What is CBT?

If you’ve done any Google™ or WebMD™ searches on helping kids with stress and anxiety, you may have found articles that say that “CBT is a recommended treatment” for childhood anxiety. And of course the next question would be, “what is CBT?” but there are rarely any clear answers that follow. Here’s my attempt at an answer:

CBT stands for Cognitive-Behavioral Therapy. It is a type of talk therapy. In this type of therapy, a therapist helps the patient see how they may be thinking (cognitive) about things in a way that is not helpful and help them see things that they are doing (behavioral) that may be holding them back. The goal of the treatment is to (1) help the person understand their own patterns, (2) think more accurately about their situations, and then (3) plan actions that will help them reach their goals. In the course of the therapy, the therapist should help them practice their new “skills” in real-world situations.

For anxiety, CBT must include one important component – and that is what is called “exposure.” Exposure just means practice doing things that have been avoided, in small steps, in real-world situations, with the help and guidance of the therapist. If you are working with a CBT therapist for help with anxiety, this should be a major part of the treatment.

How long does CBT for anxiety take?
CBT for anxiety is short-term, which means it typically involves 8-14 sessions (2-4 months of weekly or every other week visits) and it is very goal-oriented - the goal being to reduce symptoms and improve functioning in the target areas. If there are multiple problems (like depression and anxiety) or the symptoms of anxiety are very severe and it has been going on for many years, it may take longer than 14 sessions, but you should be able to start seeing positive changes within the first couple of months.

In other words, you would not be sitting on the couch talking with your therapist about your week and problem solving day-to-day issues for the next few years. We call that “supportive counseling” which can be a very helpful and important form of support, but this would not be considered active CBT.

Here’s an example of CBT for Social Anxiety:
1. Cognitive work - they will uncover with their therapist the thoughts that frequently pop-up that intrude and cause anxiety, such as “I won’t know what to say,” “I’ll mess up and everyone will make fun of me.” Then together they will think of more helpful and accurate thoughts like “I’ll be nice to them and then if they are not interested, no big deal, I’ll find other things I enjoy doing and maybe someone else will want to play what I’m playing.” Or “Everyone messes up, and people aren’t really paying attention to what other people are saying,” “mean kids might laugh but they’re being mean to everyone and they’re doing it for attention – it’s not really about me.”

2. Behavioral Practice - They will uncover the things they may have been doing to avoid these types of feelings and situations, such as, sitting in the library during recess, or staying home from school on the day of the presentation. The therapist will explain that avoiding these situations actually makes the anxiety stronger, even though it feels better in the moment. They will plan practices (or exposures) that involve doing the things they have been avoiding in small steps. In the case of speaking in front of class, the child may practice reading out loud in front of the therapist, then reading a presentation off of note cards in front of the therapist, then doing the same presentation in front of a family member and the therapist, then at home in front of a few family members for “CBT homework,” then doing the same presentation while the therapist records on a camera, and if needed, they can do the presentation in front of the teacher during study hall for a practice. By the end of all of this practice NOT avoiding the presentation, the child will feel less anxious and more ready to do the presentation in front of class.

Important parts for Parents
In CBT for anxiety in kids, parents are very much part of the team. Parents are shown how to encourage practice and not give-in to avoidance or reassurance at home. In this example, if parents were asking the teacher for accommodation to write the report instead of read it in front of class, or let the child miss school on presentation day, the therapist would help them encourage practice of small steps (like have them practice in front of them a few times, then ask the teacher if they can practice 1:1 first before doing it in front of the class) instead of avoidance.


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