Cognitve Behavioral Therapy Training in Core Skills Presentation NASBHC

8/11/2019 Cognitve Behavioral Therapy Training in Core Skills Presentation NASBHC

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Cognitive Behavioral Therapy

Training in Core Skills


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Objective

Increase SBHC (School-based health centers)primary care and mental health professionals

knowledge about skills related to youth mental

health, and to anxiety, depression, substanceabuse, and disruptive behavior disorders, more

specifically, and to increase interventions aimed to

train youth in these skills.


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A Four-Pronged Approach to

Evidence-Based Practice in

School Mental Health

Decrease stress/risk factors

Increase protective factors

Train in core skills

Implement manualized interventions


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Training in Core Skills


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What Are Core Skills?

Based in cognitive behavioral theory Buffer against the development of mental

health problems

Assist in coping with mental health problems


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What Is Cognitive Behavior

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


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Skills Training For Anxiety

Deep Breathing

Progressive Muscle Relaxation

Mental Imagery/Visualization

Systematic Desensitization General Stress Busters

Cognitive Restructuring


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Deep Breathing

Breathe from the stomachrather than from the lungs

Can be used in class

without anyone noticing

Can be used during

stressful moments such astaking an exam or while

trying to relax at home


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Alternating between states ofmuscle 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 andhigh school students


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Mental Imagery/Visualization

Can enhance other relaxationtechniques 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 afavorite pet)


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Systematic Desensitization

Anxiety reducing strategy involvingexposure of the phobic child to the

feared object or situation.

The child learns to tolerate the fearedobject 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


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General 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


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Change cognitive distortions (irrationalnegative 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!


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Case Example & Role Play:

Anxiety
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MH Provider Role Play

Anxiety: 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 justthinking about being in class.


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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 situationsusing the fear hierarchy.


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Primary Care Provider Role Play

Anxiety: 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 hissymptoms 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 goingcrazy, and worries that his friends will tease him if they find

out.


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Anxiety: Relaxation Techniques

Review relaxation techniques with Marcus, including DeepBreathing, Progressive Muscle Relaxation, and Mental

Imagery/Visualization.

First, explain to Marcus how relaxation is important inreducing 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.


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Skills Training For Depression

Cognitive Restructuring Thought Stopping

Activity Scheduling

Social Skills Training

Problem Solving

Relaxation Training


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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!


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Thought Stopping

Replaces racing thoughts or disturbingthoughts 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.
http://images.google.com/imgres?imgurl=http://netace.us/custom/images/stop-sign.jpg&imgrefurl=http://netace.us/custom/images/thumbs_8.html&h=202&w=200&sz=8&tbnid=2nPFQlRg2BUJ:&tbnh=98&tbnw=98&start=1&prev=/images?q=stop+sign&hl=en&lr=


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Activity Scheduling

Scheduling enjoyable and goal-directed

activities into the childs day

Assists withdrawn students re-engage in

pleasurable activities

Provides the child with the opportunity tofeel more effective as he or she

completes tasks such as school projects

Child needs to be educated about therelationship between involvement in an

activity and improvement in mood.


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Problem 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 tocomplete 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 doesnot work out as planned.

Evaluate the outcome.


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Relaxation Training

Deep Breathing


General Stress Busters
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Case Example & Role Play:

Depression
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Depression: 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

teachers comments as him just trying to be nice. Tonya hasgood grades in all classes except for one, yet she only

acknowledges her below average Chemistry grade.


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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


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Depression: Activity Scheduling,

Thought 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 hasnt done either recently,

and just seems bored most of the time. She also reportshaving difficulty concentrating in class because she is

constantly thinking about her problems.


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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 discusshow Tonya could use this strategy when she has intrusive

thoughts.


Depression: Activity Scheduling,

Thought Stopping


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Disruptive Behavior Disorder

Family Involvement Classroom Management


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Research On Interventions For

Disruptive 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 youths key socialization agents:

parents and teachers Engaging parents in process is crucial


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MH Interventions With Little Or NO

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


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Engaging Parents In Family

Interventions

Make services user-friendly to parents

Validate parent frustration and the fact that child isdifficult

Never blame parents for childs problems Appeal to parents desire for things to be better

Address misperceptions about learning parenting skills

Help parents with other things they need be helpfulperson in multiple ways


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What Are Behavior Management &

Parent Training?

Why children misbehave correcting misperceptions

Identifying and removing barriers to effective child management

Paying attention to and reinforcing childs good behavior

(improving emotional relationship) Issuing effective commands (compliance training)

Use of time-out

Reinforcement and response cost system (tokens or points) forappropriate/inappropriate behaviors

Extension to school and public settings - behavior report card


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Rewards and Response Cost

Systems

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)


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Improving Family Management

Of Older Youth (13+)

Parental engagement is still crucial, and engaging parentsof adolescent sometimes involves different issues

Interventions must take into account childs 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


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Parent Regression Technique

To address parental detachment from a teenager resultingfrom 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


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Improving Family Management

Of Older Youth (contd)

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.


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Classroom-based Interventions

Many engagement issues are the same what canYOU do for the teacher?

Identify important classroom behaviors to target

from the teachers perspective Modify intervention protocols to teachers needs

Emphasize prevention

Start small build on small gains


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Social 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.


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Resources

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
http://wings.buffalo.edu/adhd/http://wings.buffalo.edu/adhd/

Cognitve Behavioral Therapy Training in Core Skills Presentation NASBHC

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