Fluency Flashcards
EBBP Model
1, Best available research
2. Client’s characteristics, (preferences, state, needs, values)
2. Resources (therapist’s expertise)
3 components of therapeutic alliance
Agreement on bond, goals, and tasks.
Session 1 preliminaries
Purpose: clarification & orientation, project competence
- Introduce self:
Names, Graduate student therapist,
Supervision - Review Confidentiality
- Indicate that there is electronic medical record
- Review session length & frequency, session fee & payment options
- Orient to psychotherapy
- Explain purpose of initial sessions
- Opening- What brings you in today?
HEADSSS Assessment of Current Functioning
Home
Education/employment
Activities
Drugs (medications & substance use)
Suicide
Sleep
Sex
ADRESSING framework
Age/generational differences
Disabilities (developmental or acquired)
Religion/spirituality
Ethnicity/race
SES (Socio Economic Status)
Sexual orientation
Indigenous heritage
National origin
Gender identity
3 therapist behavioral domains of the Shifting Cultural Lens model
1) Understanding client’s perspective (Process Model; using CFI and AD[D]RESSING)
2) Sharing therapist’s perspective with client
3) Shared narrative (integration of views, soliciting buy-in, negotiating different treatment options)
3 therapist skills for evincing a multicultural orientation
Cultural humility
Incorporating cultural opportunities
Cultural comfort
Definition of cultural attunement, tailoring, & adaptation
Attunement: being open, curious, and culturally comfortable
Tailoring: Utilizing existing treatments and fitting them in with a client’s individual culture
Adaptation: Making specific changes to treatment manuals/modalities to fit with specific cultures (e.g., ACT for the Latinx community)
Stages of Change
1) Precontemplative
2) Contemplative
3) Preparation
4) Action
5) Maintenance
Assessing Stages of Change in 2-3 questions
“Do you think [behavior] is a problem for you?
“How ready are you to address [behavior] in therapy?”
OARS
Open-ended Questions
Affirmations
Reflections
Summaries
DARN-CAT
Change Talk!
Desire: wish or want for change
Ability: given the resources, feel able
Reasons: pros and cons change
Need: priorities of change
Commitment: decision to change
Activation: ID steps for change
Taking steps: what the client is doing to initiate change
Decisional Balance
MI: Produces change talk and allows client to decipher between current way of living and the way they want to live.
Pros of Status-quo
Cons of Change
Cons of Status-quo
Pros of Change
MECSTAT
SF questions and format
Miracle Questions
Exception Questions
Coping Questions
Scaling Questions
Timeout
Accolades
Tasks
Behavioral chain analysis (problem analysis and solution analysis)
- Describe the specific PROBLEM BEHAVIOR
- Describe the specific PROMPTING EVENT
- Describe the specific VULNERABILITY FACTORS
- Describe in excruciating detail the LINKS IN THE CHAIN that led up to the problem behavior
- What are the CONSEQUENCES of the PB? Be specific
- Describe what you are going to do to REPAIR
- Describe in detail ALTERNATIVE SOLUTIONS to the problem
- Describe in detail the PREVENTION STRATEGY
C-SSRS Screener (Items 1&2)
- Have you ever wished you were dead or wished you could go to sleep and not wake up?
- Have you actually had any thoughts of killing yourself?
Current suicidality assessment interview (8 items)
- Frequency, Intensity, Duration of SI
- How frequent/intense/persistent are the SI thoughts? - Reasons for Ideation
- What sort of reasons do you have for thinking about wanting to die or killing yourself? - Specificity of plans
- Have you been thinking about how you might do this? - Availability of method(s), availability of opportunity
- Do you currently have access to [method]? - Preparatory behaviors of any type
- Have you worked out the details? Have you done anything, started to do anything, or prepared to do anything to end your life? - Self-control
- Do you feel in control of your behavior right now? - Reasons for living, not acting/ deterrents
- Are there things - anyone or anything (e.g., family, religion, pain of death) - that stop you from wanting to die or acting on thoughts of committing suicide? - Intent
- Have you had some intention of acting on these thoughts/plans?
Do you have any intention of acting on the thoughts of suicide today?
Interpersonal Model of Suicide
- Desire for death (due to thwarted belongingness [feeling emotionally alienated] and perceived burdensomeness [feeling of incompetency])
- Acquired capability/capacity (to carry out attempt)
Most dangerous form of suicide desire is caused by the presence of: thwarted belongingness and perceived burdensomeness.
Safety Plan Steps
Step 1: Warning signs. Identify what specifically is upsetting me, what are some things that might make things worse for me or that will signal me that I need to use strategies to say safe.
Step 2: What are more reasonable things I will say to myself in response to suicidal thoughts
Step 3: Personal coping strategies. What are some activities or things that I will do to distract myself or enjoy myself without needing to contact anyone.
Step 4: Social coping strategies. What are some social situations I will put myself in or some people that I will contact or interact with to distract or enjoy.
Step 5: Who are some people (for youth: adults) who I will specifically ask for help/support if Steps 2-4 do not work and I’m feeling worse. If the thoughts continue, get specific, and I find myself preparing to do something I will call.
Step 6: Who are the professionals or agencies I will contact if I am in crisis. If I feel suicidal and don’t feel like I can control my behavior after steps 2-5 I will call or go to
Step 7: Prevention: Making the environment safe. I will do the following things to keep my space safe
Step 8: Commitment. I am committed to safety and self-care. I will implement this plan should my suicidal thoughts increase
Current Homicidality/Threat Assessment Interview
1) Frequency, intensity, duration and justification of violent ideation
2) Reasons for violent ideation
3) Specificity of plans
4) Availability of method(s), availability of opportunity
5) Preparatory behaviors of any type
6) Self-control
7) Reasons for not acting or acting differently / deterrents to violence
8) Intent
Behavioral activation model & rationale (using triangle model)
MODEL: Thoughts –> actions (consequences, short term, long term) –> emotions –> thoughts (antecedents, life events, situations, experiences)
RATIONALE:
1. Illustrate how the client’s depressive symptoms could be understood as a result of disrupted behavioral patterns that are the culmination of (relatively normative) reactions to life stress.
- Describe the interconnection of actions, thoughts, and feelings
- Illustrate downward spirals or TRAPS using client information
- Present focus of this treatment – stop downward spiral and begin upward spiral by changing actions or turn TRAPs into TRACs (which will have positive effects on thoughts and feelings)
- Solicit input from the client and engage him/her in a way that fits the model to his/her experience
- Attempt to instill optimism – if engaged the approach could help
Describe the key aspects of activity scheduling
- Brainstorm specific activities
Activities for pleasure, learning/mastery, personal growth & connection to values - Establish a link between activities and values
- Identify activities from multiple life contexts/domains
- Identify activities that vary in frequency and ease of completion
- Schedule activities to be completed before next contact (and means for prompting and recording)
- Discuss whether activity goals are realistic (underestimate if necessary, can always exceed goal)
- Discuss barriers to activity completion and possible solutions
Cognitive therapy model & rationale (using triangle model)
Model:
Situation: Thoughts, emotions, behaviors
Rationale:
When individuals are distressed, many of their thoughts are incorrect and dysfunctional to some degree. By learning to identify and evaluate their spontaneously occurring thoughts (i.e., automatic negative thoughts), patients can correct their thinking so that it more closely resembles reality. When they do so, they generally feel better and behave more functionally. Physiological arousal is also decreased… (Beck & Hindman, 2018).
CBT in action sequence
Assess-Ask-Offer-Intervene-Apply
CBT in action sequence: Assess
- Antecedents (situations/events) –> Feelings—Thoughts–Actions –> Consequences
- Create a list of the negative emotions, negative thoughts, and maladaptive behaviors
Primary strategies:
- Guided discovery - OARS
- Downward Arrow - “If this were
true, why would it be upsetting?
What would it mean to you/for
you? What would it say about
you? About the type of person you are?
CBT in action sequence: Ask
After summarizing..
Inquire:
Am I getting it? Are you feeling heard and understood?
What grade do I get for listening and understanding?
CBT in action sequence: Offer
You’ve talked about some things that are very powerful, personal, and important.
Let me ask you, is this a good time to work on how you’re feeling or would it be important that I provide more listening & support?
Do you want some help beyond my listening and providing support?
NO – It sounds like you don’t want any help with X, Y, and Z, and I’m fine with that. I’m wondering if there’s anything else that we could talk about or other areas of your life that might be helpful to talk about…
YES = continue on
CBT in action sequence: Intervene
- Positive reframing
- Identify cognitive distortions
- Cognitive restructuring
- Double standard technique
- Positive-negative role reversal
CBT in action sequence: Apply
- To daily life
- Home practice or exercises
- Coping card
- Activity scheduling
- Behavioral experiment to test a
negative prediction/belief - Goal-directed behavior plan
10 most common cognitive distortions and their definition
- All or nothing- view things in absolute, black or white categories
- Overgeneralization- view a negative event as a never ending pattern, “this always happens!”
- Mental filter- dwell on the negatives and ignore the positives
- Discounting the positives- you insist that positive qualities don’t count or miss positive interpretations
- Jumping to conclusions- jump to conclusions not warranted by facts –> mind reading: you assume that people are reacting negatively to you & fortune telling: you predict that things will turn out badly
- Magnification or minimization- you blow negative out of proportion and blow off positives
- Emotional reasoning- you reason from your feelings, “I feel like an idiot, so I must really be one”
- Should statements- you use shoulds, shouldn’ts, musts, oughts, and tos
- Labeling- instead of saying, “I made a mistake” you say “I’m a jerk” or “I’m a loser”
- Blaming- You find fault instead of solving the problem –> Self blame: You blame yourself for something you weren’t really responsible for & other blame: you blame others entirely and overlook ways you contributed to the problem
Positive reframing technique
What are some benefits/advantages of the negative thoughts/feelings? What do these feelings/thoughts show about you, about your deepest core values, that is beautiful, awesome, or positive? Establish a goal of decreasing the impact of negative thoughts, not elimination of them entirely
Double-standard technique
- Client plays themself
- Therapist plays role of loved one or clone
Steps:
1: Clarify roles
2: Therapist summarizes situation and offers automatic negative thoughts
3: Ask client if they agree with that conclusion (the negative thoughts)
4: Client responds
5: Therapist reflects and encourages elaboration of counter thoughts over several conversational turns
6: Therapist summarizes counter argument, says it’s helpful, and asks client if they really believe the counter argument
7: Identify counter as applying to client
Talking back to negative thoughts
- Negative voice vs Positive voice
Implementation:
(1) Clarify roles
(2) Client as negative voice offers automatic negative thought(s)
(3) Therapist as positive voice responds
(4) Ask client who won (positive or negative) and size of win (small, medium, large)
(5) Ask client if what was said was true/important/believable
(6) Role-reversal (therapist as negative voice and client as positive voice) until client wins big
Psychological (in)flexibility model (hexaflex)
- Present moment awareness/dominating concept of past and future
- Values clarity/lack of values clarity
- Committed action/persistent inaction, impulsivity, or avoidance
- Self-as-context/self-as-content
- Cognitive defusion/fusion
- Acceptance/experiential avoidance
ACT Case Conceptualization in 2 Questions
- What are your values?
- What are the barriers, what stands in the way of you living more fully toward your values?
Describe the key aspects of introducing and assessing values
Introduce concept of values (freely chosen, person-specific, way of being)
Emphasize that values are what the client wants to be about
Distinguish values from goals & activities
Reiterate values as anchors for behavior
Identify several values that can serve as anchors for activation
Describe introducing and implementing one present moment awareness strategy
“As humans we yearn to be oriented to the hear and now. It can be difficult at times, however, to participate fully in life experiences. In other words, to be here now.
Strategy: 5 senses
Practice shifting attention across the senses: Notice 5 things the patient can see, 4 they can feel, 3
they can hear, 2 they can smell/taste, and 1 believable positive self-statement they can make
Describe introducing and implementing acceptance strategy
“When we’re so wrapped up in these uncomfortable sensations, it can be really difficult to engage in ways that we find meaningful”…
Strategy: Sensations seeking
Identify a prominent sensation and observe, breathe into, expand around, objectify (give it a size, shape, color, texture, movement), allow (hold it like a newborn) and normalize as product of a working nervous system. Explore it like a scientist.
Describe introducing and implementing one cognitive defusion strategy
“When we become too attached to the thoughts that come to us, they can really get in our way. That said, it is really difficult to stop these thoughts all together. Instead, it might be more helpful to create space for these thoughts or to observe them at a distance”
Strategy: Semantic Satiation
Say a word aloud repeatedly with increasing rapidity for 20-30 seconds to experience the fading
away of conventional functions. Begin with “lemon” then a personally relevant word (e.g., “addict”)
Describe introducing and implementing one self-as-context strategy
When you are noticing these troubling thoughts, notice that there is a “you” noticing them. When these thoughts are repetitive and negative, it can be easy to forget about that observing self. That self has been a constant for all of the ups and downs in your life. It is easy to lose sight of this. To emphasize the observing self…
Strategy: Leaves on the stream
Take a moment to close your eyes and imagine that you are sitting by a stream. It is Autumn, and the leaves are falling from the trees, floating downstream. As a thought arises, imagine taking it and gently placing it on a leaf, allowing it to float away. As the thoughts inevitably arise, continue to do so. Notice what it feels like to see these thoughts come and go.
DBT hierarchy of treatment targets
- Decrease life threatening behaviors (suicide, self harm, homicidal urges)
- Decrease therapy interfering behaviors (any client or therapist behaviors that potentially disrupt the therapeutic relationship, such as attendance, lateness, noncompliance, or lying)
- Decrease quality of life interfering behaviors
- Increase behavioral skills
DBT TIPP Skills
Temperature, Intense exercise, Progressive relaxation, Paced breathing (3-5; e.g., holding ice, hot/cold shower, snap rubber band on wrist)
DEARMAN
For interpersonal effectiveness:
-Describe the situation
-Express your feelings about it
-Assert what you want (or say no, might necessitate “broken record”)
-Reinforce the other & why it’s in their interest to give you what you want
-(Be) Mindful
-Appear confident
-Negotiate
HARD
For interpersonal effectiveness:
Assertiveness is HARD
Honest-Appropriate-Respectful-Direct
GIVE
For interpersonal effectiveness:
(Be) Gentle
(Act) Interested in the other person
Validate the other person’s point of view
(Use an) Easy manner
FAST
For interpersonal effectiveness:
(Be) Fair
(Be) Assertive (Not overly Apologetic or Aggressive)
Stick to your values
(Be) Truthful
5 Secrets of effective communication
Empathy/Active Listening:
1. Disarming technique – find some truth in what other person
is saying
2. Reflection – paraphrase the other’s main ideas (thought
empathy) and acknowledge their feelings (feeling empathy)
3. Inquire – ask gentle questions, be curious and non-
defensive, to learn what person is thinking and feeling
Acknowledgement/Assertiveness:
- Use “I” statements to express yourself non-defensively and
tactfully
i. I realize I’ve ignored your
feelings” (not “You don’t talk to
me”)
ii. “I feel upset” (not “You’re making
me angry”).
iii. “I want to be closer” (not “You
push me away”)
Respect:
- Stroking - Affirm – find some genuine positives to say to the other person, even in the heat of battle
or if frustrated
RULER
Recognize
- Arousal/Energy/Intensity/Strength (high/strong—low/weak) & valence (pos—neg)
Understand
- Antecedents, vulnerability, and maintenance factors – Where did it come from?
What’s feeding/fueling it?
Label
- Give the emotion a name – if I can name it, I can claim it, tame it, or reframe it
Express
- Share how you are feeling with others.
Use “I” statements – “I’m feeling”
Regulate
o Mindfulness awareness
o Relaxation
o Cognitive restructuring or defusion
o Opposite action (act different than
you feel)
o Distraction
o Self-soothing
o Time-out
o Half smile and willing hands
posture
o TIPP skills
