cbt case study depression

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• Case study: How CBT can be applied in the treatment of depression

The aim of this case study is to show through the use of a client study, how cognitive behavioural therapy ( CBT ) can be applied in the treatment of depression . The patient is a woman with a 2-year history of depression connected with low self-esteem , guilt and shame. An account of the CBT treatment carried out over 12 sessions is given. Noticeable improvements on measurements of mood and hopelessness, with an improvement in social and occupational functioning were achieved.

Mary is a 26-year-old nurse, who was referred for treatment for the management of depression. She presented with a 3-year history of depression along with issues related to low self-esteem and relationship problems, she was referred by her GP after being prescribed various forms of antidepressant medication over a 2-year period, this medication did not seem to be effective.

Presenting problems

Mary’s depressive symptoms lead to her social and occupational functioning being impaired. She found it difficult to complete tasks related to her job, and had been disciplined at work even though she had previously excelled in her role. She explained that she felt somewhat uncomfortable at work and found making conversation with colleagues quite challenging. She considered herself to be ‘dull’, ‘boring’ and ‘unlikeable’, which as a result lead to her isolating herself socially. Over the course of her depression she decreased her pastimes and social activities, and started to use all her free time on her own, in bed or “attempting to catch up on tasks related to her job.”

Mary was in a relationship with Angela, who lived in Scotland with her two year old son. Angela was still married to her husband when they first met and Mary felt guilty for “ruining a marriage,” and “being involved in a same-sex relationship”, therefore, this was a part of her life that she didn’t tell people about. She explained her reason for keeping this to herself was due to a fear of people judging and rejecting her over it. She also did not feel secure in the relationship and had fears about Angela’s commitment to her although she did not want to end the relationship.

Mary has a sister who is two years older than her who also has a history of depression, she sees this sister as being a good form of support. She states that she also has a good relationship with her father although “he is not in touch with my generation” and therefore “he’s not really able to understand me”.

Mary’s mother died in a car crash when she was 10 years old. She described them as having a close relationship and found the first year after her mother’s death a particularly difficult time. Mary remembers her childhood as being a happy one where she spent lots of time with her parents, who had a good relationship with one another.

Mary has no previous history of therapy but had a good awareness of her difficulties and was willing to engage in a time-limited treatment of CBT as well as continuing to take the antidepressants which her GP prescribed.

Treatment outcome measures

Variations in levels of depression and anxiety were assessed using the Beck Depression Inventory (BDI) (Beck & Steer, 1993a), and Beck Hopelessness Inventory (BHI), (Beck & Steer, 1993b). Both the BDI and the BDI have been extensively tested for reliability and validity (Conoley, 1987; Dowd, 1992; Owen, 1992). These Measures were administered pre-therapy, mid-therapy, and post-therapy. The Improving access to Psychological Therapy service (IAPT) also recommends routine use of a combination of questionnaires, the PHQ-9 for depression, GAD-7 for anxiety, and three IAPT phobia scales (social, agoraphobia, and specific phobia) as well as the Work & social adjustment scale which assesses problems in functioning with work, home management, social leisure activities, private leisure activities, and family & relationships and therefore these measure were administered at the start of each session. Mary’s score on both phq-9 (16) and the BDI (32) indicate moderately severe depression, her GAD-7 score was 9 which translates as mild anxiety, WSAS scores for Mary were 18 which is associated with significant functional impairment. The IAPT phobia measures indicated that she would markedly avoid social situations and she would definitely avoid certain situations for fear of having a panic attack. Becks Hopelessness scale which was administered in order to help assess where she was at risk of suicide, Mary scored 17 on this scale which identifies severe hopelessness, Mary confirmed occasional thoughts of a suicidal nature however she denied any intent to act on these thoughts as she felt she would be letting everyone down.

FORMULATION

Case Conceptualisation

A cognitive case conceptualisation is a method of considering a client’s problems and issues using the cognitive model of emotional disorders (Beck, 1987). It includes beliefs (automatic thoughts, underlying assumptions, and schemas), emotional reactions, behavioural strengths and deficits, social factors that influence problems, and consideration of biological factors and maintaining cycles of the client’s difficulties. The conceptualisation, constructed with the client, can be amendment through the course of treatment and can used as a directive for any problems that arises for the client both outside of therapy and in the therapeutic relationship, it can also can act as a   “map” for the therapist (Persons, 1989).

Figure 2. The cognitive model as applied to depression (Persons, 1989).

After Mary’s initial assessment the therapist drew up a longitudinal formulation to help her consider Mary’s difficulties and plan treatment. This longitudinal formulation included the following.

Early experiences: Need to please mother, parents not socializing outside family home, loss of mother.

Core beliefs :

I am not likeable (As I’ve never had a lot of friends at any time in my life), I am not good enough and can never achieve enough (My sister and classmates were always better than me), I am a bad person (As I started a relationship with person of the same sex).

Irrational Rules/Assumptions :

‘If I date someone of the same sex, I am a bad person’, ‘If I tell my friends about my same sex relationship, they will disapprove and reject me’, ‘If I take on all the duties assigned to me at work’ (regardless of my large workload), ‘my workmates will like me, If I tell anyone that I suffer from depression, they will think that I am crazy’.

Precipitating factors :

A precipitating factor for Mary’s in her life was the start of a same sex relationship. Mary feels that people would not accept her because of this. As a result she prevented others from becoming to close to her to avoid having to reveal her secret.   This avoidance of social activity resulted in her spending more time at home by herself which precipitating her depression.

Figure 3. Formulation drawn up collaboratively with Mary based on Mooey’s (2010) depression model.

Perpetuating factors

The therapist used Mooray’s (2010), “The Six Cycles Maintenance Model” model to investigated Mary’s thoughts, feelings, behaviour and physical response (Figure 3) and collaboratively conceptualize Mary’s presenting difficulties while socializing Mary to the cognitive model by showing links between thoughts, feelings, behaviours and physical sensations. This diagram was used as a “road map” to help the therapist identify and focus on factors that are likely to be important in Mary’s depression and a rationale for the therapy interventions that the therapist would include in treatment (see figure 3).

The therapist helped Mary looked at a number of maintenance cycles which were feeding back into Mary’s difficulties, for instance when Mary is around her workmates she often has the automatic thought “Nobody likes me, I will never be able to form friendships”, as a result she becomes upset and feels rejected and goes on to isolate herself from workmates by avoiding them and having lunch on her own and therefore does not break the pattern of feeling uncomfortable around her workmates and rejected by them.

1. Negative Automatic Thoughts

As a consequence of feeling low Mary’s was having more negative automatic thoughts (NAT’S) about particular situations. These NAT’S seemed highly credible to her and came up regularly without much of her awareness. These NAT’s may have kept Mary’s negative core experiences going.

2. Ruminations and self-attacking

Mary sometimes found herself getting locked in ruminative, self-attacking thinking cycles of how she made so many mistakes and should have done things differently along with other self-attacking thoughts related to being weak and not good enough as a person.

3. Mood/Emotion

Mary identified various emotions connected to her depression which she frequently experienced such as stress, depression, unhappiness, dejection, guilt, shame and feeling sad about feeling sad all of which feed back into the her difficulties.

4. Withdrawal and avoidance

Throughout Mary’s depression she had isolated herself from others and avoided socializing and did not allow others to become close to her. She believed that she would not enjoy activities or be able to accomplish the things she wanted to. As a result of this avoidance she was not allowing herself the opportunity to test the truth behind her negative beliefs and limited her opportunity to find enjoyment or a sense of achievement from activities.

5. Unhelpful behaviours

Mary’s attempts to improve her emotions or balance her negative beliefs included taking on excessive work loads and seeking approval from others. These behaviours made her feel better in the short term but were part of what maintained her difficulties in the long term.

6. Motivation and Physical Symptoms

Mary’s physical symptoms of depression included feeling tired, tearful, on edge and having sleeping difficulties. These physical symptoms feed back into Mary’s depression leading to even less activity and contributing to a downward spiral

Therapeutic goals

Mary stated that through therapy she would like to focus on achieving the following:

• To disclose to her sister and friends about her relationship with Angela;
• To feel more secure with Angela, to discuss their relationship and plans for the future;
• To achieve better ways of managing her time, and allocate more time for leisure activities;
• To become better at communicating with people at work and no longer take on an excessive workload; and
• To feel more at ease in social situations particularly at work.

Treatment contract

Guidelines on the duration of treatment length suggest that most of the progress made in CBT treatment is thought to take place in the first twelve treatment sessions, and additional improvements are moderately low when treatment carries on for further sessions (Barkham & Hardy 2001). If this is the case, the duration of the CBT treatment offered should be kept within this time frame. With this in mind an initial contract of 6 sessions was agreed on which was extended for a further 6 treatment sessions.

Assessment sessions 1-3

The early sessions were spent collecting client information, building therapeutic rapport, discussing issues around confidentiality and taking baseline treatment measures (see table 3). The therapist and Mary also looked at the foundations of the CBT approach and how it might be useful, the idea of working together using a structured, and focused method, with the requirement of weekly out-of-session assignments, and the opportunity to regularly review the treatment. The meaning of core beliefs, assumptions, and NAT’s were looked at and Mary started to recognize and document a number of these, many of which the therapist and Mary planned on returning to later when completing thought Records and developing Behavioural Experiments in sessions. The therapist and Mary also constructed the cognitive case conceptualisation (Figure 2.) over the three assessment sessions drawing up maintenance cycles and getting Mary to consider what could be done to try and break out of these patterns.

Sessions 4-8

As part of her out-of-session assignments Mary completed Weekly Activity Schedules (WAS) in order to monitor the activities she was involved in for each hour of each day, and to note the amounts of pleasure and mastery (feelings of accomplishment and effectiveness) actually experienced during each activity. She assigned a percentage rating to her mood for each activity she participated in and we made the connection between her mood and the activity. It discovered that Mary’s mood was worst when she was least active. After making this discovery the therapist worked with Mary to help her come up with a list of activities that she currently enjoys or used to enjoy as well as activities that gave her a sense of achievement. The therapist used Beck’s (1987) evolutionary model of depression to explain to Mary that when people have depression these activities might not be easy to do but if there is no investment there is no return. Therefore it can be useful to plan these activities in an attempt to strike a balance between pleasure and achievement. The therapist encouraged Mary to make time for these activities several times a week and explain how scheduling something makes people more likely to commit to it and that she should try to do the activities she has planned regardless of her mood. Mary monitored the outcome of this activity scheduling by taking regular mood ratings and noticed her mood ratings improved on the days she engaged in the pleasurable activities she had planned.

Mary completed a Daily Thoughts Record (DTR), which we used to investigate her thinking patterns. At first she found it hard to recognize her “hot thoughts” (automatic thoughts that carry the strongest emotional charge) and “alternative balanced thoughts.” To overcome this difficulty the therapist suggested that Mary try to note down the thoughts and feelings that go through her mind as close to the time she is feeling the strong negative emotion as possible. Mary started to enter brief notes onto her mobile phone when she felt a strong negative emotion and would later enter the information into a thought record. The therapist helped Mary use the items she had identified on the DTR as a ‘courtroom’ to challenge her hot thoughts by looking at evidence to support the hot thought and evidence that does not support the thought and consider a more balanced alternative. One of the ‘hot thoughts’ that Mary identified was on the DTR was ‘All hell will break loose if tell anyone about my partner’. After identifying this thought the therapist helped Mary consider further what might take place if she were to disclose to her housemate Tamara about her partner Angela. The therapist asked her to think about how Tamara might respond if roles were reskilled and if Tamara was the one who disclosed the information; or how Mary would react if her friend did not choose to reveal the information to her? Mary was amazed at how her beliefs and automatic thoughts as well as the intensity of her feelings could change so much.

In session seven the therapist and Mary set up a behavioural experiment to test out what would happen if she disclosed her sexuality to her flatmate. Despite the previous work on Mary’s thoughts related to this she still believed 90% that people would reject her in some way if she disclosed her sexuality. In relation to her flatmate she believed in the worst case she would chooses to move out after the disclosure or in the best case she would start spending less time with her. An alternative belief that Mary considered was that people would be surprised at the disclosure but they would not treat her any differently which she stated she believed 10%.

Mary returned in session 8 and had revealed the truth about her relationship with Angela to her housemate who at first became angry that Mary had hid it from her. During further talks with her housemate, Mary told her about her depression, the fact that she was seeing a therapist, and her problems coping with the death of her mother. Mary was surprised by her roommate’s positive reactions and later went on to share similar information with her sister. Mary re-rated her belief that people would reject her in some way if she disclosed her sexuality as 40% and re-rated the alternative believe as 60%.

Sessions 9-12

We looked at the beliefs Mary’s held regarding how she thought others saw her. She believed that everyone she knew found her boring, and then gave an account of how someone would act if they found someone “boring.” We agreed on carrying out a behavioural experiment that could be done during her break at work. This consisted of her observing her workmates and purposely watching for any proof of them being bored by what she was saying. Before the experiment, she assigned a rating to her belief (on a scale of 0-100%). After doing the experiment, she found no definite confirmation of people being bored and she rated her belief again. The rating of her belief after the experimental belief was less (55%) than before the experiment (95%). She carried out the behavioural experiment a few times in different situations, which eventually helped her see that in fact people did not regard her as boring. As a result Mary started to engage more in conversations with her workmates and attended a social event that her colleagues invited her to outside of work.

TREATMENT OUTCOME

At the time of discharge, there were noticeable improvements in Mary’s mood, levels of hopelessness, as well as overall social and occupational functioning. Mary became able to discuss her history of depression, the relationship with her partner , and the bereavement of her mother with people in her life. She disclosed her depression to her manager, who was understanding and compassionate. He arranged to temporary decrease her workload and planned regular meetings to talk about any difficulties at work. She was able to manage her time better and included leisure activates into her week. This progress can also be seen in the scales that were administered at intake, mid-therapy and discharge (seen table 4).

Table 3. Treatment outcome measures. (Beck & Steer RA, 1993a, 1993b & 1993c; Saunders et. al, 1993), (PHQ-9, GAD-7 & WSAS; part of the IAPT Minimum data set).

The rating of depression decreased significantly over time, shifting from being in the severe depression range to being in the mild depression range (BDI: 15, PHQ-9:4). The BHI scores also improved over time, showing a decline in the intensity of hopelessness. The score on the BHI of 6 was no longer showing an indication of high psychological distress. Mary’s GAD-7 (4) and Work   and Social Adjustment Scale scores (2) also decreased to subclinical levels.

Relapse prevention

In relation to preventing set backs she has kept records of material from the therapy sessions (homework and sheets from sessions) and a relapse prevention plan and states that she looks over them at times, particularly when she is experiencing low moods or particular difficulties. This self-conducted regular review of therapy sessions may assist in increasing her chances of maintaining the improvement achieved.

The ending of therapy with Mary was carefully thought out particularly because of the losses she experienced in the past. At the start of treatment we block booked all the dates we would meet on and Mary was reminded by the therapist midway through the sessions of the date they would end therapy on, the therapist again reinstated this a number of weeks before the end. The therapist regularly checked out how Mary was feeling about ending therapy and allowed Mary the space to discuss any fears she had about ending.

This case study looked at using a cognitive behavioural approach with a client with depression. The client improved in terms of mood, hopelessness, and overall social and occupational functioning. This outcome backs up various published research findings which provide evidence for the benefit of CBT in treating depression, (Rush, Kovacs & Beck, 1981; Scott, 2001; Department of Health, 2001).

Mary stated that she views her positive outcome as being a result of a mixture of CBT and medication treatment; though, she expresses the CBT treatment as being the more beneficial. She stated that CBT had “changed her way of seeing things” and provided her with a “method or system,” allowing her to steadily sort through and resolve any difficulties she experienced. This schema modification together with the restructuring of her cognitive account of depression may reduce her risk of relapsing.

Upon receiving this referral the therapist had some initial anxiety about working with a case presenting with difficulties related to her sexuality as the therapist did not have previous experience of working with patients with this type of presentation. Another difficulty was that this was only the therapist’s second depression case she had treated and this lack of experience added further concern for the therapist initially. However the therapist found the support of supervision beneficial and quickly realised that many of the techniques she had used before could also be applied to this case.

A limitation to Mary’s treatment was that she was only offered 12 sessions of CBT due to organisational restrictions which is less than recommend dose of 16-20 weeks for moderate to severe depression, (NICE, 2007a). It may have been beneficial to offer a further four to six sessions to allow the opportunity to tackle some of Mary’s rules and assumptions and therefore reduce the risk of relapse. However evidence which is contrary to this suggests that most of the progress made in CBT treatment occurs in the first twelve sessions, and further progress is moderately low after this (Barkham & Hardy, 2001). It will have been interesting to follow-up the outcome of this case at a later date to investigate the long-term effects of the treatment.

***If you’re struggling with your mental health and think you might benefit from speaking to someone, we offer a FREE 15-MINUTE CONSULTATION with one of our specialists to help you find the best way to move forward. You can book yours  here.

About the author

Dr Becky Spelman is a leading UK Psychologist who’s had great success helping her clients manage and overcome a multitude of mental illnesses.

***If you think you might benefit from speaking to someone about the issues in this article, we offer a FREE 15-MINUTE CONSULTATION with one of our specialists to help you find the best way to move forward. You can book yours here

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Categories: Cognitive Behavioural Therapy , Depression - By Dr Becky Spelman - March 1, 2024

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Article contents

Cognitive behavioral therapy for depression.

• Stirling Moorey Stirling Moorey South London and Maudsley NHS Foundation Trust, Centre for Anxiety Disorders and Trauma
•  and  Steven D. Hollon Steven D. Hollon Department of Psychology, Vanderbilt University
• https://doi.org/10.1093/acrefore/9780190236557.013.837
• Published online: 23 February 2021

Cognitive behavioral therapy (CBT) has the strongest evidence base of all the psychological treatments for depression. It has been shown to be effective in reducing symptoms of depression and preventing relapse. All models of CBT share in common an assumption that emotional states are created and maintained through learned patterns of thoughts and behaviors and that new and more helpful patterns can be learned through psychological interventions. They also share a commitment to empirical testing of the theory and clinical practice. Beck’s Cognitive Therapy sees negative distorted thinking as central to depression and is the most established form of CBT for depression. Behavioral approaches, such as Behavioral Activation, which emphasize behavioral rather than cognitive change, also has a growing evidence base. Promising results are emerging from therapies such as Mindfulness Based Cognitive Therapy (MBCT) and rumination-focused therapy that focus on the process of managing thoughts rather than their content. Its efficacy-established CBT now faces the challenge of cost-effective dissemination to depressed people in the community.

• cognitive behavior therapy
• cognitive therapy
• behavior therapy
• evidence-based therapy

Origins and Development of Behavioral and Cognitive Models of Depression

Behavioral models of depression have been largely based on Skinnerian or operant conditioning theory. Ferster ( 1973 ) proposed a model that saw depression as characterized by a decrease in the frequency of positively reinforced activities. Factors such as decreased environmental reward (e.g., resulting from a significant loss), avoidance or escape from aversive stimuli, schedules of reinforcement, and suppressed anger contribute to a reduction in the depressed person’s behavioral repertoire which in turn leads to less rewarding experiences. Lewinsohn ( 1974 ) developed this model further, as did Staats and Helby ( 1985 ) (see Dimidjian, Barrera, Martell, Muñoz, & Lewinsohn, 2011 ). However, this did not lead to significant developments in treatment or in outcome research, partly due to the surge in interest in Beck’s cognitive approach to depression that resulted from publication of the first randomized controlled trial to show that a psychological treatment could be as effective as antidepressants in depression (Rush, Beck, Kovacs, & Hollon, 1977 ). Beck first identified the importance of thoughts in depression in the early 1960s (Beck, 1963 , 1964 ). In contrast to behavioral approach that saw “internal” self-talk as a covert behavior, Beck suggested that cognition was central to depression. Beck noted that the dreams and self-reports of depressed patients were pervasively negative: They experienced a stream of negative automatic thoughts in response to events. In depression, he hypothesized, there was a shift in information processing such that stimuli which might usually be perceived as neutral or positive are seen as negative: a systematic cognitive bias. Underlying this bias are cognitive structures or schemas, often expressed as dysfunctional attitudes which, when activated by an event or accumulation of events, skew the interpretations and evaluations the person makes about the world. Examples of these include beliefs such as, “If I fail at something it means I’m a complete failure” or “If I don’t have someone to love and accept me it means I’m unlovable.” This results in an increasingly negative view of the self (“I am a failure; I am unlovable”), the world (“the world is unrewarding; others will reject me”), and the future (“I will never achieve my goals”) during the course of a depressive episode. Reduced expectations of being valued or succeeding at what the depressed person undertakes lead to avoidance and passivity that further reinforces the depressed mood and negative beliefs (Beck, 1967 , 1987 ).

Adverse life events and experiences in childhood lead to underlying assumptions, often expressed in conditional form: “If . . . then . . . .” For instance, the belief “If I fail at something, I’m a complete failure” may be laid down over years of being on the receiving end of demanding parental expectations. A significant failure experience in adult life, such as not passing an exam, will lead to activation of this schema and consequent depression (see Figure 1 ). Evidence for the cognitive model has accumulated since its original presentation (Beck & Alford, 2009 ; Clark & Beck, 1999 ). The association between negative thoughts and depression is particularly robust and seems to apply across cultures (Beshai, Dobson, Adel, & Hanna, 2016 ). Beck has modified the model to take account of research findings to include the concept of cognitive reactivity. People who are prone to depression will have a greater activation of negative beliefs than those who are not when they experience mood shifts in response to the vicissitudes of life (Scher, Ingram, & Segal, 2005 ). While major life events may be needed to trigger first-onset depression, repeated episodes make it easier for mild events to produce depression: the so-called kindling effect (Kendler, Thornton, & Gardner, 2000 ).

Figure 1. Developmental formulation.

Cognitive approaches such as Beck’s and Alloy and Abramson’s hopelessness model of depression (Abramson et al., 1989 ) generated the most research in the last decades of the 20th century , but in the first decades of the 21st century , behavioral models of depression experienced a resurgence, initially stimulated by the finding in a dismantling trial that the behavioral component of cognitive therapy was as effective as the full package (Jacobson et al., 1996 ). Contemporary behavioral activation models, based on Lewinsohn’s more integrative model (Lewinsohn, Hoberman, Teri, & Hautzinger, 1985 ), have a more sophisticated account of positive reinforcement, pay more attention to cognition by targeting ruminations, and emphasize the importance of avoidance of interpersonal situations in maintaining depression. There has also been a shift away from cognitive content (i.e., negative thoughts) to an interest in cognitive processes such as ruminations. Post-Beckian cognitive models emphasize the importance of how one relates to one’s thoughts as a factor in maintaining depression. Trying to analyze why one is depressed or fix one’s perceived inadequacies leads to cycles of rumination that dig one deeper into depression. Metacognitive therapy, rumination-focused cognitive behavioral therapy (CBT), and mindfulness-based cognitive therapy are examples of these more process-oriented forms of CBT (Segal, Williams, & Teasdale, 2013 ; Watkins, 2018 ; Wells, 2011 ). Table 1 summarizes the CBT models for depression in chronological order.

Table 1. Current Cognitive Behavior Therapies for Depression

Beck’s Cognitive Therapy

Outline of treatment.

This form of cognitive behavioral therapy (CBT) is the best known and most researched, so it is described here in some detail. Cognitive therapy for depression (CT) is a relatively brief (20 sessions), structured, problem-focused treatment, firmly based on the cognitive model of depression. It can be understood to have a hierarchy of aims:

to reduce hopelessness and suicidality

to resolve target problems related to depression by teaching strategies to manage mood

to reduce vulnerability to future depression by modifying underlying beliefs and developing a relapse prevention plan

Target problems and goals are established at the beginning of therapy and each session is structured to use time as effectively as possible; an agenda is set which generally follows the plan:

bridge to last session with review of risk and current mood

review of homework

two to three agreed topics to address

setting homework

summary and feedback

Treatment is based on an individualized formulation which is developed in partnership with the patient. This initially focuses on the way in which thoughts, feelings, and behaviors interact to maintain the depression. The patient learns to identify situations that trigger a lowering of mood and the link between their negative thoughts and the mood shift. Similarly, the resulting patterns of behavior, such as withdrawal, are recognized. As therapy progresses, this conceptualization is deepened: Repeating sets of negative automatic thoughts reveal themes of underlying beliefs. The developmental conceptualization (Figure 1 ) links past learning experiences to these underlying beliefs or schemas and helps the patient see how these have made them vulnerable to depression. Because patients will be asked to examine deeply held beliefs, therapy tries to be as collaborative as possible. Rather than telling the patient their beliefs are maladaptive, the therapist encourages the patient to enter into a partnership to explore the validity and usefulness of them. Beliefs are turned into hypotheses that can then be tested through verbal discussion (Socratic questioning) or direct action (behavioral experiments). Depressed patients discover that their thoughts may be biased by their mood and learn to identify cognitive distortions or thinking errors. This process of putting beliefs to the test is referred to as “collaborative empiricism.” Therapy consists of a variety of cognitive and behavioral techniques. At the beginning of therapy, particularly if the patient is more deeply depressed, techniques will be more behavioral. These often begin with monitoring activities and rating them for the degree to which they are pleasurable or give a sense of achievement (mastery). Patients are then encouraged to engage in activities that promote pleasure or mastery and to note the effect on their mood. In contrast to Behavioral Activation that seeks behavioral change for its own sake, the activity work in cognitive therapy is always used in the service of cognitive change and, wherever possible, framed as an experiment to test negative thoughts. For instance, someone may predict that if they call a friend, they won’t be interested in them. The therapist can help them devise an experiment in which they take the risk of telephoning and evaluate the result: They may find that it took them half an hour to end the call because the friend was so pleased to hear from them! The next phase of therapy is for the patient to learn to recognize and evaluate their thoughts. This begins with monitoring of negative automatic thoughts as they arise in everyday situations. Patients learn to recognize how the depression biases their thinking in a negative direction. The therapist then uses Socratic questioning to evaluate the thoughts with the patient in the session, asking questions to help them examine their view of the situation. The touchstone for evaluating the thoughts is their logical consistency and the evidence available. Patients then practice identifying thoughts, asking questions such as: “What’s the evidence for and against this thought?”; “What’s the effect of thinking in this way? Is it helpful to me?”; and “Could there be an alternative explanation or way of testing my thoughts?” as homework between sessions. In the third phase of therapy, beliefs are elicited and tested that underlie the distorted thinking and make the patient vulnerable to future depression. So, for instance, a belief that “I must always succeed” or “I’m a failure” may be associated with perfectionistic behavior. The person may stay late at work, spend twice as long as their colleagues writing reports, and check them several times. The belief that “If I don’t do things perfectly, I’ll be found out and seen as a failure” can be tested through experiments where the patient spends less time preparing and checking reports and discovers that the result is just as good. They can then move on to deliberately making small mistakes and may discover that no one notices. In this final phase of therapy, the patient is encouraged to develop a blueprint or relapse prevention plan that summarizes as follows:

what she has learned from therapy

what techniques she needs to continue practicing (e.g., “make sure I structure my week so I don’t have long periods where I can ruminate”)

what risk factors and early warning signs to look out for

what she can do if her mood starts to drop

Efficacy of Cognitive Therapy for Depression

The first randomized controlled trial of CT (Rush et al., 1977 ) demonstrated a slight superiority of psychological treatment over tricyclic antidepressants with respect to acute response, but largely because the medications were tapered too soon such that early relapse was confounded with a lack of response. In the succeeding 40 years, numerous studies have compared Beck’s therapy with tricyclics and with specific serotonin reuptake inhibitors (SSRIs) and consistently found the two approaches to be equally effective (see reviews by Butler, Chapman, Forman, & Beck, 2006 ; Cuijpers et al., 2013a ; Cuijpers, Cristea, Karyotaki, Reijnders, & Huibers, 2016 ), though an individual patient data meta-analysis suggests there may be a slight advantage of medication over CBT (Weitz et al., 2015 ). There is evidence that combining CBT and medication adds to the effects of both (Cuijpers et al., 2014 ), although that effect appears to be heavily moderated (Hollon et al., 2014 ) and may come at the expense of undercutting CBT’s enduring effect (DeRubeis et al., 2020 ). CBT is significantly more effective than waiting list controls, treatment as usual, or placebo (effect size 0.71; Cuipers et al., 2013a ), while head to head comparisons of CBT with other evidence-based therapies, such as interpersonal therapy, tend to show both therapies to be equally effective (e.g., Luty et al., 2007 ). CBT is not only effective with mild-moderate levels of depression but also for the moderate-severe range when delivered by well-trained therapists (DeRubeis et al., 2005 ). Despite these encouraging findings that place CBT as the psychological treatment with the most robust empirical support, only 60% of patients achieve remission. When publication bias and use of waiting list controls are accounted for, the effect size of studies reduces considerably (Cuijpers, Cristea, Karyotaki, Reijnders, & Huibers, 2016 ; Driessen, Hollon, Bockting, Cuijpers, & Turner, 2015 ), as for antidepressant medications (Turner, Matthews, Linardatos, Tell, & Rosenthal, 2008 ). Table 2 summarizes comparisons between CBT (not exclusively Beck’s cognitive therapy), antidepressant medication, waiting list control, treatment as usual, and other psychotherapies.

Table 2. Efficacy of CBT for Depression

Notes : WL = waiting list; TAU = treatment as usual; ADM = antidepressant medication; NNT = number needed to treat.

Source : Data adapted from Cuijpers et al. ( 2013a ).

Relapse Prevention

Early randomized controlled trials comparing CBT with antidepressant medication that was withdrawn at the end of the trial reported relapse rates of 15–28% for CBT compared to 50–60% with a tricyclic (Evans et al., 1992 ; Simons, Murphy, Levine, & Wetzel, 1986 ). Biological psychiatrists argued that the antidepressant may have been withdrawn too soon for a fair comparison, since the recommendation is that medication be continued for 6–9 months after symptoms remit, but the differential relapse does indicate that CBT has an enduring effect. Later studies then compared CBT with maintenance medication. The relapse rates for patients receiving continuation medication were equivalent at 30% to patients receiving CBT alone (Cuijpers et al., 2013b ). In effect, CBT cuts risk of relapse among remitted patients by more than half relative to prior medications, and the two studies that compared prior CBT found that the enduring effect extended to the prevention of recurrence relative to recovered patients withdrawn after a year of continuation medication (Dobson et al., 2008 ; Hollon et al., 2005 ). In partially recovered depressed outpatients, adding CT to maintenance medication reduces relapse rates more than maintenance medication alone, and the beneficial effects of CBT persist for up to 3½ years (Paykel et al., 1999 , 2005 ). There is strong support in these studies for an enduring relapse prevention effect from CBT (Clarke, Mayo-Wilson, Kenny, & Pilling, 2015 ). However, it has been argued that rather than CBT preventing relapse, it is antidepressant discontinuation that promotes it (Andrews, Kornstein, Halberstadt, Gardner, & Neale, 2011 ). SSRIs increase serotonin available in the synapse by blocking reuptake but over time the system responds by reducing serotonin synthesis in the presynaptic neurone and reducing postsynaptic receptor sensitivity. This would explain why it seems to be so difficult to take patients off SSRIs without triggering a relapse (Hollon et al., 2019 ). Further research will hopefully answer this question.

Mediating Factors

Research into the factors that mediate outcome of CBT for depression fall into two categories: dismantling studies that attempt to identify active elements of treatment, and correlational studies that assess the relationship between treatment variables and reduction in depressive symptoms. Cuijpers, Cristea, Karyotaki, Reijnders, and Hollon ( 2019a ) recently carried out a meta-analysis of component studies to date and concluded that few had sufficient power to detect differences. Hundt, Mignogna, Underhill, and Cully ( 2013 ) reviewed the evidence for the impact of CBT skills on outcome and found that the small number of studies to date provided evidence that the frequency and quality of skill use influenced outcome. Click or tap here to enter text.Segal et al. ( 2019 ) found that the use of CBT skills post therapy was linked to reduced relapse and that this was mediated by the extent to which patients “decentered” from their negative thinking. Strunk and colleagues found that those patients who best mastered the skills taught in CBT were those least likely to relapse following treatment termination (Strunk, DeRubeis, Chiu, & Alvarez, 2007 ). The inclusion of homework has a significant effect on therapy outcome (Kazantzis, Whittington, & Dattilio, 2010 ). The therapeutic alliance is associated with therapy outcome across a range of different therapies (see Moorey & Lavender [ 2018 ] for a discussion of the importance of the therapeutic relationship in CBT). In CBT for depression, it may be the agreement on tasks and goals of therapy that is the most important aspect of this. Patients who accept the cognitive model and experience early symptom gains are likely to report a better therapeutic alliance and to make greater gains in therapy (Webb et al., 2011 ).

Behavioral Treatments for Depression

In 1996 , Neil Jacobson and colleagues reported the results of a three-way dismantling study that compared the behavioral activation (BA) component of Beck’s cognitive therapy (CT) for depression with BA plus thought challenging (AT), and with the full CT package. Each proved equally effective and the results held up at follow-up (Jacobson et al., 1996 ; Gortner et al., 1998 ). This revitalized the interest in behavioral models of treatment for depression and led to the development of a new therapy: BA. Like earlier behavioral approaches, BA sees depression as a result of a reduction in positive reinforcement which leads to a reduction in behavior and further low mood. In contrast to earlier models, this approach emphasizes the role of negative reinforcement of avoidance behavior: Social withdrawal and avoidance of responsibility and rumination bring temporary relief from painful affect but lead to more passivity and inactivity. BA uses activity monitoring and scheduling to encourage healthy behaviors and teaches patients to do their own functional analysis. Patients identify triggers for avoidance (Triggers, Reactions, and Avoidance Patterns—TRAPs) and replace them with coping responses (Triggers, Reactions, and Coping response—TRACs). A range of other techniques, including graded task assignment, mental rehearsal, problem-solving, and skills training, may all be employed (Martell, Addis, & Jacobson, 2001 ; Martell, Dimidjian, & Herman-Dunn, 2010 ). Behavioral activation is simpler and easier to teach than cognitive therapy (Ekers, Dawson, & Bailey, 2013 ) and there is a growing body of evidence for its effectiveness. Meta-analysis has found that there is a large effect size in comparison with controls (standardized mean difference [ SMD ] of −0.74) and a moderate superiority of BA over medication ( SMD −0.42) (Ekers et al., 2014 ).

Behavioral couple therapy (BCT) is a brief (12–20 sessions) intervention that can be applied when there is relationship distress and at least one partner is depressed. There is an interaction between the couple’s behavior and the depression such that intimacy and support is reduced and conflict increased. BCT seeks to improve the relationship through communication training, fostering positive exchanges between partners and teaching joint problem-solving skills. The approach is based on the groundbreaking work of Neil Jacobson (Jacobson et al., 1991 , 1993 ) but has developed over the subsequent 20 years. BCT improves both depression and the quality of the relationship (Christensen, Atkins, Yi, Baucom, & George, 2006 ) and is recommended in a number of guidelines such as the NICE guidelines for depression. A recent Cochrane review advised caution since the quality of randomized controlled trials (RCTs) of couples therapies and sample sizes are relatively low (Barbato, D’Avanzo, & Parabiaghi, 2018 ).

Process-Oriented Cognitive Behavioral Therapies

In contrast to cognitive behavioral therapy (CBT) for anxiety disorders, which has progressed through delineating specific models for the subgroups of anxiety diagnoses (panic, social phobia, etc.), depression has resisted this type of subcategorization beyond perhaps the distinction between acute and chronic depression. The research has therefore focused on refining the methodology of trials using Beck’s manualized cognitive therapy and more latterly behavioral activation (BA). Alternative cognitive approaches that have developed over the past 20 years have moved the focus from cognitive content (i.e., distorted negative thinking) to cognitive processes (e.g., rumination): the “third wave” behavior therapies. Well’s metacognitive therapy was first applied to anxiety and then later depression. It addresses the positive beliefs (“If I can understand why I am depressed I will be able to find a way out”) and negative (“I can’t control this rumination”) beliefs that drive worry and rumination and associated attentional processes (Papageorgiou & Wells, 2009 ; Wells, 2011 ). A meta-analysis suggests this approach may be more effective than standard CBT (Normann, van Emmerik, & Morina, 2014 ). A related approach is Watkins’ rumination-focused CBT which helps depressed patients shift their thinking style from abstract, overgeneralized thinking that maintains depression to more concrete, problem-focused thinking (Watkins, 2018 ). A randomized controlled trial has demonstrated its superiority over treatment as usual in residual depression (Watkins et al., 2011 ). One of the most influential developments in CBT in recent years has been mindfulness-based cognitive therapy (MBCT). This was originally developed as a relapse prevention program for recurrent depression. Relapse is understood to involve “a reactivation, at times of lowering mood, of patterns of negative thinking similar to the thought patterns that were active during previous episodes of depression” (Segal, Williams, & Teasdale, 2013 , p. 65). Rather than working with the cognitive appraisals, MBCT seeks to help people develop a “meta-awareness” of thoughts, feelings, and physical sensations so that there is a decentering or defusion from these patterns rather than identification with them. Mindfulness is the awareness that arises when one pays attention to one’s experiences in the present moment and in an accepting, nonjudgmental way. MBCT is delivered in groups of from 8 to 15 people and uses a combination of regular formal and informal meditation practices and insights from CBT. Meta-analysis suggests there is a relative risk reduction of 43% for those with three or more depressive episodes (Piet & Hougard, 2011 ) and that MBCT may be more effective for those with residual or fluctuating depressive symptoms (Kuyken et al., 2016 ; Segal et al., 2010 ). Acceptance and Commitment Therapy (ACT) is another “third wave” approach that is now being applied to depression with evidence for its efficacy (Bai, Luo, Zhang, Wu, & Chi, 2020 ; Zettle, 2004 ). The initial results from these process-oriented therapies are very encouraging, but sample sizes are small and more research is needed to determine what benefits they may have over the established behavioral and cognitive therapies for depression.

Application of Cognitive Behavioral Therapy to Various Populations

Cognitive behavioral therapy (CBT) has been successfully applied across the life cycle. CBT for adolescent depression is an effective intervention and in many ways similar to individual CBT for adults; it has also been used in a group format and with parental involvement. Parental engagement is understandably more important with the younger depressed patient (see David-Ferdon & Kaslow, 2008 ) for a meta-analysis of CBT for depression in children and adolescents, and Amberg & Ost [ 2014 ] in children from 8 to 12 years of age). CBT has also been successfully adapted for older people (Chand & Grossberg, 2013 ; Pinquart, Duberstein, & Lyness, 2007 ). Studies generally support the delivery of CBT to people with physical illness and associated depression (Beltman, Voshaar, & Speckens, 2010 ). Adaptations may be required to take account of difficulties in carrying out behavioral activation strategies that require physical exertion, and sensitivity in the way therapists help patients manage negative thoughts that may often have some basis in reality (Moorey, 1997 ). CBT appears to be effective across a range of health conditions (Okuyama, Akechi, Mackenzie, & Furukawa, 2017 ), including life-threatening illnesses such as cancer (Anderson, Watson, & Davidson, 2008 ; Moorey & Greer, 2011 ). Many of these trials, however, have small samples and a recent large-scale RCT comparing CBT with treatment as usual in patients with depression and advanced cancer failed to find an effect of therapy (Serfaty et al., 2020 ). CBT originated in a Western context, and the concept of collaborative empiricism assumes a relationship of equals in which clients share their thoughts and feelings and work toward solving problems and achieving their goals. In Eastern cultures, however, relationships may be structured more hierarchically. People may be less used to openly expressing and sharing their thoughts and feelings, and they may have a far more interdependent view of their goals. Adaptations of CBT in non-Western countries have tended to keep the content of the intervention relatively unchanged but have modified the forms of language used, the context, and the mode of delivery (Chowdhary et al., 2014 ). Preliminary evidence suggests that CBT can be transported cross-culturally with no loss of its effectiveness (see, e.g., a discussion of CBT in Japan: Ono et al. [ 2011 ]; Kobori et al. [ 2014 ]).

Disseminating Cognitive Behavioral Therapy

Much of the research in cognitive behavioral therapy (CBT) has been in the form of efficacy trials carried out in academic settings delivered by well-trained therapists. More effectiveness studies are needed to establish its usefulness in depression in “real world settings,” but perhaps more importantly, ways are needed to disseminate the techniques to the wider population. Freud’s model of the weekly 50-minute hour consultation has persisted into the 21st century . The prevalence of depression means it will never be possible to train enough therapists to deliver face-to-face CBT to those who need it. One solution is to move the treatment out of the one-to-one setting using groups or technology to improve cost-effectiveness. Another innovation in the United Kingdom has been the Improving Access to Psychological Therapies program that attempts to standardize evidence-based therapy nationwide. Briefer CBT delivered by nonprofessionals has been trialed in low- and middle-income countries. These three areas are described here as examples of alternative ways to deliver CBT more widely.

Alternative Formats to Individual CBT: Group, Computer, Internet, and Telephone

Group CBT is widely practiced but has not received as much research attention as individual therapy. It is usually delivered in a psychoeducational structured format (Scott, 2011 ). It may not be acceptable to about one third of patients, and the need for individual orientation sessions to prepare and engage patients means that it may not be as cost-effective as it appears on the surface. A naturalistic study, however, found that individual CBT was 1.5 times more expensive than groups that included 8–12 participants (Brown et al., 2011 ). A meta-analysis found that individual CBT was slightly superior post-treatment, but there was no difference at 3 months follow-up (Huntley, Araya, & Salisbury, 2012 ). Computerized CBT (cCBT) has become very popular because of its potential cost-effectiveness. Hofman, Pollitt, Broeks, Stewart, and Van Stolk ( 2017 ) carried out a systematic review of the available cCBT platforms and their effectiveness. They found large within-group effect sizes averaging 1.23. The findings overall do support its use in depression, but it may not be reaching groups who are less computer literate: The average cCBT participant was a female in her late 30s with a university degree who was in full-time employment. There should also be caution in assuming that participants will make full use of the program without any assistance: Reviews have consistently found guided self-help to be more effective than unguided (Andersson & Cuijpers, 2009 ). With the increased availability of the internet, online CBT programs are also being used more widely. For instance, a web-based program for depression has been shown to be more effective than treatment as usual (Farrer, Christensen, Griffiths, & Mackinnon, 2011 ). Finally, telephone CBT also appears to be an effective treatment for depression (Castro et al., 2020 ). Cuijpers and colleagues carried out a network meta-analysis comparing individual, group, telephone-administered, guided self-help, and unguided self-help for people with depression (Cuijpers, Noma, Karyotaki, Cipriani, & Furukawa, 2019b ). All approaches were equally effective and superior to a waiting list and care as usual. Guided self-help appeared to be less acceptable than individual, group, or telephone formats.

The U.K. Improving Access to Psychological Therapies Initiative (IAPT)

Psychotherapy has traditionally been something of a “cottage industry,” with an emphasis on the individual skill and discretion of the therapist, but not organized in a systematic, nationwide fashion. Provision has been patchy and many patients have not had access to evidence-based therapies. The U.K. Improving Access to Psychological Therapies (IAPT) program has been developed to redress this balance and to show that locally based therapy services that have clear targets, the means to evaluate outcomes, and are cost effective can work. In 2007 , the economist Richard Layard and the psychologist David Clark joined forces to lobby for a much-needed expansion of psychological therapies in the United Kingdom. They argued that anxiety and depression had significant deleterious effects on the economy (Layard, 2006 ). They suggested that the costs of increasing psychological therapies services would be outweighed by the benefits in savings to the health service and treasury through increased tax revenues and reduced spending on benefits. The IAPT program implements psychological treatments that have been shown to be effective and monitors their impact. The services set challenging targets for access (16% of the community prevalence of anxiety and depression) and outcomes (50% recovery: defined as PHQ-9 and GAD-7 scores falling below 10). Treatment follows a stepped care model. Low-intensity (LI) therapy is delivered by Personal Wellbeing Practitioners (PWPs). LI treatment includes guided self-help, computerized CBT, behavioral activation, and psychoeducational groups.

High-intensity therapy (HI) involves weekly face-to-face therapy delivered by fully trained CBT therapists. Patients with less severe problems are initially treated with LI and stepped up to HI if necessary, while more severe problems are treated with HI as the first intervention. A total of 36% of people receive only LI, 28% HI, and 34% both (Clark, 2018 ). IAPT services now treat nearly one million patients a year and achieve recovery in 50% of cases as well as reliable improvement in 66% (Clark, 2018 ), with evidence of substantial change in depression scores and a moderate impact on functioning (Wakefield et al., 2020 ). Over the 10 years IAPT has been operating services, recovery rates have been improving year by year. IAPT has received criticism on the grounds that it relies too heavily on quantitative measures that may give a falsely optimistic indication of improvement: There may be a mismatch between outcome measures and the client’s reported experience of distress (Bendall & McGrath, 2020 ), and also for its “managerialism” and perceived emphasis on efficiency over person-centered care (Dalal, 2018 ). Services do not always deliver the full “dose” of CBT for depression recommended in the NICE guidelines, and there is evidence that comorbid personality difficulties and complexity affect outcome and re-referral after treatment (Cairns, 2014 ; Goddard, Wingrove, & Moran, 2015 ). That being said, recovery rates have climbed from a percentage in the mid-30s to over 50% over the past decade (Clark, 2018 ). There is nothing like these rates elsewhere in the world.

CBT in Low- and Middle-Income Countries

The challenge of delivering CBT in developing countries where there are few psychiatrists and psychotherapists is substantial, but a number of programs are rising to the challenge. Community mental health workers can be trained to carry out brief CBT interventions with beneficial effects (e.g., Rahman, Malik, Sikander, Roberts, & Creed’s [ 2008 ] study of CBT for perinatal depression in rural Pakistan, and Bolton et al.’s [ 2014 ] study of CBT for depression, anxiety, and PTSD in Burmese refugees). The World Health Organisation (WHO) is rolling out a program called Problem Management Plus which trains lay helpers to deliver five weekly individual face-to-face sessions of 90 minutes for a range of problems, including depression. They teach simple evidence-based strategies such as relaxation, problem-solving, behavioral activation, and ways to strengthen social support (Rahman et al., 2016 ; WHO, 2016 ). Patel and colleagues found that from six to eight sessions of a culturally adapted version of behavioral activation, called the Healthy Activity Program delivered by lay counselors with no prior psychiatric training, was more efficacious than enhanced treatment as usual in a general practice setting in rural India (Patel et al., 2017 ), and that gains made in treatment largely held across a 9-month follow-up (Weobong et al., 2017 ).

Future Directions

The cognitive and behavioral interventions (if adequately implemented) can be as efficacious as medications in the treatment of even more severe depression (DeRubeis et al., 2005 ; Dimidjian et al., 2006 ) and have an enduring effect that medications simply lack (Dobson et al., 2008 ; Hollon et al., 2005 ). That being said, not everyone responds to either intervention, and there is emerging evidence that differential response to CBT versus medications can be predicted in advance. DeRubeis and colleagues used regression equations to combine multiple predictors of differential response into a single Personalized Advantage Index (PAI) and found that overall response could have been improved by as much as the typical drug-placebo difference if each patient had been given his or her optimal intervention (DeRubeis et al., 2014 ). This group has now moved on to using machine learning to generate precision treatment rules (PTRs) that can predict the optimal treatment for a given patient, and it should revolutionize the field (Cohen & DeRubeis, 2018 ). Even in the absence of making treatments better, overall efficiency of mental health delivery can be improved by getting each patient what he or she most needs.

Dissemination can be improved as well. Efforts to task-shift to lay counselors in low- and middle-income countries (LMIC) have shown that lay counselors with no prior psychiatric experience can be trained to deliver cognitive and behavioral therapies in an efficacious manner (Singla et al., 2017 ). The treatment gap is clearly largest in LMICs, but too few resources are available in high-income countries as well and, as IAPT has shown so well, a stepped-care approach can extend resources in a most salubrious fashion. It may well be that task-sharing approaches developed out of necessity in LMICs may readily transfer to other parts of the world also.

Finally, there is reason to think that nonpsychotic common mental disorders (including depression and anxiety) may represent adaptations that evolved to increased inclusive fitness (the propagation of one’s gene line) in our ancestral past (Hollon, Cohen, Singla, & Andrews, 2019 ). Most such “disorders” revolve around negative affects that motivate a differentiated response to different environmental challenges (Hollon, DeRubeis, Andrews, & Thompson, in press). To the extent that that is true, then simply “anesthetizing the pain” with medications may do little to resolve the problems that brought the symptoms about. Those psychosocial interventions (cognitive and behavior therapies and interpersonal psychotherapy) that teach problem-solving and interpersonal skills are likely to have broader and more enduring effects that sole reliance on pharmacological interventions (Hollon, in press).

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Cognitive-Behavioral Treatments for Anxiety and Stress-Related Disorders

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The International Journal of Indian Psychȯlogy

Cognitive Behavioral Therapy for Depression in an Adult: A Clinical Case Study

| Published: August 26, 2024

World Health Organization (WHO) reported, depression is the most common psychiatric disorder in the mental health field. Depression is various from habitual mood swings and short lived emotional responses to challenges in day to day life. Although strong evidence of supports that cognitive behavioral therapy for depression. The patient is a 22-year elderly a male which pre-treatment give a diagnosis of severe depressive symptoms without psychotic (based on case history + MSE + ICD-10 + BDI-II), low mood, frequently crying spell and suicidal ideation, highly dysfunctional attitudes and also decreased sleep and appetite. The CBT Treatment consisted of 12 standard individual therapy sessions. In this study used a case study method and also used the qualitative as well as quantitative data for the case is presented using self-report instruments or clinical case notes. Treatment effects such as his mood over the course of treatment was assessed using Beck Depression Inventory and after 6 months of follow up. Also enhancing his mood was accompanied by a reduction in dysfunctional beliefs and attitudes about self and relationship. Additionally, the patient was reported an improvement in his mood, Activity of Daily Living (ADL) functioning as well as socialization.

Depression , Cognitive Behaviour Therapy , Treatment Outcome , Case Report

This is an Open Access Research distributed under the terms of the Creative Commons Attribution License (www.creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any Medium, provided the original work is properly cited.

© 2024, Chaudhary, N.

Received: April 15, 2024; Revision Received: August 23, 2024; Accepted: August 26, 2024

Mr. Narsinh Chaudhary @ [email protected]

Article Overview

Published in   Volume 12, Issue 3, July-September, 2024

• Open access
• Published: 31 August 2024

Effectiveness of a cognitive behavioural therapy (CBT)-based intervention for reducing anxiety among adolescents in the Colombo District, Sri Lanka: cluster randomized controlled trial

• Sinha De Silva   ORCID: orcid.org/0000-0003-4578-5019 1 ,
• Renuka Peris 2 ,
• Sudharshi Senaviratne 3 &
• Dulani Samaranayake 4  

Child and Adolescent Psychiatry and Mental Health volume  18 , Article number:  108 ( 2024 ) Cite this article

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Anxiety disorders are found to be the most prevalent psychological problems among children and adolescents. Cognitive behaviour therapy (CBT) was found to be effective at reducing anxiety. The purpose of this study was to assess the effectiveness of a universal school-based intervention for reducing anxiety among Grade 9 schoolchildren. A randomized controlled cluster trial was conducted by randomly assigning 36 schools in the Colombo district in Sri Lanka into study and control arms, each comprising 18 schools with 360 students. The levels of anxiety, self-esteem and depression status were assessed using the validated Screen for Child Anxiety Related Disorders (SCARED) tool and the Rosenberg self-esteem scale, respectively, and the Depression, Anxiety and Stress Scale 21 (DASS-21) at baseline, after intervention, and after 3 months. A CBT-based universal intervention package was administered weekly by a trained teacher for eight weeks with a one-month self-practice period to a randomly selected Grade 9 class in each school in the study arm. The control arm received routine care. Anxiety and self-esteem scores and depression status were compared between the two arms after the intervention and at 3 months of follow-up using the generalized estimation equation (GEE), controlling for confounding and clustering. The nonresponse and loss to follow-up rates were < 1%. When comparing the study arm with the control arm using GEE, anxiety levels were significantly lower [β = (-0.096), 95% CI = (-0.005) − (-0.186), p  = 0.038] at follow-up but not postintervention [β = (-0.024), 95% CI = 0.006 − (-0.055), p  = 0.115]. There were no significant differences in depression status after intervention (OR = 0.257, 95% CI =0.052–1.286; p  = 0.098) or follow-up (OR = 0.422, 95% CI 0.177–1.008; p  = 0.052), and self-esteem significantly increased after intervention (β = 0.811, 95% CI = 0.314–1.309; p  = 0.001) but not at follow-up [β=0.435, 95% CI=(-0.276)-1.145, p=0.231]. This study revealed that the universal package based on CBT is effective at reducing anxiety and improving self-esteem among adolescents. The trial registration number and date were SLCTR/2018/018 and 19th of June 2018 respectively.

Introduction

Anxiety is defined as the anticipation of upcoming threats and is associated with muscle tension and vigilance in preparation for future danger and continuous or avoidant behavior [ 1 ]. It is recognized as a normal adaptive response to a stimulus that one will try to avoid. It is a brain response to something that is happening or might happen in the future. Anxiety becomes pathological, regardless of the individual’s age, when it is persistent or excessive and associated with subjective distress or impairment [ 2 ]. Individuals with any anxiety disorder (AD) may exhibit similar psychological, physical, and behavioral characteristics. These disorders are categorized based on the object or situation that induces fear, anxiety, and/or distress and avoidance behavior [ 2 ].

Anxiety disorders are the most prevalent form of psychopathology among adolescents [ 3 , 4 , 5 ]. Despite notable variations in prevalence estimates, likely due to methodological differences, the lifetime prevalence of ‘any anxiety disorder’ in studies with children or adolescents is approximately 15–20%. Period prevalence estimates, such as 1-year or 6-month rates, are not considerably lower than lifetime estimates [ 2 ]. A longitudinal study revealed significant linear associations between having anxiety disorders in adolescence and developing a range of adverse outcomes in early adulthood, including mental health problems like major depression, nicotine dependence, alcohol dependence, illicit drug dependence, and suicidal behavior [ 6 ].

Behavioral therapy plays a pivotal role in preventing and managing anxiety disorders. A review by Compton et al. (2004) of 21 randomized controlled trials concluded that cognitive behavioral therapy (CBT) is the treatment of choice for anxiety in children and adolescents, showing medium to large effect sizes for symptom reduction. CBT is favored due to its lack of adverse side effects, withdrawal problems, and association with a lower rate of subsequent relapse. Additionally, CBT can enhance self-esteem and foster an increased sense of agency [ 7 , 8 ].

Anxiety prevention measures can be directed at individuals or groups. Evidence suggests that group-targeted preventive measures are more effective than those targeting individuals. Prevention programs targeting a group may be universal, selective, or indicated. Universal interventions are directed at the entire population regardless of risk status. Selective interventions involve people identified as at risk for psychological problems, while indicated interventions target those identified as having mild to moderate symptoms. Universal prevention strategies include elements of primordial, primary, secondary, and tertiary prevention, whereas selective programs focus on primary prevention, and indicated programs concentrate on secondary prevention [ 9 ].

There are several benefits associated with universal prevention programs compared to selective and targeted programs. Universal interventions can address people with limited access to treatment, ensuring no one is omitted. People with limited access to treatment show low dropout rates, which can help avoid the stigma associated with participating in selective or targeted interventions [ 9 ]. A systematic review of universal interventions for reducing anxiety and depressive symptoms in school-aged children revealed small but significant effects on reducing these symptoms. The goal of prevention is to reduce the likelihood of future negative outcomes by reducing relevant risk factors and strengthening protective factors [ 10 ]. When developed as prevention programs, these programs are designed to build skills rather than provide therapy, meaning strategies are learned for common situations rather than specific individual difficulties [ 11 ].

Despite the established effectiveness of school-based interventions for reducing anxiety, there is a scarcity of evidence, particularly in Southeast Asia. The importance of this study becomes increasingly evident when considering the unique interaction between interventions designed to reduce anxiety and contextual factors influencing their efficacy. These factors play a central role, particularly in educational settings characterized by distinct regional attributes. The educational environments of our region have unique characteristics that can significantly impact the effectiveness of these interventions. Therefore, it is crucial to conduct this intervention study tailored to our specific context. By doing so, we can gain a deeper understanding of how these unique environmental characteristics influence anxiety reduction strategies, allowing us to fine-tune the intervention in a contextually relevant manner.

This study was conducted to assess the effectiveness of a universal CBT-based intervention for reducing anxiety among adolescents in Sri Lanka. The study was carried out in the Sri Jayewardenepura Education Zone in the Colombo district, targeting Grade 9 schoolchildren. We employed a randomized controlled cluster trial, randomly assigning 36 schools into intervention and control arms. The intervention, delivered by trained teachers, consisted of eight weekly CBT sessions followed by a one-month practice period. Outcomes were assessed using validated tools at baseline, post-intervention, and three months follow-up.

By focusing on the effectiveness of a universal CBT-based intervention within the unique cultural and educational context of Sri Lanka, this study aims to provide insights into how contextual factors influence anxiety reduction strategies, thereby enhancing the relevance and applicability of the intervention in similar settings.

Materials and methods

Study design and participants.

We conducted a randomized controlled multicenter trial in the Sri Jayewardenepura Education Zone in the Colombo district, Sri Lanka. The target population was children in grade nine (aged 13–15 years). Each school was considered a cluster, and a randomly selected class of nine grades was selected from each school for the study. The average number of students per group was 20. The sample size and number of groups for each arm were decided using a formula proposed by Hayes Moulton (2017) for an individually randomized trial with inflation for the design effect for a cluster randomized trial [ 12 ]. The values for the true mean and standard deviation of the outcome variable in the presence (µ 1  = 7.35, σ 1  = 6.93) and absence (µ 0  = 9.58, σ 0  = 6.44) of intervention were informed by Barrett and Turner (2001) in their study on reducing anxiety using a CBT-based package. For alpha (Z α ) and beta (Z β ) errors, the values used were Z α = 1.96 for α = 0.05 and Z β = 0.84 for β = 0.80 [ 13 ]. According to Shackleton et al. (2016), the ICC for psychological outcomes ranges from 0.01 to 0.07; we used the higher end of this range, setting ICC (ρ) at 0.07 to maximize sample size [ 14 ]. All Sinhala medium schools with year nine classes were invited to participate in the study; 37 schools agreed upon the study, and one school withdrew prior to randomization. A total of 720 students from 36 schools and their parents provided assent and informed written consent, respectively.

The trial was registered in the Sri Lanka Clinical Trial Register (SLCTR/2018/018) and was approved by the Ethics Review Committee of the Faculty of Medicine, University of Kelaniya (P/19/01/2018). Administrative approval was obtained from the Ministry of Education, Sri Lanka.

Randomization and masking

The consented schools were stratified by school gender type, i.e., male, female, or mixed. Within each stratum, schools were randomized to the universal intervention group based on CBT or the control group using the block randomization method to ensure allocation of schools in a 1:1 ratio to two groups (Fig.  1 ). Schools, students, and the research team were masked in the allocation.

Student progress through the trial– CONSORT flow chart

Intervention arm

Schools that were randomized into the intervention arm received a universal CBT-based intervention package that was developed based on the UK Medical Research Council guidance by De Silva et al. [ 15 ]. The intervention was delivered by a teacher who underwent a comprehensive training program covering CBT principles, specific techniques, and strategies for engaging students. To ensure consistency, the training included role-playing exercises, peer reviews, and feedback sessions. Teachers were provided with a detailed handbook outlining session plans and activities. The delivery of the intervention was monitored using a fidelity monitoring framework involving regular supervision by experienced mental health professionals. Teachers submitted weekly reports, and random observations were conducted to assess adherence to the intervention protocol. Any deviations were addressed through additional support and training, aiming to minimize variations and maintain the integrity of the intervention across different schools. Each teacher delivered the intervention package to randomly selected classes in the intervention arm in a 40-minute session per week for eight consecutive weeks and for a subsequent one-month duration to practice what they learned. An additional session was arranged for students who missed a session prior to the next session. During these eight sessions, the children were trained in CBT-based skills that were aimed at reducing anxiety and relaxing. The outline of the intervention package is shown in Table  1 , and its details are published elsewhere by De Silva et al. (2023) [ 15 ]. They were instructed to practice these skills under the close and distant supervision of the teacher.

A 40-minute session was held for parents by the same teachers, overlapping with the routine parent meeting. Parents were educated about anxiety, anxiety disorders, how to identify them, and how to adapt to reduce anxiety. This session aimed to support parents in practicing the anxiety reduction skills learned by their children at home. Materials included the Teachers’ Handbook, the Workbook for Children, and a monitoring tool for students’ practice, along with a leaflet for parents. The intervention was monitored using the process evaluation framework (PEF) at the school level [ 15 ]. The PEF of the intervention group is provided in Additional File 1 Table S1 .

We acknowledge the potential for performance bias due to the lack of blinding among intervention deliverers and participants. While blinding presents challenges in school-based interventions, several measures were taken to minimize bias and ensure the study’s internal validity. The rigorous training, monitoring procedures, and use of validated assessment tools, such as the SCARED tool for anxiety and the Rosenberg self-esteem scale, helped reduce subjective bias. Despite the difficulties in implementing blinding, these steps significantly contributed to the robustness of our findings. Future studies should explore feasible blinding strategies to further strengthen internal validity.

Control arm

Routine schoolwork was carried out in randomly selected classes from the control arm. The participants were assessed at baseline, after the intervention, and at follow-up.

Outcomes and measures

Both groups were assessed at baseline using a self-administered questionnaire consisting of sociodemographic questions, a tool to measure the level of anxiety, the state of depression, and the level of self-esteem. The participants’ level of anxiety, depression status and self-esteem were assessed postintervention, as well as at three months of follow-up, using the same tools as follows.

Level of anxiety

The child version of the Screen for Child Anxiety Related Disorders (SCARED) is a 41-item instrument rated on a 3-point Likert scale. This instrument has been validated for assessing children aged 8–18 years [ 16 , 17 ]. The translated and validated questionnaire, which has high reliability according to Cronbach’s alpha (0.87) and test-retest correlation coefficient (0.74), was used to assess the level of anxiety [ 18 ]. A higher score indicates a greater level of anxiety.

Status of depression

Depression scales of the validated DAS-21 questionnaire were used in the local setting among adolescents by Weerasinghe in 2012. This approach has been validated for use in Sinhalese adolescents, as it has good psychometric properties. All the subscales had good reliability (Cronbach’s alpha > 0.7). Its cut-off value for the depression subscale was 19, with a sensitivity = 80% and specificity = 83%. [ 19 ]. The state of depression was determined using this tool.

Self-esteem

The Rosenburg self-esteem instrument was validated for use among adolescents internationally. The NRS-2002 is a 10-item scale that measures global self-worth by measuring both positive and negative feelings about the self. The scale is believed to be unidimensional. All the items are answered using a four-point Likert scale ranging from strongly agreeing to strongly disagreeing. The scores were on a continuous scale ranging from 10 to 40. A higher score indicates greater self-esteem [ 20 , 21 ].

Statistical analysis

All the analyses were based on intention-to-treat principles. All baseline categorical variables are presented as numbers and percentages, and all numerical variables are presented as the means and standard deviations (Table  2 ). As the first step of the pre specified statistical analysis plan (SAP), all the outcome variables were compared between two groups using conventional statistics with their effect sizes. Those results are presented in the (Additional File 1 Table S2 to Table S4 ).

The outcome variables were analysed to determine the effectiveness of the intervention using marginal linear regression with coefficients estimated by the generalized estimating equation (GEE). This approach allowed us to control for the effect of clustering and adjust for imbalanced covariates and probable confounders identified at the beginning of the study. Specifically, we considered several covariates and confounding variables, including sex, age, ethnicity, religion, permanent and current residence, school functional type, attendance at tuition classes, engagement in extracurricular activities, having siblings, anxiety sensitivity, behavioral inhibition, mother’s level of education, mother’s and father’s occupation, and perceived parenting style of the mother. By adjusting for these covariates, we aimed to isolate the effect of the intervention from other factors that might affect anxiety, depression, and self-esteem levels among the participants, thereby minimizing bias and improving the internal validity of our findings. The marginal models allow the effect of the explanatory variables on the outcome, and the correlation between observations is modelled separately. Each outcome variable was analysed after the intervention and at the follow-up; in other words, separate marginal models were used for each outcome variable after the intervention and at the follow-up. Only the relevant anxiety levels from the outcome tables are shown here (Tables  3 and 4 ), and the anxiety levels for depression status and self-esteem are shown in the supplementary material. In each marginal model, the scores of the outcome variable were used as the dependent variable, the arm of the study (intervention or control), the baseline value of the outcome variable and the baseline covariates that needed to be adjusted were used as predictors. Clusters were used as subjects to control for the nested/cluster effect. SPSS 22 was used for the data analysis.

Thirty-six clusters were recruited, and all the clusters remained throughout the study. Clusters were randomized into intervention and control arms as shown in Fig.  1 . At the initial assessment before the beginning of the study, there were 720 students in both arms. At the postintervention assessment, only one student in the control arm was lost to follow-up, which was a 99.86% ( n  = 719) response rate. At the end of the three-month follow-up, only two students were lost to follow-up in the intervention arm, and four were lost to follow-up in the control arm (99.16%; n  = 714). At both points of measurement, less than 0.9% of the patients were lost to follow-up. A comparison of the baseline sociodemographic and other selected characteristics between the study arm and the control arm was performed as follows (Table  2 ):

The standardized mean difference (Cohen’s d) between the levels of anxiety in the two groups at post-intervention was calculated to be 0.12. The estimated regression coefficients of a marginal model with robust standard error to show the effects of the intervention arm on the outcome, the SCARED Child Sinhala score postintervention, after adjustment for the baseline SCARED Child score and other selected covariates/factors while controlling for the clustering effect are shown in Table  3 .

The standardized mean difference (Cohen’s d) between the levels of anxiety in the two groups at follow-up was calculated to be 0.32.The estimated regression coefficient of a marginal model with robust standard error was used to show the effects of the intervention arm on the outcome, the SCARED Child score at follow-up, after adjustment for the baseline SCARED Child score, and other selected covariates/factors controlling for the clustering effect (Table  4 ).

The standardized mean differences (Cohen’s d) in depression levels between the intervention and control groups were 0.04 at post-intervention and 0.06 at follow-up. The generalized estimating equation was used with clusters as the subject variables, a robust estimator as the covariance matrix, AR as the working correlation matrix structure, a binomial logit as the ordinal response under the type of model, and predictors that included the arm of the intervention, baseline DASS-21 Depression Scale score at baseline and some selected covariates. The status of depression, that is, having or not having depression at the postintervention time point and follow-up, was assessed as the dependent variable in two separate models (Additional File 1 Table S5 and Table S6 ). The results suggest that the study arm participants had lower odds of having depression after the intervention time point, with an OR of 0.257 (95% CI 0.05–1.27) and an OR of 0.422 (95% CI 0.177–1.008) at the follow-up time point than did the control arm participants; however, these differences were not statistically significant, with p  = 0.098 and p  = 0.052, respectively, when adjustments were made for imbalance correlates/confounders at baseline and for the effect of clustering in two separate models.

Level of self-esteem

The standardized mean differences (Cohen’s d) in self-esteem levels between the intervention and control groups were 0.3 at post-intervention and 0.2 at follow-up. The regression coefficients were estimated from two different marginal models with robust standard errors to show the effects of the intervention on the Rosenberg self-esteem scale scores after the intervention and at follow-up after adjustment for the Rosenberg self-esteem scale scores at baseline and other selected covariates/factors while controlling for the cluster effect (Additional File 1 Table S7 and Table S8 ). The results suggest that the participants in the study arm had significantly greater Rosenberg self-esteem scale scores at the postintervention time point (i.e., high self-esteem) (0.811 points; 95% CI = 0.314 to 1.309, p  = 0.001) than did the participants in the control arm; however, the participants in the study arm had greater Rosenberg self-esteem scale scores at the follow-up time point (i.e., high self-esteem) [0.435; 95% CI = (-0.276) to 1.145] than did the participants in the control arm did, but it was not statistically significant, as the p value was 0.231 when adjustments were made for imbalanced correlates at baseline and for the effect of clustering.

We examined the effectiveness of teacher-provided universal CBT-based interventions for reducing anxiety among adolescents in a school setting. The loss to follow-up was minimal, and good compliance with the intervention was reported. The baseline variables were comparable between the two arms.

There was a reduction in the level of anxiety (SCARED Child score) after the intervention and at the follow-up, but it was statistically significant only at the follow-up in the intervention arm compared to the control arm. Depression status was also reduced in the intervention arm than in the control arm at both postintervention and follow-up. The level of self-esteem (the Rosenberg self-esteem tool score) was greater in the intervention arm than in the control arm at both postintervention and follow-up but was statistically significant only at postintervention assessment.

A systematic review by Corrieri et al. 2014 of 28 RCTs conducted after the year 2000 in which outcomes were measured as continuous variables with self-reported instruments, focusing on school-based prevention interventions for anxiety and depression with the aim of exploring their effectiveness, revealed that 15 studies [ 10 ] were reported to be effective (73%), and 16 (67%) out of 24 studies reported effective outcomes for anxiety and depression [ 22 ]. Furthermore, Werner-Seidler et al. (2017) revealed that psychological program-based interventions are effective at reducing anxiety and depression after intervention and at follow-up in a systematic review that included 81 studies with 31,794 participants [ 23 ]. Similar findings to those of the present study were explored in a cluster randomized controlled trial with a universal school-based intervention based on CBT administered in 10 weekly sessions among 638 children aged 9–12 years in 14 schools in Germany, where anxiety level was assessed using a self-reported instrument (SCAS). A statistically significant reduction in anxiety was observed at follow-up ( p  < 0.05) but not postintervention [ 24 ].

Despite the fact that CBT-based interventions were effective at significantly reducing the level of depression, as shown by systematic reviews, the present study did not show a significant effect on reducing depression. Furthermore, a reduction in the level of depression was shown in the intervention arm, and a follow-up arm comparison became nonsignificant at p  = 0.52. These differences may be due to an inadequate sample size for detecting changes with respect to the level of depression.

Like in the current study, a CBT-based RCT conducted by Amin et al. (2020) among 76 adolescents aged 13–16 years in Pakistan with a study arm and a control arm, with the objective of evaluating its effectiveness in increasing self-esteem using the Rosenberg self-esteem scale for outcome evaluation, revealed a statistically significant increase in self-esteem levels in the study arm compared to the control arm ( p  < 0.001) [ 25 ].

Therefore, it could be concluded that the findings of the present intervention study align with the global literature. Furthermore, from a practical point of view, the importance of this study is manifold. First and foremost, it was carried out by the teachers themselves, seamlessly integrating into the existing educational framework. This approach not only emphasizes the feasibility of the study but also highlights its minimal intrusion into the regular schedule, preserving the quality of academic hours. In addition, the enthusiastic participation of students serves as a testament to the study’s engagement and relevance to their needs. The fact that the tool was well received by the student body not only adds to its credibility but also demonstrates its practical value in real-world educational settings. In essence, this study provides an example of how educational research can be conducted effectively and efficiently, with direct benefits for both educators and students. Therefore, universal CBT-based interventions are effective at reducing anxiety and increasing self-esteem among schoolchildren in Sri Lanka.

In order to address the delay in achieving statistical significance, it is important to consider multiple contributing factors. While the time taken by participants to practice learned skills is a key element, other potential influences must be acknowledged. Individual differences in response to the intervention, such as varying levels of baseline anxiety and differing capacities for skill acquisition and application, likely played a role. Contextual factors, including the school environment and external stressors, may have impacted the effectiveness of the intervention. Additionally, methodological limitations, such as potential biases in self-report measures and the challenges of maintaining consistency across different school settings, could have influenced the outcomes. Recognizing these factors provides a more comprehensive understanding of the intervention’s effectiveness over time and highlights areas for future research to further optimize CBT-based interventions in similar contexts. Also, in view of addressing the discrepancy in detecting changes in depression levels, several factors need to be considered. The intensity and duration of the intervention might not have been sufficient to produce a measurable effect on depression within the study period. Future research should explore longer intervention durations, increased intensity, and tailored approaches to address depression more effectively in similar populations.

The observed improvement in self-esteem among participants in the intervention arm can be attributed to several factors inherent in CBT techniques, which are particularly relevant within the cultural and educational context of Sri Lanka. CBT emphasizes the identification and restructuring of negative thought patterns, leading to a more positive self-view and enhanced self-esteem. In the Sri Lankan context, where students often face high academic pressures and societal expectations, learning to manage stress and develop a healthier cognitive outlook can significantly impact their self-esteem. Additionally, the group-based nature of the intervention facilitated peer support and interaction, providing a sense of community and shared experience among students. This is particularly important in the collectivist culture of Sri Lanka, where community and social relationships play a crucial role in individual well-being. The involvement of teachers, who are respected authority figures, in delivering the intervention likely contributed to its effectiveness by reinforcing the importance and credibility of the skills being taught. Future research should continue to explore these dimensions to further optimize the effectiveness of CBT-based interventions in diverse settings.

Conclusions

Universal CBT-based interventions delivered by schoolteachers are effective at reducing anxiety and increasing self-esteem among schoolchildren. The observed improvements, although statistically significant, reflect a modest effect size, indicating that while the intervention is beneficial, its impact may vary among individuals. The sustainability of these effects over the long term remains a crucial area for further research, as continued practice and reinforcement of CBT skills are likely necessary to maintain these benefits.

From a practical standpoint, this approach can be easily incorporated into existing educational systems with minimal external resources, making it a feasible and scalable option for improving mental health at the school level. However, implementing such interventions in real-world settings presents challenges, including ensuring fidelity to the intervention protocol, providing adequate training and support for teachers, and addressing varying levels of resource availability across different schools. Future studies should focus on these aspects to enhance the practicality and effectiveness of CBT-based interventions in diverse educational contexts.

Limitations

The study acknowledged several limitations. Performance bias due to the lack of blinding among intervention deliverers and participants was a potential issue, despite measures taken to minimize it. The sample size may have been inadequate to detect significant changes in depression levels. The delay in achieving statistical significance could be attributed to multiple factors, including the time taken by participants to practice learned skills, individual differences in response to the intervention, contextual factors such as the school environment and external stressors, and methodological limitations like potential biases in self-report measures and consistency challenges across different school settings. Additionally, the intensity and duration of the intervention might not have been sufficient to produce measurable effects on depression within the study period. The sustainability of the intervention’s effects over the long term remains uncertain, requiring continued practice and reinforcement of CBT skills. Finally, practical challenges in implementing such interventions in real-world settings include ensuring fidelity to the intervention protocol, providing adequate training and support for teachers, and addressing varying levels of resource availability across different schools.

Availability of data and materials

The data that support the findings of this study is available from the authors upon reasonable request.

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Acknowledgements

Our sincere thanks go to all the participants for their generous enthusiasm for participating in the trial. We are very much grateful to the Ministry of Education, School principals and the teachers who voluntarily participated in delivering the intervention. Additionally, our sincere appreciation goes to the Regional Director of Health Services, Colombo district; all the Medical Officers of Health; and their staff in the Colombo district for providing support in conducting this study. Furthermore, all the authors of the tools used in this study, including Dr. Boris Birmaher, MD, and the team, were included.

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Sinha De Silva

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Renuka Peris

The Central Queensland Hospital and Health Service (CQHHS), Queensland, Australia

Sudharshi Senaviratne

Faculty of Medicine, University of Colombo, Colombo, Sri Lanka

Dulani Samaranayake

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“SDS designed, implemented the study and prepared the manuscript. DS supervised the overall project from the design stage until the preparation of this manuscript. SS and RP provided technical supervision throughout the project related to their technical expertise i.e., psychiatry and education respectively. All the authors reviewed the final manuscript and approved it. “.

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Ethical approval was obtained from the Ethics Review Committee of the Faculty of Medicine, University of Kelaniya, Sri Lanka (P/19/01/2018). Informed written assent and consent were obtained from children and their parents respectively. The trial was registered in the Sri Lanka Clinical Trial Register (SLCTR/2018/018).

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De Silva, S., Peris, R., Senaviratne, S. et al. Effectiveness of a cognitive behavioural therapy (CBT)-based intervention for reducing anxiety among adolescents in the Colombo District, Sri Lanka: cluster randomized controlled trial. Child Adolesc Psychiatry Ment Health 18 , 108 (2024). https://doi.org/10.1186/s13034-024-00799-9

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Psychological Theories

What are psychological theories.

Psychological theories are systematic explanations of human mental processes and behaviors, developed through both empirical research and field observation. These theories provide frameworks for understanding how and why people think, feel, and act the way they do, and guide both academic research and practical applications in areas like therapy, education, marketing, and public policy.

The Basic Idea

If you’ve ever snoozed your alarm and then been late to work or school, you may look back and ask yourself: why did I do that? Maybe your bus driver saw you running for the bus and chose to keep on driving, and you ask yourself: what was going through his mind? Or maybe the day turned out okay, because you came home to your loving partner, and you thought to yourself: why am I so compatible with this person but not others? To begin unpacking these questions and more, we can turn to psychological theories to help us understand ourselves and the people around us.

Psychological theories are systematic frameworks for understanding, predicting, and explaining human behavior and mental processes. These theories include everything from cognitive theories , which focus on mental processes such as perception and memory, to behavioral theories , which examine the relationship between stimuli and responses. Although there are many ways to explain how and why we are the way we are, it is the constant testing and refining of different psychological theories that guides research and helps us to consistently improve our understanding of humans—both within academia and beyond. 

Most Influential Psychological Theories: 

• Psychoanalytic Theory (Sigmund Freud): Focuses on the influence of the unconscious mind on behavior and uses concepts like the id, ego, superego, and psychosexual stages of development.
• Behaviorism (John B. Watson, B.F. Skinner): Emphasizes the study of observable behaviors and the role of environmental stimuli in shaping behavior, including classical conditioning and operant conditioning.
• Cognitive Development Theory (Jean Piaget): Explains how children's thinking evolves as they grow, identifying four stages of cognitive development (sensorimotor, preoperational, concrete operational, and formal operational).
• Humanistic Psychology (Carl Rogers, Abraham Maslow): Emphasizes individual potential, self-actualization, and the importance of personal growth and free will. This also includes Maslow's hierarchy of needs and Rogers' client-centered therapy.
• Social Learning Theory (Albert Bandura): Proposes that people learn behaviors through observation, imitation, and modeling, rather than solely through direct reinforcement and uses reciprocal determinism, where behavior, personal factors, and the environment interact and influence each other.

The world makes much less sense than you think. The coherence comes mostly from the way your mind works. – Daniel Kahneman

Cognition: Mental processes involved in gaining knowledge and comprehension, including thinking, knowing, remembering, judging, and problem-solving.

Psychoanalysis: A therapy developed aimed at exploring the unconscious mind to understand and treat psychological disorders.

Positive Reinforcement : In behaviorism, the process of encouraging or establishing a pattern of behavior by offering a reward when the desired behavior is exhibited.

Montessori Method: An educational approach developed by Dr. Maria Montessori that emphasizes self-directed learning, hands-on activities, creativity, and a love for learning and collaborative play in a child-centered environment.

Herzberg's Motivation Theory: Also known as the two-factor theory, this theory proposes that job satisfaction is influenced by two distinct sets of factors: hygiene factors and motivator factors. Hygiene factors pertain to external conditions such as the workplace environment and salary, while motivator factors are typically intangible elements like receiving recognition or opportunities for personal growth.

As long as there have been humans, there have been questions about why we think and act the way we do. There have likely been countless theories developed throughout time that we have no written record of, such as those developed by native peoples. For many, the known history of psychological theories goes back to ancient philosophical inquiries about the human mind and behavior. Early thinkers like Plato and Aristotle laid the groundwork for understanding the mind's complexities, focusing on issues of perception, memory, and motivation. Hundreds of years later, the 17th century marked a significant shift with the rise of empiricism, championed by philosophers like John Locke who proposed that knowledge is derived from sensory experience. This idea laid the foundation for later psychological theories that emphasize the role of the environment in shaping behavior. 1

The formal birth of psychology as a scientific discipline is often credited to Wilhelm Wundt, who established the first psychology laboratory in Leipzig, Germany, in 1879. Wundt's work marked the beginning of experimental psychology, where he used introspection to explore the structure of the conscious mind. His approach, known as structuralism, aimed to break down mental processes into their most basic components. Around the same time, William James in the United States was developing his own approach called functionalism, which focused on the purpose of consciousness and behavior in helping individuals adapt to their environment. These early schools of thought laid the groundwork for more complex psychological theories. 1

The early 20th century saw the emergence of several influential psychological theories that have shaped the field as we know it today. Sigmund Freud's psychoanalytic theory introduced the idea of the unconscious mind and the role of early childhood experiences in shaping personality (he’s the guy who you usually picture talking to a patient while they lay on a couch, discovering a repressed memory). While Freud's ideas were revolutionary, they were (and still are) controversial, spurring the development of alternative theories. Behaviorism, led by John Watson and later B.F. Skinner, rejected the introspective methods of the past and focused instead on observable behavior, emphasizing the role of environmental stimuli in shaping actions. Behaviorism dominated psychology from the 1920s to the 1950s, particularly in the United States, influencing everything from education to advertising. 1

Toward the mid-20th century emerged a cognitive revolution, as cognitive psychologists began challenging the behaviorist movement by reintroducing the importance of mental processes. Pioneers like Jean Piaget and Noam Chomsky argued that studying internal cognitive processes (like thinking, memory, and language) was crucial for a complete understanding of behavior. This shift led to the development of cognitive psychology, which remains one of the most prominent areas of the field today. Additionally, humanistic psychology, which was considered more of a ‘counter-movement’ to behaviorism, emerged during this time, with figures like Carl Rogers and Abraham Maslow emphasizing personal growth, self-actualization, and the inherent goodness of people. All of these diverse perspectives have contributed to a more comprehensive and multifaceted understanding of human behavior, continuing to influence psychological research and practice today. 2

Plato (c. 427-347 BCE) : Greek philosopher from Athens known for his works on philosophy and the mind, including the theory of forms and the allegory of the cave.

Aristotle (384-322 BCE) : Greek philosopher from Stagira who studied under Plato and is renowned for his contributions to logic, metaphysics, and psychology, particularly his theory of the soul.

John Locke (1632-1704) : English philosopher, often called the "father of liberalism," known for his theory of empiricism, which posits that knowledge is derived from sensory experience.

Wilhelm Wundt (1832-1920) : German psychologist, often regarded as the "father of modern psychology," who established the first psychology laboratory and developed the theory of structuralism.

William James (1842-1910) : American philosopher and psychologist, known as the "father of American psychology," who founded the school of functionalism and authored the first psychology textbook, The Principles of Psychology.

Sigmund Freud (1856-1939) : Austrian neurologist and the founder of psychoanalysis, known for his theories on the unconscious mind, psychosexual development, and defense mechanisms.

John B. Watson (1878-1958) : American psychologist, best known for founding behaviorism, which focuses on the study of observable behavior rather than internal mental processes.

B.F. Skinner (1904-1990) : American psychologist and behaviorist, known for developing the theory of operant conditioning and his work on reinforcement and punishment.

Jean Piaget (1896-1980) : Swiss psychologist, famous for his theory of cognitive development, which outlines how children's thinking evolves through distinct stages.

Noam Chomsky (b. 1928) : American linguist, philosopher, and cognitive scientist, known for his theory of universal grammar and his critique of behaviorism in language acquisition.

Carl Rogers (1902-1987) : American psychologist, one of the founders of humanistic psychology, known for his client-centered therapy and emphasis on self-actualization.

Abraham Maslow (1908-1970) : American psychologist, best known for creating Maslow's hierarchy of needs, a theory that outlines the stages of human motivation from basic needs to self-actualization.

Consequences

The impact of psychological theories extends far beyond academic research; scientifically understanding our own thoughts and behavior has influenced almost all aspects of modern life, shaping practices in education, marketing, public policy, and business.

In the realm of education, psychological theories have revolutionized teaching and learning methodologies. For example, certain developmental theories have provided educators with insights into how children think and learn at different stages. Jean Piaget’s theory of cognitive development suggests that children progress through specific stages of cognitive growth, with each stage characterized by distinct thinking patterns. 3 Understanding these stages allows teachers to adjust their teaching strategies to better match the cognitive capacity of their students. 

Meanwhile, Lev Vygotsky’s concept of the zone of proximal development explains the gap between what a student can learn on their own versus with help. This theory posits that the role of education is to provide children with experiences that are in their proximal development stage, encouraging and advancing individual learning through social interaction. Students can solve problems independently, applying knowledge from conversations with peers and teachers to gradually develop the skills to perform tasks without direct help. 4 Understanding this theory has helped shape the role of teachers in the classroom; sometimes, it’s more about putting students in a situation where they can teach themselves to succeed rather than being explicitly taught. 

For better or worse, psychological theories have also left a huge mark on the field of marketing and consumer behavior. Behaviorism, with its focus on conditioning and reinforcement, has been particularly influential in understanding and shaping consumer habits. Marketers have applied principles of operant conditioning to design reward systems—like loyalty programs or memberships—that encourage repeat purchases by reinforcing desired behaviors. The understanding of cognitive biases, such as the availability heuristic and the framing effect , has also allowed many marketers to craft persuasive messages that influence buyer decision-making. All of these psychological insights have helped businesses increase sales and foster brand loyalty—potentially misleading or even taking advantage of customers. 

Public policy

Public policy is another major area where psychological theories have had significant consequences. Understanding human behavior has helped policymakers create more effective campaigns to improve public health, environmental protection, education systems, and programs that better address social issues such as poverty and crime. The application of small interventions that capitalize on our biases in a nonrestrictive way (often referred to as “ nudging ”), has gained prominence in recent years. This approach, popularized by Richard Thaler and Cass Sunstein, is based on the idea that small changes in the way choices are presented can have a substantial impact on behavior, like automatically enrolling employees in retirement savings plans, with the option to opt-out. A change as simple as this has been shown to dramatically increase participation rates in retirement plans. 

Organizations

If you’re in a traditional workplace, you may have experienced the influence of psychological theories in your office without realizing it. Organizational behavior and human resource management have been hugely shaped by Maslow’s hierarchy of needs and Herzberg’s two-factor theory. Both of these theories have changed how companies understand and manage employee motivation and satisfaction. Maslow’s theory suggests that employees (and all humans) are motivated by a hierarchy of needs, starting with basic physiological needs like food and water and progressing to self-actualization. Thus, companies that recognize and address these needs by providing a safe working environment, opportunities for social interaction, and chances for personal growth, are more likely to foster a motivated and productive workforce (perhaps this is why having free coffee and snacks in the office is so motivating?). Herzberg’s two-factor theory, which distinguishes between hygiene factors (e.g., salary, work conditions) and motivators (e.g., recognition, achievement), has also guided organizations in designing jobs and work environments to maximize employee satisfaction. 

Controversies

Psychological theories, while important to our understanding of human behavior, are theories, not facts. We can still only speculate and make educated guesses as to how and why our brains function the way they do. Many of the theories we’ve previously developed haven’t withstood the test of time, or at least not without serious criticism.

Psychoanalytic Theory

One of the most contentious figures in psychology is Freud, whose psychoanalytic theory has faced huge criticism. Although Freud's focus on the unconscious mind and his theories of psychosexual development were groundbreaking at the time, they were also largely unscientific and overly deterministic. Critics argue that many of Freud’s ideas, such as the Oedipus complex (briefly, that boys are repressing attraction to their moms and jealousy of their fathers’ genitals) and the emphasis on sexual drives, lack empirical support and are difficult if not impossible to test systematically. His theories have also been accused of being culturally biased, reflecting the patriarchal and sexually repressive values of his time, which are largely not applicable (or at least hopefully less so) today. 

Behaviorism 

Behaviorism, another major psychological theory, has also faced significant criticism, particularly for its reductionist approach. Watson and Skinner’s theory focuses exclusively on observable external behaviors and their environmental conditioning, largely ignoring the importance of internal mental processes like emotion. To no surprise, humans have a lot going on under the surface, and not taking this into account can be problematic. That’s because we are much more than machines reacting directly to the environment around us, and internal or unobservable processes (like our preferences, hunger, hormones, and social upbringing) can have dramatic influences on the way we react to stimuli. This critique helped propel the cognitive revolution to take into account the other missing piece of the puzzle: the mind. 

Cognitive Theory

Enter cognitive psychology, which has also been criticized for its heavy reliance on computational models of the mind, which can oversimplify the complexities of human cognition—after all, the brain is not a computer. Since these models usually compare the mind to a computer processing information, they’ve also been accused of neglecting the emotional, social, and cultural factors that influence thought and behavior. Thus, cognitive psychology, just like behaviorism before it, tends to focus on “universal” principles—when, of course, there are huge individual differences among people, places, and cultures. 

Humanistic Psychology

Humanistic psychology emerged as a response to both behaviorism and psychoanalysis to introduce a more optimistic view of human nature—but hasn’t escaped its share of criticisms. While prominent figures like Rogers and Maslow emphasized the potential for personal growth and self-actualization, proposing that people are inherently good and capable of achieving their full potential, many critics argue that this perspective is overly idealistic. Much like Freud’s psychoanalysis, it can be incredibly hard to test humanistic psychology empirically which can make it even harder to find acceptance from the scientific community. Also, due to the focus on the individual’s growth and self-fulfillment, it can be easy to overlook the social and structural factors that limit personal development; essentially, the individual is responsible for their own shortcomings or inadequacies, ignoring systemic issues like poverty, discrimination, and lack of access to education.

Cultural Context

Much of the existing psychology research is on a WEIRD (Western, Educated, Industrialized, Rich, and Democratic) population, which has raised concerns about the generalizability of its findings to non-WEIRD populations. All theories involve some sort of bias, and no population will ever be truly representative. The role of psychological theories in perpetuating or challenging societal norms is a controversial subject because, while the field has contributed to understanding and reducing prejudice, critics argue that some research in social psychology specifically can inadvertently reinforce stereotypes or fail to account for cultural and contextual differences. 

For example, the application of Maslow’s hierarchy of needs discussed earlier posits that individuals prioritize their needs in a specific order, starting with basic physiological needs and moving up through safety, love and belonging, esteem, and self-actualization. This model aligns well with WEIRD cultures, which tend to emphasize individualism and personal achievement since cultural values prioritize personal growth and self-fulfillment. However, in more collectivist cultures, where community, family, and social harmony are often prioritized over individual needs, Maslow’s hierarchy doesn’t fit quite as well. In addition, studies that categorize people into rigid social groups based on race, gender, or socioeconomic status may unintentionally perpetuate the very biases they aim to study. These critiques have led to a growing recognition of the need for more culturally sensitive research and a broader, more inclusive approach to studying behavior.

Behavioral Psychology in Education

Behavioral psychology—particularly the principles of operant conditioning—has been instrumental in shaping modern educational practices. Operant conditioning, a theory developed by Skinner, posits that behavior is influenced by the consequences that follow it. Specifically, reinforcement increases the likelihood of a behavior being repeated, while punishment decreases it. This approach can be applied to classroom management when teachers try to promote positive behavior that leads to academic achievement.

For instance, many schools implement reward systems like tokens or points that use positive reinforcement to encourage good behavior like completing homework on time, participating in class discussions, or staying silent during reading times. Usually, these tokens are traded in for rewards like extra recess time, which can help keep kids motivated. We can also see how punishment systems like detention or extra homework can be used to discourage unwanted or disruptive behavior. All of these systems are designed based on our understanding of different psychological theories, from how we best learn to which tools are appropriate for which ages, and have informed interventions for students with special needs, behavioral disorders, or learning disabilities. 

The Montessori Method is an educational approach that is based on principles from Piaget’s developmental psychology and Vygotsky’s zone of proximal learning principles. Montessori classrooms emphasize self-directed learning, hands-on activities, and collaborative play, giving kids the chance to explore their environment at their own pace and in their own way. Educational materials are designed to support the children’s developmental stages and foster independence, curiosity, and a love of learning: key components of the developmental theory.

Psychological Theories in Therapy 

One of the most direct applications of psychological theories is in the field of clinical psychology, where theories of human behavior and mental processes have informed the development of many therapeutic techniques. For example, many people are familiar with cognitive-behavioral therapy (CBT) , as it’s one of the most widely used therapeutic approaches today. This type of therapy is grounded in cognitive theory by helping individuals identify and change distorted thinking patterns that lead to negative emotions and behaviors. This theory-based approach has proven effective in treating a variety of psychological disorders, including depression, anxiety, and PTSD. 5

Understanding psychological theories is crucial for developing effective therapeutic approaches to provide the foundational knowledge needed to comprehend complex mechanisms underlying mental health issues. These theories can offer structured frameworks that guide therapists in assessing, diagnosing, and treating various psychological conditions and help them address the specific needs of individuals. Since so much of the work is built on tested theory, treatment can be both scientifically grounded and practically effective.

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• Wikipedia contributors. (2023, August 7). Cognitive revolution . Wikipedia, The Free Encyclopedia. https://en.wikipedia.org/wiki/Cognitive_revolution
• Cherry, K. (2023, July 20). Piaget’s Stages of Cognitive Development . Verywell Mind. https://www.verywellmind.com/piagets-stages-of-cognitive-development-2795457
• McLeod, S. (2023). Zone of Proximal Development . Simply Psychology. https://www.simplypsychology.org/zone-of-proximal-development.html  
• Gaudiano, B. A. (2008). Cognitive-behavioural therapies: achievements and challenges. Evidence-based mental health, 11(1), 5-7.

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Annika completed her Masters at the London School of Economics in an interdisciplinary program combining behavioral science, behavioral economics, social psychology, and sustainability. Professionally, she’s applied data-driven insights in project management, consulting, data analytics, and policy proposal. Passionate about the power of psychology to influence an array of social systems, her research has looked at reproductive health, animal welfare, and perfectionism in female distance runners.

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Cognitive-Behavioral Therapy for a 9-Year-Old Girl With Disruptive Mood Dysregulation Disorder

Megan e. tudor.

1 Yale School of Medicine, New Haven, CT, USA

Karim Ibrahim

Emilie bertschinger, justyna piasecka, denis g. sukhodolsky.

Disruptive mood dysregulation disorder (DMDD) is a relatively new diagnosis in the field of childhood onset disorders. Characterized by both behavior and mood disruption, DMDD is a purportedly unique clinical presentation with few relevant treatment studies to date. The current case study presents the application of cognitive-behavioral therapy (CBT) for anger and aggression in a 9-year-old girl with DMDD, co-occurring attention deficit hyperactivity disorder (ADHD), and a history of unspecified anxiety disorder. At the time of intake evaluation, she demonstrated three to four temper outbursts and two to three episodes of aggressive behavior per week, in addition to prolonged displays of non-episodic irritability lasting hours or days at a time. A total of 12 CBT sessions were conducted over 12 weeks and 5 follow-up booster sessions were completed over a subsequent 3-month period. Irritability-related material was specially designed to target the DMDD clinical presentation. Post-treatment and 3-month follow-up assessments, including independent evaluation, demonstrated significant decreases in the target symptoms of anger, aggression, and irritability. Although the complexities of diagnosing and treating DMDD warrant extensive research inquiry, the current case study suggests CBT for anger and aggression as a viable treatment for affected youth.

1 Theoretical and Research Basis for Treatment

Anger, aggression, and irritability in youth are associated with various clinical diagnoses, including attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and depression ( G. A. Carlson, Danzig, Dougherty, Bufferd, & Klein, 2016 ; Stringaris, 2011 ; Sukhodolsky, Smith, McCauley, Ibrahim, & Piasecka, 2016 ). A more recent diagnostic category now exists that also captures these symptoms: disruptive mood dysregulation disorder (DMDD; American Psychiatric Association [APA], 2013 ). DMDD is a childhood onset disorder characterized by at least three severe temper outbursts per week with distress that is disproportionate to emotional triggers. Furthermore, mood between these outbursts is disrupted, with children presenting as irritable or angry at least 50% of their waking hours. To meet criteria for the diagnosis, irritability symptoms should be present for at least 12 months without symptom-free intervals longer than 3 months. DMDD has significant overlap with symptoms of both disruptive behavior and mood disorders ( Dougherty et al., 2014 ; Mayes, Waxmonsky, Calhoun, & Bixler, 2016 ), leading to contention as to whether or not DMDD is truly a distinct diagnostic category ( Noller, 2016 ; Runions et al., 2016 ; Wakefield, 2013 ). Nevertheless, the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5 ; APA, 2013 ) includes DMDD as such ( APA, 2013 ; Roy, Lopes, & Klein, 2014 ), thus warranting further research on related assessment and treatment.

Children and adolescents with DMDD may benefit from behavioral interventions for anger and aggression. A large evidence base exists for cognitive-behavioral therapy (CBT) as a treatment for anger and aggression ( Sukhodolsky, Kassinove, & Gorman, 2004 ). Because anger outbursts, angry mood, and aggression are the core symptoms of DMDD, CBT may also be useful for children who meet diagnostic criteria for this newly characterized disorder.

Treatment studies related to DMDD are rare, despite converging evidence that DMDD may be common among clinic-referred youth ( Freeman, Youngstrom, Youngstrom, & Findling, 2016 ) and stable throughout childhood development ( Mayes et al., 2015 ). Two studies have demonstrated some effectiveness of treating concurrent ADHD and disruptive mood symptoms in children ( Baweja et al., 2016 ; Blader et al., 2016 ). One randomized controlled trial (RCT) to date has examined psychotherapeutic treatment effectiveness, specifically for youth with psychostimulant-medicated ADHD and an earlier diagnostic iteration of DMDD, known as severe mood dysregulation (SMD; Waxmonsky et al., 2015 ). The treatment program, ADHD plus Impairments in Mood (AIM), drew from extant CBT, behavioral parent training (BPT), and problem-solving models to target children’s awareness of and responses to mood dysregulation. Irritability symptoms were measured by the three items (temper loss, angry or sad mood, and hyperarousal) on two clinical parent interviews that focus on disruptive behaviors in children: the Washington University of St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS; Geller et al., 2001 ) and the Disruptive Behavior Disorders Structured Parent Interview (DBD-I; Hartung, McCarthy, Milich, & Martin, 2005 ). Disruptive behaviors were shown to significantly decrease in the experimental treatment versus an active control, whereas effects on the measured mood symptoms were not significant. Temper outbursts decreased during the course of treatment but were reported to substantially increase during treatment follow-up phase. Overall, the study indicates that behavioral interventions built from CBT and parent management training (PMT) principles may be helpful in youth with DMDD, though time-limited booster sessions may be warranted to maintain treatment benefits.

Many questions regarding the treatment of DMDD in children remain, especially in an individual therapy format. The present case study allows for an initial exploration of specially tailored CBT for anger and aggression ( Sukhodolsky & Scahill, 2012 ) as a viable treatment for a child with DMDD.

2 Case Introduction

“Bella” was a 9-year-old Hispanic girl whose mother enrolled her in our RCT for youth with anger and aggression ( Sukhodolsky, Vander Wyk et al., 2016 ). This ongoing RCT subscribes to a Research Domain Criteria (RDoC) approach by identifying dimensions of behavior and related neural markers that are not confined to specific diagnostic categories ( Cuthbert, 2014 ). Thus, Bella’s presentation of multiple diagnoses (explained below) complemented a trans-diagnostic approach to treating a broader spectrum of irritable behavior. Following assessment protocol, Bella was randomly assigned to CBT treatment (as opposed to supportive psychotherapy).

3 Presenting Complaints

Bella’s mother sought treatment due to increasing disruptive behaviors over the past year, including non-compliance at home and at school, physical aggression toward peers, and frequent behavioral meltdowns which resembled the temper tantrums of a much younger child. Tantrums included screaming, yelling, slamming doors, and crying. Triggers could include being asked to take her daily medication or feeling that someone was standing too close to her. Bella and her mother both noted that it was difficult for Bella to “move on” when something angered her. She also noted that Bella had an underlying irritable mood, manifesting as Bella appearing “cranky” the majority of the time and the family feeling they needed to “walk on eggshells” to avoid upset. Bella was at risk for suspension from her sports teams due to recurrent unprovoked aggression toward her teammates. At school, at least one phone call home per week was being placed due to Bella’s refusal to comply or sometimes to even speak to her teacher for days at a time. Bella and her mother noted that Bella was generally well liked by peers and teachers, given that she was hardworking and funny, yet her current disruptive behaviors were causing significant interference in making new friends and meeting academic goals.

Bella lived with her mother, stepfather, and three older siblings. She visited with her father who lived nearby approximately once per month. Bella’s mother denied any pre- or perinatal complications and stated that Bella met developmental milestones on time. Behavioral difficulties reportedly began around age 3, where Bella’s mother noted that she was extremely active and markedly stubborn. These concerns were exacerbated in the school setting and, by age 6, Bella participated in a pediatric evaluation that yielded a diagnosis of ADHD-Combined presentation due to ongoing difficulties with inattention and hyperactivity that were impeding her academic performance. Bella’s history was further complicated by persistent difficulties with math and related anxiety about math performance. These combinations of symptoms led to the provision of a school 504 plan that afforded Bella intensive math support, extra time on tests, and classroom breaks, as needed. At the time of intake, Bella was attending fourth grade in mainstream classes and described herself as doing well in school, save for assignments in math assignments which remained her least favored subject.

Bella had not participated in any form of psychological treatment prior to participating in our treatment study. Bella was prescribed Stratera (18 mg/day) at age 7 by her pediatrician, which was maintained at the time of our intake interview and throughout treatment. In our study, we include participants with either no medication or stable medication regimens, though medication management is not provided. Stratera is a brand name version of atomoxetine, a selective norepinephrine reuptake inhibitor. Although psychostimulant medication is generally recommended as the first-line treatment for ADHD in children ( Blader et al., 2016 ), there are sometimes reasons for prescribing alternative medications such as atomoxetine ( Pliszka, 2007 ). According to Bella’s mother, at age 7, Bella presented with mild anxiety, particularly related to school performance. Comorbid anxiety has been observed in 25% to 35% of children diagnosed with ADHD, and atomoxetine is accepted as effective with this dual diagnosis ( Hammerness, McCarthy, Mancuso, Gendron, & Geller, 2009 ). Overall, this relatively low dose of medication had reportedly proven useful in addressing both anxiety and ADHD symptoms for Bella and, according to our team’s psychiatry consultants, was appropriate for progressing with therapy without psychiatric re-evaluation.

Our study does not provide medication management or consultation regarding medication that children are receiving in the community. Children are eligible to participate if medication has been stable without plans for change for the 4-month study period. We generally only recommend psychiatric evaluation or re-evaluation for ADHD symptoms if these symptoms are clearly an underlying factor in the participant’s anger and aggression, or if symptoms grossly affect the participant’s ability to understand the material or engage in treatment. Neither of these descriptions applied to Bella, who met criteria for ADHD diagnosis based on clinical interview and was in the borderline clinical range on parent report measures ( T = 68 on the Attention Deficit/Hyperactivity subscale of the Child Behavior Checklist [CBCL]; Achenbach & Rescorla, 2001 ), but whose symptoms appeared relatively non-impairing at the time of intake.

5 Assessment

As part of the study, Bella and her mother were administered comprehensive assessments of irritability and associated psychopathology, including clinical interviews and parent report measures. With Bella’s assessment, we maintained adherence to the study protocol, which only required participation of one parent. However, we would have been happy to obtain information from Bella’s father or engage him in the study process if it had been requested by the family. In addition, Bella and her mother stated that behavior presentation was largely similar across the two households.

Diagnostic Interview

DSM-5 diagnoses were assigned based on the structured interview conducted by an experienced clinical psychologist (last author). The Kiddie Schedule for Affective Disorder and Schizophrenia for School-Age Children, Present and Lifetime (K-SADS-PL; Kaufman et al., 1997 ) is a diagnostic interview that assesses psychopathology in children based on child and parent report. Interview questions are presented to both children and parents separately, followed by integration of both informants’ report. DMDD symptoms were evaluated by the K-SADS addendum ( Leibenluft, 2011 ). DMDD symptoms are coded as “Not present,” “Sub-threshold,” or “Threshold” for DSM-5 diagnostic criteria. At the time of the interview, Bella’s prior diagnosis of ADHD-Combined presentation was confirmed due to impairing symptoms of inattention, distractibility, and hyperactivity, though these symptoms were reportedly significantly decreased and minimally impairing since medication prescription at age 7. Her preexisting community diagnosis of unspecified anxiety disorder was not confirmed with K-SADS; both Bella and her mother reported occasional bouts of worry about school performance but not to the frequency or intensity that warrants clinical diagnosis.

Per the K-SADS, Bella and her mother shared that Bella typically presented with out-of-control 30-min temper outbursts approximately 3 to 5 times per week. Outbursts consistently appeared out of proportion to the situation at hand and reportedly resembled that of a much younger child, around 3 to 4 years old. Outbursts consisted of screaming, crying, insulting others, and general non-compliance occurring at home and, less often, in the community (e.g., in the grocery store, at the sidelines of a soccer match). In between outbursts, Bella’s mood was described as generally “cranky” and her mother described feeling that she was “walking on eggshells” around Bella. Bella’s mother shared that this irritability occurred approximately 75% of the time, with Bella appearing neutral or cheerful the remaining 25% of each day. Bella’s persistently angry and irritable presentation was not only endorsed by her mother but also her elder siblings, teacher, and soccer coach. Opposition and defiance were noted since age 3; however, the outbursts and irritability described here had manifested for approximately 2 years preceding assessment (since age 7). The longest symptom-free period was as a few days, and such bouts were reportedly rare. Overall, symptoms were described as causing impairment for Bella in her family relationships, friendships, and school performance. The obtained symptom profile, in addition to the absence of past or current mania, warranted a diagnosis of DMDD. Of note, Bella also met criteria for ODD; however, a diagnosis of DMDD contraindicates ODD diagnosis ( APA, 2013 ).

Of note, we do not collect teacher ratings as part of study assessment procedure, although sometimes families bring copies of past assessments that include teacher ratings. However, in clinical settings, it is advisable to collect teacher ratings of ADHD as well as symptoms of other behavioral and mood disorders. For example, clinicians could seek out teacher report versions of the parent report measures described below, to then be integrated into the clinical assessment. Further information gathering can include discussion of core DMDD symptoms with teachers or other school professionals in order to better understand presentation of these symptoms across multiple settings.

Parent Report Measures

Bella’s mother filled out a battery of parent report measures. Scores on the measures of anger/irritability and aggression are presented in Table 1 . The 18-item CBCL–Aggressive Behavior subscale ( Achenbach & Rescorla, 2001 ) was completed as a “gold standard” measure of aggressive behavior and yielded a clinically elevated score for Bella. The Affective Reactivity Index (ARI; Stringaris et al., 2012 ) consists of seven items, six of which are averaged as an index of irritability. Youth with SMD were reported to have an average score of 7 on this measure. As such, Bella’s score of 10 reflected clinical elevation. The Disruptive Behavior Rating Scale (DBRS; Barkley, 1997 ) is an eight-item measure keyed to the DSM symptoms of ODD. A mean DBRS score of 12 and above indicates clinically significant symptoms, and Bella’s score of 13 was above this clinical threshold. Parent ratings of depression and anxiety conducted per the Child Depression Inventory ( Kovacs, 2011 ) and the Multidimensional Anxiety Scale for Children ( March, 2012 ) indicated that Bella was experiencing normative levels of internalizing symptoms. Together, these parent ratings indicated that Bella’s particular presentation of DMDD was characterized by externalizing behaviors and irritability, rather than depressive mood.

Pre-Treatment, Post-Treatment, and Follow-Up Assessments.

Note . MOAS = Modified Overt Aggression Scale; CGI-I = Clinical Global Impression–Improvement score (as compared with baseline functioning); CBCL = Child Behavior Checklist ( t scores); ARI = Affective Reactivity Index; DBRS = Disruptive Behavior Rating Scale.

Aggressive behavior was measured using the Modified Overt Aggression Scale (MOAS; Silver & Yudofsky, 1991 ; Yudofsky, Silver, Jackson, Endicott, & Williams, 1986 ) tailored to the assessment of aggression in clinical trials ( Blader, Schooler, Jensen, Pliszka, & Kafantaris, 2009 ). The MOAS was administered as an interview with the parent and child (separately) by an independent evaluator (licensed clinical social worker) who was not involved in treatment and was unaware of the treatment that Bella was receiving. The MOAS is used as a primary outcome measure in the relevant clinical trial ( Sukhodolsky, Vander Wyk et al., 2016 ) and consists of 16 items related to the aggressive behavior over the past week. Items are weighted based on potential harm and create four aggression subscales, including Verbal Aggression, Aggression Against Objects, Self-Directed Aggression, and Aggression Against Others. Bella evidenced significant levels of aggressive behaviors in all subscales excepting for self-directed aggression, resulting in an overall score of 32. For example, Bella was reported as presenting with three aggressive incidents (e.g., punching) toward non-relative peers in the week preceding evaluation.

Target Symptoms

In addition to the MOAS, the independent evaluator also elicited the two most pressing concerns in the area of anger and aggression and described these concerns, which are referred to as “target symptoms.” Target symptoms are coded in terms of frequency, duration, severity, and impact on adaptive functioning across all contexts ( McGuire et al., 2014 ). Bella’s target symptoms were (a) anger outbursts and meltdowns, characterized by verbal aggression and subsequent “shutting down,” with refusal to comply or communicate, and (b) physical aggression, such as hitting, punching, and shoving which most commonly occurred toward sports teammates, classmates, and her older brother.

Intellectual Functioning

Per study protocol, Bella completed the Wechsler Abbreviated Scale of Intelligence (WASI), indicating a verbal IQ of 93, a performance IQ of 99, and a full-scale IQ of 96. Overall, this intellectual functioning screener suggested that Bella’s intelligence was uniform across abilities and fell in the Average range of functioning. These results indicated that Bella would be a good candidate for the CBT content and activities ( Lickel, MacLean, Blakeley-Smith, & Hepburn, 2012 ).

6 Case Conceptualization

Bella, like many youth with ADHD, exhibited disruptive behavior concurrent with inattention and hyperactivity symptoms ( C. L. Carlson, Tamm, & Gaub, 1997 ). Although pharmacological treatment significantly decreased Bella’s school difficulties by age 7, anger and aggression persisted. Evidence suggests that children like Bella may possess an inherent predisposition for irritability, including impaired functioning in the amygdala and frontal lobe ( Vidal-Ribas, Brotman, Valdivieso, Leibenluft, & Stringaris, 2016 ). Her early onset of irritable behavior and aggression may have resulted in teachers and family members responding in an inadvertently reinforcing manner, for example, separating Bella from other children versus problem solving. Thus, Bella’s clinical profile reflected both a predisposition to disruptive behavior and an interaction with her environment that resulted in interference with developmental maturation of emotion regulation or social skills that were expected for her age. In addition to disruptive behaviors, Bella has also experienced some academic difficulties, particularly in the area of math. Academic performance became a source of anxiety which further compounded non-compliance with homework and behavioral problems at school. As such, Bella had learned from a young age to primarily communicate her negative emotions through avoidance, physical aggression, and tantrums, which were reinforced by Bella’s attainment of desired goals (e.g., a child going away or obeying her demands, family offering her several hours of personal space). Alone, these behaviors would have warranted a diagnosis of ODD. For Bella, however, her prolonged instances of angry and irritable mood in between temper outbursts indicated a diagnosis of DMDD. It is also important to note that early onset of ADHD and co-occurring symptoms of anxiety are also consistent with the diagnosis of DMDD ( Dougherty et al., 2014 ; Mulraney et al., 2015 ; Uran & Kılıç, 2015 ).

Although Bella demonstrated many strengths, such as athletic ability and sense of humor, many of her social experiences became overshadowed by negative interactions, which were interfering with her enjoyment of home and school life. As such, our treatment goal was to replace Bella’s maladaptive anger outbursts and aggressive behaviors with age-appropriate skills of managing frustration and communicating with others. Simultaneously, Bella’s mother was taught parenting tools for supporting Bella’s progress in learning of new emotion regulation and problem-solving skills.

7 Course of Treatment and Assessment of Progress

Bella and her mother were seen by a post-doctoral clinical psychologist (first author) for 12 weekly 60-min CBT sessions. Then, she participated in five booster sessions over the subsequent 3 months. Our program typically offers three booster sessions; however, additional booster sessions were requested by the family to maintain treatment gains. We agreed to provide extra boosters because in a recently published study of behavioral intervention for children with SMD, immediate irritability-related treatment gains were not maintained at 6-week follow-up ( Waxmonsky et al., 2015 ). Manualized CBT for anger and aggression in youth was administered using a structured treatment manual ( Sukhodolsky & Scahill, 2012 ). The treatment is organized into three modules: emotion regulation, social problem solving, and social skills.

After each session, children received a therapeutic homework, which is referred to as “anger management practice” with the child to avoid using the word homework . As part of this practice, children are asked to fill out an anger management log, different for each session, which asks for specific examples of using each skill discussed in the last session in the context of an angry or aggressive outburst, whether anger management strategies were implemented successfully or unsuccessfully. Completion of anger logs is rewarded at the next session with enthusiastic praise from the therapist and small prizes when developmentally appropriate. Parenting skills are also integrated into treatment and coached during additional parenting sessions.

The manual includes built-in flexibility features that allow the child and the therapist to select therapeutic techniques and activities that match the child’s developmental level and target symptoms. Additional material was integrated that focused on DMDD-specific symptoms (described further below). Progress was assessed through the battery of interview and parent report measures described previously, which were conducted before and after treatment, and following a 3-month “booster” phase. Treatment progress was also discussed at weekly check-ins with Bella’s mother about the form, frequency, duration, and intensity of Bella’s target symptoms (i.e., temper outbursts, physical aggression).

Emotion Regulation and Anger Management

Sessions 1 to 3 involved an introduction to therapy, psychoeducation, identification of anger triggers, and the development of strategies to prevent anger episodes, such as scripting verbal reminders and relaxation training. Bella responded well to this phase of treatment and was particularly impressed that there were alternative approaches to handling angry behaviors. She stated that she was unaware that anger could be changed. Bella’s anger triggers typically included the perception that peers or family members had wronged her and the desire to “teach them” it was not okay through yelling or aggression. For example, immediately preceding the first session, Bella had punched a basketball teammate for “putting her hands on” her. Bella’s mother confirmed that the girl had simply brushed against Bella while walking by her. Bella took to silently singing a popular song lyric, “Stop! Wait a minute!” in her mind when recognizing an anger cue or early signs of anger escalation (e.g., a 1 or a 2 on her 5-point anger thermometer), and then engaging in deep breathing or reciting verbal reminders to guide her behaviors, such as, “You are going to get in trouble” or “Maybe this isn’t something to get worked up over.” Each week, Bella earned small prizes (e.g., shopkins) for completing anger management practice logs that described her handling of an anger-provoking episode.

Social Problem Solving

Sessions 4 to 6 covered social problem-solving skills including problem identification, generating different solutions, and evaluating the possible consequences to reduce conflict. Identifying the differences between responses that are passive, assertive , or aggressive was especially useful in enhancing Bella’s ability to generating solutions to conflicts. The therapist helped Bella and her mother to collaborate on developing behavioral contracts to prevent specific conflicts at home. For instance, Bella initially presented with a 5- to 10-min anger outbursts approximately 5 times per week when asked to take her medication. This occurred despite the fact that Bella’s mother did not alter the request and, ultimately, Bella took her medication successfully each time. In treatment, Bella agreed to calmly and immediately take her medication each night and her mother agreed to take her to get doughnuts every Saturday based on that behavior. Subsequently, Bella’s tantrums regarding medication decreased to 0 within 2 weeks and maintained for the several subsequent months of treatment.

Bella also excelled at decreasing her hostile attribution bias by reframing her previously negative perceptions of others’ intentions. She recognized that many past incidents where she believed that people were attempting to bother or assault her were misunderstood. Bella showed pride in her new ways of handling these situations, making statements like, “People want to be my friend more now. They used to think I was cool but kind of crazy. Now they just think I am cool.”

Social Skills

Sessions 7 to 9 addressed social skills for preventing and resolving conflicts or anger-provoking situations with siblings, peers, teachers, and family. Potential solutions to conflicts were role-played in session, for example, acting out how to calmly handle disagreements with friends about what to play or how to politely ask her brother to stop teasing her. For example, when playing with others, Bella practiced asking for the opinions of her friends, like, “Would you all like to play it this way?” rather than insisting that they play her way at the beginning of a play session (e.g., “I’m in charge, I don’t care if you don’t like it”). These skills were practiced in session with her therapist playing the part of other children who may disagree, which was effective in escalating anger and allowing for practice of positive interactions. Monitoring of voice tone and facial expression was exercised through the use of video recording, thereby helping Bella monitor and modify her outward expression of anger. Bella agreed that these skills contributed to more positive play time and more fun with her friends, which she noted as a more important goal than getting her way.

Importantly, Bella practiced simply stating, “I need help” or “I need a break” when feeling upset, rather than using harsh words or physical aggression. Her teacher and family reinforced this effective communication by calmly and briefly discussing the situation at hand, problem solving, and allowing Bella some alone time, as needed. These communication skills were integral in decreasing aggression, as Bella felt that she had a new tool for resolving social problems that did not put her at risk for getting in trouble (unlike punching others).

Parent Training

Parents are an integral component in CBT for anger and aggression ( Sukhodolsky & Scahill, 2012 ). Three separate 60-min sessions were conducted with Bella’s mother to address family conflict and provide strategies for encouraging positive behaviors such as giving praise, attention, and privileges. This duration of sessions was sufficient with Bella’s treatment, although more flexibility may be required in other cases. The treatment manual suggests conducting parent sessions in conjunction with the first, middle, and final CBT sessions, though flexible administration is often required due to family scheduling needs and to ensure that parent training coincides effectively with CBT sessions. Treatment progress and skills covered in each CBT session were also reviewed with the parent at each visit so that parents could track and reward application of new anger management skills at home. These parenting skills were especially important to Bella’s progress, given that she was growing up in a household with multiple siblings and expected behaviors often went unnoticed, whereas misbehavior resulted in one-on-one attention. In parenting sessions, the converse response was practiced with Bella’s mother, wherein “shut down mode” or yelling received no attention, whereas Bella’s problem solving and use of other coping strategies received praise and encouragement.

School Consultation

To maximize treatment gains in the school setting, Bella’s therapist had intermittent phone conversations with Bella’s fourth-grade schoolteacher. Target behaviors (e.g., decreasing aggression, increasing compliance) and related strategies (e.g., Bella’s recognition of anger cues, practicing effective communication in place of aggression) were relayed to Bella’s teacher, who was eager to encourage Bella’s progress in the school setting through prompting and praise. Bella’s teacher provided invaluable insight into behavioral progress, including report that Bella’s decrease in irritable behaviors made her more amenable to math tutoring. Subsequently, Bella arrived to several sessions sharing about success with math during the previous week.

Adapting Treatment for DMDD

Although much of the extant CBT treatment manual was appropriate for addressing Bella’s target behaviors of aggression and tantrums, some specialized material was integrated into Bella’s care to target the prolonged periods of irritability she demonstrated at home, school, and, sometimes, in the therapy session. These adaptations included (a) extending psychoeducation, (b) emphasizing on behavioral activation, (c) building an emotion regulation template for reducing duration of irritable mood periods, and (d) including extra booster sessions during the 3-month booster period (five instead of the usual three sessions). Psychoeducation included characteristics of prolonged irritable episodes, such as specific triggers, the common feeling of being “stuck” in that mood, and creating a creative metaphor for the irritable mood. Bella described her prolonged irritable episodes as “shut down mode” wherein her brain withdrew and could only react “in a snappy way” toward others. This allowed Bella to quickly identify irritability and remind herself that it was possible to coach her brain to “reverse shut down mode” where she could enjoy herself and interactions with others.

Behavioral activation was used to reduce prolonged periods of negative mood (e.g., Pass, Whitney, & Reynolds, 2016 ). Specifically, Bella maintained a list of enjoyable activities she could do in any setting to help herself keep active and busy, which, in turn, reduced the intensity of her “shut down mode” and increased her chances of being happy. For example, she would read, watch television, or ask family members to play with her during these instances. Prior to treatment, when in “shut down mode,” she was most likely to retreat to her room and dwell on the situation that triggered her anger.

Last, although decreasing irritability was an important goal, it was also recognized that some occasional irritable mood is typical, especially after a child is particularly disappointed or frustrated. As such, Bella and her mother collaborated with the therapist to identify a goal for the form and duration of irritable behavior. Specifically, Bella decided that 20 min of alone time, which she would request of her family calmly, would be sufficient to take part in a fun activity and help her “move on,” to which her mother agreed. These skills were especially relevant during the booster sessions of therapy, likely because tantrums and aggression had significantly decreased and “shut down mode” became a more pressing behavioral concern.

Post-Treatment Assessments

All outcome data are presented in Table 1 . Bella’s improvement was assessed following 12 sessions of CBT (and also at follow-up, presented in the “Follow-Up” section below). All post-treatment measures indicated a significant decrease in anger/irritability and aggression and fell within the normative range of functioning.

MOAS score reduced from 32 to 2, demonstrating that Bella had exhibited zero instances of verbal or physical aggression in the past week, and only one instance involving property damage: slamming a door when asked to clean her room before watching a movie. At that time, her mother noted that “shutting down” occurred once during the past week and was disruptive to family activities. As such, this behavior was targeted in later booster sessions.

The independent evaluator assigned a Clinical Global Impression-Improvement (CGI-I) score as a primary categorical outcome measure in the present research study ( Arnold et al., 2003 ). This score indicates the level of behavioral change from baseline rated on a 7-point scale (1 = very much improved ; 7 = very much worse ). Bella’s target symptoms of decreasing meltdowns and decreasing physical aggression were rated as 1 “ very much improved .”

8 Complicating Factors

Bella’s irritability served as a mildly complicating factor in two treatment sessions (Session 5 and a booster session). Specifically, irritability and opposition presented to a degree that limited Bella’s engagement in session material. In both occurrences, Bella was angered by something that occurred prior to session and initially refused to speak to her therapist. Although these instances were challenging in terms of completing planned session material, they were recognized as inherent to Bella’s target symptoms and, ultimately, helpful in exercising in-vivo practice of emotion regulation skills. Fortunately, Bella and her therapist were always able to end these sessions on a positive and meaningful note by offering validation and clear contingencies that both modeled and rewarded behavior activation (e.g., “I’m sorry to see you are having a rough day, Bella. When you are ready to talk, let me know. I want to ask you one question about the past week and then I have a very funny video to show you!”). These potentially complicating factors are especially important for the consideration of students and professionals, and are addressed further in “Recommendations to Clinicians and Students” section.

9 Access and Barriers to Care

It is important to note that the current treatment was conducted as part of a research study and, thus, may not reflect the typical clinic environment. As part of the study, the family received free clinical services, monetary compensation for their time, and flexible scheduling options. These characteristics of the study likely lessened the burden of participation for the family, who did not report any significant difficulties with completing all study visits. A family of a child referred to an outpatient clinic for a similar treatment would be responsible for the treatment cost, without compensation for time dedicated to assessment and treatment, which could limit some families’ ability to access and complete treatment.

10 Follow-Up

Bella participated in five booster sessions over the course of 3 months, immediately following the completion of the standard 12 CBT sessions offered as part of our research study. These sessions were designed to review and reinforce the content of the therapy program and to identify ongoing areas of need. These sessions are administered once per month on average, although in Bella’s case, we added two additional sessions to address DMDD symptoms. In Bella’s case, these boosters were useful for check-ins regarding irritability and behavioral activation skills, which were relevant to the remaining behavioral goals at that time. Our study typically offers three booster sessions for families but, given past evidence that suggests the utility of follow-up sessions for youth with DMDD ( Waxmonsky et al., 2015 ), two additional sessions appeared appropriate. Bella and her mother noted that these sessions were helpful at maintaining progress and continuing to target irritability goals. This report was supported by the follow-up data that were consistent with data collected post treatment (see Table 1 ). During the week preceding follow-up assessment, she was reported to have slammed a door three times when frustrated by homework assignments related to math. No instances of “shut down” were reported.

Following study completion, the family was encouraged to seek out consultation from the team should any concerns arise regarding Bella’s behavior management. No such requests have been made (4 months post study at the time of manuscript preparation).

11 Treatment Implications of the Case

The current case demonstrates the feasibility of CBT for anger and aggression in children with DMDD. No existing studies have examined individually administered CBT for anger and aggression in youth with DMDD, though the need thereof is increasingly important as this new diagnosis gains clinical attention ( Leibenluft, 2011 ; Roy et al., 2014 ). Our current case study shows how a child with DMDD can be effectively treated with a structured CBT for anger and aggression treatment ( Sukhodolsky & Scahill, 2012 ) enhanced with psychoeducation and behavioral activation strategies ( Hopko, Lejuez, Ruggiero, & Eifert, 2003 ). The enhancements to the CBT program may have been especially important to Bella’s excellent response to treatment. The five booster sessions allowed for a more gradual transition out of therapy and focused on decreasing non-episodic irritability, which may have been key to her long-term progress. These results are in contrast to previous findings that treatment gains were not maintained 3 months after group therapy for SMD ( Waxmonsky et al., 2015 ).

Notably, Bella was a participant in our ongoing randomized controlled study that tests the utility of CBT for irritability in children across diagnostic categories. This study is based on the RDoC initiative ( National Institutes of Mental Health, 2016 ) that aims to explore the core dimensions of psychopathology based on neurobiology and behavior, as opposed to the traditional categorical approach to diagnosis. Ultimately, RDoC attempts to integrate findings in genetics, neurology, molecular biology, cognitive science, and other disciplines to better inform our diagnostic classification system. The Negative Valence System, one of the five RDoC domains, encapsulates anger and aggression—the variables targeted in Bella’s treatment. Applying a treatment for a core symptom area (anger and aggression) rather than a specific diagnosis may have been ideal in treating Bella. Given DMDD’s high co-morbidity with other DSM diagnoses, including ADHD, and its significant overlap with ODD and depression, treatment of a specific categorical diagnosis would be challenging and likely misguided. In addition, almost all childhood psychiatric diagnoses are associated with increased risk of aggression ( Jensen et al., 2007 ). If a treatment such as CBT for anger and aggression can be implemented successfully across diagnostic categories, it may decrease the need for diagnostic precision in an imperfect system such as the DSM-5 . The current case study indicates that this singular treatment may be applied and/or modified to effectively treat a core symptom area in children that meets criteria for various DSM-5 disorders. It will be especially useful to identify other treatment packages that may be applied trans-diagnostically, especially for commonly co-occurring disorders in youth.

A benefit of the current treatment may be the ease of implementation across professionals. Bella’s provider possessed a PhD in clinical psychology, whereas other clinicians in our current study are psychology graduate students and child and adolescent psychiatry fellows. This flexibility in implementation may be particularly relevant for treatment of children with DMDD who may present with psychiatry referrals. Potential psychopharmacologic treatments for DMDD that have been suggested might include antidepressants, mood stabilizers, stimulants, and antipsychotics ( Tourian et al., 2015 ); however, medication alone may not be ideal. Medications, of course, are not without side effects, many of them significant and/or requiring regular monitoring over the course of treatment, including with blood work. In addition, given that there are two distinct symptoms clusters being treated in DMDD—irritable or depressed mood and angry outbursts—it is reasonable to conclude that in many cases, more than one medication might be required to treat symptoms. Our CBT program with some modification appears to be effective in treating DMDD over a short period of time with minimal modifications and, as such, may be ideal for first-line treatment for youth DMDD, particularly those who present with irritable mood in between outbursts.

Bella’s presentation did not reflect the symptom profile of some other youth DMDD. Namely, while she experienced significant and impairing irritability, she did not experience depressive symptoms such as withdrawal, anhedonia, or suicidal ideation. Therefore, the treatment implications of the current case are cautioned in terms of application to youth experiencing depressive mood between anger outbursts, wherein additional or different modifications would likely be warranted for treatment results and, above all, patient safety. It is of interest to note that behavioral but not mood symptom changes were an outcome of group therapy for SMD ( Waxmonsky et al., 2015 ), which further speaks to the complex nature of treating the co-occurring symptoms captured by DMDD. Furthermore, the same must be stated in reference to anxiety symptoms, which commonly co-occur with DMDD but were not endorsed for Bella. Youth with DMDD and significant anxiety may benefit from additional anxiety-focused behavioral interventions (i.e., exposure and response prevention).

Another caution toward the current results is the fact that Bella was receiving medication for ADHD and mild anxiety. The medication was stable during the study, and it is unknown what effect the treatment would have had in a child with the same diagnostic profile without medication. Lastly, the fact that the current case study focuses on a female is not to be overlooked. Like all disruptive behavioral disorders, early evidence suggests that females may be less likely to be given a diagnosis of DMDD ( Dougherty et al., 2014 ; Tufan et al., 2016 ). We are glad to provide evidence of treatment utility with a female patient, given that they may be less likely to be featured in this area of child psychology, though further study of treatment implications as they differ (or do not differ) across the sexes is warranted.

12 Recommendations to Clinicians and Students

Although we have previously stated that CBT for anger and aggression can be delivered by a range of clinicians, it is important that clinicians feel familiar and competent with delivering the complete manual prior to starting treatment. The modules reflect a variety of themes and strategies that may be useful to children; however, a high degree of flexibility is recommended ( Kendall & Beidas, 2007 ). For example, it can be useful to improvise and incorporate material from later sessions if that material is pertinent to a child’s presenting complaint on a given day. Furthermore, some children may dislike particular strategies (e.g., deep breathing), and it is significantly more important to maintain a strong therapeutic alliance by collaborating on goals and strategies than it is to achieve 100% fidelity for every session. In fact, as part of our current research study, an 80% fidelity rating is encouraged.

In addition, children with DMDD can be difficult to engage with due to both their baseline anger and irritability, as well as recurrent temper outbursts or meltdowns. It is likely that the clinician will experience at least one disruptive behavior episode (or many more) during session. These incidents are par for the course and, perhaps in a counterintuitive manner, are extremely beneficial to the child’s progress in treatment. Specifically, therapists are able to demonstrate appropriate behavioral contingencies and extinction schedules that will be useful for parents to observe. Bella, for example, once came to session angry at her sister and refused to speak to her therapist. The therapist use the opportunity to remind Bella of the skills she could apply to “turn it around” and checked in with Bella’s mother until Bella was observed putting effort into that goal (i.e., taking deep breaths, attempting to join the conversation), at which time she was praised and given a choice of a fun activity. Thus, Bella’s mother was able to observe selective attention, which can be a particularly difficult parenting skill for parents of children with disruptive behavior, and Bella was able to practice skills with the direct support of her clinician. We encourage clinicians and students not to dread disruptive behavior in session, but rather to welcome it as a unique and effective learning opportunity. However, clinicians must, of course, have a sound understanding of behavioral intervention to successfully respond to such incidents.

As with any type of behavioral modification, progress can be quite gradual. It may take several sessions before the child “buys in” to the treatment. It can be helpful to frame the treatment in terms of tangible benefits for the child; there is often a noticeable switch where the child recognizes that decreasing anger and aggression leads to specific and appreciable outcomes. For example, most children will recognize that hitting a peer will make that peer less likely to play with them in the future, even if they feel that the peer “deserves it,” or that insulting a teacher will lead to them getting detention even if they feel it is “unfair.” It is important to remember that these children often have a long history of feeling that they are “bad,” and an integral component of treatment is to counter this belief. A strong rapport can be built in the first session, simply by validating the child’s point of view and listening to recent difficulties without criticism. It is often helpful to alert the children that nothing shared in session will get them into trouble and, in fact, that the goal of therapy is to help them get in trouble less and enjoy their day-to-day life more. Ultimately, it is ideal for the child to recognize how their behavioral change will benefit them in their day-to-day life, which usually leads to them feeling proud about their efforts and accomplishments.

The parent check-ins at the end of each session are crucial to the success of the therapy. As outlined in the manual, be sure to stress to the parents during the first session how important it is to consistently praise positive behavior and to “catch the child being good.” At each parent check-in, the parent should provide a concrete example to the clinician of the child engaging in a positive behavior or attempting to apply skills and tools learned during the previous CBT session. Due to the “review” nature of these check-ins, a notable risk is present that the parent and/or child will attempt to use the time to simply list complaints about the past week, which is counterproductive to long-term progress. As such, clinicians should troubleshoot specific concerns and integrate them into session material (e.g., problem solving) but should also assertively request “highlights” of the past week. In addition, it can be helpful to supplement the three parent sessions and parent check-ins with concepts and tools from Parent Management Training, including structured behavior plans for the home. The clinician should also remind parents that the goal of treatment is not 100% remission. Occasional outbursts are a normal part of development and are not always pathological. It is best to frame the child’s success in terms of a decrease in the frequency and intensity of the target symptoms that were defined at the beginning of the treatment.

It is also important to point out to clinicians and students that the study of treatment for DMDD is new. Here, we present the results of an extant treatment that was adapted for a child with DMDD. It would be remiss for us to imply that this may be the only viable treatment for youth with DMDD, though it is difficult to expound upon treatment alternatives. Nevertheless, as mentioned previously, DMDD overlaps with other diagnostic categories that have long-standing evidence for the utility of cognitive (e.g., Boxer & Butkus, 2005 ), behavioral (e.g., Folino, Ducharme, & Conn, 2008 ; Rote & Dunstan, 2011 ), and combined (e.g., Pass et al., 2016 ) approaches to treatment. We are not currently aware of an evidence-based psychotherapeutic approach that would be definitively distinct from the CBT treatment presented here.

Last, as shown in the current case, these youth are likely to present with a complex history and multiple diagnoses, including ADHD and internalizing disorders. Thus, it is important for clinicians and students working with these youth to be well versed in a variety of clinical presentations, as well as related behavioral and pharmacological treatments. Furthermore, in the age of RDoC, clinical training will likely benefit from integrating behavioral treatments for core symptoms—such as anger and aggression. Such a training priority may help to serve a larger population of youth, including those with more complex clinical presentations such as DMDD.

Acknowledgments

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is supported by National Institute of Mental Health (Grant/Award Number “R01 MH101514” to Drs. Denis Sukhodolsky and Kevin Pelphrey).

Biographies

Megan E. Tudor , PhD, is a postdoctoral associate at the Yale Child Study Center where she conducts clinical research, including diagnostic assessment and therapy for research participants. Her research interests relate to imporoving clinical services for youth with a variety of neurodevelopmental and behavioral disorders, as well as their family members.

Karim Ibrahim , MS, is a former trainee of the Yale Child Study Center where his focus was on behavioral interventions for autism and disruptive behavior disorders. He is a doctoral candidate in clinical psychology at the University of Hartford.

Emilie Bertschinger , BA, is a post-graduate associate at the Yale Child Study Center. She completed her bachelor’s in psychology at Boston University in 2015. She coordinates the clinical research study described in the current case study.

Justyna Pasecka , MD, is a fellow in the Solnit Integrated Training Program in Adult and Child Psychiatry at the Yale Child Study Center. She will complete her training in 2017 and will continue providing clinical services with children and adolescents.

Denis G. Sukhodolsky , PhD, is an associate professor and director of the Evidence-Based Practice Unit at the Yale Child Study Center. His lab conducts research on the efficacy and mechanisms of behavioral treatmetns for children with neurodevelopmental disorders such as autism spectrum disorder, Tourette syndrome, OCD, anxiety, and disruptive behavior disorder.

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.

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• Open access
• Published: 30 August 2024

Experiences and impacts of psychological support following adverse neonatal experiences or perinatal loss: a qualitative analysis

• Gill Thomson 1 ,
• Lara McNally 1 &
• Rebecca Nowland 1  

BMC Pregnancy and Childbirth volume  24 , Article number:  569 ( 2024 ) Cite this article

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Poor parental mental health in the perinatal period has detrimental impacts on the lives and relationships of parents and their babies. Parents whose babies are born premature and/or sick and require neonatal care or those who experience perinatal loss are at increased risk of adverse mental health outcomes. In 2021 a North-West charity received funding to offer psychological support to service users of infants admitted to neonatal care or those who had experienced perinatal loss, named the Family Well-being Service (FWS). The FWS offered three different types of support – ad hoc support at the neonatal units or specialist clinics; one-to-one person-centred therapy; or group counselling. Here we report the qualitative findings from an independent evaluation of the FWS.

Thirty-seven interviews took place online or over the phone with 16 service users (of whom two took part in a follow-up interview), eight FWS providers and 11 healthcare professionals. Interviews were coded and analysed using thematic analysis.

The analysis revealed two themes. ‘Creating time and space for support’ detailed the informational, contextual, and relational basis of the service. This theme describes the importance of tailoring communications and having a flexible and proactive approach to service user engagement. Service users valued being listened to without judgement and having the space to discuss their own needs with a therapist who was independent of healthcare. Communication, access, and service delivery barriers are also highlighted. The second theme - ‘making a difference’ - describes the cognitive, emotional, and interpersonal benefits for service users. These included service users being provided with tools for positive coping, and how the support had led to enhanced well-being, improved relationships, and confidence in returning to work.

The findings complement and extend the existing literature by offering new insights into therapeutic support for service users experiencing adverse neonatal experiences or perinatal loss. Key mechanisms of effective support, irrespective of whether it is provided on a one-to-one or group basis were identified. These mechanisms include clear information, flexibility (in access or delivery), being independent of statutory provision, focused on individual needs, active listening, the use of therapeutic tools, and positive relationships with the therapist. Further opportunities to engage with those less willing to take up mental health support should be developed.

Peer Review reports

Introduction

Perinatal mental health refers to mental health during pregnancy or within the first year after having a baby [ 1 ]. It is estimated that up to 20% of women experience poor mental health such as antenatal or postnatal depression, anxiety, post-traumatic stress, or other complications such as postpartum psychosis [ 1 ]. Two key areas that can impact perinatal mental health relate to having a baby admitted to neonatal care, or experiencing a perinatal loss (such as miscarriage, stillbirth, or early neonatal death). Both situations induce similar responses but for different reasons. The need to promote positive parental health is well-reported due to the links between poor mental health and parent relationships [ 2 ] and poorer infant and child social, emotional, behavioural, and cognitive developmental outcomes [ 3 , 4 , 5 ].

Having a baby admitted to neonatal care can be a devastating experience for parents [ 6 ] due to experiencing a traumatic birth, concerns over infant viability and the unfamiliar and technological nature of the neonatal environment [ 7 ]. A recent systematic review and meta-analysis to explore prevalence rates of depression and anxiety for mothers and fathers of preterm infants reported depression rates of 29.2% for mothers and 17.4% for fathers, and anxiety rates of 37.7% and 18.3% for mothers and fathers respectively [ 8 ]. Mothers of premature infants have also been found to experience higher rates of post-traumatic stress when compared to fathers [ 9 ]. Perinatal loss is also reported to have profound and lasting effects on the mental health of parents due to feelings of intense grief manifested through feelings of sadness, anger, guilt, and emptiness [ 10 , 11 , 12 ]. Individuals who have experienced perinatal loss are also at increased risk of trauma symptoms, such as flashbacks and nightmares [ 13 ] and developing, or exacerbating depression and anxiety [ 10 ]. Both having a premature and/or sick infant or a perinatal loss can induce guilt due to parents blaming themselves for their baby’s prematurity or untimely death [ 10 , 11 , 14 , 15 ]. These parents can also experience social isolation through feeling disconnected from friends and family due to a lack of understanding [ 10 , 16 ].

Interventions for perinatal mental health are crucial to ensure the well-being of the parents and infants. Within neonatal care, interventions can include family-centred care [ 17 , 18 ], skin-to-skin [ 19 ] and education programmes [ 20 ]. An integrative review focused on interventions designed to improve the psychosocial needs of parents of premature and/or sick infants identified 36 different studies/interventions including creative activities, peer support, relaxation/mindfulness, spiritual/religious and psychotherapeutic support [ 7 ]. This review found varying results with a general lack of effectiveness trials and wide heterogeneity within similar interventions; mechanisms of self-care, relaxation and social opportunities were highlighted as important [ 7 ]. A further systematic review and meta-analysis of 17 psychosocial interventions for individuals experiencing perinatal loss found significant impacts on reducing depression, anxiety, and grief; with most interventions offering either counselling or structured debriefing sessions [ 21 ].

In 2021 a North-West charity received government funding to develop and evaluate a two-year (April 2021-March 2023) Family Well-being Service (FWS). This service involved three types of support. (A) Ad hoc emotion-based support provided to service users while their babies were admitted to neonatal care or attending specialist clinics following perinatal loss. (B) Person-centred one-to-one therapy (~ 10–12 weeks) delivered over the telephone or face-to-face to service users whose infants were admitted to neonatal care, had experienced perinatal loss and those attending foetal medicine clinics due to their infants experiencing complex health conditions. (C) Group support, via a 6-week face-to-face guided bereavement course designed by two of the FWS therapists for service users who had experienced perinatal loss. Group support was initially introduced as an interim measure to enable service users to receive support while they waited for one-to-one therapy. The FWS was provided to service users who received care from any of four maternity Trusts in one North-West region. Here we report some of the qualitative findings from the evaluation to highlight the experiences and impacts of the FWS on service users. This work complements existing research by offering qualitative findings of a therapeutic-based intervention for those experiencing perinatal mental health difficulties following adverse neonatal outcomes [ 22 ]. It also extends the current literature by providing insights into an ad hoc form of therapeutic support delivered during a sensitive period of infant admission.

Methodology

An exploratory descriptive approach was undertaken due to this study focusing on a new area of service delivery [ 23 ].

During the evaluation, we planned to collect demographic and outcome data from all those who received one-to-one therapy from the FWS (with this information not routinely recorded for those who received ad hoc or group-based support). The service users were asked by the FWS therapists to provide consent for data-sharing purposes. Overall, less than a third of service users who received one-to-one therapy over the evaluation period provided consent. As this meant that only a partial, and potentially unrepresentative data set was available, this information has not been reported (a full copy of the evaluation report that includes all data and outcome analyses is available from the lead author). The reason for non-consent was not recorded in case this had a negative impact on the FWS therapist-service user relationship.

As part of the evaluation, we undertook interviews with the FWS therapists who provided the therapeutic support; wider healthcare care, e.g., neonatal nurses/staff who work on the neonatal units - to capture their perceptions about the FWS being delivered at the units; and service users who had received support (ad hoc, one-to-one therapy, group-based counselling) from the FWS. In this paper, we report on insights from the qualitative data that describe the experiences and impacts of the FWS on service users.

Data collection

Data collection involved interviews with the FWS therapists, wider healthcare professionals and service users. Service users were also invited to participate in a follow-up interview ~ 6 months later to assess for longer-term impacts of the FWS and whether any additional support had been accessed. While different semi-structured interview schedules were created for the different population groups (see overview of topics for each participant group in Table  1 ), all involved exploring experiences of the FWS and recommendations for service development.

All interviews were undertaken remotely via telephone or Microsoft Teams and were video and/or audio recorded. At the start of the interview, consent statements were read out by the researcher, with participants asked to verbalise their agreement to each. The consent recording was then stored separately from the interview recording. Service users were offered a £10.00 voucher for each interview completed. All interviews were between 20 and 60 min (average of 50 min) in length and were transcribed in full for analysis purposes.

Recruitment

Recruitment of FWS therapists involved the FWS project lead sending an invitation to all appropriate staff. To recruit wider healthcare professionals, FWS therapists were asked to provide contact details of relevant healthcare professionals (those who were aware of the FWS) for the evaluation team to invite. Any service user aged 16 + years who had received support from the FWS was eligible to take part. Service users were invited (via FWS therapists) by being asked to complete an Agreement to Contact form to receive further information about the evaluation. Posters about the evaluation were also displayed in key locations (e.g., neonatal unit, location where therapy or group support was provided) for service users to contact the evaluation team directly.

On all occasions, participants received an invitation email, an information sheet, and a consent form, and asked to respond to the evaluation team within two weeks if they wished to participate (with reminders issued ~ 3/4 weeks later).

Qualitative data were analysed using a reflexive thematic approach [ 24 ]. This involved the first and second authors creating an initial coding framework using MaxQDA qualitative software. The second author then continued to use this framework to code the remaining documents with codes added, re-named, or merged as appropriate. All the authors reviewed and agreed on final analytic decisions.

Reflexivity

All authors have a psychology-related background. The lead author has over 20 years of undertaking research with perinatal populations, and the other two have been undertaking research in this area for ~ 5 years. All the authors are parents. All authors consider that emotion-based support for parents who have faced these adverse situations is crucial due to the potential for negative impacts on parents, infants, and families. The second author who was responsible for data collection and analysis had experienced neonatal care with her first child and had previously worked as a volunteer with the charity. Care was taken to ensure that this prior relationship did not overtly bias data collection, or the interpretations generated – this was achieved through working closely with the project lead (first author) to review the transcripts and when analysing the data set. As listening to others’ experiences of neonatal care could trigger personal memories, regular check-ins were provided by the project lead for reflection and sign-posting purposes.

Ethics approval for this study was received from the Health ethics committee at the University of Central Lancashire (project no: 0262). All participants received a detailed information sheet and provided informed consent. As it was recognised that the interviews could elicit upset, a distress protocol was developed. This involved advising participants (in the information sheet and verbally) that the interview would be paused should they become upset, and a decision made together about how to proceed. All service users were provided with contact details of organisations where they could seek further support as needed. All information sheets noted that confidentiality would be broken should experiences of harm (to self and others) be disclosed.

A total of 37 interviews with 35 participants were undertaken, 35 interviews were completed via Microsoft Teams and two interviews were audio-recorded telephone calls. Participants included eight FWS staff, 11 healthcare professionals and 16 service users (of whom two were interviewed twice). The demographics and characteristics of service users are displayed in Table  2 .

All service users identified as female and were aged between 25 and 40 years, with a mean age of 33. Most service users were White British or White British American ( n  = 14, 87.5%), over half were married or in a civil partnership ( n  = 11, 62.5%) and the rest were single ( n  = 6, 37.5%). The age of the service users’ youngest child ranged from 10 weeks to 4 years (with the average child age being 15 months). Reasons for referral varied and were due to several different types of adverse neonatal experiences or perinatal loss (see Table  2 ). The types of support that the service users received are detailed in Table  3 . These data highlight that one service user had only received ad hoc support on the neonatal unit; the remainder had all received more prolonged support via one-to-one or group-based therapeutic support (four of whom also had received ad hoc support at the neonatal unit or specialist clinic).

The FWS staff interviewed included seven psychological therapists ( n  = 7) and the project lead. Healthcare professionals who participated in an interview held different roles including neonatal nurses, ward managers and sisters, education leads and mental health neonatal nurses. The healthcare professionals’ length of service ranged from 9 months to 14 years.

In the following sections, we present two themes and associated sub-themes. The first theme - ‘creating time and space for support’ - details the informational, contextual, and relational basis of the FWS service, as well as barriers to service delivery. The second theme - ‘making a difference’ - describes the cognitive, emotional, and interpersonal benefits of the FWS for service users. Illustrative quotes are included with identifiers that use the abbreviations SU – service user, FWSS – Family Well-being service staff, or HCP – healthcare professional. Additional identifiers that signify the type of support the service user received are also included using the codes A (ad hoc support), G (group counselling) and O (one-to-one therapy).

Creating time and space for support

In this section, we describe how the FWS therapists worked to facilitate time and space for therapeutic support across six sub-themes - ‘ tailoring the communications’ , ‘a flexible and proactive approach’ , ‘being listened to without judgement’ , ‘independent from others’ , ‘not just about the baby’ and ‘ shared experiences’. A final sub-theme reports on the ‘barriers to service delivery’.

Tailoring the communications

FWS staff used various communication modes - verbal, leaflets, email, telephone, or text – to inform and communicate with service users. Some service users spoke positively about the incremental information received and how valuable it had been to tell them ‘everything I could expect’ (SU4:O&G): this, together with the perceived ‘ non-pushy’ approach of the FWS staff enabled them to make their own decisions and to access the support on their terms, ‘I just read through it [ leaflet] because it wasn’t kind of like it straight away , we’re gonna refer you. They said have a think’ (SU16:O). Another service user reported:

It was a lot of like, what’s gonna fit for me really. Like I wasn’t just kind of told, this is what you’re going to do and that kind of thing. Like, every step of the way I was asked, like, do you want to do this? Do you want to try this? You know, do you think that would work for you? And it felt really personal. (SU4:O&G)

Service users also appreciated the immediacy of contact from the therapists, ‘found it really good , they contacted me really quick’ (SU9:O), once a decision to receive support had been made.

A further means by which FWS staff helped to tailor communications and support service user engagement was via data sharing. Several service users highlighted the benefits of the FWS staff sharing their information with others in the service, thereby mitigating the need for repeating painful accounts:

She [FWP therapist] was aware that I was gonna be contacting. I think it is helpful that they already knew my background because it can avoid questions that you don’t particularly want to answer, or things that you don’t want to have to repeatedly go over. (SU3:G)

Those receiving ad hoc support were all encouraged to take up formal therapy following infant discharge. However, the therapists also offered a text message contact for service users who were not receptive to receiving more prolonged therapeutic support during their infant’s neonatal stay, e.g., ‘six weeks after you’ve been discharged just to check in’ (FWSS1). For some, this delay in service offer was considered ‘perfect’ as it meant that they accessed support that they ‘would not have accessed’ but has ‘ helped me no end’ (SU7:A&O). Although one of the FWS staff reflected that whilst this follow-up approach was not always successful, it provided ‘peace of mind’ (FWSS5) to know that it had been offered.

A flexible and proactive approach

Participants who accessed different forms of therapeutic support from the FWS spoke very positively about the flexible and proactive nature of the service. Proactive ad hoc support on the neonatal unit enabled service users to receive support while being with their babies. Healthcare staff felt parents were unlikely to prioritise their own mental health needs when ‘all they are concerned about is the baby’ – proactively approaching them ‘ where they are’ was therefore perceived to be the ‘best way of doing it by far’ (HCP8). Ad hoc support was also considered important in preventing service users from ‘slipping through the net’ (HCP5) by expecting them to join a waiting list for an appointment that they then decide not to access.

Flexibility in how the one-to-one therapy was provided (i.e., by telephone or face-to-face) was highly appreciated. Telephone appointments were valued for practical reasons such as childcare - ‘I can’t attend in person with two children ’ and wider work commitments. Accessing support from home also allowed service users to feel comfortable in their own space, which in turn enabled them to be more open with their therapist:

You’re in your space. I was comfy, I had my coffee and then I just felt like, I don’t know if I’d have opened up so much if I was in a room and it felt like counselling, like therapy (SU6:O).

Flexibility in service users being able to change appointments, ‘they changed every appointment that I needed changing […]it was brilliant’ (SU1:O) or delaying appointments ‘she didn’t mind me texting and saying I’m running 5–10 minutes late ’ (SU6:O) was highly valued. Service users also appreciated the freedom to go at their own pace: ‘if you wanted to contribute [during the group counselling], you could do , if you didn’t , you didn’t have to ’ (SU10:O&G). One service user reflected on how this personalised approach stimulated reciprocity in terms of individuals being able to ‘get out’ what they ‘put in’ (SU15:G). This flexibility was also echoed in the bereavement groups, with the discussion topics being based on the needs of the group rather than a prescribed plan:

[Group therapists] had something as sort of an idea for each session but they would always ask if there was anything that we as a group or individually wanted to focus on or cover. (SU3:G)

Being listened to without judgement

Service users repeatedly spoke of how much they valued feeling ‘heard and listened to and valued’ (SU5) by the FWS therapists; with these accounts provided by service users who had received ad hoc, one-to-one, or group-based support. One service user also felt that while the therapist was ‘paid to listen’ it was the fact that she seemed to ‘want to listen’ that made a difference (SU1:O). Several service users reflected on how the therapists’ active listening and person-centred non-judgmental approach meant they ‘ found her really easy to talk to , it’s a really good relationship’ (SU12:A&G), and was someone who they ‘could be completely open with’ (SU6:O):

The most helpful thing is having someone to listen to me and that has no judgment whatsoever, I have to say when I went on, she was calm, she was soothing and never felt one bit of like, oh my God, I can’t believe that’s happened […] There’s no judgment, […] she was there for me and only for me. (SU14:O)

Feeling listened to and having a good relationship with their therapist gave service users a sense of being ‘wholly seen’ and a safe space to be ‘able to feel safe and valued and respected’ (SU5:A&O). Some service users described how it was like they were talking to a friend who was ‘there for me ’:

It was just like talking with an old friend, if you know what I mean. And even though I’ve never met the lady before, she was very friendly […]. So it was nice. (SU13:O)

Independent from others

Whilst service users appreciated the friendliness and authenticity of their therapist, they also talked about how helpful it was to receive regular support from the same therapist who was independent of friends, family, and healthcare professionals. Several participants who received one-to-one or group-based support considered this to be helpful as it meant they could openly share how they felt without feeling like a burden:

I was really worried that when I was talking to like my husband or my mum and my sister or anything that that I was saying was just going to end up upsetting them and having someone to talk to or just felt like I can say whatever I want, […] Like it’s not gonna ruin their day, I can just say what I want, it was just so helpful really (SU4:O&G).

The positives of the therapists being separate from clinicians were related to challenges in the relationships between healthcare providers and parents due, e.g., to life-saving care being administered to their babies which was uncomfortable to watch:

So, it’s quite nice that they have that extra person to talk to who isn’t the person that just stuck a gastric tube down your baby and made him cry or, you know, or that just cannulated your baby (HCP1).

Healthcare professionals also spoke of how parents could attempt to ‘hold it together’ during interactions with healthcare staff, due to not wanting to give the ‘impression that they’re struggling’ (HCP6). Support from an ‘outsider’ perspective was therefore perceived to be crucial in breaking down these barriers and offering dedicated needs-led support.

Not just about the baby

Another reason service users felt they could talk openly about their feelings and experiences was due to the support being focused on their needs as individuals, rather than being about the baby, or being a parent:

It helped me in a lot more ways as sometimes it was nothing to do with being a mum or [baby] and yeah, it just worked really well’ (SU6:O).

Service users acknowledged the need to process their negative experiences but also the necessity of talking about other things that were affecting their mental health and their ability to cope:

I had to grieve with what had happened in the past. Cause normally I just push everything down and deal with it, I just get on with the next day. So, we [therapist and service user] went backwards for me to be able to move forward. (SU14:O)

‘My helping hour’ (SU6:O) as one service user who had received therapy described, and mirrored in others’ narratives, related to how much they appreciated and looked forward to taking time out each week to think about their needs:

When you’ve got a newborn and you’re wrapped up with, especially with someone with a condition and wrapped up with a feeding schedule, medicines, nappies, sleepless nights, blah blah, blah blah blah. I would never have then thought, you know what? Let’s take care of you. Let’s have an hour that’s just for me. (SU7:A&O)

Shared experience

Some service users who received support on an ad hoc, one-to-one or group basis spoke of how receiving support from a therapist who had faced a similar experience had ‘definitely helped’ . One pregnant service user who had had a previous miscarriage reported the benefits of receiving one-to-one support from a therapist who had faced their own experiences of infertility and subsequent in vitro fertilisation:

She’d gone through pretty much a very similar experience to me. She’d had very similar infertility issues, and she’s also gone through losses herself. So, it was easy to bond with her very quickly because you do when someone’s gone through that same experience (SU11:O).

Others referred to how receiving support from therapists who had ‘been through it all the same’ (SU1:O) helped them to feel ‘normal’ and ‘I wasn’t being dramatic or crazy’ (SU8:A). Whereas for others, it was receiving support from a therapist who understood the realities of parenthood that mattered:

Motherhood is hard, you know, like and my counsellor was a parent as well, so really helped to, like, justify those feelings are rational and just rationalise. (SU5:A&O)

Opportunities for group support also enabled service users to normalise and validate their experiences ‘with other people who have all gone through the same thing and have the same feelings ’ (SU4:O&G).

Barriers to service delivery

Overall, there were some challenges and barriers reported in relation to communication, access, and service delivery. First, in relation to communication, some service users referred for one-to-one or group support complained about a lack of information about when it would be received:

So, it was a bit frustrating waiting and not knowing whether it was then gonna be like weeks and weeks, or months, or whether it was gonna be like a few days. (SU4:O&G)

Several service users also described communication difficulties about the delay in follow-up after the initial assessment (when referred for formal therapy). This delay meant they had to ‘unravel’ the ‘worst parts you are struggling with’ and then ’putting the phone down’ with ‘no follow-up plan or coping mechanisms’ in place (SU10:O&G). The gaps in support provision were also expressed from within the service: ’it’s not great , because those mums and dads are waiting , and they’ve reached out , and that’s when they need the help ’ (FWSS7).

Despite the benefits of ad hoc support, access-related issues were raised about therapists being unable to provide support for practical as well as emotional-based reasons. From a practical perspective, the therapists only had limited time on the units which meant ‘some people may not see her’ (HCP1), and if parents did not live in the catchment area, then support could not be offered. Healthcare staff were not always notified about the FWS therapists’ availability at the unit. This information was considered important to ensure effective signposting to, ‘just to say to a parent , well if you want to speak to anybody , we’ve got our counsellor in on such-a-day’ (HCP6). From an emotional perspective, it was recognised that therapeutic support was not suitable for all, such as those ‘who are very closed down’ (FWSS1) or ‘scared’ of disclosing negative emotions particularly ‘the ones where there are social issues’ (HCP6).

Regarding service delivery, while several service users made positive comments about the flexible nature of support, in terms of access, delivery and amount received, some wished the sessions had been longer. One also spoke of an ‘awkward finish’ when the one-to-one sessions were ending:

[So, it can be like] ohh sorry, I think I’ve lost track of time a little bit, I think we’re gonna have to pull it up there and we’re gonna have to end. So, I’ll be like, alright, OK, right, yeah fine. And it can be a bit clunky in the way that it finishes rather than it drawing naturally to a conclusion. (SU10:O&G)

Making a difference

In this section, we describe service users’ reflections on the psychological, cognitive, behavioural, and social benefits of FWS support. Four sub-themes are detailed - ‘tools for positive coping’ , ‘enhanced well-being’ , ‘improved relationships with others’ and ‘confidence in returning to work’ .

Tools for positive coping

Several service users described how the therapeutic tools they were taught as part of their therapy sessions either on the ward, one-to-one, or in the group provided positive coping mechanisms to help with ongoing adversities: with one describing them as a ‘ toolbox’ to draw on when needed (SU4:O&G). The techniques were reported to have helped them understand and articulate how they were feeling, ‘to unpick , how it was that I was feeling what I was struggling with (SU10:O&G) and the breathing and distraction techniques enabled them to ‘stop blaming myself and start breathing’ and to ‘do something else to try take my mind off it’ (SU2:O). Other service users referred to how the support had helped them to know  ‘more about their triggers’ which helped them to feel strong and to retain a sense of control during uncontrollable and uncertain situations:

The tools just to step back and be like right, […] write down everything I can’t control and everything I can control of what my memories are and then cross everything I can’t change. Like I can’t control how sick she is. I can’t control her temperature, but what I can control is her feeds and being her mum and stuff like that […] They made me feel the strength that I’ve not felt in about 5 years. (SU5:A&O)

The therapeutic techniques provided by the therapists were an ongoing source of support to help service users in the extreme circumstances of the neonatal unit as well as in day-to-day life:

I relied on one of the meditations she sent me, and it just really, really centred me at night, even as I was feeling overwhelmed, just like putting my headphones in and just saying to my husband, if he wakes up and you just see to him, and that just helped me so much. (SU6:O)

Enhanced well-being

Many service users described how the FWS support had improved their psychological well-being, using terms such as feeling ‘lighter’ , more ‘optimistic’ and a ‘stronger person’ . Some service users referred to how the therapist had provided important crisis management. For one participant who received one-to-one therapy, this related to how the support helped to ‘pull her back’ from an emotional crisis each week, associated with the threats of a further potential pregnancy loss:

If I didn’t have [therapist] once a week, I dread to think where I would have been. It was kind of like, yeah, like each week she’d pull me back in, and then I’d probably go a bit crazy again, and then she’d pull me back in. (SU11:O)

Others described fundamental changes such as moving from a state of being unable to ‘ function properly’ to being back at work and ‘happy and getting on’ and feeling ‘like a different person ’ (SU4:O&G). Another service user also described how the one-to-one therapy had improved her well-being after a traumatic birth and neonatal stay to such an extent that she had become ‘ a better version’ of herself:

I just literally feel like me again, I suppose I think you just get so wrapped up with being mum and just being on all the time and as a mum you do normally lose your confidence and you do lose yourself so it’s more like feeling like me but even a better version that I liked of me. (SU6:O)

Improved relationships with others

Service users who received one-to-one or group-based support talked openly about how their relationships with their partners and family had been enhanced due to the support the FWS had provided. One reported how the support had helped her and her husband to ‘communicate with each other’ and ‘discuss how we were both feeling ’ (SU15:G). Another service user shared how the one-to-one telephone therapy had restored her relationship with her mother:

I don’t know what magic she’s done but my mum and my relationship it’s been really good to a point where before I couldn’t wait to get my mum out of my house, but now, it’s kind of like mum I need you and I appreciate you (SU16:O).

A further way the FWS support influenced relationships with others was regarding a future conception. While following a traumatic birth, neonatal stay or loss of a baby, individuals can be hesitant to have more children [ 25 ], the FWS was reported to have helped service users’ address these concerns. Bereavement group participants also reported finding hope for future family planning together, thereby enabling a futural peer support element to the therapeutic intervention:

Hopefully, we’ll be able to support each other, hopefully in the future through future pregnancies. Like it’d just be amazing if we all managed to get pregnant together and had our babies together that’d just be unbelievable. (SU15:G)

Confidence in returning to work

Service users who had received one-to-one support reflected on how the support had helped them to address their anxieties in returning to paid employment:

[Baby] is going to nursery that was quite triggering […] And I think if I had to deal with that a long time ago, like a few months ago, I’d have just blow my head there, I just couldn’t have done that. But now, I’ve just been, like, really calm and just quite open to it and just, sort of kept my cool really. (SU6:O)

Another service user who had experienced a neonatal loss reported: ‘ If I hadn’t had had the support I wouldn’t have gone back to work and I’d probably be in a much darker place’ (SU13:O). This woman reflected that working was positive for her emotional well-being, and how this would not have been possible without the support from the FWS.

In this paper, we present findings from an evaluation of a charity that provided ad hoc support, formal therapy and group support to service users who had a premature and/or sick infant or who had suffered a perinatal loss. We highlight the informational, contextual, and relational basis of how the support was experienced, and the cognitive, emotional, and interpersonal impacts of the FWS for service users. The findings of this paper contribute to the evidence supporting the need for emotional and psychological support for those who experience adverse maternity and neonatal outcomes in the perinatal period [ 3 ]. Overall, there appear to be key mechanisms - defined as the entities or activities responsible for the phenomenon (i.e., positive experiences and impact of FWS support) [ 26 ] – that underpinned effective support, irrespective of whether it was delivered on a one-to-one or group basis. These mechanisms include clear information, flexibility (in access and/or delivery), being independent of statutory provision, focused on individual needs, active listening, the use of therapeutic tools, and positive relationships with the therapist. Furthermore, while ‘ shared experiences’ are a key mechanism of group-based support, this was also evident in one-to-one therapy when service users received support from a therapist with a shared history.

A number of our findings echo those reported in a recent qualitative systematic review of women’s experiences of specialist perinatal mental health services [ 22 ]. Similar findings concern the importance of the therapist-service user relationship, with the therapist’s open, non-judgemental, and person-centred approach found to be essential to meaningful service experiences [ 22 ]. As reported in the review, and in our study, continuity was a key feature of relationship building that engendered safety and dependability [ 22 ] and for meaningful change. While some of the included papers in the review reported how women felt clinicians had real insight and understanding of perinatal mental health conditions [ 27 , 28 , 29 ], in our work, this also related to the therapists sharing their personal experience of perinatal mental health and/or loss. These findings resonate with those by Cleary and Armour who explored the dual identity of counsellors and therapists with experiential experiences of mental health issues [ 30 ] whereby self-disclosure enhanced the therapeutic relationship. They also concur with a qualitative study by Parker et al. who found counsellors having a working knowledge of neonates and the neonatal environment was crucial [ 31 ].

Similar to the wider literature, we found that service users benefitted from receiving support independent of health care and focused on their needs as individuals [ 32 , 33 ]. This finding further supports the need for independent specialist support such as provided within the UK-based specialist perinatal mental health and maternal mental health services [ 3 ]. While specialist mental health support has been found to help service users understand their infant’s needs and develop parent-infant relationships [ 22 , 27 , 34 ], in our study, the benefits were more individualised and included enhanced personal and social well-being. Our findings of the positive impacts of group-based support also align with the wider literature regarding the value of receiving validation and reassurance from peers with shared experiences [ 29 , 35 , 36 ], as well as opportunities for ongoing social support after the groups had ended [ 35 ]. The benefits gained via support from the therapists and within the groups signal post-traumatic growth described as “positive psychological change experienced as the result of the struggle with highly challenging life circumstances” [ 37 ]. This was evidenced through women feeling stronger, developing new relationships, more able to cope with future adversities and with a new and improved outlook on themselves and their situation [ 37 ].

Flexibility in rearranging appointments and the location of support being organised to suit individual service users encouraged access and an openness to share personal issues [ 22 ]. While complaints have been reported in the previous literature about service users being unaware of wider support provision and a lack of follow-up support [ 22 , 36 ], in our study, we found that tailored information and communications provided at multiple points helped facilitate engagement. Although resource-related challenges concerning the availability of the therapists on the unit and a lack of communication as to when this support was available were noted. A further difficulty related to the reported time lag following an initial assessment: this signifies a need for ongoing contact to ensure service users gain access to the right support at the right time [ 38 ]. Proactive support is a central tenet of emotional-based care [ 39 ]. This was clear in our study as the proactive nature of the support was essential to provide parents with care at a harrowing time and to facilitate access to more structured support post-infant discharge. However, as some service users can be reluctant to disclose perinatal mental health problems, due to feeling overwhelmed or potential fears of stigma and negative reprisals [ 40 ], alternative methods to ensure that all parents receive timely support is needed. Furthermore, despite service users from minoritised ethnic communities being at increased risk of poor perinatal mental health [ 41 , 42 , 43 ], they are less likely to access support [ 40 , 43 ]. A recent systematic review to explore the reasons why minoritised ethnic women do not access mental health services identified barriers at the individual (stigma, lack of awareness), organisational (inadequate resources), sociocultural (language, cultural barriers) and structural (lack of clear policies) levels [ 44 ]. Therefore, while approaching parents in the neonatal unit may help to overcome some of these barriers, further work to elicit if and how this can influence access to specialist support amongst ethnically minoritised service users is needed.

The limitations of this study are that overall, only ~ 30% of service users who accessed one-to-one therapy consented to share their demographic and outcome data for the evaluation. However, typically studies involving mental health intervention have difficulties with recruitment and retention of participants and often achieve very low response rates [ 45 ]. It also suggests that further work on how to encourage consent and provide reassurance about how their data will be used may be needed. The intention was to interview ~ 20 service users, with only 16 recruited, despite numerous recruitment efforts. This may be due to asking service users to participate while still receiving support, and indicates that other potentially more sensitive methods, such as writing to participants after they have ended support with the FWS may have been more successful. Also, while all service users had the opportunity to be re-interviewed ~ 6 months later, only two took up this offer – both of whom had received one-to-one therapy. This low take-up may be due to symptom resolution or symptom continuation, both of which could be associated with concerns for re-triggering or magnifying negative emotions. More flexible ways, such as using a journal, may encourage long-term qualitative insights to be captured. A further limitation is that over 30% of the participants had received more than one type of support and any nuances in the experiences of the different support options were not fully explored in the interviews. Most of the participants were from a White demographic background, which may reflect wider barriers to access to mental health support in ethnic minority populations [ 40 ]. We also intended to interview more healthcare professionals, and the small number recruited is likely indicative of busy, time-poor professionals. Future research could include focus groups incorporated as part of existing professional-based meetings to maximise participation. However, despite the recruitment challenges, a total of 35 participants is a large sample for qualitative research, and generated rich, in-depth insights into the views, experiences, impacts, facilitators, and challenges associated with the FWS.

This study describes how psychological support was provided for service users experiencing adverse maternity and neonatal outcomes and the impact of this support on individual and familial well-being. This work complements existing research into perinatal counselling-based interventions and highlights the value of providing therapeutic support during a sensitive time. Despite study limitations, the findings signify the need for independent, timely, flexible, needs-based, proactive, well-resourced psychological-based support. They also emphasise how the therapists’ open and non-judgmental approach and experiential knowledge are essential mechanisms of meaningful service provision. Implications for practice concern better communication regarding support availability, and timely follow-ups. Further means to engage those less willing to take up mental health support and who may have greater needs should be developed.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

Thanks to all the participants for their time and invaluable contributions.

The research was commissioned and funded by Lancashire Women.

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Gill Thomson, Lara McNally & Rebecca Nowland

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GT was project lead who designed the original study, with support from RN. LN conducted interviews. LN and GT developed a coding framework which was applied to the transcripts by LN. All authors reviewed analyses and agreed final analytical decisions. All authors read and approved the final manuscript.

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Correspondence to Gill Thomson .

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Thomson, G., McNally, L. & Nowland, R. Experiences and impacts of psychological support following adverse neonatal experiences or perinatal loss: a qualitative analysis. BMC Pregnancy Childbirth 24 , 569 (2024). https://doi.org/10.1186/s12884-024-06713-7

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Received : 21 March 2024

Accepted : 22 July 2024

Published : 30 August 2024

DOI : https://doi.org/10.1186/s12884-024-06713-7

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