young person’s functioning or even to assist the young person to cope with a stressful situation? Obviously, there are no easy answers to these questions. For example, in the case of a 10-year-old who disrupts in a classroom that objectively may be described as having an oppressive environment, there may, nevertheless, be some merit in working toward making the child’s behavior less disruptive or in helping the child to cope more effectively with the situation. However, it is arguable that the real target of intervention in such a case should be the classroom environment, a helping situation that is beyond the scope of individual therapy. In short, we should not assume that the child should always be the sole target of interventions. Counsellors employing cognitive-behavioral approaches need to differentiate between problems of the young person and problems of the environment. They must then ensure that the proper target has been identified and that interventions are designed accordingly.
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