1. Cognitive Behavioral Interventions SOW6425 Assessment and Planning Professor Nan Van Den Bergh

2. 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

3. 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

4. SOCIAL SKILLS TRAINING: Cognitive Behavioral Intervention 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)

5. 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)

6. 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

7. Critical Social Skills Assertiveness Active listening: body language, attending, reflecting 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

8. 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

9. 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

10. 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

11. 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)

12. 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

13. 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)

14. 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)

15. 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

16. Interventions in CBT: Relaxation Training/Breathing Retraining: 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

17. 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

18. 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

19. 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 –Helps to de-catastrophize somatic experiences

20. Interventions in CBT: Imaginal Rehersal Client imagines a hierarchy of scenarios in which they might experience panic attacks Clients invited to visualize each scene –As they imagine scene, they see themselves coping

21. 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……”

22. 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

23. 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

24. 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