Master Clinician Listings

MCS #1: Within Six Feet: Treating Childhood Anxiety Disorders During the COVID Pandemic

Deborah Ledley, Ph.D., Licensed Psychologist, Children’s and Adult Center for OCD and Anxiety

Category: Child / Adolescent Anxiety; Parenting / Families
Keywords: Anxiety, Parenting, CBT

Basic to moderate level of familiarity with the material

Participants earn 2 continuing education credits.

The COVID-19 pandemic has kept families home for over a year, preventing children from regularly attending school, spending time with friends, and pursuing extracurricular interests. Although we have all become accustomed to staying 6 feet apart from others when out in the world, parents have expressed frustration with the forced closeness that the pandemic has wrought. In fact, many parents have said that when their families are at home, their children are always within 6 feet of them! Limited research suggests that the COVID pandemic has had “a devastating impact on many young people with a history of mental health needs” (Young Minds Survey, 2021). Although we do not yet have research on the long-term impact of the pandemic on anxious youth, clinical experience suggests that factors related to the pandemic are increasing parental accommodation of anxiety while limiting opportunities for skill-building and independence. As these interesting effects are unfolding before our eyes, clinicians have had to learn to effectively implement exposures when parents and children rarely have time apart. In this seminar, attendees will learn how to effectively implement cognitive behavioral strategies for anxiety disorders during the COVID pandemic, with special attention paid to creatively using telehealth. How can we treat separation anxiety when children are not going to school, friends’ houses, or activities? How can we work on sleep difficulties when parents are already so overtaxed by the stress of the past year? What are the best ways to treat social anxiety when parents and siblings might be our only “real life” companions? We will consider how to balance the comfort and protection children need right now during this prolonged time of stress without engaging in undue family accommodation that can maintain anxiety-disordered behaviors. Furthermore, attention will be paid to how to use CBT strategies to help children transition back to “normal life” as pandemic restrictions are lifted. During this presentation, we will also consider how to attend to parental needs given that stress levels during the pandemic have been particular high for parents of children under the age of 18.

Outline:

• The COVID-19 pandemic has kept families home for over a year, preventing children from regularly attending school, spending time with friends, and pursuing extracurricular interests.
• Clinical experience suggests that the forced familial closeness wrought by the pandemic might be increasing parental accommodation of anxiety (Lebowitz, 2019) while concurrently limiting opportunities for skill-building and independence.
• – attendees will learn how to effectively implement cognitive behavioral strategies for anxiety disorders during the COVID pandemic, with special attention paid to creatively using telehealth.
• Attention will be also be paid to how to use CBT strategies to help children transition back to “normal life” as pandemic restrictions are lifted and how to take what we have learned from our experiences with telehealth into the future of anxiety disorder treatment for anxious youth.

At the end of this session, the learner will be able to:

1. Understand how the COVID-19 pandemic has impacted the presentation of anxiety disorders in youth and their families.
2. Conceptualize cases of anxiety disorders in youth during the COVID pandemic, taking into account the effects of stay-at-home orders and inability to participate in school, social activities, and extracurricular activities.
3. Implement cognitive-behavioral strategies to address separation anxiety, social anxiety, sleep issues, and other anxiety disorders during the COVID pandemic.
4. Recognize the crucial role of family accommodation in the maintenance and treatment of anxiety disorders, particularly during stay-at-home orders.
5. Creatively use telehealth platforms to engage children and families in treatment for anxiety disorders.
6. Address parental stress during the COVID pandemic that might be contributing to child anxiety.

Long-term goals:

1. Use cognitive-behavioral strategies to address “re-entry anxiety” as the world emerges from the pandemic.
2. Creatively use a blend of in-person and telehealth sessions as the world emerges from the pandemic to best address anxiety in youth.

Recommended Readings:

Alvord, M. K., Zucker, B., & Grados, J. J. (2011). Resilience Builder Program for children and adolescents: Enhancing social competence and self-regulation—A cognitive-behavioral group approach. Research Press.

Chansky, T. E. (2004). Freeing your child from anxiety: Powerful, practical strategies to overcome your child’s fears, phobias, and worries. Harmony Books.

Gruber, J., Prinstein, M. J., Clark, L. A., Rottenberg, J., Abramowitz, J. S., Albano, A. M., … Weinstock, L. M. (2020). Mental health and clinical psychological science in the time of COVID-19: Challenges, opportunities, and a call to action. American Psychologist.

Khanna, M. S., & Ledley, D. R. (2018). The Worry Workbook for Kids: Helping Children to Overcome Anxiety and the Fear of Uncertainty. New Harbinger Publications.Lebowitz, E. R. (2019). Addressing parental accommodation when treating anxiety in children. Oxford University Press.

MCS #5: Using Virtual Reality (VR) to Treat Anxiety Disorders

Elizabeth McMahon, Ph.D., Clinical Psychologist, Independent Practice

Category: Adult Anxiety, Treatment – CBT
Keywords: Anxiety, CBT, Technology / Mobile Health

Moderate to advanced level of familiarity with the material

Participants earn 2 continuing education credits.

Virtual reality (VR) has unique benefits in treating anxiety. VR is increasingly affordable, available, intuitive, and evidence-based. Clients are actively searching for therapists who offer VR therapy (VRT). Attendees will see examples of VR scenarios and products and will learn how VR can be used for various therapeutic purposes, including VR exposure therapy. Benefits, risks, and research support will be reviewed. Attendees will learn the strengths and limitations of VR exposure compared to imaginal exposure and in vivo exposure. The timing and uses of VR will be discussed in the context of an overall model of anxiety disorders and their treatment.

Outline:

• What VR is and what equipment is needed.
• Key research findings supporting the use of VR in psychotherapy.
• Clinical applications of VR.
• Advantages and disadvantages of in virtuo exposure compared with imaginal exposure or in vivo exposure.
• Risks when using VR for exposure therapy.
• Choosing the most appropriate VR product(s) for attendees’ practices.

At the end of this session, the learner will be able to:

1. Describe two uses of VR in psychotherapy.
2. List two research findings supporting the use of VR in psychotherapy.
3. Name one advantage of VR exposure over imaginal exposure.
4. Explain two advantages of VR exposure over in vivo exposure.
5. Identify two risks of using VR for exposure therapy. 

Long-term goals:

1. Assess whether to add VR as a clinical tool his/her/their practice.
2. Select the appropriate VR product(s) for his/her/their practice.

Recommended Readings:

Carl, E., Stein, A. T., Levihn-Coon, A., Pogue, J. R., Rothbaum, B., Emmelkamp, P., Asmundson, G., Carlbring, P., & Powers, M. B. (2019). Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials. Journal of Anxiety Disorders, 61, 27–36. https://doi.org/10.1016/j.janxdis.2018.08.003

Fernández-Álvarez, J., Di Lernia, D., & Riva, G. (2020). Virtual Reality for Anxiety Disorders: Rethinking a Field in Expansion. Advances in Experimental Medicine and Biology, 1191, 389–414. https://doi.org/10.1007/978-981-32-9705-0_21

Maples-Keller, J. L., Bunnell, B. E., Kim, S. J., & Rothbaum, B. O. (2017). The Use of Virtual Reality Technology in the Treatment of Anxiety and Other Psychiatric Disorders. Harvard Review of Psychiatry, 25(3), 103–113. https://doi.org/10.1097/HRP.0000000000000138

McMahon, E. (2017). Virtual Reality Exposure Therapy: Bringing ‘in vivo’ Into the office. Journal of Health Services Psychology, 43, 46–49. https://doi.org/10.1007/BF03544649

Riva, G., Wiederhold, B. K., & Mantovani, F. (2019). Neuroscience of Virtual Reality: From Virtual Exposure to Embodied Medicine. Cyberpsychology, Behavior and Social Networking, 22(1), 82–96. https://doi.org/10.1089/cyber.2017.29099.gri

MCS #6: Everything Old Is New Again: The Role of Worksheets in Growing (and Measuring) CBT Competence

Torrey A. Creed, Ph.D., Assistant Professor of Clinical Psychology in Psychiatry, Perelman School of Medicine, University of Pennsylvania

Category: Treatment – CBT, Dissemination & Implementation Science
Keywords: Competence, Treatment, Implementation

Basic to moderate level of familiarity with the material

Participants earn 2 continuing education credits.

Consider the CBT worksheet — a simple clinical tool that some clinicians may brush aside in efforts to ensure that therapy is engaging, skill-based, and tailored to an individual’s goals and challenges. These client-focused goals are central to high-quality CBT, and use of CBT worksheets may facilitate, rather than hinder, the clinician and client’s success. In this Master Clinician Seminar, Dr. Creed reintroduces CBT worksheets with a three-fold purpose. First, worksheets are framed as a direct clinical tool to help clients scaffold their learning of CBT strategies so that they can ultimately use them fluidly and naturally (i.e., without a worksheet). Discussion will include how to engage clients in this process, how to integrate worksheets in telehealth, and how to support clients in transitioning to a paperless version of skill use. Second, a parallel process is described for training and supervising new CBT therapists, as clinicians rely on CBT worksheets to build their own growing competence and confidence. Finally, Dr. Creed will present a method for rating completed CBT worksheets to evaluate clinician competence, based on preliminary findings from an ongoing NIMH-funded R01 research study (Stirman, PI, Creed, Co-I).

Outline:

• (Re)-introduction of worksheets as tools to teach skills to clients and support growing clinician skills
• Providing a rationale for clients to build engagement with worksheets
• Scaffolding client skills
• Cueing steps in an intervention strategy
• Worksheets as a support during distress
• Using worksheets to examine clinician fidelity

At the end of this session, the learner will be able to:

1. Demonstrate 2 strategies for engaging clients in the use of CBT worksheets to help them integrate CBT skills into their daily lives.
2. Identify at least 1 way in which the use of CBT worksheets can scaffold news clinicians in building their confidence and CBT skills.
3. Describe 1 strategy for leveraging CBT worksheets to evaluate clinician competence.
4. Identify 2 ways in which integrating worksheets into their practice can enhance their professional growth.

Long-term goals:

1. Employ at least one strategy to integrate worksheets into their CBT clinical practice.
2. Teach trainees how to build their own CBT skills through the use of worksheets in their clinical practice.

Recommended Readings:

Affrunti, N.W., & Creed, T.A. (2019). The factor structure of the Cognitive Therapy Rating Scale (CTRS) in a sample of community mental health clinicians. Cognitive Therapy and Research. https://doi.org/10.1007/s10608-019-09998-7

Creed, T.A., Benjamin, C., Feinberg, B., Evans, A.C., & Beck, A.T. (2016). Beyond the Label: Relationship between community therapists’ self-report of a cognitive-behavioral therapy orientation and observed skills. Administration and Policy in Mental Health Services Research, 43, 36-43. doi 10.1007/s10488-014-0618-5

Creed, T.A., Frankel, S.A., German, R., Green, K.L., Jager-Hyman, S., Pontoski, K., Adler, A., Wolk, C.B., Stirman, S.W., Waltman, S.H., Williston, M.A., Sherrill, R., Evans, A.C., & Beck. A.T. (2016). Implementation of transdiagnostic cognitive therapy in diverse community settings: The Beck Community Initiative. Journal of Consulting and Clinical Psychology. http://dx.doi.org/10.1037/ccp0000105

Waltman, S.H., Hall, B., McFarr, L., Beck, A.T., & Creed, T.A. (2017). In-session stuck points and pitfalls of community clinicians learning CBT: A qualitative investigation. Cognitive and Behavioral Practice, 24, 256-267 http://doi:10.1016/j.cbpra.2016.04.002

Wiltsey Stirman, S., Marques, L., Creed, T.A., Gutner, C.A., DeRubeis, R., Barnett, P.G., Kuhn, E., Suvak, M., Owen, J., Vogt, ., Schoenwald, S., Johnson, C., Mallard, K., Beristianos, M., & LaBash, H. (2018). Leveraging routine clinical materials and mobile technology to assess CBT fidelity: the Innovative Methods to Assess Psychotherapy Practices (imAPP) study. (2018). Implementation Science, 13, 69. https://doi.org/10.1186/s13012-018-0756-3

MCS #7: Treating OCD in Children and Adolescents: A Cognitive-Behavioral Approach

Martin E. Franklin, Ph.D., Clinical Director, Rogers Behavioral Health

Category: Obsessive Compulsive and Related Disorders, Child / Adolescent Anxiety
Keywords: EPR (Exposure and Response Prevention), Child, Adolescents

Basic to moderate level of familiarity with the material

Participants earn 2 continuing education credits.

In the last 25 years, the evidence base for cognitive behavioral therapy involving exposure plus response prevention for treating youth with OCD has grown substantially.  Treatment typically involves in vivo and imaginal exposure to situations and thoughts that provoke obsessional anxiety, along with response prevention, which is aimed at reducing and ultimately eliminating compulsions and other more passive forms of avoidance.  Randomized controlled trials conducted around the world now support the efficacy of exposure-based interventions, and effectiveness trials have since provided evidence that robust and durable outcomes can be achieved outside the academic medical contexts in which these treatments were developed and validated. These advances notwithstanding, response to treatment is still neither universal nor complete, and subspecialty expertise in OCD and related disorders remains difficult to find in many, if not most, clinical settings.  This seminar will focus on common issues that arise in providing CBT for children and adolescents, and clinical strategies to address these challenges will be presented.  Psychiatric comorbidity, family accommodation, motivational readiness, and other challenges to within- and between-session protocol adherence will be addressed in turn, and ample time will be made available for discussion of clinical cases in which optimal outcomes are proving difficult to achieve.

Outline:

• Welcome and speaker introduction
  • Review of the efficacy and effectiveness literature on CBT, pharmacotherapy, and their combination for pediatric OCD
  • Discussion of moderators and mediators of outcome, and their implications for clinical practice
• Clinical management of:
  • Psychiatric comorbidity
  • Motivational issues
  • Family accommodation
  • Clinical case examples of common and less common presentations
  • Solicitation of audience case examples
• Moderated Q&A
• Where to get additional information on this topic

At the end of this session, the learner will be able to:

1. List at least five of the seminal trials examining the efficacy and effectiveness of CBT, pharmacotherapy, and their combination in the treatment of pediatric OCD.
2. Identify the four core CBT techniques for children and adolescents with OCD, including in vivo exposure, imaginal exposure, response prevention, and motivational interviewing.
3. Identify three techniques used in the clinical management of common problems encountered in CBT for youth with OCD and their families, including the clinical management of psychiatric comorbidity, procedures to address family accommodation, and pharmacotherapy augmentation strategies.

Long-term goals:

1. To master the presentation of the treatment rationale to patients and their families who are considering a course of CBT for pediatric OCD.
2. To develop clinical facility with the core techniques of CBT for pediatric OCD, including in vivo exposure imaginal exposure, response prevention, and the management of family accommodation.

Recommended Readings:

Franklin, M. E., Dingfelder, H. E., Coogan, C. G., Garcia, A. M., Sapyta, J. J., & Freeman, J. (2013). Cognitive behavioral therapy for pediatric obsessive compulsive disorder:  Development of expert-level competence and implications for dissemination. Journal of Anxiety Disorders 27, 745-753. doi:http://dx.doi.org.proxy.library.upenn.edu/10.1016/j.janxdis.2013.09.007

Franklin, M. E., Freeman, J. B., & March, J. S. (2019).  Treating OCD in children and adolescents:  A cognitive-behavioral approach.  Guilford Press.

Franklin, M., Sapyta, J., Freeman, J., Khanna, M., Compton, S., Almirall, D., et al. (2011). Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder:  The Pediatric OCD Treatment Study II (POTS II). Journal of the American Medical Association 306, 1224-1232.  doi:http://dx.doi.org.proxy.library.upenn.edu/10.1001/jama.2011.1344

Leonard, R. C., Franklin, M. E., Wetterneck, C. T., Riemann, B. C., Simpson, H. B., Kinnear, K., . . . Lake, P. M. (2016). Residential treatment outcomes for adolescents with obsessive-compulsive disorder. Psychotherapy Research, 26, 727-736. doi:http://dx.doi.org.proxy.library.upenn.edu/10.1080/10503307.2015.1065022

Wetterneck, C. T., Leonard, R. C., Adams, T. G., Riemann, B. C., Grau, P., & Franklin, M. E. (2020). The effects of depression on the treatment of OCD in a residential sample. Bulletin of the Menninger Clinic, 84, 12-33. doi:http://dx.doi.org.proxy.library.upenn.edu/10.1521/bumc.2020.84.suppA.12

MCS #8: OCD and Comorbidity: When Does Treatment Need to Be Modified Because of Other Problems and How Do You Do It?

Jonathan B. Grayson, Ph.D., Director, University of Southern California

Category: Obsessive Compulsive and Related Disorders
Keywords: OCD (Obsessive Compulsive and Related Disorders), Comorbidity, Tic Disorders

Moderate to advanced level of familiarity with the material

Participants earn 2 continuing education credits.

Designing a treatment of exposure and response prevention is relatively simple, but obtaining compliance is an art. For many sufferers, complying with treatment feels impossible. There are a number of different factors that can impede treatment, including failure to properly identify the feared consequences of exposure, issues of denial/acceptance, and comorbid merged problems (when OCD and non-OCD problems share the same feared consequences). Not all comorbid issues require a modification of exposure and response prevention for OCD. This presentation will explain when and how these issues can interfere with treatment and how to modify treatment when necessary.

Outline:

Introduction

Forms of Treatment Resistance

• Poor readiness
• Focus upon the wrong feared consequences
• Merged cases
  – Definition of merge: A problem is considered merged when the feared consequences (FCs) of their OCD problems overlap with the FCs of other issues, problems or diagnoses.

Merged and Co-Morbidity

• Deciding when and how to treat co-morbid issues.
  – Unmerged or Simple OCD
  – Merged OCD

The Model

• Adapting the model to the patient’s problems
  – Feared consequences (FC) ‒ the avoidance/compulsion “fixes”
  – Will be idiosyncratic to individual and as it relates to OCD will be driven by intolerance of uncertainty.
  – Further elaboration of FC’s and uses of ACT and CT and different paths of treatment resistance
• Merged OCD
  – A more complicated and thorough case conceptualization resulting from the interplay of merged issues
• 2 Case examples to illustrate the difference between merged and unmerged problems.
  – Ex. # 1 – Unmerged: OCD and Borderline Personality Disorder (BPD)
  – Ex # 2 -Merged: OCD and Borderline Personality Disorder
  – Ramifications of how this modifies therapy.

Case Examples: PTSD & OCD: Unmerged and Merged

• Both women suffered from sexual trauma and both came to treatment with PTSD and OCD.

Summary

• These cases are important for two reasons.  The first is the one that appeals to us and many other clinicians B sufferers who come to us are individuals, there problems may be complex, so that cookie-cutter approaches won=t work.
  – The second is that we aren’t presenting a new cookie cutter.
  – Not every patient is going to need or will benefit from simultaneously attacking treating all problems simultaneously
  – For OCD, however, it is our opinion that E+RP will probably always be a part, but when it is done is the question.
  – Resistance has many forms, we’ve just focused on one.

At the end of this session, the learner will be able to:

1. Identify roadblocks to E&RP treatment of OCD.
2. Describe how comorbid non-OCD issues can interfere with treatment.
3. Create the initial steps for attacking treatment roadblocks.
4. Differentiate merged vs unmerged OCD.
5. Modify an ERP program for merged OCD presentation.

Long-term goals:

1. To master the presentation of the treatment rationale to patients and their families who are considering a course of CBT for pediatric OCD.
2. To develop clinical facility with the core techniques of CBT for pediatric OCD, including in vivo exposure imaginal exposure, response prevention, and the management of family accommodation.

Recommended Readings:

Abramowitz, J. (2004). Treatment of Obsessive-Compulsive Disorder in Patients Who Have Comorbid Major Depression. Journal of Clinical Psychology, 60(11), 1133-1141. https://onlinelibrary.wiley.com/doi/epdf/10.1002/jclp.20078

Grayson, J.B. (2010). OCD and Intolerance of Uncertainty: Treatment Issues. Journal of Cognitive Psychotherapy, , 24, 3-15.

Olatunji, B.M., Cisler, J.M. & Tolin, D.F. (2010). A meta-analysis of the influence of comorbidity on treatment outcome in the anxiety disorders. Clinical Psychology Review, 30, 642-654.  https://www.sciencedirect.com/science/article/pii/S0272735810000711

Pallanti, S., Grassi, G., Sarrecchia, E.D., Cantisani, A. & Pellegrini, M. (2011). Obsessive-Compulsive Disorder and Comorbidity: Clinical Assessment and Therapeutic Implications. Frontiers in Psychiatry, 21. https://doi.org/10.3389/fpsyt.2011.00070

 Ruscio, A., Stein, D., Chiu, W., & Kessler, R. (2010). The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Molecular Psychiatry, 15, 53–63. https://doi.org/10.1038/mp.2008.94