Abstract
Social anxiety disorder (SAD) is a prevalent mental disorder among adolescents, often causing significant impairments in social and academic functioning with a broad pattern of fear and avoidance. Cognitive-behavioral therapy (CBT) has been shown to be an effective treatment for SAD with more than 20 randomized controlled trials. Specifically, the present case study utilized the C.A.T. Project (adolescent version of Coping Cat), which is a widely studied and commonly used treatment for youth anxiety disorders. Treatment consisted of 22 sessions over 11 months with a 14-year-old Caucasian female with outcome data demonstrating some significant reductions in anxiety. However, the client terminated prior to finishing the C.A.T. Project manual. As such, this case study emphasizes complicating factors, potential benefits and drawbacks of manual modifications, and resulting treatment implications for clinician consideration.
1 Theoretical and Research Basis for Treatment
Anxiety disorders are common among children and adolescents with studies estimating prevalence rates between 10% and 20% (Kendall, Crawford, Kagan, Furr, & Podell, 2018). For social anxiety disorder (SAD), the 12-month prevalence rate among children and adolescents in the United States is comparable to the estimates for adults (7%) and, generally, females have higher rates of SAD with this sex difference being more pronounced in adolescents (American Psychiatric Association, 2013). Anxiety disorders come with public health implications due to their impairing nature (Ginsburg et al., 2014). For youth, these are often considered gateway disorders because they predict adult psychiatric conditions (Kendall et al., 2018) and can lead to chronic anxiety, depression, suicidal ideation, suicide attempts, and substance abuse if left untreated (Kendall et al., 2010). In particular, childhood anxiety disorders often precede the development of depression (Kendall, Safford, Flannery-Schroeder, & Webb, 2004). Anxiety disorders in youth are also associated with functional deficits in interpersonal relationships (e.g., peer relationships) and reduced academic achievement (Kendall et al., 2018). Furthermore, the majority of childhood anxiety disorders do not remit over time without treatment (Kendall et al., 2004). In addition, types of anxiety disorders in youth (e.g., social anxiety, generalized anxiety, separation anxiety) tend to be highly comorbid with a recent study finding that 22% of a sample of anxious youth met criteria for only one anxiety disorder while 42% met criteria for two anxiety disorders and 36% met criteria for three anxiety disorders (Kendall et al., 2010).
The primary diagnostic criteria for SAD is persistent, excessive, and frequent worry about social situations that may involve scrutiny by others (American Psychiatric Association, 2013). Individuals meeting diagnostic criteria must fear negative evaluation (e.g., embarrassment, rejection, offending others) that is disproportional to the actual threat from the situation. The median age of onset is 13 years (American Psychiatric Association, 2013). The likelihood of developing SAD makes sense in context given the rapid changes in social, familial, and biological systems that occur during childhood development combined with a still-developing understanding of risk, capacity to regulate emotions, and management of social expectations (Kendall et al., 2010). As compared to younger children, adolescents tend to endorse a broader pattern of avoidance and fear, including around dating and romantic relationships (American Psychiatric Association, 2013).
Empirical Evidence for the Effectiveness of Cognitive-Behavioral Therapy (CBT) for SAD
The efficacy of CBT for treatment of childhood anxiety disorders, including SAD, is well established (Compton et al., 2014; Kendall et al., 2018). More than 20 randomized controlled trials (RCTs) of CBT for child and adolescent anxiety disorders suggest that CBT is effective for reducing symptoms of anxiety, functional impairment, and comorbid diagnoses (Compton et al., 2014; Peris et al., 2015). The Child/Adolescent Anxiety Multimodal Study (CAMS) was a large RCT comparing the effectiveness of CBT alone (delivered via the Coping Cat program), sertraline alone, a combined condition, or a placebo pill (Walkup et al., 2008). Participants in this multisite clinical trial were 488 youth aged 7 to 17 years with presenting diagnoses of generalized anxiety disorder, SAD, or separation anxiety disorder (Walkup et al., 2008). The program follows CBT theory by providing psychoeducation, teaching youth anxiety management skills (e.g., relaxation training, cognitive restructuring) and then engaging youth in behavioral exposures to situations that provoke anxiety (Walkup et al., 2008). Coping Cat targets the tripartite of anxiety: somatic, cognitive, and behavioral components (Kendall et al., 2018). This study found that Coping Cat achieved effectiveness levels of 59.7% for “very much” or “much” improved on a clinician-rated improvement scale (Walkup et al., 2008). With the CAMS study, initial remission rates after 12 weeks of treatment ranged from 20% to 46% (Ginsburg et al., 2011), and almost half the sample was in remission regardless of intervention arm 6 years after treatment (Ginsburg et al., 2014). Due to these rates of effectiveness, Coping Cat and its sister program for adolescents (C.A.T. Project) are regarded as “well-established” treatments for youth anxiety (Peris et al., 2015).
2 Case Introduction
“Olivia” was a 14-year-old Caucasian female who turned 15 during the course of treatment. Olivia lived with her mother, stepfather, and stepsister (age 3). Olivia’s mother suggested that she attend therapy and Olivia agreed that it would be useful. Her mother expressed a desire for Olivia to have “someone to talk to,” especially in light of recent life changes (i.e., Olivia’s father reentering her life, her mother and stepfather deciding to pursue reconciliation rather than get a divorce). Her mother worked as a store manager while her stepfather worked as a janitor. The therapist was a Caucasian American female in a clinical psychology doctoral program who was supervised by a licensed clinical psychologist.
3 Presenting Complaints
Olivia presented to a community-based psychology training clinic for individual psychotherapy. Olivia reported feeling anxious, particularly with racing and illogical thoughts but denied experiencing accompanying or precipitating physiological symptoms. Olivia expressed concerns about her upcoming transition to high school and reported anxiety when at school, including test anxiety and social anxiety. She described having a voice in her head that told her to worry about things (e.g., failing a test, her father not texting her to make weekend plans). To cope with her anxiety, Olivia would “block [it out] and pretend” that nothing was wrong. In childhood, Olivia reported a specific fear of knives that made it difficult for her to enter the kitchen. She indicated that fear was currently well managed after she engaged herself in gradual “exposures” over time (e.g., gradually entering the kitchen, standing close to knives, picking up knives) with the support of her mother.
Olivia reported that she found it difficult to express herself (e.g., “shuts down” when asked about her emotions) and avoided confrontation because she feared burdening others. In particular, Olivia feared disappointing or upsetting her mother. Olivia talked about the different “parts” of herself and indicated that she felt like she could not be herself around anyone. In particular, she felt like she was expected to be sarcastic and funny at school and could not show her friends the aspects of her that were anxious or sad because her friends would no longer like or accept her. Olivia described the sad and anxious part of herself as being “curled up in the fetal position, alone, and screaming in the forest.”
In addition, Olivia’s mother expressed concerns that Olivia did not feel equally supported and cared about in the family in comparison to her younger stepsister. Olivia described wishing she had more alone time and more time with just her mother. Olivia felt like she was often tasked with playing with her sister. Olivia was visibly anxious during the intake session and rapport building phase, avoiding eye contact, fidgeting, and telling tangential stories when emotional content arose or there were brief lapses in the conversation.
4 History
Olivia was born in the Southeastern United States and then moved to the Northwestern United States, where she and her mother moved several times within the region. Olivia and her mother moved back to the Southeast 2 years prior to treatment with her stepfather and stepsister. Her mother met her stepfather when Olivia was 10 years old. Olivia described feeling that, for most of her life, it was her and her mother against the world because her mother was the only person who had consistently been there for her. Olivia described her younger sister as intense and loud. In October 2017, Olivia’s father, a repairman, briefly reentered her life after 9 years when Olivia’s mother sued him for failure to pay child support. Olivia saw her father weekly for the first few months of treatment but then he stopped reaching out to spend time with her. Olivia described her interactions with her father as “delicate” because they were both “afraid of messing things up.” She indicated that she was angry at him for leaving but was hesitant to say anything in case he left again. Olivia reported attending therapy prior to moving to Oregon to process her father leaving but could not provide additional details.
Olivia attended four different elementary schools (two in the Southeast and two in the Northwest). She described “dreading” school because of the social interactions, strict rules, and “purposeless” lecture-style learning. Olivia was enrolled in Honors classes and earned As and Bs although she was so frightened about receiving bad grades that she refused to check her report cards. She often forgot she was having an exam, quickly studied at school, took the test, and then felt anxious and assumed she did poorly as soon as she turned in the test. Similarly, Olivia reported that she was worried about attending high school but would try to “avoid thinking about it until the last minute.” This strategy of emotional avoidance was evident throughout Olivia’s life.
She described herself as introverted and preferred to read or play videogames in her room. Olivia completed extensive chores at home (e.g., cleaning the kitchen, doing laundry). While she reported having a group of friends at school, she never spent time with them outside of school and did not have a best friend. Olivia described herself as the “mom” of her friend group, focusing on others’ feelings and needs. She reported a desire to feel closer with others but indicated difficulty connecting, feeling like her brain “warns her that it is not safe.”
Olivia took no medications before or during treatment and reported an unremarkable medical history. She reported sleeping 8 hours nightly and feeling tired in the mornings. Olivia denied past or current drug or alcohol use. Olivia had no history of self-harm and denied suicidal and homicidal ideation.
5 Assessment
Prior to the first treatment session, Olivia and her mother completed the Achenbach Youth Self Report (YSR) and the Child Behavior Checklist (CBCL), respectively (Achenbach & Rescorla, 2001), and Olivia completed the Penn State Worry Questionnaire (PSWQ) (Meyer, Miller, Metzger, & Borkovec, 1990). Prior to the beginning of SAD treatment, Olivia completed the Revised Children’s Manifest Anxiety Scale–Second Edition (RCMAS-2) (Reynolds & Richmond, 2008) and the Screen for Child Anxiety Related Disorders (SCARED) (Birmaher et al., 1997). Olivia’s mother also completed a parent version of the SCARED. Olivia then completed a SCARED and RCMAS-2 every 2 weeks during treatment. The SCARED was also sent home to her mother at regular intervals but only one was returned. At termination, Olivia completed the YSR, RCMAS-2, SCARED, and PSWQ one final time. Her mother was sent a CBCL and a SCARED to complete but did not mail it back to the clinic. See Table 1 for Olivia’s self-report symptoms ratings across time points and see Figures 1 and 2 for Olivia’s scores on the RCMAS-2 and SCARED.
Olivia’s Self-Report Ratings Across Time Points and Reliable Change Index.
Note. RCI = Reliable Change Index; PSWQ = Penn State Worry Questionnaire; RCMAS-2 = Revised Children’s Manifest Anxiety Scale–Second Edition; SCARED = Screen for Child Anxiety Related Disorders; YSR = Youth Self-Report; DSM = Diagnostic and Statistical Manual of Mental Disorders.
PSWQ and YSR were first administered prior to the first treatment session; RCMAS-2 and SCARED were first administered prior to Session 11.
Score is significantly elevated.
Score falls in the borderline range for clinical significance. If no RCI is provided, it is because no norms are available for that item. PSWQ and YSR were normed based on a clinical sample of girls. RCMAS-2 was normed based on a general population sample of girls (no clinical norms available). SCARED was normed based on a clinical comparison group (no gendered norms available).
Clinically significant change at p <.05.
Olivia’s Revised Children’s Manifest Anxiety Scale–Second Edition (RCMAS-2) administration scores.
Olivia’s Screen for Child Anxiety Related Disorders (SCARED) administration scores.
Achenbach Youth Self Report (YSR) and the Child Behavior Checklist (CBCL)
The CBCL is a parent assessment and the YSR is a parallel self-report measure of emotional and behavior problems in childhood (Achenbach & Rescorla, 2001; Erford et al., 2019). The measures contain 120 items for the CBCL and 112 items for the YSR, which are scored 2 (very true or often true), 1 (somewhat or sometimes true), and 0 (not true) based on the past 6 months. Both measures are widely used and have excellent validity and reliability (Achenbach & Rescorla, 2001). Olivia and her mother demonstrated above average agreement on responses (54%). Olivia’s mother endorsed no concerns on the initial CBCL she completed; all scores were in the normal range.
RCMAS-2
The RCMAS-2, a 49-item measure with “yes” and “no” responses, is one of the most widely used assessments for children’s anxiety (Reynolds & Richmond, 2008). It assesses for physiological anxiety, social anxiety, and worry (e.g., nervousness or worrisome thoughts) while also providing total anxiety and defensiveness (e.g., willingness to admit to commonplace imperfections) scores. The RCMAS-2 has updated norms, broader content coverage in the items, and excellent psychometric properties (Lowe, 2015). Olivia turned 15 prior to the 17th therapy session, which switched her RCMAS-2 norms from the age 9 to 14 group to the age 15 to 19 group.
SCARED
The SCARED parent and child versions each consist of 41 items rated 2 (very true or often true), 1 (somewhat true or sometimes true), and 0 (not true or hardly ever true) (Birmaher et al., 1997). The measure assesses for panic disorder/significant somatic symptoms, generalized anxiety disorder, separation anxiety disorder, SAD, and school avoidance while also providing a total score. The SCARED has been shown to have high internal consistency, moderate to large test–retest reliability, and moderate to large parent–child agreement (Behrens, Swetlitz, Pine, & Pagliaccio, 2018).
PSWQ
The PSWQ is a 16-item measure of trait worry (Meyer et al., 1990) with responses reported on a Likert-type scale ranging from 5 (very typical of me) to 1 (not at all typical of me). The measure has good test–retest reliability and high internal consistency, and it is highly correlated with measures of depression, trait anxiety, and state anxiety (Davey, 1993; Meyer et al., 1990).
Diagnosis
Based on the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (American Psychiatric Association, 2013), information gathered from sessions, and scores on the RCMAS-2 and SCARED, Olivia was diagnosed with SAD. Olivia reported disproportionate fear and anxiety about feeling scrutinized that was specific to social settings and avoided those distressing emotions. This anxiety created consistent distress with regard to, and avoidance of, social interactions, had lasted for several years, and interfered with her interpersonal and academic functioning.
6 Case Conceptualization
The case conceptualization was developed utilizing a cognitive-behavioral model of SAD. Anxiety can be conceptualized as having a tripartite structure with cognitive, behavioral, and physiological components (Kendall et al., 2018). Fear and anxiety are a normal and healthy part of development with anxiety serving a healthy, adaptive, and protective function evolutionarily (Kendall et al., 2018). As such, youth anxiety becomes an issue only insofar as it interferes with daily functioning in domains such as family, school, and peer relationships. Furthermore, the conceptual model for anxiety links avoidance of feared situations with a temporary reduction in distress that serves to further both the anxiety and avoidance behavior over time (Kendall et al., 2018).
Olivia was conceptualized as an anxious and withdrawn teenager who evidenced a substantial fear of failure and connected her self-worth to her ability to perform well in school, not make mistakes, and please others. Olivia showed strengths in terms of intelligence, curiosity, and kindness, but she was prone to avoiding or ignoring her emotions and experiencing racing and illogical thoughts. She also presented as highly introverted, which led her to spend substantial amounts of time alone in her room and to avoid interactions with her family and the wider world. Olivia demonstrated good insight into herself. For example, she recalled a vivid dream from her childhood in which she was running from an erupting volcano and feeling very scared. As she looked around, she noticed no one else appeared worried. Olivia connected this dream to her anxiety, suggesting that her anxiety is like an erupting volcano and she only knows to respond by running away even though others are not scared of the things that make her anxious.
For Olivia, the cognitive and behavioral components of the tripartite structure of anxiety were much more readily apparent. She was actively struggling to deal with her cognitions around social interactions and self-worth, which led to avoidance behaviors. However, she had difficulty identifying the physiological components of her anxiety, although several were evident in the therapy room (e.g., skin picking, fidgeting), further reinforcing the conceptualization that Olivia lived in her head much of the time.
Olivia’s tendency to utilize avoidance was an important component of the conceptualization that supported the use of CBT. She avoided numerous social situations where she feared judgment or scrutiny. Furthermore, she attempted to avoid troubling cognitions (e.g., “block and pretend” that nothing was wrong), which only served to strengthen the intensity of the thoughts and their underlying misguided assumptions over time. Furthermore, Olivia evidenced difficulty connecting with and articulating her feelings, which made it challenging for her to express herself or ask for what she needed in her day-to-day life. As such, Olivia experienced herself as having different parts, many of which felt unacceptable (e.g., anxious and sad aspects of herself).
She experienced numerous transitions in her life that led her to view her mother as her only constant support, leading Olivia to worry excessively about disappointing her mother or being a burden for her. Olivia’s current home life, while a loving environment, was often chaotic. This environment led to Olivia feeling worse about asking her mother or stepfather for things because she sensed that they were overwhelmed. Olivia’s little sister took up a large portion of the airwaves in the home, leaving less space for Olivia. Olivia’s mother presented as loving and closely connected with Olivia but quickly became less involved in treatment as her work schedule shifted. Over the course of therapy, it became difficult to get in contact with her mother via phone, and Olivia was dropped off at appointments by her stepfather. Olivia expressed anxiety about walking into the clinic alone for appointments. In addition, Olivia told the therapist that she did not want the therapist to talk to her stepfather about treatment or to have her stepfather fill out assessment measures.
7 Course of Treatment and Assessment of Progress
Intervention Selection
The C.A.T. Project is a 16-session CBT program for adolescents (ages 12-18) with anxiety, focusing on psychoeducation and exposure. It is a modified version of the Coping Cat program (ages 7-13). The program was developed at the Child and Adolescent Anxiety Disorders Clinic (CAADC) at Temple University (Beidas, Benjamin, Puleo, Edmunds, & Kendall, 2010; Kendall et al., 2018). The program consists of a treatment manual for the therapist and a workbook for client use. It was created for use with separation anxiety disorder, generalized anxiety disorder, and SAD and was tailored to focus on SAD for Olivia. The program includes relaxation, identification and labeling of cognitions related to anxiety, problem solving, exposures, and homework assignments (Kendall et al., 2004). The program emphasizes teaching youth to utilize a FEAR plan:
The modifications from Coping Cat to the C.A.T. Project include (a) adjustments to the developmental level of the treatment manual and participant workbook; (b) ownership given to the adolescent to design the program to best fit themselves, including choosing the meaning of the acronym C.A.T.; (c) additional information about the nature of anxiety (e.g., what it is, where it comes from); (d) further emphasis on the strategic implementation of the FEAR plan across a range of settings; (e) inclusion of thinking traps within the lessons on cognitions; (f) less emphasis on an ability to recognize feelings because older youth are better able to identify emotions; (g) removal of progress tracking with stickers and instead allowing adolescents to accumulate points; and (h) an emphasis on encouraging independence throughout the protocol (Kendall, Choudhury, Hudson, & Webb, 2002).
Phase 1: Intake and Rapport Building
Olivia attended 22 sessions over 11 months. Therapy was scheduled weekly. She missed or canceled 14 sessions, however, due to changes in her mother’s work schedule, family travel, and other unforeseen family scheduling conflicts (will be addressed in the “Barriers to Treatment” section). The first two sessions served as intake and information-gathering sessions. Session 3 focused on discussing Olivia’s treatment goals, which were (a) managing her anxiety more effectively and (b) becoming more comfortable sharing her emotions, especially negative emotions. The therapist was in agreement with Olivia’s initial goals given her difficulties managing her anxiety in daily life, her tendency to isolate herself, and her discomfort with expressing negative feelings. Symptoms of anxiety, negative affect, withdrawal, and rumination were all assessed via the measures presented above. Given Olivia’s visible anxiety in the therapy room, Sessions 4 to 8 were an extended baseline period focused on rapport building, supporting Olivia in becoming comfortable sharing, expressing herself, and sitting with her emotions in the therapy environment. During this time, treatment also involved helping Olivia manage her school anxiety, especially around final exams by providing her with a supportive environment to discuss her school-related anxiety. For example, psychoeducation about the triangle of emotions (i.e., feelings, thoughts, and body sensations as connected to behaviors) was provided and applied to difficulties Olivia was experiencing. After eight sessions, Olivia was noticeably less fidgety in sessions. She was more forthcoming about information and better able to clearly share and label her negative emotions (e.g., angry, sad, scared). She would frequently volunteer personal information or bring situations to therapy that she wanted to talk about with the therapist.
Phase 2: Focused Treatment of Social Anxiety
In Session 9, Olivia first revealed the specific nature and extent of her social anxiety, which initiated the second phase of treatment. She reported feeling fearful and unable to speak in various social situations (e.g., asking a store clerk for an item price, making a phone call to a stranger, speaking in class, giving a presentation, being alone in a room with a stranger, initiating conversations with strangers). She endorsed engaging in avoidance strategies (e.g., making someone else order her food at restaurants). At this time, the case was also transferred to a different supervisor who specialized in CBT. In sessions 9 and 10, Olivia and the therapist collaboratively decided to shift the focus of treatment to a manualized treatment for SAD. Olivia stated that she wanted to focus on social anxiety because if it decreased she would not have “the extra layer of anxiety” making her life more difficult. Sessions 11 through 21 utilized the C.A.T. Project manual for treating anxiety in adolescents. Session 22 was a termination session focused on reviewing treatment gains and progress yet to be made.
Because this case study is focused on implementation of the C.A.T. Project, the course of treatment will highlight Sessions 11 to 22, emphasizing manual implementation and modifications. Session 11 focused on collecting baseline assessments (RCMAS-2 and SCARED) and teaching Olivia about the treatment protocol. She indicated that she had previously read about exposures in a book about insect phobias and had found success working through her fear of knives by exposing herself to them. The collaborative nature of treatment was emphasized along with the focus on changing thinking as well as behaviors. The therapist explained that all exposures would be planned and gradual. Throughout implementation of the C.A.T. Project, the therapist prioritized Olivia leading when possible with the aim of her gaining the competencies necessary to maintain treatment gains after therapy terminated. For example, Olivia was provided with her own workbook and was asked to record her responses rather than the therapist writing while Olivia dictated.
C.A.T. Project: Lesson 1
Sessions 12 and 13 were spent on Lesson 1 of the C.A.T. Project. In Session 12, Olivia concretized her social anxiety: fear that others would look at her and fear of being the center of attention. In Session 12, the majority of time was spent having Olivia generate a list of the specific ways in which her life would look different when her social anxiety was reduced to increase her motivation (e.g., I could learn more in class; I would be more helpful and have more freedom; I wouldn’t be scared of people on the street; I could speak for myself). Olivia was able to enumerate examples with ease and detail. After this exercise, Olivia reported that the list made it evident how anxious she feels and how frequently anxiety leads to avoidance for her. The therapist provided Olivia with psychoeducation about the two general aims of treatment: (a) be able to identify when she is anxious and (b) know what to do about the anxiety. At the end of the session, initial rewards were brainstormed (e.g., going out for ice cream, a “pass” to get out of chores, and alone time in her room). Her homework included recording an anxiety-provoking situation and teaching her mother about the treatment plan. The therapist also reached out to Olivia’s mother to review the treatment aims and process; her mother was in agreement about the treatment approach and reported no questions or concerns.
Olivia arrived at Session 13 with completed homework. A good portion of the session was spent reviewing her anxiety-provoking situation to specify and differentiate her thoughts, feelings, and body sensations. Olivia chose to have C.A.T. stand for “Confused And Terrified” because that was how she described her experience while anxious. The therapist provided psychoeducation about how fears are a normal and necessary part of life. Olivia learned about how our bodies become activated when we are afraid and this was connected to her experiences (e.g., feeling exhausted all the time). Finally, the FEAR acronym was introduced at the framework for the C.A.T. Project.
C.A.T. Project: Lesson 2
Lesson 2 was covered in Sessions 14, 15, and 16. In Session 14, Olivia started to learn about identifying emotions through using facial and body clues by reviewing pre-selected magazine photos. This skill was then applied to a discussion of how Olivia can tell when her mother, sister, and friends are nervous. Subjective Units of Distress (SUDS) was introduced and applied to the anxiety-provoking situation that Olivia wrote about for her homework. Olivia created behavior anchors for her SUDS: 0 = enjoying being home alone, 2 = raising her hand in class, 4 = being cold-called in class, 6 = giving a group presentation, and 8 = giving a presentation alone in front of a group. The idea of physical sensations as a “fire alarm” that cues us in to enact the FEAR plan was introduced.
Session 15 focused on creating an initial fear hierarchy. The parameters of exposure were reviewed with Olivia: (a) nothing will be a surprise, (b) we will begin with the least anxiety-provoking situation and progress from there, and (c) exposures will be practiced both in session and outside of sessions. Olivia was given Post-It notes and pens and asked to generate ideas for her fear hierarchy. She came up with 29 fear-inducing situations (e.g., group projects without my friends in my group, ordering something alone, being somewhere crowded).
In Session 16, Olivia had forgotten to complete her homework so review of an anxiety-provoking situation was completed in session. Olivia was given ownership over organizing her fear hierarchy within the frame of situations that can only be confronted at home versus situations that can occur in the clinic and at home. Olivia organized the hierarchy based on SUDS. When asked, she was able to clarify what she meant by each item and why she assigned it a certain SUDS. SUDS for her hierarchy ranged from 2 to 8 with items fairly evenly spread out. Olivia was currently able to engage in every item on her hierarchy but felt considerable distress in most of the situations.
C.A.T. Project: Lesson 3
Lesson 3 was covered in Sessions 17 through 21. These sessions focused on teaching Olivia relaxation skills to use when she felt anxious as well as continuing to reinforce her ability to differentiate thoughts and feelings in situation and to correctly identify emotions and physical sensations. Olivia consistently failed to make recordings of the relaxation exercises on her own at home as the manual assigns because the idea of hearing her voice on a recording made her feel anxious. Therefore, she would complete this component of the homework alone in the therapy room. She also began forgetting to complete written homework assignments (e.g., of anxiety-provoking exercises) and would indicate it was because she did not experience anxiety during the week. However, in the session, she would be able to articulate situations that made her anxious. The therapist reiterated to Olivia the utility of recording the events right after they happened so it would be more accurate and collaborated with Olivia to develop a plan where she would set alarms in her phone.
For Session 17, Olivia was provided with a copy of her fear hierarchy (see Figure 3) and her thoughts and feedback were discussed. Olivia agreed to share the hierarchy with her mother. Olivia had also had her 15th birthday between Sessions 16 and 17 so a portion of this session was spent discussing her birthday. The remainder of the session involved providing Olivia with psychoeducation about somatic sensations and the value of learning how to calm oneself down in the moment. Olivia described her body sensations for various levels of her fear hierarchy while the therapist acted the sensations out (e.g., giving a class presentation). Olivia described her current strategies to help herself relax (e.g., listen to music, play videogames, find a comfortable spot and read). The therapist and Olivia collaboratively brainstormed the utility and limitations of these strategies (e.g., not portable, time consuming). The therapist taught Olivia the first of three relaxation exercises where she focused on her hand and took belly breaths for 2 min.
Olivia’s fear hierarchy.
In Session 18, Olivia had given a class presentation a few days prior so time was spent breaking the presentation down into body sensations, thoughts, and feelings as well as coping strategies that Olivia employed. The second relaxation exercise was introduced where Olivia sat in a comfortable position with her eyes closed noticing her breathing for several minutes. In Session 19, Olivia had not recorded her homework. Time was spent discussing barriers to this and implementing a new plan of setting phone alarms. The therapist taught Olivia the final relaxation exercise lying down on yoga mats.
Session 20 began with an invitation from the therapist for Olivia to lead the therapist through all three relaxation exercises that she had been practicing so the therapist could see how she has been doing them. Olivia rapidly became overwhelmed and visibly anxious. She was crying and reported feeling hot and having a racing heart. The remainder of the session was spent exploring her beliefs about leading the exercise. She reported thinking she would become so anxious she would stop talking, and the therapist would judge her. She indicated that she feared embarrassment. The therapist noted that this item was not on her hierarchy but might be worth adding. Olivia reported that she was surprised by how anxious she felt about leading a relaxation exercise. Olivia rated her SUDS a 7 during this conversation. The therapist led Olivia through a relaxation exercise to lower her SUDS to 2 before ending the session.
When Olivia arrived at Session 21, she reported that she had decided to homeschool after feeling extremely stressed about midterm exams and grades. Olivia reported feeling excited about having control over her schedule and the pace of her learning. She indicated worrying about not seeing her friends as often. The therapist engaged with Olivia in brainstorming about how she could continue to maintain social interactions while homeschooling. The therapist circled back to the previous session and reiterated to Olivia that the therapist will never make her do something she is not comfortable trying. The therapist led Olivia in a seated meditation. The upcoming holiday break was discussed and the next steps in treatment were outlined (e.g., learning how to challenge her thinking, beginning exposures).
Termination
After Session 21, Olivia canceled her next two appointments approximately 1 hour prior to the appointment. Prior to Session 22, Olivia called the clinic and expressed a desire to terminate therapy, indicating that attending therapy felt like a “chore” and that sessions felt “repetitive.” She also reported treatment gains that meant she no longer felt attendance was necessary. Session 22 focused on termination.
Olivia arrived at the termination session having dyed her hair blue. Olivia reported significant positive changes in the past month with reduced anxiety due to homeschooling. She also reported feeling like she had made significant progress in therapy and indicated that she felt confident that she now had the skills needed to manage her anxiety. It was difficult to differentiate between gains made in therapy and changes caused by homeschooling. Olivia’s exposure to anxiety-provoking stimuli was significantly reduced due to the shift in context. The therapist discussed ending therapy as a form of avoidance. However, Olivia stated, I have a little bit of control over my life now. Not just “Oh I’m feeling better, I don’t need to do the thing anymore that was making me feel better.” I know that it sounds like I’m avoiding but I have a handle on things now. Before I was just grasping at nothing but now I feel like, “I’ve got this! I can do things! I’m motivated.”
In terms of changes she has noticed in herself from attending therapy, Olivia reported: (a) that her friends now call her their “emotional support friend” or “therapist friend”; (b) she feels closer with her friend group; (c) she leaves the house more often, especially with her parents (e.g., to go shopping); (d) when she leaves the house, she often does not notice her anxiety or finds that she actually enjoys the activities; (e) reductions in her worrying and feelings of stress; (f) spending more time outside of her room by choice; (g) feeling more confident when she talks (e.g., able to order food for herself at a cash register; “I can order things for myself. I can go up to the cash register and say ‘Hey, I’d like this’ rather than ‘Hey, I’m sorry for being here and ruining your time but I’d like food’”); and (h) feeling more reflective and self-aware.
The therapist spent time talking with Olivia about where she started and where she is now, providing her with her initial list of positive changes she anticipated from completing the SAD manualized treatment. The therapist reiterated the value of a CBT approach to treating social anxiety and how it is normative for the treatment to feel like “work” or a “chore.” The therapist provided Olivia with graphs of her RCMAS-2 profiles so she could see her levels of social anxiety across time. In addition, the therapist brought in a case study of someone undergoing CBT treatment for social anxiety to illustrate for Olivia how her graph would be expected to change over time as her symptoms decreased in the exposure phase. The therapist made it clear that Olivia and her mother had the ownership over deciding whether therapy was the right choice for them but that, given her scores, she would benefit from continuing in therapy.
Given Olivia’s commitment to termination, the therapist focused on highlighting the skills Olivia has and her strengths for the remainder of the session (e.g., relaxation techniques, her curiosity about herself, her ability to express her feelings in therapy). Olivia was given resources about effective therapies for SAD, a workbook, and a phone app for anxiety. The therapist encouraged her to contact a mental health professional in the future if her anxiety increased and/or interfered with her ability to function. Finally, the therapist engaged Olivia in setting personal goals and discussing how she can meet those goals: (a) getting over my anxiety when I am in large crowds, (b) being able to talk to people I do not know, and (c) being able to present in front of people.
Assessment of Progress
The changes in Olivia’s scores over time as measured by the Reliable Change Index (RCI) is reported in Table 1; Figures 1 and 2 show Olivia’s scores on the RCMAS-2 and SCARED across sessions. Given the timeline of Olivia’s treatment, baseline reports on the YSR and PSWQ were from intake whereas baseline reports on the RCMAS-2 and SCARED were from prior to beginning the C.A.T. Project. All baseline reports were compared to assessment results at the termination session. The RCI measures statistically significant change (Jacobson & Truax, 1991), which was computed by dividing the change in Olivia’s scores by the standard error of the measure. An RCI of ±1.96 was considered statistically significant (p <.05) and unlikely to occur unless the scores reflect real change in the client’s functioning (Jacobson & Truax, 1991). RCIs for Olivia were based on clinical norms for girls when available (e.g., PSWQ, YSR) and then based on girls (RCMAS-2) or a clinical comparison group (SCARED) depending on available norms.
Olivia demonstrated a statistically reliable change on the RCMAS-2 across subscales, suggesting significant improvements for physiological anxiety (RCI = −3.21, p < .05), worry (RCI = −4.36, p < .05), social anxiety (RCI = −5.59, p < .05), and total anxiety (RCI = −3.40, p < .05). Olivia also showed a significant increase in her defensiveness across administrations of the RCMAS-2 (RCI = 18.45, p < .05). On the SCARED, Olivia demonstrated statistically reliable reductions in her total anxiety (RCI = −3.49, p > .05), generalized anxiety (RCI = −2.37, p < .05), separation anxiety (RCI = −2.57, p < .05), and social anxiety (RCI = −2.04, p < .05) scores. On the YSR, Olivia showed statistically reliable gains in her participation in activities (RCI = 2.36, p < .05) but a significant decrease in her rating of her social competence and engagement (RCI = −4.42, p < .05). On the YSR syndrome scales, Olivia showed a significant decrease in her endorsement of social problems (RCI = −2.75, p < .05).
She also exhibited non-statistically significant qualitative changes. On the SCARED, Olivia’s scores on all scales except social anxiety moved from the clinical to non-clinical score ranges. In addition, on the RCMAS-2, Olivia’s scores decreased, falling out of the high range for total anxiety, worrying, and social anxiety but moving into the high range for defensiveness, which was consistent with behavioral observations. On the YSR, Olivia moved from the borderline to normal range for endorsement of positive qualities. She went from the significantly elevated range to the borderline range for anxious/depressed symptoms. She changed from the normal range to borderline for social competence. Finally, Olivia remained in the significantly elevated range for depressive problems, withdrawn/depressed symptoms, and internalizing problems and in the borderline range for thought problems and total problems.
8 Complicating Factors
A major complication to Olivia’s treatment was that her mother became increasingly uninvolved in Oliva’s treatment over time. Greater caregiver strain, family dysfunction, and parenting stress are known predictors of worse outcomes with CBT treatment for anxiety disorders (Compton et al., 2014; Kendall et al., 2018). Parental involvement is a difficult balance to strike for adolescents and, at first, it seemed important for treatment to be solely Olivia’s space. Furthermore, the extant research has generally not found additive benefits for the addition of parental involvement to child-focused CBT (Manassis et al., 2014; Wei & Kendall, 2014).
However, parental involvement became problematic when Olivia did not have someone supporting therapy attendance, reinforcing completion of homework, praising treatment gains, and encouraging Olivia to continue with therapy even though it felt like a “chore.” For example, when Olivia initially began therapy her mother would wait with her in the waiting room. By the end of therapy, her stepfather would drop her off outside the building. Olivia described the anxiety associated with walking down the building’s hallways alone, especially if she encountered other people on her walk to the clinic. Furthermore, it took 5 weeks to get Olivia’s mother to return a signed treatment plan update, and it was difficult to get her mother to return assessments. In addition to suggesting some lack of engagement, the fact that Olivia’s mother did not return assessment measures made it more difficult to corroborate Olivia’s self-report of her symptoms from the perspective of her family members. In an attempt to facilitate engagement from Olivia’s mother, the therapist would include a blank sheet of paper on top of assessment measures that were sent home, asking her mother to record any questions, concerns, or observations she had. Furthermore, regular phone calls were placed to Olivia’s mother in an attempt to keep her in the loop about treatment.
It was difficult to communicate with Olivia’s mother given everything else that was on her plate (e.g., changing work schedule, raising Olivia’s stepsister). For example, for several months, the clinician attempted to get her mother to come in for an appointment to learn more about Olivia’s childhood and current functioning, but the appointment was never kept. It was often difficult to reach her mother via phone to loop her into the treatment plan and to gain her support (e.g., for incentives for Olivia). Prior to termination, the clinician attempted to reach Olivia’s mother several times to discuss the change to homeschooling and Olivia’s desire to terminate therapy. Without communication with her mother, it felt as though Olivia was responsible for making decisions (e.g., to homeschool, to end therapy). It is likely that Olivia’s mother recognized the importance of Olivia having a safe space to share her feelings, which may help explain her lack of involvement in therapy. However, for a child who was already anxious and easily overwhelmed, having that level of responsibility may have been inappropriate. Finally, throughout therapy, Olivia described difficulty expressing herself to her mother for fear of being a burden, which may have contributed to her desire to end therapy as she felt that her mother and stepfather were already struggling to juggle everyone’s schedules.
A second significant complication was Olivia’s decision to homeschool, which reduced her anxiety immediately prior to her decision to terminate. Because Olivia primarily experienced anxiety at school, avoiding school reduced the intensity of her anxiety and decreased her treatment motivation. Many of the reductions in her self-reported anxiety may be attributable to this change. Furthermore, Olivia’s desire to be a “good” client combined with her unexpected termination could have led her to underreport symptoms on her outcome measures at termination. However, Olivia described positive changes that extend beyond school (e.g., able to order for herself in restaurants, leaving the house more frequently). Without the assessments from her mother, it is not possible to understand how Olivia’s family members saw her current functioning and level of anxiety.
A third complicating factor was Olivia’s high scores for depression on the YSR (e.g., depressive problems, anxious/depressed, and withdrawn/depressed) as well as her primary diagnosis of SAD. Previous research suggests that the presence of other internalizing disorders and a principal diagnosis of social phobia both predict worse treatment outcomes and lower rates of remission (Compton et al., 2014; Ginsburg et al., 2011). Olivia did not endorse feeling depressed in sessions and her high scores may have been driven by her social isolation (e.g., preferring time alone as avoidance of anxiety). However, in light of her assessment scores and early termination, modifications for depression should have been considered.
Depression and anxiety are frequently comorbid, which can lead to increased functional impairment, including decreased extracurricular involvement and attenuated response to anxiety-focused CBT (Beidas et al., 2010). The most important modification for working with comorbid depression with a withdrawn presentation is increasing time spent building rapport. As Beidas et al. (2010) write, Although some therapists may feel they are doing clients a disservice by not moving quickly into the active components of treatment, the importance of developing a positive relationship should not be ignored. Clients . . . are more likely to willingly engage in the critical and challenging exposure tasks, and to work to try to implement coping strategies outside of session. (p. 151)
This modification was utilized with Olivia given her hesitation to engage at the beginning of treatment. Two additional modifications that would have been useful are (a) including depressive thinking traps during the cognitive restructuring phase (e.g., black and white thinking) and (b) incorporating behavioral activation into exposures. Olivia displayed negative and depressive cognitions about failure that would have been useful to challenge. In addition, both her social anxiety and her depressive symptoms were leading her to withdraw from activities and social engagement.
Along those lines, the recent case study by Pass, Whitney, and Reynolds (2016) provides insights into a potential alternative strategy that might have been useful when working with Olivia. The authors highlight the value of brief behavioral activation (8 sessions) to target depressive symptoms in adolescents. Given that Olivia’s depressive symptoms remained throughout treatment, a short-term focus on behavioral activation may have reduced those symptoms while also supporting progress in therapy more broadly. In the case study, the client also showed clinically significant reductions on separation anxiety and panic disorder subscales, suggesting that brief behavioral activation could have targeted symptoms of both anxiety and depression for Olivia (Pass et al., 2016). Furthermore, a component of Behavioral Activation Treatment of Depression (BATD) is a collaborative exploration of the client’s values with the goal of identifying personalized value-based activities. This treatment aspect would have combined smoothly with the exercises Olivia did in Session 12 that focused on what she values in her life, how her anxiety impedes her, and what her life would look like with reductions in social anxiety. Finally, brief treatments are useful for preventing adolescent dropout, which was an issue for Olivia as she started to feel that she was stalled in therapy (Pass et al., 2016).
A second case study with utility for Olivia’s case is that of Sherman, Tonarely, and Ehrenreich-May (2018), which highlights the value of the Unified Protocol for adolescents experiencing emotional disorders. The case involves a 15-year-old male with intense social and generalized anxiety comorbid with mild, subclinical levels of depression, which is comparable to Olivia’s presentation. The 16-session treatment focused on targeting common features that underlie both anxiety and depression, including negative affect, avoidance, and limited distress tolerance. The client showed significant reductions in both anxiety and depression by the end of treatment. Given Olivia’s co-occurring anxiety and depression and the fact that her depressive symptoms remained at the end of treatment, it would have been useful to consider a more integrated treatment focused on common features of emotional disorders rather than targeting her social anxiety alone (Sherman et al., 2018).
9 Access and Barriers to Care
There were two primary barriers to Olivia’s treatment. The first was her difficulty consistently attending appointments, which led to a payment balance. The therapist did not want to place pressure on Olivia for things that were outside of her control so phone calls were placed to her mother regarding attendance and the balance. However, given the difficulty communicating with her mother, this strategy proved ineffective for improving attendance and payment, until termination when Olivia’s stepfather paid off her balance.
The second barrier had to do with treatment modifications. Given Olivia’s initial discomfort in therapy, extended time was taken to establish rapport. Research suggests that the therapeutic relationship is critical for anxious youth, particularly supporting youth engagement in skill-building exercises and exposures (Cummings et al., 2013). In addition, the manual protocol was adjusted to slow the pace to ensure Olivia understood the concepts and was able to practice them. The pace was further slowed because Olivia often forgot to complete her homework, perhaps as a form of avoidance, which was then completed in session. Furthermore, when Olivia missed sessions, additional time had to be spent reviewing concepts. However, these adjustments led to Olivia feeling like therapy was overly repetitive as similar strategies (e.g., relaxation, reviewing thoughts and feelings associated with anxiety-provoking situations) were practiced from one session to the next. Although Olivia requested a treatment to specifically address her social anxiety, she remarked that she missed the unstructured initial rapport-building phase where she would talk about anything she wanted, perhaps because she found interpersonal intimacy in those sessions that she was not able to find with her friends or family.
A recent study found that the primary mediator of change with the Coping Cat and C.A.T. Project was improvement in coping efficacy, which is a child’s sense of their ability to manage in a situation that provokes anxiety (Kendall et al., 2016). Furthermore, Peris et al. (2015) found that two components were critical for accelerating treatment progress: cognitive restructuring (e.g., shifting self-talk) and exposure tasks. The authors found that relaxation training had limited impact on reducing anxiety, which is relevant to Olivia’s case (Peris et al., 2015). The manual modifications combined with Olivia’s missed sessions and difficulty completing homework meant that several sessions were spent teaching and practicing relaxation exercises. Olivia terminated treatment prior to sessions focused on cognitive restructuring and exposure, which likely would have yielded significant and lasting reductions in anxiety. However, as Peris et al. (2015) note, we still do not fully understand the mechanism of change for the C.A.T. Project because no treatment strategy alters progress in the specific domain it is meant to target (e.g., relaxation training does not change somatic symptoms more than cognitions or feelings).
10 Follow-Up
As discussed in the “Termination” section, this case did not allow for treatment follow-up due to Olivia’s decision to terminate treatment prior to completion of the manual.
11 Treatment Implications of the Case
This case study addresses two important domains of psychotherapy: (a) the need to balance parental involvement when treating adolescents and (b) the implications of manual modifications. If a better balance had been struck between giving Olivia agency (e.g., to teach her mother about the treatment plan) and having the therapist communicate more frequently with her mother from the beginning, Olivia’s mother might have been better positioned to be an important cheerleader and consistent presence for Olivia, especially leading up to and during exposures. Furthermore, collaboration with parents can be helpful when creating rewards that are potent reinforcers for adolescents (Beidas et al., 2010). A recent meta-analysis of CBT with anxious youth found that parental involvement that emphasized (a) transfer of control from the therapist to the parent and (b) contingency management to support exposures resulted in better long-term maintenance of improvements (Manassis et al., 2014). Our work highlights the important task of balancing directive parenting and authority-granting parenting in a developmentally informed adaptation of CBT for adolescents with anxiety-related school refusal behavior (Sauter, Heyne, & Westenberg, 2009). While highly anxious adolescents should be provided opportunities to face anxiety-provoking situations with minimal parental involvement, it is equally important for parents to adopt an authoritative role. Therapists should create a space for parents to learn developmentally appropriate strategies to reinforce behaviors that approximate the target behavior (i.e., not avoiding anxiety-provoking situations). Moreover, it is important for parents to understand common avoidant coping strategies utilized by highly anxious adolescents and to contribute to the conversation on the appropriate timing and sequence of events necessary for reducing anxiety (Sauter et al., 2009).
In terms of adjusting the manual, this case study suggests two important takeaways. First, it is necessary to maintain a balance between structured and unstructured time even when using a manual. The client must feel that therapy is their own space where they can process what is important to them even if it is somewhat tangential to the treatment focus. Second, therapy needs to maintain a pace such that the client feels like there is a purpose and forward momentum to sessions. This pace can be difficult if the client does not complete homework or misses sessions. This tension should be explicitly addressed and problem-solved with the client. Regular check-ins about how the pace and balance of structure feels for the client should be included so as to create a collaborative alliance within the context of manualized treatments (Beidas et al., 2010).
12 Recommendations to Clinicians and Students
CBT is the recommended evidence-based treatment for SAD in adolescents (Kendall et al., 2018). The treatment model implemented with the current client focused on treatment fidelity within flexibility, especially (a) balancing structured psychoeducation and skills building with unstructured time for the teen to share, (b) slowing down the pace to ensure skills were both adequately learned in session and practiced outside of session, and (c) adjusting the protocol as the client missed sessions or forgot to complete her homework. This study provides support for the utility of CBT approaches to treating SAD while offering insights into pitfalls regarding intervention pacing and into the challenges that arise when parents are uninvolved in treatment for adolescents.
Olivia experienced statistically significant improvements in anxiety across domains at termination. She reported numerous treatments gains, including feeling more comfortable with social interactions, spending more time with friends, and reductions in worrying. However, these changes must be considered in the context of Olivia beginning to homeschool, which significantly reduced her school-based anxiety. In addition, she remained high on scores of depressive problems, particularly withdrawn symptoms, suggesting that she still preferred to be alone, felt shy, and lacked energy.
The current case suggests it is important for clinicians and students to think carefully about balancing parental involvement with adolescent agency when providing therapy to teens so that teens feel ownership over their treatment while also feeling supported by their parents, especially during exposures. In addition, this case highlights the importance of being careful and thoughtful when making adjustments to existing manuals. Specifically, Olivia’s experience in therapy points to the value of finding a balance between structured and unstructured time so that the client feels she has the opportunity to bring content that feels important to her into therapy even if it may seem somewhat tangential to the therapist. For Olivia, her motivation declined with the implementation of highly structured and manualized sessions. Secondary to this, the clinician must guard against having too much unstructured time such that the therapy lacks momentum.
In summary, this case demonstrates the need for continued research on use of the C.A.T. Project in adolescents. First, additional research is needed to understand what modifications may improve treatment outcomes for those with a primary diagnosis of SAD given that SAD predicts worse treatment outcomes as compared to other anxiety disorders (Compton et al., 2014; Ginsburg et al., 2011). Second, further research on the impact of comorbid depressive symptoms is needed to better understand how depressive withdrawal interacts with SAD in affecting CBT treatment efficacy (Beidas et al., 2010). Finally, research on the role of parents in treating adolescents with SAD would be helpful to guide clinicians in balancing the establishment of trust and privacy with the adolescent while also gaining parental support for treatment.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
