Transcript Cognitive Behavioral Interventions

Cognitive Behavioral
Interventions
SOW6425 Assessment and
Planning
Professor Nan Van Den Bergh
SOCIAL SKILLS TRAINING:
TWO TYPES OF INTERPERSONAL COMPETENCE
Cognitive Competence
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Knowledge about relationships (what they are, why they are
important, how they develop, social norms)
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Perceptual skills (how the client interprets the social world)
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Decision-making skills (when and how to approach others)
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Assessment skills (how to consider a variety of possible
explanations for the behavior of others in social situations)
Social Skills Training:
Two Types of Interpersonal Competence (cont.)
Behavioral Competence
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Self presentation (to enhance likelihood of positive responses)
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Social initiatives (includes how to start conversations)
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Conversational (talking, listening, turn-taking)
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Maintenance (of relationships over time)
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Conflict resolution (handling disagreements, disappointments)
Steps in Social Skill Building
•Through assessment, determine what skill the client wants or
needs
•Describe the skill and its utility
•Outline all parts of the skill separately (there are probably
more than you first think)
•Model the skill for the client
•Role play each part of the skill
•Evaluate the role-plays
•Combine the parts of the role-plays into a full rehearsal
•Encourage the client to apply the skill in real-life formats
•Evaluate and refine the skill
Critical Social Skills
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Assertiveness
Listening
Interpreting others’ reactions
Giving and receiving positive comments
Basic self-presentation and etiquette
Emotions management
Starting conversations
Being active in conversations
Reciprocity and balance
Initiating contacts, making suggestions
Critical Social Skills (cont.)
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Identifying social support resources
Interpreting others’ reactions and comments
The ability to talk about a number of topics
Knowing whom to approach, when, and how
Being open to differences
Problem solving capacity
Having positive self-regard
The ability to organize time
SELF-INSTRUCTION TRAINING:
A FORM OF COGNITIVE RESTRUCTURING
Goal
• To increase the client’s control over his or her behavior by
improving the quality of internal, self-directed speech
Assumptions
• Behavior is mediated by internal, self-directed speech
• Self-dialogue may be dominated by negative cues
• People may have a lack of positive cues in their self-dialogue
• Intervention must also incorporate skill development activities
Steps in Self-Instruction Training
 Assess behavior and its relationship to deficits in “sub-vocal”
dialogue
 Demonstrate how overt self-directed speech can be used to
guide behavior
 Help the client rehearse new self-talk (and related behaviors)
 Help the client make plans to risk more adaptive behavior
while using covert self directed speech
 Follow up on the client’s experiences:
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Revise target behaviors, self-dialogue
Add new target behaviors or end the intervention
THE SOCIAL WORKER’S THERAPEUTIC
RELATIONSHIP IN COGNITIVE-BEHAVIORAL
INTERVENTION
»Avoid complicated explanations
»Compare verbal and nonverbal communication
»Ask clients for concrete examples of their issues of
concern
»Use deductive questioning
»Regularly elicit client’s reactions to the social worker’s
statements
»Ask clients for concrete examples of how they can
apply the material
THE SOCIAL WORKER’S THERAPEUTIC
RELATIONSHIP IN COGNITIVE-BEHAVIORAL
INTERVENTION (cont.)
» Offer options for clients
» Employ frequent modeling and behavioral rehearsal
» Use appropriate self-disclosure
» Encourage client use of prompts in the home
environment
» Validate frustrations
» Compliment extensively
Cognitive Behavioral Treatment of Panic
Disorder: Overview
• Educate client about nature and physiology of panic and
anxiety
• Train patient to lower physiological arousal through
breathing exercises to control hyperventilation
• Reduce misinterpretation of panic-related cues
• Gradually expose client to feared somatic cues and to
external triggers
• Employ cognitive restructuring and relapse prevention
procedures
Constructivist Cognitive Behavioral
Therapy
• Constructive cognitive behavioral therapy (CCBT)
focuses on accounts or stories that individuals offer to
themselves and others about important events in their
lives
– CCBT views clients as “meaning-making agents” who proactively create their own personal realities
– One of the tasks of therapy is to help clients appreciate how they
go about constructing their realities; how they author their stories
• CCBT is less structured, more exploratory and more
discovery-oriented than standard cognitive therapy
• Helps clients to explore how they create their “realities'”
and the consequences that follow those constructions
– This is more empowering than challenging the “irrationality” of
clients thoughts and beliefs
Constructivist Cognitive Behavioral
Therapy (cont.)
• In CCBT, assessment and treatment are highly
interdependent processes:
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Questions therapist asks
Specific tests that are administered
Self-monitoring exercises clients are asked to do
Therapist feedback
• All of above are means of assessment as well as ways
to treat through education and “installation of hope”
• Assessment helps clients to:
– re-conceptualize their presenting predicament into specific
problems that lend themselves to solutions
– rescript their “stories”
CBT Assessment Measures for Anxious and
Depressed Clients: Self Report
• Self report on:
– Panic attack and related anxiety symptoms, severity, etc.
– Comorbidity (depression, addictive behaviors, hypochondriasis
– Life stressors ( relationship, family, work, etc.)
• Timeline of stressful life events
• Accompanying time line of their strengths
Assessment Measures to Use in CBT for
Anxious and Depressed Clients: Self
Monitoring
• Self-monitoring data: target behaviors of anxiety and
depression
– Panic attack diary/record
– Record automatic thoughts
• Self-monitoring helps clients to become more aware of
interconnections between thoughts, feelings and
behaviors
– Particularly valuable with panic disorder patients ( who report
more worse and frequent than actuality)
CBT Assessment Measures for Anxious
and Depressed Clients: Self Monitoring
(cont.)
• Daily self-monitoring helps clients:
– Appreciate influence of feelings, thoughts, behaviors and
physiological sensations that constitute panic attacks
– Understand how external triggers, internal triggers of feelings,
cognitions, physiological reactions and behavior interconnect
and spiral to form “vicious cycle”
– Appreciate situational variability of panic attacks and
accompanying cooing efforts used to control anxiety
– Recognize low-intensity warning situations and high risk
situations
CBT Assessment Measures for Anxious
and Depressed Clients: Self Monitoring
(cont.)
• Panic diary: structured vehicle for client self-monitoring
• Panic diary components:
– Situation in which panic occurs (place activity, others present?)
– Severity of symptoms (0=absent, 4=very severe)
• Indicate panic disorder symptoms experienced first
• Indicate time in minutes from start of panic attack to
point of being able to function again (duration)
• Subjective units of distress scale: (0=anxiety totally
absent, 50=moderate level, 100-intolerable level)
Assessment Measures to Use in CBT for
Anxious and Depressed Clients: SelfMonitoring (cont.)
• Record automatic thoughts in Panic Diary :
– “catastrophic” automatic thoughts or images
– Severity of behavioral avoidance
– Anxiety sensitivity index (likelihood of future panic attacks)
– Degree to which client worries about future attacks
– Nature and success of coping efforts
– Nocturnal panic: waking from sleep in a state of panic (intense
fear or dread accompanied by feelings and thoughts of intense
arousal)
Assessment Measures to Use in CBT for
Anxious and Depressed Clients (cont.)
• Behavioral indicators: behavioral deficits and excesses
– Avoidance behaviors
– Assertive behaviors
• Quality of Life: assess for social and health
consequences
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Social adjustment
Alcohol and substance abuse
Other self-harming behaviors
Health care usage
• Interviews should be conducted in a Socratic fashion:
asking questions from a stance of curiosity
– Willing to learn from the client’s answers
Interventions in CCBT
• Education
– Socratic questioning is educative : clients see problems in new ,
more “solvable “way
– Self-help books and tapes on anxiety and depression
– Information needs to be “experimented with…”
Interventions in CBT: Relaxation
Training/Breathing Retraining: (cont)
• Breathing retraining: particularly helpful for clients who
hyperventilate
– Inhale, hold to point of comfort, slowly exhale
– Model and coach the client
• Cue-controlled Relaxation Training:
– Using self-regulatory self statements: “relax,” “be calm…” in
conjunction with controlling breathing
• Needs to be practices to be useful:
– Where and when to practice the exercises on a daily basis
– After some experience, try them in situations that evoke anxiety
• Collect “data:” monitor pulse rate before and after
relaxed breathing
Interventions in CBT: Panic Inducing
Exercises
• Purpose: to inoculate clients against symptoms of panic
attacks.
• Help client be more aware of:
– Components of panic attacks
– Warning signs
– How to cope with attacks more effectively
• By repeated exposure to physical sensations, clients can
learn to control and eliinate anticipatory fear, dread of
future atacks and accompanying avoidance behaviors
Interventions in CBT: Panic Inducing
Exercises (cont.)
• Possible exercises:
– Client holds breath for 30 seconds after exhaling
– 3 minute set of step-up exercises: going up and down the steps
at a brisk pace of one step every two seconds
– 3 minutes of hyperventilation, taking one breath every two
seconds
– Breathing through a straw
– Spinning client on chair for three minutes
• Therapist indicates bodily reactions of exercises will
dissipate when the exercises are discontinued
– Client told s/he can stop exercise at any point; or yes/no on
participating
Interventions in CBT: Panic Inducing
Exercises (cont.)
• Post-exercise discussion comparing reactions to
exercises to panic reactions client experiences
• Allows for greater self awareness of client as to “warning
signs” and to sequence of thoughts, feelings and
behaviors that constitute panic attacks
• Useful way to provide clients with exposure to panicassociated somatic symptoms
Interventions in CBT: Imaginal Rehersal
• Client imagines a hierarchy of scenarios in which they
might experience panic attacks
– Clients invited to visualize each scene; but, as they imagine
scene to see themselves coping
Interventions in CBT: Relapse
Prevention
• Likely that client will experience panic attacks or another
depressive episode in the future
– Social worker needs to anticipate and prepare client for this
potentiality
– “ It is possible that the coping mechanisms we are working on
might not prove to be effective at some point in the future. That ,
too, can be helpful. It can provide valuable information for
improving coping techniques or suggesting better ones. If we
don’t have lapses and setbacks then you really would not be
challenging yourself……”
Interventions in CBT: Relapse Prevention
(cont.)
• Designed to help client anticipate possible lapses and
setbacks so that when they do occur, s/he will not
catastrophize and relapse back to pre-treatment level
– It is not the lapses but what clients say to themselves about
lapses that is critical in determining outcome of treatment
• Also need to review “trigger” or high risk situations and
devise a coping plan
• Client writes a relapse prevention script and behaviorally
and imaginally rehearsing coping skills
– Assess self confidence in performing each of the coping skills
COGNITIVE-BEHAVIORAL INTERVENTION WITH
CHILDREN AND ADOLESCENTS
•Children and adolescents often experience cognitive deficits rather than
cognitive distortions
•Cognitive procedures can be effective for adolescents but not children
–Verbal interventions are generally limited in effectiveness prior to
adolescence
•Modeling is an effective means of teaching youth new experiences
•Behavioral interventions are effective with children lacking in language
ability
COGNITIVE-BEHAVIORAL INTERVENTION
WITH CHILDREN AND ADOLESCENTS (cont.)
• In adolescence there is a sharp decline in the value of
adult-mediated reinforcers …
• Limited life experience makes generalization difficult for
children
– but they do respond positively to warmth, non-judgmental
attitudes
COGNITIVE-BEHAVIORAL GROUP INTERVENTION
WITH ADOLESCENT SEX OFEFNDERS
• Denial or Minimization – Each offender is required to give full
disclosure of his offenses, including thoughts and feelings when
offending
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The other group members challenge the person’s minimization
practices.
• Distorted Perceptions – Group members challenge a person’s
self-serving perceptions of his behavior and the feelings of the
victim at the time of the offense
• Victim Empathy – This is a lengthy process, facilitated by role
plays:
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becoming able to recognize emotions in others,
adopt the other person’s perspective during an offense,
replicate the victim’s emotion, and take action to reduce their
distress.
COGNITIVE-BEHAVIORAL GROUP INTERVENTION
WITH ADOLESCENT SEX OFFENDERS (cont.)
• Pro-offending Attitudes include a client’s negative views
of women and children, and pro-crime beliefs.
– These are challenged as they arise in any group discussion
 Attachment Style – The offender describes his two most
recent relationships, so that his “attachment style” can
be inferred.
 The group points out the disadvantages of those ways of relating
to others
 The benefits of appropriate intimacy (sexual and otherwise) are
reviewed.
 The nature of jealousy and how it can be acted out is also
reviewed.
 The client is helped to develop social skills to promote his
potential for intimacy.
C/B Group Intervention with Adolescent Sex Offenders
(continued)
• Deviant Fantasies – Offenders are required to list their
fantasies and monitor their frequency and strength.
– They must indicate whether and how they attempt to
resist the fantasies.
– Group discussion follows around the meaning of the
person’s fantasies and the role they play in the
offending behavior.
C/B Group Intervention with Adolescent Sex Offenders
(continued)
 Relapse Prevention – This includes an
identification of the typical offense cycle
 Specifying the factors that increase risk
 Acquiring coping skills that may reduce risk
 Establishing plans to avoid risk.
 Each offender lists two warning signs
 One that only he can observe (such as fantasies)
 Another that his parole supervisor or family and
friends can observe.