Mental Health Education and Training Initiative

2005 Learning Session II

National Assembly on School-Based Health Care

IcebreakerIcebreakerWhat is your skill?What is your skill? Listening

Asking for Help Apologizing

Deep Breathing

Muscle Relaxation

– Positive Self-talk

Cognitive restructuring

– Resisting Peer Pressure

Scheduling Pleasurable Activities

Problem Solving

Overview of Day: Learning Session II AgendaOverview of Day: Learning Session II Agenda What are Core Skills?

Core Skills – Review and Role Play– Anxiety– Depression– Disruptive Behavior Disorders– Substance Abuse

Mental Health Documentation and Treatment Planning for MH Providers

Storyboards

Group Interventions: – Review and Select Manualized Interventions

Work plan Development

National Assemblyon School-BasedHealth CareWashington, DCwww.nasbhc.orginfo@nasbhc.org202-638-8872 or 1-888-286-8727 - toll free

Center for School Mental Health Center for School Mental Health Analysis & ActionAnalysis & Action

email: csmha@psych.umaryland.eduweb: http://csmha.umaryland.eduphone: 410-706-0980 (888-706-0980)

Director: Mark Weist, Ph.D.Director: Mark Weist, Ph.D.

Director of Research and Analyses: Director of Research and Analyses: Sharon Stephan, Ph.D.Sharon Stephan, Ph.D.

Mental Health Education and Mental Health Education and Training (MHET) InitiativeTraining (MHET) Initiative Funded by the HRSA Maternal and Child Health Bureau and

the Bureau of Primary Health Care

Developed by the National Assembly on School-Based Health Care in collaboration with the Center for School Mental Health Assistance (CSMHA) at the University of Maryland

In partnership with Columbia University TeenScreen Program

2004-2005 7 SBHCs from Colorado, Louisiana, New Jersey, North Carolina

2005-2006 13 SBHCs from Michigan and West Virginia

MHET MissionMHET Mission Increase knowledge and implementation

of mental health – screening, – diagnosis, – referral, – coding, and – empirically-supported short-term

interventions among SBHC primary care and mentalhealth providers.

Learning Session Two Learning Session Two Pre-assessment – Core SkillsPre-assessment – Core Skills

MHET Objectives: Learning Session IIMHET Objectives: Learning Session II

OBJECTIVE 7: To increase SBHC primary care and mental health professionals’ knowledge about skills related to youth mental health, and to anxiety, depression, substance abuse, and disruptive behavior disorders, more specifically, and to increase interventions aimed to train youth in these skills.

A Four-Pronged Approach to Evidence-A Four-Pronged Approach to Evidence-Based Practice in School Mental HealthBased Practice in School Mental Health

Decrease stress/risk factors

Increase protective factors

Train in core skills

Implement manualized interventions

Training in Training in Core SkillsCore Skills

What are “core skills”?What are “core skills”?

Based in cognitive behavioral theory

Buffer against the development of mental health problems

Assist in coping with mental health problems

What is Cognitive Behavior Therapy (CBT)?What is Cognitive Behavior Therapy (CBT)?Relatively short-term, focused

psychotherapy

Focus:– How you are thinking (your cognitions)– How you are behaving and communicating

Emphasis on present rather than past

Learn coping skills

Skills training for AnxietySkills training for Anxiety

Deep Breathing Progressive Muscle

Relaxation Mental

Imagery/Visualization Systematic

Desensitization General Stress Busters Cognitive Restructuring

Deep BreathingDeep Breathing

Breathe from the stomach rather than from the lungs

Can be used in class without anyone noticing

Can be used during stressful moments such as taking an exam or while trying to relax at home

Progressive Muscle RelaxationProgressive Muscle Relaxation Alternating between

states of muscle tension and relaxation helps differentiate between the two states and helps habituate a process of relaxing muscles that are tensed

Many good tapes/c.d.’s available on relaxation

Especially suited for middle and high school students

Mental Imagery/VisualizationMental Imagery/Visualization Can enhance other

relaxation techniques or be used on its own

Provides relief from troubling thoughts, emotions, or feelings

Evokes a pleasing, calming mental image (e.g., the beach, park, forest, playing with a favorite pet)

Systematic DesensitizationSystematic Desensitization

Anxiety reducing strategy involving exposure of the phobic child to the feared object or situation.

The child learns to tolerate the feared object by means of a series of steps beginning with the least anxiety producing aspect of the process and ending with the most difficult step.

Construction of the Anxiety Hierarchy

General Stress BustersGeneral Stress Busters Go for a walk Take a nap Play with a pet Take a bath Listen to music Talk to a friend Exercise Write in a journal Write a letter that you never send Do something creative – an art

project, poem, write a rap Watch television Talk on the phone Read

Cognitive RestructuringCognitive Restructuring Change cognitive

distortions (irrational negative thoughts and beliefs someone has about different situations) and to increase positive self talk

Steps:– Recognize and get rid of

negative self talk– Counter the negative

thoughts with realistic positive self talk

– Believe the positive self talk!

Case Example and Role Play:Case Example and Role Play:AnxietyAnxiety

MH Provider Role PlayMH Provider Role PlayAnxiety: Systematic DesensitizationAnxiety: Systematic Desensitization Marcus has come for a follow-up appointment at the SBHC.

He reported several anxiety symptoms during his comprehensive risk assessment, and screened positively for panic attacks during the Diagnostic Predictive Scales. Marcus indicates that the panic attacks are triggered by a fear of being called on in class. He experiences symptoms of panic (heart palpitations, nervousness, sweating, etc) on the way to school, while sitting in class, and even just thinking about being in class.

Begin the process of Systematic Desensitization with Marcus.– Teach Relaxation techniques (Deep Breathing, Muscle

Relaxation, Imagery)– Create a Fear Hierarchy– Practice imaginal exposure to feared situations using the

fear hierarchy.

Primary Care Provider Role PlayPrimary Care Provider Role PlayAnxiety: Relaxation TechniquesAnxiety: Relaxation Techniques Marcus has come for an initial appointment at the SBHC.

He appears short of breath, and reports that he is having heart palpitations. He is sweating, and reports nervousness. Upon interview, Marcus indicates that his symptoms were triggered by a fear of being called on in class. He has had similar symptoms before, and believes they are panic attacks. He is unsure of how to relax when he has these symptoms, but is concerned that he is “going crazy,” and worries that his friends will tease him if they find out.

Review relaxation techniques with Marcus, including Deep Breathing, Progressive Muscle Relaxation, and Mental Imagery/Visualization.– First, explain to Marcus how relaxation is important in reducing

symptoms of Anxiety.– Next, introduce each relaxation technique, and PRACTICE with

Marcus.– Encourage Marcus to practice each technique several times, and

schedule a follow-up appointment to review progress.

Skills training for DepressionSkills training for Depression

Cognitive Restructuring

Thought Stopping Activity Scheduling Social Skills Training Problem Solving Relaxation Training

Cognitive RestructuringCognitive Restructuring

Change cognitive distortions (irrational negative thoughts and beliefs someone has about different situations) and to increase positive self talk

Steps:– Recognize and get rid of negative

self talk– Counter the negative thoughts with

realistic positive self talk– Believe the positive self talk!

Thought StoppingThought Stopping Replaces “racing thoughts” or

disturbing thoughts with neutral thought.

Neutral thought – e.g., something positive and affirming; relaxing location

Thoughts can be “stopped” by practicing an abrupt interruption of thought – e.g., shouting “stop!”; snapping rubberband on wrist

Return to thinking only about the neutral situation.

Activity SchedulingActivity Scheduling Scheduling enjoyable and goal-

directed activities into the child’s day

Assists withdrawn students reengage in pleasurable activities

Provides the child with the opportunity to feel more effective as he or she completes tasks such as school projects

Child needs to be educated about the relationship between involvement in an activity and improvement in mood.

Problem SolvingProblem Solving Assist students in generating

solutions to problems Only focus on one problem at a

time.

Steps:– Define the problem.– Brainstorm all possible solutions.– Focus your energy and attention

to be able to complete your task– Identify outcomes related to the

various solutions, including who will be affected by the outcomes.

– Make a decision and carry out.– Have a contingency plan in case

the solution does not work out as planned.

– Evaluate the outcome.

Relaxation TrainingRelaxation Training

Deep Breathing

Progressive Muscle Relaxation

General Stress Busters

Case Example and Role Play:Case Example and Role Play:DepressionDepression

MH Provider Role PlayMH Provider Role PlayDepression: Cognitive RestructuringDepression: Cognitive Restructuring Tonya has come for an initial appointment to the SBHC. During the

risk assessment, Tonya reports a number of depressive symptoms, but no suicidal ideation. Tonya seems to display a lot of negative thinking and cognitive distortions. For example, she believes that “nobody” likes her and that s/he will “never” be successful in school. Her math teacher often compliments her work, but Tonya dismisses the teacher’s comments as him “just trying to be nice.” Tonya has good grades in all classes except for one, yet she only acknowledges her below average Chemistry grade.

Practice the process of Cognitive Restructuring with Tonya.– Describe the relationship between ways of thinking and depressive

symptoms– Help Tonya to identify her cognitive distortions– Identify ways of countering cognitive distortions– Have Tonya practice countering these distortions

Primary Care Provider Role PlayPrimary Care Provider Role PlayDepression: Activity Scheduling, Thought StoppingDepression: Activity Scheduling, Thought Stopping

Tonya has come for an initial appointment to the SBHC. During the risk assessment, Tonya reports a number of depressive symptoms, but no suicidal ideation. Tonya reports not engaging in any activities that she used to. For example, she used to spend time with friends after school, and used to enjoy reading. She hasn’t done either recently, and just seems bored most of the time. She also reports having difficulty concentrating in class because she is constantly thinking about her problems.

Practice the processes of Activity Scheduling and Thought Stopping with Tonya.– Discuss with Tonya activities she used to enjoy.– Identify specific enjoyable activities for Tonya to do this week.– Identify times and places for each activity, and discuss potential

obstacles.– Explain the process of Thought Stopping to Tonya, and discuss

how Tonya could use this strategy when she has intrusive thoughts.

Introduction to the ManualsIntroduction to the Manuals

FRIENDSSkillstreamingDefiant Children/TeensCognitive Behavioral Intervention for

Trauma in Schools (CBITS)

FRIENDS (Paula Bartlett)FRIENDS (Paula Bartlett)Group-administered cognitive-behavioral

treatment for depression and anxiety symptoms for children ages 7-11 (FRIENDS for Children) or adolescents age 12-16 (FRIENDS for Youth).

10 sessions between 45-60 minutes in length, administered on a weekly basis, with two follow-up booster sessions and four optional parent sessions.

Groups should be comprised of 12 or fewer youth.

FRIENDS addresses the three major components of chronic anxiety symptoms: – mind (i.e., cognition),

– body (i.e. physiological responses),

– and behavior (i.e., learning new coping skills).

Two manuals are necessary to implement the approach: the group leader’s manual, a children’s workbook.

Manuals are $65.00 each

Skillstreaming (Arnold Goldstein)Skillstreaming (Arnold Goldstein) Designed to enhance youths’ social skills, can be used as a

universal classroom or a selected smallgroup intervention.

Separate curricula exist for K-6 (Skillstreaming for Elementary School Children) and 7-12 grades (Skillstreaming for Adolescents).

Instructors can run through the entire protocol or select different component skills to meet the needs of specific youth.

Cue cards are used to prompt students to use Skillstreaming strategies.

To implement Skillstreaming, a therapists’ manual ($19.95), student workbook ($12.95), student materials ($16.95), and student skill cards ($25.00) are needed.

Defiant Children and Defiant Teens Defiant Children and Defiant Teens (Barkley, Robin, Edwards)(Barkley, Robin, Edwards) 18-step program designed both to teach parents the skills

they need to manage difficult child/adolescent behavior and to improve family relationships overall.

Delineate clear procedures for assessing defiance in children/teens and working with parents, alone or in groups, to reverse problem behavior

Clinicians are shown how to help all family members learn to negotiate, communicate, and problem-solve more effectively, while facilitating adolescents' individuation and autonomy (for Defiant Teens)

Clinician Manuals $36.00 each; Contain reproducible handouts for parents and adolescents

Cognitive Behavioral Intervention for Cognitive Behavioral Intervention for Trauma in Schools (CBITS; Lisa Jaycox)Trauma in Schools (CBITS; Lisa Jaycox)

10-session school-based, cognitive behavioral intervention for trauma exposed adolescents

Optional 1-3 individual sessions

It incorporates cognitive behavioral therapy (CBT) skills in a group format to address symptoms of PTSD, depression, and anxiety related to trauma exposure

Informational components for teachers and parents

Clinician manuals $34.95; Contains reproducible handouts

Disruptive Behavior DisorderDisruptive Behavior Disorder• Family Involvement• Classroom Management

The research on interventions for The research on interventions for disruptive behavior disordersdisruptive behavior disordersOther than stimulant medication for ADHD, no

individual or group interventions have been proven effective

Some evidence that group interventions make problems worse (peer contagion)

All empirically-supported interventions for disruptive disorders involve the youth’s key socialization agents: parents and teachers

Engaging parents in process is crucial

MH interventions with little or NO MH interventions with little or NO evidence of effectiveness for DBD:evidence of effectiveness for DBD: Special elimination diets Vitamins or other health food remedies Psychotherapy or psychoanalysis Biofeedback Play therapy Chiropractic treatment Sensory integration training Social skills training Self-control training

Engaging Parents Engaging Parents in Family Interventionsin Family Interventions

Make services user-friendly to parents Validate parent frustration and the fact that child is

difficult Never blame parents for child’s problems Appeal to parent’s desire for things to be better Address misperceptions about learning parenting

skills Help parents with other things they need – be

helpful person in multiple ways

What are Behavior Management What are Behavior Management and Parent Training?and Parent Training? Why children misbehave – correcting

misperceptions Identifying and removing barriers to effective

child management Paying attention to and reinforcing child’s good

behavior (improving emotional relationship) Issuing effective commands (compliance

training) Use of time-out Reinforcement and response cost system (tokens

or points) for appropriate/inappropriate behaviors Extension to school and public settings -

behavior report card

Rewards and Response Cost Rewards and Response Cost SystemsSystems Desired and inappropriate behaviors clearly specified Tokens for younger children; points for older Implement rewards first, then introduce loss of points Points exchanged for small (daily), medium

(weekly), and larger (monthly) rewards; should be primarily non-tangibles

Pair with social reinforcers Fade system as behavior improves (4-6 months)

Improving family management of Improving family management of older youth (13+)older youth (13+)

Parental engagement is still crucial, and engaging parents of adolescent sometimes involves different issues

Interventions must take into account child’s developmental needs

Improve emotional climate of family – increase cohesion, reduce conflict

Youth needs to be involved in family decision making and rule-setting – parents need to learn how to go “one-down” to go “one up”

Parent regression techniqueParent regression technique

To address parental detachment from a teenager resulting from problematic behavior (and resistance to changing parenting behavior)

What was it like when ____ was first born? What did you hope/wish for ____?

What went wrong? (non-blaming) What can be done now?

Emphasize that its not too late and address parents’ fear of failing again

Improving family management Improving family management of older youth cont’dof older youth cont’d

Age-appropriate rewards and punishments are still necessary, but point system no longer effective

Improve parent monitoring and consistency in delivering consequences

Break deviant peer group ties Strongly promote appropriate peer group ties Parents pulling together to set common rules, curfews,

etc.

Classroom-based interventionsClassroom-based interventions

Many engagement issues are the same – what can YOU do for the teacher?

Identify important classroom behaviors to target from the teachers’ perspective

Modify intervention protocols to teacher’s needs

Emphasize preventionStart small – build on small gains

Social SkillsSocial Skills Students who display disruptive

behaviors often have a difficult time with social interactions (e.g., reacting hostilely)

AND often become a source of ridicule by other students

Social skills can be enhanced by:– role modeling– role playing– providing positive feedback and

support for appropriate behaviors

Assist students in identifying perceptions and interpretations that others have of them as well as others’ intents.

ResourcesResources

Several empirically-supported protocols exist:– Defiant Children (Russell Barkley)– Helping the Noncompliant Child (Rex Forehand)– Videotape Parent Modeling (Carolyn Webster-

Stratton)

The University of Buffalo Center for Children and Families– http://wings.buffalo.edu/adhd/– Free resources on disruptive behavior disorders:

Parent handouts Teacher handouts Assessment tools

Substance AbuseSubstance Abuse

Family-based and Classroom-based interventionRefusal SkillsSelf-esteemEducation

Family-based and classroom-Family-based and classroom-based interventionsbased interventions Research has documented that family

involvement and classroom-based prevention programs are the most effective means of addressing substance abuse among youth

School-based health professionals can effectively act as an intermediary between the student and other important players: parents!, extended family, school, community

Refusal SkillsRefusal Skills

Encourage students to develop different ways to refuse substance use

Examples:– Switching topic (“hey, did you hear about the game

last night?”)– Using an excuse (“I can’t, I’m meeting a friend in 10

minutes)– Put the “blame” on others/parents (“my mom would

kill me if she found out”)– Walk away– State the facts (“No thanks, I’ve read about what

drugs can do to your body”)

Self-esteemSelf-esteem

Children with low self-esteem and self-awareness are more likely to engage in substance abuse

Therefore, teaching skills to enhance self-esteem and awareness are critical

EducationEducation

Educating students about the harmful effects of substance use may equip them with knowledge necessary to help them avoid abusing alcohol or drugs

Substance Abuse Screening: Tips Substance Abuse Screening: Tips for interviewing adolescentsfor interviewing adolescents

Private setting without parents present Display related pamphlets, with multiple copies to give

away Discuss confidentiality Introduce the topic of alcohol/drugs in a nonjudgmental

way: “I know that some kids your age use alcohol, or smoke, or use other drugs…”

Introduce the topic in the context of concern for the student’s health: “I’d like to know a little bit of what you do in this regard and how you feel about it, because it’s important to your health.”

Administer a screening instrument (examples in manual)

Motivational Interviewing (MI)Motivational Interviewing (MI)(Miller & Rollnick, 1991)(Miller & Rollnick, 1991) A useful strategy for those who have ambivalence about changing

behavior (including alcohol/drug use)

MI can be used at all stages of change:DURING: MI can:

– Precontemplation – raise awareness– Contemplation – help decision making – Action

and Maintenance - enhance and remind of resolution to change– Relapse - enables reassessment

Provides clarification. Students with confusion around issues often find the process of motivational interviewing helps to sort thing out for them.

Assessment As students identify their benefits, costs, life goals, decision and subsequent goals, they have uncovered a lot of information for themselves and their counselor.

Motivational Interviewing: StrategiesMotivational Interviewing: Strategies Express empathy: Reflecting back to the student his/her feelings

and thoughts not only helps build rapport, but in this process, helps mirror the student’s experience in a way which allows him/her to fully experience their dilemma.

Develop discrepancy: The discrepancy is not so much between the positives and not positives of the behavior but between the present behavior and significant goals which will motivate change.

Avoid argumentation: Arguments are counter-productive and results in defensiveness.

Roll with resistance: Otherwise known as verbal judo. The use of reframe or simply changing tack may help maintain momentum towards change.

Support self-efficacy: Motivation is partly made up of two main factors - importance and confidence. While it may be important to change, it won't happen if the student feels unable to do it. Every opportunity is taken to support the student's abilities to aid motivation to change.

Motivational InterviewingMotivational InterviewingStep 1: Set the AgendaStep 1: Set the Agenda

It can be useful to 'make a space' in which to conduct Motivational Interviewing. Having clarified the agenda around which there is ambivalence, ask for 20 minutes or so to try a series of special questions called "Motivational Interviewing" to help sort things out.

Motivational InterviewingMotivational InterviewingStep 2: Ask about positive aspects of substance useStep 2: Ask about positive aspects of substance use

This is often an engaging surprise for the student. However, it will only work if you are genuinely interested. Use questions like:– What are some of the good things about…?– People usually use drug because they help in some way - how

have they helped you?– What do you like about the effects…?– What would you miss if you weren't..?– What else, what else..?

Give praise and support self efficacy – e.g., You’ve done a nice job of explaining why drinking works for you… Your drug use seems to be a way you have found to cope with some of your problems…

SUMMARIZE positives

Motivational InterviewingMotivational InterviewingStep 3: Ask about less good thingsStep 3: Ask about less good things Use questions like:

– Can you tell me about the down side?– What are some aspects you are not so happy about?– What are the things you wouldn't miss?– If you continued as before, how do you see yourself in

a couple of years from now if you don't change?

Give praise and support self efficacy: You've done well to have survived all of that…

SUMMARIZE less good things

Motivational InterviewingMotivational InterviewingStep 4: Life GoalsStep 4: Life Goals These goals will be the pivotal point against which costs

and benefits are weighed. Ask questions like:– What sort of things are important to you?– What sort of person would you like to be?– If things worked out in the best possible way for you, what would

you be doing in one year from now?– What are some of the good things your friends and family say

about you?– How does your drug use (or you as a drug user) fit in with your

goal(s)?

Give praise and support self efficacy: I can see you've got some great vision for yourself…

SUMMARIZE life goals

Motivational InterviewingMotivational InterviewingStep 5: Ask for a decisionStep 5: Ask for a decisionRestate their dilemma or ambivalence then

ask for a decision:– You were saying that you were trying to decide

whether to continue or cut down…– After this discussion, are you more clear about

what you would like to do?– So, have you made a decision?

Motivational InterviewingMotivational InterviewingStep 6: Goal SettingStep 6: Goal Setting Use SMART goal setting (Specific,

Meaningful, Assessable, Realistic, Timed)– What will be your next (first) step now?– What will you do in the next one or two days (week)– Have you ever done any of these things before to

achieve this? What will you need to do to repeat these?

– Who will be helping and supporting you?– On a scale of 1 to 10, what are the chances that you

will do your next step? (be hesitant about accepting anything under a seven - their initial goal or next step may need to be more achievable)

If no decision or decision to If no decision or decision to continue substance usecontinue substance use If no decision, empathize with difficulty of

ambivalence. Ask if there is something else (information, time, etc.) which would help to make a decision? Ask if they have a plan to manage not making a decision. Ask if they are interested in reducing some of the problems (restate problems) while they are trying to make a decision.

If decision to continue use, accept decision. Ask if they are interested in reducing some of the problems (restate problems). Use problem solving and harm reduction strategies as necessary.

Final thoughts on substance Final thoughts on substance abuse…abuse…Even with good screenings, appropriate

referrals, etc., students may not be motivated to change work on increasing their motivation!

Substance use is often multigenerational be sure to address family needs also

Mental Health Documentation Mental Health Documentation and Treatment Planningand Treatment Planning

Benefits of Good Mental Health Benefits of Good Mental Health DocumentationDocumentationAssists in monitoring of treatment progressMindful of different components of

treatment – family involvement, assessment, intervention (not just content)

Structures intervention around treatment goals/objectives

Liability!

Mental Health DocumentationMental Health Documentation What do you currently include in MH Progress

Notes?– Date, Time, Duration– Diagnosis– Type of Contact– Mental Status

Affect, Mood, Relatedness, Thought Process, Speech– Content of Session– Assessment Strategies– Intervention Strategies – include CBT skills– Progress on Objective Treatment Goals– Family Involvement– Plans for Future Intervention

Benefits of Good Mental Health Benefits of Good Mental Health Treatment PlanningTreatment Planning Interventions are matched to Needs/Problems Short- and long-term goals are identified and

clear to provider(s) and student/family Identifying objective treatment goals allows for

monitoring of treatment progress Structured treatment plans reduce risk of

engaging in unnecessary/unhelpful interventions– Avoid the unproductive habit of just seeing those who

continue to come for appointments for as long as they will come!

Mental Health Treatment PlanningMental Health Treatment Planning

How do you treatment plan?– Identify Strengths– Identify Needs/Problems– Match interventions to needs/problems– Identify who will implement intervention– Identify short- and long-term goals with

timeline