INTERVENTION PROTOCOL

CHLOE HUDGINS
2/21/2017
Intervention Protocol
Coping Skills

GENERAL PROGRAM PURPOSE

To increase the ability to manage and reduce stress in lifes daily situations for individuals with
Conduct Disorder. The program will help clients gain techniques to identify and regulate
emotions, reduce personal stress, and develop skills to manage aggressive behaviors.

DESCRIPTION OF PROGRAM
Coping Skills Program will engage the clients through a variety of approaches, experiential
therapy, didactic sessions, and creative expression. The two hour group sessions will be
facilitated two times per week. By learning a diverse set of coping skills, clients will acquire
techniques to identify and regulate emotions reduce personal stress, and develop skills to
manage aggressive behaviors
Program Outcomes
The coping skills program will:

Assist clients to be able to identify personal stressors.

Assist clients in developing coping skills to reduce daily stress levels.
Assist clients in develop coping skills to increase self-control and reduce behavioral
outbursts
Assist clients in learning relaxation as a specific coping skill.

PROBLEMS TO BE ADDRESSED
Lack of self-control
Behavioral outbursts
Emotional regulation problems
Anger management issues
Aggression

REFERRAL
Referred to program by social worker and psychiatrist

CONTRAINDICTATED CRITERIA
Individuals with severe Conduct Disorder who pose substantial harm to others
INTERVENTIONS
S-T-R-E-S-S-I-N-G L-E-S-S WORD GAME

Population: Adolescent boys with conduct disorder

Age: 12 17

Group Size: 6 12

Setting Considerations: The room should be big enough to accommodate the size of the group.
Place chairs in a semi-circle. Be sure there is enough space to maintain physical boundaries.
Therapist should be able to see all clients at all times.

Group Stage Considerations: Forming, Storming, Norming, Performing

Purpose: This intervention introduces the topic of stress, stressors, and coping techniques to
clients. It will assist clients in identifying personal stressors and overall educate them on the
topic of stress, stressor, and coping techniques.

Goals:
Clients will be able to identify at least 5 personal stressors and coping techniques
through the exploration of the topic of stress.
Clients will be able to identify triggers of behavioral outburst and learn de-escalation
skills through learning about stress, stressor, and coping techniques.

Supplies Needed:
S-T-R-E-S-S-L-I-N-G L-E-S-S Word Game handout for each member of the group (see
attached worksheet)
Writing utensils
Enough chairs for each group member
Whiteboard
Whiteboard marker
Timer

Intervention Description:
After preparing the chairs in a semi-circle and retrieving appropriate materials, gather
teens in therapy room.
Make sure to follow the facilities staff to client ratio
Review group rules and welcome/introduce any new clients.
Opening
Introduce stress by referring to the following outline:
Stress can be anything that challenges ones ability to cope.
 This does not necessarily mean an unexpected trauma or event
Stress comes in three forms:
1. Motivational called eustress (birthdays, new job, football game)
2. Day-to-day stress called neustress (school work, hot day, noise outside)
3. Negative stress is produced from trauma or crisis called distress (failed
exam, break up, grounded)
Stress is the bodys physical, chemical, emotional and mental reaction, to a given
situation. The situation can be environmental, physical or a psychological interpretation
of the experience, it is the accumulation of all forms of stress and the persons ability to
manage and cope with the stress that determines the long-term effect on the body. The
actual even, circumstance or condition is called the Stressor. The stress symptoms are
the bodys reaction to stressors.
To cope with stress teens must
Learn to identify stressful situations.
Build an awareness of their responses to those situations.
Understand that negative effects of stress on the mind and body are directly
related to their individual responses to given situations.
Develop coping techniques to handle the inevitable stress.
This process will reduce the symptoms and the long-term damage caused by stressors.
There is a direct link between stress and stress symptoms, and substance abuse,
physical illnesses and disease. Recognizing early warning signs of stress can help teen
stake action to reduce those stress symptoms. Learning coping techniques reduce the
stress symptoms and promote health. It is not that a teen no longer has stress the
teen learns lifetime techniques to recognize and cope with stressors and stress
symptoms. (Negley & Leutenberg, 2015)
Body
Pass out S-T-R-E-S-S-L-I-N-G L-E-S-S Word Game worksheet and one writing utensil to
each client
Explain that when therapist says GO! teens will have 15 minutes to come up with as
many words as possible using the letters in S-T-R-E-S-S-L-I-N-G L-E-S-S.
Ask if anyone has any questions and give an example if necessary.
Set timer for 15 minutes, say GO! and start time.
After 15 minutes, instruct everyone that time is up and to put down their writing
utensils.
Collect writing utensils
Move group to theater-style seating so everyone can see the board.
Make three columns on the whiteboard with the titles Stress, Stressors, and Coping
Strategies. Starting with the Stress column, have the group name things that fall under
that category and record answers on board. Do this with each category.
Have each client pick at least one thing from each category that will be used for
homework that is assigned during closing
Processing
See Possible Discussion Questions below
Closing
Collect all writing utensils
Close by summarizing stress, stressor, and coping techniques.
Ask if any clients have any questions on stress, stressor, or coping techniques.
Assign homework (see Possible Group or Individual Assignments below)

Special Considerations or Risks: There should always be a precaution of aggressive behavior. Be

sure to count the writing utensil before and after the group to make sure everything was
collected and avoid anything being used as a weapon. Make sure physical boundaries are
maintained throughout the intervention.

Possible Discussion Questions:

Remembering
What is stress?
What is a stressor?
What is a coping technique?
Understanding
Why did we do this activity?
Applying
Where in your life is it important to have coping techniques?
Analyzing
What were some personal stressors you identified?
What are some coping techniques that will help you with those stressors?
Evaluating
How can identifying your personal stressors help you better cope with the daily stress of
life?
Creating
What will you take away from this activity?

Possible Group or Individual Assignments: Each client should have chosen at least one thing
from the three categories written on the whiteboard. Instruct each client to write a short story
about a stressor and ways they might cope with that stressor.

Modification or Adaptations: The intervention was originally designed to be competition to see

who can write the most words. Based on areas of concern for individuals with conduct disorder,
competition could lead to strong emotions and outbursts. Therefore this intervention omitted
the competition aspect. Also, this activity requires a high level of concentration during the 15
minutes of completing the worksheet. If necessary and depending on the group, that time
should be decreased to 10 minutes or less.

Reference/Source:
Negley, S. K., & Leutenberg, E. R. A. (2015). Like Skills to Help Teens Balance Way Too Much.
Duluth, MN: Whole Person Associates.
ACID RIVER

Population: Adolescent boys with conduct disorder

Age: 12 17

Group Size: 6 12

Setting Considerations: Location needs to be at least 20 to 25 feet long and large enough for
the group and all of the required materials (see Supplies Needed). The area must be clear of
chairs, tables, or any other furniture. This intervention can be done either outside or inside. If
performed outside, make sure ground is level and stable.

Group Stage Considerations: Forming, storming, norming, or performing.

Purpose: To facilitate communication among the group as a means of coping with and reducing
aggressive behaviors.

Goals:
Client will learn communication as a way to help regulate emotions
Clients will learn communication as a de-escalation skill

Supplies Needed:
Five 1 gallon cans (empty without tops) or 5 short stumps
Three 2 x 6 x 8 boards
Two 2 feet pieces of rope

Intervention Description:
After preparing all of the materials, gather clients in a circle, sitting on the ground. (Be
sure to allow for enough space to maintain physical boundaries).
Make sure you follow the facilities staff to client ratio
Review group rules and welcome/introduce any new clients
Opening
Open the intervention by talking about the importance of communication in stressful
situations.
o Learning to effectively communicate with others can reduce aggressive
behaviors and behavioral outbursts.
o Proper communication can be used as a means of coping with stressful
situations.
o Go around in the circle and have each member give a short answer to the
following question:
What are some aspects of good communication?
Body
After discussing communication, instruct group that they will be participating in Acid
River.
Explain that the goal of the activity is to get everyone safely to the other side of the river
without anyone falling in.
With the two pieces of rope, mark the length of the acid river. Depending on the size
and ability of the group, the river should be 15 25 feet long. If you fell the group needs
more of a challenge, extend this distance.
Explain the rules:
o The team must get from one rope to the other by crossing the acid river. The
materials they can use are the Five 1 gallon cans (empty without tops) or 5 short
stumps (depending on which you use) and the three 2 x 6 x 8 boards.
o If any member of the group touches the ground (Acid River) the entire group
must start over.
o If one of the boards touch the ground the group must start over or continue
without the use of that board.
o Emphasize the importance of safety for yourself and others.
After making sure everyone understands the rules, ask the group if they have questions.
Instruct the group to start the activity.
Since there are no spotters in this initiative, the therapist and other staff need to keep a
close eye out for any unbalanced clients or unstable bridges.
Once the group has completed the activity, gather participants in a sitting circle.
Processing
See Possible Discussion Questions
Closing
Ask if any of the clients have any questions.
Check for physical and emotional safety
Clean up the materials.

Special Considerations or Risks: There is always a precaution of aggressive behavior. This

activity requires group cooperation so be sure every member is able to work as part of a group.

Possible Discussion Questions:

Remembering
What did we just do?
Understanding
What was the purpose of that activity?
What did you learn?
Why is it important to communicate with others?
Applying
Where else is good communication important?
Analyzing
How does this activity relate to stress and coping skills?
 How does what you learned here relate to your daily life?
Evaluating
What communication strategies were helpful?
Creating
What would you do different next time?

Possible Group or Individual Assignments: Challenge clients to practice good communication

strategies anytime they are working with others or in a stressful situation.

Modification or Adaptations: The activity requires little physical contact which should be
minimized to avoid any physical altercations. Furthermore, if the activity seems too easy for
participants, challenges can be added i.e. inability to speak, loss of a limb, etc. Blind folds
should not be used with individuals with conduct disorder.

Reference/Source: Intervention adapted from Sandy Negley

BOX BREATHING

Population: Adolescent boys with conduct disorder

Age: 12 17

Group Size: 6 12

Setting Considerations: The room should be big enough to accommodate the size of the group.
Place chairs in a semi-circle. Be sure there is enough space to maintain physical boundaries.
Therapist should be able to see all clients at all times. Leave lights on during the entirety of the
intervention.

Group Stage Considerations: Norming or Performing The teens might have a hard time
feeling comfortable closing their eyes and relaxing with the group in the forming or storming
stages.

Purpose: The purpose of Box Breathing is to teach clients a technique that can help reduce
stress and cope with lifes daily situations. This intervention will assist clients in learning
relaxation through breathing as a specific coping skill.
Goals:
Clients will learn the Box Breathing technique.
Clients will use Box Breathing as a coping skill to regulate emotions.
Client will learn Box Breathing as a de-escalation technique.

Supplies Needed:
Box Breathing script (see below)
Whiteboard
Whiteboard marker
Enough chairs for members of the group.

Intervention Description:
After preparing the chairs in a semi-circle and retrieving appropriate materials, gather
teens in therapy room.
Make sure to follow the facilities staff to client ratio.
Review group rules and welcome/introduce any new clients.

Opening
Introduce Box Breathing
o Breathing can be a helpful technique used in any stressful situation and aid in
calming nerves. Breathing helps the body make full use of
o Imagine a square. In Box Breathing, each of the sides represents a count of four.
(Draw a large square on the board and label it like the diagram below)

Inhale

Hold

Hold

Exhale
Body
Explain that you will now practice Box Breathing and read the script below
o Sit straight up in your chair. Put your feet flat on the floor and relax your hands
in your lap. You may overlap your hands or let them lie separately with palms
facing up. The important factor is to maintain an aligned posture and to be at
ease.
Close your eyes if you are comfortable doing so.
 (Pause for a few seconds)
Close your mouth and breathe in slowly through your nose. Count to four as you
inhale. Hold your breath for four seconds. You are not trying to deprive your
body of oxygen, but need to allow a few seconds for the air to fill your lungs.
Concentrate on your belly and notice how it also moves when you inhale deeply.
Open your mouth slightly and slowly exhale to a count of four. Hold the exhale
to another count of four.
Allow the air to fill your belly and notice how it passes over your chest. One of
the goals of boxed square breathing is to bring the respiratory system back into
alignment and end the shallow breathing that results from the fight or flight
response mode the body enters when feeling stressed. Researchers with the
National Center for Complementary and Alternative Medicine report that in
addition to reducing stress, controlled breathing is used to treat insomnia,
anxiety, depression and pain control.

We will now practice this breathing for a few minutes

Breathe in 1, 2, 3, 4
Hold 1, 2, 3, 4
Breathe out 1, 2, 3, 4
Hold 1, 2, 3, 4
(Repeat process for four to five minutes)
Ideally, you should repeat the exercise for four minutes, but two or three times
will help you to achieve a more relaxed state, relieve tension and settle your
nerves. (adapted from livestrong.com)
Process
See Possible Discussion Questions below
Closing
Ask if any of the clients have any questions.
Check for physical and emotional safety
Assign Box Breathing practice (see Possible Group or Individual Assignments)
Thank clients for participating

Special Considerations or Risks: Individuals with conduct disorder might feel uncomfortable
with lights dimmed or closing their eyes. It is important to be aware of this and keep the lights
on at all times. Do not force clients into closing their eyes if they are not comfortable doing so.
Furthermore, there should always be a precaution of aggressive behavior.

Possible Discussion Questions:

Remembering
What did we just do?
Understanding
What is the purpose of this activity?
Applying
Where else in your personal life could you use Box Breathing?
Analyzing
In what situations could Box Breathing be useful? Why?
Evaluating
What is the relationship between breathing and stress?
Creative
What did you gain from this activity?
What are some ways you can continue in the practice of Box Breathing?

Possible Group or Individual Assignments: Have the clients practice Box Breathing once a day
for at least three minutes and have them journal about their practice.

Modification or Adaptations: This activity requires a high level of concentration and quiet.
Individuals with conduct disorder might have a hard time during the 5 minute practice of Box
Breathing. That time may need to be adjusted depending on the reaction of the group to the
practice.

Reference/Source:
Ray, L. (2013, August 19). Box Breathing Technique. Retrieved February 18, 2017, from
http://www.livestrong.com/article/74944-box-breathing-technique/

TRAFFIC JAM
Population: Adolescent boys with conduct disorder

Age: 12 - 17

Group Size: 6-12

Setting Considerations: Room should be big enough to accommodate size of group. This
activity can be done inside or outside. Be sure there is enough space to maintain physical
boundaries. Therapist should be able to see all clients at all times.

Group Stage Considerations: Forming, storming, norming, or performing.

Purpose: The purpose of this activity is to facilitate communication between the group and
present an opportunity for the group to problem solve which are techniques that will help
clients to manage and reduce stress in lifes daily situations. Also, to help clients develop skills
to manage aggressive behaviors.
Goals:
Clients will learn communication and problem solving to improve self-control through
stressful situations.
Clients will learn use communication and problem solving to help regulate emotions.

Supplies Needed:
1 piece of paper for each member of the group plus one extra

Intervention Description:
Gather teens in a circle, sitting on the ground.
o Maintain physical boundaries
Make sure to follow the facilities staff to client ratio.
Review group rules and welcome/introduce any new clients.
Opening
Review the topic of Stress
o Ask the group to explain the following
Stress
Stressors
Coping Skills
Communication as a coping skill
o Introduce the concept of problem solving as a coping skill
instrumental coping (referred to as problem-solving) focuses on ways to
tackle the issue in order to reduce stress around a given situation and
aims to locate the source of the problem and determine solutions (How
Do You Cope?, 2017)
Body
Divide the group into two groups. Below is an example of how to creatively divide the
group.
o Without giving further instructions, tell everyone to fold their arms. Those that
have their left arm on top are on one side. Those with their right arm on top are
on the other. If needs be, switch people around to create even numbers on each
side.
Instruct the group that they will have an opportunity to practice communication and
problem solving in the activity Traffic Jam
The goal of Traffic Jam is to have two groups of people exchange places on a line of
squares that has one more square than people in both groups.
The Rules:
o The two groups will line up at opposite ends of the line facing the center, one
person per piece of paper. The center square should be vacant (extra).
o Only 1 group member can move at a time
o Only forward moves are allowed. No one can move backwards
 o You may move into an empty square directly in front of you, or you can move
around a person facing you, into an empty square directly behind that person.
You may not move around any facing the same direction as you.
Lay the pieces of paper in a line and have the two sides take their positions and began.
When the group completes the activity, gather clients in a circle on the ground for
processing.
Processing
See Possible Discussion Questions below
Closing
Ask if any of the clients have any questions.
Check for physical and emotional safety.
Thanks clients for participating.

Special Considerations or Risks: There should always be a precaution of aggressive behavior.

Since this activity requires no physical contact, the chance of aggressive behavior is reduced but
should still be considered as a possibility. Be aware that lack of cooperation between
participants might be an issue as well and therapist should be ready to make appropriate
changes if necessary (See Modifications or Adaptions).

Possible Discussion Questions:

Remembering
What did we just do?
Understanding
What was the purpose of the activity?
Applying
Where else is it important to use communication and/or problem solving?
Analyzing
How does this activity relate to stress/stressors/coping skills?
Evaluating
What were the strong points of this activity?
What were the difficult points of this activity? Why?
Creating
What did you learn from this activity?
How will you take what you learned and apply it lifes daily situations?

Possible Group or Individual Assignments: Instruct group to ponder the question How will you
take what you learned and apply it lifes daily situations? and journal about how they are going
to apply this activity in daily life.

Modification or Adaptations: Like stated earlier, this activity involves little physical contact. To
further reduce the risk of aggressive behaviors, space pieces of paper farther apart and make a
no physical contact rule. In this activity, it is important for the group to establish a leader. If
they are struggling with this, therapist should help group in establishing a leader. On the other
hand, if this activity is too easy, challenge the group to solve the problem smoother than the
first time.

Reference/Source:
How Do You Cope? (2017). Retrieved February 22, 2017, from UCLA Dual Diagnosis Program,
https://www.semel.ucla.edu/dual-diagnosis-
program/News_and_Resources/How_Do_You_Cope
Intervention adapted from Sandy Negley

THE STRESS PROCESS

Population: Adolescent boys with conduct disorder

Age: 12 17

Group Size: 6 12

Setting Considerations: The room should be big enough to accommodate the size of the group.
Place chairs in a circle. Be sure there is enough space to maintain physical boundaries. Therapist
should be able to see all clients at all times.

Group Stage Considerations: Forming, Storming, Norming, Performing

Purpose: To summarize what participants have learned about stress/stressors/coping skills.

This activity will help clients gain techniques to identify and regulate emotions, reduce personal
stress in lifes daily situations, and develop skills to manage aggressive behaviors.

Goals:
Client will be able to identify coping skills to improve self-control through stressful
situations.
Client will learn coping skills to help regulate emotions.
Client will be able to identify personal stressors and coping techniques.
Client will be able to identify triggers of behavioral outbursts and learn de-escalation
skills.
Supplies Needed:
The Stress Process handout for each participant (see below).
Writing utensils
Enough chairs for each group member.
Intervention Description:
After preparing the chairs in a semi-circle and retrieving appropriate materials, gather
teens in therapy room.
Make sure to follow the facilities staff to client ratio
Review group rules and welcome/introduce any new clients
Opening
Review the topic of stress, stressor, and coping techniques with an open discussion of
the following topics: (refer to S-T-R-E-S-S-L-I-N-G L-E-S-S Word Game intervention for
details)
o What is stress?
Anything that challenges ones ability to cope.
o What is eustress?
Motivational stress
o What is neustress?
Day-to-day stress
o What is distress?
Negative stress produces from trauma or crisis
o What is a stressor?
The event, circumstance, or condition that causes stress
o What is a coping skill?
Techniques that help to reduce stress symptoms and promote health
Body
Distribute The Stress Process handout to each participant.
Using the information provided in the opening the information client have learned in
other groups, begin to facilitate the handout.
Teens should focus on only one column at a time
o Column 1: have teens write their most significant stressors and place one in each
box
o Column 2: ask teens to mark the type of stress
o Column 3: ask teens to mark the kind of stress
o Column 4: have teens identify and write their stress symptoms
o Column 5: have teens brainstorm the kinds of stress strategies they can
implement to decrease each identified stressor.
(Negley & Leutenberg, 2015, p. 60)
Processing
See Possible Discussion Questions
Closing
Collect all writing utensils
Ask if any clients have any questions on stress, stressor, or coping techniques.
Assign homework (see Possible Group or Individual Assignments below)
Special Considerations or Risks: There should always be a precaution of aggressive behavior. Be
sure to count the writing utensil before and after the group to make sure everything was
collected and avoid anything being used as a weapon. Make sure physical boundaries are
maintained throughout the intervention.

Possible Discussion Questions:

Remembering
What did we just do?
What is stress?
What is a stressor?
What is a coping technique?
Understanding
Why did we do this activity?
Applying
How will you use The Stress Process handout in your personal life?
Analyzing
In this activity, what did you learn about yourself?
How will this help you in relation to what you need to work on?
Evaluating
What were the strong points of this activity? What were the weak points? How can you
improve the weak points?
Creating
What did you gain from this activity?

Possible Group or Individual Assignments: If clients did not finish handout, encourage them to
finish it on their own time and post it in a place that will be beneficial to them as a reminder of
their coping strategies. Additionally, have clients implement at least one coping technique in
their daily life and journal about the experience.

Modification or Adaptations: This intervention requires little to no modifications for individuals

with conduct disorder.

Reference/Source:
Negley, S. K., & Leutenberg, E. R. A. (2015). Like Skills to Help Teens Balance Way Too Much.
Duluth, MN: Whole Person Associates.
STAFF TRAINING/CERTIFICATION REQUIREMENT
National Certification by NCTRC as a CTRS
Staff should have thorough knowledge of all coping techniques and strategies-specialty
certification may be necessary
Staff are trained in de-escalation techniques and restraints in case of aggressive
behaviors
South Carolina drivers license

RISK MANAGEMENT
Maintain staff to client ratio of 1:4 during group and at least two staff during outings
Avoid situations that cause contention among participants
Count supplies before and after any activity
Avoid sharp objects or anything that could be used as a weapon
Do not teach techniques that could have long term harm on clients
No off campus activities for clients at a level 3 or below.
Emergency response procedures

CLIENT OUTCOMES
Client will be able to identify coping skills to improve self-control through stressful
situations by discharge.
Client will learn coping skills to help regulate emotions by discharge.
Client will be able to identify personal stressors and coping techniques by discharge
Client will be able to identify triggers of behavioral outbursts and learn de-escalation
skills by discharge.

PROGRAM EVALUATION
Clients will be evaluated every two weeks by

Observation of clients participation

Observation of any changes in clients behavior
Stress tests
The Post-Session Report Form will be completed by the recreation therapist after each
session. This will be used to evaluate the program and improve upon it in the future
(Stumbo, pg. 368).
Information will be gathered when clients are discharged or leave program

A client satisfaction survey will be given to clients and their families to evaluate
programs on overall satisfaction. This information will be given to facility directors.
 Clients will be evaluated based on programs outcomes to help improve program in the
future
C. Hudgins TRS, CTRS (student) 2/21/2017
 Works Cited
How Do You Cope? (2017). Retrieved February 22, 2017, from UCLA Dual Diagnosis Program,

https://www.semel.ucla.edu/dual-diagnosis-

program/News_and_Resources/How_Do_You_Cope

Negley, S. K., & Leutenberg, E. R. A. (2015). Like Skills to Help Teens Balance Way Too Much.

Duluth, MN: Whole Person Associates.

Ray, L. (2013, August 19). Box Breathing Technique. Retrieved February 18, 2017, from

http://www.livestrong.com/article/74944-box-breathing-technique/

Stumbo, N. J., & Peterson, C. A. (2009). Therapeutic Recreation Program Design (5th ed.). Pearson.