1 / 37

The Essentials of Mental Health Care in CAN

The Essentials of Mental Health Care in CAN. Lucy Berliner lucyb@u.washington.edu ISPCAN Honolulu September 28, 2010. Colleagues. Here: Tine Jensen, University of Oslo & Norwegian Centre for Violence and Traumatic Stress Studies Lutz Goldbeck , University Hospital Ulm Not Here:

kevlyn
Download Presentation

The Essentials of Mental Health Care in CAN

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. The Essentials of Mental Health Care in CAN Lucy Berliner lucyb@u.washington.edu ISPCAN Honolulu September 28, 2010

  2. Colleagues • Here: • Tine Jensen, University of Oslo & Norwegian Centre for Violence and Traumatic Stress Studies • Lutz Goldbeck, University Hospital Ulm • Not Here: • David Kolko, University of Pittsburgh • Ben Saunders, Medical University of South Carolina • Laura Murray, Johns Hopkins University • Shannon Dorsey, University of Washington

  3. What Do We Know • Emotional and behavioral problems for CAN • The usual: anxiety (incl PTS), depression, behavior problems • Effects vary • Not all children need formal therapy interventions • Some interventions (lack of ) can make children worse • Remaining in an environment where the children are very scared all the time • Multiple out of home placement moves • There are effective treatments

  4. The Special Case of Attachment Insecurity • Insecure attachment rates are high • Insecure attachment is an adaptation, not a pathology • Perceptions matter (e.g., labeling, reduced expectations) • Secure attachment can be achieved • Many standard parent-child interventions • Promote attachment security + • Reduce child behavior problems

  5. The Essentials • Identify abuse/trauma/neglect • Establish basic safety • Determine what the problem is • Engage the family and child • Systematically address current mental health problems • Child • Child-parent

  6. Identify Abuse/Trauma/Neglect • Ask routinely • Child welfare, mental health, health, juvenile justice • Why? • Children will tell • Demonstrates: • Normalization (e.g., not alone) • Validation • Begin exposure

  7. UCLA Reaction Index Trauma Screen

  8. Basic Safety • Consider psychological as well as physical • Separate when necessary (minority of cases) • Sexual assault • Serious and very serious physical abuse • Reduce risk • Explicitly address violence (don’t avoid) • Written safety plan • Reduced force contract • Monitoring (formal and informal)

  9. Assess to Determine Problem • Identify the target problem • Clinical interview (specific) • Standardized measures • Observation • Collateral (when indicated) • Give Feedback • To child/family • Achieve agreement

  10. Approach to Clinical Interview • Communicate interest and commitment to be helpful; be warm • Take open-ended, inquiring, non-judgmental stance • Elicit child and family perspective • Use prompts and then listen and encourage elaboration • Focus more on the ***here and now***, less on history except as critical to understanding the clinical problem(s) now

  11. Posttraumatic Stress Disorder (PTSD): Child PTSD Sx Scale (CPSS) • Kids 7/8 and older • Add up child’s responses to sx items 1-17 • Clinical score: 12+ • May use DSM IV algorithm for dx • Impairment questions (7 at the bottom) not scored

  12. Anxiety: SCARED • Kids 7/8 + • Add up responses • Anxiety scale: Clinical = 3+ • PTS scale: Clinical = 6+

  13. Depression: Moods and Feelings Q Kids 7/8+ Add up responses Clinical = 11+

  14. Overall Problems: Pediatric Symptom Checklist-17 (PSC-17) Parent/caregiver report4-17 years Total Score clinical = 15+ Internalizing clinical = 5+ Attention clinical = 7+ Externalizing clinical = 7+

  15. Engagement in Services • Overcoming barriers • Beliefs about counseling • Prior unhelpful experiences • Problem solving concrete obstacle • Increasing in motivation to change • Assessing stage of change • Moving towards change

  16. Initial Encounter to Enhance Treatment Engagement • Elicit client concerns • Communicate hope and confidence “I can help you” • Find out about previous counseling experiences or attitudes toward therapy and provide psychoed • Proactively addressing things that could keep people from coming back – the concrete barriers

  17. Stages of Change Not ready On the fence Ready (Precontemplation) (Contemplation) (Action)

  18. Key Strategies • Secure agreement to discuss topic • Explore importance • Goal is to increase • Explore confidence • Goal is to increase • End on good terms • Summarize • Praise effort

  19. Reasons NOT to Change Reasons to Change Results of NOT Changing Results of Changing Decisional Balance Scale

  20. Change Talk • Always attend (pay attention and respond) to change talk • Elicit disadvantages of status quo • Negative aspects of not changing (elicit the specifics) • “What will happen if you don’t change?” • Identify advantage of change • Positive aspects of change (elicit the specifics) • “What will be better if you do change?”

  21. Addressing Identified Mental Health Problems • Strategies across all targets: • Feedback on the nature and level of the problem • Information about the condition (s) • What it is • Causes and what keeps it going • Treatment model • Managing negative emotions • Promoting accurate and helpful cognitions

  22. Clinical Targets • Depression • Anxiety • Includes PTSD • Behavioral • Oppositionality • Conduct • Conflict • Attention

  23. Key Ingredient: Changing Behavior • Anxiety = Exposure • Child faces fears (real and imagined) • Depression = Activation • Child increase activities that produce positive affect • Child takes steps toward goals • Behavioral Problem = Interactional skills • Parent uses positive parenting • Parent and child learns social skills (communication, problem solving)

  24. Gradual Exposure Steps • Explain mechanism • Imaginal and in vivo • Imaginal = imagining the feared situation • In vivo = facing cues in environment • Make a plan • Gradual steps • Reinforce safety • Do SUDs ratings before, during and after • Never leave the session with high anxiety

  25. Gradual Exposure: Fear Hierarchy

  26. Behavioral Activation Steps • Identify goals (“build the life you want”): • Have friends • Accomplish a task • Get on team • Break steps into small pieces • Make a specific plan • Anticipate obstacles

  27. Find a Positive Action that Lifts Mood • Listen to music, watch a funny show or smell a flower • Notice difference in mood • Experience control over emotions

  28. Behavior Problems Steps • Working with the caregiver is KEY • If you aren’t seeing the caregiver, in most cases, you can’t treat the behavior (especially with young kids) • PCIT, Triple P, Incredible Years, Helping the Noncompliant Child • So…who’s buy-in do you need?

  29. FIRST: Functional Behavior Analysis • Define the problem behavior: What’s it look like, sound like? • Make it behavioral • Define the positive opposite • Get the details: Frequency, Duration, Intensity • Plan depends on the details

  30. Key Components • Increase positive time together • Planned child-lead, fun, parent-child interactions • Praise • Attend to/praise positive behavior (positive opposite) • Selective attention • Actively ignore minor irritating (attention-seeking) behavior • Giving effective instructions • Reasonable, understandable and doable instructions • Rewards Plan • Always start here; make them meaningful • Consequences for misbehavior • Non-violent • Consistently and immediately applied

  31. Maximizing Effectiveness of Mental Health Intervention • Promote family as primary resource for child • Take a collaborative approach with families and children that involves them in all aspects of the process • Identify and reinforce natural supports and resources • Make formal intervention as brief as is necessary

  32. Summary of Essentials • Assess problems/needs for child and family • Have some form of measurement of progress • Engage and motivate child and family • Secure agreement for treatment focus • Select treatment approach matched to identified problem (s) • Apply interventions systematically

  33. TF-CBT Manuals and Website

  34. PTSD Manuals

  35. Anxiety and Depression Manuals • http://www.starcenter.pitt.edu/

  36. Behavior Problem Manuals

  37. Finding Evidence Supported Treatments on the Web • www.nctsn.org • www.cachildwelfareclearinghouse.org/ • http://modelprograms.samhsa.gov/ • www.cochrane.org • www.campbellcollaboration.org • www.colorado.edu/cspv/blueprints/model/overview.html • www.strengtheningfamilies.org/ • www.ncptsd.va.gov/topics/treatment.html • http://ebmh.bmjjournals.com/

More Related