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Riskilaste konverents 2012: Jostein Matre: Cognitive behavior therapy
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Riskilaste konverents 2012: Jostein Matre: Cognitive behavior therapy

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Riskilaste konverents 2012: Jostein Matre: Cognitive behavior therapy Riskilaste konverents 2012: Jostein Matre: Cognitive behavior therapy Presentation Transcript

  • HSS – Helhetlig Støtte System Cognitive Behavior Therapy ++delivered to the Norwegian Directorate for Children, Youth and Family Affairs, region North Per Jostein Matre, MSW, child welfare expert Cognitive Therapist and National Supevisor in CBT Authorized supervisor for social workers Robert Jensen, BSW Cognitive Therapist and National Supevisor in CBT
  • Background In November 2010 the Norwegian Directorate for Children, Youth and Family Affairs, region North decided a procurement and called for offers to meet needs of systematizing and improving the work carried out in all the institutions in the northern region 14 units all in all were included - (during the first year two have been closed down), - at the moment there are 12 left The main goal was to systematize and improve ongoing practice The implementation should be based on existing practice and have a «bottom up» design, meaning that ongoing, existing practice should be the base for change through teaching, training and supervision
  • Requirements from region northMethods:By documenting existing practice and using data from the documentation, - develop and changeexisting practice.Practice:Client data (level III) will be the basis for developing practice.As the units lack a solid support system it is crucial first to focus on strengthening staff performance,leader behavior and organizational procedures linked to problem-solving. – Focus on results (Staff, leader and organizational level) • What do the unit try to achieve with their existing practice? • How do staff and leaders know they do a good job (quality wise)? • The goals are that every unit establish own targets and quality criteria’s for their daily practice. – Using CBT (client level III)Evaluation:Shall be carried out using standardized assessment tools (level III) and be basis in documentation andsupervision for leaders and staff . Assessment, feedback and evaluation (organization, staff and client level)
  • Main GoalsTo systematize and improve existing practice
  • Timeline – from the call for procurement to contracting Mid. of November 2010 - Region north send out the demands and specifications to be met 22.1.2012 Time limit to deliver a full detailed description of what, when and by who 30.3. 2011 Negotiations on contrakt terms 28.4. 2011 Contracting 22.5.2011 Starting point of the project
  • Our offer – related to different Goal levels – I - IIII. Organization and the leadersAssess existing practice, competence and needs for supervision Localy: Visit each unit, both the leaders alone and leaders together with a group of staff Intervention; leader gathering setting up goals and following up performanceII. StaffStaff assessment using New Goal Setting Questionnaire: (seven domains – well-being, support from leaders,goal directedness, self – efficacy, specified goals etc.) Quest – back, – on the internet Local supervisionIII. ClientTraining in principles, theory and models in a module based Cognitive Behavior Therapy – Training in both standardized and other assessment (ASEBA, SDQ, Global assessment, BYI etc.) – Training in analyzing and conceptualization – Training in goal setting and evaluating procedures based on Goal Atainment Scalling and weekly based reports – Training in specific interventions based upon different types of problems (e.g; anxiety, depression, trauma etc) – Establishing procedures for; monitoring operations, satisfaction with sercvice and evaluating client satisfaction and client involvement Core group gatherings Local training and supervision
  • Implementing – HSS in region north co – operation with who A project carried out by Centre of Cognitive Practice – CCP (Asker – 20 km west of Oslo)Per Jostein Matre Head of clinical services , cand. polit – MSW – clinical social workRobert Jensen Manager , BSW – clinical social workPartnersKitty Dahl Psychol. PhD - Regional Centre for child and adolescent mental health (RBUP)Hans Nordahl NTNU, Professor at psychological institute – clinical departmentEric Trupin University of Washington, USA Professor & Vice Chair in the Department of Psychiatry & Behavioral Sciences Director of the Division of Public Behavioral Health and Justice PolicyArne Martin Nytrøen Considium, consultant in performance review (leaders)Claes Linden Psychologist, specialistHarald Stokkeland Consultant – leader support
  • Who is doing what – in the whole project?Activity Per Robert Kitty Arne Harald Hans Eric Claes Jostein MartinLocal X XworkshopsCore group X X XworkshopsLeader X X XsupportPerformance X X XreviewsEvaluation X X X XData X X XcollectionSupport XProject Xmanager
  • Where are we working In black; facilities / centers for youth / adolescent, age group 13 – 18 In red; facilities / centers for children and families, age group 0 – 12
  • Timeline for implementation in Child Care Services in North of Norway Evaluation Target First year Second year Third year Instruments Group 2011(May) -2012(April) 2012(May) - 2013(April) 2013 (May) -> O= Organization 2011 2012 2013 L= Leaders S=Staff Spring Fall Spring Fall Spring FallC/Y/P/CWW/T= Children/ Youth/ Parents/ Child welfare workers/ TeachersSVQ O/L/S May/August Results May/June Feedback May/June Results (pre interventions) Feedback (short version) (short version) Feedback Provided localy for staff once a year and to the leaders at the facility three times a yearGAS O/L/S May/June/ April/May April/May augustQuest-back O/L/S June/August Results June/August Results June/August Results Feedback Feedback FeedbackSatisifaction C/Y/P/ Once: End of the stay at the facilitymeasures CWW Given to the Youth, Parents and/other key peopleEBPAS Staff September / April April/SeptemberCTACS Staff September / January / April September / January / AprilSDQ C/Y/P/T Twice: Start and end of the Youths stay at the facilityASEBA C/Y/P/T Twice : Start and end of the Youths stay at the facility(CBSL, YSR, TRF)Specific C/Y/P At least twice: Early and end of the stay at the facilityInstruments forproblem areas
  • OrganizingTraining and supervision directed todifferent groups Regional workshops Local workshopsLeaders 8 full day performance review workshops 4 full day leadersupport workshops4 Core groups, aprox. 8 staff member per unit; 6 workshop for every group25 – 30 %Staff at the unit 13 full days of training and supervision at eache unit (total of 156 days + additional 12 + 12)HSS-team meetings as regular as possible
  • Done at all unitsSemi structured interviewSite Visit Questionnaire (SVQ)Goal Attainment Scaling (GAS) – 5 point scale from 0-4 (weak – strong practice) – 21 domains (e.g. organization, target (client) group, written practice / routines, procedures / assessment procedures, analytical practice, working with goals, interventions, evaluating procedures, need for training and supervision etc.) • Two interviewers, both make notes and score • Ca. 2 – 2 ½ hours with the leaders • Ca. 3 hours with leaders and staff togetherInternet based survey both for staff and leadersQuest-back (put together based on 3 different instruments) • 90 questions, around 35 minutes • 15 domains, e.g.; (1) Colleague support, (2) leader support, (3) own goal directed behavior, (4) self – efficacy, (5) optimism, (6) engagement & commitment, (7) own practiceSelf reportsCTACS: Cognitive Therapy Adherence & Competence Scale • 21 questions • Ca 10 minEBPAS: The Evidence-Based Practice Attitude Scale • 15 questions (own attitudes to evidence-based practice) • 5 point Likert scale (0-4) • 4 subscales and one total score • Ca 10 min
  • Main findings – first year (2011) Scoring each unit based on Site Visit Questionaire (SVQ) Assessment Conceptualization Evaluation and Max / minVirksomhet Analysis Goal setting Interventions Reporting Score procedures procedures documentation 35 / 7 3 2 2 3 3 3 3 19 3 3 3 4 4 3 3 23 4 3 4 4 4 3 3 25 4 3 3 4 4 3 2 23 3 3 3 4 3 3 3 22 4 4 3 4 4 3 3 25 4 3 3 4 4 3 3 24 3 3 3 3 3 3 3 21 4 3 2 3 4 3 3 22 4 3 3 3 4 4 4 25 4 3 4 3 4 4 3 25 Ikke skåret Ikke skåret
  • Implementing a blend of compatible theories and working models
  • The plattforms Cognitive Social Ecological Behavior Behavior cognitive Theory analysis Therapy theory•Reinforcement • Automatc thougths • PSE• Generalization • Transition • Assumptions • Resiprocal and •System support • Core beliefs model maintenance CBT With children, adolescents and families
  • Module based approach to CBT Psychoeducation module Behavioral Cognitive Rational Performance /Interventions Restructuring analysis Attainment Module Module Module / Exposure Module Assessment, Self monitoring, and evaluation Module Friedberg, R.D, McClure, J.M. & Garcia, J.H (2009)
  • So, - what do we do, basics, the modules and beyond ?
  • 1. Assessment of strengths and challenges 6. 2. Evaluation Analysis and and re – conceptualiz -conceptualiz - ing on four ing levels 3. 5. Setting goalsSkill training, for the stayexperiments, and theexposure and specific response treatment prevention 4. General and specific interventions Kuyken, Padesky, Dudley (2009); Friedberg & McClure (2002); Friedberg, McClure & Garcia (2009); Stark (2010)
  • Assessment proceduresGlobal assessment Descriptive Functional Longitudinal Strengths and Resources Standardized ASEBA, SDQ and specific Anxiety assessment Depression Trauma Addiction etc. Re – assessment Evaluation re - conceptualization
  • Examples of Global assessment GI Youth
  • Anamnestic Interview - AISykehistorie, opplysninger om tidligere helseforhold og nåværende symptomerinnhentet fra ungdommen og/eller pårørende
  • Standardized assessmentswww.sdqinfo.com/
  • ASEBA
  • Analysis and conceptualizationLevel 1 Context– increase the persons understanding of Othersconnections between trigger – own Timebehavior and thoughts in the situation and Behaviourhow these two domains has impact onemotions and bodily sensations Emotions Thoughts Trigger Bodily sensations
  • Level 2– increase the persons understanding oftrigger – own behavior and thoughts andhow reduced negative emotions and bodilysensations together with contextualreactions maintain patterns
  • Escalation curve Patterson 1987 Kan du rydde Jeg sa du skulle Opp etter deg rydde, nå! Toppen er nådd når det gjelder følelser. ordbruk og handlinger NedtrappingØkt og økende intensiteti følelse, ordbruk og Åhh – slutt RYDD NÅ!!handlinger med den gråtingen InnhentingArgumenteringirritert og opprørt Utløser Lære å stoppe her Utløser Bearbeiding Rolig
  • A B C (Activating event) (Belief) (Consequences)Sitting down by the kitchen table, - Everything will fall apart Laying down at the sofaWorrying about future events in a very I am a bad mother for my two daughters Reduced anxietynegative way I can`t make it Reduction of body sensation of heaviness Nothing works
  • FULL - KONSEPTUALISERING Level 4 Actuel situation Problem Strengths and resources Strengths and resources Level 3 Experiences Temperament, Rules, values and goals history biology, medicine; Longitudinell both family significant events social and economy and individual conceptualization Triggers AT – varme og kalde kognisjoner. Mellomliggende Level 2 Level 1 antagelser (normer, regler, mål og forventninger) ABC – both triggers Connection between Kjerneantagelser (globale fore-stillinger omand Maintenance factors Descriptive conceptualization seg selv, andre, verden og tid) dvs. Skjema Functional conceptualization Behavior Emotions (0 til 10) Bodily sensations (0 – 10) Maintaining factors Kuyken, Padesky and Doodley (2009); nnnn Adapted by Per J Matre & Robert Jensen vers 11 2011
  • Goal setting What can be changed by interventions Behaviour ContextEmotions Thoughts Trigger Bodily sensations
  • Specifying goals in therapy – an example Can you imagine yourself together with your two daugters doing something positive What do you actually see ? How does it look in Whe do you start doing like this, details? Do you get a what is yuor time frame? clear imagery of it? When you see this what more do you see? Goal setting procedure - working with visualized goals in Is it realistic? therapy What can you do to make it more realistic? Do you see your own Who, besides yourself can performance and effeort help, so that it becomes ? Do you get a clear more realistic? What imagery of it? Do you obstacles are there, act as your own Can you handle supportive helper? them with own Is it actual and strengths attainable to you? Can you see details of how to make it more achievable for you? Who can help you besides your – self?
  • Ines plan part I
  • Ines plan part II – evaluation
  • Interventions Skill training  Skill training Behavior experiments  Skill training & changing thoughts Exposure  changing behavior and thoughts Response prevention  changing behavior and thoughts Tasks between sessions  Skills, changing behavior and thoughts Parental involvement  changing behavior, thoughts and interactions
  • Example - Ines behavior experiment
  • Evaluation and reconceptualizingGlobal assessment Descriptive Functional Longitudinell Strengths and Resources Standardized Anxiety and specific Depression assessment Trauma Addiction etc. Re – assessment Evaluation re - conceptualization
  • This is our plan Evaluation Target First year Second year Third year Instruments Group 2011(May) -2012(April) 2012(May) - 2013(April) 2013 (May) -> O= Organization 2011 2012 2013 L= Leaders S=Staff Spring Fall Spring Fall Spring FallC/Y/P/CWW/T= Children/ Youth/ Parents/ Child welfare workers/ TeachersSVQ O/L/S May/August Results May/June Feedback May/June Results (pre interventions) Feedback (short version) (short version) Feedback Provided localy for staff once a year and to the leaders at the facility three times a yearGAS O/L/S May/June/ April/May April/May augustQuest-back O/L/S June/August Results June/August Results June/August Results Feedback Feedback FeedbackSatisifaction C/Y/P/ Once: End of the stay at the facilitymeasures CWW Given to the Youth, Parents and/other key peopleEBPAS Staff September / April April/SeptemberCTACS Staff September / January / April September / January / AprilSDQ C/Y/P/T Twice: Start and end of the Youths stay at the facilityASEBA C/Y/P/T Twice : Start and end of the Youths stay at the facility(CBSL, YSR, TRF)Specific C/Y/P At least twice: Early and end of the stay at the facilityInstruments forproblem areas
  • What have we done - May 2011 - September 2012 Spring 2011 Fall 2011 Spring 2012 Fall 2012 RemainsSVQ, GAS X X 2013Quest-back X X 2013EBPAS X X X 2013CTACS X X2 X2 2013SDQ X X X 2013ASEBA X X X 2013(CBSL, YSR, TRF)Specific X 2013Assessmentinstruments forproblem areasSpecific X 2013interventions foranxiety, depression,trauma, addictioncd etcSatisifaction X 2013measuresResult review and X X X 2013feedbackLeader support X 2013