Ingrid Diaz, MA, MSW, LCSW, PhD (candidate)

Transcription

1 Ingrid Diaz, MA, MSW, LCSW, PhD (candidate)

2 Objectives: Understand CB Strategies Define CBT CBT techniques and strategies for Latinos

3 Evidence has shown that culturally competent services significantly increase treatment compliance within Latino population (Interian et al. 2007).

4 Latinos Largest growing group in the United States through migration and population shifts. The population has been on a steady rise since the 1970 s As of 2009, there are 50.5 million Latinos in the United States or 17 % of the population. ( 2010 U.S. Census)

5 Assessment Conduct ethnocultural assessment described as: understanding ethnic heritage country of origin rural versus urban background reasons for migration, how they arrived to the United States the impact of migration on the family dynamics among other components.

6 Cognitive Behavioral Approach Combines cognitive psychology & learning principles of behaviorism Uses a broad set of techniques to improve emotional functioning and modify behaviors by cognitive restructuring, changing behavior, or both to acquire new adaptive ways of thinking and behaving

7 Cognitive-Behavioral Techniques Reinforcement Shaping Modeling Role Plays Homework Cognitive Restructuring Use of CBT skills

8 Reinforcement Positive Reinforcement: to increase future frequency of a behavior due to the addition of a stimulus immediately following a response. Negative Reinforcement (NOT Punishment): to increase future frequency of a behavior when the consequence is the removal of an aversive stimulus

9 Examples of Reinforcers POSITIVE: Foods or liquids Hugs, handshakes Smiles, praise Tokens, points, or credits Certificates Special privileges NEGATIVE: Headache, take aspirin Confused, ask questions Too many people, leave Too cold, put on sweater

10 Shaping Reinforce successive approximations of steps toward a desired goal Identify approximations Reinforce success Understand that change can be rapid and/or slow

11 Modeling A powerful method to teach a new skill Moves the teaching of a new skill from abstract to application Use the skill you want consumers to learn

12 Role Plays Practicing new skills reduces anxiety, makes it more comfortable and realistic to use new behaviors Can be applied when modeling Role Plays in group work can be helpful for individuals to get feedback from others

13 Homework Gives people the means to practice new skills Consumers should be familiar with the new skill: when and where to practice it Examine what went well and not so well in applying the new skill Positive reinforcement increases the rates of completing HW

14 Cognitive Restructuring Reframing: Taking consumer information and rephrasing it so the person views it in a new light that is more likely to be helpful

15

16 Early Contributors CBT Albert Bandura Social Learning Tx Albert Ellis Rational Emotive Tx Aaron Beck Cognitive Beh. Tx

17 Today s Cognitive Behaviorists Judith Beck David Burns Feeling Good: New Mood Therapy Marsha Linehan Dialectical Beh. Tx

18 Feedback Loop How you think and act affects how you feel, and how you feel affects how you act and think

19 How you think and act affects how you feel. How you feel affects how you act and think. Thoughts Behavior Mood

20 CBT in a Nut Shell It is not events but the interpretation of events that trouble us. Beliefs and thoughts affect our perception of an event. These thoughts affect feelings and influence behaviors.

21 Cognitive Behavioral Therapy A psychotherapeutic approach used to understand the relationship between thinking & beliefs, & how they affect emotions & behavior and changing dysfunctional thoughts and beliefs to more realistic ones, feelings can be experienced differently which can influence behaviors A variety of cognitive, behavioral and experiential strategies are used separately and together to increase adaptive functioning

22 Misunderstandings of CBT It is NOT positive thinking: People learn to recognize the way they structure their life experiences through dysfunctional beliefs, thoughts, and behaviors that cause distress and maladaptive behaviors. It does NOT exclude other approaches: CBT does support the use of Rogerian, MI, and other approaches that create a sound therapeutic alliance.

23 Essentials For The Therapeutic Relationship Person Centered Empathic Non-possessive warmth Genuine Develops trust Provides hope Offers education Gentle Patient Non-judgmental

24 Elements of CBT Goal Oriented Here and Now Focused Time Limited Structured Collaborative Educational Includes Homework and/or Action Plans

25 Structure of the Therapeutic Session 1. Mood check 2. Setting agenda 3. Bridge from the last session 4. Discussion of today s agenda items 5. Homework assignment 6. Capsule summarizations and session summary 7. Feedback from person

26 Core Techniques Identify Automatic Thoughts (ATs) Dispute ATs Guide Discovery/Socratic Questioning Uses Behavioral Experiments and Tests Hypotheses Identify Core Beliefs

27 Core Techniques Identify Automatic Thoughts (ATs) Dispute ATs Guided Discovery/Socratic Questioning Test Hypothesis Testing or Behavioral Experiments Identify Core Beliefs Rules For Core Beliefs Change Core Beliefs

28 The ABC Model of CBT A - Activating event B - Belief C - Consequences (mood & behavior)

29 Feedback Loop Event Feeling: Physiological sensations emotion Thought Mckay, M et al Thoughts & Feelings. Oakland CA. New Harbinger Pub. Inc.

30 Erroneous Interpretations of Events Affect mood negatively Affect our physiological response Affect behaviors Limit choices Create a negative feedback loop

31 Negative Feedback Loop Event Feeling: Physiological sensations emotion Thought Mckay, M et al Thoughts & feelings Oakland CA. New Harbinger Pub. Inc.

32 Identify Automatic Thoughts Appear in shorthand Are always believed Experienced as spontaneous Use terms like should, ought, must Tend to awfulize Relatively idiosyncratic Persistent & selfperpetuating Differ from public statements Habitual themes Are learned Mckay, M et al Thoughts & feelings Oakland CA. New Harbinger Pub. Inc.

33 How to Identify Automatic Thoughts Record your thoughts in a Thought Journal to link the relationship between thinking and feeling Learn to listen to automatic thoughts by recording the situation, the distressing feeling and then the thoughts.

34 Unproductive Thinking Patterns When examining these ATs, we discover unproductive thinking patterns (UTPs) These UTPs are called cognitive distortions By observing these patterns, the person can see how they habitually use UTPs in all types of situations

35 Unproductive Thinking Patterns All or Nothing Overgeneralization Mental Filter Disqualifying the Positive Jumping to Conclusions Mind Reading Fortune Teller Error Catastrophic Magnification Minimization Emotional Reasoning Should Statements Labeling & Mislabeling Personalization Adapted from Burns, D., MD Feeling Good. New York: William Morrow Company, Inc.

36 Adding D & E to the ABC model to overcome distress We now add two new concepts to our model to gain relief from distressing feelings and behaviors: D= Disputing automatic thoughts E= Evaluating these thoughts and developing an action plan

37 D Disputing Unproductive Thoughts Dispute ATs by not taking them as absolute truths; check the evidence. In a guided discovery, use Socratic questioning to: help find more realistic responses check the evidence of a belief test a hypothesis

38 Guided Discovery/Socratic Questioning How are my thoughts necessarily true? How are my thoughts consistent with the evidence? What are other ways of thinking about the situation? How are my thoughts helpful? What would I say to someone else in this situation? How did I learn to think this way? What types of experiments can I do to prove or disprove my beliefs? What s the worst that could happen?

39 E Evaluate the Outcome Are my responses based on fact? Do my alternative thoughts help me achieve my goals? Do my alternative thoughts help me feel the way I want to feel? What s the benefit of thinking this way? What responses will I use in developing my Action Plan?

40 Developing an Action Plan Alternative thoughts may suggest actions the person can take: Gather information Check assumptions/behavioral experiments Practice a new technique or behavior Create coping cards Make an assertive request Make plans Resolve unfinished business Prioritize

41 Getting to the Core of the Problem

42 Core Beliefs Assumptions or long-standing views that we hold about ourselves, other people, the world and the future Mainly formed during childhood years or other important times in life People filter their experiences through these core beliefs

43 Examples of Core Beliefs I am Beautiful or Ugly Worthy or Unworthy Lovable or Unlovable Capable or Inadequate Normal or Abnormal Connected to others or alone

44 How to Identify Core Beliefs Laddering Technique Select a statement from the automatic thought journal for its meaning Now ask if this is true, what does this mean? Uncovers core beliefs by working down rung by rung

45 Conceptualization of the cognitive model Childhood data Core beliefs/rules Situation Emotions Meaning of ATs ATs Behaviors Coping strategies

46 Shorthand For the ABC Model: Catch It! Check It! Change It! After the person has learned the ABCs of cognitive therapy, simplified mnemonics index cards are reminders on how to practice CBT

47 Catch It! What happened! How do you feel? What s the automatic thought?

48 Check It! How is this thought true? What s the evidence? What are alternative explanations? What are the odds? What reasons are there that this may not be true? What Unproductive Thinking Pattern am I using here?

49 Change It! What would be a more realistic thought? Is there a more productive way to view this? Make an action plan!

50 Applications of CBT: Psychosis Depression Stress Reduction/Anxiety Social Skills Refusal Skills Increase Self-esteem Relapse Prevention Plans

51 Schizophrenia Research Results: Improved symptom severity Depressive symptoms were reduced

52 Latinos and CBT utilizing culturally sensitive adaptations along w CBT such as the dichos & nervios, improve adherence and outcomes (Comas-Diaz, 1996; Interian & Diaz-Martinez, 2007; Rousseau & Kramer, 2009).

53 There is a significant shortage of Spanish speaking mental health providers. There are only 29 Latino mental health professionals for every 100,000 Latinos in this country. Latinos tend to seek mental health services from their primary care physicians, and when referred to a mental health facility they have a drop out rate of approximately 58% (Delgado et. al, 2006).

54 Interpersonal Components These components become of significant importance particularly in the assessment process, adaptation of treatment modalities and establishing rapport. Simpatia- refers to friendly, warm- Not NEUTRAL Neutrality is considered as detachment and uncaring. Greeting with a kiss or a hug & gift giving Formalismo-refers to formality and the ascription of the hierarchal. Treated with respect and courtesy Señor or Señora

55 Personalismo refers to personalism, the intrinsic value of the person. preference of having personal interactions instead of institutional interaction. Receiving calls from the clinician personally. Remembering the names of children and family members. Utilizing a balance between these components seems to increase compliance and. Other components include: Fatalismo Familismo Desahogo

56 Stress Vulnerability Model Alcohol & Drug use Worsens Helps Coping Meaningful activity Healthy lifestyle Supportive Relationships Coping Strategies Biological Vulnerability to Symptoms Helps Medication Helps Worsens Stress

57 Early Treatment Protocol Make use of engagement skills Explore what having a mental illness means to the person Reframe (de-stigmatize) Normalize feelings Normalize symptoms of person s illness Psychoeducation

58 How do we do this??? Bridge from last session Create an agenda together Summarize Session

59 Help Consumers Gain Insight Educate consumers about the Stress-Vulnerability Model Identify warning signs, triggers and/or problem situations that increase the risk of symptom severity

60 Facilitator s Toolbox Motivational Strategies Educational Strategies

61 WHAT WILL YOU ADD TO YOUR TOOLBOX?

62