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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
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
TENDING TO MY INTROVERTS
Optional means optional
Feel free to choose to focus on empathy, listening, & reflection.
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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
Lauren Ashbaugh, Ph.D., NCSP
USE A WHOLISTIC, COMPREHENSIVE APPROACH
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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
Lauren Ashbaugh, Ph.D., NCSP
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
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
Healthy Youth Survey
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
Pierce Co
Healthy Youth
Survey
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
Healthy Youth Survey
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
Healthy Youth Survey
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
Healthy Youth Survey
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
Healthy Youth Survey
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
Healthy Youth Survey
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
Source: The State of Mental Health in America 2016 (SAMHSA & CDC data)
WASHINGTON: HIGH RATE MENTAL ILLNESS, LOW ACCESS TO CARE
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
• 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
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
COGNITIVE-BEHAVIORAL THERAPY (CBT)
• Anxiety
• Depression
• PTSD/Trauma exposure
• Substance Use Disorders
• Personality Disorders
• Sleep Disorders, Eating Disorders
Lauren Ashbaugh, Ph.D., NCSP
GOLD STANDARD
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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
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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
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CBT IN PUBLIC SCHOOLS
Lauren Ashbaugh, Ph.D., NCSP
UNIVERSAL
Intensive(Tier III)
Targeted(Tier II)
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Lauren Ashbaugh, Ph.D., NCSP
UNIVERSALSELPBISMindfulnessRestorative PracticesMental Health LiteracyB&G Club, YMCA, sports etc
UNIVERSAL
TIERED MENTAL HEALTH SUPPORT
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TIERED MENTAL HEALTH SUPPORT
Lauren Ashbaugh, Ph.D., NCSP
TARGETED
CBT GroupsCICO, SSGRINTargeted groups (i.e., grief)Parent Training & Support
And many more
Targeted
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Lauren Ashbaugh, Ph.D., NCSP
INTENSIVE
Individual CBTCBITS (Group for trauma)Individual counselingCrisis ResponseWrap-aroundFBA & BIP
Intensive
TIERED MENTAL HEALTH SUPPORT
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COGNITIVE BEHAVIORAL THERAPY/THEORY IN TPS
Lauren Ashbaugh, Ph.D., NCSP
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
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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)
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
TIER III: EVIDENCE-BASED MENTAL HEALTH
Lauren Ashbaugh, Ph.D., NCSP
Social SkillsSS Grin, SkillStreaming, Restorative Practices
PREPaRECrisis intervention & preparation
Continua Consulting Group, LLC
CBT CBITS
Lauren Ashbaugh, Ph.D., NCSP
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
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
CBT: BASIC APPROACH
Change mood states through cognitive and behavioral strategies
Focus on ‘here and now’
Preference for concrete examples
Promote rapid symptom change
Lauren Ashbaugh, Ph.D., NCSP
Good for students AND staff!!!Continua Consulting Group, LLC
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
AN EVIDENCE-BASED PRACTICE
How do you know it’s effective?
1. Assessment
2. Progress Monitoring3. Evaluation4. Relapse Prevention
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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.
Continua Consulting Group, LLCLauren Ashbaugh, Ph.D., NCSP
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
Continua Consulting Group, LLCLauren Ashbaugh, Ph.D., NCSP
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
Continua Consulting Group, LLCLauren Ashbaugh, Ph.D., NCSP
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
Continua Consulting Group, LLCLauren Ashbaugh, Ph.D., NCSP
BECK’S COGNITIVE THERAPY
Temperament (biology) + learning (experiences) =
cognitive processes (thoughts)
Adverse life events àautomatic thoughts and core beliefs
Lauren Ashbaugh, Ph.D., NCSP
BECK’S COGNITIVE THEORY
Lauren Ashbaugh, Ph.D., NCSP
Anxious temperamentAnxious parents
Scored on in goalTeam losesCoach yells
I am bad at sports.I can’t do anything right.Mistakes are terrible.
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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.
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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:
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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
Lauren Ashbaugh, Ph.D., NCSPContinua Consulting Group, LLC
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
Continua Consulting Group, LLCLauren Ashbaugh, Ph.D., NCSP
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
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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…
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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?
Lauren Ashbaugh, Ph.D., NCSP
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?
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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)
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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.
Lauren Ashbaugh, Ph.D., NCSP
Worry likes to tell you these three things:
Continua Consulting Group, LLC
CBT for Anxiety: Working with Youth
1. Teach IDENTIFICATION and RATING of anxietya) Feelings thermometer
2. EXTERNALIZE anxietya) What does Anxiety tell you?
Lauren Ashbaugh, Ph.D., NCSPContinua Consulting Group, LLC
SUBJECTIVE UNITS OF DISTRESS (SUDS)
Lauren Ashbaugh, Ph.D., NCSP
CALMING THE BODY
Strategies:
1. Diaphragmatic breathing2. Muscle relaxation3. Visualization4. Meditation & Mindfulness5. Distraction
YOU CAN TEACH
THIS IN CLASS!!
Lauren Ashbaugh, Ph.D., NCSPContinua Consulting Group, LLC
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
Lauren Ashbaugh, Ph.D., NCSPContinua Consulting Group, LLC
Changing Thinking:Cognitive Restructuring: Self-Monitoring
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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
Lauren Ashbaugh, Ph.D., NCSP
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.”
Lauren Ashbaugh, Ph.D., NCSP
Goals:
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Coping Skills Instruction:Cognitive Restructuring: Challenging Thoughts
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
Changing Thinking:Cognitive Restructuring: Challenging Thoughts
Continua Consulting Group, LLCLauren Ashbaugh, Ph.D., NCSP
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.
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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?
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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”?
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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:
Lauren Ashbaugh, Ph.D., NCSPContinua Consulting Group, LLC
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
Lauren Ashbaugh, Ph.D., NCSP Continua Consulting Group, LLC
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!*
Lauren Ashbaugh, Ph.D., NCSPContinua Consulting Group, LLC
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
Lauren Ashbaugh, Ph.D., NCSPContinua Consulting Group, LLC
1. Adding positive activities2. Sleep, eating, & exercise3. Problem-solving:
What do you control? What can you change? What do you need to accept?
Lauren Ashbaugh, Ph.D., NCSP
BEHAVIORAL ACTIVATION
Continua Consulting Group, LLC
1. Self-monitor2. Calm the body3. Balanced thinking4. Choose behaviors5. Repeat
Lauren Ashbaugh, Ph.D., NCSP
Generalizing GainsSTIMULUS
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QUESTIONS??
Lauren Ashbaugh, Ph.D., NCSPLicensed Clinical & School Psychologist
Ph: 253-260-3141; Fax: 253-753-2080www.continuaconsulting.com
www.pacificnwpsychology.comPronouns: She/Her