Cognitive Behavioral Therapy Cognitive Behavioral Therapy Training in Core Skills Training in Core Skills

ObjectiveObjective

• Increase SBHC primary care and mental health professionals’ knowledge about skills related to youth mental health, and to anxiety, depression, substance abuse, and disruptive behavior disorders, more specifically, and to increase interventions aimed to train youth in these skills.

A Four-Pronged Approach to A Four-Pronged Approach to Evidence-Based Practice in Evidence-Based Practice in School Mental HealthSchool Mental Health

• Decrease stress/risk factors• Increase protective factors• Train in core skills• Implement manualized interventions

Training in Core SkillsTraining in Core Skills

What Are “Core Skills”?What Are “Core Skills”?

• Based in cognitive behavioral theory• Buffer against the development of mental

health problems• Assist in coping with mental health problems

What Is Cognitive Behavior What Is Cognitive Behavior Therapy (CBT)?Therapy (CBT)?

• Relatively short-term, focused psychotherapy• Focus:–How you are thinking (your cognitions)–How you are behaving and communicating

• Emphasis on present rather than past• Learn coping skills

Skills Training For AnxietySkills Training For Anxiety

• Deep Breathing• Progressive Muscle Relaxation• Mental Imagery/Visualization• Systematic Desensitization• General Stress Busters• Cognitive Restructuring

Deep BreathingDeep Breathing

• Breathe from the stomach rather than from the lungs

• Can be used in class without anyone noticing

• Can be used during stressful moments such as taking an exam or while trying to relax at home

Progressive Muscle RelaxationProgressive Muscle Relaxation

• Alternating between states of muscle tension and relaxation helps differentiate between the two states and helps habituate a process of relaxing muscles that are tensed

• Many good tapes/c.d.’s available on relaxation

• Especially suited for middle and high school students

Mental Imagery/VisualizationMental Imagery/Visualization

• Can enhance other relaxation techniques or be used on its own

• Provides relief from troubling thoughts, emotions, or feelings

• Evokes a pleasing, calming mental image (e.g., the beach, park, forest, playing with a favorite pet)

Systematic DesensitizationSystematic Desensitization

• Anxiety reducing strategy involving exposure of the phobic child to the feared object or situation.

• The child learns to tolerate the feared object by means of a series of steps beginning with the least anxiety producing aspect of the process and ending with the most difficult step.

• Construction of the Anxiety Hierarchy

General Stress BustersGeneral Stress Busters

• Go for a walk• Take a nap• Play with a pet• Take a bath• Listen to music• Talk to a friend• Exercise

• Write in a journal• Write a letter that you

never send• Do something creative –

an art project, poem, write a rap

• Watch television• Talk on the phone• Read

Cognitive RestructuringCognitive Restructuring• Change cognitive distortions (irrational

negative thoughts and beliefs someone has about different situations) and to increase positive self talk

• Steps:– Recognize and get rid of negative self

talk– Counter the negative thoughts with

realistic positive self talk– Believe the positive self talk!

Case Example & Role Play:Case Example & Role Play:AnxietyAnxiety

MH Provider Role PlayMH Provider Role PlayAnxiety: Systematic DesensitizationAnxiety: Systematic Desensitization

• Marcus has come for a follow-up appointment at the SBHC. He reported several anxiety symptoms during his comprehensive risk assessment, and screened positively for panic attacks during the Diagnostic Predictive Scales. Marcus indicates that the panic attacks are triggered by a fear of being called on in class. He experiences symptoms of panic (heart palpitations, nervousness, sweating, etc) on the way to school, while sitting in class, and even just thinking about being in class.

MH Provider Role PlayMH Provider Role PlayAnxiety: Systematic DesensitizationAnxiety: Systematic Desensitization

• Begin the process of Systematic Desensitization with Marcus.–Teach Relaxation techniques (Deep Breathing,

Muscle Relaxation, Imagery)–Create a Fear Hierarchy–Practice imaginal exposure to feared situations

using the fear hierarchy.

Primary Care Provider Role PlayPrimary Care Provider Role PlayAnxiety: Relaxation TechniquesAnxiety: Relaxation Techniques

• Marcus has come for an initial appointment at the SBHC. He appears short of breath, and reports that he is having heart palpitations. He is sweating, and reports nervousness. Upon interview, Marcus indicates that his symptoms were triggered by a fear of being called on in class. He has had similar symptoms before, and believes they are panic attacks. He is unsure of how to relax when he has these symptoms, but is concerned that he is “going crazy,” and worries that his friends will tease him if they find out.

Primary Care Provider Role PlayPrimary Care Provider Role PlayAnxiety: Relaxation TechniquesAnxiety: Relaxation Techniques• Review relaxation techniques with Marcus, including Deep

Breathing, Progressive Muscle Relaxation, and Mental Imagery/Visualization.– First, explain to Marcus how relaxation is important in

reducing symptoms of Anxiety.– Next, introduce each relaxation technique, and

PRACTICE with Marcus.– Encourage Marcus to practice each technique several

times, and schedule a follow-up appointment to review progress.

Skills Training For DepressionSkills Training For Depression

• Cognitive Restructuring• Thought Stopping• Activity Scheduling• Social Skills Training• Problem Solving• Relaxation Training

Cognitive RestructuringCognitive Restructuring• Change cognitive distortions

(irrational negative thoughts and beliefs someone has about different situations) and to increase positive self talk

• Steps:– Recognize and get rid of

negative self talk– Counter the negative thoughts

with realistic positive self talk– Believe the positive self talk!

Thought StoppingThought Stopping

• Replaces “racing thoughts” or disturbing thoughts with neutral thought.

• Neutral thought – e.g., something positive and affirming; relaxing location

• Thoughts can be “stopped” by practicing an abrupt interruption of thought – e.g., shouting “stop!”; snapping rubberband on wrist

• Return to thinking only about the neutral situation.

Activity SchedulingActivity Scheduling• Scheduling enjoyable and goal-directed

activities into the child’s day• Assists withdrawn students reengage in

pleasurable activities• Provides the child with the opportunity to

feel more effective as he or she completes tasks such as school projects

• Child needs to be educated about the relationship between involvement in an activity and improvement in mood.

Problem SolvingProblem Solving• Assist students in generating solutions to problems• Only focus on one problem at a time.

• Steps:– Define the problem.– Brainstorm all possible solutions.– Focus your energy and attention to be able to

complete your task– Identify outcomes related to the various solutions,

including who will be affected by the outcomes.– Make a decision and carry out.– Have a contingency plan in case the solution does

not work out as planned.– Evaluate the outcome.

Relaxation TrainingRelaxation Training

• Deep Breathing

• Progressive Muscle Relaxation

• General Stress Busters

Case Example & Role Play:Case Example & Role Play:DepressionDepression

MH Provider Role PlayMH Provider Role PlayDepression: Cognitive RestructuringDepression: Cognitive Restructuring

Tonya has come for an initial appointment to the SBHC. During the risk assessment, Tonya reports a number of depressive symptoms, but no suicidal ideation. Tonya seems to display a lot of negative thinking and cognitive distortions. For example, she believes that “nobody” likes her and that s/he will “never” be successful in school. Her math teacher often compliments her work, but Tonya dismisses the teacher’s comments as him “just trying to be nice.” Tonya has good grades in all classes except for one, yet she only acknowledges her below average Chemistry grade.

MH Provider Role PlayMH Provider Role PlayAnxiety: Systematic DesensitizationAnxiety: Systematic Desensitization

• Practice the process of Cognitive Restructuring with Tonya.–Describe the relationship between ways of

thinking and depressive symptoms–Help Tonya to identify her cognitive distortions– Identify ways of countering cognitive distortions–Have Tonya practice countering these distortions

Primary Care Provider Role PlayPrimary Care Provider Role PlayDepression: Activity Scheduling, Depression: Activity Scheduling, Thought StoppingThought Stopping• Tonya has come for an initial appointment to the SBHC.

During the risk assessment, Tonya reports a number of depressive symptoms, but no suicidal ideation. Tonya reports not engaging in any activities that she used to. For example, she used to spend time with friends after school, and used to enjoy reading. She hasn’t done either recently, and just seems bored most of the time. She also reports having difficulty concentrating in class because she is constantly thinking about her problems.

• Practice the processes of Activity Scheduling and Thought Stopping with Tonya.– Discuss with Tonya activities she used to enjoy.– Identify specific enjoyable activities for Tonya to do this week.– Identify times and places for each activity, and discuss potential

obstacles.– Explain the process of Thought Stopping to Tonya, and discuss

how Tonya could use this strategy when she has intrusive thoughts.

Primary Care Provider Role PlayPrimary Care Provider Role PlayDepression: Activity Scheduling, Depression: Activity Scheduling, Thought StoppingThought Stopping

Disruptive Behavior DisorderDisruptive Behavior Disorder

• Family Involvement• Classroom Management

Research On Interventions For Research On Interventions For Disruptive Behavior DisordersDisruptive Behavior Disorders• Other than stimulant medication for ADHD, no individual

or group interventions have been proven effective• Some evidence that group interventions make problems

worse (peer contagion)• All empirically-supported interventions for disruptive

disorders involve the youth’s key socialization agents: parents and teachers

• Engaging parents in process is crucial

MH Interventions With Little Or NO MH Interventions With Little Or NO Evidence Of Effectiveness For DBD:Evidence Of Effectiveness For DBD:

• Special elimination diets• Vitamins or other health food remedies• Psychotherapy or psychoanalysis• Biofeedback• Play therapy• Chiropractic treatment• Sensory integration training• Social skills training• Self-control training

Engaging Parents In Family Engaging Parents In Family InterventionsInterventions• Make services user-friendly to parents• Validate parent frustration and the fact that child is

difficult• Never blame parents for child’s problems• Appeal to parent’s desire for things to be better• Address misperceptions about learning parenting skills• Help parents with other things they need – be helpful

person in multiple ways

What Are Behavior Management & What Are Behavior Management & Parent Training?Parent Training?

• Why children misbehave – correcting misperceptions• Identifying and removing barriers to effective child management• Paying attention to and reinforcing child’s good behavior

(improving emotional relationship)• Issuing effective commands (compliance training)• Use of time-out• Reinforcement and response cost system (tokens or points) for

appropriate/inappropriate behaviors• Extension to school and public settings - behavior report card

Rewards and Response Cost Rewards and Response Cost SystemsSystems• Desired and inappropriate behaviors clearly specified• Tokens for younger children; points for older• Implement rewards first, then introduce loss of points• Points exchanged for small (daily), medium (weekly),

and larger (monthly) rewards; should be primarily non-tangibles

• Pair with social reinforcers• Fade system as behavior improves (4-6 months)

Improving Family Management Improving Family Management Of Older Youth (13+)Of Older Youth (13+)• Parental engagement is still crucial, and engaging parents

of adolescent sometimes involves different issues• Interventions must take into account child’s developmental

needs• Improve emotional climate of family – increase cohesion,

reduce conflict• Youth needs to be involved in family decision making and

rule-setting – parents need to learn how to go “one-down” to go “one up”

Parent Regression TechniqueParent Regression Technique

• To address parental detachment from a teenager resulting from problematic behavior (and resistance to changing parenting behavior)

• What was it like when ____ was first born? What did you hope/wish for ____?

• What went wrong? (non-blaming) What can be done now?• Emphasize that its not too late and address parents’ fear of

failing again

Improving Family Management Improving Family Management Of Older Youth (cont’d)Of Older Youth (cont’d)• Age-appropriate rewards and punishments are still

necessary, but point system no longer effective• Improve parent monitoring and consistency in delivering

consequences• Break deviant peer group ties• Strongly promote appropriate peer group ties• Parents pulling together to set common rules, curfews, etc.

Classroom-based InterventionsClassroom-based Interventions

• Many engagement issues are the same – what can YOU do for the teacher?

• Identify important classroom behaviors to target from the teachers’ perspective

• Modify intervention protocols to teacher’s needs• Emphasize prevention• Start small – build on small gains

Social SkillsSocial Skills• Students who display disruptive behaviors often have a

difficult time with social interactions (e.g., reacting hostilely)• AND often become a source of ridicule by other students• Social skills can be enhanced by:– role modeling– role playing– providing positive feedback and support for appropriate

behaviors• Assist students in identifying perceptions and interpretations

that others have of them as well as others’ intents.

ResourcesResources• Several empirically-supported protocols exist:– Defiant Children (Russell Barkley)– Helping the Noncompliant Child (Rex Forehand)– Videotape Parent Modeling (Carolyn Webster-Stratton)

• The University of Buffalo Center for Children and Families– http://wings.buffalo.edu/adhd/– Free resources on disruptive behavior disorders:

• Parent handouts

• Teacher handouts

• Assessment tools