Mental Health Education and Training Initiative
2005 Learning Session II
National Assembly on School-Based Health Care
Icebreaker
What is your skill?

Listening

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Apologizing

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Asking for Help
Deep Breathing
Muscle Relaxation
– Positive Self-talk

Cognitive restructuring
– Resisting Peer Pressure

Scheduling Pleasurable Activities

Problem Solving
Overview 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 Assembly
on School-Based
Health Care
Washington, DC
www.nasbhc.org
info@nasbhc.org
202-638-8872 or 1-888-286-8727 - toll free
Center for School Mental Health
Analysis & Action
Director: Mark Weist, Ph.D.
Director of Research and Analyses:
Sharon Stephan, Ph.D.
email:
web:
phone:
csmha@psych.umaryland.edu
http://csmha.umaryland.edu
410-706-0980 (888-706-0980)
Mental Health Education and
Training (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 Mission

Increase knowledge and implementation
of mental health
– screening,
– diagnosis,
– referral,
– coding, and
– empirically-supported short-term
interventions
among SBHC primary care and mental
health providers.
Learning Session Two
Pre-assessment – Core Skills
MHET 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 EvidenceBased Practice in School Mental Health

Decrease stress/risk factors

Increase protective factors

Train in core skills

Implement manualized interventions
Training in
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)?

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 Anxiety






Deep Breathing
Progressive Muscle
Relaxation
Mental
Imagery/Visualization
Systematic
Desensitization
General Stress Busters
Cognitive Restructuring
Deep 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 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/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 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 Busters






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





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 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:
Anxiety
MH Provider Role Play
Anxiety: 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 Play
Anxiety: 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 Depression






Cognitive
Restructuring
Thought Stopping
Activity Scheduling
Social Skills Training
Problem Solving
Relaxation Training
Cognitive 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 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 Scheduling

Scheduling enjoyable and goaldirected 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 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 Training

Deep Breathing

Progressive Muscle
Relaxation

General Stress
Busters
Case Example and Role Play:
Depression
MH Provider Role Play
Depression: 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 Play
Depression: 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 Manuals
FRIENDS
 Skillstreaming
 Defiant Children/Teens
 Cognitive Behavioral Intervention for
Trauma in Schools (CBITS)

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)

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
(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
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 Disorder
•
•
Family Involvement
Classroom Management
The research on interventions for
disruptive behavior disorders
Other 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
evidence of effectiveness for DBD:

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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
in 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
and Parent Training?



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
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
Systems



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
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
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 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
of 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 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 prevention
 Start small – build on small gains

Social 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.
Resources

Several empirically-supported protocols exist:
– Defiant Children (Russell Barkley)
– Helping the Noncompliant Child (Rex Forehand)
– Videotape Parent Modeling (Carolyn WebsterStratton)

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 Abuse
Family-based and Classroom-based intervention
Refusal Skills
Self-esteem
Education
Family-based and classroombased 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 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-esteem

Children with low self-esteem and selfawareness are more likely to engage in substance
abuse

Therefore, teaching skills to enhance selfesteem and awareness are critical
Education

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
for 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)
(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:
Precontemplation –
Contemplation –
Action
and Maintenance Relapse -
MI can:
raise awareness
help decision making
enhance and remind of resolution to change
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: 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 Interviewing
Step 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 Interviewing
Step 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 Interviewing
Step 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 Interviewing
Step 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 Interviewing
Step 5: Ask for a decision

Restate 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 Interviewing
Step 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
continue 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
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
and Treatment Planning
Benefits of Good Mental Health
Documentation
Assists in monitoring of treatment progress
 Mindful of different components of
treatment – family involvement,
assessment, intervention (not just content)
 Structures intervention around treatment
goals/objectives
 Liability!

Mental 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
Treatment 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 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