FIRST: A Principal-Guided Approach to Evidence-Based Youth Psychotherapy

Children and adolescents with disorders and problems involving anxiety (including obsessive compulsive disorder [OCD]), depression, misconduct, and posttraumatic stress

FIRST is a transdiagnostic synthesis of empirically supported treatment procedures for children and adolescents with disorders and problems involving anxiety (including OCD), depression, misconduct, and posttraumatic stress. The treatment program is organized around 5 empirically supported principles of therapeutic change:

• Feeling Calm (skills in calming and self-regulation)
• Increasing Motivation (skills, primarily for caregivers, in boosting motivation to change [e.g., praise, differential attention])
• Repairing Thoughts (cognitive restructuring)
• Solving Problems (skills in solving everyday problems rather than being overwhelmed by them)
• Trying the Opposite (identifying and practicing the positive opposite of unhelpful behavior [examples: exposure for anxious avoidance, behavioral activation for depression])

John R. Weisz, PhD, ABPP

• Title: Professor
• Agency/Affiliation: Harvard University, Department of Psychology
• Email: john_weisz@harvard.edu

Sarah K. Bearman, PhD

• Agency/Affiliation: University of Oregon, Ballmer Institute for Children’s Behavioral Health, Department of Special Education and Clinical Sciences
• Website: https://leaplab.uoregon.edu/current-research-projects/
• Email: skb75@oregon.edu

The goals for FIRST: A Principle-Guided Approach to Evidence-Based Youth Psychotherapy are:

• Increased coping skills of the kind represented in the FIRST acronym
• Reduced internalizing (anxiety and depression) symptoms
• Reduced externalizing (anger, aggression, disobedience) symptoms
• Reduced severity of idiographic “top problems” identified by the youth at baseline

The essential components of FIRST: A Principle-Guided Approach to Evidence-Based Youth Psychotherapy include:

• For all youths:
• Personalized application of the best-fit FIRST skills

• For Youths with Anxiety and OCD
• Trying the Opposite: Exposure
• With scaffolding, as needed, via one or more of the following:
• Increasing motivation for change
• Repairing anxious cognitions
• Problem solving skills training

• For Depression
• Trying the Opposite: Behavioral activation
• With scaffolding, as needed, via one or more of the following:
• Increasing motivation
• Calming & emotion-regulation skills
• Repairing thoughts
• Problem solving skills training

• For Misbehavior
• Increasing Motivation: Teaching caregivers effective parenting skills (e.g., differential attention, praise, consequences)
• With scaffolding, as needed, via one or more of the following:
• Calming skills
• Cognitive restructuring
• Problem solving skills training for caregiver

• For Posttraumatic Stress
• Calming—emotion regulation skill-building
• Trying the Opposite—building and reviewing a trauma narrative
• With scaffolding, as needed, via one or more of the following:
• Increasing motivation
• Cognitive restructuring
• Problem solving skills training

Child/Adolescent Services

FIRST: A Principal-Guided Approach to Evidence-Based Youth Psychotherapy directly provides services to children and addresses the following:

• Anxiety, OCD, depression, misbehavior/disruptive behavior, posttraumatic stress

Recommended Intensity

Ideally 45- to 60-minute sessions, once per week

Recommended Duration

Duration of treatment episodes is highly variable, because measurement-based care is used to determine when treatment goals have been met and treatment should end.

Delivery Settings

This program is typically conducted in a(n):

• Community Daily Living Setting
• Hospital
• Outpatient Clinic
• School Setting (Including: Day Care, Day Treatment Programs, etc.)
• Virtual (Online, Smartphone, Zoom, Telephone, Video, etc.)

Homework

This program does include a homework component.

Skills are taught in sessions, with skill practice assigned after each session, and then reviewed at the beginning of the next session.

Languages

FIRST: A Principal-Guided Approach to Evidence-Based Youth Psychotherapy has materials available in the following languages other than English:

• Spanish

For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed in this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

Personnel who provide counseling or psychotherapy to youths and caregivers in clinics, schools, or hospital settings. Space is needed to permit confidential meetings.

Prerequisite/Minimum Provider Qualifications

Training in counseling or psychotherapy. Providers can have a range of degrees from bachelor’s level individuals with a counseling certification to doctoral-level clinicians, but most have master’s degrees in mental health fields (most often social work).

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Manual details:

• Weisz, J. R., & Bearman, S. K. (2020). Principle-Guided psychotherapy for children and adolescents: The FIRST Treatment Program for Behavioral and Emotional Problems. Guilford Press.

The manual can be purchased via this link.

Training Information

There is training available for this program.

Training Contact

Training Type/Location:

Multiple trainings are offered each year.

Number of days/hours:

• 18-hour training for front-line clinicians (can be virtual or in-person)
• Consultation/coaching available for clinicians
• Train-the-consultant option also available for supervisors

Regular consultation is provided to clinicians following training. It is offered remotely, with duration determined by clinicians and their employers. Support for effectiveness evaluation can also be provided. Fidelity supports are also available.

"What is included in the Relevant Published, Peer-Reviewed Research section?"

• Note: The following study was not included in rating FIRST: A Principal-Guided Approach to Evidence-Based Youth Psychotherapy on the Scientific Rating Scale.

  Weisz, J., Bearman, S. K., Santucci, L. C., & Jensen-Doss, A. (2017). Initial test of a principle-guided approach to transdiagnostic psychotherapy with children and adolescents. Journal of Clinical Child & Adolescent Psychology, 46(1), 44–58. https://doi.org/10.1080/15374416.2016.1163708

  Summary:

  The purpose of the study was to address implementation challenges faced by some evidence-based youth psychotherapies. FIRST [now called FIRST: A Principal-Guided Approach to Evidence-Based Youth Psychotherapy] was developed as a transdiagnostic approach—guided by five empirically supported principles of therapeutic change. Measures utilized include the Therapist Integrity in Evidence-Based Interventions (TIEBI), the Therapeutic Alliance Scale for Youths (TASC-C) and Parents (TASC-P), the Client Satisfaction Questionnaire (CSQ-8), the Therapist Satisfaction Inventory (TSI), the Brief Problem Checklist (BPC), the Top Problems Assessment (TPA), the Clinical Global Impression–Improvement (CGI) Scale, the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS), the Child Behavior Checklist (CBCL), the Youth Self Report (YSR), and the Services for Youths and Adolescents-Parent Interview (SCAPI). Results indicate that weekly assessments throughout FIRST treatment showed effect sizes for clinical improvement ranging from 0.41 to 2.66 on weekly total problems and problems deemed “most important” by caregivers and youths. Limitations include small sample size, an open trial design, and diversity was limited. Note: This article was not used in the rating process due to the lack of a control group.

• Kramer, U. (2009). Between manualized treatments and principle-guided psychotherapy: Illustration in the case of Caroline. Pragmatic Case Studies in Psychotherapy, 5(2), 45–51. https://doi.org/10.14713/pcsp.v5i2.970

• Marchette, L. K., & Weisz, J. R. (2017). Practitioner review: Empirical evolution of youth psychotherapy toward transdiagnostic approaches. Journal of Child Psychology and Psychiatry, 58(9), 970–984. https://doi.org/10.1111/jcpp.12747

• Weisz, J. R., Fitzpatrick, O. M., Venturo-Conerly, K., & Cho, E. (2021). Process-based and principle-guided approaches in youth psychotherapy. World Psychiatry, 20(3), 378–380. https://doi.10.1002/wps.20887