9/14/2012

Cognitive Behavioral
Play Therapy
Janine Shelby, Ph.D., RPT-S
Associate Professor, UCLA
Director, Child Trauma Clinic, Harbor-UCLA

Why Learn More About CBT?

 Most Researched Method

 Powerful Results for Many Disorders
 Increasingly Popular
 Can Be Integrated Easily With Play
Therapy Methods

Typical Points of Skepticism

 “How Would Anyone Else Know What A
Useful Thought Would Be For Me?”
 “How
How Can Children Engage in Therapies
with Such Sophisticated Cognitive
Demands”
 “CBT Takes the Art Out of Therapy”
 “The Relationship Doesn’t Matter In CBT”

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Group Experiential Activity

Here
Is the Point Where
You
Become Convinced
That This Might Be Useful

Course Outline
 What CBT Is
 Prior Cognitive Behavioral Play Therapies
 Cognitive Model and CBT Theory
 Session Structure for Older Youth
 Typical Child/Adolescent CBT Interventions
 Play Therapy CBT Interventions
 Behavioral Therapies Involving Play
 Interventions Specifically for Depression and Suicidality
 Play Therapy Interventions for Depression and Suicidality

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Cognitive-Behavioral Therapy
 Cognitive-Behavioral Therapy
(CBT):
CBT is not a single therapy, but multiple
models
d l ffollowing
ll i a common th theoretical
ti l
basis
Multiple treatment manuals/models exist
to treat a variety of disorders/diagnoses
Empirically-based

CBTs (cont.)
 Techniques draw from cognitive and behavioral
theories
 Focus on symptom resolution in the here and now
 Sessions are structured and goal
goal-oriented
oriented
 Sessions focus on teaching cognitive and behavioral
skills to manage symptoms
 Model originally developed with adults, downward
extension to children/teens

CBT Play Therapies Are Not New

 Susan Knell
 www.ncbi.nlm.nih.gov/pubmed/9561934
 www.a4pt.org/download.cfm?ID
www.a4pt.org/download.cfm?ID=28322
28322
 Drewes
 Blending Play Therapy with CBT (2009)
 Play Therapists
 Goodyear-Brown, Kinney-Noziska, Shelby

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Origins of CBT
 Theory: Beck’s cognitive model:
 Situation → Thought → Feeling/Behavior
 The situation itself doesn’t directly determine how one
feels emotions/behaviors are determined by the
feels,
INTERPERTATION of the situation
 Scenario: You are walking down the street and see a
friend of yours. You say “Hi!” He/she does not respond
and walks right by you. What is going through your
mind?
 Behavioral models/behaviorism also part of CBT (e.g.,
classical and operant conditioning, teaching behavioral
skills, etc.)

Aaron T. Beck is widely

considered to be the
founding father of CBT

Started as an analyst
Found focusing on conscious
thoughts more productive and
practical
Major contribution is
conducting research on
psychotherapy outcome

SITUATION

THOUGHTS

BEHAVIORS FEELINGS

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Initial Assessment: Is CBT an

appropriate treatment for your client?

 Diagnosis
Is CBT the right treatment for the
disorder?
CBT models tend to be diagnosis-
specific
 Use of Standardized Measures
 Establish Diagnosis Clearly Before Developing a
Treatment plan

Is CBT Appropriate for Your

Patient?
 Ability to do “talk therapy”
 More of an issue for the “C” vs. the “B”
 Foryoung children, need to incorporate play
methods, but can still follow same theory
 Environmental intervention is critical with
young children

Initial Sessions
 Introduction to CBT model and structure
 Defining problems and setting measurable
goals for treatment
 Build rapport/therapeutic relationship
 This is central to CBT

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CBT is Goal-Oriented!
 Choose a personal goal to discuss during
presentation
 How Will This Goal Be Accomplished?

CBT Has Shown Powerful

Results for Youth
 Trauma
 Depression
 Other Anxiety Disorders and Selective
Mutism
 Panic
 OCD
 GAD
 SAD

 Suicidality

BTs Have Shown Strong

Results for:
 Developmental Delay Level of Functioning
 ADHD symptoms
 Disruptive Behavior Disorders
 Reduction in Child Abuse Fequency

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Resources
 Friedberg and McClure (2002)
 Clinical Practice of Cognitive Therapy with
Children and Adolescents
 www.abct.org
 www.copingcat.com
 www.tfcbt.musc.edu
 www.pcit.org
 www.incredibleyears.com

CBT Session
Structure

General Session Structure

 Brief update and mood check
 (How was your week? What has your mood been
like?)
 Bridge
g from p
previous session
 (Do you remember what we talked about in the last
session?)
 Review of homework
 Setting the agenda
 Discussion of agenda items
 Assignment of new homework
 Final summary and feedback

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Check-In and Mood Check

Brief Check-In
 Patient needs to be adequately socialized
to expectations/procedures of CBT
 May Need Assistance Prioritizing
 Q-Sort Tasks with “Most-Important,” “Can
Wait,” and “Not Necessary Categories”
 Q-Sort with “My Problem” and “Adult Problem”

Problems with Brief Update for

Adolescents
 Patient gives rambling, too detailed, or
unfocused account of week
 Therapist should jump in and encourage
synthesis
 Point is to get a quick overview of the
week to decide what to put on the agenda
 Too brief/no description of week
 Ask multiple choice questions

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Mood Check with

Children and Adolescents
 Mood check
 Teach Affective Expression
 Use faces, pictures, movies to help identify mood
states
 Introduce Cognitive Model in simplified way
 faces and thought bubbles
 baseball diamond
 playful activities
 Need to ask a lot of questions when identifying
problems

Feeling Thermometer
Feel the Worst
10

0
Feel the Best

Play-Based
Mood Check Techniques

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Problems with Mood Check

 Patient has difficulty reporting her
mood/uses vague terms (“I feel ok”)
 May need to coach patient on how to
identify and label emotions first
 Patient doesn’t want to fill out BDI, etc.
 Socialize patient to usefulness of these
forms

Bridge
 Links sessions and session content
 If patient doesn’t remember last session
 Usememory jogs
 Teachpatient importance of connecting the
sessions

CBT Homework

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Increasing Homework Compliance

 Practice homework in session
 Explain and have patient explain rationale for homework
 Assign specific behaviors – specify what behavior should
occur, how frequently, when, and so forth
 Review how homework will be monitored
 Get feedback about thoughts/beliefs and practical
obstacles that might pose barriers
 Get an 80% commitment to completing homework
 Titrate homework (i.e., small increments that ensure
success)
 Use rewards
 Work with parents to support and not interfere with
homework
 Patients who do homework are most likely to get
better!

Homework
 Typical types of homework assigned in CBT
include:
 Altering cognitions
 Trying behaviors (e.g.,
(e g exposure
exposure, behavioral
activation, coping skills)
 Self-monitoring (e.g., Panic Record, Mood Monitor,
DTR)
 Homework should be connected to treatment
goals and theoretical rationale/approach

Sample

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Homework for Young Children

 Usually involves caregivers
 Should be a game or play-based activity
 Can be playing about a targeted situation
 Should be an experiential activity
 Behavioral experiment
 Exposure

Make sure to
review homework
If you don’t ,it gives the message
that it is unimportant

and the patient won’t do it

Common Difficulties with

Homework Completion
 Doing homework at the last minute
 Forgetting the rationale for the homework
 Disorganization (help patient schedule and prioritize)
 Homework is too hard/difficult for the patient
 Interfering cognitions
 “This won’t help me” “I shouldn’t have to do homework”
 Therapist cognitions
 “I’ll offend the patient if I assign homework,” “the exposure will be
too upsetting for her,” “I’m not sure I really believe in CBT”
 Lack of motivation/commitment to the treatment

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General Session Structure

 Brief update and mood check (How was your
week? What has your mood been like?)
 Bridge from previous session (Do you remember
what we talked about in the last session?))
 Review of homework
 Setting the agenda
 Discussion of agenda items
 Assignment of new homework
 Final summary and feedback

Agenda Setting

Agenda--Setting Is Important
Agenda
 Makes therapy efficient/Decreases unproductive
discourse
 Lets patient know how therapy works
 Highlights take-
take-home points
 Keeps
K treatment goal-
goall-oriented
i d
 Allows therapist/patient to prioritize topics and use time
wisely
 therapist knows what topics need to be covered
 therapist can flexibly configure session topics to
integrate patient needs
 Agenda is combination of therapist and patient
patient--initiated
topics

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Agenda Setting
 2-3 items at the most on the agenda
 Beginning of session discussion is very
brief (mood check
check, brief update
update, bridge)
and items that need to be discussed
further are put on the agenda
 In the first session, socialize patient to the
practice of agenda setting

Problems with Agenda

 Patient doesn’t contribute to agenda
 Patient wants to put too many things on agenda
 Rambling/Difficulty defining a prob. for agenda
 Teach patient how this is done
 Help patient transform thoughts (or lack thereof)
into agenda items
 Assess for cognitions that may be in the way,
(e.g., “You are the doctor, you know best what
we should talk about”, “I don’t want to be here
anyway”)
 Assess commitment to therapy

Agenda Items
 Never more than 2-3 items on agenda

 Use capsule summaries

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Agenda Setting Practice

 Divide into pairs
 Ask your partner to give you a “brief
update” of his/her past week at work
update
 Set an agenda with 2-3 items to discuss

Agenda Content
 The actual work/interventions
 (Will follow with Cognitions later in this
presentation)

Final Summary and Feedback

 Patient may be reluctant to share
feedback or may be critical

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Interventions with
Children, Adolescents and Families

CBT with Younger Children

and Adolescents
 Same theory guides treatment
 Interventions may look different
 Can use same session structure
 Can also integrate ke
key concepts with
ith less
distinct components
 Children usually do not seek their own treatment
 Children usually do not find talking to a therapist
or about feelings/thoughts enjoyable
 Need to make therapy fun and engaging
 Learn by doing
 Work with the family and the school

Working with Families in CBT

 Family/collateral work
 Generally supports individually-based interventions in CBT
 In BTs, improves quality of parent-child interactions
 Less focus on systems-based interventions
 Parents are taught skills taught to youth, so parents can
serve as coaches
 Psychoeducation
 Helping parents facilitate interventions v. interfere with
them
 Decreasing family conflict
 Providing youth with support for difficult interventions
(e.g., exposure)
 As in all therapy with children/teens, parents are an
important source of information, assist in measuring
progress

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Cognition-Based Interventions

Types of Cognitions
 Beliefs
 Global
 Developed in childhood
 “I am helpless” “I am unlovable”
 Intermediate Beliefs
 Attitudes: judgments, “being weak is bad”
 Rules: “Shoulds,” (e.g., “I should be able to handle everything”)
 Assumptions: “If/then” statements, (e.g., “If I hurt them before
they hurt me, then I’ll be ok”)
 Automatic Thoughts
 Situation-specific
Situation-
 Stream of consciousness, “surface” thoughts
 “I can’t handle this” or “I’m going to fail out of school”

Identifying Automatic Thoughts

 What was going through your mind?
 Ask in response to negative emotions/problematic behaviors
 Can use imagery if patient if having difficulty identifying
thoughts
 With kids – may need to give multiple choice
 W t the
Want th exactt thoughts
th ht the
th patient
ti t had,
h d nott interpretations
i t t ti
 (e.g., NOT Thx: “What was going through your mind when you saw your best
friend leaving for a play date with the new girl?” Pt: “I think I was in denial
about my feelings”)
 Encourage patient to put thoughts into statement form (this
form is easier to work with)
 Underlying purpose: How do these thoughts impact
mood and behavior?
 When thoughts impact mood and behavior negatively,
we are going to try to change them.

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Common Cognitive Distortions

 All or none thinking

 Catastrophizing

 Futurizing

Cognitive Restructuring
 Can look at both the validity and usefulness of
an automatic thought
 Automatic thoughts are often true and should not
be assumed to be “distorted”
 CT has moved away from idea of thoughts being
“rational” v. “irrational”
 If the automatic thought about is true (e.g., “I am
going to fail math,”) then help the youth cope
with the situation and think about it in the most
helpful way possible (e.g., “I can get through
this” vs. “my life is over.”)

Cognitive Restructuring:
Automatic Thoughts
 Test the evidence for the thought (validity)
 Is there another way to look at the
situation that might make me feel better?
(usefulness)
 Is this a helpful thought? (usefulness)
 What are the pros/cons of having this
thought? (usefulness)
 If the situation is true, what is the most
useful way for me to think about it?
(usefulness)

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Cognition Test
Is It True?
Is It Helpful?

True and Helpful True and

Unhelpful

Untrue but Nice To Untrue and

Think About Unhelpful

Play Therapy Techniques for

 Validity of Cognitions
 Donkey Story
 Solomon Role Plays

 Helpfulness of Cognitions
 Scared Samantha

 Testing cognitive distortions (validity)

 Behavioral experiments (validity)
 Engaging in previously avoided
situations/behaviors (validity)
Cognitive Interventions
 Distraction
 If youth is unable to engage in
cognitive restructuring, focus on
behavioral techniques and/or
experiential techniques

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Dysfunctional Thought Record

 Typically assigned as homework

 Way to track automatic thoughts and

cognitive restructuring

Cognitive Restructuring
 Therapist uses Socratic Method
 Do not directly challenge the patient
 Beginner
Beginner’ss mistake is to try to “argue”
argue the
patient out of a thought
 Restructuring works best when patient
comes to conclusion that thought should
be changed on his/her own, not by
therapist lecturing him/her

Creating Alternative Responses

 This is a PROCESS. Often need to test several
alternative responses before the patient finds
one that “fits”

 Always ask patients to what degree, out of

100%, that they believe the new thoughts

 If they don’t believe at the 80% level or higher, it

won’t work!

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Cognitive Restructuring with

Younger Children
 With younger children, keep “restructuring”
simple
 (e.g.,Thx: When I am scared I tell myself things that
make
k me feel
f l better,
b tt liklike “it will
ill b
be ok.”
k”
 What can you say to yourself to make yourself feel
better when you are scared?)
 Can give multiple choice, use handouts, puppet
shows, and play-based activities

Sample Play Therapy Techniques

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EMT
for Preschoolers
(Experiential Mastery Technique; Shelby, 1994)
 Child draws what he or she fears
(refrain from drawing past or present perpetrators who
are currently involved in child’s life)
 Child can say anything to drawing, though
he/she could not do so at the time
 Child instructed that he/she is in charge of this
drawing and he/she can do anything he/she
wants to the drawing.

Lose the Bruise

(Goodyear-Brown, 2004)

 Name Unhelpful Thought

 Represent it with tossed ball

 Hit or Shield ball while responding with

contradictory, more helpful thought

Shelby, Bond, Felix, Hsu, 2004; National Center for Child

Traumatic Stress

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Thought Trial
(Shelby, 2000)

•Describe Trial Process

•Select Thought to Be Tried
•Pt. Role-Plays Attorney #1: Argues Veracity of the
Thought
•Pt. Role-Plays Attorney #2: Disputes Evidence
Presented By First Attorney
•Therapist Serves as Judge: Must Be a Fair Trial
•Pt. Is Asked How Jurors Would Vote
Based on Evidence

BLAMEBERRY PIE
 In this pie go all
the reasons why it
happened
 Th.
Th writes
it & adds
dd
to pie
 Review each to
determine fit
 Separate
Misattributions

Coping Card Example

Negative Belief:
I can’t tolerate the pain
Feeling:
Depression, hopelessness

Positive Beliefs:
1) I can handle it. I have always handled it in the
past.
2) I am capable of feeling good.
3) There are things to look forward to.
4) I’ve gotten through it before.

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Core Beliefs

Core Beliefs
 Typically fall into two categories:
 helpless
 unlovable
 Are derived in childhood
 Operate as “schemas” which selectively
attend to consistent information and
discount contrary information.
 Tend to be global and cross-situational

Identifying Core Beliefs

 Downward arrow technique

 (“what would that mean about you?”)

 Recognizing a common theme in ATs

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Additional techniques for

modifying core beliefs

 Psychoeducation
 Reviewing
g historical origins
g

 Amongst Children:
 Caregiver and Teacher Training/Support
 Target The Opposite of the Core Belief
 Increase Frequency, Quality, or Intensity

Case Example:
 CBT Play Therapy Session with a
Preschooler Whose Mother Accidentally
Ran Over Him With Her Car

SITUATION

THOUGHTS

BEHAVIORS FEELINGS

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Mood?

Experiential Activity

Behavioral Intervention Techniques

 Behavioral assessment – define behavior,
baseline rate of behavior, antecedents and
consequences
 Activity monitoring and scheduling
 Contingency management
 Coping: Distraction, Relaxation, Mindfulness
 Exposure
 Role plays/Social skills/Assertiveness/Problem-
Solving
 Behavioral experiments

Behaviorism
 Functional/chain analysis (determine
empirically what is causing and maintaining
the behavior)
 Operant conditioning/reinforcement – what is
maintaining the behavior?
 Classical conditioning – pairing of stimulus
and response
 Teaching new behaviors (skills training)

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REINFORCEMENT

Consequence following a behavior that

increases the likelihood of a behavior
occurring again

POSITIVE REINFORCEMENT

Increase frequency of a behavior by

providing a consequence that the
person finds p
p positive/rewarding
g

 If teen gets money for emptying the dishwasher,

he/she is more likely to do it again
 If a suicide attempt leads to a boyfriend coming
back, patient is likely to do it again

NEGATIVE REINFORCEMENT

Increases frequency of a behavior by

removing or stopping a consequence
that the p
person finds aversive
 Baby stops crying if mom gives a pacifier, mom is
likely to give pacifier again when baby cries
 Suicide attempt leads mom to stop yelling at teen,
youth is likely to attempt suicide again when mom
yells
 Patient yells at therapist every time he/she asks
about diary card, therapist stops asking about diary
card

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Decreasing the Likelihood

of a Behavior
 Extinction – stopping reinforcement of a
behavior that was previously reinforced

 Punishment – application of aversive

consequences

Contingency Management
 “Contingency” means that a reward is
contingent on performing a desired act.
 “Management”
Management is the artart, science
science, or
practice of arranging these rewards to
shape behavior.
 Rewards=reinforcement

Reinforcement
 Contingency Management Opportunities
 Reinforcement within Interaction
 Differential Reinforcement Procedures
 Situational Reinforcement
 Premack Principle
 Systematic Reinforcement of Behavior
 Behavior Modification Systems

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Behavioral Therapies
 For the Treatment of Disruptive Behavior
Disorders
 Parent Child Interaction Therapy (PCIT)
(www.pcit.org)
 Incredible Years (IY)
(www.incredibleyears.com)

Play Is Included
 Both Methods Appreciate the Importance
of Enhancing Caregiver-child relationships
through
g Caregiver-Child
g Playy

PCIT
 Child-Directed Phase:
 Relationship Enhancement
 Parent-Directed Phase:
 Compliance

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PCIT PRIDE Skills

 Praise
 Reflection
 Imitation
 Description of Child’s Behaviors
 Enthusiastic/Engaged

PCIT Case
Examples
Behavioral Interventions

Behavioral Theory and Principles

For Your Resource

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Premack Principle
 As a rule, preferred behaviors can be used to
reinforce non-preferred behaviors. A formal
statement of the Premack principle is as
follows:
o o s high-probability
g p obab y bebehaviors
a o s ((those
ose
performed frequently under conditions of free
choice) can be used to reinforce low-
probability behaviors.
 “First this, then this”
 “First eat your vegetables, then you can have
dessert.”

Behavior Modification Systems

 “Sticker charts don’t work with my child.”
 Establishing clear, specific behaviors
 Identifying “positive” behaviors
 Measurable
 Get a baseline
 Rates of observation/data collection
 Who is responsible for recording? Generating new charts?
 Reinforcer scheduling
 Daily, Weekly, Monthly

Behavior Modification Systems

for School
 Linking school behavior to home
contingencies
 Use of a Daily Report Card
 Working with teachers

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Behavior Modification Systems

 Points to emphasize to parents
 Kids can help design it
 Explain contingencies clearly
 Use of a Rewards menu
 Start low, go slow
 Reward immediately
 Reinforce AFTER the desired behavior
 Consistency
 Extinction burst

Extinction Burst

Depression

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Michele Berk, Ph.D.

Director: Adolescent Cognitive-
Behavioral Therapy Program
Harbor-UCLA Medical Center
Assistant Professor
UCLA School of Medicine

 Depressed/irritable mood
 Loss of interest or pleasure
 Change in weight or appetite
 Insomnia or hypersomnia
 Lack of energy
 Psychomotor agitation or retardation
 Feelings of worthlessness or guilt
 Inability to concentrate or make decisions
 Thoughts of suicide

 5/9 symptoms are present most of the day, nearly

every day, for at least 2 weeks, one of symptoms must
be #1 or 2.
 Substantial impairments in school functioning, social
relationships, and family relationships
 Need to consider symptoms in terms of adolescent-
specific impairments

 Increased irritability, anger, or hostility

 Lack of interest in playing with friends, sports,
games
 Persistent boredom
 Frequent vague,
vague non-specific
non specific physical
complaints such as headaches, muscle aches,
stomachaches or tiredness
 Frequent absences from school or poor
performance in school
 Talk of or efforts to run away from home
 Excessive late night television, refusal to wake
for school in the morning
 Alcohol or substance abuse
S i l i l ti i ti

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Pharmacotherapy
Psychotherapy
Combinationpsychotherapy
and pharmacotherapy

SSRIs have mixed support, with

positive RCTs for several
(fluoxetine, paroxetine,
citalopram,
citalopram sertraline),
sertraline) but
majority are negative studies
Prozac and Lexapro only FDA-
approved medications for
depression in children and teens
(Lexapro recently approved)
Prior TCA studies negative

 2004 – FDA issues black box warning

 Findings based on adverse event reports –
2% v. 4% experienced suicidal thoughts or
behavior (as compared to placebo)
 No differences using standardized measures
 No completed suicides
 Depression
D i is
i a risk
i k factor
f t forf suicide
i id
 Research has shown higher rates of SSRI
prescriptions are associated with lower suicide
rates
 Recent increase in teen suicide rates may be
related to decrease in SSRI prescriptions
 Follow-up studies have found mixed results
 Need to weigh relative risk of untreated
depression v. small SSRI-related risk
 Youth on SSRIs must be carefully monitored

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439 randomized to:

Fluoxetine (up to 40 mg)
Cognitive behavior therapy (CBT)
Fluoxetine plus CBT
Placebo
Primary outcome measure is
change in CDRS-R scores across 12
weeks

 Subjects received maintenance treatment until week

36
 Improvement occurred in all 3 treatment groups by 36
weeks.
 Response rates: 86% combined treatment, 81%
meds alone,
alone 81% CBT alone.
alone
 Treatment with Prozac led to quicker improvement
(both alone and combined with CBT).
 CBT alone catches up to Prozac at midpoint of
treatment and to combination treatment at the end of
treatment
 Patients treated with Prozac alone 2x more likely to
have a suicidal event
 CBT may be protective against suicidality
 Overall, combined treatment appears to be the best
course of action

6 site, 5-year NIMH study

 334 outpatient adolescents, ages 12-
17 years,
years with diagnosis of major
depression
 Depression persists despite at least 6
weeks of SSRI treatment
 Acute phase 12-week trial
JAMA Feb 27, 2008

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Randomized to:
Different SSRI
Different SSRI p plus CBT
Different class of agent
(venlafaxine)
Different class of agent
(venlafaxine) plus CBT

N= 334
80
70
60 SSRI
% 50 SSRI & CBT
VLX
40
VLX & CBT
30
20
10
0
Treatment Group

CBT vs none, 54.8% vs 40.5%, p<0.009, no difference JAMA Feb 27, 2008
between Effexor and SSRIs

 Psychoeducation
 Connection between thoughts, feelings, behaviors
 Positive/Negative Spirals
 Activity Scheduling/Behavioral Activation
 Mood and Activity Monitoring
 Cognitive Restructuring
 Cognitive Distortions and Positive Counter-thoughts
 Family Intervention
 Communication
 Education
 Reinforcement
 Social Skills
 Problem Solving
 Emotion Regulation

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 9/14/2012

Feel unhappy

Crabby

Withdraw
to room

Feel worse

Fight with family

members and
Feel even worse friends

Feel great

Have fun
with friends

Feel
good

Do well
in school or work

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 9/14/2012

 Review importance of pleasant activities in

decreasing depression
 Have youth select pleasant activities they would like
to do from list
 Assign homework to monitor mood and activities
 Look
L k att graph h off mood
d and
d activities
ti iti
 Set mood and activity goals (e.g., “how many
activities do you need to do to reach your mood goal?”)
 Pleasure and mastery activities (fun and success)
 Problem-solving impediments to doing pleasant
activities
 Review plan with parents!

 “Nothing is fun for me”

Encourage acting “as if”
 Use reinforcements/contingency
management
 Activities are impractical
 Look past pleasant activities
 Need to work on social skills for social
activities

1. Did you notice patterns/changes in your

mood and activity levels?
2. How many activities does teen have to do
to
t reach h a certain
t i mood d goal?
l?
3. What are some of the things that seem to
be related to doing pleasant activities?
What got in the way of you doing fun
activities?
4. High impact activities
5. Process of trial and error

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 Beck’s cognitive model:

Situation → Thought → Feeling/Behavior
 The situation itself doesn’t directly determine
o o
how onee feels,
ee s, e
emotions/behaviors
ot o s/be a o s a are
e
determined by the INTERPERTATION of the
situation
 Therefore, you need to change thoughts to
change mood
 Scenario: You are walking down the street and
see a friend of yours. You say “hi!” He/she does
not respond and walks right by you. What is
going through your mind?

 What was going through your mind?

 Ask in response to negative emotions and
problematic situations
 Can use imagery if youth is having difficulty
identifying
id tif i thoughts
th ht
 May need to give multiple choice options
 Underlying purpose: How do these
thoughts impact mood and behavior?
 When thoughts impact mood and
behavior negatively, we are going to try to
change them

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 9/14/2012

 Test the evidence for the thought

 Is there another way to look at the situation
that might make me feel better?
 Is this a helpful thought?
 If the situation is true,
true what is the most
useful way for me to think about it?
 Testing cognitive distortions
 Behavioral experiments
 Engaging in previously avoided
situations/behaviors
 Distraction

 One of most challenging interventions

 Difficult
to do when youth is still
severely depressed
 Do not argue with patients if they are
not ready for this yet
 For younger children use affirmations
or positive self-statements

Typically assigned as homework

Way to track automatic thoughts

and cognitive restructuring

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Negative Belief:
I shouldn’t be depressed.
Feeling:
Depression, hopelessness
Positive Beliefs:
1) I’ve been through a lot. I have every right to feel however
I want.
want
2) I have a chemical imbalance which lots of people have.
I’m sad because of that.
3) There are reasons why I am depressed. Reasons can be
from the past or current issues.
4) It’s ok to be depressed.
5) One advantage to being depressed is that I’ve met some
real good friends because of it.
6) Being depressed has made me be able to be a very
feeling person and I can be very understanding of others
due to all that I’ve been through.

“Hotseat” exercise
Have group choose an activating
event
Have group say negative
thoughts that might occur
Have youth in the “hot seat” say
positive counter-thoughts
“Walk Toward the Light”

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 9/14/2012

 Depression is an illness
 Depression is not under the teen’s control
and he/she cannot overcome it using g
“willpower”
 Parents often come down hard on teens
who are functioning poorly and worsen the
depression by being critical or having
unrealistic expectations
 Remind them they are seeing symptoms
not a bad kid

 Teach communication skills

 Speaker/listener technique
 “I” statements.
 Identify negative communication strategies, such as
interrupting others, lecturing, blaming, name-calling,
and pputtingg others down.
 Review nonverbal indicators of negative
communication
 Not looking directly at the person who is talking
 Negative expressions
 Listening does not mean agreeing
 Role plays
 Start with neutral topics before moving on to “hot”
topics.

 Help family members develop

reasonable expectations for their
depressed teen
 Tell parents to “pick
pick their battles
battles”
 Education families about depression
 Provide positive
feedback/reinforcement
 Tokens
 Catch a positive

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 9/14/2012

 Maintaining gains
 Emergency planning
Identify potential stresses
Develop coping plans

 Recognize signs of depression early

 Depression prevention plan

Suicidality

 Suicide was the 3rd leading cause of death among

10-14 year-olds (behind accidents and malignant
neoplasms) and among 14-19 year olds (behind
accidents and homicide).

 Prior suicide attempts

p are one of the strongest
g
predictors of completed suicide and subsequent
suicide attempts in youth (e.g., Lewinsohn et al.,
1993)

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43
 9/14/2012

 Despite the seriousness of the problem, relatively little

empirical research exists.
 Two randomized treatment trials showing an impact on
suicidal behavior:
 Multi systemic therapy was shown to be more effective
Multi-systemic
than hospitalization at decreasing rates of youth-
reported suicide attempts (Huey et al., 2004)
 Developmental group therapy (including CBT
strategies) was shown to be more effective than routine
care at decreasing deliberate self-harm (Wood et al.,
2001)

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 Suicidal Ideation: thoughts about wanting to be

dead or killing oneself
 Suicide attempt: A potentially self-injurious
behavior, associated with some evidence of intent
to die
 Completed
C l t d suicide:
i id A fatal
f t l self-injurious
lf i j i
behavior that was associated with some intent to
die
 Non-suicidal self-injury behavior: Self-injurious
behavior not associated with intent to die (intent
may be to relieve distress or communicate with
another person), often called self mutilation
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 Past suicide attempt

 Access to weapons/lethal means
 Psychopathology: Depression, substance abuse,
conduct disorder (males)
 Sadness, anger, or other very painful negative
emotions (emotion dysregulation)
 The tendency to be aggressive and violent, and to
engage in i dangerous,
d illegal,
ill l or risky
i k activities
ti iti
 Impulsivity or acting without thinking
 Alcohol and drug use/abuse
 Family conflict
 Stressful life events: Problems with school, peers,
and relationships
 Hopelessness
 The perception that problems cannot be solved, poor
problem solving ability
 Family history of suicide
 Male gender
9/14/2012
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 9/14/2012

 Ideation
 Plan
 Intent
 Ability tocontract for safety/agree to a
safety plan
 Distal factors
 Proximal triggers (suicide attempts are
generally the result of distal risk factors
combined with a proximal trigger)
 Safety of home environment/ability of
parents to monitor safety
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 Access to lethal means
9/14/2012 Program - Do Not Copy

 Remove lethal means

 Create a safetyyp
plan
 Establish parental monitoring
 Increase frequency of visits
 Consider hospitalization

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 Client is asked to select a box to be filled

with reminders of coping skills and reasons
to live
 Can be done in session or as homework
 Instructions to client: “Sometimes when a
person is really upset and overwhelmed by
their emotions, it is hard to think straight and
remember to do something positive and safe.
The purpose of the hope box is to have it all
ready to go in advance so you can jump start
yourself into positive thinking and acting.”
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 9/14/2012

 Photographs of family, friends, favorite places, pets, etc.

 CDs, tapes, MP3s of favorite songs
 Videos, DVDs, of favorite television shows or movies.
 Favorite books, magazines, comic books
 Favorite foods (e.g., chocolate, tea bags – should be non-
perishable!)
 Favorite scents (e.g., perfume, scented candles, incense)
 Videogames
id
 Crossword puzzles, word search puzzles
 Coping Cards
 Letters
 Favorite gifts (e.g., a bracelet from a friend)
 Paper, pencils, paints, etc. (if youth likes to draw or paint)
 Sheet music, guitar strings, etc. (if the youth plays a
musical instrument)
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 Work with patient and family on removal of lethal means

 Create a detailed safety plan. Review with youth and parents.
 Have family monitor youth at risk
 Increase frequency of visits/level of care if needed
 Assess and document suicide risk in every session
 Keep the family updated/confidentiality
 Create a hope
p kit as a companion
p to the safety
ypplan
 Conduct a chain analysis/retelling of the suicide attempt to
conceptualize what triggers youth suicidality
 Intervene to decrease triggers of suicide attempts
 Work with family to decrease conflict
 Teach youth skills for regulating emotions
 Work with youth on hopeless thoughts/negative cognitions
 Consult with other clinicians

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 Panic Disorder
 GAD
 OCD
 Social Phobia
 SpecificPhobia
 Separation Anxiety
 Selective Mutism
 PTSD

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 9/14/2012

 16 sessions
 8 – 13 years old, adolescent version 14-17 years old
 FEAR Plan
 Feeling Frightened (awareness of physical symptoms of
anxiety)
 Expecting bad things to happen (recognition of anxious
self-talk)
 Attitudes and Actions that will help (behavior and coping
talk to use when anxious)
 Results and Rewards (self-evaluation and rewards for
effort)

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 Based on the principle of habituation (until anxiety

decreases by 50%)
 Create a graded exposure hierarchy
 Get SUDS ratings before, during, after exposure
 Imaginal and in vivo (imaginal useful to start out and for
fears that are more abstract or unlikely to happen [e.g.,
[e g
death of a parent in SA])
 Try not to have the client use distraction or safety
behaviors
 Assign for homework, in-session practice is not enough
 Practice, practice, practice
 Also leads to cognitive shift over time

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 Assess parental factors that may interfere

with treatment

“Rescuing” the child

Belief that child is unable to handle anxiety
Belief that the child should be able to handle
anxiety on his/her own

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