Academic journal article Journal of Cognitive Psychotherapy

Differential Sequencing of Cognitive-Behavioral Techniques for Reducing Child and Adolescent Anxiety

Academic journal article Journal of Cognitive Psychotherapy

Differential Sequencing of Cognitive-Behavioral Techniques for Reducing Child and Adolescent Anxiety

Article excerpt

Treatment outcome research has rarely allowed investigators to declare how or why therapeutic techniques work. As an initial step to understand such change processes, the current study investigated the timing of positive changes typically achieved during a course of cognitive-behavioral therapy for anxiety reduction. Using an interaction element multiplebaseline design across four children (N = 4) diagnosed with selected anxiety disorders, anxiety levels, cognitive errors, and treatment outcome were repeatedly assessed as children progressed through four a priori determined treatment sequences. Results varied across reporters, dependent variables, and the order in which each treatment technique was delivered. Child-reported trends were slightly clearer than those reported by parents and suggested that exposure was a key element for triggering some (but not all) positive changes after completing self-monitoring and psychoeducation techniques.

Keywords: mechanisms; anxiety; cognitive behavior therapy; single subject design

Child and adolescent psychotherapy research has advanced considerably in the past few decades. Kazdin (2000a) reported that more than 1,000 controlled outcome studies can be identified, and meta-analytic reviews of such studies have identified treatments that produce strong effects (Hoag & Burlingame, 1997; Weisz, Weiss, Han, Granger, & Morton, 1995). Psychotherapy research has progressed to the point where one can differentiate between many treatments based on the strength of evidence for their efficacy. Furthermore, evidence-based treatments have been identified for several areas of clinical concern including anxiety, depression, and conduct disorder (Kazdin & Weisz, 1998; Lonigan & Elbert, 1998).

Despite these marked and impressive gains, most between-group research investigations (e.g., Barrett, 1998; Barrett, Dadds, & Rapee, 1996; Cobham, Dadds, & Spence, 1998; Kendall, 1994; Kendall et al., 1997; Silverman et al., 1999) are largely restricted to identifying relations between various treatment and control conditions and outcomes. Kazdin (2001a) referred to this type of research investigation as descriptive research and distinguished it from explanatory research. Descriptive research examines relations between an intervention and a therapeutic outcome, whereas explanatory research "includes an explicit component that focuses on mechanisms, understanding, processes, and why effects are achieved" (Kazdin, 2001a, p. 62).


Scant attention has been given to explanatory research, and research to date has largely ignored theory and change processes (i.e., processes that explain exactly how psychotherapy works). As Kazdin (2000b, p. 340) points out, "there is very little evidence available to explain how therapy works, even among well-suited treatments." For example, within the adult literature, cognitivebehavioral therapy (CBT; American Psychiatric Association [APA], 2000b) has emerged as an evidence-based treatment for depression. This treatment is based on the theory that cognitive schemata contribute to and account for depression and that changes in schema (and related processes) ameliorate such feelings (Kazdin, 2000b). Outcome data from randomized clinical trials (RCTs) currently cannot explain why CBT works for depression (Kazdin, 2000b, 2001a; Kazdin & Nock, 2003). Specifically, RCTs usually do not allow for the identification of specific mechanisms of change because the proposed mechanism (e.g., change in cognitions or schema) and outcome (e.g., depressive symptomology) are assessed at the same time, namely, at pretreatment and posttreatment.

The study of change in therapy requires assessment during the course of treatment to establish a timeline in which a change in a proposed process precedes therapeutic change (Kazdin, 2000b; Kazdin & Nock, 2003). Demonstrating a causal relation (as in traditional RCTs), therefore, is not sufficient in and of itself to identify a mechanism of change. …

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