Cognitive Behavioral Therapy

Training in Core Skills

Objective
• 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
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 • Write in a journal
• Take a nap • Write a letter that you
• Play with a pet never send
• Take a bath • Do something creative –
an art project, poem, write
• Listen to music a rap
• Talk to a friend • Watch television
• Exercise • 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 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 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
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 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 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.
Primary Care Provider Role Play
Depression: Activity Scheduling,
Thought Stopping
• 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.
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 youth’s 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 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 &
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
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 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 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 (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 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 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