Back / Parent Skills – September 2018


Partial Hospitalization Program or Intensive Outpatient Program (PHP / IOP):
The Partial Hospitalization and Intensive Outpatient Programs provide short-term stabilization for children between the ages of 9 and 12 with difficult emotional challenges such as anxiety and depression. The primary purpose is to provide a safe and therapeutic environment for children who are at risk and having difficulty managing daily life stressors. During the course of treatment, we provide evidenced-based therapies that will improve their level of functioning by helping them gain strategies and learn how to utilize them effectively. Individualized treatment plans are developed by our multi-disciplinary team to best address your child’s specific needs. Through a combination of group therapy, individual support, family therapy, and expressive art therapy, your child will be empowered with new skills, such as distress tolerance, emotional regulation, mindfulness skills, social interaction, and effective communication tools. Our goal is to help children transition from an intensive level of care and restore them to a level of functioning that allows them to return to their communities and live fulfilling lives.

Each day your child will be asked to “check in/out” using a Mood Rating. Our mood rating scale is 0 – 8 (0 = calm, 8 = out-of-control emotions). Children are also encouraged to name an emotion that corresponds with their mood rating in order to expand their emotional vocabulary.

Cognitive Behavioral Therapy (CBT):
Cognitive Behavioral Therapy (CBT) focuses on the interplay between our thoughts, emotions, actions, and physical reactions. CBT teaches children specific strategies to challenge negative thoughts that are contributing to unpleasant emotions and dysfunctional behavior patterns. Ready with a new mindset, children learn strategies to challenge and reframe their negative thoughts,
which lead to an increase in pleasant emotions and adaptive behaviors.

Dialectical Behavior Therapy (DBT):
The basis of Dialectical Behavioral Therapy (DBT) is the balance of accepting what is out of our control and changing what is in our control. There are four tenets of DBT: mindfulness, distress
tolerance, interpersonal effectiveness, and emotion regulation. Mindfulness and distress tolerance skills help children get through difficult situations. Interpersonal effectiveness and emotion
regulation skills teach children how to change their own behaviors in an adaptive/helpful way. The aim of DBT is to allow your children to be able to tolerate difficult situations and respond with
helpful behaviors.

Acceptance and Commitment Therapy (ACT):
Acceptance and Commitment Therapy is a values-guided behavioral therapy. ACT encourages us to accept what is out of our control and commit to taking action that enriches our life. The goal of ACT is to help us create a rich, full, and meaningful life, while accepting the pain that life will inevitably bring. ACT does this by teaching mindfulness skills to lessen the impact of painful thoughts and feelings, clarifying what is truly important to us, and using our values to set goals and take action that enhances our lives.


Cognitive Behavioral Therapy Skills:

ANTs: ANTs are defined as automatic negative thoughts. This acronym will be frequently used to describe any unhelpful thought that typically leads to an increase in mood rating. Identifying negative thoughts is the first step to then applying CBT skills.

Feelings ID: This group focuses on expanding your child’s emotional vocabulary. When we learn how to identify and explain our feelings, we are more likely to get the help we are looking for and get our needs met.

Physiological Symptoms: Physiological symptoms are bodily reactions that tell us how our body is responding to unpleasant emotions such as anxiety, stress, or frustration. For example: headaches, stomach pains, fatigue, hunger, sweating, trembling, etc. These symptoms are described as “warning signs” that we may be feeling depressed or anxious and that it may be time to use a coping skill. By using coping skills when we first notice our physiological reactions, we are able to prevent our mood rating from rising and we are often more successful and effective in using our coping skills. Recognizing our thoughts, emotions, and behaviors affect how we feel physically is an imperative tenet of CBT. Coping skills that are most helpful with physiological symptoms are deep breathing, progressive muscle relaxations, guided imageries, and ABC mindfulness.

Lemons to Lemonade: Lemons to lemonade introduces children to the concept of reframing negative thoughts, a fundamental technique from CBT. In this activity, children identify negative thoughts as “lemons,” which are defined as any challenging or unpleasant situations or thoughts. Children apply the CBT model to personal examples to illustrate the impact these thoughts have on emotions and behavior. Lemons to lemonade is finding a glimmer of positivity in difficult, negative, and/or challenging situation. When teaching lemons to lemonade, we make actual lemonade with the children to make the group more experiential and fun.

Clue Snooping: Clue snooping is a form of challenging negative thoughts. Challenging thoughts involves identifying and then disputing irrational or maladaptive thoughts by looking at facts and evidence. After weighing all the evidence, we generate a thought that is accurate and balanced. This activity will help patients have a more realistic and rational understanding of their thoughts.

Positive Self Talk: Positive self-talk or cheerleading statements are the words or phrases we say to ourselves for encouragement and support. These powerful statements, such as “I can do this!” give us the courage to do things when times are tough.

Identifying Cognitive Distortions: Cognitive distortions are thoughts that are twisted, extreme, and feel very true. Identifying these thoughts helps us challenge them and develop new patterns of thinking. Once we identify the cognitive distortion we reframe or thought challenge by using clue snooping, lemons to lemonade, or positive self-talk. We teach children to identify three specific kinds of cognitive distortions:

  • Fortune Telling: Predicting the future in a negative way (ex: “Today will be a terrible day”)
  • Black and White Thinking: All or nothing thinking (ex: “Everyone hates me”)
  • Focusing on the Negative: Only giving attention to the negatives in a situation (ex: “Even though I had fun with my friends during lunch, today was a terrible day”

STOP – Change the Channel: The CBT version of STOP helps children when they are experiencing racing, negative thoughts. Children are encouraged to tell themselves “stop” or visualize a stop sign. Once they put the brakes on the ANT, they “change the channel” by thinking of or visualizing a positive memory or imaginative place, such as your favorite vacation or videogame. Thinking of something else for just a few minutes may impact the patient’s CBT triangle to stop racing thoughts from continuing or becoming more negative. This does not eradicate ANTs, but helps children ride through the distress.

SMART Goals: Every Monday, your child creates a SMART goal for the week. Creating a SMART goal helps us make short-term, concrete, and achievable goals.
    Specific- who, what, when, where
    Measurable- how will you know when you achieve the goal
    Action oriented- what will you do to achieve the goal
    Realistic- how much control do you have over the goal
    Time-bound- when will you complete it by

Dialectical Behavioral Therapy Skills:

Mindfulness – Mindfulness is explained as “paying attention in a particular way; on purpose, in the present moment, and nonjudgmentally.”

  • ABC Mindfulness: Pick a category, such as movies, foods or animals, and think of something from that category for each letter of the alphabet.
  • Take 10: Pick a category and name your top 10 favorites in that category (types of food, TV shows, etc.).
  • Deep Breathing or 4×4 Breathing: Breathe in for 4 counts, hold for 4 counts (optional), and breathe out for 4 counts.
  • Labeling/Counting: Labeling is a grounding strategy that helps bring your attention back to the present moment and reorient yourself to the here-and-now. This can be done by counting items in the room, such as all the squares, blue objects, chairs, etc. These strategies can be helpful in managing overwhelming feelings or intense anxiety.
  • 5 Senses: Mindfulness can be practiced by engaging in different activities that involve each of the five senses: smell, taste, touch, sight, and sound. Patients are encouraged to focus on bringing all of their attention to one sense at a time, such as touching various objects or eating certain flavorful foods.
  • Guided Relaxation: Imagine your own safe place. Picture the place completely and engage your senses. Imagine a place that is safe, comforting and soothing for you. Picture the 4 sounds, smells, sights, feelings and tastes in this place. This can be a place you create from your own imagination or use an existing guided relaxation. The following apps have helpful guided relaxations: Insight Timer, Relax Melodies, and Stop Breathe & Think.
  • Progressive Muscle Relaxation: Slowly tense and relax different muscle groups in your body. Typically this begins at your toes and you slowly work your way up your entire body, focusing on different areas at a time.
  • Push, Pull, Dangle: A form of progressive muscle relaxation when you are seated in a chair. First, push yourself up with your hands so that you are suspended for a few moments, then grip the bottom of the chair and try to pull it up, then dangle your arms and relax those muscles.
  • Ride the Wave: No emotion lasts forever. Using coping skills before, during, and after an intense emotion does not completely take the unpleasant emotion away, but rather, makes the emotional experience more manageable.

TIP: TIP is a helpful tool for mood ratings 6 through 8. To get tolerate difficult emotions, we use:
    Temperature change (holding ice, splashing cold water on face)
    Intense exercise (running in place, plank)
    Progressive muscle relaxation (body scan, push pull dangle, pencil squeeze)

Gratitude List: A gratitude page is a list of all things you are grateful for. This is especially helpful when we are feeling hopeless. Gratitude is strongly and consistently associated with greater happiness. Gratitude helps people feel more positive emotions, relish good experiences, improve their health, deal with adversity, and build strong relationships.

Opposite Action: Opposite action is an emotion regulation skill where we do an action that is opposite to the emotion we are feeling. The key to opposite action is to break down the difficult action into smaller, more manageable steps.

DISTRACT: When you are feeling very low and need a quick break from your distressing thoughts, do something that you can count on being engaging and will occupy your mind for a short period of time (3-5 minutes) using the acronym DISTRACT:
    Do something else
    Imagine feel good events
    Stop thinking about it
    Think about something new
    Remind yourself of positive experiences
    Ask others for help
    Count things
    Take a break

STOP: The DBT version of STOP helps children with impulsive behaviors. We often need to take a moment before we act, in order to ensure we are choosing the best response to each situation.
    Stop yourself, don’t move a muscle
    Take a step back
    Observe the situation
    Proceed mindfully

DEAR: DEAR is a communication skill that helps us get our needs met.
    Describe the situation, using only facts
    Express your emotion using an I statement
    Ask for what you need, ensure it is realistic
    Reward the listener

SEEDS of Mastery: Take care of your SEEDS to stay out of emotional mind.
    Sleep as much as your need—not too much, not too little: 10.5 hours for ages 9 – 12
    Eat a balanced diet
    Exercise 20 minutes a day for an improvement in mood
    Doctors-take medications as prescribed by your doctor
    Self-Care – engaging in leisure activities and proper hygiene practices

Pros and Cons List: Listing out and weighing the benefits and consequences of acting on our emotional responses helps us make more purposeful choices.

Wise Mind: Wise mind balances our emotional mind and our reasonable/ logical mind. The integration of these two states of mind help individuals to think more clearly, make more intuitive decisions, and thinking in a more balanced way. For example, “I feel anxious AND I can use coping skills to go to school today.”

Wise Mind ACCEPTS: The following strategies help us stay in wise mind and out of emotional mind.
    Activities: Doing an activity you enjoy (ex: drawing, yoga, reading, playing with a pet)
    Contributing: Doing something helpful for other people (ex: volunteering, walking the dog, helping a sibling)
    Comparisons: Choosing a person you look up to and thinking about how he or she would handle during a difficult situation
    Emotions: Challenge difficult emotions with coping skills
    Put your thoughts on something new: Think about something calming or positive
    Thoughts: Positive Self Talk
    Sensations/Senses: Use your 5 senses to ground yourself back to the present moment

Radical Acceptance: Radical acceptance focuses on not fighting what is out of our control (other people, rules, etc.) and changing what is in our control (ourselves). When we fight things that are out of our control, we increase our emotional suffering and nothing changes. Radical acceptance does not mean we like or approve of a situation, it just means we accept it. Before we can figure out how to help ourselves, we have to accept/acknowledge what is going on, figure out what is in or out of our control, and use skills to get through it.

GIVE FAST: GIVE FAST is a communication tool that helps us keep relationships and maintain self-respect.
    (be) Gentle: Be courteous and temperate
    (act) Interested: Listen to the other person
    Validate: Acknowledge the other person’s feeling, wants, difficulties, and opinions.
    Easy Manner: Use humor, smile. Be light-hearted
    (be) Fair: to yourself and to the other person
    (no) Apologies: for making a request, having an opinion, or for disagreeing
    Stick: to your own values. Be clear on what you believe is the moral or valued way of thinking and acting
    (be) Truthful: Don’t lie or act helpless. Don’t exaggerate or make up excuses

ABC Emotion Regulation: ABC is an emotional regulation skill. ABC helps us learn ways to stay out of emotional mind and build a life worth living. ABC provides a concrete system for building up and enjoying feel-good events. It helps us learn how to respond to our emotions rather than react to our emotions.
    Accumulate positive emotions by doing activities that help us feel good
    Building mastery is practicing a skill so you gradually improve each time you use it
    Coping ahead helps us plan for a potentially difficult situation so you set yourself up for success

Other Helpful Skills:

POPS: POPS is a problem solving method used to help us make more helpful choices and stop making the same unhelpful choice repeatedly.
    Problem (identify the problem)
    Options (what options do you have)
    Pick one (pick an option to try)
    See if it works (test it out; if it doesn’t work pick a new option)

Thought Defusion: Visualize your thoughts connected to an image or images drifting or floating away slowly (balloon in the sky, headlights on the highway drifting away, negative thought written in sand and getting washed away, etc.). This is helpful when you are getting stuck on thoughts and challenging them isn’t working. Simply imagine the thoughts drifting away and getting smaller and smaller. Don’t fight them; just watch them slowly go away.

Coping Skill Box: A Coping Skills Box has various coping skills or grounding objects that can Preparing a box of things you can use when you are feeling distressed. Examples include: art materials, a gratitude list, scented lotion, manipulatives, crossword puzzles, etc. This is helpful because often it is hard to think of coping skills in the heat of an intense emotion.