Using Components of an Evidence-Based Therapy in the Classroom SPARCS SPARCS Angel Knoverek, MS,...

Using Components of an Using Components of an Evidence-Based Therapy Evidence-Based Therapy

in the Classroomin the Classroom

SPARCSSPARCS

Angel Knoverek, MS, LCPCChaddock, Director of Trauma Initiative

[email protected]

Copyright 2008 by North Shore - Long Copyright 2008 by North Shore - Long Island Jewish Health Systems, Inc., Great Island Jewish Health Systems, Inc., Great

Neck, New YorkNeck, New York

SPARCS:SPARCS:StructuredStructuredPsychotherapy for Psychotherapy for AdolescentsAdolescentsResponding to Responding to Chronic StressChronic StressA Trauma-Focused GuideA Trauma-Focused Guide

Ruth DeRosa, Mandy Habib, David Pelcovitz, Jill Rathus, Jill Sonnenklar, Julian Ford,

Suzanne Sunday, Christopher Layne, William Saltzman, Ayme Turnbull, Karen Mahoney, Victor Labruna, & Sandra Kaplan

North Shore University HospitalManhasset, New York


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Why SPARCSSPARCS:


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““SparcSparc””To set in motion; activateTo set in motion; activateTo rouse to [mindful] actionTo rouse to [mindful] actionA latent element capable of A latent element capable of growth or developmentgrowth or development


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For adolescents between 12-21 years oldFor adolescents between 12-21 years old

16 Sessions (60 minutes per session)16 Sessions (60 minutes per session)

History of chronic (interpersonal) trauma History of chronic (interpersonal) trauma

Designed for adolescents who may be living with Designed for adolescents who may be living with significant ongoing stressorssignificant ongoing stressors

May or may never have met full criteria for PTSDMay or may never have met full criteria for PTSD

Exhibit functional impairmentExhibit functional impairment

Present-focused and Strength-basedPresent-focused and Strength-based

No systematic exposure component includedNo systematic exposure component included

SPARCS


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SPARCS Core SPARCS Core SkillsSkills MAKE A LINKMAKE A LINK = = communicationcommunication & & connectingconnecting with others with others

Let’MGo Let’MGo = = problem-solving and problem-solving and creatingcreating meaning meaning

Distress ToleranceDistress Tolerance = = copingcoping more effectively more effectively in the momentin the moment

MindfulnessMindfulness = = cultivatingcultivating awarenessawareness


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Session 1Session 1 Welcome and Intro Welcome and Intro Session 2Session 2 Stress, trauma & the body Stress, trauma & the body Session 3Session 3 Mindfulness: States of MindMindfulness: States of MindSession 4Session 4 Mindfulness: Path to Wise MindMindfulness: Path to Wise MindSession 5Session 5 Distress Tolerance: Self-Distress Tolerance: Self-Soothe Soothe Session 6Session 6 Distress Tolerance: Distract Distress Tolerance: Distract Session 7Session 7 What is Trauma?What is Trauma?

Session 8 Session 8 LET’M GOLET’M GO

Treatment Overview


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Session 9Session 9 LET’M GO, Part 2LET’M GO, Part 2Session 10Session 10 MAKE a LINKMAKE a LINKSession 11Session 11 MAKE a LINK, Part 2MAKE a LINK, Part 2Session 12Session 12 Anger & TriggersAnger & TriggersSession 13Session 13 Portrait of My LifePortrait of My LifeSession 14Session 14 Expectations & BeliefsExpectations & Beliefs

Session 15Session 15 LET’M GO & MAKE a LINK, LET’M GO & MAKE a LINK, RevisitedRevisited

Session 16Session 16 GraduationGraduation

Treatment Overview


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SOSSOSSSLOW DOWN LOW DOWN

Take a time out; calm your body; one Take a time out; calm your body; one thought at a timethought at a time

OORIENT YOURSELFRIENT YOURSELFBring your mind & body back to the Bring your mind & body back to the present time and placepresent time and place

SSELF-CHECKELF-CHECKRate your level of personal distress and Rate your level of personal distress and sense of control here and nowsense of control here and now


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See SPARCS HandoutSee SPARCS Handout

H 1.2H 1.2

SOSSOS

Slow DownSlow Down

OrientOrient

Self-CheckSelf-Check

Ford et al., 2001Ford et al., 2001


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Feeling Intensity Feeling Intensity ThermometerThermometer

1

5

10

Personal Distress Right now I feel … Completely Calm 1 2 3 4 5 6 7 8 9 10 Most Distressed Ever

Personal Control Right now I feel … In complete control 1 2 3 4 5 6 7 8 9 10 Totally out of control


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See SPARCS HandoutSee SPARCS Handout

H 1.3H 1.3

SOSSOS

ThermometerThermometer


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Woven Throughout Woven Throughout the Treatmentthe Treatment


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Paying attention in a particular Paying attention in a particular way:way:

On purpose, On purpose, in the present moment, in the present moment,

and nonjudgmentallyand nonjudgmentallyKabat-Zinn, 1994Kabat-Zinn, 1994


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The quality or state of being mindfulThe quality or state of being mindful…….of being.of being

AttentiveAttentiveHeedfulHeedfulThoughtfulThoughtfulEarnestEarnestIntentionalIntentional

Adapted from the Adapted from the Oxford DictionaryOxford Dictionary


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Mindfulness Practice: Mindfulness Practice: Observe Your ThoughtsObserve Your Thoughts

ObserveObserveDescribeDescribeParticipateParticipate

Without Judgment

Stay Focused

Do What works


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It’s not just WHAT you’re It’s not just WHAT you’re thinking but HOW you’re thinking but HOW you’re experiencing it.experiencing it.

What you’re thinking is What you’re thinking is separate from who you are.separate from who you are.


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Wise Mind & Wise Mind & Mindfulness:Mindfulness:

Regulation of Affect and ImpulsesRegulation of Affect and Impulses Somatization Somatization Attention Attention Self-perceptionSelf-perception Rated most helpfulRated most helpful

Pieces of the Intervention Pieces of the Intervention for…for…


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Mindfulness ResearchMindfulness Research

Mindfulness practice associated with:Mindfulness practice associated with: changes in brain function

improved physical health- improvement in symptoms: – cancer, diabetes, fibroymyalgia, psoriasis, chronic pain

improvements in psychological well-being – Decreased rate relapse and recurrence of MDD (Baer, 2003)

– Decrease in anxiety (Baer, 2003)

– Improvements in general mood and decrease in stress Improvements in general mood and decrease in stress (Baer, 2003) (Baer, 2003)


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Mindfulness Practice: Mindfulness Practice: Changes in Changes in

Brain FunctionBrain Function Mindfulness Practice “can produce increases in Mindfulness Practice “can produce increases in

relative left-sided anterior activation that are relative left-sided anterior activation that are associated with reductions in anxiety and associated with reductions in anxiety and negative affect and increases in positive affect” negative affect and increases in positive affect” (Davidson, et al., 2003)(Davidson, et al., 2003)

– Still evident 4 months laterStill evident 4 months later

Activates the neural structures involved in Activates the neural structures involved in attention and arousal/autonomic control” of the attention and arousal/autonomic control” of the nervous system nervous system (Lazar et al., 2000)(Lazar et al., 2000)


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Mindfulness Practice: Mindfulness Practice: Changes in Changes in

Brain FunctionBrain FunctionMonks & Mindfulness Monks & Mindfulness (Lebow, 2005):(Lebow, 2005):

““Monks’ brain waves were better organized and coordinated”Monks’ brain waves were better organized and coordinated”

Higher activity in left prefrontal cortex = associated with Higher activity in left prefrontal cortex = associated with happinesshappiness

Differences apparent during periods of non-meditation = Differences apparent during periods of non-meditation =

fundamental changes in how the brain operatesfundamental changes in how the brain operates

Magnitude of differences related to length of practiceMagnitude of differences related to length of practice


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Mindfulness Practice: Mindfulness Practice: Improved Improved

Physical HealthPhysical Health Increased flu antibodies following 8 weeks of Increased flu antibodies following 8 weeks of

mindfulness mindfulness (Davidson 2003)

Improvements in symptoms related to numerous Improvements in symptoms related to numerous medical conditionsmedical conditions– Chronic pain Chronic pain (Kabat-Zinn 1982, 1987; Randolph et al. 1999)(Kabat-Zinn 1982, 1987; Randolph et al. 1999)

– Fibroymyalgia Fibroymyalgia (Goldenberg et. al. 1994)(Goldenberg et. al. 1994)

– Psoriasis Psoriasis (Kabat-Zinn, et. al. 1998) (Kabat-Zinn, et. al. 1998)


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Mindfulness Practice: Mindfulness Practice: Improvements in Psychological Well BeingImprovements in Psychological Well Being

Rated as most helpful by teens diagnosed with BPD Rated as most helpful by teens diagnosed with BPD (Miller et al., 2000)

Improvements in general mood and decrease in stress Improvements in general mood and decrease in stress (Baer, 2003)

Decrease in anxiety Decrease in anxiety (Baer, 2003)

Decreased rate of relapse and recurrence of MDD Decreased rate of relapse and recurrence of MDD (Baer, 2003)**

Findings evident in many populationsFindings evident in many populations– e.g. cancer patients - maintained at 6 months e.g. cancer patients - maintained at 6 months

– e.g. patients with anxiety disorders - maintained at 3 yearse.g. patients with anxiety disorders - maintained at 3 years

Research in its infancyResearch in its infancy Meta-analysis: effect size = .74Meta-analysis: effect size = .74

- - (i.e. 74% did better than tau or no treatment)(i.e. 74% did better than tau or no treatment)


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Mindfulness: States of Mindfulness: States of MindMind

Linehan, 1993


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Traumatic Reminders/Triggers


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Distress Tolerance:Distress Tolerance:(Hanging In)(Hanging In)

– When?When? Situations you can’t fix right nowSituations you can’t fix right now To get through the moment- To get through the moment- ((short-termshort-term

solution!)solution!)

After After SOS or Wise MindSOS or Wise Mind

– What are Distract and Self-Soothe?What are Distract and Self-Soothe? Distract- not as simple as it soundsDistract- not as simple as it sounds Self-Soothe with the 5 senses Self-Soothe with the 5 senses


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Distress Tolerance:Distress Tolerance: Distract & Self-SootheDistract & Self-Soothe

– How?How? On purpose & mindfullyOn purpose & mindfully

– Why?Why? To manage the momentTo manage the moment To keep from doing something that To keep from doing something that

might make the situation worsemight make the situation worse To avoid engaging in a harmful behaviorTo avoid engaging in a harmful behavior


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Distract With…Distract With… AActivities ctivities

Hobbies, exercise, cleaning, go to events, call or visit a friend, Hobbies, exercise, cleaning, go to events, call or visit a friend, play computer or video games, go online, go for a walk, read a play computer or video games, go online, go for a walk, read a magazine or book, do homework, play sports, go out to eat, magazine or book, do homework, play sports, go out to eat, draw, paint, listen to music.draw, paint, listen to music.

CContributing ontributing Contribute to someone else, do volunteer work, give something Contribute to someone else, do volunteer work, give something

to someone else, make something nice for someone, do a to someone else, make something nice for someone, do a surprising, thoughtful thing for someone you care about or surprising, thoughtful thing for someone you care about or someone you don’t even know.someone you don’t even know.

CComparisons omparisons Compare yourself to others who are also in tough Compare yourself to others who are also in tough

situations. situations. OOpposite pposite EEmotions motions

Read emotional books or stories, listen to emotional music. Be Read emotional books or stories, listen to emotional music. Be sure the event creates sure the event creates different different emotions. Ideas: scary movies, emotions. Ideas: scary movies, joke books, comedies, funny records, go to the store & read joke books, comedies, funny records, go to the store & read funny greeting cards.funny greeting cards.


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Distract With…Distract With… PPushing awayushing away Leave the situation mentally for a while. Just for now, build an Leave the situation mentally for a while. Just for now, build an

imaginary wall between and you the situation or block it from imaginary wall between and you the situation or block it from your mind. Refuse to think about the situation. Censor your mind. Refuse to think about the situation. Censor ruminating. Put the pain on a shelf. Box it up and put it away ruminating. Put the pain on a shelf. Box it up and put it away for a while. for a while.

OOther ther TThoughtshoughts Count to 10, count colors in a painting or tree, work, do Count to 10, count colors in a painting or tree, work, do

puzzles, watch TV, read. Deliberately engage in other puzzles, watch TV, read. Deliberately engage in other thoughts. thoughts.

IIntense other ntense other SSensationsensations Hold ice in hand, squeeze a ball very hard, stand in a hot Hold ice in hand, squeeze a ball very hard, stand in a hot

shower, listen to loud music. shower, listen to loud music.


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Distress Tolerance:Distress Tolerance:Key PointsKey Points

– When When not not to useto use When you or someone else is in dangerWhen you or someone else is in danger If it’s all you use all the time (avoiding things you can If it’s all you use all the time (avoiding things you can

address)address)

– Short vs. Long-Term CopingShort vs. Long-Term Coping

– Expand RepertoireExpand Repertoire

– Distress Tolerance vs. MindfulnessDistress Tolerance vs. Mindfulness Must be mindful to practice distress tolerance, Must be mindful to practice distress tolerance, but not all mindfulness is distress tolerance (e.g. but not all mindfulness is distress tolerance (e.g.

mindfully observing thoughts when it might be better to mindfully observing thoughts when it might be better to distract)distract)


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When faced with a stressful When faced with a stressful situation/reminder of the past:situation/reminder of the past: These steps were designed to help you These steps were designed to help you figure out figure out

what you want to hold on towhat you want to hold on to—what is important to —what is important to you, you,

and what and what youyou want to let go of want to let go of because it’s just because it’s just causing you more problemscausing you more problems. .

It’s about making a mindful choice and listening to It’s about making a mindful choice and listening to your wise mind. your wise mind.

LET ‘M GOLET ‘M GO


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What We Don’t MeanWhat We Don’t Mean

When you’ve been upset, mad, When you’ve been upset, mad, worried, etc. people may have said to worried, etc. people may have said to you at one time or another—or maybe you at one time or another—or maybe you even said to yourself—just let it you even said to yourself—just let it go. Move on, get a grip. go. Move on, get a grip.

That’s not what these steps mean. If it That’s not what these steps mean. If it were that easy, you would have done were that easy, you would have done that a long time ago.that a long time ago.


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What are you doing that’s What are you doing that’s working – working –

why not do more of that why not do more of that

And let go of what is not workingAnd let go of what is not working

LET ‘M GOLET ‘M GO


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Losing itLosing it Why am I losing it?What are my triggers?

EmotionsEmotionsWhat am I feeling?

ThoughtsThoughtsWhat am I thinking?

MeaningMeaning What is really important to me?

GoalsGoals What do I want?

OptionsOptions What are my choices?

LET ‘M GOLET ‘M GOSOS BeMindful SOS BeMindful SOS BeMindful

SOS BeMindful SOS BeMindful SOS BeMindful


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Making MeaningMaking Meaning

Meaning is the sense that, no Meaning is the sense that, no matter what is going on in your life, matter what is going on in your life, you can hang onto the things that you can hang onto the things that really matter to you. It is the belief really matter to you. It is the belief that there are elements and people that there are elements and people and views that cannot—no matter and views that cannot—no matter what—be taken from you.” what—be taken from you.”

-Viktor E. Frankl-Viktor E. Frankl


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Making MeaningMaking MeaningIdentify beliefs and values

Identify what went well, their contribution

Look to the future

Reframe


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Making Making MeaningMeaning

1) Help them identify underlying sustaining beliefs and values driving behavior or goalsWhat was most important to you in this

situation?

The thing that upsets The thing that upsets people is not what people is not what happens but what they happens but what they think it means.think it means.

EpictetusEpictetus

Copyright 2008 by North Shore - Long Copyright 2008 by North Shore - Long Island Jewish Health Systems, Inc., Island Jewish Health Systems, Inc.,

Great Neck, NYGreat Neck, NY


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MAKE a LINKMAKE a LINK Communication SkillsCommunication Skills

Based upon Interpersonal Effectiveness skills Based upon Interpersonal Effectiveness skills taught in DBT (Dialectical Behavior Therapy)taught in DBT (Dialectical Behavior Therapy)

When?When? Why?Why?

– Get what you want or say “no” to a requestGet what you want or say “no” to a request– Keep the relationshipKeep the relationship– Keep your self-respectKeep your self-respect


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In order to get what you want and need, you In order to get what you want and need, you must must “MAKE A LINK”“MAKE A LINK”

or connection with the other personor connection with the other person

((be) be) MMindfulindful AAct confidentct confident KKeep a calm & gentle mannereep a calm & gentle manner EExpress interestxpress interest

AAsk for what you wantsk for what you want

LLet them know you get their point of viewet them know you get their point of view IInclude your feelingsnclude your feelings NNegotiate—give to getegotiate—give to get KKeep your self respecteep your self respect

For more For more information….information….

Contact Angel Knoverek at Contact Angel Knoverek at [email protected]@chaddock.org

Contact Michele Stinnett in Contact Michele Stinnett in the Admissions Department the Admissions Department at [email protected] at [email protected] or call 1-888-242-3625, ext. or call 1-888-242-3625, ext. 347347

Using Components of an Evidence-Based Therapy in the Classroom SPARCS SPARCS Angel Knoverek, MS,...

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