Flexibility Within Fidelity

Abstract

The American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, and the American Psychological Association emphasize the importance of evidence-based practice. The central theme for all three groups is the integration and implementation of the best available research within the provision of optimal clinical services. Consistent with this mission, research has evaluated the efficacy and effectiveness of a variety of interventions for a range of mental health problems. Based on criteria detailed by Chambless and Hollon, a treatment is considered to be ‘‘empirically supported’’ when it has been shown to be efficacious for a particular disorder in controlled clinical trials across multiple research settings. Manual-based protocols for psychiatric treatment hold great promise for increasing evidence-based practice. This column addresses concerns regarding manual-based treatments and contends that many of these concerns arise from misperceptions about how these treatments are optimally implemented in practice. We illustrate the flexible application of manuals through the examples drawn from the Coping Cat program, a cognitive-behavioral therapy (CBT) for anxiety problems in youths that has been found to be efficacious. These examples underscore the importance of implementing manual-based treatments within the context of a child-centered, individualized approach to facilitate the child’s involvement in the treatment process. CBT for anxiety disorders in youth has received a great deal of empirical attention. CBT emphasizes the relations between thoughts, feelings, and behavior and uses cognitive restructuring, problem-solving strategies, relaxation exercises, and, of great importance, graduated exposure tasks to help the child master and manage distressing anxiety. Results from randomized controlled trials suggest that children assigned to CBT are significantly more improved after treatment compared to those assigned to a waitlist condition. Approximately 50% to 65% of children no longer met criteria for their principal anxiety disorder after 16 weeks of CBT, and gains have been reported to be maintained several years after the completion of treatment. Using the established criteria for determining whether a treatment is empirically supported, several reviews have concluded that CBT is an efficacious treatment for youth anxiety. Although several versions of CBT for youth anxiety have been developed and evaluated empirically, the core components of each treatment are akin to one another. This article focuses specifically on the Coping Cat program as one example of CBT for youth anxiety. The Coping Cat program is a manual-based CBT for children, ages 7 to 13 with generalized anxiety disorder, separation anxiety disorder, and/or social phobia. The treatment is divided into two segments, each of which consists of approximately eight 1-hour sessions. The first segment focuses on skills training, whereas the second segment emphasizes exposure tasks that place the child in/expose the child to anxiety-provoking situations. To facilitate the learning and recall of several skills, the Coping Cat program presents the steps of anxiety management through the use of an acronym (the FEAR plan). The ‘‘F’’ step of the FEAR plan, ‘‘Feeling Frightened?,’’ involves identifying bodily reactions that accompany anxiety and gaining an awareness of and control over physiological and muscular anxiety through Accepted March 3, 2008 Dr. Kendall, Ms. Furr, and Ms. Sood are with Temple University; Dr. Gosch is with the Philadelphia College of Osteopathic Medicine. Correspondence to Dr. Philip C. Kendall, Department of Psychology, Temple University, Weiss Hall, 478, 1701 North 13th Street, Philadelphia, PA 19122; e-mail: pkendall@temple.edu. 0890-8567/08/4709-0987 2008 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/CHI.0b013e31817eed2f E V I D E N C E B A S E D P R A C T I C E John D. Hamilton, M.D., M.Sc.