Cognitive-Behavioral Strategies for Children: Evidenced-Based Interventions for the School Setting

Cognitive-Behavioral Strategies for Children: Evidenced-Based Interventions for the School Setting

Dr. Melissa Reeves
Cognitive-Behavioral Strategies for Children:
Evidenced-Based Interventions for the School
Setting
Melissa A. Reeves, Ph.D., NCSP, LPC
Winthrop University
mereev@aol.com or reevesm@winthrop.edu
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
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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
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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
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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
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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
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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
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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
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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
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Mennuti, Christner, & Freeman (2012); Mennuti, Freeman, and Christner (2006)
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Dr. Melissa Reeves
Various Strategies
& Techniques
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BECK – 3 GENERAL COMPONENTS
1. Identify dysfunctional thoughts and
maladaptive assumptions causing
debilitating emotions
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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
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Cognitive Techniques …
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Disputing Irrational Thoughts
Thought Stopping
Reattribution of thoughts
Decastrophizing
Refocusing
Desensitization Imagery
Coaching
Self-Instructional Training
Problem Solving Training
Evaluating Pros and Cons
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http://www.youtube.com/watch?v=Ow0lr63y4Mw
http://www.youtube.com/watch?v=BYLMTvxOaeE (Bob Newhart video)
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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
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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
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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)
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 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
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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
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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)
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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”
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Activity: “Thoughts & Feelings”
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Activity: “Erase the Slate”
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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
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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
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Additional Resource:
Therapy Materials Handout
Basic Steps:
1. Assess awareness of emotional problems being
linked to thoughts
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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
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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
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Cormeir & Nurius (2003)
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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
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Meichenbaum (1985)
Watkins (1983); adapted from Maultsby (1976)
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Commonalities needed in group
members
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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
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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
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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
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ROLE PLAY: GROUP PROCESS
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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
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Mennuti, Freeman, & Christner ( 2006)
CBT Case Conceptualization Approach
7. Maintaining Factors/Impediments to
Change
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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
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Mennuti, Freeman, & Christner (2006)
Role of therapist
& insights to develop
 Need repeated, effortful attempts to challenge beliefs
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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”
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Dr. Melissa Reeves
CBT Interventions: Depression
Depression: Affective education
Training in:
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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
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“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
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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
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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
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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
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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
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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
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 Medication and CBT results in the
best outcomes, followed by
medication alone, followed by CBT
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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
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Anxiety
10 sec clip
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Dr. Melissa Reeves
Specific Strategies for Specific Problems
Anxiety: Cognitive Distortions
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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
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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).
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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
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How different feelings are associated with different physical
expressions that act as cues
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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
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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
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 Role plays to practice coping
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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
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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
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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.
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 Cognitive-Behavioral Approaches
 Imaginal and In Vivo Exposure
Therapy
 School-Based Group Interventions
 Anxiety Management Techniques
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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
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 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.
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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.
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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/
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http://www.socio.com/srch/summary/cedeta/ced04.htm
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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
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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
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Menutti, Freeman, & Christner (2004)
School Refusal: Child-Based
Interventions
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School Refusal: Parent/Family
Interventions
Psychoeducation
Self-monitoring
Somatic control exercises
Cognitive strategies
Exposure-based
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Contingency management
Establishment of routines
Improving commands
Forced school attendance (*last
resort)
*consider skills deficits and additional
support/direct instruction needed
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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
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ADD/ADHD
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Kearney & Spear (2012)
Specific Strategies for Specific Problems:
ADD/ADHD- Cognitive Deficiencies
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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!
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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
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management (behavior modification)
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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
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Emotional aggression
Instrumental aggression
Reactive aggression
Proactive aggression
Relational aggression
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Crick & Grotpeter (1995); Dodge (1991); Larson & Lochman (2002)
Aggression: Cognitive Distortions
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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)
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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
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Lochmar, et al (2009)
Aggression: Cognitive Behavioral
Interventions
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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
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Dr. Alan Kazdin:
http://www.yale.edu/childconductclinic
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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
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 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
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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
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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
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 Encourage child to see benefits of
managing anger
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Self-talk
Relaxation
Problem-solving
Humor
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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
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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
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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
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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
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Patterson (1982);Swearer & Cary(2003); Rodkin (2004)
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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”
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Patterson (1982); Rodkin (2004); Swearer & Cary (2003)
Interventions for bullying
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Plan ways to stop bullying
Anger management
Conflict resolution
Affective education
Empathy training
Social skills training
Problem solving training
Resiliency
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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
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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
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Neenan (2009)
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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.
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Build Resilience
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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)
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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 ____.
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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
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 Discount on resources/publications and
shipped directly to you from publisher 114
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