trails · 2018. 2. 15. · • trails coaches paired with smhps • collaboratively plan 10-12...
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TRAILS:A Collaborative Approach to Meeting the Mental Health Needs of Students
System of Care Conference, Kalamazoo, MIFebruary 15, 2018
Kristen Miner, LMSWJennifer Vichich, MPHChassi Jensen, LLMSW
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Agenda10:30 TRAILS introduction & background11:00 What is CBT & Small group practice11:50 Q&A12:00 Conclude
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Prevalence of Mental Illness in Adolescents
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
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Leading causes of death, ages 15-24
Unintentional Injury39.6%
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
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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
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Treatment access• 80% of students with a mental illness receive no care
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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
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Traditional model of school staff training
Graduate School
Professional Development
Independent Delivery
Care As
Usual
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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
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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
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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
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Didactic instruction for school staff
Online resources
In-person coaching from an expert
Effective mental health care, accessible in all schools.
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TRAILS Training Agenda9:00 Registration, surveys9:15 Intro to TRAILS9:30 What is CBT?10:15 BREAK10:30 Cognitive Coping11:15 Relaxation & Mindfulness12:00 LUNCH12:30 Exposure1:15 BREAK1:30 Behavioral Activation2:15 Consultation & Next steps
Didactic Training
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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)
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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)
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The TRAILS Website trailstowellness.org
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Research to dateSchool professionals (N=66)• Frequency of intended use &
CBT competence improved significantly from pre- to post-training
0
2
4
6
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12
Perceptions Frequency of Use CompetenceAv
erag
e Se
lf-re
port
ed S
cale
Sco
re
Pre-Training Post-Training
*
*
*p<0.05 compared to pre-training
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Research to dateSchool 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
0
2
4
6
8
10
12
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Perceptions Frequency of Use CompetenceAv
erag
e Se
lf-re
port
ed S
cale
Sco
re
Pre-Training Post-Training Post-Coaching
* *
*
*
*
*p<0.05 compared to pre-training
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0.00
2.00
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10.00
12.00
PHQ-9 GAD-7Av
erag
e Sc
ore
Baseline Post-groupResearch to dateStudents (N=404)• Student depressive and anxiety
symptoms also showed significant reductions after participating in CBT groups
**
*p<0.05 compared to baseline
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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
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• We respond to all situations with thoughts, feelings, and behaviors
• Depression & anxiety contribute to inaccurate and unhelpful thoughts anduncomfortable feelings
• Each component of CBT targets a specific part of the cycle, but they all work together
Cognitive Behavioral Theory
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Depression Example:
“I’m such a loser.”“I’ll never have any
friends.”
SadLonelyBored
Worthless
Sleep until 2pm, watch YouTube videos all day.
Weekend with no plansSocial isolationInactivity
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Anxiety Example: “I can’t go – everyone thinks I’m a freak.”
“Everyone is going to laugh at me.”
PanicWorry
StomachacheFear
CryRefuse to leave
home.
School day starting on
Monday morning.
Lack of successful
experience.Reinforcement
of anxiety.
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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
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PsychoeducationCognitive Coping
RelaxationDistress Tolerance
Behavioral ActivationExposure
Interrupting the Cycle
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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
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Rapid heartbeatSweating
HyperventilationAggression 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?
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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
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5 Steps to Untwisting Your Thinking
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Small Group Activity1) 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.
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• Overcome avoidance
and dependence on
safety behaviors
• Weaken link between
triggers and anxiety
• Test anxious beliefs
Exposure
The Mechanics of Avoidance
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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!
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The role of exposure
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Behavioral Activation
Depression makes us do less. Doing less makes us feel worse.
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Depression Example:
“I’m such a loser.”“I’ll never have any
friends.”
SadLonelyBored
Worthless
Sleep until 2pm, watch YouTube videos all day.
Weekend with no plansSocial isolation
Inactivity
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Behavioral Activation
Step 1: Notice activity levelsStep 2: Set a goal & a reward to increase activityStep 3: Identify activities that have the potential to be funStep 4: Anticipate and problem solve potential barriersStep 5: Use a schedule to set reasonable goals, track progress, and monitor moodStep 6: Aim for the goal, use rewards. Reinforce attempts – not just success!
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TRAILS CBT Components
• Psychoeducation• Relaxation, Mindfulness, and Distress Tolerance• Cognitive Coping• Exposure• Behavioral Activation
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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
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Questions?
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TRAILS Program Partners
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AcknowledgmentsThe Prosper Road Foundation
The Mackey Family
The Ouida Family
Michigan Medicaid
MDHHS & MDE
The Michigan Health Endowment Fund
The American Psychological Foundation
The University of Michigan Department of Psychiatry & Comprehensive Depression Center
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Thank you!
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