The brief cognitive-behavioral COPE intervention for depressed adolescents: outcomes and feasibility of delivery in 30-minute outpatient visits.

Abstract

Despite a U.S. prevalence of 9%, less than 25% of depressed adolescents receive treatment because of time constraints in clinical practice and lack of mental health providers available to deliver it.
To assess the feasibility and effects of a brief manualized seven-session cognitive-behavioral skills building intervention entitled COPE (Creating Opportunities for Personal Empowerment) delivered to 15 depressed adolescents in routine 30-minute mental health medication management outpatient visits.
A preexperimental one group pre- and posttest design was used.
Adolescents reported significant decreases in depression, anxiety, anger, and destructive behavior as well as increases in self-concept and personal beliefs about managing negative emotions. Evaluations indicated that COPE was a positive experience for teens and parents.
COPE is a promising brief cognitive-behavior therapy-based intervention that can be delivered within 30-minute individual outpatient visits. With this intervention, advanced practice nurses can work with practice time limitations and still provide evidence-based treatment for depressed teens.

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COPE for Depressed and Anxious Teens: A Brief
Cognitive-Behavioral Skills Building Intervention to
Increase Access to Timely, Evidence-Based Treatment
Pamela Lusk, DNP, RN, PMHNP-BC, and
Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FAAN, FNAP
Pamela Lusk, DNP, RN, PMHNP-BC, is Associate Professor, Director, Post-Masters to DNP Program, Brandman University, Irvine, CA.
Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FAAN, FNAP, is Associate Vice President for Health Promotion, University Chief Wellness Officer,
Dean and Professor, College of Nursing, and Professor of Pediatrics and Psychiatry, College of Medicine, The Ohio State University, Columbus, OH,
USA.
Search terms:
Adolescent, anxiety, brief therapy,
cognitive-behavioral therapy, COPE
intervention, depression, evidence-based
practice
Author contact:
lusk@brandman.edu, with a copy to the Editor:
kathleen_r_delaney@rush.edu
Note: This article was supported, in part, by the
NIH/National Institute of Nursing Research
(R01#1R01NR012171); PI: Bernadette Mazurek
Melnyk.
doi: 10.1111/jcap.12017
TOPIC: Evidence-based cognitive-behavioral therapy skills building interven-
tion—Creating Opportunities for Personal Empowerment (COPE)—for depressed
andanxiousteensinbrief 30 minoutpatientvisits.
PURPOSE: BasedonCOPEtrainingworkshops,thisarticleprovidesanoverviewof
theCOPEprogram,itsdevelopment,theoreticalfoundation,contentofthesessions,
andlessonslearnedforbestdeliveryof COPEtoindividualsandgroupsinpsychiat-
ricsettings,primarycaresettings,andschools.
SOURCES: Publishedliteratureandclinicalexamples.
CONCLUSION: WiththeCOPEprogram,theadvancedpracticenurseinbusyout-
patient practice can provide timely,evidence-based therapy for adolescents and use
thefullextentof his/heradvancedpracticenursingknowledgeandskills.
Adolescents are not receiving the evidence-based mental
health services they need (National Research Council [NRC]
& Institute of Medicine [IOM], 2009). A 2010 nationally
representative sample of U.S. adolescents (National Com-
orbidity Survey, Adolescent Supplement) found that
approximately one in every four to five youth meets the cri-
teria for a mental disorder that will impair their functioning
across their lifetime (Merikangas et al., 2010). In adolescents
ages 13–18 years, the prevalence of mental disorders with
distress and/or severe impairment is 22% (11% with mood
disorders, 8.3% with anxiety disorders, and 9.6% with
behavior disorders) (Merikangas et al., 2010). Forty percent
of teens who meet the criteria for one disorder have comor-
bidity, which meets the criteria for another class of lifetime
disorder (Merikangas et al., 2010). Unfortunately, these
young people are suffering, but fewer than 25% are getting
the treatment they need (Foy,2010).Because many common
mental disorders first emerge in childhood/adolescence and
are now being considered as neurodevelopmental disorders,
prevention, early intervention, and timely evidence-based
treatment are critical (March,2009; Merikangas et al.,2010).
Advanced Practice Psychiatric Nurses (APPN), along with
their family nurse practitioner and pediatric nurse practitio-
ner (PNP) colleagues, strive to provide excellent evidence-
based treatment for the many depressed and anxious teens
they see in their practice settings. It is a challenge to find
developmentally appropriate, evidence-based interventions
that are portable and easily used by clinicians who have the
time constraints, productivity requirements, and full sched-
ules characteristic of practice settings today (Foy, 2010).
Interventions that incorporate the principles of sound,
empiricallytestedpsychotherapy,
behavioral therapy (CBT), into manuals or formats that are
well accepted by the teens and their parents are needed.
There are time-tested manualized CBT-based programs
available for anxious and depressed teens: Lewinsohn and
Clarke (Adolescent Coping with Depression Course,
CWD-A; Lewinsohn, Clarke, Hops, & Andrews, 1990);
Coping with Stress Course, CWS (Clarke et al., 1995; Clark,
Rohde, Lewinsohn, Hops, & Seely, 1999); Steady Project
(Clarke,Debar,Ludman,Asarnow,& Jaycox,2002),but these
are primarily structured for the 50 min individual therapy
hour characteristic of the traditional psychotherapy model
(Rhode, Feeny, & Robins, 2005; Whisman, 2008). In busy
such as cognitive-
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clinics today, it is the 20-30 min medication management
visit that frames our practice and challenges us to find new
models of effective, evidence-based treatment.
The high prevalence of depression and anxiety in young
people, in combination with current estimates that the
national economic burden of mental disorders on the well-
being of American youth and their families approaches a
quarter of a trillion dollars, underscores the importance of
actively addressing emerging mental health needs of Ameri-
can youth (Merikangas et al.,2010).The U.S.Preventive Ser-
vices Task Force (USPSTF) has recommended that all young
people ages 12–18 years old be routinely screened for major
depressive disorder in primary care (USPSTF, 2009). The
USPSTFrecommendationaddsthecaveat,“whensystemsare
inplacetoensure:accuratediagnosis,cognitive-behavioralor
interpersonal psychotherapy and follow up”(USPSTF, 2009,
p. 1,223). Screening for elevated levels of depression and
anxiety can be routinely conducted in clinical settings with
such instruments such as the PHQ-9 modified (Patient
Health Questionnaire 9-Modified for Teens) for depression
and the SCARED scale (Screen for Childhood Anxiety
Related Emotional Disorders) for anxiety, which are both in
the public domain and can be used without a fee. Anxiety is
oftenco-morbidwithdepression.APPNshavetheknowledge
and skills to screen, diagnose, perform psychotherapy, and
provide follow-up care for adolescents and are in ideal posi-
tions to evaluate and provide treatment for teens needing
mental health care (Wheeler, 2008). Further, primary care
advanced practice nurses also can be instrumental in screen-
ing, identifying, and providing evidence-based care for ado-
lescents with mild to moderate depressive and anxiety
symptoms.
There is strong evidence to support CBT as an effective
first-line treatment for depressed and anxious teens (March,
2009; Watanabe, Hunot, Omori, Churchill, & Farukawa,
2007;Williams,O’Connor,Eder,&Whitlock,2009).Thereisa
needforevidence-basedCBTinterventionsthatareportable,
havedemonstratedeaseof use,andcanbeusedinavarietyof
settings where adolescents are routinely seen.Teens are often
placed on long waiting lists for specialty psychiatric care,
whentheyneedaccesstotimely,active,evidence-basedtreat-
ment (Jaycox et al., 2006; Weersing & Weisz, 2002). One
cognitive-behavioral skills building (CBSB) program for
teensthatcanbepresentedinthe20–30 minvisitscharacter-
istic for current advanced practice was developed by Melnyk
(2003) and is named COPE, an acronym for “Creating
Opportunities for Personal Empowerment.” COPE is a
manualized 7-session,brief,
behavioralskillsbuildingtherapythathasbeendeliveredina
variety of settings, including outpatient mental health
centers, primary care clinics, and schools. The developmen-
tally based intervention is clearly written with teen appropri-
ate illustrations, and has been well accepted by adolescents
time-limitedcognitive-
from 12 to 18 years of age and their parents (Lusk & Melnyk,
2011a). Measured outcomes pre- and post-COPE indicate
this CBT-based intervention decreases anxiety and depres-
sion in teens, and improves self-concept (Lusk & Melnyk,
2011a). Because the COPE sessions can be delivered within
20–30 min visits, including the usual medication manage-
ment visits,the advanced practice NP can practice within the
fullscopeof theadvancedroleandprovidetherapy(Wheeler,
2008)aswellasmedicationmanagementandfollow-up.
Evidence-basedpsychotherapycanbepartofstandardcare
for teens seen in practices where COPE is offered. In many
clinicalsettings,insuranceandMedicaidreimbursetheAPPN
for the COPE sessions (CPT Code 90805) as individual psy-
chotherapy and evaluation and management, which is often
reimbursed at a slightly higher rate than (CPT 90862) medi-
cation monitoring. The COPE sessions clearly meet the CPT
code90805criteriaofface-to-facetherapyformorethan50%
of the visit (Schmidt, Yowell, & Jaffe, 2004), with time spent
assessing the teen for need for medication,response to treat-
ment (medication if applicable), vital signs (pulse, blood
pressure), or other evaluation of health status and ongoing
managementof healthconcerns.
Development of the COPE Intervention
COPE was developed by Bernadette Mazurek Melnyk,a PNP
andpsychiatric/mentalhealthNP,firstasahealthpromotion/
educational and skills building intervention for adolescents
on an inpatient psychiatry unit in order to enhance their
abilitytocopeanddealwithstressfulchallengesandengagein
healthy behaviors. The first rendition of the COPE program
was a 15-session CBSB healthy lifestyle intervention,entitled
the COPE Healthy Lifestyles TEEN (Thinking, Emotions,
Exercise, and Nutrition) Program, and tested in 60–75 min
sessions with groups of teens in after-school and school-
based classroom programs. The first 7 sessions of the
15-session program contain the CBT-based educational
contentwithactivitiesthataredeliveredinthebriefCOPEfor
teen depression and anxiety (Table 1). The other eight ses-
sions of the COPE TEEN program contain education and
skills building activities focused on nutrition, physical activ-
ity, and healthy lifestyle behavior change. Over a period of
years delivering the COPE program, assessing adolescent
responses to the program, and incorporating their feedback
and preferences, Melnyk fine-tuned the sessions to be devel-
opmentally appropriate and engaging for the teens.Findings
frompilotstudiestestingthe15-sessionCOPEprogramwith
high school teens indicate (a) decreases in depressive and
anxiety symptoms, (b) increases in self-esteem, healthy life-
style beliefs, healthy lifestyle behaviors, and physical activity,
and (c) higher academic retention rates (Melnyk et al., 2007,
2009). The 15-session COPE Healthy Lifestyle Program is
now currently being tested in a randomized controlled
COPE for Depressed and Anxious Teens
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trial with 779 predominantly Hispanic teens in 11 Phoenix
area high schools with funding from the National Insti-
tutes of Health/National Institute of Nursing Research
(1R01NR012171; Melnyk, principal investigator). In this
trial, the 15 COPE sessions are integrated into the students’
health course and taught by the teachers who were trained to
deliver the program. High schools in other geographic areas
withruralpopulationshaveincorporatedtheCOPEprogram
into the 9th-grade health course as well (Ritchie & McCrone,
2012). COPE also has been delivered as part of after-school
group intervention programs in an urban high school and
suburban high school with adolescent participants who were
overweight (Melnyk et al., 2007). The 7-session program as
discussed here (using Melnyk’s original COPE manual
content) has been presented in a brief 20–30 min individual
therapyformatto12-to18-year-olddepressedadolescentsin
a rural Southwestern U.S. community mental health center
(Lusk & Melnyk, 2011a) and as the standard intervention
(individual sessions) at an urban primary care clinic for
anxious and depressed teens (Lusk & Melnyk,2011b).Exclu-
sions for participating in the COPE program have been teens
with developmental delays/low cognitive functioning and
youth with active psychosis,as it is thought that the cognitive
approach of COPE is not the best treatment approach for
theseteens.TheCOPE7-sessionindividualtreatmentformat
iscurrentlybeingofferedtoawiderangeof teenswithmental
healthandphysicalconcernsinpediatricpractices,inner-city
outpatient mental health clinics, and federally qualified
health centers in a variety of geographical areas. COPE par-
ticipantshaverepresentedethnicallydiversegroups,andages
have ranged from 12-year-old middle school students to
18-year-old high school seniors. In the authors’ previous
COPE study (Lusk & Melnyk, 2011a), teens who had com-
pleted the COPE 7-session program and their parents filled
out post-COPE questionnaires. They reported that the ses-
sions were interesting and covered topics of interest. All
reported that, in the 20–30 min sessions, they were able to
coverthesession’smainidea(content),reviewthehomework
practice assignments,and still have time to bring up any par-
ticular concerns they had at that time. Outcomes
monitoring—by administration of the Beck Youth Invento-
ries (BYI)—for depression, anxiety, and self-concept indi-
cated a significant decrease in depressive and anxiety
symptoms,andanincreaseinself-conceptpre-topost-COPE
completionoftheBYIquestionnaires(statisticalanalysispre-
viously published, Lusk & Melnyk, 2011a). When the young
people who have completed the program provide feedback
later,boththeyoungteensandthe18-year-oldsallreportthat
COPE addressed their “presenting problem” and provided
them with new ways of thinking, and new coping skills that
they continue to use in their daily lives. They have provided
specific examples of improvement in their school,social,and
family relationships, “I learned about how to cope with
anxiety,becausebeforeIdidn’treallyknowhowtodealwithit
in the right ways.”“It made me more confident in myself. I
tried out for the school choir,and made it.I have made some
goodfriendsthere.”“Ithelpedmetakeasecondtothinkabout
things before I react. . . . I am less mean to people.”They can
alsoidentifyspecificCOPEsessionskills,suchasdeepbreath-
ing, imagery, or changing a negative thought to a positive
thought, which they used to handle difficult situations that
they experienced, “I was in a car, and there was a drive by
shooting,andIjustdidthedeepbreathinglikewepracticed.I
was scared,but that got me through it.”From a foster parent,
“She will repeat positive statements about herself, instead of
the negative ones she repeated frequently when she was
placedinmyhome.”Theyexpressthattheyfeelproudoftheir
increased ability to self-regulate their responses to stressful
events (triggers) and deal with the problematic situations/
triggers in healthier ways, “I’m bringing out my anger in a
healthy way, instead of punching walls and stuff like that.”
From parents,“I think it has given him ideas on dealing with
angertriggersthatmaynothaveoccurredtohimbefore.”“He
seems to try harder, like when he gets mad; I’ve seen him
trying to stop.” When asked what they remembered most
about the COPE program,the nearly unanimous response is:
the thinking, feeling, behaving triangle. Figure 1,“I remem-
ber the triangle that shows you how you think is how you
feel and behave . . . because I could see when that actually
happened.”
Table 1. COPE Session Topics
IntroductionCOPE programs and goals
Session 1
Session 2
Session 3
Session 4
Session 5
Session 6
Thinking, feeling, behaving triangle
Self-esteem and positive thinking, self-talk
Goal setting and problem-solving
Stress and coping
Emotional and behavioral regulation
Effective communication, personality, and
communication styles
Barriers to goal progression and overcoming barriers
Energy balance; ways to increase physical activity
and benefits
Heart rate; stretching
Food groups and a healthy body; stoplight diet
(red, yellow, green)
Nutrients to build a healthy body: reading labels,
media and advertising effects on food choices
Portion sizes; “supersize,” influences of feelings on
eating
Social eating: strategies for eating during parties,
holidays, and vacations
Snacks and eating out
Integrate skills and knowledge to develop a healthy
lifestyle plan
Putting it all together; review of course content
Session 7
Session 8
Session 9
Session 10
Session 11
Session 12
Session 13
Session 14
Session 15
COPE, Creating Opportunities for Personal Empowerment.
COPE for Depressed and Anxious Teens
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COPE as an Evidence-Based Intervention
Evidence to support CBT-based interventions as effective
first-line treatment for depressed and anxious teens includes
systematic reviews, and several meta-analyses, the strongest
level of evidence (Klein, Jacobs, & Reinecke, 2007; McCarty
& Weisz, 2007; Weisz, 2007; Watanabe et al., 2007; Williams
et al.,2009).Themeta-analysisbyMcCartyandWeisz(2007)
identified the components of psychotherapy for depressed
teens,present in the most effective therapy programs.The 12
components of effective therapy for depressed adolescents
according to the Weisz and McCarty review of studies are:
achieving measurable goals/competency, adolescent psycho-
education,self-monitoring,relationship skills/social interac-
tion, communication training, cognitive restructuring,
problem-solving, behavioral activation, relaxation, emo-
tional regulation, parent psycho-education, and improving
the parent–child relationship (McCarty & Weisz, 2007). The
COPE program includes all of these 12 components of
effectiveCBTfordepressedteens.
Theoretical Framework
Cognitive behavior theory largely guided the development
of the COPE Healthy Lifestyles TEEN Intervention program
(Beck, Rush, Shaw, & Emery, 1979; Melnyk et al., 2007). In
cognitive behavior theory, it is contended that how an indi-
vidual thinks affects his or her feelings or emotions and
behaviors (Beck, 2011), otherwise known as the “thinking,
feeling, behaving” triangle, Figure 1 (Melnyk, 2003; Melnyk
et al., 2007). The cognitive theory of depression and psycho-
therapy as developed by Beck et al. (1979) focuses on identi-
fying and correcting “cognitive distortions” or automatic
negative thoughts. From this theoretic perspective, a person
who has negative thoughts or beliefs is more likely to have
negative emotions (e.g., anxiety and depression) and display
negative behaviors (e.g., risk taking and poor school perfor-
mance). Active components of CBT include reducing
negative thoughts (cognitive restructuring), increasing plea-
surable activities (behavioral activation), and improving
assertiveness and problem-solving skills (homework assign-
ments). Melnyk found that incorporating skills building
activities, and reinforcing the practice of these skills were a
critical element in the teen’s improvement. Lewinsohn and
Clarke had stressed with their programs, Adolescent Coping
with Depression Course, CWD-A (Lewinsohn et al., 1990),
and Coping with Stress Course, CWS (Clarke et al., 1995),
that lack of positive reinforcement from pleasurable activi-
ties leads to negative thought patterns. Behavior theory sug-
gests that individuals are depressed/anxious not only
because of lack of positive reinforcement but also lack of
skills to elicit positive reinforcement from others or to ter-
minate negative reactions from others. In COPE sessions,
these concepts are emphasized and the teen identifies activi-
ties (especially physical activities) that are pleasurable for
them, and they are encouraged to increase time spent with
those. Self-regulation of behavior is a key coping strategy
reinforced throughout the program. COPE is a CBSB
program that actively promotes mastery of adolescent devel-
opmental tasks by each participant. The message to the teen
is“You can do it.You can develop skills to COPE with what-
ever you are facing.By monitoring your thoughts and beliefs
and changing negative thinking to positive thoughts, you
can change/regulate your subsequent feelings and behaviors
and feel better.” The thinking, feeling, behaving model of
CBT “resonates beautifully with recent developments in
cognitive,affective and social neuroscience”(March,2009,p.
173), and is health enhancing from a neurodevelopmental
view of emerging mental disorders.We know that in adoles-
cence, there is pruning and growth of new neuronal connec-
tions. When the young person learns to think and practices
coping in positive ways, myelin lays down new tracks. Psy-
chotherapy interventions during the period of adolescence
provide a prime opportunity to establish new healthy neu-
ronal connections and the practice and reinforcement of
skills learned in CBT programs such as COPE likely modify
developmental trajectories in a positive way (March, 2009;
Merikangas et al., 2010).
Delivery of the COPE Program
In presenting COPE sessions weekly, lessons have been
learned and delivery protocols have been refined. The “how
to”deliver COPE sessions are presented here using Beck’s 10
principles of CBT as the organizing framework (Beck,
2011).
Figure 1. The Thinking, Feeling, Behaving Triangle
(Reproduced with permission, Melnyk, 2003)
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#1 Cognitive Therapy Is Based on an Ever-Evolving
Formulation of the Patient and His/Her Problems in
Cognitive Terms
Priortoinitiationof anyCOPEsessions,thenewpatientado-
lescent and parent meet with theAPPN for a couple of visits.
The first visit is an initial psychiatric evaluation (including
chief complaint, history of presenting problem, family
history, medical problems, environmental stressors, mental
statusexam).FollowingtheUSPSTFrecommendations,ado-
lescents 12–18 years are screened using the Beck Youth
Depression Inventory, Beck Youth Anxiety Inventory, and
BeckYouthSelf-ConceptInventory—self-reportinstruments
that generally take about 10–15 min to fill out (Beck,Beck &
Jolly,2005;Steer,Kumar,Ranieri,&Beck,1998).Teensalsofill
out a personal beliefs scale developed by Melnyk to assess
their perceived beliefs in influencing their own health
(Melnyk et al., 2009). The teens’ identification of personal
strengths, accomplishments, and goals is a very important
part of this initial diagnostic formulation. At the conclusion
of the initial evaluation, recommendations are shared with
the teens and parents/or caregivers. The family is invited to
share their previous experiences with mental health care,
their personal preferences and values,and these are incorpo-
rated into the treatment plan.In evidence-based practice,(a)
the best evidence and (b) the personal preferences of the
patient and family, as well as (c) the clinical expertise of
the provider, are all essential components of establishing
the treatment plan (Melnyk & Fineout-Overholt, 2011).
APPNs have the education and expertise to provide the best
evidence-basedinterventionsfordepressedandanxiousado-
lescentsasagreeduponwiththeteensandfamily.
ConfidentialityandSafety
Issues about confidentiality and times when the APPN need
to involve others for the safety of the teens are directly stated
at this first appointment and teens/parents are asked to voice
their understanding of these basic “rules” of treatment. If at
any time during the COPE program, the teens or family
present in crisis, the crisis situation (suicidal ideation or
homicidal ideation) is addressed as a priority. The COPE
processcancontinueoncethepriorityissueisresolved.
#2 Cognitive Therapy Requires a Sound
Therapeutic Alliance
After the initial evaluation, another visit is scheduled, and at
this second less-structured visit, the APPN again reviews the
treatmentoptionsfortheteenandallowstimeforlisteningto
teen and parents’ questions and concerns. This visit sets the
stageforthebeginningtherapeuticrelationship.Itiscritically
importantthattheteensperceivethatthetherapistisinvested
in the youth and parent. The therapist has as primary goals:
instilling hope, providing information that depression and
anxiety are treatable medical conditions, and developing
rapportandcognitivelyconnectingwiththeteens.
#3 CBT Emphasizes Collaboration and
Active Participation
If teens are depressed, anxious, or both, the family is told
abouttheoptionsofcognitive-basedtherapy,medications,or
a combination of the two. The family is advised that there is
strong evidence to support CBT as the first-line treatment in
mild and moderate depression in adolescents (Birmaher &
Brent, 2007; Cheung et al., 2007; Van Voorhees, Smith, &
Ewigmen,2008).Atourclinic,theCOPEprogramisthestan-
dardtreatmentfordepression/anxietyinteens.Theverybasic
premise of CBT is explained using the COPE manual Think-
ing, Feeling, Behaving diagram, Figure 1. In addition, some
written materials (i.e.,the article byVanVoorhees et al.,2008
from the Journal of Family Practice) are provided for them to
take home and review. In our practice, we often find that
families and/or teens feel quite strongly that they want a
treatment/interventionthatdoesnotincludestartingamedi-
cation. It is at this point that we show them the COPE
for Teens manual and allow time for them to look through
it. They are instructed to make an appointment for a
follow-up visit if they want to begin COPE. If they agree
to have outcomes measured long term as part of our
study,those consents and questionnaires are filled out at this
time. Teens are given their own COPE manual with their
name on it. Parents are encouraged to become an active
participant in the program, attend sessions with their teens,
and review the homework for the weekly sessions with their
teens.
#4 Cognitive Therapy Is Goal Oriented and
Problem Focused
From the initial visit, the teens identify the problems that
they wish to address, and very specific goals are established
to work together toward solving their identified problems.
We frame their identified chief concerns in CBT language—
using the thinking, feeling, behaving triangle. The COPE
sessions address usual developmental concerns of adoles-
cents. Within the context of the session content, teens are
prompted to bring up their version of developmentally
based dilemmas, such as expressing emotions in ways that
get your feelings expressed without hurting others or your-
self, setting goals, the steps of problem-solving, etc. In the
COPE program, there is always a strong emphasis on identi-
fying the strengths and special abilities of the teens. Positive
self-talk is one of the earliest skills introduced. This skill is
reinforced throughout the COPE program. This emphasis
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on the teens’ individual strengths, abilities, and dreams
versus the teens’ problem behaviors has proven to be an
important element in improving parent/child relationships
over time.
#5 Cognitive Therapy Initially Emphasizes
the Present
This approach is very positively received by teens and their
parents. When the emphasis is on the present versus past
experiences,parents tend to feel less“blamed”for their teens’
difficulties. The COPE sessions identify current experiences,
andsetgoalsthataremeasurableandproactiveforaddressing
current concerns.The skills learned in relation to the present
areapplicabletopastandfuturestressfulsituations.
#6 Cognitive Therapy Is Educative, Aims to Teach
the Patient to Be His/Her Own Therapist, and
Emphasizes Relapse Prevention
The teen and the parent are taught the theory of CBT, the
background studies that have led to this being the best
evidence-basedinterventionfordepressedandanxiousteens,
(March et al., 2004) and why and how CBT works. They are
shown examples of functional magnetic resonance imaging
that now “prove” that psychotherapy changes the brain. We
review neurodevelopment in adolescents, and discuss that
this is a stage of development when new neuronal connec-
tions are rapidly being made, and how that growth in the
brain makes psychotherapy especially effective and health
promoting with 12- to 18-year-olds (and actually up to 25
years) (Dobbs, 2011; March, 2009). When families under-
stand why a therapy works and the rationale for the session
structure (homework, and skills practice), they are more
likely to follow through and complete the course of treat-
ment. Homework assignments provide an opportunity
betweensessions,fortheteenstoapplytheskillsandconcepts
totheireverydaylives.
#7 Cognitive Therapy Aims to Be Time
Limited (4–14 Sessions)
In keeping with the Beck approach of time-limited
therapy, COPE is generally 10 weekly visits (psychiatric
evaluation at first visit, establishment of alliance, and
answering questions at the second visit, then the 7-session
COPE, and a follow-up visit to complete post-COPE
surveys). With busy family schedules, an occasional week is
missed. Generally from initial appointment until comple-
tion of the post-COPE surveys is 12 weeks, with an oppor-
tunity to schedule “booster” sessions at 3 month intervals
post treatment.
#8 Cognitive Therapy Sessions Are Structured
The clear, predictable structure of COPE sessions reduces
anxiety in young people in our experience. Teens tell us they
havebeenveryuncomfortableattimeswithtraditionalcoun-
seling sessions where they felt pressure to come up with a
meaningful narrative account of their past week, and to pri-
oritize issues they need to address in the therapy session.The
structureof theCOPEsessionisalwaysthesame.Homework
from the last session is reviewed, and then the COPE session
content is covered word for word from the manual, and just
priortoendingthesession,thehomeworkassignmentforthe
session is reviewed and weekly goals are identified. The
manual’s clarity and straightforward approach makes it easy
to use for teens in brief sessions. To present a COPE session,
the clinician reads the content, word for word. This assures
thateachteenreceivesa“puredose”—thatis—allof theCBT
content,and then the teens can supply their own examples of
the situations, experiences, etc. described in the sessions.
Homework not only provides an opportunity for teens and
parents to share and practice new skills, but it also “extends
the session,”a clear benefit with a program delivered in brief
visits.
Table 2. Automatic Negative Thoughts as Classified in CBT (Beck, 2011)
Teen examples from COPE sessions ©
“If I don’t get all A’s then I am not keeping up with the smart kids and I am a failure.” “Less than an A is not acceptable.”
“If I get a B– on that test, I will get a B in the course, and I won’t have the grades I need to get into college, and I will end
up working at a bad job the rest of my life, no one will marry me and I’ll live life as a pathetic loner.”
“I’m an idiot.” “I’m a loser.” “I am stupid.” “I am slow.” “I’m ugly.”
“I know that group of girls thinks I am stupid, and awkward. I know they would never want to be seen with me.”
“I should never get angry.” “I should be able to give an oral report without feeling all nervous, I’m a junior.”
“I don’t care if I have an A in the course, this last assignment is 10 pages and I probably will mess it up so bad the teacher
won’t even accept it.”
“That school trip is scheduled for Washington DC, but what if the plane crashes, or what if no one will sit by me on the
tour bus, or what if the parents that chaperone are annoying?”
“I don’t know what cognitive behavior therapy is, but I am sure I’ll be an utter failure at COPE.”
All or nothing thinking
Catastrophizing
Labeling
Mind reading
Should’s
Ignoring evidence
Expecting the worst
Jumping to conclusions
CBT, cognitive-behavioral therapy; COPE, Creating Opportunities for Personal Empowerment.
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#9 Cognitive Therapy Teaches Patients to Identify,
Evaluate, and Respond to Their Dysfunctional
Thoughts and Beliefs
Parents and teens are taught that the principles of CBT apply
to everyone. There are difficult events and situations that
occur in our everyday lives and these“triggers”are often out
of our control; however, the good news is, the thoughts we
have(andthesubsequentfeelingsandbehaviors)canbeiden-
tified and changed. This is empowering; we can take control
of our responses to difficult events/situations.This,in Beck’s
terms, is positive reappraisal of our negative automatic
thoughts. Everyone has negative automatic thoughts,
thoughts that are so well practiced they are almost reflexive.
Wedevelopautomaticthoughtsfromourparenting,personal
experiences, peer relations, media messages, and popular
culture, Table 2. These are enduring views of ourselves,
people in our world, and the way the world works (J. Beck,
2011; A. Beck et al., 1979; Creed, Reisweber, & Beck, 2011).
Teens are taught to“catch,”or become attuned to when they
have a negative thought (younger teens can actually use a
catching motion), Table 3. Often it is a mood change or
Table 3. Cognitive Reappraisal With Teens
When my mood changes, and my emotions are going in a negative direction, and I feel body sensations like flutters in my gut, I can “catch” my
automatic negative thought by asking: (Beck, 2011; Creed et al., 2011)
“What was just going through my mind?” “What was my thought?”
COPE cognitive reappraisal process ©
In COPE sessions, we encourage the teens to be a detective, a lawyer/judge, a personal scientist.
Questions to ask about that negative automatic thought:
1. What is the evidence that the thought is true? Not true?
2. Is there an alternative explanation?
3. What is the effect of my believing this thought? On my feeling? On my behavior? (The teen labels the three circles with their thought,
emotion/feeling, behavior.)
Thinking – No one will like me at this new school. I am awkward and
not cool.
Feeling – lonely, anxious, dread
Behaving – keep my head down, sit away from others
4. What would I say to a friend if they had the same thought in this situation? What can I say to myself?
5. If this thought is true, then what? Is it helpful to dwell on this every hour, every day?
6. How can I change my thought, to think of this differently? In more positive terms? (They write/or state: negative thought, then possible new
thoughts about this situation/experience.)
7. If I think differently, how will I feel? Will I act or behave differently? (The teen writes out the new thought, emotion/feeling, actions next to the
thinking, and feeling, behaving circles).
Thinking – I had many friends at my last school. I can make friends.
Feeling – scared but excited. Curious, hopeful
Behaving – I will smile and talk to students who sit near me in class.
I’ll ask them questions about the school.
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physicalsensationthatsignalsanautomaticnegativethought.
Thefirstquestionwelearntoaskis:WhatwasIjustthinking?
As a detective or personal scientist,we ask more questions—
and reappraise the automatic negative thought in order to
restructure—to change from a negative thought to a positive
thought(cognitiverestructuring).QuestionsweuseinCOPE
for questioning automatic negative thoughts are presented
inTable 3.
Positivereappraisalandcognitiverestructuringareimpor-
tant components of the treatment. As the teens learn the
process of using the thinking, feeling, behaving triangle, the
parent and the APPN can provide examples from their own
automatic negative thoughts, and how those thoughts con-
tributed to feeling bad, and behaving in ways that may not
lead to positive responses from others. Teens enjoy hearing
their parents share about their own automatic negative
thoughts and how the parents have learned to cope with
stressorsandinterpersonalproblemsintheirownlives.
#10 Cognitive Therapy Uses a Variety of
Techniques to Change Thinking,
Mood, and Behavior
Examples of skills taught in COPE sessions are:staying in the
moment, guided imagery, thought stopping, abdominal
breathing, and communicating with others in positive ways.
The whole set of skills is covered with each teen,and then the
individual teens choose skills that resonate with them as the
skill that feels “like me” to address their priority symptoms,
i.e., thought stopping for obsessive worrying. For example,
some thought-stopping techniques would include: visualiz-
ing a stop sign, saying stop out loud, wearing a rubber band
on the wrist and snapping it to stop, visualize watching the
thought on TV,and having a remote control and clicking off.
A guided imagery script to help the teens to visualize a pleas-
ant,peacefulplaceforthemisintheCOPETeenmanual.
Conclusions and Implications for Practice
Cognitive therapy is a straightforward approach for
depressedandanxiousteens,andCOPEsessionspresentCBT
conceptsinaclear,concisewayusingdevelopmentallyappro-
priate illustrations and examples. This “simple” portable
intervention approach is powerful and effective for the teens.
They learn and practice coping skills,and apply the thinking,
feeling, behaving triangle at each session, which allows them
tobecomesocomfortablewiththeskillsthatwhentheyneed
them (i.e.,deep breathing) they have them ready at their dis-
posal. COPE is an example of a portable intervention, easily
used in a variety of settings where teens are usually seen
(officepractice,inpatientsettings,schools,juveniledetention
facilities,home visits).COPE training workshops are offered
to prepare NPs to offer the program in their particular prac-
ticesettings.Topresentasessiontoateen,alltheNPneedsisa
COPETeenmanual(availableelectronicallyforprinting)and
a notation in a progress note about which session the teen
completedatthepreviousvisit.Safetyassessmentsandmedi-
cation management/evaluation,if indicated,fit nicely within
the20–30 minCOPEsessions.AmajoradvantageofCOPEas
the standard evidence-based treatment in practice is that
teenscangetstartedinactivetreatmentrightaway.
With COPE, even with our fast-paced, busy practice envi-
ronments, APPNs and other NPs can provide timely,
evidence-basedtherapyforadolescentsandpracticeusingthe
full extent of our skills, educational background, and
experience.
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