Stop and think: the application of cognitive-behavioral approaches in work with young people

Peter Gabor and Carol Ing

Abstract: A general overview of cognitive-behavioral approaches is presented, along with a more detailed description of one approach. Applications with children and adolescents are considered.

For there is nothing either good or bad,
but thinking makes it so.
 – Shakespeare

Introduction
Cognitive-behavioral approaches have become increasingly popular during the last two decades. These interventions are a group of related therapy systems, derived from the tenets of rational-emotive therapy developed by Ellis (1979) in reaction to the insight- and feeling-oriented approaches that once dominated the helping professions. Cognitive-behavioral approaches focus on cognition as covert behavior and take the view that people’s problems arise from their beliefs, evaluations, and interpretations regarding life events and situations (Corey, 1986). Irrational or negative thoughts and interpretations may lead to problematic feelings and performance difficulties; the task of cognitive behavioral interventions is to modify negative cognitions. This process, it is asserted, leads to more positive feelings and performance.

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
As early as the first century A.D., the philosopher Epictetus noted that “men are disturbed not by events, but by the views they take of them.” Cognitive-behavioral approaches are based on premises derived from this view; they assume that “there is an essential interaction between the way individuals feel and behave and the way they construe their world, themselves, and prospects for the future” (Freeman, 1987, p. 19). In essence, they hold that cognitive processes affect emotions and behavior. Thus negative thinking (often called internal dialogue) is likely to lead to emotional difficulties or stress and/or self-defeating behaviors. For example, a high-school student writing her first article for the student newspaper may worry that her work will not be “good enough” and that she will lose her position on the paper. These thoughts create so much anxiety and stress that her performance is inhibited and, indeed, the quality of the article is not nearly commensurate with her abilities.

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.

COGNITIVE-BEHAVIOR THERAPY
As the foregoing description indicates, rational-emotive therapy (RET) is concerned with modifying or eliminating irrational beliefs. Although a variety of techniques are used, RET pays particular attention to central beliefs and relies heavily on the cognitive approach of disputation. A number of related therapeutic approaches have developed and modified both the concept of irrational beliefs and the mix of techniques utilized. For example, Beck’s (1976) cognitive therapy has replaced irrational beliefs with the concept of automatic thoughts that arise and lead to emotional or behavioral problems. The approach described by Beck is primarily cognitive, relying on challenging these thoughts through Socratic questioning.

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
Six main steps can be identified in the implementation of cognitive-behavior therapy (Meichenbaum, 1977, 1985). The approach and the six process steps are illustrated in the following case example, in which the counsellor works with Adam, an 8-year-old boy experiencing peer relationship problems. Specifically, he is easily hurt and quickly angered by minor (and imagined) slights and provocation, and often starts fights as a result. Consequently, the other children avoid him or tease him, leading to yet more confrontations and hurt feelings. In the example, a combination of restructuring and coping techniques is used.

1. Provide the client with a rationale for an overview of the technique.
During this step, the counsellor explains the difference between self-enhancing and self-defeating inner dialogue and shows the connection between self-statements and feelings and behaviors. Of course, it is important to take into account the cognitive developmental level of the client; in the present case, the explanation was provided through the medium of a skit utilizing a stuffed animal. The plot was simple: A teddy bear who had not been invited to an animal picnic was saying, “No one likes me,” and consequently became even more sad and unhappy. At first the counsellor provided the action and dialogue; the skit was then repeated with the child controlling and speaking for the animal. The counsellor then showed another bear, but this time the internal dialogue was, “I have been left behind and I don’t like it, but maybe I can find some way that I can have fun too. ”Adam agreed that the second bear was less unhappy. Adam was then asked to create a happier (or “smart”) dialogue for a bear who had been left behind. His bear said, “I don’t know why they didn’t invite me to the picnic, but I should find some new friends who won’t leave me behind.”

2. The counsellor helps the child to describe the problem situation and identify his or her thoughts at the time.
The counsellor asked Adam to describe the problem situation, asking him to relate what he saw and heard. Depending on the verbal skills of the child, a variety of media, including drawing, puppetry, and role-play, may be used to arrive at a complete description of the events and the child’s thoughts. In this case, Adam related that “Chris called me names. He is not my friend; he doesn’t like me!” Adam was then asked, “You mean Chris told you he doesn’t like you?” Adam conceded that he had not heard this but merely assumed it, based on the name calling. The counsellor then asked Adam to describe what he thought when he was called a name. He readily responded, “I didn’t like it,” but was at a loss to identify further thoughts. At this point the counsellor used a role-play technique to re-enact the situation, and this revealed that Adam had also thought, “All the kids are always bugging me; I’ll show them!” The role play also identified that these thoughts led to feelings of hurt and anger. Adam then described what happened next: “I hit him! He deserved it! Then I got in trouble for hitting him.”

3. The client is asked to evaluate his or her thoughts as facilitating or self-defeating.
The counsellor then asked Adam to consider the outcome of his thinking that he is always being “bugged” and that he will “show them.” The counsellor asked Adam to consider whether thinking in this way helped him get what he wanted or created a further problem for him. Adam readily saw that thinking that he “will show them” led him to hit Chris, which got him into trouble with his worker as well, making him feel even worse.

4. At this point the counsellor introduces the concept of coping thoughts and helps the client develop some “smart” thoughts that are more helpful.
The connection between thoughts and feelings and behavior was again explained to Adam, this time with specific reference to his problem. The counsellor explained, “Adam, remember the two bears who were left behind from the picnic. Remember you told me that the bear who had the smart thoughts felt happier. Well, that’s how it works with people, too. When someone does something you don’t like – calls you a name, maybe – how you feel depends on what you tell yourself. You said to yourself that everybody always bugs you and you felt even more unhappy, so unhappy that you then hit Chris. You then got into trouble, which made you feel even worse. Now, you could think some smart thoughts instead, like the bear, and you won’t feel as bad. You may not like being called a name but you won’t feel as bad.”
Adam was then asked if he could think of a smart thought when Chris called him a name. With some help from the counsellor, he finally came up with, “I don’t like it when kids call me names but at least they don’t pick on me as badly as they do on Brian. I am not going to let them get me so angry that I get into worse trouble; I’ll stay in charge of my own feelings and behavior.”

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.
Adam was provided an opportunity to practice using smart thoughts through role play with the counsellor. A situation in which Adam was the victim of name calling was role played, with the counsellor first taking the role of Adam. The counsellor then modeled the skills for Adam: “Oh oh. Chris has just called me a name again. He shouldn’t be doing that, he always bugs me, I’m... But wait, I’m getting angry again, I’m going to get into trouble. I better think smart thoughts. OK, start by taking a deep slow breath. Good. I am already less angry. I’ll stay in charge, I’m not going to let anyone get me into trouble. He called me a name. So what, he has done that before, I don’t like it but I can put up with it. I’m just going to tell him I don’t like it ... There, I told him. I feel better. I did it! Good job! I didn’t lose my cool!”

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.
Adam was then instructed to use the skills at least once during the week. At the next session, Adam was debriefed about the experience and reinforced for using the coping skills. Depending on the experience, Adam may be given further training in the implementation, the coping statement may be altered, or some other modification may be made.

Intervention Strategies
The foregoing example illustrates a number of strategies used in CBT. Other strategies, not illustrated, are also frequently utilized. Cognitively oriented strategies are used to help clients test the reality of their cognitions, and behavioral techniques are used to change cognitions and behavior (Freeman & Greenwood, 1987). Some of the most commonly used strategies are listed below (Corey, 1986; Cormier & Cormier, 1985; Freeman & Greenwood, 1987).

1. Clients may be asked what evidence they have for certain beliefs. In the example above, Adam assumed, but had no evidence, that Chris did not like him.

2. Clients may be asked to generate and examine a list of options and choices. For example, Adam may have thought that he had no option but to get angry and strike out.

3. Clients may be asked to visualize an event in their mind’s eye. Such cognitive rehearsal can enhance performance. It could, for example, have been used in the example above, just prior to actual implementation of the coping skills.

4. Actual performance can be rehearsed, as was the case in the preparatory role play in the example.

5. Modeling by the counsellor can help clients obtain a concrete idea of the skill being taught and is also an effective method of teaching.

6. Relaxation, meditation, and breathing exercises can help clients gain control over, or at least reduce, stress and anxiety.

7. Positive reinforcement is useful in increasing the probability that newly learned skills will be used again. In the example above, Adam is taught to provide reinforcement for himself immediately after using the skills, and the counsellor provides reinforcement at the beginning of the next session.

Considerations in Using Cognitive-Behavioral Approaches with Children and Adolescents
Cognitive behavioral approaches were initially designed for adults, but very early on Ellis adopted his approach for work with children (Grieger & Boyd,1980). Since then, both RET and CBT have been applied to a wide range of child and adolescent problems. Although the basic tenets of these therapies remain unchanged, a number of unique issues do arise and need to be taken into account when implementing these approaches in work with young people. Among these are the nature and quality of the therapeutic relationship, the developmental stage reached by the young person, and the ecological context of the problem.

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.

CONCLUDING COMMENTS
Cognitive-behavioral approaches have been used with good results to help young people with a wide range of problems. These approaches make use of concrete, relatively specific interventions and, because of the way target problems are identified, appear to have very good evaluability. Their principal techniques are logical and straightforward, making it feasible to teach the skills both inservice and preservice. These features ensure that the approaches have considerable applicability in work with children and suggest that they are practical to implement within child and adolescent services.

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