SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2019/Day 3

Day 3

Keynotes

Ordinary Magic: Advances in Developmental Resilience Science

Presenter: Ann S. Masten, Ph.D., Professor, Institute of Child Development at the University of Minnesota Twin Cities

Powerpoint:

At the conclusion of this presentation, participants will be able to:

Define resilience from a contemporary developmental systems perspective

Resilience: The capacity of a system to adapt successfully to challenges that threaten system function, survival, or development. Current times are challenging Threat from disasters (war, natural disasters, etc.) Lifelong effects of early adversity We know more about biological causes, effects of trauma World War II: study of resilience rooted here Norman Garmezy, Emmy Werner, Michael Rutter: pioneers of resilience science around 1970 Many of the kids they followed who had shared risk factors were growing up successfully or surprising people w/recovery Need to understand underlying processes of good outcomes w/adversity Since WWII, we have developed better ways of measuring stress & advanced our statistics 3 defining questions about resilience What are the challenges? Threats: trauma, neglect, poverty, war, natural disaster, ACEs What fosters adaptive success? How do we explain how well a person is doing in a maladaptive environment? Promoters/Protections: neurobiological, individual, family & relational, community, cultural, societal How is the person doing? Adaptive success: Developmental tasks, mental health, physical health, happiness, school or job achievement, caregiving Varies based on culture The current definition "The capacity of a system to adapt successfully to challenges that threaten system function, survival, or development" (same as given above) Developmental science definition Can talk about resilience of child, family, economy, community, climate (planet as a whole) using this definition Development is dynamic, influenced constantly by experiences, lots of interactions that shape development (from genetic to molecular to environment) Resilience of the family is important to resilience of child; resilience of family depends on environmental supports, etc. So many different systems that interact, within and without (embedded, interacting, interdependent) Resilience always changing, depends on interaction of many other systems Resilience globally will depend on that of children, families, communities; growing in importance as rise of natural disasters, threats

Identify salient evidence-based protective processes for children and families

Developmental cascades: impact in one system spreads to other systems Both negative and positive examples High licking behavior in rats alter genes in anxious rats Family resilience: regulatory purpose Parenting resilience: capacity of parents to deliver competent parenting despite adversity Good family functioning mitigates risk of adolescent health problems, psychological well-being Executive function skills Schools can be a huge protective factor Efficacy, skill building, accomplishment Basic needs: food Positive adult role models Communities matter Support they provide for families Education, recreation, healthcare Some have virtually no resources for children and families and others have lots Other protective systems Within the individual: immune, arousal regulation, stress regulation Religion and cultural systems Provide meaning-making systems of belief, rituals and rules, ceremonies, practices to help cope Meditation processes (mindfulness, etc.) Improve outcomes for kids Reduce risk exposure: prevent premature birth, homelessness, put positive resources into the lives of kids and families (asset resources), quality early childcare Practitioners play many roles in development and nurturing of resilience Promoting school success in children from high-risk homeless and highly mobile families Interventions more successful if stakeholders help with design process

Describe new directions of research on resilience in children, families, and communities

Masten et al. 2016 figure demonstrates possible resilience patterns following trauma (post-traumatic growth) Some people galvanized by trauma Delayed breakdown (depletion model) Annette LaGreca 1992 post hurricane Andrew 3 patterns in kids: doing well, improving (recovering), chronically affected We don’t know how they were doing before hurricane (problem in disaster research)- can’t see clinically significant change Hair cortisol sampling: hair collects cortisol levels Luo et al. 2012, earthquake in 2008, started PTSD study afterward in young Chinese girls; could see levels of cortisol before and after earthquake Some people starting to use baby teeth too Chronic adversity shows different pathways than trauma Child soldiers, orphanages, maltreatment Don’t expect resilience, look for it when conditions improve (b/c most kids are overwhelmed) Gradual deterioration Rescued child soldiers: some stayed stable, some deteriorated over time (Betancourt et al 2018) Osofsky et al 2015: Katrina and BP oil spill trajectory analyses looking at PTSD symptoms over time Intriguing questions Are there hidden skills? When kids adjust to stress, they may exhibit poorly in school but adaptive in neighborhood Is there a price for resilience? It can take a toll biologically. Lots of work to be done still More attention to leveraging power of integrated systems (family, school, peers; pulling resources across levels and sectors)

Resources by Ann Masten

Book on resilience Masten, A. S. (2014). Ordinary magic: Resilience in development. New York: Guilford Press. Paperback (2015) Available through Amazon and Guilford for about $25. Opening chapter free at Guilford Press. Poptech talk on resilience MOOC: Resilience in Children Exposed to Trauma, Disaster and War: Global Perspectives. Mass Open Online Course (free or pay for CEU credits from CEHD, University of Minnesota). There is a video Resilience overviews and commentaries [open access; google the doi to locate a free copy] Masten, A. S. (2018). Resilience theory and research on children and families: Past, present, and promise. Journal of Family Theory and Review, 10, 12-31. doi:10.1111/jftr.12255 Masten, A. S., & Barnes, A. J. (2018). Resilience in children: Developmental perspectives. Children, 5, 98. doi:10.3390/children5070098 Masten, A. S. (2014). Global perspectives on resilience in children and youth. Child Development, 85, 6-20. doi:10.1111/cdev.12205 Southwick, S. M., Bonanno, G. A., Masten, A. S., ...(2014). Resilience definitions theory, and challenges: Interdisciplinary perspectives. European Journal of Psychotraumatology, 5, 25338 (1-14). doi:10.3402/ejpt.v5.25338 Encyclopedia on Early Childhood Development ~ section on resilience http://www.child-encyclopedia.com/resilience/introduction. (free to download complete topic) Risk and resilience in homeless families – overviews of 25 years of research Masten, A. S. et al., (2015). Educating homeless and highly mobile students: Implications of research on risk and resilience. School Psychology Review, 2015, 44, 315-330. https://www.achievempls.org/edtalks Concise articles on resilience for educators Masten, A. S. (2018). Schools nurture resilience of children and societies. Green Schools Catalyst Quarterly, V(3), 14-19. Masten, A. S. (2009). https://www.edcan.ca/?s=Ordinary+magic. Education Canada, 49(3), 28-32.

Mass Violence: Understanding the Complexity of Trauma & Grief in Communities

Presenter: Melissa Brymer, Ph.D., Director, Terrorism and Disaster Programs, UCLA-Duke National Center for Child Traumatic Stress

Powerpoint:

Learning Objectives:

1.Participants will be able to name characteristics of mass violent events that impact the long-term recovery and healing of communities.

Needs to be a connection, interplay between those who do the research and those who do the community work Are we touching all systems? Pediatric, schools, military, child welfare, DOD, disaster care 20 school shootings in past year vs. 105; not fake news, it’s because there’s not a universal definition of what we mean by mass violence Casualties can mean injured or dead Operationalization is important! Information to gather prior to responding to an event: Learn about the community (e.g., previous adverse events; in one community experiencing a mass shooting, many residents had moved there b/c of Hurricane Harvey) All of this influences how we intervene, what support we provide (even things like is graduation or prom coming up?) Think about magnitude; how has it influenced community? Certain populations targeted? How many people were affected? Sandy Hook: had to bring in previous principal who had retired b/c principal who had been killed, had to support hierarchy Temporary building, felt displaced while they built new building San Bernardino: Dept. of Public Health; peer of workers, not an outsider; led to a lot of mistrust; had to change everything the perpetrator had signed (permits throughout the community), emails he sent, etc. What is going to influence/change how the community reacts? Vegas Shooting: 62% of ticket holders were from California; just as much a CA disaster as a NV disaster Does recovery happen where it occurred or do we have a larger scope? (e.g., Boston bombing, thinking about all the different areas and making sure support was provided) How do we adapt based on circumstances? Different elements to take into account Dose of exposure Who was in life threat or had most exposure and how to help them (those in classroom in Sandy Hook; several kids who ran out when he was reloading had a lot of exposure; sounds projected over intercom, so others could hear too) Traditional first responders but also others; taxi drivers, etc. Need to make sure EVERYONE who is witness has to get support Secondary adversities People call and put in threats on anniversaries, etc.

2. Participants will be able to describe the 5 key empirically-supported trauma intervention principles.

Intervention Strategies “Once I was very very scared”- a book using animals to explain coping strategies, etc. Good for working with kids who have experienced trauma https://www.amazon.com/Once-Was-Very-Scared/dp/0998412600 Identify people who need to expand network for different types of supports Tap them into community resources Attending to the Injured Make sure people are getting proper supports, rehab Use evidence-based treatments Psychological first-aid is an acute intervention in immediate aftermath Different translations: schools, faith-based, victim advocates 8 core actions; not fixed, flexible depending on where person is at. May need to help with basic needs, may only need to help with coping and resource support Mobile app (PFA mobile)- goes into 8 core actions. Talks about provider care https://learn.nctsn.org/course/index.php?categoryid=11 More resources for psychological first aid: https://www.nctsn.org/treatments-and-practices/psychological-first-aid-and-skills-for-psychological-recovery/nctsn-resources Skills for psychological recovery (intermediate; weeks- months afterwards) People with some distress may not be motivated for tx, but things go on that keep them stuck in recovery Skill-building, strength-based model How do we ameliorate some of the things that keep them stuck? Trauma focused CBT web- goes into orientation about TFCBT, component on traumatic grief: https://tfcbt2.musc.edu/ Consideration for those involved in handling crime: first responders, funeral directors, self care for psychologists Brain research as a result of Newtown shooting: https://aviellefoundation.org/

3. Participants will be able to describe how grief impacts individuals, families, and communities adjustments to mass violence.

Need to understand difference between trauma and grief Different pathways We don’t recover from grief; we learn to adjust, create meaning Trauma reactions might settle, move on Need to respect both Critical role of trauma & loss reminders Triggers of watching movies for Las Vegas survivors Amusement park lines, feeling of being trapped for Newtown survivors 9/11: disaster experience gave kids support and help but many had trauma beforehand too that went unnoticed Think about individual and community level Community as a whole; how can we make sure systems come together to help with healing process? Sense of privacy gone after tragedy

Towards a Cultural Psychotherapy: Including Meaningful Clinical Evidence

Presenter: Martin J. La Roche, Ph.D., Director of Mental Health Training, Boston Children’s Hospital/Martha Eliot Health Center

Powerpoint:

Learning Objectives:

Attendees will learn about the three main types of cultural empirical research

Individualistic model Focus is on the patient and treatment goals relate to improving the individual e.g., increasing self-esteem, self-efficacy, etc. Treatment does not focus on the cultural context These therapies are based on a great deal of evidence that shows their efficacy, and these types of therapies have indeed helped many people While the extant evidence base was built mostly on homogeneous samples, the empirically-supported treatment movement includes race and ethnicity as an important area of focus Evidence shows that these factors make a difference e.g., Sue (1997) looked at outcome data in California to assess how many ethnic minorities would return to a second therapy appointment and found that only 50% would (in contrast, white clients with white clinicians returned at a rate of 80%) The cultural competence model grew out of this type of work This work also highlighted the dearth of mental health providers compared to the extant need in communities Relational Psychotherapies Relational psychotherapy recognizes that therapy is a process between the patent and the therapist The relationship plays a role in the therapy outcomes e.g., in making decisions This has been shown with some research Quantitative methods are often used in this work to identify the ways that the therapeutic relationship predicts outcomes Within this framework, culture is defined more broadly (not just race and ethnicity) It is considered part of how you make sense of the world This point is an important innovation over the individualistic model, as it allows us to refine the research on cultural competence It raises important issues for assessing how people make sense of their race/culture This is helpful for, among other things, combating stereotypes It emphasizes the importance of asking people how they make sense of their own culture One of the most important meanings that a person makes is self-orientation This is part of how we make sense of the world One of most studied cultural variables has two dimensions: Individualism vs. egocentrism Collectivism vs. allocentrism These facets are not mutually exclusive, and they tend to break down along racial lines e.g., Asians and Latinxs have more allocentric tendencies, whereas white and African American people tend to be more egocentric One study found differences in the effectiveness of a relaxation training exercise based on allocentric/egocentric framing The level of allocentrism in participants predicted the effectiveness of the relational intervention Takeaway message: making the intervention more culturally specific makes a difference in terms of symptoms and service utilization Critically, this is not just about skin color but more importantly it concerns the way people see the world When we give people what they want (something that accords with their self-view) they come to treatment and get better Contextual Psychotherapies Guiding principle: the meanings we make only make sense in context We cannot understand the meanings of our behaviors without understanding the contexts in which they are embedded There have been a few big-data studies to support this idea e.g., people are often motivated to make choices (voting, buying, etc.) not because of their beliefs, but because of the people with whom they interact I.e., context has an influence on what we do Community is an important factor for understanding behaviors New studies are including measures of SES, but another thing to consider is implicit processes Implicit Processes: things we do that we're not aware of Many of our experiences in society are implicit E.g., knowing how we should behave, how to interact with others We are often on auto-pilot when engaging with the world Some of the scripts for auto-pilot are based on relevant cultural assumptions This can lead to problems or miscommunication E.g., a therapist may assume that a client leaning in closer to them indicates borderline personality disorder, whereas it could equally be a cultural trait Measures like the Implicit Association Task are designed to measure the implicit processes that guide our assumptions about the world See also: micro-aggressions (Sue et al., 2019); stereotype threat (Steele and Aronson, 1995) Ethnic minorities report more trauma, partly because of continued assaults on their worldview Implications Clinicians should include implicit assessments in studies of psychotherapy

Attendees will learn about Cultural Psychotherapy’s basic assumptions and characteristics

Fundamental tenet: we all have a culture Culture is not solely the domain of minority groups Culture has an effect on all interactions, including psychotherapy It is important to examine the impact that culture has on our lives People who recognize their own culture may be more open to others' Culture is central It is part of our internal identities and how we relate to one another Global cultural psychotherapy is an approach that benefits from many different therapeutic approaches and evidence bases We should understand the cultural context underlying differential responses on our measures This would capture people more holistically so that they feel heard and continue to engage in therapy This approach complements existing evidence-based therapies It means paying attention to both individual features and features of a person's culture It involves being mindful of the evidence base and also cultural factors Culturally-adapative interventions have been shown to be effective Recent meta-analyses show that including relevant cultural measures (like assessing level of discrimination) can improve outcomes of interventions The more variables we have, the better we can match people to interventions It is important to recognize that many of our samples are from the US We should start to include information from other parts of the world Differences can be enriching: understanding cultural biases helps clinicians work with broad populations Not just those with which a person has particular experience Being sensitive to cultural backgrounds means measuring individual characteristics and adapting treatment accordingly

Attendees will learn the three-phase therapeutic model of cultural psychotherapy

'Overview The three phase model integrates interventions to the client's context Phase 1: Address basic needs and client goals Focus on symptom reduction and safety This follows the individualistic paradigm This phase rests on the evidence-based approaches as much as possible Phase 2: Understand the client's experiences through the therapeutic relationship This only happens after you already formed the foundation of the relationship This phase is highly influenced by the relational paradigm Phase 3: foster empowerment This phase utilizes the contextual and ecological paradigm Rationale: it is sometimes not enough to just address symptoms and improve relationships It can be important to help children change unjust environments, e.g., by helping reduce levels of violence in their communities Characteristics of the three phase model Phase 1 addresses treatment goals and ensure safety Gets at what the client came in the door looking for Focus on reducing symptoms as quickly as possible Also address basic needs through other systems e.g., food, shelter This improves retention and also helps the therapist learn how the person solves problems and copes with basic issues Basic strategies The most important skill is to listen to the person's chief complaint Make sure that what they ask for is what is given first of all Teaching basic skills for managing affect and communicating effectively Phase 2 address understanding a person's experiences in more detail This involves listening to the client to understand how they see the world This cannot happen if a person doesn't have effective affect-regulation strategies Otherwise, the client might resort to negative communication strategies Phase 2 involves understanding a person's experiences e.g., poverty, violence, etc. This requires having a safe and trusting relationship between the therapist and client A key to knowing you are in the second phase is that the client is adapting aspects of the therapeutic relationship to other parts of their lives e.g., with parents, teachers, other members of the community This trust opens up opportunities to explore topics more effectively, such as race and cultural issues The client needs to have the skills to disagree with the therapist, otherwise there is a risk of the therapist imposing their worldview Phase 3: Once the therapeutic relationship is developed, clients can start feeling empowered Through this, psychotherapy can have an impact on improving communities To do this, clients and therapists must be interested and able to talk about this in the context of therapy Often, therapists are not trained to talk about community issues However, it can be important to understand contextual threats, such as gang violence and other conflicts These factors impact how children see the world and therefore have an impact on their sticking with therapy The empowerment phase is like an awakening to making change and engaging with social justice Many people don't realize that this is an important thing at first, but through therapy they explore these issues and ultimately land on a desire to change them The timing of these phases is important because each phase builds on the previous one in terms of skills and awareness

Workshops

Resilience in Action: Implications of Science for Practice and Policy

Presenter: Ann S. Masten, Ph.D., Professor, Institute of Child Development at the University of Minnesota Twin Cities

Powerpoint:

At the conclusion of this presentation, participants will be able to:

Describe multiple components of a resilience framework for practice

Identify three basic strategies for promoting resilience in practice

Apply a resilience framework to practice and policy goals

Creating a School Recovery Program

Presenter: Melissa Brymer, Ph.D., Director, Terrorism and Disaster Programs, UCLA-Duke National Center for Child Traumatic Stress

Powerpoint:

Learning Objectives:

1. Participants will be able to identify components of a recovery program.

2. Participants will be able to name trauma interventions that are appropriate for the 3 Tiers of a Public Health intervention model.

3. Participants will be able to identify resources for educator/provider self-care.

A Cultural Psychotherapy Workshop: A Clinical Illustration

Presenter: Martin J. La Roche, Ph.D., Director of Mental Health Training, Boston Children’s Hospital/Martha Eliot Health Center

Powerpoint:

Attendees will learn:

Cultural Psychotherapy’s basic assumptions and characteristics and how to translate these characteristics into specific psychotherapeutic interventions

Global and Cultural Psychotherapy (GCP) aims to complement current psychotherapeutic approaches by embedding these into a cultural and global context. GCP is an integrative approach that benefits from different psychotherapies and evidence. Not only ethnic minorities have a culture: We all have a culture. Methodologically, this means that we can not assume psychological characteristics because of race and ethnicity; it is necessary to measure more proximal characteristics (e.g., experiences of discrimination, self-orientation, ethnic identity). Race and ethnicity alone are not sufficient to predict psychological attributes. GCP emphasizes the importance of culture throughout all the phases of the development of a theory or research project and the psychotherapeutic process. GCP underscores distinct conceptual, research and methodological strategies. Psychotherapy is embedded in global contexts Global and Cultural Psychotherapy proposes a three–phased model that is a systematic set of conceptualizations and interventions that are beneficial at distinct therapeutic times. GCP=Individual factors x relational factors x contextual factors

The basic goals, characteristics and requirements of each of the three-phases of Cultural Psychotherapy as illustrated through a clinical example

Phases of Cultural Psychotherapy Phase 1: Address basic needs/goals and symptom reduction [Individual] The length of this phase varies greatly depending on the individual Explicit Systems (increasing coping strategies) are emphasized Targets affect regulation and flexibility Individualistic Paradigm and Evidence-Based strategies Phase 2: Understand patients experience through the therapeutic relationship [Relational Paradigm] Implicit systems (relational procedural assumptions) are emphasized Targets relational skills Phase 3: Foster empowerment [Contextual and Ecological Paradigm] Targets enhanced empowerment Emphasizes contextual or ecological change Characteristics of the Three-Phased Global and Cultural Psychotherapeutic Model Phases are used because each has specific requirements. A pt needs to have met some requirements to be dealing with certain issues.However, once all requirements are met phases do not occur in linear, stepwise fashion, but are often overlapped and experienced in cycles The clinical recommendations of each phase are not rigid or exhaustive, they are designed to be heuristic tools This model is highly influenced by three phased models Participants need to pass through 3 phases to accomplish some level of empowerment although some participants may be more ready than others to do so Clinical Strategies for Each Phase Phase I: Safety and basic needs are always a priority Patients’ chief complaints are understood in a culturally sensitive manner Conduct cultural assessments and diagnosis Address cultural and demographic differences Learn and use patients language and patients formulation Use evidenced based psychotherapies Use indigenous healing practices to address symptoms Enhance affect regulation and psychological flexibility Encourage culturally-sensitive lifestyle changes Phase II: Prerequisites No recent psychological crises, optimal levels of affect regulation, a safe and trusting psychotherapeutic relationship. Phase II: Start by exploring patients’ lives not only their problems Examine the complex and changing nature of meanings Explore and expand meanings The psychotherapeutic relationship is a reflection of larger macro-social process in which power dynamics are played-out Address the cultural influences affecting the psychotherapeutic relationship Ruptures/mistakes are inevitable Use patients renewed sense of vitality Phase III: Prerequisites: Know and be interested in understanding our cultural context Meanings of symptoms are often culturally dependent Link contextual influences to patient’s life Culturally differences are assets Awaken to social justice Embrace multiple stories Restore connections and encourage new ones Talking is not enough: Action is necessary Understand that what is local is global Cope with termination issues

Specific Cultural Psychotherapy skills through a clinical vignette provided by the presenter

Case Study: An Anti-Violence T-Shirt Campaign A group of adolescents led by one of La Roche’s students who was Japanese American. The group of adolescents consisted of three Latino and three African American boys. Their initial goal was to enhance communication, but as the group progressed they changed goals based on what they wanted to change. The group of adolescent boys decided to be an anti-violence group and created T-shirts to support their anti-violence stats. Phase I: Safety was one of the main priorities Discussion of cultural and demographic differences in the group, so the individuals would feel comfortable mentioning and further addressing these cultural differences. Psychoeducation in this phase is incredibly important Phase II: The phase where it begins to be more “we” than “I” Rules and regulations needs to be put in place and enforced, so that no one gets hurt Boundaries and objectivity is important in this phase because we can make more mistakes here Phase III: Be aware of what is happening in the community - the patients want to know the cultural context See cultural differences as aspects, which takes a long time Group leader/clinician should do it with patient(s), feel it with them Group started realizing they need to be more open to social justice Seeing different perspectives

Other 2019 Days

• SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2019/Day 1
• SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2019/Day 2