What to Expect in Cognitive Behavioural Therapy (CBT)
by Dr Jacqueline Sperling, PhD
You have decided to pursue CBT for your child with an anxiety disorder, and understandably, it can be anxiety-provoking not knowing what to expect. Below is what to anticipate from someone, who practices CBT.
CBT is a collaborative treatment. You and your child present with a tremendous amount of expertise on the symptoms, and the provider has an expertise in the treatment. Everyone needs to pool their knowledge and work together to address the anxiety. CBT providers will be transparent and share the rationale for each technique described. The aim is to empower the child to be its own therapist and expert in CBT.
Feedback will be elicited regularly as a therapist will want to make sure that your family is getting the most out of treatment. Please feel free to share what went well and what did not to maximize the treatment experience.
An initial meeting may be longer (e.g., 100 minutes) than the duration of a weekly session (e.g., 50 minutes) for the provider to conduct a diagnostic evaluation (also referred to as an assessment). Information typically is collected from caregivers and the child, and a treatment plan next will be established using measurable goals.
After the initial evaluation, the weekly therapy sessions will begin. Treatment may include 12-16 weekly sessions but can continue for longer if there were a need. Depending on the presenting issue and developmental stage of the child, the provider may start a session with the child individually and then have a caregiver join for the remaining 10 minutes.
At the beginning of each session, the provider will set an agenda. The agenda will start with a mood check to facilitate the child’s identification of feelings as well as an action plan review, one that goes over the activity assignments from the previous session. Next, the provider may teach a new skill and have the child practice it. Afterward, an action plan assignment that entails practicing the skill during the week will be developed. At the end of the session, the child often will help teach the skill learned that day to the caregiver. The action plan will be reviewed, and rewards for effort in the session and action plan completion will be provided. Using a reward system can facilitate motivation.
Exposure and Response Prevention (ERP)
A key element of CBT for many anxiety disorders is ERP, a technique that helps children face their fears gradually during exposures.
Imagine a child’s fears as a swimming pool on a chilly day. A CBT clinician will not ask a child to jump into the deep end as that would be a shock to the system. Instead, a child will start with a big toe, or one step toward approaching a fear, and dip it into the shallow end.
The temperature may feel cool at first, and after a few minutes, the child will learn to adjust to the temperature of the water and that the child could do it. Next, the child may dip another toe into the water.
Afterward, the child may stick both feet in the water, and so on and so forth, until the child has dunked its head and reached the deep end. The child got its whole body wet just like the child could have done by jumping into the deep end; however, ERP allows the child to ease into the process and give the child time to realize that experiences may not be as challenging as expected and/or that the child can handle them.
Children are taught the models of how exposures work and how to engage in an exposure effectively. Some key terms that children will learn include the subjective units of distress (SUDS) scale, the inhibitory learning model, and safety behaviors.
You already are helping your child take a very brave step by pursuing this treatment. CBT goes at the child’s pace and hopefully will help your child engage in daily activities.
About the author of this blog
Jacqueline Sperling, PhD, is a clinical psychologist, who specializes in implementing evidence-based treatments, such as cognitive behavioral therapy (CBT), and in working with youth who present with anxiety disorders and Obsessive-Compulsive Disorder (OCD). In addition, she is experienced in providing parent guidance on how to manage children with internalizing and externalizing behavior issues.
Currently, Dr. Sperling is the Director of Training and Research at and helped develop the McLean Anxiety Mastery Program (MAMP), an intensive group-based outpatient program for children and adolescents ages 6 to 19 with anxiety disorders and OCD, at McLean Hospital. She also is an Instructor in Psychology at Harvard Medical School and Harvard Extension School and has a private practice in Cambridge, MA.
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