TIER III SUPPORTS FOR SCHOOL-BASED PROVIDERS€¦ · social workers; individual and group, ages 7-adult Cognitive Behavioral Theory: •Component of SEL, Growth Mindset, “Grit”

June 24th & 25th 2019

Lauren Ashbaugh, Ph.D., NCSP

TIER III SUPPORTS FORSCHOOL-BASED PROVIDERS

AGENDA FOR TODAY

1. Introduction & Orientation 20 minutes

2. CBTs in Schools 30 minutes

3. Why CBT? What is it? 60 minutes

4. Wrap-up & Questions 10 minutes

Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC

1. Increase knowledge and understanding of CBT.

2. Increase comfort with changing thinking patterns (Cognitive Theory)

CBT INTRO OBJECTIVES


TENDING TO MY INTROVERTS

Optional means optional

Feel free to choose to focus on empathy, listening, & reflection.


SELF-CARE AND YOUR RIGHTS

• You have the right to take all the space you need. Please do. Some content may be distressing.

• You have the right to choose how you prefer to participate.

• You have the right to use humor and laughter.

• You have the right to speak and be heard.

• You are invited to talk to me about any and all of this.

THINK OF TWO KIDS YOU HAVE MADE A DIFFERENCE WITH THIS YEAR.

WHAT MADE THE DIFFERENCE?WHAT DID YOU DO?

SHARE ONE SUCCESS STORY WITH YOUR TABLE.

MENTAL HEALTH

Continua Consulting Group, LLC

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


USE A WHOLISTIC, COMPREHENSIVE APPROACH


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


WHY CBT IN SCHOOLS?

~60% of students who need MH services do not receive them1.

~70% of students who DO receive MH services receive them in schools2.

Rates of depression & anxiety have been rising3.

Rates of suicidality and self-injury are rising4.Continua Consulting Group, LLCLauren Ashbaugh, Ph.D., NCSP

+ Difference between this estimate and the 2017 estimate is statistically significant at the .05 level.

FFR1.43

N/A = not available.

Major Depressive Episode (MDE) and MDE with Severe Impairment in the Past Year Among Youths Aged 12 to 17: Percentages 2004-2017


Healthy Youth Survey


Pierce Co

Healthy Youth

Survey












Source: The State of Mental Health in America 2016 (SAMHSA & CDC data)

WASHINGTON: HIGH RATE MENTAL ILLNESS, LOW ACCESS TO CARE


• Younger generations of Black Americans are at significantly higher risk for suicide attempts than older generations.

• Minorities more likely to receive inadequate treatment/poor quality care or no treatment at all than White Americans.

• Asian-Americans are less likely to report suicidality or mental health concerns to anyone than White Americans. They are less likely to access care.

DISTRESS, ACCESS, AND EQUITY

Source: SAMHSALauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC

BUILDING RESILIENCE

The ability to withstand, adapt to, and recover from adversity

Staying mentally and physically healthy within the context of early adversity1

1. Zolkoski SM, Bullock LM. 2012


WHY CBT IN SCHOOLS?

Fixed Mindset ???? Growth

Mindset

I can’t do algebra. I don’t know how to factor yet – but I have learned hard things before…

CBT


COGNITIVE-BEHAVIORAL THERAPY (CBT)

• Anxiety

• Depression

• PTSD/Trauma exposure

• Substance Use Disorders

• Personality Disorders

• Sleep Disorders, Eating Disorders


GOLD STANDARD


WHO CAN “DO” CBT?

• Cognitive Behavioral Therapy: • Most often provided by counselors, therapists, psychologists,

social workers; individual and group, ages 7-adult

Cognitive Behavioral Theory: • Component of SEL, Growth Mindset, “Grit” literature, PBIS

Many people are self-taught. It benefits everyone


Trauma informed Tier 1 for Schools

13%

13%

13%

13% 13%

13%

13%

13%

Ac c

e s s to R

i g o r o u s , D iffe r e n t i a t e d , C o re Content

C o n t i n u a C o n s u l t i n g G r o u p , L L C

Social Emotional Learning

(SEL)Common

Language & Expectations

Regulation: Emotional &

Physiological

Restorative Practice

Community Engagement & Integration

ACEs Understanding

(trauma informed)

Culturally Responsive or Identity Safe

Pedagogy

Universal Screening & Data Driven

Practices

Leadership Relationship

Values Vision

Trauma-Informed Multi-Tiered Systems of Support Tier 1 Main Components


CBT IN PUBLIC SCHOOLS


UNIVERSAL

Intensive(Tier III)

Targeted(Tier II)



UNIVERSALSELPBISMindfulnessRestorative PracticesMental Health LiteracyB&G Club, YMCA, sports etc

UNIVERSAL

TIERED MENTAL HEALTH SUPPORT




TARGETED

CBT GroupsCICO, SSGRINTargeted groups (i.e., grief)Parent Training & Support

And many more

Targeted



INTENSIVE

Individual CBTCBITS (Group for trauma)Individual counselingCrisis ResponseWrap-aroundFBA & BIP

Intensive



COGNITIVE BEHAVIORAL THERAPY/THEORY IN TPS


Grant funded

• Year 1: Five-session CBT Groups (Tier II)• Year 1: Individual counselor CBT support (Tier III)

• Year 2: Support for School-Wide (Tier I) CBT practices


TIER III: EVIDENCE-BASED MENTAL HEALTH

TraumaBounce Back (K-5)Cognitive Behavioral Intervention for Trauma in Schools (CBITS)Support for Students Exposed to Trauma (SSET)

Anxiety & DepressionCognitive Behavioral Therapy (CBT)


TIER III: EVIDENCE-BASED MENTAL HEALTH


Social SkillsSS Grin, SkillStreaming, Restorative Practices

PREPaRECrisis intervention & preparation


CBT CBITS


CBT is the ‘BACKBONE” of trauma treatmentsContinua Consulting Group, LLC

WHY CBT? IT WORKS!!

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.

Connections to:

SELGrowth Mindset/Grit

PBIS


CBT: BASIC APPROACH

Change mood states through cognitive and behavioral strategies

Focus on ‘here and now’

Preference for concrete examples

Promote rapid symptom change


Good for students AND staff!!!Continua Consulting Group, LLC


AN EVIDENCE-BASED PRACTICE

How do you know it’s effective?

1. Assessment

2. Progress Monitoring3. Evaluation4. Relapse Prevention


WHAT IS CBT?

Find your worksheet and follow along!

Continua Consulting Group, LLCLauren Ashbaugh, Ph.D., NCSP

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, isolationContinua Consulting Group, LLCLauren Ashbaugh, Ph.D., NCSP

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


BECK’S COGNITIVE THERAPY

Temperament (biology) + learning (experiences) =

cognitive processes (thoughts)

Adverse life events àautomatic thoughts and core beliefs


BECK’S COGNITIVE THEORY


Anxious temperamentAnxious parents

Scored on in goalTeam losesCoach yells

I am bad at sports.I can’t do anything right.Mistakes are terrible.


NEGATIVE CORE BELIEFS

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.


BECK’S COGNITIVE THEORY

OurselvesI'm unlovable, a bad kid

Others (the world)Others will reject me

FutureI will be alone

We develop negative automatic thoughts about:


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 trustedOthers 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.

Lauren Ashbaugh, Ph.D., NCSPContinua Consulting Group, LLC

EXPOSURE TO DV & PHYSICAL ABUSE: FEELINGS

Primary:FearPainFatigueWorryAngerSadnessHurtConfusion

Secondary:

ShameGuiltEmbarrassment

WorthlessnessMistrustLonelinessIsolationMisunderstoodUnseen


Peer relational difficulties related to mistrust & misinterpretation

Avoidance of situations or activities that elicit shame

Sensory reactivity to noise, touch, sound, chaos

Slow to warm up; doesn’t trust adults easily

Difficulty with focus/concentration and activity level

EXPOSURE TO DV & PHYSICAL ABUSE: BEHAVIORS


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, defensivenessUnderlying emotions: Hurt, sadness, rejection, anger at perpetrator


Between stimulus and response, there is a space.

In that space lies our freedom and our power to choose our response.

In our response lies our growth and our happiness.

-Steven R. Covey, summarizing Viktor Frankl’s work

CBT:

Reliance on “Socratic” questioning

“Detective” approach to test beliefs

Teach how to get to balanced thinking themselves.

CBT: COGNITIVE APPROACH

Nobody likes me.“Don’t say that! That’s not true! Cassie likes you.”

USUALLY…


WORRIES ARE BASED ON A

KERNEL OF TRUTH.

DO NOT DENY THE TRUTH.

ADJUST THE DIAL ON THE INTENSITY.

• Something could happen to a parent. How likely is that?

• Other kids could make mock them. If they did, how bad would it be?

• They might not do well on this quiz. What does it mean if they fail?

• They could be stung by a bee. Do they need an epi-pen? Do they have it?

• Sometimes the dark is dangerous. How often?


SOCRATIC QUESTIONING

Check the facts—• How do I know this is true?• Has this happened before?• Has this happened with other people or in other situations?

Other ways to think about it—• Is there another way to look at this?• Is there another reason why this would happen?


CORE COMPONENTS OF CBT

1. Education & Self-monitoring2. Calm the body3. Change the thinking

• Evaluate evidence• Generate alternatives

4. Change behavior • Exposure (anxiety)• Behavioral Activation (depression)


EDUCATION: WHAT IS ANXIETY?

Fear is a natural and important emotion!

Anxiety is your body getting ready to do something important.

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?

1. Tells you something terrible is likely going to happen,even when it is actually highly unlikely if not impossible

2. Makes things out to be worse than they really are.

3. If something bad happens, you will not be able to handle it.


Worry likes to tell you these three things:


CBT for Anxiety: Working with Youth

1. Teach IDENTIFICATION and RATING of anxietya) Feelings thermometer

2. EXTERNALIZE anxietya) What does Anxiety tell you?


SUBJECTIVE UNITS OF DISTRESS (SUDS)


CALMING THE BODY

Strategies:

1. Diaphragmatic breathing2. Muscle relaxation3. Visualization4. Meditation & Mindfulness5. Distraction

YOU CAN TEACH

THIS IN CLASS!!


Changing Thinking:Cognitive Restructuring: Automatic Thoughts

• Catastrophizing• Black and white thinking• Overestimating, Fortune telling• Mind reading• Mental filter• Jumping to conclusions• Emotional reasoning• “Should” statements• Personalization and blame• Magnification and minimization


Changing Thinking:Cognitive Restructuring: Self-Monitoring


Situation/trigger Teacher called on me in class

Intensity of anxiety (0-10) 7

Physical sensations/ symptoms Sweating, lightheaded, choked up, heart racing

Anxious thoughts “I am going to freeze up,” “I sound like an idiot”

Anxious behaviors Said “I don’t know”; avoided eye contact; mental retracing after


CHANGING THINKING:COGNITIVE RESTRUCTURING

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.”


Goals:


Coping Skills Instruction:Cognitive Restructuring: Challenging Thoughts


Changing Thinking:Cognitive Restructuring: Challenging Thoughts


THOUGHT RECORD EXERCISE

I can’t do math.

I’m failing and my teacher will think I don’t care.

I have to present in science and I’ll cry and they’ll laugh at me.

I can’t wear shorts for gym class because my legs are hideous.

My class is out of control. My administrator thinks I’m useless.


USE SOCRATIC QUESTIONING

• All the time? Has there ever been a time…?

• How do you know? Are you mind-reading? What else might your teacher think?

• How do you feel when your classmates present? What would you do if they cried?

• Do other kids wear shorts? What happens the first time they do wear shorts? Do they like wearing shorts?


USE SOCRATIC QUESTIONING

Watch for new negative thoughts provided as evidence!!Add them to the list!

“No, my math teacher hates me.” “I ALWAYS cry when I present.”

“No one looks as terrible as I do in shorts.”

Could you submit that to the court as “evidence”?


CHANGING BEHAVIORS

• Anxiety: oDecrease avoidant behaviorsoDecrease safety behaviorsoIncrease exposures

• Depression:• Increase positive experiences• Increase connection to others• Increase self-care

REDUCE

AVOIDANCELauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC

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: THE BASICS

Dr. Ali Mattu, The Psych Show

Exposure Therapy: Goals and Strategies

Goals:1. Create fear ladder2. Complete steps on hierarchy3. Practice anxiety management strategies4. Evaluate outcome objectively


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.

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

Lauren Ashbaugh, Ph.D., NCSPDON’T FORGET THE REWARDS!!!! Continua Consulting Group, LLC

10 Perform in front of the school

8 Present in front of whole class

7 Being called on without warning

6 Present in small group

5 Make a small mistake in small group

4 Raise my hand (know answer)

4 Imagine raising my hand

Behavioral Activation:Using Action to Change your Thoughts & Feelings

• Sadness and loneliness è call friend, accept invitation• Want to curl up and sleep è go for a walk• Feel guilty about missing work è start it with a friend • Struggling to eat well è start eating breakfast


1. Adding positive activities2. Sleep, eating, & exercise3. Problem-solving:

What do you control? What can you change? What do you need to accept?


BEHAVIORAL ACTIVATION


1. Self-monitor2. Calm the body3. Balanced thinking4. Choose behaviors5. Repeat


Generalizing GainsSTIMULUS


QUESTIONS??

Lauren Ashbaugh, Ph.D., NCSPLicensed Clinical & School Psychologist

Ph: 253-260-3141; Fax: 253-753-2080www.continuaconsulting.com

www.pacificnwpsychology.comPronouns: She/Her

http://www.continuaconsulting.com/

http://www.pacificnwpsychology.com/

Documents

TIER III SUPPORTS FOR SCHOOL-BASED PROVIDERS€¦ · social workers; individual and group, ages 7-adult Cognitive Behavioral Theory: •Component of SEL, Growth Mindset, “Grit”