Fluency Material Flashcards
EBBP (Evidence-based behavioral practice) 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 bonds, goals, tasks
Session 1 Preliminaries
Purpose: clarification & orientation, project competence
“Before we get started, there are some preliminary items to take care of”
1. Introduce self:
Names (how you and client will address one another, pronouns)
Graduate student therapist (have degree, seeking advanced degree)
Supervision (discuss, record, watch–help me provide best service to you)
2. Review Confidentiality (threat of harm to self or others, child and elder abuse)
3. Indicate that there is electronic medical record (session notes, brief and to the point, access restricted to clinic/supervisory staff)
4. Review session length & frequency, session fee & payment options
5. Orient to psychotherapy (works best when we collaborate, see each other regularly, and test ideas out in daily life)
6. Explain purpose of initial sessions, get to know one another for me to start to understand your concerns, listen, ask ?s for you to see what, it is like to interact with me
7. Opening- What brings you in today? What brings you in to therapy at this time?
HEADSSS Assessment of current functioning
Home
Education/employment
Activities
Drugs (medications & substance use)
Suicide
Sleep
Sex
AD[D]RESSING 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
- Process model (understanding client’s perspective; using CFI and AD[D]RESSING)
- Sharing therapist’s perspective with client
- 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
Stages of change & four processes of MI
- Precontemplation: resistance to recognizing a problem, not seeing a need for change
Nurturing parent (engaging): connecting/rapport - Contemplation: have yet to make a commitment to change or action, considering making a change but has not decided yet
Socratic teacher (focusing): developing a direction for motivational enhancement - Preparation: report the intention to take action in the near future, decided to make changes and is considering how to make them
Experienced coach (evoking): change talk - Action: overt changes in behavior, experiences, and/or environment, actively doing something to change
Expert advisor/consultant (planning): specified actions - Maintenance: prevent relapse and stabilize behavior change, maintaining the change
Assessing stage of change in 2-3 questions
“Do you think [behavior] is a problem for you?”
No: “What leads you to say that?”
Yes: “What are your thoughts about making a change? When do you plan to make a change?”
“How important is it that we focus on [behavior]?”
“How confident are you that you can change [behavior]?”
“How ready are you to address [behavior]?”
“How ready are you to address [behavior] in therapy?”
“How ready are you to brainstorm strategies/skills to address [behavior]?”
OARS (Motivational Interview, basic interaction techniques and skills)
Open-ended questions
Affirmations
Reflections
Summary
DARN-CAT (change talk: mechanism of action in MI)
Desire: wish or want for change
Ability: given the resources, change may be possible
Reasons: pros and cons of behavior change
Need: how change impacts priorities
Commitment: communicating decision to make a change
Activation: identifying steps for change
Taking steps: what the client is doing to initiate change
Decisional balance
Function: develop discrepancy between current behavior and who the person wants to be
1. “What are the pros/benefits of maintaining your current life?”
2. “What are the cons/costs of making a change?”
3. “What are the cons/costs of maintaining your current life?”
4. “What are the pros/benefits of making a change?”
Simplified: create list of reasons to stay the same (status quo) versus reasons to change
Solution-focused questions – MECSTAT
Miracle questions: pretend the problem is solved…what are you doing differently?
Exceptional questions: What will you do to make this happen again?
Coping Questions: How are you preventing this from getting worse?
Scaling Questions: On a scale of 1-10, where 1 is the worst it’s ever been, where is the problem today?
It is important to ask why the number is not lower (to evoke change talk)
Time-out: 10-minute break for reflection or consultation
Accolades: emphasizes strengths and abilities in patients
Task: Negotiated task
8 steps to chain/functional (1-5) & solution (6-8) analysis
Identify problem behavior (PB)
Identify prompting event/precipitating factors
Identify vulnerability factors
Identify “links on chain” (i.e., thoughts, emotions to the PB)
Assess consequences to PB
Repair consequences to PB
Identify alternative solutions
Identify prevention strategies
Suicide ideation prompts
- “Have you wished you were dead or wished you could go to sleep and not wake up?”
- “Have you actually had any thoughts of killing yourself?”
If YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6. - “Have you been thinking about how you might do this?”
- “Have you had these thoughts and had some intention of acting on them?”
- “Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?”
- “Have you ever done anything, started to do anything, or prepared to do anything to end your life?”
If YES to 6, ask: “Was this within the past three months?”
Current homicidality/threat assessment interview (8 items)
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
DBT acceptance skills
Distress tolerance
TIPP skills
Temperature, Intense exercise, Progressive relaxation, Paced breathing (3-5; e.g., holding ice, hot/cold shower, snap rubber band on wrist)
DBT acceptance skills
Distress tolerance
Self-soothing
5 senses (vision, touch, hearing, smell, taste)
DBT Distress tolerance
ACCEPTS
ACCEPTS:
Activities
Comparisons
Contribute to others/society
Emotion change actions
Push away distress temporarily
Thoughts to distract
Sensations to distract
DBT Change skills
Interpersonal effectiveness
DEAR MAN (objective goal)
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
DBT Change skills
Interpersonal effectiveness
GIVE (relationship maintenance goal):
Be Gentle
Act Interested in the other person
Validate the other person’s point of view
Use an Easy manner
DBT Change skills
Interpersonal effectiveness
FAST (self-validation goal):
Be Fair
Be Assertive (Not overly Apologetic or Aggressive)
Stick to your values
Be Truthful
DBT Change skills
Emotion Regulation
PLEASE
Physical conditions/illnesses treated
Exercise
Avoid substance misuse
Sleep hygiene
Eating balanced
Cognitive therapy model (using triangle method)
Situation: thoughts, emotions, behaviors
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
Double-standard technique
- Client plays themself
- Therapist plays role of loved one or clone
- Clarify roles
- Therapist summarizes situation and offers automatic negative thoughts
- Ask client if they agree with that conclusion (the negative thoughts)
- Client responds
- Therapist reflects and encourages elaboration of counter thoughts over several conversational turns
- Therapist summarizes counter argument, says it’s helpful, and asks client if they really believe the counter argument
- Identify counter as applying to client
6 psychological flexibility processes
Contact with the present moment
Definition: Capacity to control attention, focus on the here-and-now
Skill: Ability to notice and describe internal and/or external experience as it occurs.
Implementation: Observe X – external (5 senses) or internal sensations
Purpose: To participate fully in life experiences, be able to be where your feet are. Be here now.
Yearning: Orientation
Be here now
Flexibly paying attention to our experience in the moment
Narrowing, broadening, shifting, or sustaining your focus
Paying attention to the world around us or the psychological world within us, or both
Connecting and engaging fully
6 psychological flexibility processes
Cognitive Defusion
Definition: taking thoughts less literally
Skill: ability to distance oneself from unhelpful internal dialogue
Implementation: expose thoughts as just words, unchosen ideas (not facts) and evaluations (not descriptions), which we do not have to pay heed to. Think X, Do Y
Purpose: reduce the effects of self-criticism and self-judgment, separate chosen actions from unchosen thoughts
Yearning: Coherence
Watch your thinking
Learning to “step back”, detach from our thoughts, images and memories
Cognitive defusion
Step back and watch our thinking instead of getting tangled up in it
Thoughts are nothing more or nothing less than words or pictures
Let them guide us but not dominate us
6 psychological flexibility processes
Acceptance
Definition: Openness to receive (negative) inner experiences; not tolerance, resignation, or “reverse psychology”
Skill: Active willingness to have whatever inner experiences are present. Open up.
Implementation: Experience X, Experience X – Choose to do Y
Purpose: Reduce impulsive, urge-related behavior and escape/avoidance of private event that prevent positive action
Yearning: Feeling
Open up
Opening up and making room for unwanted private experience
Thoughts, feelings, emotions, memories, urges, images, impulses, and sensations
Instead of fighting, resisting, running from them we open up and make room for them
Flow through us, come and stay and go as they please in their own time
6 psychological flexibility processes
Self as context
Definition: the consistent perspective from which you have all of your experiences
Skill: Awareness of the who (self) that is separate from the think, feel, and do (Observer Self / Noticer Self)
Implementation: Contact a sense of self > individual experiences
Purpose: Establish a safe and consistent perspective from which to view ever-changing experiences
Yearning: Belonging
Noticing self
Part that thinks
The mind: Thoughts, beliefs, memories, judgment, fantasies, plans
The part that notices
Aware of what we are thinking, feeling, sensing, or doing in the moment
Noticing self, observing self
6 psychological flexibility processes
Values
Verbally described, globally desired life consequences. What do you want your life to be about?
Skill: State (and contact) what life domains matter most to you and how you want to be in that sphere of life.
Implementation: Freely chosen, distinct from goals (never finished), stated as ways of being.
Purpose: Enhance motivation and impact of actions; basis for change, dignifies the hard work of facing challenges.
Yearning: Meaning
Know what matters
What you want to stand for in life, what you want to do with your life. How you want to treat yourself, others, and the world
Desired qualities of physical or psychological action
How we want to behave on an ongoing basis
6 psychological flexibility processes
Committed action
Definition: Purposeful overt behavior linked to values
Skill: Ability to engage the behavior
Implementation: Goal setting, graduated activity scheduling, task analysis, behavioral experiments, skills training, role-playing
Purpose: Contact positive reinforcement, develop accurate verbal rules based on direct experience, establish ongoing patterns of behavior
Yearning: Competence
Do what it takes
Taking effective action, guided by our values
Physical action (with our body)
Psychological action (what we do in our inner world)
Putting values into action that life becomes rich, full, and meaningful
Doing what it takes to live up to our values even when that brings u difficult thoughts and feelings
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?
DBT skills modules
Acceptance skills: mindfulness, distress tolerance
Change skills: interpersonal effectiveness, emotion regulation
DBT Change skills
Emotion regulation
RULER (dealing with complaints)
Recognize
Understand
Label
Express
Regulate
DBT skills modules
HARD
Honest-Appropriate-Respectful-Direct
Current suicidality assessment interview (8 items)
- Frequency, intensity, duration of suicidal ideation
How frequent/intense/persistent are the thoughts of killing yourself? - 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?
Have you taken any steps to prepare for killing yourself?
Have you acted on these thoughts in any way? - 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?
Safety plan sequence (8 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
Behavioral activation model
Thoughts –> actions (consequences, short term, long term) –> emotions –> thoughts (antecedents, life events, situations, experiences)
Behavioral activation rationale
- 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
Positive negative role reversal (externalization of voices)
Talking back to negative thoughts
Roles: Negative voice & 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
Positive strategies to include:
Self defense- arguing back at negative with logic and passion (like a defense attorney)
Self acceptance- acknowledging impossibility of perfection, being a fallible
human who (like everyone) is a work in progress
Counterattack- one of my biggest problems is listening to you (the negative voice)
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
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
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
CBT in action sequence
Assess-Ask-Offer-Intervene-Apply
CBT in action
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
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
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
Intervene
- Positive reframing
- Identify cognitive distortions
- Cognitive restructuring
- Double standard technique
- Positive-negative role reversal
CBT in action
Apply
- To daily life
- Home practice or exercises
- Coping card
- Activity scheduling
- Behavioral experiment to test a negative prediction/belief
- Goal-directed behavior plan
Cognitive therapy 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).
Key aspects of introducing 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
Provide rationale for values (provide a direction for behavior, can be acted on immediately, dignifies the
hard work of outside-in approach)
Assign homework related to values clarification
Key aspects of assessing values
Engage client in interaction to identify his/her values (discussion, exercises, Valued Living Questionnaire)
Reiterate values as ways of being that are meaningful to participant
Reiterate values as anchors for behavior
Identify several values that can serve as anchors for activation
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.
