1. Using Components of an Evidence-Based Therapy in the Classroom
SPARCS
Using Components of an Evidence-Based Therapy in the Classroom
Collaboration with many folks
Angel Knoverek, MS, LCPC
Chaddock, Director of Trauma Initiative 1

2. SPARCS: Structured Psychotherapy for Adolescents Responding to
Chronic Stress
A 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 Hospital
Manhasset, New York
Copyright 2008 by North Shore - Long Island Jewish Health Systems, Inc., Great Neck, New York

3. Why SPARCS: A little bit of light pushes away a lot of darkness 3
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4. “Sparc” To set in motion; activate To rouse to [mindful] action
A latent element capable of growth or development
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5. SPARCS For adolescents between 12-21 years old
16 Sessions (60 minutes per session)
History of chronic (interpersonal) trauma
Designed for adolescents who may be living with significant ongoing stressors
May or may never have met full criteria for PTSD
Exhibit functional impairment
Present-focused and Strength-based
No systematic exposure component included
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6. SPARCS Core Skills
MAKE A LINK = communication & connecting with others
Let’MGo = problem-solving and creating meaning
Distress Tolerance = coping more effectively in the moment
Mindfulness = cultivating awareness
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7. Treatment Overview Session 1 Welcome and Intro
Session 2 Stress, trauma & the body
Session 3 Mindfulness: States of Mind
Session 4 Mindfulness: Path to Wise Mind
Session 5 Distress Tolerance: Self-Soothe
Session 6 Distress Tolerance: Distract
Session 7 What is Trauma?
Session 8 LET’M GO
All of the skills you bring to the group are key
Most imp to learn the concepts and then adapt the language, examples and role plays to fit your kids
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8. Treatment Overview Session 10 MAKE a LINK
Session 9 LET’M GO, Part 2
Session 10 MAKE a LINK
Session 11 MAKE a LINK, Part 2
Session 12 Anger & Triggers
Session 13 Portrait of My Life
Session 14 Expectations & Beliefs
Session 15 LET’M GO & MAKE a LINK, Revisited
Session 16 Graduation
All of the skills you bring to the group are key
Most imp to learn the concepts and then adapt the language, examples and role plays to fit your kids
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9. SOS SLOW DOWN ORIENT YOURSELF SELF-CHECK
Take a time out; calm your body; one thought at a time
ORIENT YOURSELF
Bring your mind & body back to the present time and place
SELF-CHECK
Rate your level of personal distress and sense of control here and now
See handout 3.3
Discuss S and O then go to next slide then return to this slide
Beginning of sessions 1-4 and then used in most sessions. Use whenever you think would be helpful
RTC story: rating staff—group member said to a co-leader outside group, “you look like an 8 and a 3” and she was right
Always start LET’M GO and all other skills with this
At beginning co-leaders may have to do this but after a little while, have youth lead themselves
LEFTOVER
RTC story: rating staff
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10. See SPARCS Handout SOS H 1.2 Slow Down Orient Self-Check
Ford et al., 2001
Copyright 2008 by North Shore - Long Island Jewish Health Systems, Inc., Great Neck, NY

11. Feeling Intensity Thermometer1 5 10
Separating these two concepts can be very helpful
Good place for leaders to bring in their own examples and share them—it is especially helpful if you are upset but still in control since this is often a surprise to youth
Kids often use this outside of group in discussing how they feel
Suzanne: LEFTOVER
The Copers
Andrus: to staff person (who was upset) folding laundry-
- your personal control looks like a 3, but I bet you’re personal distress is a seven.
Andrus: child to staff when upset- “take my pulse”-
- showing an understanding of the connection between emotions and the body.
Personal Distress Right now I feel …
Completely Calm Most Distressed Ever
Personal Control Right now I feel …
In complete control Totally out of control
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12. See SPARCS Handout SOS Thermometer H 1.3
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13. Woven Throughout the Treatment
Mindfulness
Core skill in dbt
From buddhism
People often think about meditation & breathing. Actually much more than that
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14. Paying attention in a particular way:
Mindfulness
Paying attention in a particular way:
On purpose,
in the present moment,
and nonjudgmentally
Kabat-Zinn, 1994
Use example (e.g. ruth didn’t know who our waitress was)
Judgment throws kids into emotion mind (e.g. play music you think they’ll hate and describe it non-judgmentally.)
Often individuals in the group have great difficulty tolerating discomfort and negative emotions and the goal is to reduce reactivity to them. E.g., fight with boyfriend so go out drinking or get high, verbally attacking another student in class because offended by a comment she made and ruminate for days, visualizing wanted to strangle her instead of experiencing the shame she felt in class. If one is being mindful, there will be a reduction in impulsive behavior because there will be a slower reactivity to things like this.
Much of the suffering comes after these events—thinking about the past or anticipating the future. Focusing on what the other student said in class, how unjust and mean it was, and how she’s going to fight fire with fire when they meet up again—how justice will be served. When this goes on over a long period of time, there is almost a loss of the present.
Listen to music to practice with holding judgment
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15. Mindfulness The quality or state of being mindful ….of being Attentive
Heedful
Thoughtful
Earnest
Intentional
Adapted from the
Oxford Dictionary
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16. Mindfulness Practice: Observe Your Thoughts
What
How
Without Judgment
Stay Focused
Do What works
Observe
Describe
Participate
Provide instructions. Observe thoughts, (like on a conveyor belt, or clouds floating past in the sky). Categorize if that helps: e.g. thoughts about work, thoughts about home, etc. If you drift, that’s ok. Notice that and pull yourself back. Don’t judge
Observe: noticing the experiencing inside and outside of you
let the experience wash over you
don’t push it away
don’t change it
Describe: just describe
feet in water/sand
water cold, don’t run from it; feels good, don’t go in more. Just describe
Participate: be present
even if painful
can use distract skills, but only after have made a wise mind decision to do so. 1st must participate.
Without Judgment: judging throws you into emotion mind
don’t judge your judging
One-mindfully: one thing at a time
e.g. come home, play on machine, rifle through fridge, if someone asks
how you are feeling, would you be in a position to tell them?
Do what works: don’t cut off nose to spite your face
let go of hard feelings
focus on what will help you reach your goals (e.g. yell at mom b/c wants
you home by 10pm, now she says you’re not going anywhere)
break goals down into small steps
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17. It’s not just WHAT you’re thinking but HOW you’re experiencing it.
Mindful Awareness
It’s not just WHAT you’re thinking but HOW you’re experiencing it.
What you’re thinking is separate from who you are.
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18. Mindfulness takes Practice, Practice, Practice!
Discuss change in grp over time—more giggles at first and shorten time in the beginning to 1 minute and work our way up to 2 minutes
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19. Wise Mind & Mindfulness:
Pieces of the Intervention for…
Regulation of Affect and Impulses
Somatization
Attention
Self-perception
Rated most helpful
Reg of affect and impulses: to be mindful one must observe and describe affect & urges and this practice will lead to slower reaction time to upsetting/stressful events
Attention: part of mindfulness is about focus, one thing at a time
Self-perception: Wise mind is an intuition and wisdom that everyone has. Runs contrary to feeling damaged and ineffective
Somatization: better able to observe and describe physiological reactions, normalize them and properly label the emotion that precedes or maintains them—listening to the body’s alarm system in a more effective way
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20. Mindfulness Research 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 (Baer, 2003)
CHANGES IN BRAIN FUNCTION
DAVIDSON: mindfulness- affect and immmune function
Mindfulness Practice “can produce increases in relative left-sided anterior activation that are associated with reductions in anxiety and negative affect and increases in positive affect”
Methods: 8 weeks at work, hours/week and home for 1hr. day (6 days a week), and one 7-hour retreat. N = 25. wait list control
Measures: EEG (fyi: didn’t look at or find anything going on on the right side of brain). Panas- brief measure of positive and negative affect
State-Trait anxiety inventory
Results: increase in left-sided activation (which was previously associated with positive affect- but this wasn’t demonstrated on the panas. Instead, showed less negative affect at time 2 & 3 than at time 1)
? Decrease in anxiety (double check)
increase in antibody titers to flu vaccine
(evident 4 months later)
LAZAR
“Activates the neural structures involved in attention and arousal/autonomic control” of the nervous system
Methods: fmri taken during meditation (had practiced meditation for 4 years- observe breath and repeat phrase)
Mindfulness with prison populations (Marlatt):
10 day mindfulness course vs. tau
Fewer arrests, alcoholism, drug use
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21. Mindfulness Practice: Changes in Brain Function
Mindfulness Practice “can produce increases in relative left-sided anterior activation that are associated with reductions in anxiety and negative affect and increases in positive affect” (Davidson, et al., 2003)
Still evident 4 months later
Activates the neural structures involved in attention and arousal/autonomic control” of the nervous system (Lazar et al., 2000)
DAVIDSON: mindfulness- affect and immmune function
Methods: 8 weeks at work, hours/week and home for 1hr. day (6 days a week), and one 7-hour retreat. N = 25. wait list control
Measures: EEG (fyi: didn’t look at or find anything going on on the right side of brain). Panas- brief measure of positive and negative affect
State-Trait anxiety inventory
Results: increase in left-sided activation (which was previously associated with positive affect- but this wasn’t demonstrated on the panas. Instead, showed less negative affect at time 2 & 3 than at time 1)
? Decrease in anxiety (double check)
increase in antibody titers to flu vaccine
(evident 4 months later)
LAZAR
Methods: fmri taken during meditation (had practiced meditation for 4 years- observe breath and repeat phrase)
MISC: davidson 2003 and Goleman 2005
Increase in positive affect associated with activity in left pre-frontal cortex
decrease in negative affect associated with activity in right pre-frontal cortex and amygdala
How often do they practice? How old were the subjects?
Was it in a class or at home or both?
What does the increase in activity mean in terms of behavior?
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22. Mindfulness Practice: Changes in Brain Function
Monks & Mindfulness (Lebow, 2005):
“Monks’ brain waves were better organized and coordinated”
Higher activity in left prefrontal cortex = associated with happiness
Differences apparent during periods of non-meditation =
fundamental changes in how the brain operates
Magnitude of differences related to length of practice
What does higher levels of consciousness mean?
What changes occurred during non meditation
How much practice?
Monks have higher levels of gamma brain waves = higher levels of consciousness (re-insert this bullet after goold “higher level of gama brain waves and find out what that actually means. Re-insert it just before “differences apparent…” bullet.
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23. Mindfulness Practice: Improved Physical Health
Increased flu antibodies following 8 weeks of mindfulness (Davidson 2003)
Improvements in symptoms related to numerous medical conditions
Chronic pain (Kabat-Zinn 1982, 1987; Randolph et al. 1999)
Fibroymyalgia (Goldenberg et. al. 1994)
Psoriasis (Kabat-Zinn, et. al. 1998)
Ratings based on:
SCL-90
Self-report
Bdi
Sleep
Bai
Mandy: add more info on the davidson article. Methodology and measures. Tau, or wait list control? How often did they practice? Were they assessed for imprvmnts in psychological well being as well?
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24. Mindfulness Practice: Improvements in Psychological Well Being
Rated as most helpful by teens diagnosed with BPD (Miller et al., 2000)
Improvements in general mood and decrease in stress (Baer, 2003)
Decrease in anxiety (Baer, 2003)
Decreased rate of relapse and recurrence of MDD (Baer, 2003)*
Findings evident in many populations
e.g. cancer patients - maintained at 6 months
e.g. patients with anxiety disorders - maintained at 3 years
Research in its infancy
Meta-analysis: effect size = (i.e. 74% did better than tau or no treatment)
Improvements in general mood and decrease in stress (in several populations) (Baer, 2003)
pops = chronic pain, axis I, binge-eating disorder, depression, gad, panic, fibro myalgia, psoriasis, cancer, Gad, Decreased rate of relapse and recurrence of MDD (Baer, 2003)*
most significant differences were with more severe patients (3+ episodes)
Are these studies separate from teasdale’s work?
Bullet 1 – jill’s group at montefiore? yes
** = well-established, well-controlled studies
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25. Mindfulness: States of Mind
Reasonable Mind
Emotion Mind
Kids don’t develop the brain capacity to make decisions while emotional until they’re young adults. These are regular kids (imagine with traumatized kids). (Ruth read this somewhere)
Emotion Mind
Fight—bad outcome
Good outcome when there is danger—after 9/11 terrorist lighting his shoe
Personal experience with emotion mind in the airport
Long line to get boarding pass, long line to screen bag, 3rd line to get to gate, david throws himself on the ground
--happy yelling at football game, absorb yourself in a good movie
Reasonable mind- don’t need to be in touch with our emotions all the time.
Wise mind is about paying attention to your intuition, your gut feeling, what you know to be true.
Wise mind is about experiencing the world as it is, as it occurs to your true self. Being aware. Everyone can get into wise mind it’s just a matter of getting into it when you want to. Learning to access it.
Some group members may feel they have no wisdom—they do, it just takes practice to access it. This can be empowering because the message is that this powerful, invaluable state of being is something that they already have.
I think we all try to teach this to our kids as well—how to access their wise mind
Sam example, trying to decide whether or not to spend the night at grandparents
Role play here: 4 volunteers to play the 3 states of mind and a difficult boss
Wise Mind
Copyright 2008 by North Shore - Long Island Jewish Health Systems, Inc., Great Neck, NY
Linehan, 1993 25

26. Traumatic Reminders/Triggers
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27. Distress Tolerance: (Hanging In)
When?
Situations you can’t fix right now
To get through the moment- (short-term solution!)
After SOS or Wise Mind
What are Distract and Self-Soothe?
Distract- not as simple as it sounds
Self-Soothe with the 5 senses
About “hanging in” when you feel horrible. Doing something “in the moment”.
When?
When there is nothing you can do to change the situation right away.
- e.g. yelling at home, angry at someone but can’t get in touch with them to talk it out.
b. To get through the moment
c. When you make a WISE MIND decision to do it. Don’t do it absent-mindedly
2.Distract MINDFULLY-
different from picking up a book and reading it. You should do it mindfully, be aware of what you are doing, know that it is is time-limited.
Fully participate- block out other distractions.
Many people are good at distracting, but don’t necessarily do it mindfully
3. Soothe with 5 senses MINDFULLY-
different from scarfing down a pint of ice cream when your upset.
Notice each sensory experience- pay attention to nothing else
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28. Distress Tolerance: Distract & Self-Soothe
How?
On purpose & mindfully
Why?
To manage the moment
To keep from doing something that might make the situation worse
To avoid engaging in a harmful behavior
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29. Distract With… Activities Contributing Comparisons
Hobbies, exercise, cleaning, go to events, call or visit a friend, play computer or video games, go online, go for a walk, read a magazine or book, do homework, play sports, go out to eat, draw, paint, listen to music.
Contributing
Contribute to someone else, do volunteer work, give something to someone else, make something nice for someone, do a surprising, thoughtful thing for someone you care about or someone you don’t even know.
Comparisons
Compare yourself to others who are also in tough situations.
Opposite Emotions
Read emotional books or stories, listen to emotional music. Be sure the event creates different emotions. Ideas: scary movies, joke books, comedies, funny records, go to the store & read funny greeting cards.
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30. Distract With… Pushing away Other Thoughts Intense other Sensations
Leave the situation mentally for a while. Just for now, build an imaginary wall between and you the situation or block it from your mind. Refuse to think about the situation. Censor ruminating. Put the pain on a shelf. Box it up and put it away for a while.
Other Thoughts
Count to 10, count colors in a painting or tree, work, do puzzles, watch TV, read. Deliberately engage in other thoughts.
Intense other Sensations
Hold ice in hand, squeeze a ball very hard, stand in a hot shower, listen to loud music.
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31. Distress Tolerance: Key Points
When not to use
When you or someone else is in danger
If it’s all you use all the time (avoiding things you can address)
Short vs. Long-Term Coping
Expand Repertoire
Distress Tolerance vs. Mindfulness
Must be mindful to practice distress tolerance,
but not all mindfulness is distress tolerance (e.g. mindfully observing thoughts when it might be better to distract)
When not to?
When you or someone else is in danger and you need to do something
When it becomes your only way of coping- AVOID things you CAN address
Short vs. long-term solution: Distress Tolerance is meant as a short-term solution ONLY. If find yourself relying on it repeatedly, then need to come up with other ways to cope. An adaptive strategy can become maladaptive if it becomes your sole coping mechanism.
Expand repertoire: people tend to practice things that have worked for them in the past, however, the same thing won’t work for every situation. If used to distracting with t.v., try self-soothe. If used to soothing with food, try soothing using a different sense.
Distress tolerance vs. mindfulness: e.g. if observe thoughts or emotions while your parents are fighting, it may be harder for you to cope in the moment.
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32. LET ‘M GO When faced with a stressful situation/reminder of the past:
These steps were designed to help you figure out what you want to hold on to—what is important to you,
and what you want to let go of because it’s just causing you more problems.
It’s about making a mindful choice and listening to your wise mind.
It’s about having the freedom to make a choice about what you want; what you want to hold on to and what you want to let go of in your life and relationships—rather than letting other people or letting the pain from the past choose it for you.
For those who have had experience with CBT, LET’M GO is a problem-solving strategy including generating pros and cons but with a little twist (including meaning)
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33. What We Don’t Mean
When you’ve been upset, mad, worried, etc. people may have said to you at one time or another—or maybe you even said to yourself—just let it go. Move on, get a grip.
That’s not what these steps mean. If it were that easy, you would have done that a long time ago.
This validates their life experiences—
doesn’t just suggest they should have let go of problematic experiences
doesn’t imply that they should have or could have let things go that have caused them problems
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34. LET ‘M GO What are you doing that’s working – why not do more of that
And let go of what is not working
It’s about having the freedom to make a choice about what you want; what you want to hold on to and what you want to let go of in your life and relationships—rather than letting other people or letting the pain from the past choose it for you.
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35. LET ‘M GO Losing it Why am I losing it? What are my triggers? Emotions
SOS BeMindful SOS BeMindful SOS BeMindful
Losing it
Why am I losing it?
What are my triggers?
Emotions
What am I feeling?
Thoughts
What am I thinking?
Meaning
What is really important to me?
Goals
What do I want?
Options
What are my choices?
Just put this up now—will go through each letter in a few slides
LET’M GO is a group activity
Either co-leaders should model scenario at the start or use actual problems members bring to group (after asking if it is okay to have the group use someone’s problem)
Done as a group. Although there is usually one volunteer—leaders reach out to everyone to answer the questions based on how someone else might also feel in that same situation
How would you feel if that happened to you?
What do you think made him feel so upset?
Discuss goals and option, writing down all ideas no matter what they are—don’t judge.
As a second step list pros and cons for each goal and option, this will lead the youth to dismiss many of the goals and options
Look for short-term and long-term goals and short-term and long-term options—this leads back to meaning again
Look for something that did go well even if it was only their intentions (& the behavior didn’t go so well)—this can lead to discussion of meaning again
SOS BeMindful SOS BeMindful SOS BeMindful
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36. Making Meaning
Meaning is the sense that, no matter what is going on in your life, you can hang onto the things that really matter to you. It is the belief that there are elements and people and views that cannot—no matter what—be taken from you.”
-Viktor E. Frankl
This idea can help your group members identify this complex concept
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37. Making Meaning Identify beliefs and values
Identify what went well, their contribution
Look to the future
Reframe
What is important—related to identifying their purpose in life, what gives their lives meaning. Allows therapist to validate and connect—therefore, the problem solving steps will be more personally relevant and important
Suzanne’s:
2. Be sure to look for intent—at the beginning it might be very hard to find something that really went well so look at the intent:
e.g. Boy in group beat-up a bully in school and sent him to the hospital for threatening his friend and got expelled. Despite the very bad outcomes the intent had strong
meaning—protecting a friend from a bully
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38. Making Meaning
Help them identify underlying sustaining beliefs and values driving behavior or goals
What was most important to you in this situation?
Leaders need to guide through questions and then label
e.g. “Why do you think you got SO upset?” “It’s wrong for anybody to talk to somebody like that.” “So it sounds like it is really important to you that people be treated with respect.”
LEFTOVER from before
e.g. family bond, being connected, relationships and trust.
e.g. fitting in, to be liked.
Go to flip chart
Justice, Fairness, Equality, Democracy
Why is it bad things happen to good people?
Why is life unfair at times?
Honesty, Being trustworthy
Loyalty: To friends, family, community, country, etc
Freedom to make choices—being empowered
Kindness & Helping others: Friends, family, animals, strangers
Spirituality- higher power, religion, etc.
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39. The thing that upsets people is not what happens but what they think it means. Epictetus
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40. MAKE a LINK Communication Skills
Based upon Interpersonal Effectiveness skills taught in DBT (Dialectical Behavior Therapy)
When?
Why?
Get what you want or say “no” to a request
Keep the relationship
Keep your self-respect
Will review each step in-depth on day 2
MISC:
Why make a link? (Good for yourself and good for the relationship).
1.It is interpersonally effective.
2. get what you need.
3. meet the needs of people you are dealing with.
4. keep your self-respect.
Mindfully Ignoring:
Mindfulness is not just about you. It’s about others. Your relationships.
What you do or don’t do affects others.
When make a link?
When have a clear goal in mind.
When dealing with an immediate problem.
The person you want to make a link with is willing and able to listen (when you are in wise mind and they are in wise mind)
When what you need involves others. (most often the case).
Communication- anytime communication is involved, try making a link.
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41. In order to get what you want and need, you must “MAKE A LINK” or connection with the other person
(be) Mindful
Act confident
Keep a calm & gentle manner
Express interest
Ask for what you want
Let them know you get their point of view
Include your feelings
Negotiate—give to get
Keep your self respect
Give dissertation example
Refer to handouts
Discuss each point and give examples:
First 4 steps are how, the rest are skills
Review each step, focus on some: validating does not mean agreeing, difference between being assertive and aggressive (Madonna heights valley girl example), getting respect thru aggression. Negotiating can be empowering. Most difficult steps are the “l”, “n”
Dissertation example: sent an outlining each step.
Catherine’s example of trying to make a link when son wasn’t ready
Example of teen who negotiated skipping (1 out of 4) baseball practices per week to come to group.
TAP: teen missed class (schedule changed). Practiced make a link in group to make a link with the teacher after class.
Group member took make a link handout home and taught it to her sister and sister’s boyfriend (who had been fighting).
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42. For more information….
Contact Angel Knoverek at
Contact Michele Stinnett in the Admissions Department at or call , ext. 347