Therapeutic Interventions for High-risk Clients in College Counseling

1. Use of individual and group therapeutic interventions with high risk clients as a case manager in a college counseling setting

2. Kristal Pollack, LCSW graduated from FSU and FIU and has been with CAPS since August 2013. She is a qualified Supervisor for the State of Florida. Interests include depression, anxiety, non suicidal self injury, and crisis intervention. Past experiences include homeless shelter for youth, school social work, and community mental health. Campus liaison to Active Minds. Coordinates professional development for CAPS. Created and co-facilitates a DBT group for high risk students. Sits on the Substance Abuse Treatment Team. • Vanessa Stein, LCSW graduated from UF and UCF and has been with CAPS since January 2013. She is a member of NASW and is a qualified Supervisor for the State of FL. Interests include anxiety, non suicidal self injury, crisis intervention and mindfulness. Past experiences in hospital, hospice, and middle school settings. Campus liaison with VARC (Veterans) and Hillel (Jewish students). Awarded a grant to launch an innovative Peer Educators program. Created and co-facilitates a DBT group for high risk students. Sits on the Substance Abuse Treatment Team. About Us

3. Observe, Describe, Participate! Mindfulness Activity

4. Dual Role = Finding Balance! Care Management Clinical Therapist • Identifies and facilitates the coordination of services to meet the complex needs of an individual student • Organize the flow of mental health information between CAPS and partners (on and off campus) while adhering to confidentiality and ethical standards • Develops after-care plans for CAPS clients, and monitors the progress of plans to ensure a successful triage or transfer of mental health care • Collaborate with division, and the university in helping students meet their goals for retention and academic success • Advocates and coaches students using a strengths based approach • Assesses a student’s situation, risk level, and engagement in voluntary services • Implement and coordinate treatment plans based on diagnosis from DSM-5 and short term model • Continue risk monitoring and evaluation of SI, HI, SIB, substance, eating, or other risk concerns • Assists in motivating students to make appropriate connections, modeling the counseling relationship, and encouraging students to seek positive change • Provides flexibility and empathy to students who may have had negative experiences or encountered stigma in the past

5. Used to help clients who have experienced an event that has triggered an immediate state of disequilibrium resulting in not being able to access typical methods to cope and/or access resources. The goal here is short term and immediate with the therapist taking an active role to work on reducing the intensity of the reactions to the crisis and return to a normal level of functioning using coping skills. Crisis Intervention

6. Crisis Intervention • Risk assessment • Plan for Living • Incorporating support • Psychological First Aid • Reducing vulnerabilities and discussing self care • Distress tolerance skills • Providing resources/ connection to campus partners

7. Used with the therapist taking an active role in eliciting and strengthening the client’s motivation for change. Within this approach, the students’ ambivalence is explored and resolved. The client’s level of motivation for change is assessed based on readiness to act on a new healthier behavior using Trans-theoretical model of change Motivational Interviewing

8. Motivational Interviewing • Central concept is evaluating, discussing the ambivalence about changing the behavior • Person-centered • Collaborative conversation to strengthen a person’s own motivation to commit to change • Uses collaboration, evocation, autonomy • Expresses empathy, supports self-efficacy, rolls with resistance

9. Interventions for MI • OARS • Open Ended Questions • Affirmations (recognize client strengths) • Reflections (Validation/express empathy) • Summaries

10. Interventions for MI • Change Talk- DARN-CAT • DARN • Desire ( I want to change) • Ability (I can change) • Reason (It’s important to change) • Need (I should change) • CAT • Commitment (I will make changes) • Activation (I am ready, prepared, willing to change) • Taking Steps (I am taking specific actions to change) Preparatory Change Talk Implementing Change Talk

11. Interventions for MI • Strategies for evoking change talk • Explore decisional balance (pros/cons of both changing and staying same) • Good things/not so good things of target behavior • Ask to elaborate when change talk starts (“Tell me more” “What does that look like”) • Look back at how things were prior to target behavior • Look forward and explore what will happen if things continue the same way, and if things change • What would be the worst thing that happens if you don’t change? The best thing? • Use change rulers • Explore goals and values and how target behavior fits into these goals/values • “Perhaps _____ is so important to you that you won’t give it up, no matter what the cost”

12. Designed to aid in preventing the relapse of depression, specifically in clients with Major Depressive Disorder. MB-CT was developed by Zindel Segal, Mark Williams and John Teasdale, based on Jon Kabat-Zinn’s Mindfulness-Based Stress Reduction program. Mindfulness Based Cognitive Behavioral Therapy (MB-CBT)

13. MB-CBT • Goal was to create alternate approaches to relapse prevention by teaching people to decenter from their negative thoughts that would take up cognitive “space” (help prevent depression from coming back) • Combines mindfulness, exploring thoughts/emotions, and self care • Become more aware of bodily sensations and feelings • Develop different way of relating sensations, feelings, and thoughts from moment to moment • Help clients be able to choose the most skillful way to respond while in distress (unpleasant thoughts, feelings, or situations)

14. MB-CBTCore Themes • Explore best way to prevent patterns of negative thinking • Exploring what drives old habits of thinking • Core skill- be mindful/aware, accept • Experiential learning • Empowerment • Learning • Concentration • Awareness/mindfulness of thoughts, feelings, sensations • Being in the moment • Decentering • Letting go • “Being” rather than “Doing” • Bringing awareness to the manifestation of a problem in the body

15. MB-CBT Interventions • Body Scan • Observation- every day activities • Discuss barriers and psycho education on mindfulness (Mind Wandering) • Mindfulness of the Breath • Recording pleasant and unpleasant events (thoughts, feelings, and bodily sensations associated with the events- no matter how fleeting or momentary) • Every activity needs to be practiced daily for one week and logged

16. MB-CBT Interventions • Mindfulness of Sound and Thoughts • Thoughts are not facts (sitting with thoughts as thoughts) • Exploring negative thoughts using MB-CBT learnings (Perhaps I am thinking in black and white terms? Perhaps I am concentrating on my weaknesses and forgetting my strengths? Perhaps I am judging myself?) • Depression Self Care Action Plan • Identifying Relapse Triggers • Every activity needs to be practiced daily for one week and logged

17. A form of clinical behavior analysis developed by Steven Hayes. Clients benefit from this empirically-based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behavior-change strategies to increase psychological flexibility. Acceptance and Commitment Therapy (ACT)

18. ACT • Goal is to increase psychological flexibility to increase vitality = show up for your own life! • Assumption that suffering is inevitable: if you’re not willing to have it, you’ve got it • Avoidance causes inflexibility, leads to lack of clear values • Control is best applied to where it works – overt behavior… not thoughts/feelings/sensations (use mindfulness instead!) • Values clarification builds motivation for committed action • Cognitive fusion happens when thoughts dominate behavior ie: we take it literally, or we entangle in judgement

19. ACT Hexaflex

20. Originallydeveloped by Marsha Linehan to treat chronically suicidal clients diagnosed with borderline personality disorder (BPD) and is now recognized as an evidenced based psychological treatment for multiple disorders. Students learn mindfulness based skills to increase distress tolerance, regulate emotions, and gain interpersonal effectiveness Dialectical Behavior Therapy (DBT)

21. DBT – Goals of Group Behaviors to Decrease • Interpersonal Chaos • Intense/unstable relationships • Trouble maintaining relationships • Panic/Anxiety • Dread over relationships ending • Frantic efforts to avoid abandonment • Labile Affect • Extreme emotional sensitivity, ups and downs • Moodiness/intense emotional reactions • Chronic depression • Problems with anger (controlled/uncontrolled) • Impulsiveness • Alcohol, drugs, eating, spending , fast driving • Para-suicidal behaviors • Suicide threats • Confusion about self/Cognitive Dysregulation • Pervasive sense of emptiness • Problems in maintaining one’s feelings, decisions, opinions when around others • Delusions, Depersonalizations, Disassociations

22. DBT – Goals of Group Behaviors to Increase Interpersonal Effectiveness Learning how to deal with conflict How to say no How to be assertive Emotional Regulation Control of emotions Understanding complete control may not be achieved Distress Tolerance Learning how to tolerate distress Learning how to decrease impulsiveness Reduce intolerable distress Core Mindfulness Go within to find oneself and observing oneself

23. DBT- Structure and Content Structure • 12 sessions total • Group session 1 focused on Introduction to group, consents, and overview of DBT • Group session 2 focused on Mindfulness • Group session 3-5 focused on interpersonal skills • Group session 6-8 focused on Emotion Regulation • Group Session 9-11 focused on Distress Tolerance • Group Session 12 focused on completion of group Content Feelings check in/Homework discussion/CCAPS review Mindfulness Activity Teach Skill Practice Skill Review rating scale/diary card from previous week, and pass out for next week Set goal for next week Mindfulness Activity

24. BSL-23 (6) • Pre: 47.50 • Post: 19.00 • T (5) 7.31, p < .001, which indicates a significant decrease in symptoms. • 71% strongly agreed or agreed that the group helped with their personal relationships • 86% strongly agreed or agreed that the group helped to understand their feelings better • 100% felt the group helped them to develop better coping skills • 100% felt that the group was very effective and helpful overall • 100% experienced the benefits of being in a therapy group, and were able to learn something DBT – Quantitative and Qualitative Data Effective for some personal problems, but not all.” “It’s changed my life.” “I enjoyed having the binder, I needed something tangible to keep.” “This was a good choice.”

25. Resources and References • Crisis Intervention • See attached handouts • http://www.nctsn.org/content/psychological-first-aid • Motivational Interviewing • http://store.samhsa.gov/product/Enhancing-Motivation-for-Change-Inservice-Training/SMA12-4190 • http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf • MB-CBT • https://www.amazon.com/Mindfulness-Based-Cognitive-Therapy-Depression-Preventing/dp/1572307064/ref=sr_1_4?ie=UTF8&qid=1466081609&sr=8-4&keywords=mindfulness+based+cognitive+therapy+for+depression • ACT • Contextualscience.orgwww.actmindfully.com.au/free_resources • http://www.actwithcompassion.com/ • DBT • http://behavioraltech.org • http://www.linehaninstitute.org