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Cognitive Behavioral Intervention for Trauma in Schools CBITS Maria Olvera, MSW October 2016

CBITS Manual  Created for use with groups of school children (ages 11-15) who have experienced traumatic events or behavioral problems, and/or are suffering from Post Traumatic Stress Disorder or depression 3

Who can use this manual?  Psychologist  Social Workers  Psychiatrists  School Counselors who have mental health intervention experience  It is recommended that CBITS facilitators have SPECIALIZED training in cognitive behavioral therapy and with trauma survivors due to sensitive issues 4 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

CBITS Model  A skill-building, early intervention approach  For students with MODERATE levels of symptoms  The CBITS model is specifically focused on the reduction of symptoms of PTSD 5 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

CBITS Sessions  Student group work program (10 sessions)  Individual student sessions (1-3 sessions, per student)  Parent education program (2 sessions)  The teacher education program (1 session) 6 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

CBITS Implementation  Select school and population of students to be included  Have permission slip ready for the pre-screening and group participation  Identify teachers that will be impacted and provide CBITS information  Meet with selected students to conform that the program is appropriate for them (This includes a parent meeting and an assessment)  Assess the students to be included and begin the child program 7 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Selection of Participants  CBITS is intended for students ages who have experienced a significant trauma and have significant symptoms of PTSD  It is recommended that a screening instrument be used in order to identify participating students 8 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Consent for Screening 9

Memorandum to teachers Memorandum To: Mr. Martin From: Mr. Jerold Date: November 1, 2016 Re: CBITS begins Wednesday, November 12, 2016 Alison M. is fortunate to have a special counseling program for students who have experienced stressful events in the community. We have found that students who have experienced stressful situations often suffer from a unique kind of stress, called traumatic stress, which can impact academic, social and emotional functioning, thereby negatively affecting school performance. Your student, Alison has been selected to participate. We will be conducting groups one time per week for one school period over the course of the next ten weeks. Students will be summoned for each session for the next 10-Wednesdays at 1:00 p.m. for approximately 45 minutes. If at all possible, please excuse her for these sessions as they are cumulative. Thanks you, James Jerold, School Psychologist Office No. XX Telephone number XXX 10

Screening Points  First you will need to screen for exposure to a significant traumatic event (community violence, domestic violence, the death of a loved one, witnessing or being involved in a car accident)  Second you will need two measures of symptoms (PTSD and depression) that provide validated cut-offs for scores that indicate a significant or clinical level of severity 11 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Consent for CBITS Group Participation 12

Cognitive-Behavioral Therapy  CBT- an organized, symptom focused intervention that includes providing skill-building techniques to make maladaptive thoughts and behaviors more functional  CBT is based on the idea that thoughts and behaviors can cause negative emotions, negative interactions, and behavior patterns 13 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Cognitive-behavioral Therapy 14 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Cognitive Behavioral Therapy Goals  Change maladaptive thoughts (challenge negative thinking, stopping automatic negative thoughts, and changing negative patterns of thinking)  Improving social skills  Increasing positive activities  Decreasing avoidant behaviors and thoughts 15 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Cognitive Behavioral Therapy Structure  Structured sessions: agenda is set for each session (activities review, new skills, or practice with skills, and activity assignment)  Collaboration between patient and therapist: therapist acts as a “coach” to help patient develop new skills and guide with practicing  Emphasis on practice of new skills during sessions and between sessions  Short-term interventions: to enable patient to remember skills and to continue to practice oh his/her own after intervention ends 16 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Post-Traumatic Stress Disorder  PTSD: an anxiety disorder that can develop after exposure to an extreme stressor  re-experiencing the event through nightmares, and re-living through thoughts  Avoidance of trauma reminders by avoiding thoughts, situations, places and have emotional numbing  More irritable and have difficulty sleeping and/or focusing 17 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

What does CBITS address?  CBITS is designed to address moderate symptoms of Post Traumatic Stress Disorder (PTSD)  Students with a diagnosis of severe PTSD can also benefit from CBITS but it is recommended that they also receive individual treatment 18 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

What will students learn from CBITS  Education  Relaxation Training  Cognitive Therapy  Real Life Exposure  Stress or Trauma Exposure  Social Problem-Solving 19 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Education  Education: students are educated on the common reactions to stress or trauma. With the goal of destigmatizing and normalizing symptoms related to a stressful or traumatic event 20 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Relaxation Training  Through controlled breathing and progressive muscle relaxation the student learns to combat anxiety  These simple relaxation techniques are taught and practiced periodically during treatment 21 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Cognitive Therapy  Students are taught to recognize maladaptive thoughts  Students are taught how to combat the maladaptive thoughts by replacing them with more realistic appraisals of danger and competence 22 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Real Life Exposure  Students are guided on the process of habituation by which anxiety decreases when a feared situations are discussed in order to reduce anxiety  Students are helped to construct a list of situations that they fear as a situation of their traumatic experiences and are encouraged to confront such situations in a controlled manner with help 23 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Stress of Trauma Exposure  The students are guided to use imaginal exposure to decrease the intense anxiety and discomfort that relate to the traumatic event  The first exposure is to occur in during the individual therapy session in order to provide a safe environment for the student to share  Following exposures take place during the group through a descriptive of the drawing 24 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Social Problem Solving  Students are taught problem-solving techniques to control feelings of anger and impulsive behaviors  Students learn to self-regulate and to understand reality vs distorted thoughts of reality  Role playing is used to reinforce these problem solving skills 25 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Program Format  Activities and assignments: activities that allow the students to consolidate skills and learn to apply them in real life  Practice of Intervention Techniques: Students are encouraged to practice techniques during their daily life as needed  Individual Treatment Planning: Each student has a case with individual goals  Group Format and management: Group is held during school hours, once per week for one hour (preferably the same week day and time)  Materials: notebooks, pencils, drawing paper, crayons 26 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Special Issues  Working with stress or trauma survivors require sensitivity and patience  Children who have been exposed to violence may be…  Overly cautious and have lack of trust  Triggered easily and seem like they are provoking adults  Hypervigilant and scare easily  Have experienced more than one traumatizing event, it is recommended to focus on the event causing more symptoms 27 Jacox, L (2004) Cognitive Behavioral Intervention for Trauma in Schools. Sopris West Ed Services

Time to start group  Once the time and space has been allocated. It is recommended that communication is clear at all times  This can be facilitated by creating a schedule that you can share with the student, teacher, and parents 28

CBITS Group Meeting Schedule 29 DATESESSIONSUBJECT Wednesday, November 12 Session 1Introduction, Confidentiality, Group Procedures Wednesday, November 19 Session 2Education about Common Reactions to Stress Monday, December 2 Individual Sessions Wednesday, December 3 Session 3Thoughts and Feelings Wednesday, December 10 Session 4Combating negative thoughts Wednesday, December 17 Session 5Avoidance and Coping Wednesday, January 14 Session 6 Brief review of session 5 Exposure to stress or trauma memory through imagination/drawing/writing Wednesday, January 21 Session 7 Exposure to stress or trauma memory through imagination/drawing/writing Monday, January 26 Individual Sessions Wednesday, January 28 Session 8Introduction to social problem-solving Wednesday, February 4 Session 9Practice with social problem-solving and Hot Seat Wednesday, February 11 Session 10Relapse prevention and graduation ceremony

Confidentiality Reminders for Participants  Out of respect for other group members please keep everything that is talked about in the group private – keep what others say in the group private.  You can talk about your own stories and activities in the group with anyone you want.  As group leaders, we are mandated to report suspected child abuse and neglect. We are also mandated to report plans to harm self or others. 30

National Center Traumatic Stress Network  Online training is free and gives you access to the videotaped training course, along with advice from the intervention developers and experienced CBITS providers, downloadable materials, a list of resources, and an online community where you can take part in peer-to-peer discussion boards, document sharing, and Ask an Expert. 31

Reflective Learning Group (RLG) A group of mental health providers that will meet throughout the CBITS implementation for the following purposes :  Review upcoming CBITS session  Collaboration  Case Consultation  Support  Guidance 32

33 Reflective Learning Group (RLG) Sample Schedule

34 Reflective Learning Group (RLG) Sample Schedule

35 Reflective Learning Group (RLG) Sample Schedule

References  Jaycox, L., PhD. (2004). Cognitive Behavioral Intervention for Trauma in Schools. Longmont, Co. Sopris West Educational Services.  Cognitive Behavioral Innervation for Trauma in Schools   The National Child Traumatic Stress Network 

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