cognitive-behavioral therapy for treating depression and suicide in teenagers

1. Military Child Education Coalition National Training Seminar National Harbor, Maryland July 8, 2013 cognitive-behavioral therapy for treating depression and suicide in teenagers Jeff Bergmann, M.A., LPC, NCC Clinical Psychology Ph.D. Candidate, George Mason University Lieutenant Colonel, US Army

2. Training Schedule • introduction (5 minutes) • cognitive-behavioral theory (5 minutes) • conceptualization of how depression develops (5 minutes) • maintenance of depressive symptoms (5 minutes) • treatment plan development (10 minutes) • conceptualization of how suicidal ideation develops (10 minutes) • maintenance of suicidal symptoms (10 minutes) • treatment plan development (10 minutes) • teen case studies practical exercise (20 minutes) • questions (10 minutes)

3. Acknowledgements/Disclaimers Information for this workshop is taken from the CBT Teen Depression Manual authored and utilized by Dr. Christy Espisito-Symthers in training psychologists at George Mason University. Information presented in this workshop is not intended for use by unlicensed mental health professionals, does not reflect endorsement by George Mason University, the US Army or the Department of Defense. The material presented reflects the views of the presenter and is intended for self-awareness educational and informational purposes only. This workshop presents cognitive-behavioral theory conceptualization of the development and maintenance of teenage depression and suicidal ideation. Information is presented to describe the connection of thoughts, behaviors, and feelings to the development and maintenance of depression and suicidal ideation. The information includes how a cognitive-behavioral therapy treatment plan is developed and implemented. Practical application include processing two case studies of military-connected teenagers, one dealing with depression and the other depression and suicidal ideation, for the purposes of illustrating the cognitive-behavioral conceptualization and developing a treatment plan. The following skills would be introduced and illustrated: deep breathing, progressive muscle relaxation, problems solving, thought challenging, cognitive restructuring, behavioral activation, and suicidal ideation safety plans.

4. CBT Skills Introduced & Illustrated • deep breathing • progressive muscle relaxation • problem solving • thought challenging • cognitive restructuring • behavioral activation • suicidal ideation safety planning

5. Cognitive Behavioral Theory

6. Thinking-Behaving-Feeling

7. Thought Challenging

8. Depressed Military Teen • 15 year-old April just relocated to Texas • April hates hot weather • April thinks Texas is obnoxious • April left her 17 year-old boyfriend back in NY and is worried the relationship won’t last • April is not adjusting well in her new school and her mom has noticed an increased pattern of withdrawal • April says no one in Texas likes her

9. April’s Depression • Depression Development & Maintenance • CBT Triangle • Thinking-Behaving-Feeling Spirals • Treatment Plan • Psychoeducation (Information) • Thought Challenging & Cognitive Restructuring • Behavioral Activation

10. Cognitive Restructuring

11. Thought Challenging

12. Problem Solving

13. Teen Suicidal Ideation Interview • DEGREE OF SUICIDE RISK • 1. How frequent have your suicidal thoughts been (everyday, few days a week, etc.)? How long do they last when you do have them (most of the day, few hours, few minutes)? • 2. Have you told anyone about your suicidal thoughts? • 3. Do you have a suicide plan? How long have you been thinking about this plan? Have you made preparations for this plan? Have you acted on this plan in any way (e.g., held pills in hand)? Do you intend to act on this plan? • 4. Have you made any final preparations for a suicide attempt (e.g., suicide note, given away belongings)? • 5. One a scale of 1 (not at all likely) to 10 (highly likely), what is the likelihood that you will make a suicide attempt?

14. Interview Continued • PREFERRED METHOD FOR SUICIDE • 1. If you were to make an attempt, how would you do it? • 2. Do you have access to this method at your home or anyone else’s? • 3. Do you have access to guns at your home or anyone else’s? Do you have access to ammunition? • 4. Do you have access to pills at your home or anyone else’s? If so, how many, what type, and how are they stored (e.g., locked up)? • INTOXICATION • 1. Have you used any alcohol or drugs recently? Was the use of drugs or alcohol associated with your suicidal thoughts? • 2. If yes, do you plan to continue to use drugs or alcohol? Do you have access to drugs or alcohol?

15. Interview Continued • SUICIDE PRECIPITANT • 1. What triggered your suicidal thoughts? • 2. Does that problem still exist? • 3. Can you avoid this problem in the future? Do you intend to avoid this problem?

16. Assess Suicidal Intent • 1. Do you actually want to die? Or, is it that you don’t really want to die but do want to escape an intolerable situation? • 2. Do you think that things will get better with time or is this situation hopeless? • 3. What reasons do you have for living? Let’s list any reasons that you have on this Reasons For Living List. • [Note: Examples might include future plans mentioned in previous sessions, leaving parents/siblings/family member/pet he/she cares about, the way people might feel if he/she committed suicide, things he/she will never get to do, or anything important to the teen.]

17. Assess Reasons for Living

18. Introduce the Safety Plan • 1. Can you 100% promise that you will not attempt suicide between now and the next outpatient appointment? (Note - this is asked for assessment purposes not intervention) • 2. Can you promise that you will inform an adult should you feel in danger of making a suicide attempt? Who will you tell? (Inquire about people in and outside the home). What are their phone numbers? Let’s write them down on this Safety Plan. Be sure to keep them by your phone at home. • 3. If there is not an adult available when/if you were to feel in danger of attempting suicide, will you promise to phone me (if during hours when I am available), call the suicide hotline, go to/have someone take you to the nearest emergency room, or call 911 for help? Can you think of anything that could get in the way of you using this plan? • 4. Will you make every effort to avoid activities/situations which you believe may increase the chance of thinking about or attempting suicide? • 5. If you are unable to avoid these activities/situations or others that leave you feeling very upset, what can you do to help calm yourself down? These can be things that you can do or tell yourself. Let’s write them down on this Safety Plan. • [NOTE: If teen was able to list any reasons for living be sure to have him/her include “read reasons for living list” as a coping technique].

19. Suicidal Ideation Safety Plan

20. Practical Exercise

21. Cognitive Restructuring

22. Thought Challenging

23. Problem Solving

24. Relaxation Techniques

25. Relaxation Techniques Continued • Deep Breathing • Progressive Muscle Relaxation

26. Request for research participants! Online survey (45 minutes) for veterans, National Guard, reserves & active duty related to deployments, psychological well-being, sleep problems, character strengths and academic transitions. Questions/Discussion jeffreybergmann@gmail.com