tier iii supports for school-based providers3+supp… · continua consulting group, llc 1. gain...
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February 21st & 22nd 2019
Lauren Ashbaugh, Ph.D., NCSP
TIER III SUPPORTS FORSCHOOL-BASED PROVIDERS
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USE A WHOLISTIC, COMPREHENSIVE APPROACH
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2. CAREGIVERS ARE CRITICAL
3. Involve as many systems as you can
4. Attend to health, eating, exercise, nutrition
5. CAREGIVERS ARE CRITICAL
6. Increase areas of competence, belonging
7. Plan sessions mindfully: breaks, vacations, duties etc
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MENTAL HEALTH
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Delivery should be:
1. Specific to role
2. Evidence-based
3. Relevant to needs of building, district, community
• Needs assessment!
4. Designed to address prevention, intervention, and relapse prevention/sustainability
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COGNITIVE-BEHAVIORAL THERAPY (CBT)
• Anxiety
• Depression
• PTSD/Trauma exposure
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Group & Individual Support, ages 7-adult
• Substance Use Disorders
• Personality Disorders
• Sleep Disorders, Eating Disorders
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TIER II I : MENTAL HEALTH
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Evidence-based school mental health interventions:
Trauma
Bounce Back (K-5)
Support for Students Exposed to Trauma (SSET),
Cognitive Behavioral Intervention for Trauma in Schools (CBITS)
Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS): ages 12-19
Social Skills Depression
PATHS, SkillStreaming, SS Grin, peer mediation Mind Over Mood/CBT
PREPaRE Anxiety
Crisis intervention & preparation Coping Cat; Think Good, Feel Good/CBT
UW/Harborview:ENTIRE (FREE) CBT TRAINING PROGRAM
http://depts.washington.edu/hcsats/PDF/TF-%20CBT/pages/therapist_resources.html
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COPING CAT
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CBITS
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COPING CAT
Designed for students with: generalized anxiety disorder, social phobia, and/or separation anxiety disorder
Manualized Cognitive-Behavioral Treatment (CBT), and related workbook
• Ages 6-12 = “Coping Cat” Program
• Ages 13-17 = “C.A.T Project” Program
• Parent companion materials
• Computerized version = “Camp Cope-A-Lot: The Coping Cat DVD”
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WHY CBT? IT WORKS!!
CBT is:
1) collaborative,
2) strengths-based,
3) easy to understand, and
4) can be applied in multiple situations and settings over the course of someone’s life.
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CBT: BASIC APPROACH
Change mood states through cognitive and behavioral strategies
Focus on ‘here and now’
Preference for concrete examples
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Reliance on Socratic questioning
Empirical approach to test beliefs
Promote rapid symptom change
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WHY CBT? EFFECTIVENESS OF INTERVENTIONS
Cognitive Behavioral Therapy (CBT)
• First-line treatment for anxiety disorders, first line for children
• Superior to medication over the long term for GAD and Social Anxiety Disorder
• Superior (with relaxation) to medication for Panic Disorder
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WHY CBT? EFFECTIVENESS OF INTERVENTIONS
Medication
• Effective for severe/moderate symptoms
but with side effects and more limited research in children
• Parental reluctance, cultural factors
• Combination therapy (with CBT) can be very effective
• ACCESS!!!
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BECK’S COGNITIVE THERAPY
Albert Ellis (Rational-Emotive Therapy) & Aaron T. Beck (Cognitive Therapy)
Temperament (biology) + learning (experiences) = cognitive processes (thoughts)
Emotions Behaviors
Adverse life events → automatic thoughts and core beliefs
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BECK’S COGNITIVE THERAPY
Ourselves
I'm unlovable, a bad kid
Others (the world)
Others will reject me
Future
I will be alone
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We develop negative automatic thoughts about:
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WHAT IS CBT?
Imagine you are in a crowded cafeteria.
Someone bumps into you hard from behind.
What is the first thought that comes into your head?
1. Wow that was mad disrespectful. Someone just wanted to start something with me.
2. Wow, I don’t even matter enough for someone to notice that I’m standing here. I guess this is just how
everything in my life always goes. It’s going to be that kind of day. Again.
3. Something’s really wrong! Someone is dangerous and trying to hurt me
4. Ouch! I’m ok though. Someone must have just tripped – I hope he’s ok. I wonder if I can help.
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SCENARIO 1: MAD DISRESPECT
THOUGHT:
Wow that was mad disrespectful. Someone just wanted to start something with me.
FEELING:
Angry, defensive, aggressive, self-protective
BEHAVIOR:
Immediately confrontational, argument or a fight, everyone nearby is tense and worried
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SCENARIO 2: I DON’T MATTER.
THOUGHT:
Wow, I don’t even matter enough for someone to notice that I’m standing here. I guess this is
just how everything in my life always goes. It’s going to be that kind of day. Again.
FEELING:
Worthless, sad, defeated, lonely
BEHAVIOR:
Withdrawal, isolation
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SCENARIO 3: SOMETHING’S WRONG!
THOUGHT:
Something’s wrong! Someone is trying to hurt me!
FEELING:
Fear, alarm, intense anxiety
BEHAVIOR:
Flee, escape, panic
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SCENARIO 4: IT’S AN ACCIDENT
THOUGHT:
Ouch! Hmm, I think I’m ok. Someone must have just tripped – I hope he’s ok. I wonder if I can help.
FEELING:
Concern, empathy, curiosity about what happened, maybe irritation
BEHAVIOR:
Reaching towards someone else, making connection
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COMPONENTS OF CBT
1. Assessment
2. Education
3. Coping Skills
4. Behavioral change
5. Relapse prevention
6. TEACHING CAREGIVERS HOW TO REINFORCE IT
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COMPONENTS OF CBT FOR DEPRESSION
1. Assessment (rating scales, teacher/parent report)
2. Education (depression, triangle, treatment course)
3. Coping Skills Instruction
1. Behavioral activation (positive activities, sleep & exercise, problem-solving)
2. Cognitive restructuring (change thinking patterns)
3. Emotion regulation (SUDs ratings, relaxation, breathing, calming, distraction)
4. Caregiver support
5. Relapse Prevention
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Behavioral Activation:Using Action to Change your Thoughts & Feelings
• Sadness and loneliness ➔ call a friend, accept invitation out
• Want to curl up and sleep ➔ go for a walk
• Feel guilty about missing work ➔ start it with a friend at a coffee shop
• Struggling to eat well ➔ start eating breakfast
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Coping Skills Instruction:Cognitive Restructuring: Challenging Thoughts
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THOUGHT RECORD EXERCISE
Teenager feels worthless. Struggling to be social, go to school.
I can’t do anything right.
I won’t be successful. I’m a failure.
No one would want to date me.
I don’t have any friends.
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COMPONENTS OF CBT FOR ANXIETY
1. Assessment
2. Psychoeducation
3. Coping Skills Instruction
1. Somatic (Body) Management
2. Cognitive Restructuring (change thinking patterns)
3. Problem Solving
4. Exposure and Response Prevention
5. Relapse Prevention
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CBT Model of Fear & Anxiety Disorders
Fear Stimulus
(trigger or cue)
Misinterpretation
of Threat
Anxiety
Avoidant Coping
(primary and secondary)
Absence of Corrective
Experience and Learning
Pre-existing
Beliefs
Environmental
Factors
Cognitive Restructuring
Relaxation/Coping skills
Graduated exposure
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EDUCATION: WHAT IS ANXIETY?
Fear is a natural and important emotion!
• Fight, flight, or freeze - critical to safety
Anxiety is your body getting ready to do something important
• Shifting blood and energy to your brain, muscles, lungs
• Enhancing senses (pupils dilate), enhance strength
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Your body usually adjusts and learns from “false alarms”
Goal: management, not elimination of symptoms
Relearn what is safe, what is not safe
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EDUCATION: WHAT IS A WORRY PROBLEM?
Worry likes to tell you these three things:
1. Worry tells you something terrible is likely going to happen, even when it is actually
highly unlikely if not impossible
2. Worry can make things out to be worse than they really are.
3. Worry tells you that if something bad happens, you will not be able to handle it.
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CBT for Anxiety:Working with children
1. Teach identification and rating of anxietya) Fear thermometer
b) Brave ladder
2. EXTERNALIZE anxietya) Mr. Worry
b) Ms. Bossypants
c) Worry bully
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SUBJECTIVE UNITS OF DISTRESS (SUDS)
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COPING SKILLS INSTRUCTION:
SOMATIC (BODY) MANAGEMENT
Strategies:
1. Diaphragmatic breathing
➢ Belly breathing, blowing out bubbles of worry
➢ One hand on chest, one hand on stomach
➢ Focus on sensation: hand on belly rising, cold air in & warm air out
2. Muscle relaxation➢ Cannot be relaxed and tense at the same time
➢ Try scripts
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Coping Skills Instruction:Cognitive Restructuring: Automatic Thoughts
Great place for a list of distortions!
• Catastrophizing
• Black and white thinking
• Overestimating
• Mental filter
• Jumping to conclusions
• Emotional reasoning
• “Should” statements
• Personalization and blame
• Magnification and minimization
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COPING SKILLS INSTRUCTION:
COGNITIVE RESTRUCTURING
Goals:
1. Identify unhelpful thoughts
• ”I can’t do this. I’m terrible at math.”
2. Challenge those thoughts to get to more helpful, realistic thoughts
• ”This looks hard, but I haven’t tried it yet. I can try and see how far I get.
My teacher will help me. This might not come naturally to me, but it
doesn’t mean that I won’t be able to learn how to do it.”
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Coping Skills Instruction:Cognitive Restructuring: Self-Monitoring
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Situation/trigger Teacher called on me in class
Intensity of anxiety (0-10) 7
Physical sensations/
other symptoms
Sweating, lightheaded, felt choked
up, heart racing
Anxious thoughts
(words or images)
“I am going to freeze up,” “I will sound
like an idiot”
Anxious behaviors
(e.g., avoidance, safety
behaviors, rituals)
Said “I don’t know”; avoided eye
contact; mental retracing after
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Coping Skills Instruction:Cognitive Restructuring: Challenging Thoughts
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EXPOSURE THERAPY: THE BASICS
Dr. Ali Mattu, The Psych Show
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Exposure Therapy: What is it?
EXPOSURE means staying in the presence of a feared
stimulus long enough to learn that it is not as scary as you
thought it would be.
Want habituation:
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Exposure Therapy:Goals and Strategies
Goals:
1. Create fear ladder
2. Complete steps on hierarchy
3. Practice anxiety management strategies
Strategies
1. Exposures
a) Imaginary
b) Simulated. (Practice)
c) In Vivo. (Out in the world)
d) Interoceptive. (Bodily sensations)
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Exposure Therapy: The basics
1. Gradual exposure to fears: least feared to most feared
2. Student *must* stay in feared situation long enough to learn that feared response will not occur – with restructuring of thoughts!
3. Practice and repetition are critical to habituation
*Get to the point that it is really no big deal!*
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Exposure Therapy:Rating the exposure
Before:
• What will you do?
• What are your thoughts/beliefs/distortions?
• Rate your anxiety level
After:
• What actually happened?
• Rate your anxiety level now
****DON’T FORGET THE REWARDS!!!!*** Continua Consulting Group, LLCPacific Northwest Psychology & Consulting, LLC
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AVOIDANCE
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CBT:Relapse Prevention
1. Goals:
• Review anxiety management strategies
• Generalize treatment gains
• Create feelings of mastery and independence
2. Strategies:
• Reduce intervention/session frequency
• Anticipate problems
• Discuss “booster sessions”
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USING CBT TO ADDRESS TRAUMA EXPOSURE
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TIER I I I : GROUP TRAUMA INTERVENTION
COGNITIVE BEHAVIORAL INTERVENTION FOR T RAUMA IN SCHOOLS (CBITS)*
SUPPORTS FOR ST UDENTS EXPOSED T O T RAUMA (SSET)*
How is CBITS implemented?
• Mental health professionals in schools
Is CBITS evidence-based?
• Yes. Extensive research demonstrates fewer symptoms of post-traumatic stress, depression, and psychosocial dysfunction.
How has CBITS been adapted for different settings and populations?
• Adapted for use with Spanish-speaking populations, low-literacy groups, and children in foster care.
• Also modified for delivery by nonclinicians and in a variety of settings (urban, rural, suburban, and tribal).
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*Developed with UCLA, LAUSD, & Rand
Lisa Jaycox, Ph.D.
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1. Education & Relaxation (Group)
2. Exposure (Individual)
3. Exposure (Individual)
4. Introduction to Cognitive Therapy (Group)
• Emotion rating (Fear thermometer)
• Thoughts and Feelings
• Thought challenging (Hot Seat)
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5. Introduction to Real-Life Exposure
• Avoidance and Coping; Fear Hierarchy
• Alternative Coping
6. Exposure (Individual)
7. Exposure (Group)
• Imagined, Drawn, Shared
8. Social Problem-Solving
9. Practice with Social Problem-Solving
10. Wrap-up
COMPONENTS OF CBITS
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PLUS: TWO GUARDIAN SESSIONS!
• Enhance connection & relationships
• Generalization & supported exposures
• Many of your students have siblings
• Intergenerational transmission of trauma
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PLUS: TWO TEACHER SESSIONS!
• Enhance connection & relationships
• Generalization & supported exposures
• Multiple classmates also affected
• Enhance trauma responsiveness
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COMPONENTS OF SSETScreening, consent, baseline Post-test, follow-up
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BUT…IT’S TRAUMA. WHAT IF I MESS UP?
• Bring presence.
• Bring courage. Trust the process.
• Climb in the hole. Listen. Wait to speak.
• Demonstrate faith and unwavering support. Be honest.
• Watch for the desire to fix, blame, avoid – in yourself.
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BUT…IT’S TRAUMA. HOW CAN I HANDLE IT?
Be self-aware. Seek and use supports. Cultivate meaning, learning, growth – in
yourself.
Consider balance.
Remember that what you are learning about is not happening right now, in this space.
You can be a safe space.
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TRAUMA AND ACES: COGNITIVE DISTORTIONS
Cognitive Model of PTSD: Cognitive distortions fuel secondary feelings
“I am a bad kid so I deserved to get hit”
Secondary emotions: Shame, humiliation, low self-worth
Underlying emotions: Sadness, anger, loss, grief
“Everyone is out to get me. You can’t trust anyone.”
Secondary emotions: Suspicion, anger, mistrust, rage, defensiveness
Underlying emotions: Hurt, sadness, rejection, anger at perpetrator
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EXPOSURE TO DV & PHYSICAL ABUSE : THOUGHTS
Self: I’m a bad kid.
This is my fault.
I can’t do anything right.
If I try, I fail.
No one would love me if they knew who I really am.
Other: Adults can’t be trusted
Others will reject me.
Others are out to get me.
World/Future: Everything can go bad in a split second.
The world is not safe.
I don’t have a positive future.
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EXPOSURE TO DV & PHYSICAL ABUSE : FEELINGS
Primary:
Fear
Pain
Fatigue
Worry
Anger
Sadness
Hurt
Confusion
Secondary:
Shame
Guilt
Embarrassment
Worthlessness
Mistrust
Loneliness
Isolation
Misunderstood
Unseen
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Peer relational difficulties related to mistrust & misinterpretation
Avoidance of situations or activities that elicit shame
Sensory reactivity to noise, touch, sound, chaos
Reactivity to unexpected change and unpredictability
Slow to warm up; doesn’t trust adults easily
Difficulty with focus/concentration and activity level
EXPOSURE TO DV & PHYSICAL ABUSE : BEHAVIORS
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EXPOSURE THERAPY: A QUICK LOOK
Audra Langly, Ph.D., CBITS trainer
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TOOLS & STRATEGIES
• Information & education – prepare for the process.
• Always honor choice and voice.
• Socratic questioning. Introduce the grey.
• Calm the body, desensitize to trauma.
• Track progress, celebrate success.
• Facilitate generalization. Want application in the real world.
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Visualization