Terminating Therapy and Referrals

Cognitive behavioral therapy (CBT) is an efficacious and efficient intervention; as such, closure encompasses an essential part of intervention planning. Chapter 9 discusses closure: how to graduate clients from CBT, arrange booster sessions, ethically terminate CBT, and, if needed, progress clients to a higher level of care. It describes reasons for why clients may become demotivated for treatment and demystifies insurance coverage and co-pays. For clients with more severe issues, Chapter 9 explains the many referral options available, like in-home family services, outpatient clinics, intensive outpatient services, partial hospitalization, acute inpatient hospitalization, and residential treatment facilities. The chapter concludes with a discussion of psychopharmacology and incorporates a multidisciplinary, consultative approach throughout.

CBT Applications in Schools

Anxiety, depression, substance use, conduct disorders, attention-deficit/hyperactivity disorder, and learning disorder are but a subset of problems that youth experience throughout their lives. Chapter 1 presents the school-based practitioner as a first-line interventionist for these difficulties. Framing school-based care within a multi-tiered system of support, Chapter 1 introduces cognitive behavioral therapy (CBT), an evidence-based intervention with flexible applications for children and adolescents. It acknowledges the complex intersection between CBT, 504 plans, and Individualized Education Programs; discusses the many ways students may receive services under the law (and otherwise); and highlights the details of school-based practice integral to evaluating these plans. Chapter 1 ends with a thorough case presentation complete with background information, interviews, behavior and symptom assessment, CBT session planning, and outcome data.

Theory and Research

Cognitive behavioral therapy (CBT) was created by two central figures, Albert Ellis and Aaron T. Beck, both of whom contributed uniquely to its contemporary formulation. Since its inception, CBT’s research and clinical applications have spanned thousands of scientific papers and assisted many more children, adolescents, and families. This chapter discusses CBT’s theoretical development and the differing and converging views of its central theorists and describes three major theoretical conceptualizations: rational-emotive behavior therapy, cognitive therapy, and a general model. This chapter then reviews CBT’s research effectiveness for a wide range of internalizing and externalizing disorders, including anxiety, depression, autism, oppositional defiant disorder, and attention-deficit/hyperactivity disorder. It concludes with a case study delineating the two major theoretical approaches.

Core CBT Components

Chapter 7 presents another core cognitive behavioral therapy (CBT) skill: CBT with exposure and response prevention, a first-line treatment for obsessive-compulsive and anxiety-related disorders. After briefly highlighting the efficacy research for children and adolescents, this chapter describes the technique’s theoretical framework, explains it in detail, addresses common misconceptions, and guides practitioners in developing customized fear hierarchies for students. Next, the chapter carefully describes the technique’s trauma applications, including trauma narratives and in vivo exposures. Differences between treatments for anxiety and trauma are noted, as well as complexities that arise from complex trauma. The chapter concludes with a discussion of trauma-focused CBT in schools and stepped-care models and provides a detailed case study.

Psychoeducation, Relaxation Training, and Mindfulness

Chapter 5 presents fundamental counseling skills that are easily implemented within a cognitive behavioral therapy framework: psychoeducation, motivational interviewing, relaxation training, and mindfulness. The chapter offers a brief historical note on each technique, an evaluation of its research support, and authentic client–therapist dialog that emphasizes its utility and key elements. Each technique is discussed within the context of cognitive behavioral theory, including its overall effect on intervention outcomes and applicability for different referral problems. This chapter’s appendix material includes practical school-based resources for practitioners seeking to apply these techniques in session (detailed breathing, muscle relaxation, and guided imagery scripts) along with multimedia resources for children and families.

Culturally Responsive Mental Health Services

Chapter 4 guides readers in applying cognitive behavioral therapy within culturally responsive mental health services, a cornerstone to individualizing student mental health services. The chapter begins by identifying who a therapist’s clients are and then delves into the many developmental considerations and stages that children and adolescents progress through to adulthood. The author acknowledges that in addition to a developmental perspective, addressing treatment barriers for youth in the minority also entails more culturally aware practitioners who understand, respect, and value their clients’ cultural strengths. The chapter concludes with two case studies that show readers how these elements coalesce into culturally responsive mental health services.

Integrating Technology into School-Based Interventions

Cognitive behavioral therapy (CBT) was formulated well before the first cellphone hit the market, but computer- and smartphone-assisted applications are increasingly popular. Chapter 8 reviews the rationale for incorporating technology into CBT and the research supporting it. It includes detailed considerations for selecting mobile apps for behavior change, mindfulness, and therapy/self-help goals and offers advice on how to utilize them with students and teachers. Select apps are described in detail, along with their pros and cons and utility for specific presenting problems. The chapter concludes by acknowledging some limitations of mobile apps and presenting a case study that applies mobile apps in a school-based session.

Core CBT Components

Chapter 6 describes two core components of cognitive behavioral therapy (CBT): behavioral activation and cognitive restructuring. These two components are viewed as first-line interventions for depression and mood disturbances. Chapter 6 begins by describing behavioral activation and walking practitioners through each step of the intervention process. It describes how practitioners can assist clients to identify their values, monitor their activities, and build behavioral activation hierarchies to address demotivation, anhedonia, and maladaptive thoughts. The second part of the chapter discusses cognitive restructuring, whereby children and adolescents learn how to evaluate evidence for their thoughts, create thought records, and assess the validity of their thoughts. The efficacy of both techniques is reviewed, as well as progress-monitoring strategies.

Counseling Preparation

All counselors have to start somewhere, so Chapter 3 opens by describing the broader ethical and legal considerations an effective school-based practitioner must understand before initiating cognitive behavioral therapy (CBT). Special attention is paid to the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA), in addition to the careful attention practitioners must pay to these laws when serving students with medical needs. Chapter 3 highlights important ethical principles that school psychologists often abide by, including confidentiality and mandated reporting. Next, Chapter 3 introduces basic counseling skills that all practitioners can benefit from. These micro skills, like how to build a strong therapeutic alliance and how to listen, observe, and ask questions, are essential to maximizing CBT’s effectiveness.