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Case Conceptualization

Ex-CBT Treatment Planning Guide

Let’s say that based on assessment and screening, you determine that a youth has anxiety and OCD symptoms worth targeting through Ex-CBT. For some youth, Ex-CBT may be sufficient for them to reach their treatment goals. However, for many others, Ex-CBT will be only one tool of many for effectively supporting youth with anxiety and OCD. 

 

This five-step guide will help you map out a treatment plan to address the client’s symptoms that considers the client’s cultural context and treatment goals, alongside any chronic environmental and identity-related stressors and other common co-occurring mental health difficulties. This guide builds on the cultural and contextual factors and specific anxiety and OCD symptoms assessed in the Person-Centered Cultural Assessment section to support you in identifying an initial, cohesive set of treatment strategies to address the client’s needs. 

 

Note: This section is intended to help you develop a high-level treatment plan. Subsequent sections of this toolkit, on specific treatment strategies, will go into more detail of how each treatment strategy can be optimally delivered in a culturally responsive way, as well as provide examples of how to apply them. 

Step 1: General considerations for tailoring treatment based on cultural and contextual factors

Selecting treatment strategies that align with a family’s values and cultural context can foster treatment relevance and engagement. For all clients, treatment should be tailored to align with their culture and context. These considerations will be woven within the remaining treatment planning steps and within the specific Ex-CBT and augmented strategies described in this toolkit.  

Step 2: Shape the treatment support team

Using information from the assessment and your reflections in Step 1, work with the family to determine who in the child’s life should ideally be involved in treatment (whether they attend all or only some sessions). Some examples of support team members include, but are not limited to: parents, grandparents, other family members, teachers, religious leaders, natural healers, interpreters, nannies, coaches, close family friends. 

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Below are guiding questions to help determine the treatment support team: 

  • Who is the child’s family support network? 

  • Where are symptoms most impairing (e.g., school, community, home)? 

  • What cultural and family supports can be leveraged (sports teams, religious groups)? 

  • Are language supports needed for client or family members? 

Step 3: Identify a cohesive set of treatment strategies to address youth needs

Psychoeducation and exposure techniques are always included in treatment for youth with anxiety and OCD. However, there are often additional strategies that should be utilized to best meet the client’s needs. The below table is intended to highlight various ways youth may present clinically and provide targeted suggestions for indicated treatment strategies, alongside psychoeducation and exposure techniques to address specific clinical presentations (including environmental and identity-related stressors). Specific guidelines for delivering each strategy are presented later in the toolkit (see Psychoeducation, Exposure, Cognitive Skills, or Augmented Strategies section). Your treatment plan may shift, as you build relationships with your client and learn more about their needs. 

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Step 4: Determine what, if any, advocacy steps are needed

It is important to recognize that there will be many factors out of a family’s control. We know that structural and systemic issues lead to many of the stressors experienced by our clients. We cannot take on all the burden of systemic failures– doing so will inevitably lead to us feeling hopeless and burnt out. Instead, focus on where you can support the client by advocating for them (see Clinician Advocacy Strategies in the Augmentation Strategies section). Below are some examples of how we can advocate to ensure the family’s needs are being met: 

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  • Communicate with school to ensure IEP is being followed appropriately or assist family with developing IEP/504 plan, attend school or meetings with client if needed 

  • Communicate with other providers (e.g., psychiatry, medical providers) 

  • Connect family to advocacy groups in their area 

Step 5: Proactively identifying and generating strategies for potential therapy interfering processes

Barriers

Barriers to Engagement:

  • Social determinants of health

  • Previous negative experiences with providers or mental health system

  • Limited motivation for exposure

Potential Clinical Biases

  • Clinician biases, identities, or experiences that may affect their work with the client 

Potential Strategies for Addressing Barriers

  • Case Management

  • Transportation passes

  • Offer flexible scheduling (hybrid telehealth)

  • Extended concentrated rapport and trust building

  • Values exercise → understand values to encourage values consistent behaviors and align strategies with client’s values and goals 

See Engagement and Empowerment Section in Relationship Strategies

  • Seek consultation

  • Discuss potential biases in supervision

See Self-Reflection Section in Relationship Strategies

Putting it All Together: Ex-CBT Treatment Planning Checklist 

The below checklist can help ensure you have the information you need to develop an initial treatment plan with the family. 

 

  • Step 1: Tailoring treatment based on cultural and contextual factors 

  • Are the client’s basic needs being met? If the client’s basic needs are not being met, it is unlikely they will be able to engage in and benefit from care.  

  • Do I understand how external stressors or social determinants of health may be influencing the client’s mental health including the causes and experiences of their current mental health difficulty? 

  • In what areas is the client’s anxiety/OCD most impairing? What are the most important aspects of the problem in the family’s own words? 

  • Do I know if a client’s anxiety is related to aspects of their identity?  

  • Do I have knowledge gaps (e.g., about religious practices or cultural groups) and need to do research and consult? 

  • Have I considered how to leverage their current cultural and individual strengths to increase relationship-building and treatment relevance? 

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  • Step 2: Shaping the treatment support team 

  • Have I identified all of the key family and community members who should be involved in the client’s care? 

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  • Step 3: Identifying a cohesive set of strategies to address youth needs 

  • Do I have a clear understanding of areas of maladaptive avoidance for this client to move forward with Ex-CBT? 

  • Have I identified what Augmentation Strategies are needed for my client (e.g., grounding, relaxation, racial socialization)? 

  • These next three items are important for moving forward but will continue to be refined as you work more with your client. 

  • Do I have an initial sense of how and when I will use each of these strategies? 

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  • Step 4: Determine what, if any, advocacy steps are needed 

  • Have I asked myself how I can help my client work against systemic barriers, in service of seeing my client succeed? 

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  • Step 5: Proactively identifying and generating strategies for potential therapy-interfering processes 

  • Do I understand what factors may make it difficult for the client/family to engage in treatment?  

  • Have I problem-solved barriers with the family to foster engagement? 

  • Have I identified barriers that may influence my ability as a clinician to serve this client (e.g., knowledge gaps, personal beliefs or experiences)? 

A brief case conceptualization and treatment planning chart along with an example of how it would be utilized in case #1 can be downloaded below. 

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