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

• lescen

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

Unintentional Injury 39.6%

Suicide 17.6%

Homicide 14.6%

Malignant Neoplasms 5.7% Heart Disease 3.3% Congenital Anomalies 1.6% Chronic Low Resp. Disease 0.9% Influenza & Pneumonia 0.7% Diabetes Mellitus 0.6% Cerebrovascular 0.6% All Others 14.7%

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

Graduate School Professional Development Independent Delivery

Care As 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

Graduate School Professional Development Implementation Strategies

Revised models of school staff training

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 Online resources In-person coaching from an expert

Effective mental health care, accessible in all schools.

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

Didactic Training

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

• f 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

Research to date

School professionals (N=66)

• Frequency of intended use &

CBT competence improved significantly from pre- to post- training

2 4 6 8 10 12

Perceptions Frequency of Use Competence

Average Self-reported Scale Score

Pre-Training Post-Training

* * *p<0.05 compared to pre-training

Research to date

School professionals (N=66)

• Frequency of intended use &

CBT competence improved significantly both post-training and post-coaching from pre- training

• Perceptions of CBT improved

significantly post-coaching

2 4 6 8 10 12 14

Perceptions Frequency of Use Competence

Average Self-reported Scale Score

Pre-Training Post-Training Post-Coaching

* * * * * *p<0.05 compared to pre-training

0.00 2.00 4.00 6.00 8.00 10.00 12.00

PHQ-9 GAD-7

Average Score

Baseline Post-group

Research to date

Students (N=404)

• Student depressive and anxiety

symptoms also showed significant reductions after participating in CBT groups

* * *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

• 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

Cognitive Behavioral Theory

Depression Example:

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

Anxiety Example:

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

• f anxiety.

Why Common Elements?

• More efficient clinician learning
• Better clinician satisfaction
• Better client engagement
• Faster recovery trajectories
• Fewer diagnoses at post-treatment

Scale up or out?

• Population – same vs. different
• Delivery system – same vs. different

Chorpita et al., 2015; Park et al., 2015; Weisz et al., 2012 Aarons et al., 2017

Psychoeducation Cognitive Coping Relaxation Distress Tolerance Behavioral Activation Exposure

Interrupting the Cycle

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

Rapid heartbeat Sweating Hyperventilation Aggression increases Upset stomach/GI problems  Readies body for peak exertion  Keeps body cool and slippery  Oxygenates blood and muscles  Readies body for self-defense  Blood diverted to large muscles

Fight or Flight: How does anxiety help us?

The Black Dog

31

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

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.

• Overcome avoidance

and dependence on safety behaviors

• Weaken link between

triggers and anxiety

• Test anxious beliefs

Exposure

The Mechanics

• f Avoidance

Exposure

Avoidance of anxiety triggers feels good. Avoidance reinforces the anxiety. Avoidance is a problem when it gets in the way

• f 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.

Depression Example:

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

Behavioral Activation

Step 1: Notice activity levels Step 2: Set a goal & a reward to increase activity Step 3: Identify activities that have the potential to be fun Step 4: Anticipate and problem solve potential barriers Step 5: Use a schedule to set reasonable goals, track progress, and monitor mood Step 6: Aim for the goal, use rewards. Reinforce attempts – not just success!

TRAILS CBT Components

• Psychoeducation
• Relaxation, Mindfulness, and Distress Tolerance
• Cognitive Coping
• Exposure
• Behavioral Activation

Opportunities for involvement!

• Agencies / Providers
• Coach training to sustain statewide implementation / clinical trial
• Training March 1st in Lansing
• Schools
• Enrollment as training recipients for outcomes evaluation
• Public Health / State Policymakers
• Design of program model
• Identification of sustainable funding streams (local & state level)
• Integration with MDE/MDHHS/Other priorities/initiatives
• Foundations / Investors
• Support program development, evaluation, design of sustainable

model

Questions?

TRAILS Program Partners

Acknowledgments

The he P Prosper Road d Founda datio ion The he M Mackey F Family ily The he Oui uida da F Family ly Mic ichigan M Medicaid MDHH DHHS & & MDE DE The he M Michi higan H Health Endo ndowment Fund Fund The he Americ ican P n Psycholo logical l Found ndatio ion The he U Uni niversity of M Michi higan Depa partment o

• f P

Psychiatry & & Comprehen ensive D e Depres ession Center

Thank you!