Cognitive Behavioral Interventions

SOW6425 Assessment and Planning

Professor Nan Van Den Bergh

SOCIAL SKILLS TRAINING:TWO TYPES OF INTERPERSONAL COMPETENCE

Cognitive Competence

Knowledge about relationships (what they are, why they are important, how they develop, social norms)

Perceptual skills (how the client interprets the social world)

Decision-making skills (when and how to approach others)

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

Self presentation (to enhance likelihood of positive responses)

Social initiatives (includes how to start conversations)

Conversational (talking, listening, turn-taking)

Maintenance (of relationships over time)

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

• 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.)

• 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: 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 pro-

actively 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: – 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: Self-

Monitoring (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– 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 panic-associated 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 INTERVENTIONWITH ADOLESCENT SEX OFEFNDERS

• Denial or Minimization – Each offender is required to give full disclosure of his offenses, including thoughts and feelings when offending • 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:• 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 INTERVENTIONWITH 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.