tier iii supports for school-based providers3+supp… · continua consulting group, llc 1. gain...

February 21st & 22nd 2019

Lauren Ashbaugh, Ph.D., NCSP

TIER III SUPPORTS FORSCHOOL-BASED PROVIDERS

USE A WHOLISTIC, COMPREHENSIVE APPROACH

Continua Consulting Group, LLC

1. Gain consent to collaborate, limited if necessary

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

Pacific Northwest Psychology & Consulting, LLC

MENTAL HEALTH


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


COGNITIVE-BEHAVIORAL THERAPY (CBT)

• Anxiety

• Depression

• PTSD/Trauma exposure


Group & Individual Support, ages 7-adult

• Substance Use Disorders

• Personality Disorders

• Sleep Disorders, Eating Disorders


TIER II I : MENTAL HEALTH


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


COPING CAT


CBITS


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”

Pacific Northwest Psychology & Consulting, LLCContinua Consulting Group, LLC

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.

Continua Consulting Group, LLCPacific Northwest Psychology & Consulting, LLC

CBT: BASIC APPROACH

Change mood states through cognitive and behavioral strategies

Focus on ‘here and now’

Preference for concrete examples


Reliance on Socratic questioning

Empirical approach to test beliefs

Promote rapid symptom change


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


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!!!


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


BECK’S COGNITIVE THERAPY

Ourselves

I'm unlovable, a bad kid

Others (the world)

Others will reject me

Future

I will be alone


We develop negative automatic thoughts about:


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.


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


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


SCENARIO 3: SOMETHING’S WRONG!

THOUGHT:

Something’s wrong! Someone is trying to hurt me!

FEELING:

Fear, alarm, intense anxiety

BEHAVIOR:

Flee, escape, panic


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


COMPONENTS OF CBT

1. Assessment

2. Education

3. Coping Skills

4. Behavioral change

5. Relapse prevention

6. TEACHING CAREGIVERS HOW TO REINFORCE IT


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


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


Coping Skills Instruction:Cognitive Restructuring: Challenging Thoughts


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.


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


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


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


Your body usually adjusts and learns from “false alarms”

Goal: management, not elimination of symptoms

Relearn what is safe, what is not safe


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.


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


SUBJECTIVE UNITS OF DISTRESS (SUDS)

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


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


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.”


Coping Skills Instruction:Cognitive Restructuring: Self-Monitoring


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


Coping Skills Instruction:Cognitive Restructuring: Challenging Thoughts


EXPOSURE THERAPY: THE BASICS

Dr. Ali Mattu, The Psych Show

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:


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)


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!*


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

AVOIDANCE

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”


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).


*Developed with UCLA, LAUSD, & Rand

Lisa Jaycox, Ph.D.

1. Education & Relaxation (Group)

2. Exposure (Individual)


4. Introduction to Cognitive Therapy (Group)

• Emotion rating (Fear thermometer)

• Thoughts and Feelings

• Thought challenging (Hot Seat)


5. Introduction to Real-Life Exposure

• Avoidance and Coping; Fear Hierarchy

• Alternative Coping


7. Exposure (Group)

• Imagined, Drawn, Shared

8. Social Problem-Solving

9. Practice with Social Problem-Solving

10. Wrap-up

COMPONENTS OF CBITS


PLUS: TWO GUARDIAN SESSIONS!

• Enhance connection & relationships

• Generalization & supported exposures

• Many of your students have siblings

• Intergenerational transmission of trauma

PLUS: TWO TEACHER SESSIONS!

• Enhance connection & relationships

• Generalization & supported exposures

• Multiple classmates also affected

• Enhance trauma responsiveness

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.


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.


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


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.


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


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


EXPOSURE THERAPY: A QUICK LOOK

Audra Langly, Ph.D., CBITS trainer

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.


Visualization

tier iii supports for school-based providers3+supp… · continua consulting group, llc 1. gain...

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