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

Agenda10:30 TRAILS introduction & background11:00 What is CBT & Small group practice11:50 Q&A12:00 Conclude

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

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

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 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

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

Research to dateSchool professionals (N=66)• Frequency of intended use &

CBT competence improved significantly from pre- to post-training

0

2

4

6

8

10

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

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

14

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

0.00

2.00

4.00

6.00

8.00

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

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 anduncomfortable 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.”

SadLonelyBored

Worthless

Sleep until 2pm, watch YouTube videos all day.

Weekend with no plansSocial isolationInactivity

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.

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

PsychoeducationCognitive Coping

RelaxationDistress Tolerance

Behavioral ActivationExposure

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 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?

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 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.

• Overcome avoidance

and dependence on

safety behaviors

• Weaken link between

triggers and anxiety

• Test anxious beliefs

Exposure

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.

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

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!

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

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

Thank you!