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Think Good, Feel Good ebook

Paul Stallard

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Opis

Newly updated edition of the highly successful core text for using cognitive behaviour therapy with children and young people The previous edition of Think Good, Feel Good was an exciting, practical resource that pioneered the way mental health professionals approached Cognitive Behaviour Therapy with children and young people. This new edition continues the work started by clinical psychologist Paul Stallard, and provides a range of flexible and highly appealing materials that can be used to structure and facilitate work with young people. In addition to covering the core elements used in CBT programmes, it incorporates ideas from the third wave CBT therapies of mindfulness, compassion focused therapy and acceptance and commitment therapy. It also includes a practical series of exercises and worksheets that introduce specific concepts and techniques. Developed by the author and used extensively in clinical practice, Think Good, Feel Good, Second Edition: A CBT Workbook for Children and Young People starts by introducing readers to the origin, basic theory, and rationale behind CBT and explains how the workbook should be used. Chapters cover elements of CBT including identifying thinking traps; core beliefs; controlling feelings; changing behaviour; and more. * Written by an experienced professional with all clinically tested material * Fully updated to reflect recent developments in clinical practice * Wide range of downloadable materials * Includes ideas for third wave CBT, Mindfulness, Compassion Focused Therapy and Acceptance and Commitment Therapy Think Good, Feel Good, Second Edition: A CBT Workbook for Children and Young People is a "must have" resource for clinical psychologists, child and adolescent psychiatrists, community psychiatric nurses, educational psychologists, and occupational therapists. It is also a valuable resource for those who work with young people including social workers, school nurses, practice counsellors, teachers and health visitors.

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CONTENTS

Cover

Title Page

Copyright

About the author

Acknowledgement

Online resources

Chapter One: Cognitive behaviour therapy: theoretical origins, rationale, and techniques

The foundations of cognitive behaviour therapy

First wave: behaviour therapy

Second wave: cognitive therapy

Third wave: acceptance, compassion, and mindfulness

Core characteristics of cognitive behaviour therapy

The goal of cognitive behaviour therapy

The core components of cognitive behaviour therapy

Chapter Two: Cognitive behaviour therapy with children and young people

Cognitive behaviour therapy with children

Adapting CBT for children and young people

Facilitating engagement in CBT

Common problems when undertaking CBT with children

Chapter Three: Think good, feel good: an overview of materials

Be kind to yourself

Here and now

Thoughts, feelings, and what you do

Automatic thoughts

Thinking traps

Balanced thinking

Core beliefs

Controlling your thoughts

How you feel

Controlling your feelings

Changing your behaviour

Learning to problem-solve

Chapter Four: Be kind to yourself

Eight ways to be kind to yourself

Chapter Five: Here and now

Do you really notice what you do?

Focus

FOCUS on your breathing

FOCUS on your eating

FOCUS on an activity

FOCUS on an object

Step back from your thoughts

Thought spotting

Step back from your feelings

Let them float away

Chapter Six: Thoughts, feelings, and what you do

Thoughts, feelings, and what you do

How does it work?

What you think

Core beliefs

Beliefs and predictions

Unhelpful beliefs and predictions

Core beliefs are strong and fixed

Important events

Automatic thoughts

How you feel

What you do

STOP!

Putting it all together

Chapter Seven: Automatic thoughts

Me, what I do, and my future

Why do I listen to my automatic thoughts?

The negative trap

‘Hot’ thoughts

Chapter Eight: Thinking traps

Negative filter

Blowing things up

Predicting failure

Being down on yourself

Setting yourself to fail

Chapter Nine: Balanced thinking

What is the evidence?

So how does it work?

The ‘four Cs’

So how does it work?

How would you help a friend?

Chapter Ten: Core beliefs

Finding core beliefs

Challenging core beliefs

Talk with someone

Chapter Eleven: Controlling your thoughts

Step back from your thoughts

Refocus your attention

Distraction

Coping self-talk

Positive self-talk

Thought stopping

Turn the volume down

Limit the time you worry

Test them

Throw them away

Chapter Twelve: How you feel

What feelings do I have?

Feelings and what you do

Feelings and what you think

Putting it together

Chapter Thirteen: Controlling your feelings

Learn to relax

Physical exercise

4-5-6 breathing

Your calming place

Relaxing activities

Stop the build-up

Chapter Fourteen: Changing your behaviour

Being busy is helpful

Have more fun

Map how you feel and what you do

Small steps

Face you fears

Dump your habits

Remember to reward yourself

Chapter Fifteen: Learning to solve problems

Why do problems happen?

Learn to stop and think

Identify different solutions

Think through the consequences

Remind yourself what to do

Practice getting it right

Plan to be successful

Talk yourself through it

References

Index

End User License Agreement

List of Illustrations

Figure 1.1

Figure 1.2

Guide

Cover

Table of Contents

Begin Reading

Chapter 1

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Think Good, Feel Good

A Cognitive Behavioural Therapy Workbook for Children and Young People

Second Edition

Paul Stallard

This edition first published 2019

© 2019 John Wiley & Sons Ltd

Edition History

John Wiley & Sons Ltd (2002)

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of Paul Stallard to be identified as the author of this work has been asserted in accordance with law.

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John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA

John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

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For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.

Wiley also publishes its books in a variety of electronic formats and by print-on-demand. Some content that appears in standard print versions of this book may not be available in other formats.

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While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

Library of Congress Cataloging-in-Publication Data

Names: Stallard, Paul, 1955- author.

Title: Think good, feel good : a cognitive behavioural therapy workbook for children and young people / Paul Stallard, Professor of Child and Family Mental Health, University of Bath, UK and Head of Psychological Therapies (CAMHS), Oxford Health NHS Foundation Trust, UK.

Description: Second edition. | Hoboken, NJ : Wiley, 2019. | Includes bibliographical references and index. |

Identifiers: LCCN 2018023891 (print) | LCCN 2018024522 (ebook) | ISBN 9781119395317 (Adobe PDF) | ISBN 9781119395300 (ePub) | ISBN 9781119395287 (paperback)

Subjects: LCSH: Behavior therapy for children. | Cognitive therapy for children. | Behavior therapy for teenagers. | Cognitive therapy for teenagers. | BISAC: PSYCHOLOGY / Clinical Psychology.

Classification: LCC RJ505.B4 (ebook) | LCC RJ505.B4 S72 2019 (print) | DDC 618.92/89142–dc23

LC record available at https://lccn.loc.gov/2018023891

Cover Design: Wiley

Cover Image: © www.davethompsonillustration.com

About the author

Paul Stallard is Professor of Child and Family Mental Health at the University of Bath and Head of Psychological Therapies (CAMHS) for Oxford Health NHS Foundation Trust. He has worked with children and young people for almost 40 years since qualifying as a clinical psychologist in Birmingham in 1980.

Clinically, Paul continues to work within a specialist child mental health team where he leads a Cognitive Behaviour Therapy (CBT) clinic for children and young people with a range of emotional disorders including anxiety, depression, obsessive compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).

He is an international expert in the development and use of CBT with children and young people and has provided training in many countries. He is an active researcher and has published widely many leading journals. Recent research projects have included large school-based CBT programmes for depression and anxiety and the use of eHealth with children and young people.

Acknowledgement

There are many people who have directly and indirectly contributed to the development of this book.

First, I would like to thank my family, Rosie, Luke, and Amy for their encouragement and enthusiasm. Despite many long hours working, writing, and travelling, their support for this project has been unwavering.

Second, I have had the good fortune to work with many amazing colleagues during my career. A number of our clinical discussions have informed the ideas in this book. Of my colleagues, I would particularly like to thank Kate and Lucy who I have had the privilege to work with in our CBT clinic for over a decade. Their patience, creativity, and thoughtfulness have helped me to develop and test the ideas contained in this book.

Third, I would like to thank the children and young people I have had the honour to meet. Their determination to overcome their challenges continues to inspire and motivate me to find ways in which effective psychological interventions can be made more available.

Finally, I would like to thank those who read this book. I hope that these materials will help you to help a young person make a real difference to their life.

Online resources

All the text and workbook resources in this book are available free, in colour, to purchasers of the print version. To find out how to access and download these flexible aids to working with your clients visit the website

www.wiley.com/go/thinkgoodfeelgood2e

The online facility provides an opportunity to download and print relevant sections of the workbook that can then be used in clinical sessions with young people. The materials can be used to structure or supplement clinical sessions or can be completed by the young person at home.

The online materials can be used flexibly and can be accessed and used as often as required.

Chapter OneCognitive behaviour therapy: theoretical origins, rationale, and techniques

Cognitive behavioural therapy (CBT) is a generic term to describe psychotherapeutic interventions based on cognitive, behavioural, and problem-solving approaches. The overall aim of CBT is to facilitate an awareness of the important role of cognitions on emotions and behaviours (Hofmann, Sawyer, and Fang 2010). CBT therefore embraces the core elements of both cognitive and behavioural theories and has been defined by Kendall and Hollon (1979) as seeking to

preserve the efficacy of behavioural techniques but within a less doctrinaire context that takes account of the child's cognitive interpretations and attributions about events.

CBT has established itself through numerous randomised controlled trials as an effective psychological treatment for children. It has proven to be effective in the treatment of anxiety (James et al. 2013; Reynolds et al. 2012; Fonagy et al. 2014), depression (Chorpita et al. 2011; Zhou et al. 2015; Thapar et al. 2012), post-traumatic stress disorder (Cary and McMillen, 2012; Gillies et al. 2013), chronic pain (Palermo et al. 2010; Fisher et al. 2014), and obsessive compulsive disorder (Franklin et al. 2015). In addition, CBT has informed many school-based prevention programmes and been found to be effective in reducing symptoms of depression (Hetrick et al. 2016; Calear and Christensen 2010), anxiety (Werner-Seidler et al. 2017; Stockings et al. 2016, Neil and Christensen 2009), and post-traumatic symptoms (Rolfsnes and Idsoe 2011).

The substantial body of knowledge demonstrating effectiveness has resulted in CBT being recommended by expert groups such as the UK National Institute for Health and Care Excellence (NICE) and the American Academy of Child and Adolescent Psychiatry for the treatment of young people with emotional disorders including depression, obsessive compulsive disorders, post-traumatic stress disorder, and anxiety. This growing evidence base has also prompted the development of a national training programme in the UK in CBT, Improving Access to Psychological Therapies (IAPT), which has now been extended to children and young people (Shafran et al. 2014).

CBT is an evidence-based intervention for the prevention and treatment of psychological problems.

The foundations of cognitive behaviour therapy

The theoretical basis for CBT has evolved over many years through the work of a number of significant influences. A review of this research is beyond the remit of this book, although it is important to note some of the key concepts and approaches that have underpinned and shaped CBT as we currently know it.

CBT is a generic term to describe therapeutic interventions based on behavioural, cognitive, and problem-solving approaches. It has evolved through three distinct phases or waves, each of which has significantly contributed to clinical practice.

First wave: behaviour therapy

The first phase was based on learning theory and was shaped by the pioneering work of Pavlov (1927), Wolpe (1958), and Skinner (1974) demonstrating classical and operant conditioning. This work established how emotional responses, such as anxiety, could become associated (conditioned) with specific events and situations, i.e. spiders or talking with people. Thus anxiety could be reduced by pairing events that trigger the anxiety (i.e. seeing a spider, approaching a group of people) with an antagonistic response (relaxation). This procedure (systematic desensitisation) continues to be widely used in clinical practice and involves graded exposure, both in vivo and in imagination, to a hierarchy of feared situations whilst remaining relaxed.

The second major influence of behaviour therapy highlighted the important role of environmental influences on behaviour. This work demonstrated that behaviour is triggered by environmental influences (antecedents) and that the consequences which follow will influence the likelihood of that behaviour occurring again. Behaviour will increase in occurrence if it is followed by positive consequences (positive reinforcement), or not followed by negative consequences (negative reinforcement). A detailed understanding of antecedents and the use of reinforcement to increase adaptive behaviours continue to be widely used techniques in CBT interventions.

Relaxation training, systematic desensitisation, exposure, and reinforcement are effective techniques.

Second wave: cognitive therapy

The second phase built on the efficacy of behavioural techniques by paying attention to the personal meanings and interpretations that individuals make about the events that occur. This was heavily influence by the work of Ellis (1962), Beck (1976), and Beck et al. (1979) who proposed that problems with emotions and behaviour arise from the way events are construed rather than by the event per se. As such, emotions and behaviours can be changed by challenging the meanings and ways in which events are processed. This led to the development of a comprehensive understanding of different types of cognitions (core beliefs, assumptions, and automatic thoughts); their focus (cognitive triad – about me, the future, the world); their content (personal threat, failure, responsibility, and blame); and the way in which information is processed (selective and biased). This is summarised in Figure 1.1.

Figure 1.1 The cognitive model.

In terms of cognitions, the strongest and deepest are core beliefs (or schemas) which are developed during childhood as a result of significant and/or repeated experiences. Overly critical and demanding parents may, for example, lead a child to develop a belief that they are a ‘failure’. Core beliefs are very strong, global, rigid, fixed ways of thinking that are resistant to change. They underpin the meanings and interpretations that we make about ourselves, our world, and our future and lead us to make predictions about what will happen. The child with a belief that they are a ‘failure’ will therefore expect to fail in most situations.

These beliefs are activated by events similar to those that produced them (i.e. school tests). Once activated, attention, memory, and interpretation processing biases filter and select information that is consistent with the belief. Attention biases result in attention being focused on information that confirms the belief (i.e. looking for evidence of failure), whilst neutral or contradictory information is overlooked. Memory biases result in the recall of information that is consistent with the belief (i.e. remembering past failures), whilst interpretation biases serve to minimise any inconsistent information (find a reason to negate any success).

Identifying and challenging attention, memory, and interpretation processing biases can improve psychological functioning

The most accessible level of cognitions are automatic thoughts or ‘self-talk’. These are the constant stream of thoughts that race through our minds providing a running commentary about what we do. These are related to our core beliefs with dysfunctional and negative beliefs producing negative automatic thoughts. A child with a belief that they are a failure may experience a stream of negative automatic thoughts such as ‘I will get this wrong’, ‘I can't do this’, and ‘what is the point of trying when I never do well’ when preparing for a school test.

The focus of cognitive therapy is on the content and nature of the processing deficits and biases that are underpinning the child's problems. In general, young people who are anxious tend to have cognitions and biases towards the future and personal threat, danger, vulnerability, and inability to cope (Schniering and Rapee 2004; Muris and Field 2008). Depression tends to be related to cognitions concerning loss, deprivation, and personal failure with the process of rumination increasing feelings of hopelessness (Kendall, Stark, and Adam 1990; Leitenberg, Yost, and Carroll-Wilson 1986; Rehm and Carter 1990). Aggressive children tend to perceive more aggressive intent in ambiguous situations, selectively attend to fewer cues when making decisions about the intent of another person's behaviour, and generate fewer verbal solutions to problems (Dodge 1985; Lochman, White, and Wayland 1991; Perry, Perry, and Rasmussen 1986).

Interventions involve the identification of biased or selective cognitions and processing (negative thinking, thinking errors) which are then subject to objective testing (cognitive evaluation). Testing involves challenging selective attention biases by attending to overlooked information; challenging memory biases by recalling contradictory experiences, and challenging interpretation biases by exploring alternative explanations. This leads to the final stage (cognitive restructuring) where more functional and balanced thoughts, assumptions, and beliefs are developed.

Third wave: acceptance, compassion, and mindfulness

Cognitive therapies have proven to be very effective, although there remains a minority of people who do not respond to this form of psychotherapy. Some do not find the process of actively challenging and re-appraising specific cognitions easy or acceptable. Similarly, a number of studies have highlighted that changes in cognitions are not necessarily related to improved emotional well-being. Changes occur without directly and explicitly challenging the content of cognitions.

This has led to what has been called a third wave of cognitive behaviour therapies (Hofmann, Sawyer, and Fang 2010). These psychotherapies focus on changing the nature of the relationship between the individual and their own internal events rather than actively changing the content of their cognitions. This has been led to the development of Acceptance and Commitment Therapy (Hayes 2004; Hayes et al. 2006), Compassion-Focused Therapy (Gilbert 2009, 2014) and Mindfulness (Segal, Williams, and Teasdale 2012).

These interventions encourage the individual to live with, tolerate, and accept their experiences, cognitions, and emotions rather than attempting to change them. This requires the individual to connect with and experience the here and now with openness and curiosity. Mindfulness techniques are used to increase awareness as attention is focused on internal and external events as they occur. Thoughts and emotions are accepted without judgement as ongoing internal mental events and physiological reactions that are separate from their personal core identity.

A second theme is that of acceptance where individuals learn to accept and value themselves for who they are rather than constantly criticising themselves for their imperfections or weaknesses. This value-based approach helps the individual to focus on those aspects of life which are personally important and motivates them to work towards their goals.

The third theme is that of compassion where self-criticism is replaced with self-kindness. Individuals are helped to focus on their strengths, positive skills, and acts of kindness. Compassionate reasoning helps to develop balanced, kinder, alternative thinking where self-criticism is replaced with self-compassion. Compassionate behaviour encourages the individual to behave in more helpful ways such as facing frightening events or displaying self-kindness. Compassionate imagery helps to create a positive self-image, whilst compassionate feeling helps to notice and experience acts of kindness from others.

Our relationship with our thoughts and feelings can be changed by mindfulness, acceptance, and self-compassion

Core characteristics of cognitive behaviour therapy

Although CBT is used to describe a range of different interventions, they often share a number of core features.

CBT is theoretically determined

CBT is based upon empirically testable models. Strong theoretical models provide the rationale for CBT, i.e. cognitions are associated with emotional problems and inform the content of the intervention, i.e. change the nature of the cognitions or our relationship with them. CBT therefore provides a cohesive and rational intervention and is not simply a collection of disparate techniques.

CBT is based on a collaborative model

A key feature of CBT is the collaborative process by which it occurs. The child has an active role in identifying their goals, setting targets, experimenting, practicing, and monitoring their performance. The approach is designed to facilitate greater and more effective self-control, with the therapist providing a supportive framework within which this can occur. The role of the therapist is to develop a partnership in which the child is empowered to develop a better understanding of their problems and to discover alternative ways of thinking and behaving.

CBT is time limited

It is often brief and usually time limited, consisting of no more than 16 sessions, and in many cases far fewer. The brief nature of the intervention promotes independence and encourages self-help. This model is readily applicable to work with children and adolescents, for whom the typical period of intervention is considerably shorter than that with adults.

CBT is objective and structured

It is a structured and objective approach that guides the young person through a process of assessment, problem formulation, intervention, monitoring, and evaluation. The goals and targets of the intervention are explicitly defined and regularly reviewed. There is an emphasis on quantification and the use of ratings (e.g. the frequency of inappropriate behaviour, strength of belief in thoughts, degree of distress experienced, or progress towards achieving goals). Regular monitoring and review provides an objective way of assessing progress by comparing current performance against baseline assessments.

CBT has a here-and-now focus

CBT interventions focus upon the present, dealing with current problems and difficulties. They do not seek to ‘uncover unconscious early trauma or biological, neurological, and genetic contributions to psychological dysfunction, but instead strives to build a new, more adaptive way to process the world’ (Kendall and Panichelli-Mindel 1995). This approach has high face validity for children and young people, who may be more interested in and motivated to address real time, here-and-now issues, rather than understanding their origins.

CBT is based on a process of guided self-discovery and experimentation

It is an active process that encourages self-questioning and the development and practice of new skills. Children are not simply passive recipients of therapist advice or observations, but are encouraged to observe and learn through a process of experimentation. The link between thoughts and feelings is investigated and alternative ways of changing the content or nature of the relationship with his or her thoughts is explored.

CBT is a skills-based approach

CBT provides a practical, skills-based approach to learning alternative patterns of thinking and behaviour. Children are encouraged to practice skills and ideas that are discussed during therapy sessions in their everyday life, with home practice tasks being a core element of many programmes. These provide opportunities to identify what is helpful and how potential problems can be resolved.

CBT is theoretically determined.

It is based on a model of active collaboration.

It is brief and time limited.

It is objective and structured.

It focuses on current problems.

It encourages self-discovery and experimentation.

It advocates a skills-based learning approach

The goal of cognitive behaviour therapy

The overall aim of CBT is to improve current well-being and to enhance resilience and future coping. This is achieved through developing increased self-awareness, improved self-control, and enhancing personal efficacy through the promotion of helpful cognitive and behavioural skills. The process of CBT moves the young person from a dysfunctional to a more functional cycle as illustrated below.

CBT helps to reduce the negative effect of what people think (cognitions) on how they feel (emotions), and what they do (behaviour). This is achieved by either actively focusing on the content of the child's cognitions or by changing the nature of their relationship with them.

If focusing on content

, the child is encouraged to observe and identify common dysfunctional thoughts and beliefs that are predominantly negative, biased, and self-critical. Through a process of self-monitoring, education, and experimentation, these are tested and replaced by more balanced and functional cognitions that acknowledge strengths and success.

If

focusing on the relationship

with cognitions, the child is encouraged to stand back from his or her thoughts and to observe them in a curious, non-judgemental way as passing cognitive activity. Mindfulness maintains attention on the here and now with the young person being encouraged to accept themselves and the events that occur.

The core components of cognitive behaviour therapy

CBT includes a range of techniques and strategies that can be used in different sequences and permutations. This flexibility allows interventions to be tailored towards particular problems and the individual needs of the child rather than being delivered in a standardised cookbook approach. Similarly, the wealth of techniques means that CBT can be used for prevention to enhance future coping and resilience as well as an intervention to reduce current psychological distress.

Although the primary focus of second wave (i.e. test and challenge the content of cognitions and processes) and third wave (i.e. change the nature of the relationship with our thoughts) CBT differ, embedded within these approaches are a number of different skills and techniques.

Psycho-education