VAPTC EBP Presentation 1 VA Training in Evidence-Based Psychotherapies

Background In recent years, health care policy has incorporated evidence-based practice as a central tenet of health care delivery (Institute of Medicine, 2001). In recent years, health care policy has incorporated evidence-based practice as a central tenet of health care delivery (Institute of Medicine, 2001). The VA developed a Mental Health Strategic Plan in response to the Presidents New Freedom Commission on Mental Health report (2004) The VA developed a Mental Health Strategic Plan in response to the Presidents New Freedom Commission on Mental Health report (2004) The Mental Health Strategic Plan calls for the implementation of EBPs at every VAMC in the country The Mental Health Strategic Plan calls for the implementation of EBPs at every VAMC in the country VAPTC EBP Presentation 2

Goals of VA Training in EBPs To train VA staff from multiple disciplines in evidence-based psychotherapies To train VA staff from multiple disciplines in evidence-based psychotherapies To augment psychotherapies already being offered in VA medical centers To augment psychotherapies already being offered in VA medical centers VAPTC EBP Presentation 3

VA Dissemination and Training in EBPs Cognitive Behavioral Therapy (CBT) for Depression Cognitive Behavioral Therapy (CBT) for Depression Acceptance and Commitment Therapy (ACT) for Depression Acceptance and Commitment Therapy (ACT) for Depression Cognitive Processing Therapy (CPT) for PTSD Cognitive Processing Therapy (CPT) for PTSD Prolonged Exposure (PE) for PTSD Prolonged Exposure (PE) for PTSD Social Skills Training (SST) for severe mental illness (SMI) Social Skills Training (SST) for severe mental illness (SMI) Integrative Behavioral Couple Therapy (IBCT) Integrative Behavioral Couple Therapy (IBCT) Family Psychoeducation (FPE) Family Psychoeducation (FPE) –Behavioral Family Therapy (BFT) –Multi-Family Group Therapy (MFGT) VAPTC EBP Presentation 4

EBP Presentations for Interns and Postdoctoral Fellows VA EBP roll-out training has been focused on staff VA EBP roll-out training has been focused on staff VA Psychology Training Council (VAPTC) developed a workgroup in 2009 to focus on developing EBP didactics for interns and postdoctoral fellows VA Psychology Training Council (VAPTC) developed a workgroup in 2009 to focus on developing EBP didactics for interns and postdoctoral fellows VAPTC EBP Presentation 5

Goals of this EBP Presentation To provide a basic working knowledge of each of the roll-out EBPs To provide a basic working knowledge of each of the roll-out EBPs To provide the foundation for trainees to seek out further training and supervision in the EBPs they intend to implement To provide the foundation for trainees to seek out further training and supervision in the EBPs they intend to implement VAPTC EBP Presentation 6

Limitations This presentation will not provide equivalent training to the EBP roll-outs This presentation will not provide equivalent training to the EBP roll-outs This presentation will not provide the skills to implement the treatment without further training and supervision This presentation will not provide the skills to implement the treatment without further training and supervision VAPTC EBP Presentation 7

VAPTC EBP Training 8 VA Social Skills Training

VA Psychosocial Rehabilitation Training Program (VA-PRT) Program funded and supported by OMHS at VACO Program funded and supported by OMHS at VACO Part of effort to increase availability of psychosocial EBP to veterans Part of effort to increase availability of psychosocial EBP to veterans Provides training, support, consultation to VA practitioners and MH leaders working with Vets with Serious Mental Illness (SMI) Provides training, support, consultation to VA practitioners and MH leaders working with Vets with Serious Mental Illness (SMI) Training in 2-day workshop and 24 weeks of consultation Training in 2-day workshop and 24 weeks of consultation Also includes a train-the-trainer component Also includes a train-the-trainer component Current focus on Social Skills Training (SST) for Veterans with SMI Current focus on Social Skills Training (SST) for Veterans with SMI VAPTC EBP Training 9 Taken from slides composed by SST Training Program

Background of Social Skills Training (SST) Identified as an evidenced-based practice for persons with serious mental illness Identified as an evidenced-based practice for persons with serious mental illness Currently used in multiple research projects: Currently used in multiple research projects: –Vocational social skills –Reduction of Substance Abuse –Improvement of health behaviors –Increasing leisure and recreation activities Currently used in multiple VA treatment settings, with Veterans of different functioning levels Currently used in multiple VA treatment settings, with Veterans of different functioning levels VAPTC EBP Training 10 Taken from slides composed by SST Training Program

Several Models of SST Model used in the VA-SST Rollout: Social Skills Training for Schizophrenia: A Step by Step Guide, 2 nd edition. Bellack, A., Mueser, K., Gingerich, S., & Agresta, J. VAPTC EBP Training 11 Taken from slides composed by SST Training Program

Guilford Press, Second Edition, 2004 Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

Why is SST required? Poor social role functioning is a key issue in the development and maintenance of chronic disability Poor social role functioning is a key issue in the development and maintenance of chronic disability SST is an evidence-based practice to improve social role functioning SST is an evidence-based practice to improve social role functioning SST is consistent with a recovery approach to care SST is consistent with a recovery approach to care Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

What is Recovery? Consumer/Survivor Perspective Recovery is a process, rather than an end state or outcome. Recovery is a process, rather than an end state or outcome. Recovery is strengths-based, rather than symptom- based, and involves: hope, respect, and empowerment. Recovery is strengths-based, rather than symptom- based, and involves: hope, respect, and empowerment. Recovery is a model that involves the nature of treatment, as well as a person variable Recovery is a model that involves the nature of treatment, as well as a person variable Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

What are the Implications of the Recovery Model for Treatment Services? ( Presidents New Freedom Commission, 2003) First, services and treatments must be consumer and family centered, geared to give consumers real and meaningful choices about treatment options and providers… First, services and treatments must be consumer and family centered, geared to give consumers real and meaningful choices about treatment options and providers… Second, care must focus on increasing consumers ability to successfully cope with lifes challenges, on facilitating recovery, and on building resilience, not just managing symptoms Second, care must focus on increasing consumers ability to successfully cope with lifes challenges, on facilitating recovery, and on building resilience, not just managing symptoms Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

Recovery Attributes of SST Focuses on behavior rather than symptoms Focuses on behavior rather than symptoms Teaches skills needed to increase independence Teaches skills needed to increase independence Provides choice Provides choice Fosters hope: assumes change is possible Fosters hope: assumes change is possible Fosters self-efficacy Fosters self-efficacy Based on respect: assumes failures result from skill deficits and/or the environment, not personal faults (e.g., low motivation) Based on respect: assumes failures result from skill deficits and/or the environment, not personal faults (e.g., low motivation) Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

17 Social skills are interpersonal behaviors that are normative and/or socially sanctioned. They include such things as dress and behavior codes, rules about what to say and not to say, and stylistic guidelines about the expression of affect, social reinforcement, interpersonal distance, and so forth. Social skills are interpersonal behaviors that are normative and/or socially sanctioned. They include such things as dress and behavior codes, rules about what to say and not to say, and stylistic guidelines about the expression of affect, social reinforcement, interpersonal distance, and so forth. Bellack et al, 2004, Page 3 So, what are social skills? Taken from slides composed by Shirley Glynn, Ph.D. Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

Factors Contributing to Poor Social Role Functioning in the Community Diminished motivation Diminished motivation –Negative symptoms/deficit state –History of failure / low self-efficacy Lack of opportunity Lack of opportunity Lack of positive social pressure Lack of positive social pressure Societal stigma Societal stigma Cognitive impairments Cognitive impairments –Executive functions –Attention and memory deficits Functional Impairments Functional Impairments –social skills deficits Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

Model of Social Skills, SST, Mediators and Functional Outcome Social Occupational Independent Living Rehabilitation Success Substance abuse Social Occupational Independent Living Rehabilitation Success Substance abuse Mediating Variables Functional Outcome Domains Neurobiologic al Factors Environment al Factors Social Skills Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

Model of Social Skills, SST, Mediators and Functional Outcome Social Occupational Independent Living Rehabilitation Success Substance abuse Social Occupational Independent Living Rehabilitation Success Substance abuse Mediating Variables Functional Outcome Domains Social Skills Training Neurobiologic al Factors Environment al Factors Social Skills Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

Social Skills Model Social skill is a hypothetical construct conceptualized as comprising three interrelated functions: 1. Social perception ability to accurately perceive social cues 2. Social problem solving ability to correctly analyze the social situation and identify an effective response 3. Behavioral competence ability to effectively implement the response Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

Behavioral Components of Social Skill Speech Content Speech Content Paralinguistic Features voice volume pace pitch tone Paralinguistic Features voice volume pace pitch tone Nonverbal Behavior proxemics kinesics gaze facial expression Nonverbal Behavior proxemics kinesics gaze facial expression Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

Evidence for SST: Literature Reviews Narrative Period # studies Halford & Hayes, Bellack & Mueser, Scott & Dixon, Penn & Mueser, Smith et al., Heinssen et al., Huxley et al., Bustillo et al., Narrative Period # studies Halford & Hayes, Bellack & Mueser, Scott & Dixon, Penn & Mueser, Smith et al., Heinssen et al., Huxley et al., Bustillo et al., Meta-analyses Benton & Schroeder, Corrigan, Dilk & Bond, Pilling et al., Meta-analyses Benton & Schroeder, Corrigan, Dilk & Bond, Pilling et al., Pfammatter et al., Pfammatter et al., Kurtz & Mueser, Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

Areas of Effectiveness Outcome Effects Domain Symptoms N Relapse N Behavioral skills Y Social role function Y Specialized skill Y Self-efficacy Y Outcome Effects Domain Symptoms N Relapse N Behavioral skills Y Social role function Y Specialized skill Y Self-efficacy Y Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

Training Procedure Instructions:what to do and why keep it simple keep it relevant Instructions:what to do and why keep it simple keep it relevant Modeling: illustrate how to do it keep it simple keep it relevant Modeling: illustrate how to do it keep it simple keep it relevant Role Play: rehearsal keep it brief make it successful Role Play: rehearsal keep it brief make it successful Positive Feedback and Shaping keep it positive Positive Feedback and Shaping keep it positive Repeat Role Plays: repeated practice Repeat Role Plays: repeated practice Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

Logistical Considerations Small groups (6-10 max) Small groups (6-10 max) Predefined curricula (content and goals) Predefined curricula (content and goals) 2-3 sessions per minutes 2-3 sessions per minutes Co-therapists preferred by not required Co-therapists preferred by not required Group duration varies with content Group duration varies with content Emphasis on behavioral rehearsal Emphasis on behavioral rehearsal Level of training geared to veterans Level of training geared to veterans Closed groups preferred but not required Closed groups preferred but not required VAPTC EBP Training 26 Taken from slides composed by SST Training Program

Important Characteristics of SST Groups, slide 1 Structured format in every session Structured format in every session Abstractions are minimized Abstractions are minimized Emphasis on role playing and practice Emphasis on role playing and practice Focus on one skill at a time Focus on one skill at a time Curriculum is planned Curriculum is planned VAPTC EBP Training 27 Taken from slides composed by SST Training Program

Important Characteristics of SST Groups, slide 2 Role plays and home assignments are tailored to each member Role plays and home assignments are tailored to each member Group demands geared to members abilities Group demands geared to members abilities Communications are always positive Communications are always positive Explicit and frequent reinforcement Explicit and frequent reinforcement VAPTC EBP Training 28 Taken from slides composed by SST Training Program

Who Should Deliver Services? Training at least MA level clinicians, select BA level psychology, social work, rehab counseling, nursing Training at least MA level clinicians, select BA level psychology, social work, rehab counseling, nursing Requirements Experience with SMI population Comfortable with a structured, teaching approach Reinforcing interpersonal style Requirements Experience with SMI population Comfortable with a structured, teaching approach Reinforcing interpersonal style Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

Key Points SST is teaching, not verbal group therapy SST is highly structured SST is teaching, not verbal group therapy SST is highly structured SST therapists must do their homework SST therapists must do their homework SST therapists must be consistently positive and encouraging SST therapists must be consistently positive and encouraging Keys to effective teaching include: shaping behavior rehearsal Keys to effective teaching include: shaping behavior rehearsal Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

Session Sequence 1. Give a rationale for the skill 2. Briefly have members share a relevant experience or rationale 3. Explain the steps of the skill 4. Model the skill 5. Have a group member role play 6. Give feedback 7. Have the member role play again 8. Solicit feedback from the group 9. Repeat role play again and provide feedback 10. Repeat Steps 5-9 with each other group member 11. Give out homework Taken from slides composed by Alan Bellack, Ph.D., Direct, VA Capitol Health Care Network MIRRECC

32 Two Key Components of VA-SST 1. Individual session for engagement, orientation, obtaining consent, and goal setting 2. Group sessions for teaching specific social skills Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

33 Individual Goal Setting Session Benefits Benefits –Helps with engagement, building rapport –Prepares veterans for what to expect in a skills training group –Links SST to recovery –Identifying vets goals important for selecting curriculum, setting up meaningful role plays, developing home assignments Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

34 Examples of Common Goals Making friends Making friends Developing leisure activities to do with others Developing leisure activities to do with others Getting a job Getting a job Keeping a job Keeping a job Getting along with roommates Getting along with roommates Reducing substance use Reducing substance use Being a better parent Being a better parent Dating Dating Dealing more effectively with angry feelings Dealing more effectively with angry feelings Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

35 Group Session Treatment Format Small groups (6-10 max) Small groups (6-10 max) Predefined curricula (content and goals) Predefined curricula (content and goals) 2-3 sessions per min 2-3 sessions per min Co-therapists preferred but not required Co-therapists preferred but not required Group duration varies with content Group duration varies with content Emphasis on behavioral rehearsal Emphasis on behavioral rehearsal Level of training geared to participants Level of training geared to participants Closed groups preferred but not required Closed groups preferred but not required Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

36 Group Session Sequence 1. Review homework 2. Give a rationale for the skill 3. Briefly have members share a relevant experience or rationale 4. Explain the steps of the skill 5. Model the skill 6. Have a group member role play 7. Give feedback 8. Have the member role play again 9. Solicit feedback from the group 10. Repeat role play again and provide feedback 11. Repeat Steps 5-9 with each other group member 12. Give out homework Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

37 Training Methods Used Modeling Modeling Role playing Role playing Reinforcement Reinforcement Feedback Feedback Taking a shaping approach Taking a shaping approach Overlearning Overlearning Generalization of learning Generalization of learning Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

38 Modeling Leaders set up a role play to demonstrate how they would use the steps of the skill in a situation that group members might have experience with Leaders set up a role play to demonstrate how they would use the steps of the skill in a situation that group members might have experience with Group members are asked to observe the leaders and to discuss how they followed the steps Group members are asked to observe the leaders and to discuss how they followed the steps Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

39 Role plays Set up role plays to be realistic and lively Set up role plays to be realistic and lively –Individualize scene –Choose appropriate level of complexity –Review steps prior to role play to make sure group member understands what is expected Aim for 3 role plays for each group member in each session: Third time is the charm! Aim for 3 role plays for each group member in each session: Third time is the charm! Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

40 Feedback Emphasis on positive feedback; always start with positive Emphasis on positive feedback; always start with positive Feedback should be specific, and related to steps of the skill Feedback should be specific, and related to steps of the skill Leaders: Leaders: –Provide feedback –Routinely elicit feedback from group members Corrective feedback: Corrective feedback: –One or two suggestion for improvement at a time –Can be integrated into second and third role plays (One thing that might make your role play even more effective.... ) Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

41 Supplemental Training Strategies Supplementary Modeling: taking the role of the veteran Supplementary Modeling: taking the role of the veteran Discrimination Modeling: showing difference between good and poor examples Discrimination Modeling: showing difference between good and poor examples Coaching: giving verbal prompts Coaching: giving verbal prompts Prompting: giving nonverbal signals Prompting: giving nonverbal signals Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

42 SST Curriculum 1. Basic skills 2. Conversation 3. Assertiveness 4. Conflict management 5. Communal living 6. Friendship and dating 7. Health maintenance/Communicating with providers 8. Vocational/Work 9. Coping skills for drug and alcohol use Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

43 Basic Skills Listening to Others Listening to Others Making Requests Making Requests Expressing Positive Feelings Expressing Positive Feelings Expressing Unpleasant Feelings Expressing Unpleasant Feelings Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

44 Maintaining Conversations 1. Make eye contact and say Hello 2. Ask a general question 3. Make small talk by asking questions 4. Give a reason and say Good-bye Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

45 General Questions Whats up? Whats up? How are you doing? How are you doing? How have you been? How have you been? What do you think of this weather? What do you think of this weather? Whats new? Whats new? Are you new here? Are you new here? Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

46 Maintaining Conversations 1. Make eye contact and say Hello 2. Ask a general question 3. Make small talk by asking questions 4. Give a reason and say Good-bye Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

47 Reasons to Say Goodbye Well, I have an appointment. I have to go. Well, I have an appointment. I have to go. I have to catch a bus. See you later. I have to catch a bus. See you later. I have to meet a friend. It was good to see you. I have to meet a friend. It was good to see you. Group is about to start. Ill talk to you later. Group is about to start. Ill talk to you later. Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

48 Making a Request 1. Look at the person 2. Say exactly what you would like the person to do. 3. Tell the person how it would make you feel if they did what you requested. In making your request, try using phrases such as I would like you to... I would really appreciate it if you would... Its very important to me that you help me with.... Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

49 Homework Sheet for Making A Request Name: _______________ Practice making a request using the steps below: 1. Look at the person. 2. Say exactly what you would like the person to do. 3. Tell the person how it would make you feel if he or she did what you requested. In making your request, try using phrases such as I would really appreciate if if you would... I would really appreciate if if you would... I would like you to... Its important to me that you help me with.... Date: _____ Who did you make a request to? __________

50 Points to remember Skills training is teaching, not traditional group psychotherapy Skills training is teaching, not traditional group psychotherapy Keep sessions lively and interactive Keep sessions lively and interactive Use flip charts, white boards, handouts Use flip charts, white boards, handouts Prepare for sessions Prepare for sessions Stay with the structure Stay with the structure Do not work in isolation Do not work in isolation Do not passively expect participation Do not passively expect participation Be patient: learning skills will benefit group members,but it takes time and repetition Be patient: learning skills will benefit group members,but it takes time and repetition Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

51 Challenges for clinicians learning SST Allow too much time for discussion/processing Allow too much time for discussion/processing Hesitant to take role of being in charge Hesitant to take role of being in charge Quickly accept when veterans do not want to role-play Quickly accept when veterans do not want to role-play Models scenarios or develops role play scenarios that are complicated and not relevant Models scenarios or develops role play scenarios that are complicated and not relevant Insufficient amount of positive reinforcement Insufficient amount of positive reinforcement Provides/allows vague, non-behavioral feedback Provides/allows vague, non-behavioral feedback Does not engage or encourage group members to be actively involved in group Does not engage or encourage group members to be actively involved in group Experiencing practical/systems issues in starting SST group Experiencing practical/systems issues in starting SST group Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

52 Fidelity resources Social Skills Group Format (Bellack et al., 2004) Social Skills Group Format (Bellack et al., 2004) Social Skills Observation Checklist (Bellack et al., 2004) Social Skills Observation Checklist (Bellack et al., 2004) –Clinician rated –Other rated Two primary sections Two primary sections –General structuring/positive engagement –Steps of SST Taken from slides composed by Joanna Strong Kinnaman, Ph.D., VA-SST Program Manager

SST Curriculum: 9 basic categories 1. Basic Skills 2. Conversation 3. Assertiveness 4. Conflict management 5. Communal living 6. Friendship and dating 7. Health maintenance/Communication with providers 8. Vocational/Work 9. Coping skills for drug and alcohol use VAPTC EBP Training 53 Taken from slides composed by SST Training Program

Format of Teaching a Social Skill, Steps Give a rationale for the skill 2. Briefly have members share a relevant experience or rationale 3. Explain the steps of the skill 4. Model the skill and review with members 5. Have a group member role play 6. Give and elicit feedback VAPTC EBP Training 54 Taken from slides composed by SST Training Program

Format of Teaching a Social Skill, Steps Have the member role play again 8. Give and elicit feedback 9. Repeat role play again and give/elicit feedback 10. Repeat Steps 5-9 with each group member 11. Develop home assignments * Next session will begin with Review Homework as first step. VAPTC EBP Training 55 Taken from slides composed by SST Training Program

Video Example 56

VA-SST Website: For more information and resources on SST and the VA-SST program, please visit our website: 57