5/28/2014 Using Structured Behavioral Interventions to Enhance - - PDF document

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Using Structured Behavioral Interventions to Enhance Mental Health Recovery in Psychosocial Rehabilitation

Melanie Bennett, Ph.D., Julie McCarthy, MS, Thomas Tsuji, MA, Michele Crisafulli, MA Department of Psychiatry, University of Maryland School of Medicine

Workshop Overview

• Welcome
• Background
• Sample SBIs
• Breakout groups to practice
• Brief wrap-up

What are SBIs?

• Targeted and focused
• Planned curriculum
• Standard elements and content
• Teach new skills
• Can be tailored to individuals’ needs,

interests, and abilities

• Can target a range of skill domains or health

behaviors

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Components of SBIs

• One meeting (individual) for engagement,
• rientation, obtaining consent (if needed),

and goal setting (what skills domains and specific skills to work on)

• Meetings for teaching specific skills (can be

done in individual or group format)

• Groups are good for SBIs.

Outline of a Standard SBI Meeting

 1. Review homework  2. Give a rationale for the skill / lesson  3. Briefly share a relevant experience that relates to rationale  4. Explain the steps of the skill / components of the lesson  5. Model the skill / components  6. Role-play / complete experiential activity  7. Give feedback  8. Role-play / complete experiential activity again  9. Solicit feedback from the group  10. Repeat role play / activity / feedback  11. Repeat Steps 5-9 with each other group member (if in group format)  12. Give out homework

Sample SBI Meeting Checklist

5/28/2014 3 Methods Used in SBIs

• Teaching
• Modeling
• Role-playing
• Reinforcement
• Feedback
• Taking a shaping approach
• Overlearning
• Generalization of learning

Teaching

• Content is provided as needed so that

participants have context for the skills they are learning.

• Content is also related to experiential

activities that are part of some SBIs

– Ex. Learning about habits, cravings, triggers, and high risk situations (for SBIs focused on substance abuse)

Modeling

• Group leaders set up a role-play to

demonstrate how they would use the steps

• f the skill in a situation that group members

might have experience with.

• Group members are asked to observe the

leaders and to discuss how they followed the steps.

5/28/2014 4 Role-plays

• Set up role-plays to be realistic and lively

– Individualize scene – Choose appropriate level of complexity (start easy and get more difficult) – Review steps prior to role play to make sure group member understands what is expected

• Aim for 3 role plays for each group member

in each session: “Third time is the charm!”

Feedback

• Emphasis on positive feedback; always start

with positive

• Feedback should be specific and related to steps
• f the skill
• Routinely elicit feedback from group members
• Corrective feedback

– One or two suggestions for improvement at a time – Can be integrated into second and third role plays (“One thing that might make your role play even more effective. . . . “)

Tone of SBIs

• Positive, reinforcing
• Collaborative, motivational approach
• Consumer is most knowledgeable about

him/her self

• Learn skills and encouraged to think about

how to apply them to one’s life

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SBIs: Points to Remember

• SBIs are teaching, not psychotherapy
• Keep sessions lively and interactive
• Use flip charts, white boards, handouts
• Prepare for sessions
• Stay with the structure
• Do not work in isolation
• Do not passively expect participation
• Be patient: learning skills takes time and

repetition

Challenges for Clinicians Learning SBIs

• Allow too much time for discussion/processing
• Hesitant to take role of “being in charge”
• Quickly accept when consumer doesn’t want to

role-play

• Role-play scenarios are too complicated
• Insufficient amount of positive reinforcement
• Provide vague, non-behavioral feedback
• Do not encourage consumer to be actively involved

Practical/systems issues in starting groups

Addressing Cognitive Deficits

• Small group format
• 1-2 leaders per group
• Meetings are highly structured
• Skills are reduced to smaller steps
• Over-learning of a few basic skills
• Use of visual aids, handouts, frequent review
• f material
• Pacing, content can be adjusted as needed

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SBIs and Mental Health Recovery

Elements of Recovery Model Goals and Strategies of SBIs

Self-direction The client, not the counselor, should direct discussion around how skills are useful in his/her life.

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Strengths based Start where client wants to start. Build

• n strengths and competencies.

√

Individualized/person-centered Collaborative, tailored to an individual’s interests and goals

√

Empowerment The client is the primary resource in finding answers and solutions.

√

Responsibility Client has autonomy. Responsibility for use of skills is with client.

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Respect Empathic, client-centered style. Avoid arguing.

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Hope Belief in the possibility of change.

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SBIs We Have Done

• Social Skills Training
• Smoking Cessation
• Weight Loss
• Drug / Alcohol Abuse
• Coping Skills
• Stress Management
• Vocational Skills
• Relationship Skills

Sample 1: Social Skills Training

• SST helps consumers maintain or re-establish

social relationships and prevent social withdrawal and isolation.

• 4 domains:

– Communication (“Social Networking”) – Friendship and dating (“Relating and Dating”) – Assertiveness (“Expressing Yourself”) – Conflict management (“Keeping Cool”).

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Behavioral Components of Social Skills

• Speech Content
• Paralinguistic Features

– Voice volume – Pace – Pitch – Tone

• Nonverbal Behavior

– Proxemics, kinesics, gaze, facial expression

• All are important to good social interaction.

SST Goal Setting Meeting

• Benefits

– Helps with engagement, building rapport – Prepares consumer for what to expect – Links SST to consumer’s recovery goals – Identifying consumer’s goals important for selecting curriculum, setting up meaningful role plays, developing home assignments

Common SST Goals

• Making / re-making friends
• Developing leisure activities to do with others
• Getting a job
• Keeping a job
• Getting along with roommates
• Reducing substance use
• Being a better parent
• Dating
• Dealing more effectively with angry feelings

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Sample SST Session: Maintaining Conversations

• Today we’re going to learn about Maintaining
• Conversations. This involves learning how to start talking

with someone and keep talking to them for a few minutes.

• Why do you think this is an important skill?
• We’ve broken the skill down into steps:

Step 1. Make eye contact and say Hello Step 2. Ask a general question Step 3. Make small talk by asking questions Step 4. Give a reason and say Good-bye

General Questions

• What’s up?
• How are you doing?
• How have you been?
• What do you think of this weather?
• What’s new?
• Are you new here?

Topics for Small Talk

• Weather
• Hobbies
• Sports
• Culture

– TV – Music – Entertainment

• Remember: Small talk involves topics that

everyone can talk about.

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Ways to Say Goodbye

• Well, I have an appointment. I have to go.
• I have to catch a bus. See you later.
• I have to meet a friend. It was good to see

you.

• Group is about to start. I’ll talk to you later.

Sample 2: Behavioral Treatment for Smoking Cessation

• BTSC helps consumers prepare to quit and

take steps towards quitting

• 4 domains:

– Motivational Enhancement & Reinforcement [Motivational interviewing, breath CO monitoring, goal setting] – Engagement [Education, smoking cessation care coordination] – Skills Training [Stop smoking skills, social and coping skills training, relapse prevention] – Psychopharmacology [Education re: Zyban/NRT, coordination with prescribers, tracking NRT use, problem-solving]

Goal Setting in BTSC

• Participants create a concrete goal to work
• n between sessions.
• Goals written down in a formal "contract".
• Allows for a review of individual progress

towards smoking reduction/quitting.

• Can vary for those planning a quit date and

those who are working on staying quit.

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Sample Goal Setting Form: Setting a Quit Date Skills Training in BTSC

• Stop smoking skills focus on strategies for

quitting smoking.

• Coping skills focus on strategies for coping

with negative states (depression, stress, medication symptoms and side effects) without smoking.

• General social skills focus on helping patients

reduce interpersonal conflict/stress.

Sample Quit Smoking Skills

Coping with Withdrawal Symptoms After Quitting

(adapted from the American Lung Association Freedom from Smoking)

Symptom Relief Irritable, anxious Walk, bath, relaxation Depressed Do something fun, talk Restless Walk, relaxation, fun Trouble sleeping No caffeine, relaxation Poor concentration Plan light load, avoid stress Hungry, weight Drink water and low-cal drinks, eat low-cal snacks (carrot sticks, pretzel sticks, sugar free candy/gum) Stomach problems Drink fluids, lots of fiber

Ways to Cope with the Habit of Smoking Hold a pencil Squeeze a tennis ball in your hand. Carry some carrot or celery sticks around with you and eat them if you have this feeling Chew something - a toothpick, a lollipop (remember Kojak), hard candy, sugar free gum. Drink a glass of water Change your routine Brush your teeth after a meal; Go for a walk; Spend time in nonsmoking locations (library) or with nonsmoking people

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Education in BTSC

• Positive and negative aspects of smoking (functional analysis)
• Negative health effects of smoking (most know this)
• Positive health benefits of quitting (most don’t know this)
• Tailor to SMI

– Include connection with cognitive function – Include connection with weight gain – Keep it simple – Use handouts – Review whenever possible – Have clients teach others

Good Reasons for Quitting

• At every age, no matter how old or young, quitting

increases your life expectancy. You’ll live longer and better!

• 24 hours after quitting, chances of having a heart attack

decrease.

• Within a month or two you can feel your lungs working

better, you have more energy and no more cough.

• Quitting will greatly lower your chances of having a stroke

and getting cancer.

• The people you live with will be healthier.
• Smoking interferes with your sex life. By quitting, these

risks decrease quickly.

• You will have money and time to spend on other things!

Relapse Prevention

• Plan for high risk situations
• Plan for lapses
• Address situations that are relevant to SMI:

– Coping with anger and other negative emotions – Coping with stress – Coping with boredom – Coping with symptoms and side effects

• Build in rewards for quitting

– New ways to use money that would have been spent on cigarettes – Track positive health effects – Share success with others

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Learning SBIs Through Practice

• Breakout into smaller groups

– Social skills training – Smoking cessation – Coping skills

• We will model how to do different

components of the SBI

• We will ask all of you to practice – this is a

great way to learn!

SBIs - Resources

• Bellack, A.S., Mueser, K.T., Gingrich, S., & Agresta, J. (2004)

Social Skills Training for Schizophrenia, Second Edition: A Step-by-Step Guide. NY: Guildford.

• Bellack, A.S., Bennett, M.E., & Gearon, J.S. (2007).

Behavioral Treatment for Substance Abuse in People with Serious and Persistent Mental Illness: A Handbook for Mental Health Professionals. NY: Taylor and Francis.

• VA VISN5 MIRECC Social Skills Training Program -

http://www.mirecc.va.gov/visn5/training/social_skills.asp

MD QUIT – Free help for quitting smoking