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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:

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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
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
what do we know
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
the special case of attachment insecurity
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
the essentials
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
identify abuse trauma neglect
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
basic safety
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)
assess to determine problem
Assess to Determine Problem
  • Identify the target problem
    • Clinical interview (specific)
    • Standardized measures
    • Observation
    • Collateral (when indicated)
  • Give Feedback
    • To child/family
    • Achieve agreement
approach to clinical interview
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
slide11

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
anxiety scared
Anxiety: SCARED
  • Kids 7/8 +
  • Add up responses
  • Anxiety scale:

Clinical = 3+

  • PTS scale:

Clinical = 6+

depression moods and feelings q
Depression: Moods and Feelings Q

Kids 7/8+

Add up responses

Clinical = 11+

overall problems pediatric symptom checklist 17 psc 17
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+

engagement in services
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
initial encounter to enhance treatment engagement
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
stages of change
Stages of Change

Not ready On the fence Ready

(Precontemplation) (Contemplation) (Action)

key strategies
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
slide19

Reasons NOT to Change

Reasons to Change

Results of NOT Changing

Results of Changing

Decisional Balance Scale

change talk
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?”
addressing identified mental health problems
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
clinical targets
Clinical Targets
  • Depression
  • Anxiety
    • Includes PTSD
  • Behavioral
    • Oppositionality
    • Conduct
    • Conflict
    • Attention
key ingredient changing behavior
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)
gradual exposure steps
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
behavioral activation steps
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
find a positive action that lifts mood
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
behavior problems steps
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?
first functional behavior analysis
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
key components
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
maximizing effectiveness of mental health intervention
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
summary of essentials
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
anxiety and depression manuals
Anxiety and Depression Manuals
  • http://www.starcenter.pitt.edu/
finding evidence supported treatments on the web
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/