TRAILS: A Collaborative Approach to Meeting the Mental Health Needs - PowerPoint PPT Presentation

TRAILS: A Collaborative Approach to Meeting the Mental Health Needs of Students System of Care Conference, Kalamazoo, MI February 15, 2018 Kristen Miner, LMSW Jennifer Vichich, MPH Chassi Jensen, LLMSW

Agenda 10:30 TRAILS introduction & background 11:00 What is CBT & Small group practice 11:50 Q&A 12:00 Conclude

Prevalen ence o e of M Mental Illnes ess in A Adol olescen ents Any mental illness: 49.5% • Anxiety Disorders: 31.9% • Depressive Disorders: 14.3% • Substance Use Disorders: 11.4% Comorbid disorders: 20% • Severe Impairment: 22.2% Merikangas et al., 2010. Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry

Leading causes of death, ages 15-24 Cerebrovascular 0.6% All Others 14.7% Diabetes Mellitus 0.6% Influenza & Pneumonia 0.7% Chronic Low Resp. Disease 0.9% Congenital Anomalies 1.6% Heart Disease 3.3% Unintentional Injury 39.6% Malignant Neoplasms 5.7% Homicide 14.6% Suicide 17.6% National Center for Health Statistics (NCHS), National Vital Statistics System, 2015

Barriers to care are common • Limited information among families • Inadequate insurance coverage • Lack of transportation • Insufficient time for appointments • Low comfort in clinical settings • Social stigma • Few trained clinicians • Scarce appointments • Long waitlists • Low availability of EBPs

Treatment access • 80% of students with a mental illness receive no care

Schools as sources of mental health services “Today, more than ever, school health programs could become one of the most efficient means available to improve the health of our children and their educational achievement.” - School health services and programs, 2006 Kolbe, Kann, & Brener

Traditional model of school staff training Care Graduate Professional Independent As School Development Delivery Usual

Challenges of mental health care in schools • Limited identification of students with Depression & Anxiety: Casia-Warner et al., 2012 • Poor perceptions of Evidence-Based Practices among school staff: Beidas et al., 2012; Forman et al., 2012 • Limited use of Evidence-Based Practices: Evans, Koch, Brady, Meszaros, & Sadler, in press; Kelly et al., 2010 • Child health and academic outcomes rarely improved: Farahmand, Grant, Polo, Duffy, & DuBois, 2011; Pas, Bradshaw, & Cash, 2014

Revised models of school staff training Graduate Professional Implementation School Development Strategies Aarons et al., 2017; Durlak & DuPre, 2008; Fixsen, et al., 2005, Joyce & Showers 2002; Powell et al., 2015; Proctor et al., 2013

Implementation strategies at work Theory based strategies to increase the impact of training • Community based care: Hoagwood et al. 2001; Glasgow et al. 2005; Herschell et al. 2010; Kolko et al. 2012; Funderburk et al. 2015; Kirchner et al. 2012 • School settings (PBIS & academic interventions) Hershfeldt et al. 2012; Joyce and Showers 2002 • School settings (clinical care) Powell et al. 2015; Eiraldi et al. 2015; Edmunds et al. 2013; Owns et al., 2013 Powell et al., 2015; Proctor et al., 2013

Didactic instruction for school staff Effective mental health care, Online resources accessible in all schools. In-person coaching from an expert

Didactic Training TRAILS Training Agenda 9:00 Registration, surveys 9:15 Intro to TRAILS 9:30 What is CBT? 10:15 BREAK 10:30 Cognitive Coping 11:15 Relaxation & Mindfulness 12:00 LUNCH 12:30 Exposure 1:15 BREAK 1:30 Behavioral Activation 2:15 Consultation & Next steps

Coaching • TRAILS Coaches paired with SMHPs • Collaboratively plan 10-12 session student CBT skills group • Weekly pre-session planning • Co-facilitation of group • Post-session feedback Coaching elements informed by study of supervision and consultation (Bearman et al., 2017; Dorsey et al. 2013)

TRAILS dual aims • Research • Feasibility • Impact on school MH professionals • Impact on students • Sustainability • Program Development and Evaluation • Statewide model (1-2/county) • County model (saturation)

The TRAILS Website trailstowellness.org

Pre-Training Post-Training Research to date 12 * * 10 School professionals (N=66) Average Self-reported Scale Score • Frequency of intended use & 8 CBT competence improved significantly from pre- to post- 6 training 4 2 0 Perceptions Frequency of Use Competence *p<0.05 compared to pre-training

Pre-Training Post-Training Post-Coaching Research to date 14 * * 12 * School professionals (N=66) Average Self-reported Scale Score * 10 * • Frequency of intended use & CBT competence improved 8 significantly both post-training and post-coaching from pre- 6 training 4 • Perceptions of CBT improved significantly post-coaching 2 0 Perceptions Frequency of Use Competence *p<0.05 compared to pre-training

Baseline Post-group Research to date 12.00 Students (N=404) 10.00 • Student depressive and anxiety * 8.00 * symptoms also showed Average Score significant reductions after 6.00 participating in CBT groups 4.00 2.00 0.00 PHQ-9 GAD-7 *p<0.05 compared to baseline

2016-2018: • Development of statewide coaching network • Partnerships with MDHHS and MDE • Medicaid and Foundation funding 2018-2023: • NIMH grant • 5-year clinical trial • 200 school partners • 2000 students • All 83 Michigan counties 2023+ • Development of a national model

Cognitive Behavioral Theory • We respond to all situations with thoughts, feelings, and behaviors • Depression & anxiety contribute to inaccurate and unhelpful thoughts and uncomfortable feelings • Each component of CBT targets a specific part of the cycle, but they all work together

Depression “I’m such a loser.” “I’ll never have any Example: friends.” Sad Lonely Weekend with Social isolation no plans Bored Inactivity Worthless Sleep until 2pm, watch YouTube videos all day.

“I can’t go – everyone Anxiety Example: thinks I’m a freak.” “Everyone is going to laugh at me.” Panic School day Lack of Worry starting on successful Monday experience. Stomachache morning. Reinforcement Fear of anxiety. Cry Refuse to leave home.

Why Common Elements? • More efficient clinician learning • Better clinician satisfaction • Better client engagement • Faster recovery trajectories • Fewer diagnoses at post-treatment Chorpita et al., 2015; Park et al., 2015; Weisz et al., 2012 Scale up or out? • Population – same vs. different • Delivery system – same vs. different Aarons et al., 2017

Psychoeducation Interrupting Cognitive Coping the Cycle Relaxation Distress Tolerance Behavioral Activation Exposure

Psychoeducation • You are not alone • You are not crazy, weak, unlovable, or broken • Some sadness and worry is normal and okay • Symptoms are concerning if they interfere life • Common symptoms • Avoidance feels good but doesn’t help • Mental illnesses come from biology and experience • There are effective ways to help you get better

Fight or Flight: How does anxiety help us? Rapid heartbeat  Readies body for peak exertion  Keeps body cool and slippery Sweating  Oxygenates blood and muscles Hyperventilation  Readies body for self-defense Aggression increases  Blood diverted to large muscles Upset stomach/GI problems

The Black Dog 31

Cognitive Coping Depression & Anxiety can cause irrational or unhelpful thoughts. Cognitive Coping helps promote more flexible thinking. • Step 1: Become aware of thinking traps • Step 2: Notice and verbalize automatic thoughts • Step 3: Question the accuracy or helpfulness of thoughts • Step 4: Identify and focus on a coping thought • Step 5: Evaluate – did the situation get better?

Cognitive Coping in Action 33

5 Steps to Untwisting Your Thinking

Small Group Activity 1) Using your example situation, take a moment to write down 2-3 associated automatic thoughts. 2) Pick one thought to focus on and write it at the top of the page. 3) Use the 5 Steps worksheet to evaluate your thought. 4) When you are finished, write a “reframe” or replacement thought. 5) If comfortable, share this with the small group around you.

Exposure Overcome avoidance • and dependence on safety behaviors Weaken link between • triggers and anxiety Test anxious beliefs • The Mechanics of Avoidance

Exposure Avoidance of anxiety triggers feels good. Avoidance reinforces the anxiety. Avoidance is a problem when it gets in the way of things we want or need to do. Exposure: Facing fears to overcome avoidance • Step 1: Identify what is avoided & why it matters • Step 2: Build a hierarchy from easiest to hardest • Step 3: Plan a reward • Step 4: Get help to act on your plan!

The role of exposure

Behavioral Activation Depression makes us do less. Doing less makes us feel worse.