CBT for Children and Adolescents Workshops:
March 23-25 (Level 1), June 1-3 (Level 2)


Avoiding Traps in Treatment: Case Formulation Driven 

Cognitive Therapy With Youth


By Robert D. Friedberg, Ph.D., ABPP, ACT

Adjunct Faculty, Beck Institute

Cognitive therapy incorporates an impressive collection of therapeutic methods and procedures. There are plentiful resources for eager practitioners to rely upon in their clinical work with young patients. Textbooks, workbooks, manuals, mobile phone apps, and web-based intervention options abound. While the plethora of materials provides much to be thankful for, clinicians who become overly enamored with techniques may fall into traps when conducting CT with youth (or patients of any age). A sure-fire way to minimize these missteps into therapeutic black holes is to base interventions on a sound formulation. Accordingly, this brief commentary urges cognitive therapists to count on their conceptualization (shared with the patient) to guide treatment.


Consider this example. A clinician begins treating an African American male child age 10 years old who presents with considerable somatic distress marked by autonomic hyperarousal, multiple worries about potential dangers that are inaccurately perceived as probable, and avoidance of feared novel situations. The child also notes he feels "blue" and "low" much of the time. Consequently, the well-intentioned eager clinician jumps on the blue mood bandwagon armed with behavioral activation/ pleasant activity scheduling procedures. The clinician initially develops an assignment for the child to increase his physical exercise by 15 minutes daily. However, exercise has never been part of the child's daily routine. Additionally, the assignment is perceived by the patient as a new situation and he feels anxious. Not surprisingly, when the patient returned to the clinic for his next session, he hadn't completed the action plan.


What can we learn from this? Behavioral activation and pleasant activity scheduling are effective interventions and upon review of a videotape, the clinician was found to be technically proficient. But this intervention was simply not appropriate for this particular patient. The clinician had failed to develop a provisional formulation, so she applied the intervention in a conceptual vacuum. After conceptualizing the case, the clinician soon recognized that this young patient held significant core doubts about his competency (e.g "I can't cope and I am out of control in all unfamiliar situations"), the world ("It is unsafe, filled with danger, and unknown"), and other people ("People are not helpful and they don't understand"). Once the conceptualization was unpacked, the clinician readily recognized that she had unwittingly reinforced some key beliefs (e.g, "Unfamiliar activities will end badly," "I can't cope," "People aren't helpful").


The urge to intervene is understandable. Young people are in distress, vulnerable, and suffering. We want to help. But methods, procedures, and techniques must be firmly embedded in a case conceptualization (Friedberg & McClure, 2015).


Many clinicians I supervise are burdened by heavy caseloads and concomitant productivity demands. They often lament "I wish I could do a case conceptualization,  but there is just not enough time to do so!" Case conceptualization does not need to be time-consuming and cumbersome (Beck, 2011; Kuyken, Padesky, & Dudley, 2009; Manassis, 2014; Persons, 2008). And much of this conceptual work actually occurs during the session. Finding out, for example, what the child (described above) imagines will happen if he does engage in exercise will generally take little time, yet the payoff is great when the patient is able to think differently about situations, behave in more functional ways, and feel better between sessions. 


Simple case conceptualizations that are collaboratively constructed using the child's language, are jargon-free, and linked to presenting problems should be shared with children and their caretakers (Kuyken et al., 2009). This process makes treatment more transparent and more accessible to children and their families by letting them in on the rationale for treatment. Moreover, it facilitates genuine informed consent because patients know how clinicians are perceiving their presentation and why treatment is proceeding in certain ways.


Case formulation is also quite practical and allows for the creative modification of traditional techniques (Friedberg & McClure, 2015). For example, an anxious eight year old Euro-American girl was seen at the clinic due to GAD.  She said, "I like to think I am a Disney Princess." This led to the use of the "Thought Crown Technique" (Friedberg, McClure, & Garcia, 2009) because "All Princesses wear crowns!" Naturally, the thought crown made the self-instructional procedure more accessible and engaging to her.


Seeing CT as merely a collection of techniques is a trap. CT is founded on a robust theoretical paradigm and a sound empirical data base.  The genius of the theoretical approach lies in its accessibility. Wise clinicians remember that good CT is rooted in flexible and individualized case formulations.



Beck, J.S. (2011). Cognitive Behavior Therapy: Basics and beyond (2nd Edition). New York: Guilford.


Friedberg, R.D., & McClure, J.M. (2015). Clinical practice of cognitive therapy with children and adolescents: The Nuts and Bolts (2nd Ed). New York: Guilford.


Friedberg, R.D., McClure, J.M., & Garcia, J.H. (2009). Cognitive therapy techniques for children and adolescents. New York: Guilford.


Kuyken, W., Padesky, C.A., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavior therapy. New York: Guilford.


Persons, J.B. (2008). The case formulation approach to cognitive-behavioral therapy. New York: Guilford.

CBT for Children and Adolescents:
3-Day Workshops

When:   March 23-25, 2015 (Level 1)
June 1-3, 2015 (Level 2)
Where:     Beck Institute, Suburban Philadelphia
Time:  8:45am - 4pm
Faculty:  Torrey Creed, PhD
Enrollment: Limited to 42 participants
CE/CMEs: 18

To register for March 23-25 (Level 1):   

To register for June 1-3 (Level 2):   

We offer two experiential workshops for children and adolescents under the direction of Judith S. Beck, Ph.D., and led by Torrey Creed, Ph.D. Level 1 focuses on depression and anxiety. Level 2 builds on what was taught in Level 1, with advanced techniques of conceptualization and treatment, emphasizing complex conditions such as OCD and Autism Spectrum Disorders.

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