Dr. Melissa Reeves Cognitive-Behavioral Strategies for Children: Evidenced-Based Interventions for the School Setting Melissa A. Reeves, Ph.D., NCSP, LPC Winthrop University [email protected] or [email protected] Wisconsin School Psychologists Association October 24, 2012 Madison, WI Workshop Objectives  An overview of the components underlying cognitive-behavioral therapy (CBT)  How to utilize and teach cognitive-behavioral strategies in a school setting  Identifying the commonalities and specific differences among various cognitivebehavioral strategies  Understand research-base and efficacy underlying specific components to CBT  How to integrate and generalize skills to the educational setting and academic instruction 2 Assumptions of cognitive-behavioral theory  Interacting perspectives:  cognitive & behavioral  Emotions and accompanying behaviors are results of:  connection between the situation,  child’s belief system (through which he/she interprets situation)  child’s thoughts about event (+ or -)  Multi-directional interaction 3 Assumptions of cognitive-behavioral theory  The way individuals construe or interpret situations moderates how they feel and behave  Interpretation of events is active and ongoing  Individuals develop idiosyncratic belief systems that guide behavior  Stressors and belief systems contribute to impaired cognitive processing and activate maladaptive, overlearned coping responses 4 Cognitive schemata  Cohesive and persistent internal representations, formed from past cognitive and emotional reactions and memories  Not in conscious awareness  Means of assimilating incoming information  Changed through accommodation 5 6 1 Dr. Melissa Reeves Typical distortions and irrational beliefs encountered in schools Attributions  Cognitive products  Emerge from interaction of information, cognitive structures, content, and processes  Example: depressed persons tend to attribute negative events to internal, negative, and stable causes (“I am a bad person”)  Dichotomous thinking  Global condemnation of worth/overgeneralization  Mind reading/Fortune telling  Emotional reasoning  Disqualifying the positive  Catastrophizing/ awfulizing*  Personalization  Demandingness/Should statements/Absolutes  Comparing  Selective abstraction/deletion  Labeling  Condemning 7 8 Christner & Stewart-Allen (2004); Mennuti, Freeman, & Christner (2006) View of normal and psychopathological functioning Basic tenets and goals of (CBT)  Cognitions and beliefs are the most identifiable cause of disturbance  Thinking patterns  Irrational thinking  anxiety, depression, anger  Rational thinking  concern, sadness, annoyance  Elements of irrational beliefs  Illogical  Inconsistent with empirical reality  Inconsistent with accomplishing one’s long-term goals Beck Handout: Common Irrational Beliefs 9 Pros of CBT  Offers techniques for treating problems with children  Can easily include caregivers/family systems  Greatest strength is its insistence on observing what happens and then measuring change  Developed many reliable assessment methods  Teaches general problem solving, cognitive and communicational skill (addresses distorted cognitions)  Modular tx interventions organized to meet the specific and changing needs of the individual 11 and family Basic Tenets  Emphasizes the learning process  Individual’s information processing style is central  Integrationist perspective Goals:  To demonstrate, teach, and hone problem-solving skills to better prepare individuals for the inevitable difficulties of life  To help movement toward successful adjustment and to reduce negative thoughts  Offer exposure to multiple behavioral events with concurrent cognitive processing to build new 10 cognitive schemata Research on CBT - Effectiveness  More effective than no treatment or placebo treatment  Effective for all types/severities of child problems  More effective with older children (11-13) than younger children (5-11)  More therapy sessions and more experienced therapists associated with larger effect sizes  Changes in cognition do not lead to changes in behavior 12 Mennuti, Christner, & Freeman (2012); Mennuti, Freeman, and Christner (2006) 2 Dr. Melissa Reeves Various Strategies & Techniques 13 BECK – 3 GENERAL COMPONENTS 1. Identify dysfunctional thoughts and maladaptive assumptions causing debilitating emotions 14 Beck’s Cognitive Triad  Thoughts and views can be described and assessed in three areas Depression  Visualization exercises and easily answerable questions  Self  Others/World Around  Future 2. Counteract dysfunctional thought  Reality checking or hypothesis testing 3. Test hypothesis through homework assignments Interprets experience in negative manner- assumes won’t get better  Role rehearsal, observation and recording, Negative View Self 15 Cognitive Techniques …           Disputing Irrational Thoughts Thought Stopping Reattribution of thoughts Decastrophizing Refocusing Desensitization Imagery Coaching Self-Instructional Training Problem Solving Training Evaluating Pros and Cons 17 http://www.youtube.com/watch?v=Ow0lr63y4Mw http://www.youtube.com/watch?v=BYLMTvxOaeE (Bob Newhart video) 16 RATIONAL-EMOTIVE BEHAVIOR THERAPY (REBT): Basic Tenets (Ellis)  We have choices  We control our ideas, attitudes, feelings, actions and arrange our lives according to our own dictates  Have little control over what actually happens or what exists…but  We have choices and control over how we view world and react to difficulties, regardless of how we’ve been taught to respond 18 3 Dr. Melissa Reeves Circular Irrational Process ABCs of REBT  ABCs Sally engages in irrational thinking ABC Self-Analysis Form http://www.sosprograms.com/resources/ABC_Self-  A = activating event Analysis_Form.pdf  B = Beliefs about event  C = Consequences resulting from irrational beliefs  Focus on C (emotional reaction that is problematic)  Teach connection between B and C  Assess irrational beliefs Others react irrationally towards Sally Sally hates herself  Question clients about these thoughts to find the underlying belief  Link irrational belief with emotional disturbance  Dispute the irrational belief Sally hates others  Engage in deliberate, ongoing process of dissection Sally engages in selfdestructive behavior  A, B, C, D, E, F, Theory of Personality Charlie’s ABC’s of Emotions 19 http://www.sosprograms.com/resources.html Thompson & Rudolph (2000) Behavioral Techniques cont…  Shaping  Systematic Desensitization  In-vivo  Imaginal  Time-Out  Grounding  Relaxation Training  Social Skills Training  Self-Monitoring  Charting  Activity Scheduling Ellis – REBT Classical Conditioning Contingency Contracting Extinction Positive Reinforcement Contingency Management  Quid Pro Quo “something for something”  Premack Principle  Reciprocity  Modeling and Role Playing (rehearsal)       Catastrophizing and awfulizing is central  Disputes irrational beliefs aggressively  Uses relentless logical arguments Beck  Does not emphasize tendency to catastrophize or awfulize as much as Ellis  Gentler approach by assigning homework to test empirically 21 22 www.interventioncentral.org 4 Stage model of RET/REBT with younger populations 1. 2. Relationship Building Assessment  Problem Identification (4 types)  Practical, Manipulative, Vocational, Emotional  Secondary Emotional Problems  Problem Analysis –assess irrational thoughts/beliefs 3. Treatment/Goals  Cognitive Change Method  Disputing  Rational Self-Statements  Rational Emotive Imagery  Cognitive Rehearsal and Role Play  Assign homework 4. Evaluation 23 ROLE PLAY DEMO: REBT - Jeff Bernard (n.d.) Rational Emotive Behavioral Therapy: an example – Elementary Basic Steps: 1. Assess how badly the person feels about their problem. How bad is the consequence (“C”) to them. Activity: Like „Em or Not 2. Discuss some of their likes, strengths, and things they are good at in any area. Activity: People Hunt. 3. Start explaining the idea of thinking and teach the person to more aware of their thinking than their feeling. Teach them to think about their thinking. Activity: Criticism Thinking, Feeling, Behaving: An Emotional Education Curriculum for Adolescents (Grades 1-6) by Ann Vernon.; sequence to follow = Alderman, (2009) 4 Dr. Melissa Reeves Rational Emotive Behavioral Therapy: an example- Secondary Rational Emotive Behavioral Therapy (con’t) 4. If needed, again assess how bad the “C” is for that student. Activity: It‟s Awful! 5. Explain how bad thoughts (self-talk) leads to the “C.” Try to get them to make the connection (muddy mind/clear mind activity). Discuss how this leads to being unproductive. Activity: Beliefs, Feelings, and Behaviors 6. Start examining the thoughts generated in #3 and pulling in the strengths from #2. Generate more strengths if needed. Show how the strengths contrast with the negative thinking. Thinking, Feeling, Behaving: An Emotional Education Curriculum for Adolescents (Grades 1-6) by Ann Vernon.; sequence to follow = Alderman, (2009) Rational Emotive Behavioral Therapy (con’t) Activity: “Tough Emotions” 5. Discuss how negative feelings and irrational beliefs are connected to self-worth and selfesteem which can impact decisions. Show how the strengths contrast with the negative thinking.  Activity: “Affirm Yourself” 6. Recognize that problem situations can be turned into opportunities for growth.  Activity: “Not A Problem, an Opportunity”  Activity: “Thoughts & Feelings”  Activity: “Erase the Slate”  Activity: “Challenging Irrational Beliefs” 2. Discuss that past behavior doesn’t have to influence present self-concept. Can make better decisions 3. Start explaining the idea of thinking and teach the person to more aware of their thinking and potential irrational beliefs 26 Thinking, Feeling, Behaving: An Emotional Education Curriculum for Adolescents (Grades 7-12) by Ann Vernon. Rational Emotive Behavioral Therapy (con’t) 4. Develop ability to modify negative feelings  Additional Resource: Therapy Materials Handout Basic Steps: 1. Assess awareness of emotional problems being linked to thoughts 27 Thinking, Feeling, Behaving: An Emotional Education Curriculum for Adolescents (Grades 7-12) by Ann Vernon. COGNITIVE MODELING & SELF INSTRUCTIONAL TRAINING MODEL 7 steps overall: 1. Treatment rationale 2. Model of task and self-guidance 3. Overt external guidance 4. Overt self-guidance 5. Faded overt-self-guidance 6. Covert self-guidance 7. Homework and follow-up 29 7. Start the process of disputing the irrational thoughts and developing more rational or productive thoughts. Activity: Erase the Irrational. * Important to do role plays to reinforce and generalize skills* •Thinking, Feeling, Behaving: An Emotional Education Curriculum for Children (Grades 1-6 & Grades 7-12) by Ann Vernon. •The Talking, Feeling, Doing Game by Richard Gardner. Cognitive Modeling w/Self-Instructional Training Strategy – 5 steps 1. Adult demonstration of self-instruction (modeling) 2. Student performs same task, adult verbalizes 3. Student instructed to perform same task again while instructing self aloud; child initiates 4. Student whispers instructions while performing task (fading overt instructions) 5. Student performs task while instructing self covertly 30 Cormeir & Nurius (2003) 5 Dr. Melissa Reeves SELF-ANALYSIS TECHNIQUE: Rational Self-Analysis for Children Self- Instructional Model with Stress Focus on: 1. Identifying certain internal stimuli produced by stressful situation and by negative comments made to self 2. Learning to use the discriminative stimuli for engaging in appropriate self-instruction 3. Practicing modeling and behavioral rehearsal to learns self-talk to counteract negative selfstatements Stress Inoculation: Three phase strategy 1. Reinterpretation Phase 2. Coping Training Phase 3. Application Phase Step 1: Write down what happened? Step 2: Be a video camera Step 3: Write down your thoughts about what happened? Step 4: How did you feel? What did you do? Step 5: Decide if your thoughts are “smart” enough? Step 6: How do you know if your thinking “smart” thoughts? Step 7: How do you want to feel? Step 8: Write down thoughts that would be “smarter” than those listed. Step 9: What do you want to do? Self-Analysis Handout 31 Meichenbaum (1985) Watkins (1983); adapted from Maultsby (1976) 32 Commonalities needed in group members        Group Process with Students Goals are similar Can provide feedback and support Willing to listen to feedback Willing to learn new behaviors Open to practicing techniques Can be respectful Abide by confidentiality 34 Selecting the Group Sessions Explain purpose of group Clarify misperceptions Conduct an intake interview Homogenous vs. heterogeneous grouping  Personality characteristics  Number in group  1st session           Establish ground rules Discuss confidentiality Attendance Behavioral expectations Ice-breaker activities Begin formulating tentative individual goals  Subsequent sessions:  Brief summary of previous meeting  Discuss homework results  Define, explore, decide on plan 35 ROLE PLAY: GROUP PROCESS 36 6 Dr. Melissa Reeves CBT Case Conceptualization Approach 1. 2. 3. 4. Specific Strategies for Specific Problems Problem List Assessment Data Developmental Considerations Working Hypothesis  “heart of the formulation” 5. Origins of Working Hypothesis 6. Antecedents/Precipitating Factors 38 Mennuti, Freeman, & Christner ( 2006) CBT Case Conceptualization Approach 7. Maintaining Factors/Impediments to Change     Therapist  Bringing out the best in a person with opportunities, support, and feedback  “Coach” Individual Family Systemic Teacher/Classroom  Consultant/co-investigator  Diagnostician  Educator Insights  Beliefs, not events, cause disturbance  Regardless of how one learns beliefs, one continues to believe in them due to rehearsal/acceptance of beliefs  Insight alone will not change beliefs 8. Protective and Resiliency Factors 9. Diagnostic Impressions/Educational Classification 10. Intervention Plan 39 Mennuti, Freeman, & Christner (2006) Role of therapist & insights to develop  Need repeated, effortful attempts to challenge beliefs 40 Specific Strategies for Specific Problems: Depression – Cognitive Distortions Depression Cognitive Distortions Attribution errors Self-evaluation Perceptions of past and present events External locus of control Low self-esteem Perceived inability to succeed academically and socially  “Negative Triad”        42 7 Dr. Melissa Reeves CBT Interventions: Depression Depression: Affective education Training in:     Self-control Self-evaluation Assertiveness Social skills  Initiating and maintaining interactions  Conflict resolution  Specific Cognitive Interventions:  Relaxation  Imagery  Cognitive restructuring  Establish goals and monitor progress 43 “Cover the Bases” Technique Depression: Coping skills 2nd (Emotion) 3rd (Physical Feeling) 1st (Cognitive) Home (Behavior)  Educate participants about depression and how to manage it  Teach link between thoughts, feelings, and behaviors and encourage them to identify body, brain, and behavior response when depressed  Catch negative thoughts and change them to more positive, realistic ones ½ full, ½ empty activity  Learn coping strategies  If undesirable situation cannot be changed, use a coping strategy  If undesirable situation can be changed, use 44 problem-solving  Taught as a general strategy for enhancing mood, particularly during a stressful situation that cannot be changed  Core coping strategies  Do something fun and distracting  Do something soothing and relaxing  Do something that expends energy  Talk to someone  Change the way you think about it 45 46 Depression: Cognitive restructuring Depression: Problem solving  Altering automatic thoughts  Develop plan for changing an undesirable situation  Problem-solving steps Identify problem Psych up Generate alternative solutions Predict likely outcomes for each possible solution Review possible solutions, choose and enact best one  Evaluate      47      Identify the negative thought Come up with another way to think about it Look for evidence that disputes the thought Model more adaptive thought Use self-instructional training  Teach children to be “thought detectives”  Talk back to the “muck monster”  Change “caterpillar thoughts into butterfly thoughts”  Teachers –  praise newly learned skills; help with cognitive restructuring 48 8 Dr. Melissa Reeves Depression: Examples of individualizing goals/interventions for specific symptoms Symptom Intervention Trouble Sleeping Education on healthy sleep Relaxation training Hopelessness Problem-solving Cognitive restructuring Poor self-esteem Self-monitor positive qualities Cognitive restructuring Social withdrawal Cognitive restructuring Activity scheduling Teach skills Depression: Activity Scheduling  Monitor current activity level  Rate pleasure of activities (0 to 100)  Schedule pleasant activities  Enlist parental support  Identify impediments and problemsolve  Self-monitor completion of activities 49 50 Depression: Treatment outcome research Depression: Teacher consultation  Educate teachers on depression  Work with teacher to praise child for using newly learned skills  Design ways that teacher can facilitate cognitive restructuring  Multicomponent cognitivebehavioral interventions have been found to be efficacious with nonclinically and clinically depressed children 51  Medication and CBT results in the best outcomes, followed by medication alone, followed by CBT 52 Mennuti, Ray & Freeman (2012); National Institute of Mental Health – www.nimh.nih.gov Special considerations in group treatment for depression  Keep groups small (4-5 members) to attend to individual needs  Depressed children can be difficult to engage in group process (may complain of boredom, fatigue)  Focus on engaging activities and experiencing enjoyment  Use games as springboards for discussion about emotions, link between affect and behavior  Emotion vocabulary  Emotion charades  Sculptures 53 Anxiety 10 sec clip 9 Dr. Melissa Reeves Specific Strategies for Specific Problems Anxiety: Cognitive Distortions     Anxiety: Triple Vulnerability Model Information processing Memory biases for distressing events Hypersensitivity to threat cues Bias towards interpreting unambiguous situations as threatening Vasey & McCloud (2001) a) A general genetic vulnerability b) General psychological vulnerability concerning a sense of impending uncontrollable and unpredictable threat c) Specific psychological vulnerability resulting from early learning experiences 55 56 Barlow (2000) “Worried No More -2nd Ed.” Curriculum “Worried No More -2nd Ed.” Curriculum Anxiety: CBT techniques for anxiety R = Rename I = Insist D = Defy E = Enjoy  Somatic management  Muscle relaxation  Deep breathing Robot/Ragdoll (Coping Cat Program)  Cognitive imagery – graded exposure  systematic desensitization  Problem solving  Contingency management “Worried No More -2nd Ed.” Curriculum http://www.youtube.com/watch?v=wE5F-FjbTRk Video: Example of Exposure Therapy “Thermometer” “Facing Fears” (Worry No More Program) Kendall (1993); Kendall & Hedtke (2006). 60 10 Dr. Melissa Reeves Example of a Group Process Example of a Group Process  Session 1: build rapport – decorated workbooks, played personal facts game, made lists of rewards  Sessions 2-5: learning about emotions and managing somatic reactions to anxiety  How different feelings are associated with different physical expressions that act as cues        Outlined bodies on large pieces of butcher paper and illustrated how body responded Looked at pictures of kids showing different emotions Played “feelings charades” Created “feelings collage” Introduced “feelings thermometer” – wrote personal hierarchy Imagine self in anxious situation; school psychologist provided example of her own anxieties speaking Began learning relaxation exercises 61 Coping Cat Program (Kendall & Hedtke, 2006) Example of a Group Process  Session 6 – begin to identify thoughts in anxious situations and understand how certain thoughts increase anxiety Show cartoons with empty thought boxes Link to what person might feel or do Propose alternative thoughts Different people feel differently with different thoughts  Different cartoons and scenarios presented  “Thinking traps”  FEAR plan – practice first two steps  Feeling, Expecting, Actions/Attitudes, Ratings/Rewards 62  Role plays to practice coping     Example of a Group Process  Session 7 – Learning approach to problem solving  Take action to cope (e.g. FEAR)  Provided mildly-anxiety provoking scenario  Brainstorm solutions to cope (silly, unhelpful, and adaptive)  Evaluate solutions (pros and cons)  Played game – student draws card with anxiety provoking situation and write as many solutions as can, student’s compare lists  Get points for solutions no one else thought of  Session 8 – Final Step in Plan - rating and rewarding themselves for trying to cope (FEAR)  Identify how selves and other provide rewards  Game – received a penny for each reward then could name – created a list  Discussed how self-talk can serve as a reward or punishment  Reviewed all 4 steps of FEAR Plan  Practice all steps by applying to real situations encountered by group members 64 63 Example of a Group Process  Sessions 9-18 – apply skills to variety of graduated exposure to anxiety eliciting situation  Tailor situations to individual fears  Practice segments:  Imaginal exposures taking place within group  In-vivo exposure to specific fears with group support  In-vivo exposure independently Children exposed to trauma  Concluded with making a videotaped commercial about learning to cope with anxiety 65 11 Dr. Melissa Reeves Specific Strategies for Specific Problems: Trauma Exposure Empirically Studied & Effective Interventions  PTSD Intervention Groupings: 1. Research based interventions proven to be effective among children. 2. Research based interventions proven to be effective among adults, but with no research among children. 3. Interventions lacking empirical support for use among children and/or that have been suggested to possibly cause harm. 67  Cognitive-Behavioral Approaches  Imaginal and In Vivo Exposure Therapy  School-Based Group Interventions  Anxiety Management Techniques 68 Feeny et al. (2004); Nickerson, Reeves, Brock, Jimerson (2009) Nickerson, Reeves, Brock, & Jimerson (2009) Imaginal Exposure Therapy In Vivo Exposure Therapy  Designed to help children confront feared objects, situations, memories, and images associated with the crisis event through repeated re-counting of (or imaginal exposure to) the traumatic memory.  Involves …  Visualization  Anxiety rating  Habituation 69  Involves repeated and prolonged confrontation with the actual traumarelated situations/objects that evoke excessive anxiety.  Should only be a therapeutic choice if the child has successfully followed the treatment steps of imaginal exposure.  Can cause some distress as children confront traumatic situations/objects.  School staff should be prepared for this. 70 Carr (2004) C-BITS: Cognitive Behavioral Interventions for Trauma in Schools School-Based Group Interventions  The effectiveness of group interventions has been proven effective.  Benefits of a group approach included:  Assisted a large number of students at once.  Decreased sense of hopelessness.  Normalizes reactions. 71 Ehntholt et al. (2005) CBITS teaches six cognitive-behavioral techniques:  Education about reactions to trauma  Relaxation training  Cognitive therapy  Real life exposure  Stress or trauma exposure  Social problem-solving CBITS also includes two parent education sessions and one teacher education. Average = 10 sessions http://www.rand.org/health/projects/cbits/ 72 http://www.socio.com/srch/summary/cedeta/ced04.htm 12 Dr. Melissa Reeves Anxiety Management Techniques (AMT)  Two phase treatment  First Phase: Learning  Second Phase: Doing  At post-treatment follow-up, significant decreases in PTSD symptoms was observed among all subjects. School Refusal 73 Ehntholt et al. (2005) Specific Strategies for Specific Problems: School Refusal Why?? 1. Avoid school-based stimuli that provoke general sense of negative affectivity 2. Escape aversive social/evaluative situations 3. Obtain attention from significant others 4. Obtain tangible rewards outside of school 75 76 Menutti, Freeman, & Christner (2004) School Refusal: Child-Based Interventions      School Refusal: Parent/Family Interventions Psychoeducation Self-monitoring Somatic control exercises Cognitive strategies Exposure-based     Contingency management Establishment of routines Improving commands Forced school attendance (*last resort) *consider skills deficits and additional support/direct instruction needed 77 78 13 Dr. Melissa Reeves School Refusal: Additional School Interventions Increasing supervision or “peer buddy” Remove obstacles to attendance Provide school-based incentives Maintain peer support groups across home room and classes  Close communication between home and school  Mental health support at school     ADD/ADHD 79 Kearney & Spear (2012) Specific Strategies for Specific Problems: ADD/ADHD- Cognitive Deficiencies           Sustained attention Impulsive cognitive tempo Deficits in impersonal and interpersonal problem solving Deficits in means-end thinking Information-processing errors caused by misattribution of intent or selective attention and recall of environmental information Generate fewer alternative solutions to interpersonal problems See fewer consequences associated with their behavior Fail to recognize causes of others’ behavior Less sensitive to interpersonal conflict Deficits in mediation of behavior, affect, cognition 81 Anastopoulous & Gerrard (2003); Yeschin, (2000) ADD/ADHD: CBT Approach Specific Behavioral Deficiencies  Off-task behaviors  Noncompliance  Deficits in application and performance of social skills  Aggressive behavior  Anti-social behavior *Multi-component tx program is critical! 82 Ervin, Bankert, DuPaul (1996), Hirshaw (2000), Pfiffner, et al (2007) CBT strategies: ADD/ADHD  Specific Cognitive strategies:  Self-instruction  Learn to identify irrational thoughts  Initiate internal dialogues  Halt automatic thinking  Change automatic thoughts to mediated ones  Social Problem Solving  Attribution Training  Specific CB strategies:  Self-management  Self-reinforcement *Research supports that most effective interventions are psychotrophic medications coupled with contingency 83 management (behavior modification) 84 14 Dr. Melissa Reeves Aggression  Have both distortions and deficiencies in cognitive processing  Problem solving skills/conflict resolution, selfmonitoring, social skills are needed Types of aggression: Aggression      Emotional aggression Instrumental aggression Reactive aggression Proactive aggression Relational aggression 86 Crick & Grotpeter (1995); Dodge (1991); Larson & Lochman (2002) Aggression: Cognitive Distortions     Aggression: Cognitive-behavioral Therapy  Focuses on improving information processing skills and increasing adaptive coping. Include following steps: Dichotomous/All or nothing thinking Hostile attributional bias Emotional reasoning Rigidified should statements 1. 2. 3. 4. 5. 6. 7. Goal setting Organization and study skills Emotional awareness Anger management Perspective taking Social problem solving Handling peer pressure  Uses various modalities Beck (1995) 87      Problem-solving and social skills education Role playing In vivo experiences/homework assignments Affective education Operant conditioning  Range from 12-20 sessions, depending on specific approach 88 Lochmar, et al (2009) Aggression: Cognitive Behavioral Interventions        Self-monitoring Example: thermometer Social skills training Problem solving training Time projection Self-instruction and stress inoculation React To Conflict Reattribution Cognitive restructuring Beck (1995); Friedberg, Friedberg & Friedberg (2001); Friedberg & McClure (2002); Overview: Problem Solving Skills Training (PSST)  Treatment that emphasizes thought processes that guide children’s responses to interpersonal problems  Therapists actively teach children 5 steps:  What am I supposed to do? (problem identification)  I need to figure out what to do (at least 3 alternatives)  What will happen if I do this?  Make a choice  Find out how I did 89 90 Dr. Alan Kazdin: http://www.yale.edu/childconductclinic 15 Dr. Melissa Reeves Overview: Parent Management Training (PMT) Aggression: PSST  Teach the problem-solving steps and apply them to various interpersonal problems/scenarios through games, activities, and stories  Therapist serves as model, cues responses, provides feedback, and manages behavior (through token economy)  Increasingly apply the steps to real-life situations  It is essential to have in vivo practice outside of group  Parents are invited to session to learn steps and help child  The use of steps transitions from an overt process to a more covert and automatic process 91  Treatment that emphasizes teaching parents to identify, define, and observe behaviors in new ways (e.g., antecedent, behavior, consequence) and to alter behaviors through operant conditioning Influenced by Patterson’s Social Learning Theory  Parental management practices play a central role in the development of aversive child behavior  Compliance with requests/demands is key to developing social skills and rule-following behavior 92 A. Kazdin Research Findings on PSST and PMT  PSST effective  Combined PSST and PMT more effective than either alone  Children with aggression who receive relationship therapy do not do as well (some even do worse than before they started)  Therapeutic changes for PSST and PMT are maintained at 1-year and 2-year follow-ups 93 http://www.nrepp.samhsa.gov/ViewLegacy.aspx?id=75 CBT Group Therapy: Education CBT Group Therapy: Teaching Self Control  Teach children to become competent in identifying events that trigger anger and their internal states of affective arousal  Education about ABC  Provide child with specific cognitive and behavioral techniques to use during coping process to manage anger  Activating experience/trigger  Behavior  Consequence      Encourage child to see benefits of managing anger 95 94 Self-talk Relaxation Problem-solving Humor 96 16 Dr. Melissa Reeves CBT: Teaching Social Perspective Taking CBT: Teaching Problem Solving & Assertiveness Problem Solving:  Identify problem  Generate multiple alternatives  Evaluate alternatives/predict consequences  Choose and enact best alternative Assertiveness:  Teach children to distinguish among aggressive, passive, and assertive responses  Improve child’s ability to infer accurately others’ intentions and enhance understanding of others’ feelings and emotional states  Present ambiguous picture from magazine or clip from popular movie  Ask child to generate stories about picture  Engage in discussion about different perceptions Perception Activity  Can be done with cartoons  Identify and change irrational thoughts supporting nonassertive behavior  Practice assertive responses 97 98 RATIONAL SELF-ANALYSIS EXERCISE : Example Application Training  When practicing, use hierarchy from less to more emotionally arousing “barbs” Bullying  Ask child if any topic is “off limits”  Use structured scenarios  Give direct feedback/support to help them practice skills in more difficult situations 99 Social-Cognitive Model of Bullying Cognitive Distortions - Bullying  Model of social coercion; the cycle  Reinforced by social-ecological factors; influenced by settings and contexts  Perceptions of participants can perpetuate an escalate behavior Of Bullies:  Magnification  Emotional reasoning  Personalization  Minimizing  Their parents: justification 101 Patterson (1982); Swearer & Cary (2003); Rodkin (2004) Of Onlookers:  Emotional reasoning  Minimization  Overgeneralization  Selective abstraction ** shifting cognitive distortions of onlookers is key so they confront and discourage bullying 102 Patterson (1982);Swearer & Cary(2003); Rodkin (2004) 17 Dr. Melissa Reeves Cognitive Distortions - Bullying Of Victims:  Lack of power/All or nothing thinking  Minimization  Magnification Interventions for bullying  Focus on whole school climate, include parents and community Of Teachers:  Minimizations  Emotional reasoning  Personalizing  Parent meetings and education  Class meetings – increase knowledge and awareness; reframe cognitions to positive alternatives  Encourage prosocial norms and behaviors  Reinforcement for positive behaviors  Challenge prevailing cognitions that minimize and enable bullying and replace with accurate cognitions Teachers, students, and parents need to examine beliefs and cognitions and change cognitive distortions that precede or accompany bullying behaviors.  “Kids are just like this” “Bullying must be stopped and no one should be treated this way” 103 104 Patterson (1982); Rodkin (2004); Swearer & Cary (2003) Interventions for bullying        Plan ways to stop bullying Anger management Conflict resolution Affective education Empathy training Social skills training Problem solving training Resiliency 105 Olweus & Limber (1999); Horne, Bartolomucci, & Newman-Carlson, (2003) CB View of Resilience Can you change the situation?  A set of flexible cognitive, behavioral, and emotional responses to acute or chronic adversities  Attitude is the heart of resilience  Thoughts, emotions, behavior  Experience the pain but you move forward towards goal  Development can be facilitated or impaired by context  Can teach attitudes and skills to help deal more effectively with situation 107 3 aspects to consider: 1) If the situation (or aspects of it) can be changed, then take steps to do so. 2) If the situation (or aspects of it) cannot be changed, then work on changing emotional reaction. 3) If the situation (or aspects of it) can be changed but current level of emotional distress stops you from seeing this, important to reduce level of stress before you undertake any practice problem solving steps  Encourage new thinking: 3 Steps 108 Neenan (2009) 18 Dr. Melissa Reeves Attitudes that Undermine Resilience  It’s not my fault I’ve been made a victim  I’ll never get over it  I can’t stand it.  Why me?  You can’t escape the past?  It shouldn’t have happened.  I’m a failure.  Why can’t I find happiness?  I shouldn’t have to struggle in coping with setbacks.  I need to know.  I don’t feel confident.  I’m a pessimist by nature. 109 Build Resilience            Look for strengths Examine daily life for evidence of resilience Identify when did handle adversity well Envision future adversities Deal with adversity as it unfolds Move out of comfort zone to develop greater tolerance Resolve to be more resilient Support from others Develop problem solving skills Find interests and become involved Classroom-based approach: “Resilient Classrooms….” by Doll, Zucker, & Brehm (2004) 110 Feeling Good About Myself Build self-esteem 1. Blow up 6 or more balloons 2. Write question on each balloon 3. Try and keep two balloons up in air for one minute 4. Then catch one 5. Answer question Sample Questions: 1. One time I felt good about myself was when ______. 2. Something I do well is _______. 3. Once I found math difficult but I did it by _____. 4. If feel good when ____. 111 112 Liana Lowenstein “Creative Counseling Interventions for Children of Divorce” David- 9th grade – Bullying Issues Online Resources Clip #1:  Child Outcome Rating Scales by Dr. Scott Miller 1. What stage(s) of RET/REBT is evident? 2. What is the therapist beginning to identify?  ORS/CORS – free download when register  http://www.scottdmiller.com (click on “Performance Metrics”) Clip #2 3. What stage is evident here? 4. What concepts of CBT and REBT are evident? Clip #3 5. What techniques is the therapist now using? 6. What is he trying to accomplish? Clip #4 7. What therapeutic techniques are now being used?  www.behavioralinstitute.org 113  Discount on resources/publications and shipped directly to you from publisher 114 19