cognitive-behavioral therapy for treating depression and suicide in teenagers

Military Child Education Coalition National Training SeminarWashington DCJuly 29, 2014

Jeff Bergmann, PhD, LPC, NCCClinical Psychology, George Mason UniversityLieutenant Colonel, US Army

Training Schedule

introduction (5 minutes)

cognitive-behavioral theory (5 minutes)

conceptualization of how depression develops (5 minutes)

maintenance of depressive symptoms (5 minutes)

treatment plan development (10 minutes)

conceptualization of how suicidal ideation develops (10 minutes)

maintenance of suicidal symptoms (10 minutes)

treatment plan development (10 minutes)

teen case studies practical exercise (20 minutes)

questions (10 minutes)

Acknowledgements/Disclaimers

Information for this workshop is taken from the CBT Teen Depression Manual authored and utilized by Dr. Christy Espisito-Symthers in training psychologists at George Mason University.

Information presented in this workshop is not intended for use by unlicensed mental health professionals, does not reflect endorsement by George Mason University, the US Army or the Department of Defense. The material presented reflects the views of the presenter and is intended for self-awareness educational and informational purposes only.

This workshop presents cognitive-behavioral theory conceptualization of the development and maintenance of teenage depression and suicidal ideation. Information is presented to describe the connection of thoughts, behaviors, and feelings to the development and maintenance of depression and suicidal ideation. The information includes how a cognitive-behavioral therapy treatment plan is developed and implemented. Practical application include processing two case studies of military-connected teenagers, one dealing with depression and the other depression and suicidal ideation, for the purposes of illustrating the cognitive-behavioral conceptualization and developing a treatment plan. The following skills would be introduced and illustrated: deep breathing, progressive muscle relaxation, problems solving, thought challenging, cognitive restructuring, behavioral activation, and suicidal ideation safety plans.

CBT Skills Introduced & Illustrated

deep breathing progressive muscle relaxation problem solving thought challenging cognitive restructuring behavioral activation suicidal ideation safety planning

Workshop Learning Objectives Discuss the Cognitive Behavioral Theory of

personality, the development and maintenance of depressive symptoms, and approach to treatment.

Utilize patterns of problematic thinking to challenge irrational thoughts.

Recognize differences between upward and downward cognitive spirals.

Assess suicidal intent. Create a suicidal ideation safety plan. Practice Cognitive Behavioral Therapy skills

in a teen case study.

Learning Assessment

List the 3 parts of our personality according to Cognitive Behavioral Theory.

Employ at least two Cognitive Behavioral Therapy skills.

Discuss how upward and downward spirals explain the relationship between thoughts, behaviors, and feelings.

Explain how to assess suicidal ideation. Apply Cognitive Behavioral Therapy skills to

create a suicidal ideation safety plan. State that I had the opportunity to practice

Cognitive Behavioral Therapy skills during the workshop.

Cognitive Behavioral Theory

Thinking-Behaving-Feeling

“There must be something wrong Feel better

with me. I am such a loser! I can’t stand my life. I feel so angry and sad”

↓ ↑ Isolate in room Call a friend and make

plans to go see a movie

↓ ↑

Feel more sad and angry “It’s his/her loss. I can

do better. He/she was not really my type anyway.”

Thought Challenging

1. Is it true? Am I making a thinking mistake? What evidence do I have that it is true/false? What would my friend say if he/she heard this belief? 2. Is this belief helpful? Does this belief help get me what I want? Does this belief help me feel the way I want? Does this belief help me avoid conflicts?

Depressed Military Teen

15 year-old April just relocated to Texas

April hates hot weather April thinks Texas is obnoxious April left her 17 year-old boyfriend

back in NY and is worried the relationship won’t last

April is not adjusting well in her new school and her mom has noticed an increased pattern of withdrawal

April says no one in Texas likes her

April’s Depression

Depression Development & Maintenance CBT Triangle Thinking-Behaving-Feeling Spirals

Treatment Plan Psychoeducation (Information) Thought Challenging & Cognitive

Restructuring Behavioral Activation

Cognitive Restructuring

1st Step: Activating Event __________________________________________________________

2nd Step: Beliefs (skip 2nd step) 1_________________________________________________________ 2_________________________________________________________ 3_________________________________________________________ 4_________________________________________________________

3rd Step: Consequences or Feelings (go back to 2nd step) 1___________________________ 2___________________________

4th Step: Disputes 1_________________________________________________________ 2_________________________________________________________ 3_________________________________________________________ 4_________________________________________________________

5th Step: Effect or Change 1. I feel better 2. I can make better decisions

HELP WITH DISPUTING BELIEFS

Thought Challenging

You view a situation or person as all good or all bad, without noticing any points in between.

You predict the future negatively without considering other more likely outcomes.

You focus on the negatives and fail to recognize your positive experiences and qualities.

You think something must be true because you “feel” it so strongly, ignoring evidence to the contrary.

You assume that you know what others are thinking without asking.

You assume that you can control how others behave in situations where you really don’t have any control.

You believe that you (or others) should be perfect in the things that you (or others) say or do.

Problem Solving

Name: ________________________ Date: _________________________

Select problem:_____________________________________________________

Options Likely Outcome (+, -, +/-) 1. ________________________________ 2._________________________________ 3. _________________________________ 4. _________________________________ 5. _________________________________ 6. _________________________________ 7. _________________________________ 8. _________________________________

Circle the Very Best One Evaluate: How well did it work? 1 2 3 4 5 not very _______________________________ well well

Teen Suicidal Ideation Interview DEGREE OF SUICIDE RISK  1. How frequent have your suicidal thoughts been (everyday, few

days a week, etc.)? How long do they last when you do have them (most of the day, few hours, few minutes)?

  2. Have you told anyone about your suicidal thoughts?  3. Do you have a suicide plan? How long have you been thinking

about this plan? Have you made preparations for this plan? Have you acted on this plan in any way (e.g., held pills in hand)? Do you intend to act on this plan?

  4. Have you made any final preparations for a suicide attempt (e.g.,

suicide note, given away belongings)?  5. One a scale of 1 (not at all likely) to 10 (highly likely), what is the

likelihood that you will make a suicide attempt?

Interview Continued

PREFERRED METHOD FOR SUICIDE

1. If you were to make an attempt, how would you do it?  2. Do you have access to this method at your home or anyone else’s?  3. Do you have access to guns at your home or anyone else’s? Do you

have access to ammunition?  4. Do you have access to pills at your home or anyone else’s? If so, how

many, what type, and how are they stored (e.g., locked up)?

INTOXICATION 1. Have you used any alcohol or drugs recently? Was the use of drugs or

alcohol associated with your suicidal thoughts?   2. If yes, do you plan to continue to use drugs or alcohol? Do you have

access to drugs or alcohol?

Interview Continued

SUICIDE PRECIPITANT

1. What triggered your suicidal thoughts?

2. Does that problem still exist?  3. Can you avoid this problem in the

future? Do you intend to avoid this problem?

Assess Suicidal Intent

1. Do you actually want to die? Or, is it that you don’t really want to die but do want to escape an intolerable situation?

2. Do you think that things will get better with time or is this situation hopeless?

  3. What reasons do you have for living? Let’s list any

reasons that you have on this Reasons For Living List.

[Note: Examples might include future plans mentioned in previous sessions, leaving parents/siblings/family member/pet he/she cares about, the way people might feel if he/she committed suicide, things he/she will never get to do, or anything important to the teen.]

Assess Reasons for Living

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Introduce the Safety Plan

1. Can you 100% promise that you will not attempt suicide between now and the next outpatient appointment? (Note - this is asked for assessment purposes not intervention)

2. Can you promise that you will inform an adult should you feel in danger of making a suicide attempt? Who will you tell? (Inquire about people in and outside the home). What are their phone numbers? Let’s write them down on this Safety Plan. Be sure to keep them by your phone at home.

  3. If there is not an adult available when/if you were to feel in danger of attempting

suicide, will you promise to phone me (if during hours when I am available), call the suicide hotline, go to/have someone take you to the nearest emergency room, or call 911 for help? Can you think of anything that could get in the way of you using this plan?

4. Will you make every effort to avoid activities/situations which you believe may increase the chance of thinking about or attempting suicide?

  5. If you are unable to avoid these activities/situations or others that leave you feeling

very upset, what can you do to help calm yourself down? These can be things that you can do or tell yourself. Let’s write them down on this Safety Plan.

[NOTE: If teen was able to list any reasons for living be sure to have him/her include

“read reasons for living list” as a coping technique].

Suicidal Ideation Safety Plan

SAFETY PLAN

As part of my therapy, I ___________________________, agree to the following: 1. One of my goals is to work on my problems to help myself feel better. 2. While working on my problems, I will keep myself safe and not end my life. 3. If at any time I should feel unable to keep myself safe, I will immediately tell at least one of the following adults and call my therapist (during office hours). ________________________________ at (_____)__________________ ________________________________ at (_____)__________________ ________________________________ at (_____)__________________ Therapist:________________________ at (_____)__________________ 4. If I am unable to reach an adult immediately, I will call a suicide hotline (listed below), call 911 for help, or go to a local emergency room.

1-800-273-TALK (8255) National Suicide Prevention Lifeline 1-800-SUICIDE (784-2433) HOPELINE

5. I will also use the following coping techniques to help calm myself as needed. _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _______________________ _______ _______________________ _______ Signature Date Therapist’s Signature Date

Practical Exercise

1st ____________

2n d ____________ 3r d ____________ 4t h ____________

Cognitive Restructuring

1st Step: Activating Event __________________________________________________________

2nd Step: Beliefs (skip 2nd step) 1_________________________________________________________ 2_________________________________________________________ 3_________________________________________________________ 4_________________________________________________________

3rd Step: Consequences or Feelings (go back to 2nd step) 1___________________________ 2___________________________

4th Step: Disputes 1_________________________________________________________ 2_________________________________________________________ 3_________________________________________________________ 4_________________________________________________________

5th Step: Effect or Change 1. I feel better 2. I can make better decisions

HELP WITH DISPUTING BELIEFS

Thought Challenging

You view a situation or person as all good or all bad, without noticing any points in between.

You predict the future negatively without considering other more likely outcomes.

You focus on the negatives and fail to recognize your positive experiences and qualities.

You think something must be true because you “feel” it so strongly, ignoring evidence to the contrary.

You assume that you know what others are thinking without asking.

You assume that you can control how others behave in situations where you really don’t have any control.

You believe that you (or others) should be perfect in the things that you (or others) say or do.

Problem Solving

Name: ________________________ Date: _________________________

Select problem:_____________________________________________________

Options Likely Outcome (+, -, +/-) 1. ________________________________ 2._________________________________ 3. _________________________________ 4. _________________________________ 5. _________________________________ 6. _________________________________ 7. _________________________________ 8. _________________________________

Circle the Very Best One Evaluate: How well did it work? 1 2 3 4 5 not very _______________________________ well well

Relaxation TechniquesGUIDED IMAGERY SCRIPT

I would like you to sit back, relax, and practice your deep breathing. Breathe in through your nose………and out through your

mouth…………..in through your nose……. and out through your mouth…..just keep deep breathing for a few moments…….……Keep your eyes closed until your journey is over……… Good. Now we are going to take an imaginary trip. Imagine that we leave this room, go down the stairs, and through the hall to the door. Outside of the door waiting for you is a hot air balloon. The balloon has big beautiful bright stripes of color on it, red……blue….. green…… …orange….. and yellow. Across the middle is your name written in big black letters. This is your very own balloon for the day. You climb inside the big sturdy brown wicker basket underneath the balloon. Once you are settled, it slowly takes off into the air. You have control over how high off the ground the balloon will go. The wicker basket that you stand in has high sides so that you don’t have to worry about falling out. You feel very very safe. As the balloon takes off, you feel excited about the trip you are about to take. The balloon begins to float slowly through the air. You float over trees bustling with green leaves waiving in the wind. You fly over tranquil blue lakes that sparkle with the sunshine. As you look down you also see streets and highways with cars that look like they are the size of march box cars whizzing by. You can see the roofs of long shopping malls and tall office buildings. As you float out of the city you leave the busy streets behind and start to see only the countryside. You fly over trees of many different shades of green, orange, red, and yellow. Then wide rambling green fields with big bright flowers blowing in the wind which seem to go on for miles and miles. All the while you hear the soft breeze blow by your ears and nothing else. Now your balloon is headed toward the coast. As it approaches, you begin to see the deep blue ocean and a sandy beach in the distance. You can hear the soft roar of the waves as they reach the shore. You notice that the air is getting warmer and it makes you feel more and more relaxed. The closer you get to the beach the better you can see the clear, white sand. The balloon begins to slowly descend as you reach your destination. The balloon lands softly on the white sand. You take off your shoes, grab the big soft royal blue beach towel lying in the balloon basket, and step out of the basket onto the sand. The white sand feels soft and warm under your feet. You scrunch your toes in the sand for a moment and feel its smooth soft texture. You can taste the salt in the air and smell the refreshing clean scent of the ocean. You begin to walking down the beach looking for a good spot to lay down in the sun. After you find your spot, you lay your oversized blue beach towel on the warm sand and then lie down. You feel very very relaxed and happy to be there. There is not a cloud in the sky and the sun is warm. You can feel the sun on your body. The sun makes you feel very very relaxed. You hear the rhythmic waves splash against the shore. The waves go in and out, in and out. They seem to match your breathing. You breathe in and out, in and out. With every breath you take in, you feel more and more relaxed. With every breath you let out, you let go of your tension. You hear the seagulls calling above you. It is just you and the seagulls on this beach. It is ever so peaceful. You pick up a handful of sand and let the sand trickle through your fingers. You feel very relaxed. Lay here for a while and enjoy how relaxed you feel. Remember how this moment feels. LONG PAUSE.

Relaxation Techniques Continued

Deep Breathing Progressive Muscle Relaxation

jeffreybergmann@gmail.com

Questions/Discussion