Manualized Program Increases CBT Access for Children and Teens

Through the Creating Opportunities for Personal Empowerment (COPE) program, children and adolescents can receive cognitive behavioral therapy (CBT) even if they do not have access to a mental health care provider.

The 7-session, manualized program allows an instructor such as a teacher or primary care doctor to use evidence-based techniques to help young people struggling with depression, anxiety, or stress. It was developed by researcher Bernadette Mazurek Melnyk, PhD, APRN-CNP, FAANP, FNAP, FAAN, who has worked as a nurse, pediatric nurse practitioner, and psychiatric mental health nurse practitioner.

In this Q&A, in conjunction with National Nurse Practitioner Week 2020, Dr. Melnyk describes the founding and future of the program, the outcomes and implementation of it, and barriers still faced by children and adolescents who are in need of mental health treatment.

Q: Can you describe how and why the COPE program was started?

A: I lost my mom when I was 15 years of age. She wasn't having any issues outside of headaches. She sneezed, and stroked out right in front of me. You can imagine, I suffered with terrible post-traumatic stress disorder, depression, anxiety. Where I grew up in southwestern rural Pennsylvania, there was no help for me at all. There was no counseling.

I was taken to my family physician after about 4 months of not eating, sleeping, doing well in school. That provider did what so many do today, got out his prescription pad, wrote a script for Valium, said, "Give Bern one of these every night. She'll sleep and be just fine." Bottom line is, there was no help for me; no counseling.

Flash forward to 2020. Most recent figures before the pandemic showed that about 1 in 5 children and teens have a mental health problem, yet less than about 30 percent get any treatment. Those mental health issues are skyrocketing even more now. One of the latest studies has shown among 18 to 24-year-olds, 25 percent have thought of suicide since the pandemic struck.

That whole traumatic event triggered a passion in me to become a nurse, a pediatric nurse practitioner, a psychiatric mental health nurse practitioner, and go on to get my PhD so I could develop and test cognitive behavior therapy-based interventions to improve mental health outcomes in children, teens, and young adults.

After I became a psychiatric nurse practitioner, I started to become specialized in cognitive behavior therapy and say to myself, "What happens if I could manualize cognitive behavioral therapy so that other people besides psychiatric providers could actually deliver it to children, teens, and college students? We could help so many more than are getting help today." That's how it came to be.

Q: What outcomes have you seen from the COPE program?

A: I've got over 20 years of testing, developing, and refining this program through 17 studies. In every single population, the COPE program has been delivered, we see the same outcomes: drops in stress, anxiety, depression, suicidal thinking, and an improvement in healthy lifestyle behaviors, and even academic performance.

Q: In what settings is COPE being used and how widely used it is?

I'm blessed because not many researchers can say what they spent their whole life developing and testing through research is being used in the real world to improve outcomes. COPE is being used now in 49 states, 5 countries, primary care settings, community health settings, mental health settings, schools, and universities.

Q: How has the delivery of the program changed during the pandemic?

A: It's being used more now, to be honest with you. Some of the practitioners that deliver it in primary care settings have even gone to virtual delivery of COPE because of the pandemic.

I also want to share that providers are getting reimbursed to deliver COPE in primary care settings. That's huge. So oftentimes, providers have a hard time taking something else on unless they can get reimbursed for it. Nurse practitioners, social workers, psychologists, I haven't had one person call me to say they submitted this for reimbursement, and it got rejected. It is getting covered, these 7 COPE sessions.

Q: What do you see as the biggest barriers to children and adolescents getting appropriate treatment for depression and anxiety?

A: One, screening is not being done in every practice, like primary care practice, throughout the country. Stigma is still an issue, even in 2020. And, not enough mental health providers. We still have a severe shortage of mental health providers in so many counties throughout the nation.

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COPE can be delivered by nonmental health providers and the key is them sticking to the manual. It is manualized and has all the key elements of cognitive behavior therapy in it. Emotional regulation, the thinking-feeling-behaving triangle, problem-solving skills, the ABCs, teaching the children, the teens, the college students that they need to monitor their thinking when they start to feel stressed, anxious, or depressed, learn their triggers for negative thoughts or beliefs and how to stop them and turn them around to the positive so they feel better and behave in healthier ways.

Fidelity is important. If people don't stick to the manual, you can't expect the same great outcomes. That fidelity piece is really important. The other really important piece is putting into practice what is being learned in the content. That is an important piece of CBT, but I don't call it homework. Children and teens don't want more homework. I call it skills-building. Let's put what you're learning into daily practice.

Behavior change usually takes 30 to 60 days on average. Negative thought patterns are well-established by the time a child gets to be, say, 8, 9 years of age. You've got to practice at the skills if you expect to change a negative pattern of thinking, which is the root cause of a lot of depression, anxiety, and stress.

Q: Do you have any future expansion or other plans for the COPE program?

A: Absolutely. I just refined it for adults. And, I just adapted it for health care clinicians and workers, because they are under tremendous stress right now. It keeps mushrooming and growing. The cool thing is it's evidence-based. That's the really good thing.

As far as schools go, I believe we need to integrate this—and a lot of schools are—into their curriculum as a preventive strategy. We wouldn't send a diver into an ocean without an oxygen tank, right? Why would we send children and teens throughout life without giving them evidence-based skills that we know can help them with life stressors? I'm seeing a lot more uptake in schools across the country right now.

People are so struggling with this pandemic as we know. This program's only going to continue to mushroom and grow even more.

Q: Is there anything else you'd like to add?

A: My next dream is to start a nonprofit mental health foundation for children and teens. I want all children, teens, and young adults to be able to get this program.

We've got to shift our paradigm from crisis and sick care to well-care. We've got to build these resiliency and evidence-based cognitive behavioral skills in everybody prior to them getting in crisis. Then maybe we wouldn't have such crisis.

We are always going to need counselors, always. This program's not intended to replace counselors by any way, shape, or form. But there are so many children, teens, young adults not getting any evidence-based help for their depression and their anxiety. This is a wonderful evidence-based intervention that has been supported through so many studies.

I believe in evidence. I have a philosophy: “in God we trust but everybody else better bring data to the table.” I was talking to legislators last year on Capitol Hill, and they said to me, “Bern, don't tell me you guys need more funding. Tell me what we can do with the funding we have.”

My answer was simple, but it's a workable answer. "Let's de-implement everything that we know is not evidence-based and instead replace those nonevidence-based programs with evidence-based programs." Simple solution but not easy to change. If we would translate COPE into real-world settings, schools, and institutions of higher learning throughout the US, we would equip children, teens, and college students with protective skills that would benefit them throughout their entire life.

Bernadette Mazurek Melnyk, PhD, APRN-CNP, FAANP, FNAP, FAAN, is a nurse practitioner, researcher, educator, and  author on child and adolescent health, evidence-based practice, and intervention research and health and wellness. Dr. Melnyk has secured more than $33 million in sponsored funding from federal agencies as principal investigator and her findings have appeared in more than 430 publications. She is co-editor of 7 books and recently completed a term as a member of the National Quality Forum’s Behavioral Health Standing Committee. She has a master's degree with a pediatric nurse practitioner specialty from the University of Pittsburgh, Pennsylvania, and completed her PhD in clinical research and a post-master's certificate as a psychiatric mental health nurse practitioner at the University of Rochester, New York. She is the founder of COPE2Thrive, which disseminates the COPE program.

MORE NP WEEK COVERAGE:
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How COVID-19 Is Changing the Nurse Practitioner Role