Why have we not been more successful in improving public mental health?

The problem of “time on task” and a proposed solution

Joseph Strayhorn, M.D. Private practice, Ithaca, NY

Org. for Psychoeducational Tutoringjstray@gmail.com

Disclosures

Psychological Skills Press

Organization for Psychoeducational Tutoring

Practice of Child Psychiatry

Outline of Argument

Part 1: Are we winning the game?

Part 2: Time on task, and why the medical (insurance) model is not conducive

Part 3: School more conducive to time on task, but other problems

Part 4: Psychoeducational tutoring as service delivery method

Part 5: Some of the psychological skills exercises you may be able to use

Some Definitions and Assumptions

Mental health: The abilities that tend to result in happiness in oneself and the others one affects.

Skills for mental health: Productivity, joyousness, kindness, honesty, fortitude, good decisions (individual and joint), nonviolence, respectful talk, friendship-building, self-discipline, loyalty, conservation, self-care, compliance, positive fantasy rehearsal, courage.

Learning component to psychological skills

Mental health skills influenced by genetics/biological factors, situational factors, and learned patterns.

Influences on learning: Objective-formation, hierarchy, relationship, attribution, modeling, practice opportunities, reinforcement and punishment contingencies, instruction, stimulus control, monitoring of outcomes.

Lots of work done in MH

● Over 4 million papers indexed in Psychinfo

● Over 1 million papers for “mental disorders” in Pubmed

● NIMH Budget now over $1.4B per year

● Over half a million mental health professionals in US

● About $113B-$170B per year spent on MH treatment

Are we succeeding? How much?

● One type of answer: evidence for effective treatments. RCT is “gold standard.” Given that person signs on for treatment, what is effect?

● Second type of answer: How mentally healthy is the population? What is the “burden” of mental health problems for society? Are we getting healthier and healthier as a result of the resources devoted? Takes into account how many people sign on and for how long.

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Suicide rates US 1999-2014, CDC

New York Times

● U.S. Suicide Rate Surges to a 30 Year High

● By SABRINA TAVERNISE APRIL 22, 2016

● WASHINGTON — Suicide in the United States has surged to the highest levels in nearly 30 years, a federal data analysis has found, with increases in every age group except older adults. The rise was particularly steep for women. It was also substantial among middle-aged Americans, sending a signal of deep anguish from a group whose suicide rates had been stable or falling since the 1950s.

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http://blog.gaborcselle.com/2006/03/will-money-make-you-happy.html

Twenge et al. 2010: MMPI Changes over Time

“Two cross-temporal meta-analyses find large generational increases in psychopathology among American college students (N=63,706) between 1938 and 2007 on the MMPI and MMPI-2 and high school students (N=13,870) between 1951 and 2002 on the MMPI-A. The current generation of young people scores about a standard deviation higher (average d=1.05) on the clinical scales, including Pd (Psychopathic Deviation), Pa (Paranoia), Ma (Hypomania), and D (Depression). Five times as many now score above common cutoffs for psychopathology, including up to 40% on Ma. The birth cohort effects are still large and significant after controlling for the L and K validity scales, suggesting that the changes are not caused by response bias.”

Twenge 2011

“Almost all of the available evidence suggests a sharp rise in anxiety, depression, and mental health issues among Western youth between the early 20th century and the early 1990s. Between the early 1990s and the present, more serious problems such as suicide and depression have receded in some data sets, whereas feeling overwhelmed and reporting psychosomatic complaints have continued to increase. Other indicators, such as anxiety, have remained at historically high levels but not continued to increase.”

Hidaka 2012: Depression as a Disease of Modernity

● The largest community-based, cross-sectional studies of mental illness use retrospective methodology. They report a greater lifetime risk of mood disorders (Kessler et al., 2007) and, specifically, MDD in each successive generation (Andrade et al., 2003).

● “To summarize, retrospective studies claim younger cohorts are more likely to develop depression with an earlier age of onset, but the evidence is confounded by recall bias. Longitudinal studies mostly confirm a rising prevalence of depression. In conclusion, available evidence suggests we may indeed be in the midst of an epidemic of depression.”

Antidepressant Use

“In 2011, the Centers for Disease Control and Prevention reported that the rate of antidepressant use in the United States rose by 400 percent between 1988 and 2008.” (Luhrmann 2014).

● Twenty-three percent of women aged 40–59 take antidepressants, more than in any other age-sex group. (Pratt et al. 2011)

Zhinchin et al. 2016: Suicide rates not correlated with psychotropic use

“The relationship between adult suicide rates and prescription rates of psychotropic drugs by the broad British National Formulary (BNF) categories, for individual psychotropic drug groups within the BNF categories (e.g. selective serotonin reuptake inhibitors) and for individual psychotropic drugs was examined over a 12year period (1995-2006) was examined using Spearman's rank correlation.

“There was an absence of significant correlations between adult suicides rates and rates of prescriptions of psychotropic drugs in the broad BNF categories, individual psychotropic drug groups and individual psychotropic drugs.”

Kessler et al. 2005 National Comorbidity Survey Replication

“Lifetime prevalence estimates are as follows: anxiety disorders, 28.8%; mood disorders, 20.8%; impulse control disorders, 24.8%; substance use disorders, 14.6%; any disorder, 46.4%.”

“Lifetime prevalence estimates are higher in recent cohorts than in earlier cohorts and have fairly stable intercohort differences across the life course....”

...The observed cohort effect is at least partly due to substantive rather than methodological factors.”

Nuffield Foundation 2012 Report UK

“Trends in the UK included: Increases in the proportion of young people reporting frequent feelings of depression or anxiety. This figure doubled between the mid 1980s and the mid 2000s. For boys aged 15-16, rates increased from approximately 1 in 30 to 2 in 30. For girls they increased from approximately 1 in 10 to 2 in 10.”

Nuffield Foundation 2012 re. UK Data for Youth

Increases in parent-rated behaviour problems. For example, approximately 7 per cent of 15-16 year olds showed high levels of problems in 1974, rising to approximately 15 per cent in 1999.

A similar rate of increase in ‘conduct disorders’ (mainly nonaggressive antisocial behaviour like lying and theft) for boys and girls, and for young people from different kinds of backgrounds.

Encouraging signs of leveling off in these trends post-2000.

Rosen et al. 2010 Eating Disorders

“Results of epidemiologic studies have indicated that the numbers of children and adolescents with eating disorders increased steadily from the 1950s onward. During the past decade, the prevalence of obesity in children and adolescents has also increased dramatically, accompanied by further emphasis on dieting and weight loss among children and adolescents.”

Rosen et al. 2010

“Of particular concern is the increasing prevalence of eating disorders at progressively younger ages.... From 1999 to 2006, hospitalizations for eating disorders increased most sharply—119%—for children younger than 12 years.”

Konrath et al. 2011: Empathy in College Students

Konrath et al. 2011

● “One especially relevant program of research finds increasing levels of narcissism in American college students from the mid-1980s until late into the first decade of the new millennium, using similar cross-temporal methods as in the current study.”

Social Isolation in America, McPherson et al. 2006

● Discussion networks are smaller in 2004 than in 1985. The number of people saying there is no one with whom they discuss important matters nearly tripled. The mean network size decreased by about a third (one confidant), from 2.94 in 1985 to 2.08 in 2004. The modal respondent now reports having no confidant; the modal respondent in 1985 had three confidants.

SSI and SSDI for Mental Disorders

● “The tally of those who are so disabled by mental disorders that they qualify for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) increased nearly two and a half times between 1987 and 2007 — from one in 184 Americans to one in 76. For children, the rise is even more startling — a thirtyfive-fold increase in the same two decades,” as Marcia Angell summarizes (http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/?page=1) in the New York Times Book Review.

●

Assumptions for rest of argument

● Not all mental disorders are curable by drug therapy

● Mental health consists at least partly in a set of skills that are teachable and learnable

● These skills usually do not appear without learning influences such as models, practice, reinforcement, instruction

● Learning psychological skills has much in common with learning other skills

Survey: How much time to learn “not virtuoso, but good operating or

performing level of skill”

● Violin: 1200 hours

● Piano: 450 hours

● Harmonica: 50 hours

(reported in de Bono & de Saint-Arnaud)

Ericsson et al. 1993: Talent development as function of “deliberate practice” hours

● “Best” violinists age 18: 7,410 hours

● “Good” violinists age 18: 5,301 hours

● Good enough to be a music teacher: 3,420 hours

Benjamin Bloom Talent Development Study

● Tennis players, in middle years, 12 or 13 years old to the end of high school: 21 hours a week in the summer and 14 hours a week in the winter. Comes out to about 760 hours per year

● Swimmers: 4 hours a day, 6 or 7 days a week, more in the summer. Comes out to at least 1200 hours per year

Math: One hour per school day

For K-12, assuming a 180 day school year, only 1 hour on class and homework combined, comes out to 2,340 hours.

Ivar Lovaas Autism 1987

“Follow-up data from an intensive, long-term experimental treatment group (n-19) showed that 47% achieved normal intellectual and education functioning, with normal-range IQ scores and successful first grade performance in public schools. Another 40% were mildly retarded and assigned to special classes for the language delayed, and only 10% were profoundly retarded and assigned to classes for the autistic/retarded. In contrast, only 2% of the control-group children (n-40) achieved normal educational and intellectual functioning: 45% were mildly retarded and placed in language-delayed classes, and 53% were severely retarded and placed in autistic/retarded classes.”

“The experimental group subjects gained on the average of 30 IQ points over Control Group 1 subjects.”

Lovaas 1987 post-intervention results. (Nonrandom assignment,

equivalent groups design)

Experimental Group

Control Group

Normal 47% 2%

Mild 40% 45%

Severe 10% 53%

Hours of Intervention for Lovaas Study

● “an intensive-treatment experimental group (n-19) that received more than 40 hours of one-to-one treatment per week,”

● “the minimal-treatment Control Group I (n-19) that received 10 hours or less of one-to-one treatment per week.”

● “Both treatment groups received treatment for 2 or more years.”

● “The parents … were extensively trained in the treatment procedures so that treatment could take place for almost all of the subjects’ waking hours, 365 days a year.”

Minimal estimate of hours of intervention for Lovaas study

● 50*40*2= 4000 hours

● This doesn't count the parental intervention outside the formal training time.

Intervention Times CBT, Big Acronym Studies NIH

CAMS Child Anxiety 14 hours

TADS Adolescent Depression

<=24 hours

TORDIA Adolescent Depression

<=18 sessions

POTS Children Adolescents with OCD

14 hours

RUPP Autistic Children with severe behavior problems – Parent training

<=16.5 hours

Merikangas et al. National Comorbidity Survey 2011

Of children and youth with disorders, only about 1/3 had ever received any services for their mh problem.

Of those who received services, only about 16% were seen for >20 visits.

68% were seen for 5 visits or fewer.

3 Studies: Gopalan, McKay, Harpaz-Rotem,

Of those children with mh disorders who start treatment, the median hours of therapy is in the single digits.

Gopalan: The majority of children with mh disorders have no treatment.

Gopalan: Of those referred for psychosocial treatment, >1/3 never keep the first appointment.

Similar findings with adults: Wang et al. 2005

Of 12 month cases, 41% received some treatment in 12 months.

<1/3 treated by mh specialists

Of treated patients, 32.7% classified as “at least minimally adequate” treatment

For psychotherapy, minimally adequate = 8 visits of 30 minutes (4 hours)

Wang et al. 2005 more findings

60% of patients seen by psychiatrists made fewer than 5 visits per year.

Those making 50 or more visits in the year represented 1.6% of patients, 20% of all psychiatric visits.

Wang et al. Violent and Angry Patients

Pts with intermittent explosive disorder had the lowest service utilization amongst all dx categories studied.

Only 14% saw any mh provider.

Among those seeing provider, median for visits in the year was 3.5.

Medical Necessity, weekly therapy, from Anthem BCBS manual

● “The goals of treatment are not primarily for providing support, ... or primarily self improvement.

● “Symptoms and/or functional impairment of at least a moderate degree as evidenced by report of specific domains and/or GAF score <_60 are still present related to the DSM/ICD diagnoses listed ....

● “The condition has not stabilized to the point where maintenance treatment is appropriate, where ... the purpose of continued treatment is to prevent relapse or maintain previous achieved progress.”

Educational model rather than medical model?

● Hypothesis: Psychoeducation should be accomplished in educational formats as well as medical settings, and with educational type financing, time on task, expectations about the time required, and lack of necessity for extensive medical training of the trainers.

● However, when people think of educational settings, they usually think of School.

School Classrooms as the Locus for Psychoeducation?

“In every class for four long blocks, the expectation was for us to come in, take our seats, and sit down for the duration of the time. By the end of the day, I could not stop yawning and I was desperate to move or stretch.

● I was drained, and not in a good, long, productive-day kind of way. No, it was that icky, lethargic tired feeling. I had planned to go back to my office and jot down some initial notes on the day, but I was so drained I couldn’t do anything that involved mental effort (so instead I watched TV) and I was in bed by 8:30.”

From a teacher who shadowed a student in classes

From a blog on school-survival.net

● School sucks, because when you are actually sick for a long period of time, they blame you. And even though you are staying home by DEFINITION because you are too SICK to function, you are Expected to come because if you don't you will be covered and drowning in homework and even if all you can do with your brain is cry because all of the homework that makes NO SENSE is crushing you down into a pit of depressing despair, its STILL YOUR FAULT BECAUSE YOU DIDN'T SUCK IT UP AND GO TO SCHOOL!

Student comments about school

● The assignments ar pointless, and the teachers are sadistic f***s. Also bullying other kids is sick and evil. The teachers dont stick up for you if you are being bullied. Of course my parents think I am a whining brat whenever I bring this up.

More student comments

● I REALLY HATE SCHOOL I WANT TO DIE JUST THINKING ABOUT IT! I meen really you wake up early go to school get home do your homework then ooh and what do you know you wake up early again and you keep on doing that for 12 years!!!!!

● Yes. All of these are true. I'm an A student, but I hate school sooo much.

Poll Results

● Monmouth University, 2016: “Only 27% of respondents agree that human activity is the main cause of climate change.”

● CNN 2015: 20% of U.S. sample believe Barack Obama was not born in the U.S.

● CNN 2015: 29% of polled American adults believe Obama is Muslim

More poll results

● About 15% of US adults believe that “extra-terrestrial intelligent life has already contacted us but the government has covered it up.”

● Newsweek poll 2011: 29% couldn't name the vice-president of the US.

● National Geographic survey 2003: 29% could not locate the Pacific Ocean on a map.

● Gallup 1999: 18% choose “the sun revolves around the earth” vs. earth around sun

U.S. Literacy

● National Assessment of Adult Literacy: 14 percent of the adult population is “below basic” in reading. “Below basic” = “No more than the most simple and concrete literacy skills.”

https://nces.ed.gov/naal/kf_demographics.asp

Health Literacy

● Study in two US public hospitals:

● 1/3 of English-speaking patients could not read and understand basic health-related materials

● 42% couldn't comprehend directions for taking a medicine on an empty stomach

● 26% couldn't understand info on appointment slip

● 60% couldn't understand standard consent form

jama vol. 281, p. 552, Health literacy: Report of the Council on Scientific Affairs

Characteristics of Ideal Psychoeducational Intervention

● Adequate time on task

● No transportation necessary

● Magic of one-to-one

● Positive emotional climate

● Structured curriculum

● Helpers/preceptors/mentors/tutors do not need degrees and certifications

● Long term relationship with same teacher

The Magic of One-To-One

● Strayhorn & Bickel study, 2002:

Meta-analyses of effect size of stimulant meds for ADHD average about 0.84 standard deviations, where 0.8 is a “large” effect size

In our study, the difference between classroom ADHD ratings and individual tutoring ratings was 1.1 standard deviation (compared to postintervention scores) and 2.5 sd (compared to preintervention scores).

87% of children meeting ADHD criteria in classroom did not meet criteria in one-to-one.

Psychoeducational Tutoring by Telephone

● Tutors are college students (often majoring in psych, ed, soc)

● Trained by a college graduate long-term tutor using lots of written and recorded training materials

● Students are mostly elementary aged, with problems with behavior, emotions, academic skills

● Sessions are by phone, 6 days/wk, 30 min, intention to last at least a year

The Psychoeducational Session: 4

Parts

Alternate Reading

Psychological Skills Exercises

Academic work (especially reading, sometimes

math) (some may not need this)

Social Conversation

What if the student can't read well enough to do “alternate reading?”

Teach Reading. ● Assess where child is on hierarchy of reading skills:

Oral language development

– Phonemic awareness and spatial awareness

– Letter-sound correspondence

– Word recognition

– Text reading

● About 1 grade level progress per 10,000 “word list” points: mostly “sounding and blending”

● “Sounding and blending” exercises phonemic and spatial awareness, letter-sound correspondence, word recognition, and “learned industriousness” skills

Effects of Telephone Tutoring on Reading Skills

The Connection Between

Reading and Conduct Problems

• Dishion et al., 1984: “Academic skill deficits may

be the strongest covariates of antisocial behavior.”

• NCES: “Literacy behind prison walls”: 71% of

prisoners at level 1 or 2 (out of 5)

• British study of juvenile offenders: A total of 62% of

the sample had not achieved Level 1 in literacy.

(Bryan et al. 2007)

• Illiteracy -> frustration, inattention, hostility

• Low self-control -> illiteracy

From article, “Predictors of

Antisocial Personality”

“Lower IQ and reading problems were most

prominent in their relationships with

childhood and adolescent antisocial

behaviour.” Simonoff....Rutter et al., British

J. Psychiat. 2004

More on Connection, Reading

and Self-Control

• “Reading scores accounted for a larger

proportion of the variance in the later

behavior problem scores than did school-

age IQ scores....The results indicated that

the association between IQ scores and

problem behavior was mediated by reading

ability.” Stanton et al., 1990

Teaching Academics Helped Social

Standing

Coie, J. D., & Krehbiel, G. (1984) Effects of academic tutoring on

the social status of low-achieving socially rejected children.”

Child Development, 55, 1465-1478.

Random assignment to academic skills training, social skills

training, combination, and control groups.

“The academic skills groups … improved their social standing so

dramatically....” (p. 1474)

“Findings... support … strategies of intervention that leave less

opportunity for disruptive behavior by refocusing children on the

successful performance of classroom tasks, … reading and

mathematics.” (p. 1476)

Hypotheses Regarding Reading

1. Reading instruction may be one of the most efficacious methods of preventing or even remediating conduct disorders and other disruptive behavior disorders.

2. Reading instruction may be a favorable context for “learned industriousness” training: that is, reinforcement for progressively larger amounts of sustained effort. (See work of Robert Eisenberger on learned industriousness)

Elements of reading tutoring:

● Activities and challenges for every point on the hierarchy of difficulty, including the very easiest

● Tutors trained to give social reinforcement with vocal tones that are really reinforcing

● Sounding and blending of progressively more difficult word lists wherein the phonetic principle is invariate (So that interference doesn't take place within a given list.)

Easy phonemic awareness

1. I’m thinking of something that means not little. It’s buh ĭ guh. (big)

2. I’m thinking of something that a baseball player likes to get. It’s to get a huh ĭ tuh. (hit).

3. I’m thinking of a place where they grind up flour. It’s a muh ĭ ll. (mill)

4. I’m thinking of something that keeps it from being dark. It’s the lll i tuh. (light)

Easy phonemic awareness

Easy spatial awareness

Sheila saw a woman. The woman dropped something. Sheila saw

what happened.

Alternate Reading As a

Psychoeducational Method

Reading aloud and answering

comprehension probes has great

educational benefit

The big ideas of psychological health can

be written down.

The rhythm where preceptor and student

take turns reading each session, the student

answers the probe, and the preceptor

reinforces, is usually a pleasant one.

Jack was with his pal Jed. They were in the woods. Jed saw a bug. Jed said, “I will step on the bug.”

Jack said, “No, Jed. Let the bug live. The bug will not

hurt us. Let us not hurt or kill when it does no good.”

Jed said, “OK, Jack.” Jed did not kill the bug.

Jack felt good.

A. productivity,

or

B. nonviolence?

Within a few minutes the two men had come up with an agreement. They were shaking hands.

"That was wonderful!" said Lilly to Dr. Kuolo. "They might have killed each other otherwise. You and the squoo are a big success!"

At this, the squoo returned to the four people, and they all congratulated the squoo for his fine work, and everyone hugged one another, and a big celebration was held.

"We shouldn't get our hopes up too high," said Dr. Kuolo. "But if it can work for two people, it just might work for two countries. And that," she said, "is what we may call the mission."

"Let's give it a try," said Sam, Lilly and Bo. "Let's go for it!" Were they

goal-setting, or not awfulizing?

The Concept of a “Psychological Skills Exercise”

Some activity that allows practice in skillful patterns of thought, emotion, and behavior.

Doesn't require that the person have a “problem” that the person wants to solve.

Hypothetical situations drawn from a list are often used.

These are to psychological skills as physical exercises are to strength, agility, cardio health.

Tones of Approval and Enthusiasm Exercise

Neutral

Small to moderate approval

Large Approval

Anti-Hyperventilation Exercises

Exercise 1. Hold the breath, note the feeling of CO2 excess, then take a couple of deep breaths to cure the CO2 excess.

Exercise 2. Hyperventilate (about 15 breaths fast and deep), note the feeling of CO2 deficit, then breathe very slowly for about half a minute to cure the CO2 deficit.

The Reflections Exercise

To do a “reflection,” fill in the blank:

So you're saying ___. What I hear you saying is ____. If I understand you right, ____. In other words, you're saying ____.

One person talks and stops talking often. The other does a reflection every time the talker gives him/her the floor.

This can be used as a concentration exercise and/or a social skills exercise.

The Listening with Four Responses Exercise

The four responses are: reflections, facilitations, follow-up questions, and positive feedback.

The talker speaks on any subject, and stops talking often. The listener responds with any of the four responses.

The talker says, “Thanks for the ____,” and keeps going.

They switch roles.

Social conversation, a crucial psychological skill

Tendency is to try to elicit it from children by direct questions, that take on the quality of interrogation

Better strategy: Modeling, silence, reinforcementNice to have other activities that social

conversation can be sandwiched amongModel telling about things with enthusiasm,

creation of suspense and resolution, inflection of tones, emotion. Not: bland, apathetic, “dead fish” talk

The Celebrations Exercise

What What have we done that we're glad we've done? What psychological skills are those things examples of?

Productivity Joyousness

Kindness

Honesty

Fortitude

Good individual decisions

Good joint decisions

Nonviolence

Respectful Talk

Friendship-building

Self-discipline

Loyalty

Conservation

Self-care Compliance

Positive Fantasy Rehearsal

Courage

The Divergent Thinking Exercise

Two people take turns coming up with answers to a prompt or question – as many answers as possible, with as much creativity as possible.

Someone opens a box. What's in it?

Someone is happy. Why?

Someone says “Oops.” Why did they say that? Someone makes a wish. What is it?

The Big Idea of Cognitive

Therapy

By purposely choosing your

thoughts, you can greatly

influence your emotions and

behaviors.

Twelve Types of Thoughts

1. Awfulizing

2. Getting down on yourself

3. Blaming someone else

4. Not awfulizing

5. Not getting down on yourself

6. Not blaming someone else

7. Goal-setting

8. Listing options and choosing

9. Learning from experience

10. Celebrating luck

11. Celebrating someone

else's choice

12. Celebrating your own

choice

The Twelve-Thought Exercise

Pick almost any situation.

Task is to generate each of the 12 thoughts

about this same situation.

Tutor and student start with awfulizing and go

through the 12 thoughts one by one, taking

turns, making up an example of each.

Part of the purpose is to generate cognitive

flexibility – the ability to think in more than one

way, to see options for types of thoughts.

A person writes a paper for a class. They're

very excited about the paper, and very proud

of what they turn in. But then they get a bad

grade on the paper.

The Four-Thought Exercise

The four thoughts are: 1) not awfulizing, 2)

goal-setting, 3) listing options and choosing,

and 4) celebrating your own choice.

Tutor and student take turns with situations,

doing all four thoughts with each.

Part of the purpose is to create a “default”

reflex for handling problem situations,

provocations, or scary situations.

Brainstorming Options Exercise

Tutor and student take turns generating

options for a choice point or problem.

E.G.: Someone is getting picked on at school.

What options could the person consider?

Research literature: The capacity to think of

several nonviolent options correlates with,

probably partially causes, mental health.

Dr. L.W. Aap, a.k.a. The Conflict-

Resolution Role Play Criteria for joint-decision conversations:

defining, reflecting, listing, waiting,

advantages, agreeing, politeness.

In the role-play, you attempt to have each

person meet all 7 criteria.

There's a long list of hypothetical conflicts for

practice in an Appendix to our Anger Control

book.

Fantasy Rehearsal

Many studies reveal that practice in

imagination influences real life behavior

Format for a fantasy rehearsal aloud: go

through the STEBC: situation, thoughts,

emotions, behavior, and celebration. Try to

rehearse the best possible way of handling

the situation. Mastery and coping rehearsals.

Relaxation and Meditation Methods

Breathe and Relax

Mind-watching

Mantra

Pleasant Dreams Exercise

Psychological Skills Meditation

Kindness Meditation

Good will meditation

Biofeedback

Is Phone Tutoring Financially

Feasible as a Mass Method?

About 4 million children per class, in U.S.

Around same ballpark for college students

Imagine 25% of kids able to receive and in

need; imagine 25% of college students able

and willing

Imagine 4 years of tutoring

$2500 per year for tutors; posit equal amount

for all other costs, per child

Phone Tutoring Finances Continued

4 cohorts x 5K apiece x 1 M kids = $20 B/yr

“Current expenditures for public elementary and

secondary schools are projected to be $584.4

billion for the 2016–17 school year.”

http://nces.ed.gov/fastfacts/display.asp?id=372

$20B/$584.4B = 3.4%

$20B/$150B mh budget = 13.3%

Benefit to tutors? Labor in exchange for free or

reduced college tuition?

20 Billion Compared to:

100 Billion per year in US on illegal drugs

17 Billion on video games in one year

35 Billion on gambling

96 Billion on beer

65 Billion on soft drinks

40 Billion on lawn care

A Vision for Time On Task

Vision of a world in which time is devoted to the

teaching and learning of psychological skills in

proportion to the importance of those to

humanity.

A significant fraction of such learning takes

place in the context of long-term one-to-one

relationships with very positive emotional

climates.