Using Cognitive Behavior Therapy in Schools

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					Using Cognitive Behavior                     Cognitive Behavior
  Therapy in Schools                              Therapy



          William (Bill) Pfohl, Psy.D.
         Western Kentucky University
          Bowling Green, Kentucky




             Defined
                                           Cognitive…dysfunction
• CBT uses enactive performance-         • Distortions? Anxiety/depression
  based procedures and structured        • Deficiency? – absence of (self-
  sessions as well as strategies           instruction) [impulsive]
  designed to produce changes in
  thinking, feeling, and behavior
         » Kendall 2006, p. 7




   CBT with Children &                        Five Interrelated
      Adolescents                                  Factors
• Based on social learning theory        • Interpersonal/environmental context
• Contexts influence behavior and        • Individual’s physiology (tight body)
  behavior in turn shapes context        • Emotional functioning
• Child’s appraisal of situation or      • Behavior
  context will influence his/her         • Cognition
  behavior and emotion
                                         Behaviors do not occur in a vacuum




                                                                                  1
    Information Processing
           Model                                                       CBT is
• Hierarchical & layered                                  Problem focused
• Consists of                                             Active
    – Cognitive products = automatic thoughts
    – Cognitive operations = cognitive distortions;
                                                          Goal-oriented
      cognitive schemas
    – Cognitive structures = map - “content-
      specificity hypothesis” [depression - negative
      cognitive triad; anxiety - future focused]




    Some Treatment Issues                                           CBT Tasks
•   Client is sent/brought to treatment                   • Assessment
•   Need to motivate to engage in process
•   Here and now focused                                  • Educational phase
•   Understand ALL systems client lives in                • Skills acquisition
•   Consider client’s age, sex, and developmental level
•   Consider language abilities; use non-verbal tasks     • Application training – practice,
•   Parent or teacher involvement                           practice…
                                                          • Relapse prevention




      Emotional Continuum
•   Positive continuum
•   Negative continuum                                        Interviewing – Children
•   Regulation of emotion is critical                             & Adolescents
•   Must recognize emotional states e.g.
    arousal                                                           Assessment Phase




                                                                                               2
              Setting Up                                     Introductions
• Room                                                 • Explain Process
• People to be there - child, family,                  • Defining “psychologist” - “head
  school personnel                                       shrinker”
• Privacy                                              • Why are we here?
• Agenda                                               • What were you told? Not in trouble!
                                                       • Who referred?
                                                       • Establish rapport!
                                                       • What do you want to be
                                                         called/addressed as?




                                                       Assessing Disorders
                 Ethics
                                                       • Clinical Interviews
    • Confidentiality - limits for harm, abuse,
        domestic violence, court                       • Developmental & family history
    •   Custody - who has it                           • Mental Status Exam
    •   Don’ be “color blind”                            –   Appearance & behavior
    •   Acknowledge cultural/language issues             –   Thought processes
    •   Competence                                       –   Mood & affect
    •   Supervision/Supervisor                           –   Intellectual functioning
    •   APA/NASP ethics apply                            –   Sensorium
    • Informed consent                                 • Semistructured Interview




    Areas to Question                                        School Issues
    • Defining the Problem?                       •   Academics
        –   Who Starts?                           •   Social
        –   Multiple perspectives                 •   Behavior
        –   Who, what, where, why, & when         •   Strengths/Weaknesses
        –   Frequency, Intensity & Duration
        –   Why now?
        –   Makes it better/worse?
        –   What has been tried to deal with
            problem? +/-




                                                                                               3
                Family
      • Who lives in home?
                                                     Social
      • Primary caretaker(s)          •   Friends - ages
      • Siblings                      •   Behavior with others
      • Areas of conflict             •   Behavior out of home
      • Jobs/schedules                •   Outside activities
      • Discipline                    •   Strengths/Weaknesses
      • Stressors - $$, marital,
        alcohol/drugs, illness
      • “Dirty Half Dozen”




                                                    Personal
               Health                       • Sleep - dreams, wet bed, sleep walk,
•   CHI                                       where
•   Pregnancy                               • Eat - Increase/decrease, picky,
•   Hospitalizations                          weight
•   Medications                             • Stomach & Headaches
•   Previous diagnosis (who, when)          • Aches & Pain
•   Developmental - walk, talk, TT          • Diarrhea or Constipation
                                            • Self-help skills
                                            • Language




             Emotional                            Activities
•   Temperament - 9 characteristics   •   Sports
•   Sad/Down?                         •   Music
•   Anxiety/fears/worries             •   School clubs/organizations
•   Phobias                           •   TV/Video (violence) - Power Rangers
•   Anger/temper/”fits”               •   Computer
•   Happy                             •   Interests




                                                                                     4
               Behavioral                                    Family History
                                                    • Health
•   ABC                                               – MI, Stroke, cancer, diabetes, blood
•   SORC(K)                                             pressure, genetics
•   FBA                                             • Mental Health
•   Strengths/weaknesses                              – depression, anxiety, psychosis, bipolar,
                                                        alcohol, drugs, suicides, legal, MR,
                                                        educational, ADHD, PDD
                                                    • Who in the family is like_____?




                                                                Adolescent
            Adolescents                                •   Friends
        •   Alcohol                                    •   Legal problems - arrests/DUI/PI
        •   Drugs - experiment/use                     •   Suicide risk
        •   Smoke                                      •   Relationship with parents/teachers
        •   Date                                       •   Who do you talk to about your problems?
        •   Sex - active/identity - (GLB)              •   Anyone bothering you? - bully/sexually
        •   Music                                      •   Fun activities
        •   Job                                        •   Free time? How Spent?
        •   Curfew                                     •   Trauma
        •   $$ - allowance




       Additional Issues                                          Diagnosis
     • Observations during interview
                                                           • Personality assessment
        – silence, language, who talks for whom?,
                                                             – what do we know?
          physical - FLK, syndrome
                                                             – What do we want to know?
     • Understanding of child about process - not
       cop or parent or friend                             • Behavioral Checklists
     • Language spoken                                     • Environmental factors - family,
     • Cultural issues                                       school, etc.
     • Understanding of emotions                           • Gathering all the data for decision
     • Reliability/Validity of data - history                making
     • Handicaps/Disability                                • DSM-IV TR/IDEA 2004
     • Genralizability of information                      • R/O - Rule Out




                                                                                                     5
                       Case Formulation                                                                        Case Formulation –
                   •   Reason for referral
                                                                                                                 Arnold Lazarus
                   •   Background information                                                                    •   B ehavior
                   •   Medical & Psychiatric history                                                             •   A ffect
                   •   Developmental & School history                                                            •   S ensation
                   •   Behavioral Observations                                                                   •   I magery
                   •   Assessment data                                                                           •   C ognition
                   •   Diagnostic Impression - 5 axis                                                            •   I nterpersonal
                   •   Hypotheses                                                                                •   D rugs (Health/fitness)
                   •   Recommendations




                                                                                                               Building Relationships
                    History &                                                     Cultural
                   Development                                                    Context

  Behavioral
                                                                                                              • Models
                                                                                               Cognitive
  Antecedents                               Presenting Problems
                                                                                              Structures &
& Consequences                                                                               Predisposition
                                                                                                                – Me adult/you child
                                                Physiological
                                                 Symptoms
                                                                                                                – Good enough parent - I have kids - take
                        Interpersonal                                      Mood
                                                                                                                  home
                                                                                                                – Big sibling
                                                                                                                – Baby sitter
                                        Cognition               Behavior
                                                                                                                – Teacher
                                                                                                                – “Cop”
                                                                                                                – True Faith healer - when you have a
                 Figure 2.1 The relationship between the components of a case formation.                          hammer everything looks like a nail




                             Relationships                                                                           Counseling Process
                                                                                                              • Defining Problems through Active
                  • Important!
                                                                                                               Listening
                  • Family variables
                                                                                                              • Clarifying the child’s expectation
                       –   Attachment
                       –   Separation problems
                                                                                                              • Exploring what has been done to
                                                                                                                solve the problem
                       –   Enmeshment
                       –   Poorly attached problem                                                            • Exploring what new things could be
                       –   trauma                                                                               done to solve the problem
                  • Conflict                                                                                  • Obtain a commitment to try one of
                                                                                                                the problem solving ideas
                  • Resistance
                                                                                                              • Closing the session




                                                                                                                                                            6
      Therapist’s Issues
 •   Records - available
                                                        Ethnic Minorities
 •   Cultural                                    • Problems faced by minorities
 •   Self-disclosure                               –   prejudice
 •   Using the child’s language                    –   poverty
 •   Silences                                      –   schooling
 •   Giving information?                           –   discrimination
 •   Staying on task
 •   Activities - play games?
 •   Limit setting
 •   Is child being truthful?




       Client’
       Client’s of Color &
            Diversity
                                                   Communication Styles
• Culture & Values
     – human nature - basically good/evil        • Verbal
     – relationship between person & nature -      –   authority figure image
       subjugation v. mastery                      –   stigma to talk about family
     – time - past - v. present                    –   pace - “Indian time”
     – activity level - being v. doing             –   Misinterpret what is said
     – social relations - lineal v. collateral
• Acculturation
• Identification - what group?




         Communication
 • Non-verbal
      – proximity - AA and Hispanic closer,
        Chinese not face to face
                                                           Collaborative
      – Gestures - smiles - Asian = weak
      – AA - eye contact when speaking                 Empiricism and Guided
      – Japanese - little emotion                            Discovery
 • Silences and indirectness of
   communication
      – Asians, Native Americans, Hispanics
 • Using interpreters - need to coach
   well




                                                                                     7
                                                     Thoughts, feelings and
          Review - CBT                                   what you do
                                                 •   What you think affects you
• Goals are relationships between                •   Core beliefs
  – Cognitions (what we think)                   •   Beliefs and Assumptions
  – Affect (what we believe)                     •   Automatic Thoughts
  – Behavior ( what we do)
• It is a psychoeducational process too




    Tenets of Cognitive
     Behavior Therapy                                      Guided Discovery
• Build relationship with client                 • Recipe like = different ingredients
                                                     –   Empathy
• “teamwork” metaphor
                                                     –   Socratic questioning
• “Empiricism” = data-based approach.                –   Behavioral experiments
  Data comes from client                             –   Homework
• Belief system is explored =                    • Designed to cast doubt on client’s beliefs
  “detectives” together to explore               • Created new adaptive functioning and
  belief system                                    explanations for themselves




              Process                                     Session Structure
• To learn more about client’s paradigms –       • General template by which you
  anxiety, self-worth, depression, anger, etc.
                                                   function
• Collaboration – working together
• Teach rules, responsibility, and roles         • Flexibility is important
• Developmental considerations – age,
  motivation, attention span, cognitive level,
  IQ,
• Relationship style – match with therapist




                                                                                                8
        Six Components                              Mood Check-in
•   Mood or Symptom check-in                • Allows child to understand feelings and
                                              thoughts
•   Homework review                         • Tracks progress/symptom relief
•   Set agenda for session                  • Understand intensity of symptoms
                                            • Helps distinguish between mood states
•   Session content                         • Establish possible antecedents
•   Set homework assignment                 • Self-report measures?
•   Feedback about session                  • Mood rating – 1-10




       Homework Review                             Agenda Setting
• Important to work on skill(s)             • Focus on current difficulties
  development, discovery and                • What will we work on during the
  reinforcement                               session?
• Completed assignments? Did they?          • Must demonstrate for client – not
  why or why not?                             natural to them
• Different title for ”homework”?           • Can write it down – if necessary




        Session Content                       Homework Assignment
• Use a variety of techniques               • Follows from session content
• Goal – maintaining and build rapport,     • Deal with resistance
  reinforcing cognitive model, problem,
  solving, identifying Automatic Thoughts   • Be focused – symptom relief,
  (AT), and providing symptom relief          behavior skills, problem solving, etc.
• Balance content, process and structure




                                                                                        9
                                                    Treatment Model and
        Eliciting Feedback                         Problem Identification
• Allows time to explore the session –                    • How to introduce –
  likes, dislikes, etc.                                     drawing, narrative,
                                                            “Diamond
• Build relationship
                                                            Connection”, etc.
• What was helpful, not helpful?                          • Develop your
• Correct misperceptions about                              “questioning
  therapy, therapist, etc.                                  process”
• Therapy is “hard work”                                  • What is the
                                                            problem or
                                                            problems?




     “Diamond Connection”                                      Techniques
•   Cognitive                                    • Drawings
                                                 • Situation, Feelings, and Thought columns (connect
•   Behavioral                                     thoughts and feelings)
•   Emotional                                    • Identifying problems – be creative
                                                    – Letter writing
•   Physiological
                                                    – Tape recorder
                                                    – Drawings
                                                    – Therapeutic game – “Talking Feeling and Doing” Game;
• Cover all the bases!                                Berg Games
                                                    – Problem list




    Identifying and Connecting
      Feelings and Thoughts
• 1- Identify feelings (reactions?)              • What is going through your mind right
• 2- Note distressing feelings                     now?
     – Classification of feelings – chart/art?   • Automatic thoughts
• 3- content-specificity hypothesis              • Developing a “feelings” vocabulary
• 4- exposure exercises require client           • Daily Thought Record or thought diary
  to identify and endure emotional               • Teach difference between thoughts and
  expression                                       feelings (one word)




                                                                                                             10
                                                 Techniques – Basic Tools
                                                 • Relaxation training
       Cognitive Behavior                        • Systematic Desensitization
      Therapy - Techniques                       • Social Skills
                                                   – Role playing
                                                 • Contingency Management
                                                 • Pleasant Event Scheduling/Activity
                                                   Scheduling




                                                       Self-Instruction
                                                         Techniques
• Pleasure prediction/anxiety                    • Changing thought content
  prediction                                       – Meichenbaum
• Basic Problem Solving Interventions              – Prepared phrase or script “Stay cool in
                                                     school”
• Time Projection (problem solving)
• Evaluation advantages and
  disadvantages




  Basic Rational Analysis
        Technique                                 Basic Exposure Therapy
• Decatastrophing                                • Developing self-confidence through
  – What is the worst that could happen?           performance attainment
  – How would you cope with it?
                                                   – In—vivo practice
• Test of Evidence
                                                   – Exposure may upset a child – but real
  – What convinces you it is true?
                                                     life does too
• Reattribution – alternative explaination
  – Responsibility Pie – only 100% of anything




                                                                                               11
        REBT - BELIEF
        STATEMENTS                           REBT - Solutions
• Awfulizing
• I-Can’t Stand-It-Itis (Low          •   Moderate evaluations of badness
  Frustration Tolerance)              •   Statements of toleration
• Damnation                           •   Acceptance of Fallibility
• Always and Never Thinking           •   Flexible Thinking with Respect to
                                          the Occurrence of Events




                                          Anxiety Disorder – Case
      Anxiety Strategies                          Studies
•   Relaxation
•   Future focus                           Gus – GAS (General Anxiety Disorder)
                                           Molly – trauma & separation anxiety
•   Possibilities verse probability
                                           Bill – test anxiety [perfectionism]
•   Self-talk




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