Posted: February 15th, 2023

Case Study 3: anxiety disorders

Please read the following chapter and respond to the following questions.

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Manualized Cognitive theraphy for anxiety nd depression.pdf

. What are the pros and cons of using a CBT treatment manual with adults?

Discuss fidelity with flexibility.

2. What is an automatic negative thought that you “catch” yourself saying to yourself in times of stress?

3. CBT requires collaboration and active participation from the participant. If you are working with a highly anxious adult female patient, what strategies might you use to help her cope with the anxiety using this modality?

4. With the content of the sessions described and the skills taught, what do you think will be the more challenging skills? Please use examples and cite the literature?

9 Manualized Cognitive Behavioral Therapy: An Adolescent With Anxiety and Depression Pamela Lusk


I had an exceptional psychiatric nursing rotation on a small adolescent unit at a private psychiatric hospital in the late 1970s during my bachelor of nursing degree program. My psychiatric nursing instructor and the psychiatric inpatient treatment team, which included a psychiatric clinical nurse specialist, were inspiring. I found working with this population to be the most interesting rotation of my nursing education, and I knew when I graduated that my goal was to practice psychiatric nursing with older children and adolescents. Soon after graduation, I was hired as the adolescent team nurse at a psychiatric hospital for children and adolescents. I loved my work there and became increasingly interested in learning more and expanding my role in this specialty area of psychiatric nursing.

A few years later when exploring options for graduate school, I found a master’s degree program in psychiatric nursing that prepared students to conduct psychother- apy with adults during the first year and, with faculty approval, to specialize in con- ducting psychotherapy with children and adolescents during the second year of the program. After starting the program, I was approved for the second year in the child and adolescent specialty and was able to register for courses in child psychotherapy and developmental psychology in the university’s clinical psychology graduate program. During my second year of specializing in children and adolescents, half of my time was spent working on an inpatient children’s unit where I was supervised by a psychiatrist with a psychoanalytic play therapy background and the other half of my time was spent working in the community with adolescents where I was supervised by a clinical psy- chologist, who was an expert in developmental psychopathology and the author of our developmental psychopathology textbook. After graduation with my master’s degree in psychiatric nursing, I became certified as a child and adolescent psychiatric clinical nurse specialist. Since then, I received a post-master’s degree in a psychiatric-mental

Copyright Springer Publishing Company. All Rights Reserved. From: Case Study Approach to Psychotherapy for Advanced Practice Psychiatric Nurses DOI: 10.1891/9780826195043.0009


health nurse practitioner program and became certified as a psychiatric mental health nurse practitioner (PMHNP). For the past 15 years, I have practiced as a PMHNP at a variety of primary care settings where I have integrated behavioral health into primary care. Currently, I am the PMHNP at a large pediatric medical practice and see children and adolescents from our practice as well as those who are referred from other commu- nity agencies and practices for behavioral healthcare.

Ten years ago, I decided to go back to graduate school for a doctorate in nursing prac- tice (DNP) degree. While reviewing the literature on evidence-based psychotherapy for adolescents with depression, my topic for my clinical scholarly project, it became very clear to me that cognitive behavioral therapy (CBT) had the strongest evidence of sup- port for the first-line treatment of adolescents with anxiety and depression. At that time, I only had a rudimentary understanding of this therapeutic approach. Consequently, I attended an introductory training in CBT and began to use the approach with teens I was working with at a community mental health center. Experiencing great outcomes with the teens I saw for depression, I decided to obtain further training. I completed the Beck Institute training in CBT with children and adolescents in 2011. I have attended additional trainings at the Beck Institute since that initial training and continue to learn more with each course. In a primary care setting, most of my referrals are for teens experiencing anxiety and depressive symptoms that are significantly impairing their functioning at school, home, or in social situations. CBT is an evidence-based approach indicated for this population with these types of problems.


Aaron Beck (1921–) and Albert Ellis (1913–2007) are recognized as the fathers of CBT. Aaron Beck, an American psychiatrist and professor emeritus in the department of psy- chiatry at the University of Pennsylvania, found in his work as a psychoanalyst in the 1960s that his clients with depression had automatic negative thoughts about certain situations they encountered. He discovered that the content of these thoughts fell into three categories that he eventually called the cognitive triad of depression: negative ideas about oneself, negative ideas about the world, and negative ideas about the future (Beck, 2011). Beck found that he could lessen the depressive symptoms of his clients by helping them identify and evaluate these negative thoughts and develop alternative, more prob- able thoughts. By doing so, clients were able to think more realistically, feel better emo- tionally, and behave more functionally. CBT soon after became a model of psychotherapy with principles and strategies for implementation and eventually many outcome studies to support the approach (Beck, 2011). Since that time, Beck and his colleagues have found CBT to be efficacious in treating a wide variety of disorders in addition to depression including anxiety disorders, bipolar disorders, personality disorders, psychotic disor- ders, and substance use disorders, among others. In addition, CBT has been shown to be very effective in working with children and adolescents (Beidas & Kendall, 2014).

Albert Ellis, an American clinical psychologist, was first trained as a psychoanalyst like Aaron Beck. Ellis became dissatisfied with aspects of the psychoanalytic method and developed Rational Therapy in the 1950s. His approach focused on helping clients understand their self-defeating irrational beliefs (rational analysis) that led to upset- ting emotional consequences and behaviors and then develop more rational constructs (cognitive reconstruction) and functional behaviors. His well-recognized ABCD model specified that it is not the activating event that causes the upsetting emotions, but the irrational beliefs (self-talk) about the event.


• A is the Activating Event • B is the Self-Talk or Irrational Beliefs about the event • C are the Upsetting Emotional Consequences • D is the Disputing of the Irrational Idea

During his life, Ellis authored over 75 books for professionals as well as the lay public. He founded The Institute for Rational Living in 1959 to train other therapists and to pro- vide therapy for clients in the community. In 1993, he changed the name of his therapy to Rational Emotive Behavior Therapy (REBT). His institute continues to thrive in New York City and is now known as The Albert Ellis Institute: The Home and Headquarters of Rational Emotive Behavior Therapy.


CBT is a structured, short-term, present-oriented psychotherapy, which is well received by adolescents and their parents. Adolescents are, according to Piaget’s theory of cogni- tive development, in the formal operations stage—the stage in which the young per- son gains the ability to think abstractly and draw conclusions about information. Using one’s cognitive abilities to problem-solve and identify coping strategies in therapy fits well with this cognitive developmental level described by Piaget. Erikson’s psychoso- cial theory of development emphasizes mastery of developmental tasks. For the ado- lescent, the task is identity versus role confusion, which is the ability to understand oneself and others, the ability to see oneself as a unique and integrated individual, and the ability to have success in relationships with others (Adler-Tapia, 2012). Adolescents are very interested in exploring where they fit in the world; thus, the self-exploration required in CBT is appealing to them.

In CBT, the therapist works with clients on cognitive restructuring, problem- solving, and behavioral activation. Cognitive restructuring refers to identifying, evaluating, and modifying faulty thoughts and beliefs that are responsible for negative mood states. Adolescents are curious about their thinking and beliefs of others. They develop skills in challenging beliefs and coming up with creative ways to solve problems. When they apply CBT skills to their own cognitions, clients learn to solve their own prob- lems. Behavioral activation is the identification of activities that are pleasurable and then increasing these activities in their life. This allows teens to express their individual preferences and choices for activities, develop skills in those activities, and increase time in those activities that are fun and interesting for them. They often learn to experi- ence these activities as “being in the zone”—a time where usual worries don’t intrude (Adler-Tapia, 2012).


CBT is based on a cognitive theory of mental health and psychopathology. CBT believes that mental health is the result of sound information processing that manifests itself in realistic and accurate thinking, which leads directly to appropriate emotions and adap- tive behaviors. In contrast, psychopathology is the result of faulty information process- ing that reveals itself in distorted and dysfunctional thinking, which leads directly to negative emotions and maladaptive behaviors (Beck, 2011).



  1. Pros and cons of using a CBT treatment manual with adults:


  • The manual provides a structured, standardized approach to treatment, which can be beneficial for inexperienced therapists.
  • The manual ensures that all participants receive the same treatment, which can improve treatment outcomes and research findings.
  • The manual can be used as a teaching tool for therapists to learn and improve their CBT skills.


  • The manual may not be flexible enough to meet the unique needs of each individual participant.
  • The manual may not cover all the relevant issues that need to be addressed in therapy.
  • The manual may become too rigid and prevent the therapist from adapting to the participant’s changing needs.

Fidelity with flexibility:

Fidelity refers to the degree to which the therapist adheres to the treatment manual, whereas flexibility refers to the ability of the therapist to adapt the treatment to meet the unique needs of each participant. Fidelity and flexibility are both important in CBT. On one hand, fidelity ensures that the core components of CBT are being delivered, and that the treatment is evidence-based. On the other hand, flexibility allows the therapist to tailor the treatment to the participant’s specific needs, which can enhance engagement and improve outcomes.

  1. An automatic negative thought that one might say to themselves in times of stress is “I’m not good enough” or “I can’t handle this.”
  2. Strategies that may be helpful for a highly anxious adult female patient include:
  • Psychoeducation about anxiety and its physical sensations, to help the patient better understand and manage their symptoms.
  • Relaxation techniques such as deep breathing and progressive muscle relaxation, which can help reduce anxiety and promote relaxation.
  • Cognitive restructuring, which involves identifying and challenging negative thought patterns that contribute to anxiety.
  • Exposure therapy, which involves gradually exposing the patient to feared situations or objects in a safe and controlled manner, to help them overcome their anxiety.
  1. The more challenging skills in CBT may vary depending on the individual participant, but some examples might include:
  • Behavioral activation, which involves engaging in enjoyable activities to improve mood and motivation. This may be challenging for individuals who are struggling with low energy or lack of interest in activities.
  • Cognitive restructuring, which involves identifying and challenging negative thought patterns. This may be challenging for individuals who have deeply ingrained negative beliefs about themselves or the world.
  • Exposure therapy, which involves confronting feared situations or objects. This may be challenging for individuals who have high levels of anxiety or avoidance behaviors.

Literature has identified that therapist competence and participant engagement are critical in determining the effectiveness of CBT interventions. It is important for therapists to balance fidelity with flexibility to meet individual needs while ensuring treatment adherence to core components.

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