Question 1

I am a Mental Health Lead for Northern Ontario Aboriginal communities in schools, fly in. Little access to resources.
I deal with trauma, death-murder or suicide. sometime multiples at a time. How best do I support our schools staff and students?

Torrey Creed · Accepted Answer

Working with students who have such acute needs, coupled with limited access to resources, can require creative approaches to building in additional supports for students. Drawing on the strengths of the Aboriginal community may be particularly important with your clients, given the strong emphasis on community connection as a source of wellness. You may already be aware of some of the resources (https://www.sac-isc.gc.ca/eng/1576089278958/1576089333975) that have been developed with and for First Nations and Inuit communities – emphasizing this kind of culturally responsive care may increase the likelihood that supports may be helpful. In addition, you might consider Psychological First Aid (https://www.nctsn.org/treatments-and-practices/psychological-first-aid-and-skills-for-psychological-recovery/about-pfa) training for school staff and community members to offer additional skills and resources for people who can respond quickly when crises occur.

In your own work with students, Trauma-Focused CBT (https://tfcbt2.musc.edu/) is a well-established evidence-based practice for treating children impacted by trauma and their families or caregivers, which can be very helpful – although adaptations may be needed to ensure that the treatment is an appropriate fit. Treatments like TF-CBT are not appropriate immediately after a student has experienced a trauma; instead, support for a normative reaction like grief or anger can be very helpful. However, if their experiences lead to ongoing distress or impairment several months after the traumatic event, treatments like TF-CBT can be very helpful.

I’d also like to note the importance of self-care for you as a provider working with students with such highly acute needs. If you are not already doing so, seeking out support for yourself may be key to reducing burnout, including supervision, peer mentorship groups, or seeking out your own therapist. In addition, using the skills we teach to our clients to manage our own challenges can be helpful in a number of ways – it’s humbling and inspiring to experience those skills ‘from the other side of the table,’ it’s affirming of the value of those skills when we as providers see them work for ourselves, it normalizes the use of the skills, and it will help you bring your own personal experience to the conversation when you share those skills with others in future sessions.

Question 2

What are the pros and cons of young people having CBT delivered in a school setting vs a private practice/medical setting?

Torrey Creed · Accepted Answer

On average, young people spend a majority of their days in a school setting, which means that school-based services offer increased access to mental health care. Students are able to access treatment without the coordination and disruption of travel to another site for care. Further, offering treatment in the school setting allows for true integration between the skills being learned in treatment and one of the contexts in which those skills may be most frequently used. Rather than planning for the client to practice a new strategy and waiting a week for them to return to an outpatient appointment to report back on what they learned, the provider and client can plan a practice, have the child execute the plan, and have them drop back by to report out later that day. The clinician’s presence in the school context also allows them to engage others in supporting a client’s progress. For example, the clinician and client may, as appropriate, collaborate with a teacher to practice an exposure (e.g. reading aloud in class), or the client may join a group treatment with peers who share similar experiences. Overall, school-based treatment integrates care into the client’s established routine and environment.

An inherent challenge in school-based services is that time spent in a treatment session may be at the cost of whatever the client would have otherwise had scheduled during that time. A young person may miss short periods of instruction or free time, or they may end up multitasking by eating lunch while they engage in a session. However, school-based treatment typically focuses on challenges that may be interfering with school success, so the investment of the time in treatment can ultimately lead to greater comfort and success at school. Further, the client’s privacy about engaging in treatment may be compromised if the client and staff are not mindful of how their engagement is coordinated.

Question 3

Are there any particular ways that you introduce the cognitive model to teens?

Torrey Creed · Accepted Answer

As with other complex or abstract ideas, connecting the ideas underlying the cognitive model to a relatable story or experience can help adolescents to connect to these important ideas. For example, my colleagues and I developed the Rollercoaster Story (which can be found here https://myemail.constantcontact.com/Explaining-the-Cognitive-Model-in-Child-Friendly-Language.html?soid=1105231688833&aid=PBwMlquNUQA or in Cognitive Therapy for Adolescents in School Settings by Creed, Reisweber, and Beck https://www.guilford.com/books/Cognitive-Therapy-for-Adolescents-in-School-Settings/Creed-Reisweber-Beck/9781609181338).  In this story, we highlight how our perceptions of a situation influence the way we think, feel and behave in that situation – and how changing perceptions can lead to new thoughts, feelings, or behaviors. However, the Rollercoaster Story is just one illustration of the ideas underlying the cognitive model; I encourage therapists to listen closely to their clients to get a sense of what might grab a specific client’s attention. Rather than using the example above, a therapist might choose any situation where the client can resonate with the idea that two different people might react differently in the same situation based on their perceptions of the situation. A sports-lover might understand that one person could be up at bat and be very nervous while another is quite confident at bat (based on their thoughts in that moment, and leading to different reactions). A teen who likes animals might be able to imagine that while they might be excited to meet a new dog, another person might feel nervous (again, based on different thoughts and leading to different behaviors). In each situation, the teen can be encouraged to generate a new, more helpful or accurate thought for the person having a negative experience.

A few words of warning, though – when I use a story or situation to introduce the cognitive model, I avoid using examples related to the presenting problem or a trauma experience. Remember, the goal of introducing the cognitive model is to help the teen to understand that different perceptions lead to different thoughts, feelings, and behaviour in a given situation. When the hypothetical situation is related to the teen’s own presenting problem, they may struggle to relate to the teen in the story who is having a very different reaction than theirs. In addition, trauma experiences or other clinically-hot examples will pull the clinician to attend to the distressing reactions the teen may have when talking about these difficult situations. More broadly in CBT, the goal is to first teach the client a skill, and then support the client to use the skill until they are ultimately able to do so independently.  When we are first teaching about the cognitive model, it’s too soon to also ask the client to use related skills to handle strong reactions related to clinically-hot topics. Application of CBT skills to sensitive topics comes after the skill has been introduced and understood.

Question 4

I'm an early career school psychologist just starting out with a pretty big case load and limited time with students. Would it be better to focus on a behavioral activation approach to depression or an emphasis on the cognitive?

Torrey Creed · Accepted Answer

School psychologists can face a real challenge in trying to scale treatments to meet the needs of their large caseloads, especially when time is limited. If the question is specifically about the students on the caseload whose primary presenting problem is depression, then beginning with behavioral activation is a very reasonable approach supported by the science. However, other considerations may also be helpful in this situation. Many CBT-related skills can be taught to students in larger groups so that you can focus individual time on helping students to fine-tune their use of the skills for their particular experiences. For example, some broadly-relevant skills can be integrated into classroom topics (e.g. health classes), including basic catching, checking, and changing of thoughts (https://beckinstitute.org/blog/using-the-mnemonic-three-cs-with-children-and-adolescents/), behavioral activation, relaxation, and other strategies. Individual or small-group treatment time may then focus on helping the students to practice and apply these skills, rather than using your finite time to teach the same skills separately to students. Other advantages of this approach include destigmatizing mental health challenges, as well as creating opportunities for students to practice their skills together and cheer each other on!

Question 5

How does CBT help students with emotion regulation?

Torrey Creed · Accepted Answer

In brief, CBT can help students to regulate their emotions at several points in the chain of events related to strong emotional reactions: reducing responsiveness to events that could trigger strong negative emotions, managing the strength of the emotional response when it occurs, and shortening the length of time the negative emotion lasts. (For more information about emotional dysregulation, check out these resources https://cogbtherapy.com/cbt-emotion-regulation.)

Reducing responsiveness: CBT can help students to shift the way they perceive events in ways that lead to less strong or less negative responses. For example, students who typically interpret situations as threatening can learn to pause, examine evidence about whether the situation actually merits a strong reaction, and then act accordingly rather than responding in an ‘autopilot’ way that may not always be appropriate or helpful.

Managing strength of emotional response: CBT can also help students to learn to identify strong negative emotions quickly so that they can use skills to navigate those emotions in ways that are helpful and socially appropriate. For example, a student may notice that they are beginning to feel angry and then use mindfulness strategies to help them shift their focus from patterns of thinking that escalate their negative emotion to patterns of thinking that allow the feelings to dissipate.

Shortening length of emotional response: CBT skills can also be used to help students to manage strong emotions in a way that brings them more quickly back to baseline after an event. For example, a student may notice that they are beginning to feel signs of anxiety in their body and use deep breathing to calm their system.

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