Cognitive Behavioral Therapy

Training in Core Skills

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, substance
abuse, and disruptive behavior disorders, more
specifically, and to increase interventions aimed to
train youth in these skills.
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
Training in 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
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 Anxiety
Deep Breathing
Progressive Muscle Relaxation
Mental Imagery/Visualization
Systematic Desensitization
General Stress Busters
Cognitive Restructuring
Deep 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 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/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 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 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 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:
Anxiety
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 just
thinking about being in class.
MH Provider Role Play
Anxiety: 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 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 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 Play
Anxiety: 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 Depression
Cognitive Restructuring
Thought Stopping
Activity Scheduling
Social Skills Training
Problem Solving
Relaxation Training
Cognitive 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 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 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 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 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 Training
Deep Breathing
Progressive Muscle Relaxation
General Stress Busters
Case Example & Role Play:
Depression
MH Provider Role Play
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 has
good grades in all classes except for one, yet she only
acknowledges her below average Chemistry grade.
MH Provider Role Play
Anxiety: 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 Play
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 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 Play
Depression: Activity Scheduling,
Thought Stopping
Disruptive Behavior Disorder
Family Involvement
Classroom Management
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
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
Engaging Parents In Family
Interventions
Make services user-friendly to parents
Validate parent frustration and the fact that child is
difficult
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 helpful
person in multiple ways
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) for
appropriate/inappropriate behaviors
Extension to school and public settings - behavior report card
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)
Improving Family Management
Of Older Youth (13+)
Parental engagement is still crucial, and engaging parents
of 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
Parent 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
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.
Classroom-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 teachers needs
Emphasize prevention
Start small build on small gains
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.
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