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self-reported believability of symptoms and rehospitaliza-tion rates over a 4-month follow-up, but these differenceshad begun to subside by the end of the follow-up period andmay not have been sustained if patients had been followedlonger. Controlled trials of CBT need to be conducted in theUnited States with outpatients in order to determine itseffectiveness in typical U.S. public health systems.

The term “CBT” has been used very loosely in this lit-erature to refer to a wide variety of different treatment tech-niques. As indicated above, they all have some commonvalues and assumptions about the illness and how to relateto patients, but few, if any, would be immediately recogniz-able as CBT practiced with depressed and anxious patients.In appraising the literature as a whole, it is safer to concludethat there is good evidence for these values and the generalstyle of interacting with patients, including the use of psy-choeducation to decrease stigma, developing shared goals,and teaching patients how to cope, than for any specific orunique CBT techniques.

In addition to research on the applicability of the cog-nitive model to schizophrenia (noted above), future researchon CBT for schizophrenia should focus on identifying char-acteristics of patients who are most likely to benefit fromCBT, key elements of treatment, and optimal duration oftherapy. In addition, it will be important to better understandfactors associated with the implementation of CBT treat-ment programs into various mental health care settings andthe successful training of competent therapists.

See also: Social skills training

REFERENCES

Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitmenttherapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting and ClinicalPsychology, 70, 1129–1139.

Dickerson, F. B. (2000). Cognitive behavioral psychotherapy for schizo-phrenia: A review of recent empirical studies. Schizophrenia Research,43, 71–90.

Garety, P. A., Fowler, D., & Kuipers, E. (2000). Cognitive–behavioral ther-apy for medication-resistant symptoms. Schizophrenia Bulletin, 26,73–86.

Gould, R. A., Mueser, K. T., Bolton, E., Mays, V., & Goff, D. (2001).Cognitive therapy for psychosis in schizophrenia: An effect size analy-sis. Schizophrenia Research, 48, 335–342.

Kuipers, E., Fowler, D., Garety, P., Chisholm, D., Freeman, D., Dunn, G.,Bebbington, P., & Hadley, C. (1998). London—East Anglia random-ized controlled trial of cognitive–behavioural therapy for psychosisIII: Follow-up and economic evaluation at 18 months. British Journalof Psychiatry, 173, 61–68.

Lewis, S., Tarrier, N., Haddock, G., Bentall, R., Kinderman, P., Kingdon, D.,Siddle, R., Drake, R., Everitt, J., Leadley, K., Benn, A., Grazebrook,K., Haley, C., Akhtar, S., Davies, L., Palmer, S., Faragher, B., & Dunn,

G. (2002). Randomised controlled trial of cognitive–behavioral therapy in early schizophrenia: Acute-phase outcomes. The BritishJournal of Psychiatry, 181, 91–97.

Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Orbach, G.,& Morgan, C. (2002). Psychological treatments in schizophrenia: I.Meta-analysis of family intervention and cognitive behaviour therapy.Psychological Medicine, 32, 763–782.

Rector, N. A., & Beck, A. T. (2001). Cognitive behavioral therapy for schizophrenia: An empirical review. Journal of Nervous and MentalDisease, 189, 278–287.

Sensky, T., Turkington, D., Kingdon, D., Scott, J. L., Scott, J., Siddle, R.,O’Carroll, M., & Barnes, T. R. E. (2000). A randomized controlledtrial of cognitive–behavioral therapy for persistent symptoms in schiz-ophrenia resistant to medication. Archives of General Psychiatry, 57,165–172.

Tarrier, N., Wittkowski, A., Kinney, C., McCarthy, E., Morris, J., &Humphreys, L. (1999). Durability of the effects of cognitive–behavioural therapy in the treatment of chronic schizophrenia:12-month follow-up. The British Journal of Psychiatry, 174, 500–504.

Turkington, D., Kingdom, D., & Turner, T. (2002). Effectiveness of a brief cognitive–behavioural therapy intervention in the treatment ofschizophrenia. British Journal of Psychiatry, 180, 523–527.

School-Based Therapy

Rosemary Mennuti and Ray W. ChristnerKeywords: school-based interventions, CBT in schools

The provision of school-based psychological services datesback to the turn of the twentieth century when all statesenacted compulsory attendance laws, the average number ofschool days increased, and public school enrollment was onthe rise (Fagan, 2000). School-based clinicians receivedreferrals to address academic problems, behavioral con-cerns, as well as issues complicated by health problems.While the types of referrals have remained the same, theneed for comprehensive school-based psychological serv-ices has never been greater. Recently, a Report of theSurgeon General’s Conference on Children’s Mental Healthnoted that the country is now facing a crisis in mental healthcare. In the United States alone, 1 in 10 children and ado-lescents have a diagnosed mental illness severe enough tocause some level of impairment. Yet, in any given year, it isestimated that fewer than 1 in 5 of these children receiveneeded treatment (U.S. Public Health Service, 2001).

Education plays a dominant role in the lives of youth,and we believe it is a natural entry point for addressing themental health needs of children and families. As emotionaland behavioral problems arise with students, it is more

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likely that school-based clinicians will have an obligation todesign and provide effective and efficacious interventionsfor various presenting problems and populations. Consi-dering the needs of students and the legal dictum for the pro-vision of psychological counseling in schools, we believecognitive–behavioral therapy (CBT) represents a promisingoption for school-based clinicians as a well-founded,effective treatment model for a wide range of problemsexperienced by children.

USING CBT WITH CHILDREN AND ADOLESCENTS

CBT’s initial momentum occurred as an innovativetreatment for various adult disorders; however, it has movedto the forefront of treatment for a number of difficultiesaffecting children and adolescents (Friedberg & McClure,2002; Reinecke, Dattilio, & Freeman, 2003). Research onthe use of CBT with children and adolescents has grown inrecent years, although the literature on the use of CBTwithin a school setting remains minimal.

When applying the CBT framework in the conceptual-ization and treatment of school-age children with problems,professionals must possess an understanding of the funda-mentals of child and adolescent development. Those clini-cians grounded in the “nuts and bolts” of development willavoid implementing interventions that are incompatible witha child’s functional level. To benefit from a number ofcognitive-based strategies, a child must have the capacity toattend to information, comprehend language, use workingmemory, and verbally express him- or herself. School-basedpractitioners should use and focus on these individual fac-tors when designing a specific program for a student. In caseconceptualization and treatment design, school-based clini-cians should determine the precise mix of cognitive andbehavioral techniques based on the student’s developmentallevel. For instance, the more immature a student’s cognitiveor language development, the greater is the proportion ofbehavioral to cognitive interventions the clinician will use.This is not to say that cognitive techniques are inappropriatefor use with young children, but instead that the use of cog-nitive interventions will be less relied on for those studentsat a lower developmental level. We note further that school-based clinicians should be aware that developmental level isnot always consistent with chronological age.

In addition to cognitive and language development,school-based clinicians should also have awareness of otherprominent research in the developmental psychopathologyliterature including risk factors (Coie et al., 1993) and protective factors (Rutter, 1985). Coie et al. (1993) groupedempirically derived risk factors into seven domains:(1) constitutional handicaps, (2) skills development delays,

(3) emotional difficulties, (4) family circumstances, (5) inter-personal problems, (6) school problems, and (7) ecologicalrisks. Similarly, Rutter (1985) identified three broaddomains of protective factors including individual charac-teristics, interaction with the environment, and broader soci-etal influences (e.g., quality schools). Coie et al. (1993)indicated that protective factors work in one of the follow-ing ways: (1) directly decreasing risk, (2) serving as a bufferthrough interaction with risk factors, (3) disrupting the chainreaction from risk factors to disorder, or (4) preventing theinitial occurrence of the risk factor.

Clinicians can use this knowledge to help conceptual-ize and design interventions for students. When workingwith children and adolescents, the treatment may initiallyfocus on building social skills and problem solving throughpsychoeducation. It is essential that the psychoeducationalcomponents facilitate skill building and the correction ofmaladaptive practices in order to promote protective factorswhile minimizing risk factors (e.g., strengthening peer relationships, increasing self-monitoring skills, improvingparent–child interactions, and increasing school success).For instance, building social–cognitive skills in angry andaggressive children has been identified as an effective mediator in the reduction of angry or aggressive outburst(Kazdin & Weisz, 1998). Furthermore, CBT strategies suchas cognitive restructuring have the potential to raise a child’s protective mechanisms (e.g., cognitive skills) whilelessening risk such as emotional dysregulation and low self-esteem.

A final key component regarding the use of CBT withchildren and adolescents in school settings is the collabora-tive relationship. Interestingly, professionals who are criticalof CBT claim it ignores the relevance of the “therapeuticrelationship.” This assertion, however, is far from traditionalpractice, and in fact, it is contrary to work and writings ofprominent figures in CBT such as Aaron Beck. Beck, Rush,Shaw, and Emery (1979) emphasize the need of active inter-action between a therapist and a patient, and they refer to“slighting the therapeutic relationship” (p. 27) as a commondrawback in therapy.

The idea of a connected, collaborative relationshipwhen treating children is imperative to the child’s process ofhealthy growth and development, as a positive authenticrelationship facilitates the therapy process and the outcome.In a meta-analytic review, Shirk and Karver (2003) foundthat therapeutic relationship has a modest, but consistent,correlation with therapeutic outcome for youth. While collaboration generally suggests an “equal” involvementbetween the school-based clinician and child, this is not thecase in actual treatment. In fact, a school-based clinicianwill need to meet a specific student at his or her level (basedon age, motivation, and so on).

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In addition to previously mentioned factors, a student’smotivation and attitude have an impact on the collaborativerelationship and subsequent treatment outcomes. A studentreferred by his teacher for losing his temper and displayinganger outbursts is not likely to be receptive of a directiveapproach that mimics existing interactions with others.However, using his motivation (e.g., getting his teacher offhis back) may increase his adherence to interventions aswell as foster a stronger partnership. Simple tasks such asfrequent and brief summations throughout the session mayfurther assist in keeping focus while establishing and main-taining the collaborative relationship. Summations commu-nicate to the student that the clinician follows andunderstands what he or she is saying, though also obtainingfeedback to clarify information or misunderstandings. Thistype of interaction empowers the student to confront the clinician appropriately, which is atypical with most school-based interactions.

RATIONALE FOR CBT IN SCHOOLS

While psychological counseling services may be difficult to “fit” into the educational culture, the structureand framework of CBT parallels other educational servicesmaking it more easily accepted among educators. The time-limited, present-oriented, and solution-focused aspects ofCBT (Reinecke et al., 2003) are consistent with the educa-tional environment, where both time and resources are often limited. The solution-focused and present-oriented approachof CBT is also appealing in education, as it addresses the student’s issues without overly relying on diagnosing aspecific pathology. Basic CBT components such as psy-choeducation, skill building, between-session work (i.e.,“homework”), agenda setting, and progress monitoring areactivities congruent with most activities already existing inschool settings. Thus, while these components assist in pro-viding effective counseling services, they also strengthen thelink between psychological counseling and other servicesprovided in schools.

The combination of teacher interaction, peer influence,and personal performance efforts and outcomes providesschool-based clinicians a unique environment to gain insightinto a student’s perceptions, to which many outside cliniciansdo not have access. The school setting is essentially a “natu-ral laboratory” to observe interpersonal dynamics and togather data about the problems facing students. Additionally,it provides a natural and “safe” setting for students to “exper-iment” with applying the new skills learned through CBT.

In addition to the parallels between CBT and other school activities, the provision of school-based CBTinterventions further affords opportunities to students and

families who may otherwise not have the resources toreceive services outside of school. Despite the number ofchildren and adolescents in need of psychological services,many youngsters never obtain the services needed whileothers frequently cancel and eventually drop out of counsel-ing services (Kazdin, Holland, & Crowley, 1997). Kazdin et al. (1997) identified several characteristics that predicttreatment dropout including socioeconomic status, high levels of stress and discord, and difficult life circumstances(e.g., single-parent families). Rendering school-based coun-seling services, such as CBT, may minimize the impactsome of these barriers (e.g., transportation, time) have onchildren and families receiving effective services.

EMPIRICAL SUPPORT FOR CBT WITH CHILDREN

“Evidence-based practice” has become a commoncatchphrase within the educational and mental health pro-fessions. However, most of the literature on the use of CBTwith children and adolescents has involved clinical popula-tions rather than addressing the use of CBT in schools. Theliterature has shown CBT to be effective in the treatment ofa number of childhood difficulties including depression,anxiety, and disruptive behaviors (see reviews in Kazdin &Weisz, 1998; Weisz & Jensen, 1999). There continues, how-ever, to be a need for further investigation into a number ofchildhood difficulties including eating disorders, posttrau-matic stress disorder, bipolar disorder, substance abuse,school-related problems, and other health conditions (e.g.,pain management, obesity). Additionally, further investiga-tion is necessary regarding the provision of CBT in alterna-tive settings such as a school system.

CAUTIONS OF CBT WITH CHILDREN

Notwithstanding the positives of providing psycholog-ical counseling services in school, school-based cliniciansmust also consider a number of challenges and barriers. Inthe view of many educators, the primary purpose of schoolfor children is to receive academic instruction. As teachersand other staff members provide valuable services to meetthis goal, school-based clinicians must be mindful of thetime constraints already facing these individuals. The pres-ence of educational legislation (e.g., No Child Left Behind)has restricted the views of some educators and minimizedthe focus on students’ emotional and behavioral needs.However, given the overwhelming and lasting effects thatcan accompany emotional and behavioral difficulties inchildren, including academic problems, there is a need forschool-based clinicians to educate school systems regarding

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the necessity to meet the psychosocial needs of children andto enhance positive academic and behavioral outcomes forstudent success. School-based professionals must accom-plish this, however, while respecting the challenges alreadyfacing educators. For children whose emotional and behav-ioral issues are interfering with academic functioning,psychological counseling services may assume a prominentrole in the child’s educational program. Scheduling weeklyappointments is another challenge facing school-based clinicians. Coordination with various members of the stu-dent’s educational team is essential in providing efficientand effective services.

The collaborative relationship between clinicians andstudents presents another obstacle. In the school environ-ment, there are numerous occasions for casual interactionswith the student (e.g., passing “hellos” in the hallway).While this may help facilitate the collaborative relationshipwith the child, it may also test the school-based clinician’sability to maintain appropriate boundaries.

The protection of the child’s confidentiality furtherposes a conflict when providing psychological counselingservices in schools. The issues of scheduling session times,the referral process itself, and the request for communica-tion between referring teachers, parents, and school-basedclinicians regarding the student’s needs and progress maycompromise traditional confidentiality standards.

School-based clinicians providing CBT services withinthe school system should consider and address each of theaforementioned issues from the onset of treatment. Having astructure and plan on handling such situations will preventundue concerns over time. Those providing services in aschool system must fully understand the state laws andethics of their own profession and those of the educationalsystem.

FUTURE DIRECTIONS FOR CBT IN SCHOOLS

The CBT model is ideal for delivering effective, short-term, and flexible psychological counseling services withinthe school environment. It complements the already existingstructure and framework in the school environment whilefocusing on the cognitive, behavioral, affective, and socialfactors inherent in many difficulties seen in youth. Despitethe already existing work in CBT with children and youth,several areas must be addressed before full advancements inthe use of CBT in school will occur.

First, as noted above, research is needed to evaluate theefficacy and effectiveness of CBT with a wider variety ofchild and adolescent problems. Additionally, its applicationwithin the school setting may be contingent on studiesfocusing on nonpathological problems seen in educational

settings such as academic motivation, test anxiety, studentunderachievement, home–school collaboration, and crisisintervention, to name a few.

Second, while there is definitely a need for school-based psychological counseling services in schools, there isa question whether school-based professionals have thetraining and education necessary to provide such services ina competent manner. This is a challenge facing universitytraining facilities as well as those organizations providingcontinuing professional development for school-based prac-titioners. Effectively using CBT with children and adoles-cents, as well as any other populations, requires appropriatetraining and supervision beyond attending a workshop orreading an article.

Finally, providing CBT within a school setting willrequire an understanding of the school culture. Traditionally,psychological counseling services in many schools haveinvolved primarily behavioral interventions. The movetoward a model integrating cognitive and behavioral princi-ples will require, to some extent, a paradigm shift in educa-tors’ views of these services. This may involve not only achange in the orientation of services but also an expandedview of the continuum of psychological counseling servicesthat could be available to students including consultation,individual and group counseling, classwide interventions,and schoolwide mental health programs.

See also: Children—behavior therapy, Treatment of children

REFERENCES

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy for depression. New York: Guilford Press.

Coie, J. D., Watt, J. F., West, S. G., Hawkins, J. D., Asarnow, J. R.,Markman, H. J., Ramey, S. L., Shure, M. B., & Long, B. (1993). Thescience of prevention: A conceptual framework and some direction for a national research program. American Psychologist, 48,1013–1022.

Fagan, T. K. (2000). Practicing school psychology: A turn-of-the centuryperspective. American Psychologist, 55, 754–757.

Friedberg, R. D., & McClure, J. M. (2002). Clinical practice of cognitivetherapy with children and adolescents: The nuts and bolts. New York:Guilford Press.

Kazdin, A. E., Holland, L. H., & Crowley, M. (1997). Family experiencesof barriers to treatment and premature termination from child therapy. Journal of Consulting and Clinical Psychology, 65, 453–463.

Kazdin, A. E., & Weisz, J. R. (1998). Identifying and developing empiri-cally supported child and adolescent treatments. Journal of Consultingand Clinical Psychology, 66, 19–36.

Reinecke, M. A., Dattilio, F. M., & Freeman, A. (Eds.). (2003). Cognitivetherapy with children and adolescents: A casebook for clinical practice (2nd ed.). New York: Guilford Press.

Rutter, M. (1985). Resilience in the face of adversity: Protective factors andresistance to psychiatric disorders. British Journal of Psychiatry, 147,598–611.

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Shirk, S. R., & Karver, M. (2003). Prediction of treatment outcome from relationship variable in child and adolescent therapy: A meta-analytic review. Journal of Consulting and Clinical Psychology, 71,452–464.

U.S. Public Health Service. (2000). Report of the Surgeon General’sConference on Children’s Mental Health: A National Action Agenda.Washington, DC: U.S. Department of Health and Human Services.

Weisz, J. R., & Jensen, P. S. (1999). Efficacy and effectiveness of child andadolescent psychotherapy and pharmacotherapy. Mental HealthServices Research, 1, 125–157.

Severe OCD

Jonathan D. Huppert and Edna B. FoaKeywords: OCD, obsessions, compulsions, exposure, insight

Obsessive–compulsive disorder (OCD) is an anxiety disor-der characterized by both obsessions and compulsions.Obsessions are intrusive thoughts, images, or impulses thatcome into one’s mind for no apparent reason, are unwanted,and are distressing. Compulsions are characterized byrepeated behaviors or thoughts that serve to decrease theobsessional distress. To meet criteria for OCD, obsessionsand/or compulsions must take up at least 1 hour a day andbe distressing or interfere with the patient’s functioning inlife. Severe OCD is characterized by substantial frequencyof obsessions and compulsions (from 4 hours a day to everyminute of the patient’s waking hours), substantial impair-ment from the OCD (usually in all domains of life includingsocial, work, and family), poor insight into the symptoms(or how realistic the patient thinks their fears are), and/orsubstantial comorbidity which complicates the presentationof the symptoms (e.g., posttraumatic stress disorder orschizophrenia).

Severity of symptoms, as characterized by high frequency of symptoms or significant distress, is oftenmeasured by the Yale–Brown Obsessive Compulsive Scale(Y-BOCS; Goodman et al., 1989), and can also be measuredthrough self-report measures such as the Obsessive–Compulsive Inventory-Revised (OCI-R; Foa et al., 2002).Either of these scales may not capture all severe cases; how-ever, administered together, the large majority of severecases should be detected.

Poor insight, also known as overvalued ideation (OVI;Kozak & Foa, 1994), is also a predictor of worse outcomefor CBT. OVI is assessed through the Y-BOCS, but also canbe assessed using a number of measures including the

Brown Assessment of Beliefs Scale (BABS; Eisen et al.,1998). The main characteristic of OVI is that the patient isconvinced that his or her obsessional fears are realistic. A classic example is a patient who believes that touchingdoorknobs really can lead to contracting AIDS. Such apatient will often state that he or she is just extremely care-ful. For patients with extreme OVI of this type, most peoplein the world are viewed as careless, and they are either luckythat they have not contracted AIDS or may have it and notbe aware because they have not had an AIDS test. Mostpatients with OVI will acknowledge that other people thinkdifferently, but attribute this difference to the idea that others are wrong. Patients with severe OVI may appear delu-sional, but they present differently than patients who have aco-occurring psychotic disorder such as schizophrenia.

Comorbid disorders may exacerbate OCD symptomsand make it harder to treat. There are few data on the treat-ment of OCD and comorbid schizophrenia with CBT, butour clinical experience suggests that most patients withschizophrenia who have co-occurring OCD do not benefitfrom exposure and ritual prevention. Recent studies havesuggested that patients with severe depression (i.e., the top10% of depressed patients; Abramowitz, Franklin, Foa,Gordon, & Kozak, 2000) or PTSD (Gershuny, Baer, Jenike,Minichiello, & Wilhelm, 2002) may respond less well toCBT. Depression has been found to interfere with habitua-tion in patients with OCD, and may also interfere withcognitive changes. In such cases, treatment of the comorbiddisorder either prior to conducting CBT for OCD or simul-taneously may be indicated.

Standard CBT for OCD involves the use of exposureand response (ritual) prevention with cognitive processing(Foa & Wilson, 2001). The basic concept underlying thetreatment is that patients with OCD attempt to avoid orescape their obsessional fears through a number of strategiesincluding thought suppression, mental and behavioral compulsions, safety behaviors, and avoidance. All of theavoidance behaviors function to decrease or avoid anxiety inthe short run, but perpetuate the vicious cycle of anxiety in the long run. Exposure encourages the patient to confrontthe fears, and ritual prevention serves to prevent the patientfrom engaging in behaviors that are intended to decreaseanxiety and/or to prevent feared consequences. Through thistreatment the patients learn that the feared consequences donot occur and their anxiety decreases even when confrontingfears and not ritualizing. This new information creates newassociations in the fear structure of the patient whichbecome predominant through repeated exposure, renderingthe pretreatment fear structure less likely to be activated(Foa & McNally, 1996), and thereby decreasing symptoms.

There are two types of exposure: in vivo and imaginal.In vivo exposure is direct confrontation with feared stimuli

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