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Rebecca C. Shaffer, Psy.D - Guest
Rebecca C. Shaffer, Psy.D. is a clinical psychologist and currently serves as an Associate Professor of Pediatrics at Cincinnati Children’s Hospital with an affiliated appointment at the University of Cincinnati. Rebecca is the director of Psychological Services for the Cincinnati Fragile X Center, where she oversees the assessment and treatment of individuals with fragile X syndrome (FXS). Rebecca and her team have created an emotion dysregulation treatment program for children with ASD called Regulating Together. Regulating Together treats emotion dysregulation, especially with reactivity and irritability, in a group setting with concurrent caregiver training. She currently leads several research studies, as well as publications, focused on the development and efficacy of this program. She also serves as the primary investigator of the Simons Foundation Powering Autism Research (SPARK) study at Cincinnati Children’s and other ASD-specific studies. Rebecca has had numerous publications and trains clinicians in Regulating Together throughout the country. To learn more about training in Regulating Together and the research behind it, check out the Shaffer Lab and contact by clicking here. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, PsyD: (00:22)
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up-to-date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the Director of the Institute for the Advancement of Psychotherapy. Today, I'll be speaking with Dr. Rebecca Schafer who is a clinical psychologist and serves as an associate professor of pediatrics at Cincinnati Children's Hospital, and she also has an affiliate appointment at the University of Cincinnati. Rebecca is the director of the Psychological Services for the Cincinnati Fragile X Center, where she oversees the assessment and treatment of individuals with Fragile X syndrome. Rebecca and her team have created an emotional dysregulation treatment program for children with autistic spectrum disorders called Regulating Together. Regulating Together treats emotional dysregulation, especially with reactivity and irritability, in a group setting with concurrent caregiver training. She currently leads several research studies, as well as publications, focused on the development and efficacy of this program. She also serves as a primary investigator of the Simons Foundation Powering Autism Research SPARK study at Cincinnati Children's and other ASD-specific studies. Rebecca has had numerous publications and trains clinicians in Regulating Together throughout the country. Let's listen to the interview. Well, hi Rebecca. Welcome. Thanks for coming in.
Rebecca C. Shaffer, PsyD: (01:50)
I'm so happy to be here. Thanks for inviting me.
Keith Sutton, PsyD: (01:53)
Yes, definitely. So I heard about the program Regulating Together from one of my clients. I'm actually working with a younger brother, but the older brother had gone through this program and the parent had said that it was really helpful. I think they're doing it at UCSF here, University of California, San Francisco. So, yeah, I would love to hear more about it. Before we even kind of get into that, I always like to hear about folks’ trajectory, of the things they've done and how they got to do what they're doing and the evolution of their thinking. So, yeah. Take it away.
Rebecca C. Shaffer, PsyD: (02:33)
Sure. All right. So, I knew that I wanted to be a psychologist for a long time, from a pretty young age, and I knew I wanted to work with children. So I got my doctorate at a program at Chestnut Hill College in Philadelphia that had a fairly generalist program. So I definitely got experience with adults and with kids, but it had a family-based component to it or a track. And so I was very interested in working with families in general, really wanted to make sure that I had skills to be able to work with caregivers and with kids both. So I had gotten lots of kid experience in internship, got lots of kid experience on an inpatient residential program.
Rebecca C. Shaffer, PsyD: (03:16)
And then realized that a gap in my training was within autism. So I really sought out a fellowship program that was going to give me some more experience with autism specifically. And then I fell in love with the autistic population and really enjoyed working with the kids and with their families. I was at Indiana University Riley Hospital for Children in Indianapolis and got a really nice experience with kids with autism both in individual therapy and in group therapy. So then started faculty at Cincinnati Children's Hospital, and there was a real gap in our service line. So we have an inpatient hospitalization here that serves kids with developmental disabilities and autism. And then we have a really great outpatient program. But there is a gap in between. So there were kids that needed a step down from inpatient, or they needed a higher level of care, but weren't really at the point where they needed a hospitalization.
Keith Sutton, PsyD: (04:18)
Sure.
Rebecca C. Shaffer, PsyD: (04:19)
And so I was asked to create this intensive outpatient model for these kids. And so we started off with some curriculums that were available, but once we got into it, we really realized it's not really attacking or addressing what we wanted within emotion dysregulation, and there just really weren't any interventions available that were going to tackle it for our kids with autism. So we ended up writing it ourselves as we did it. The research line really came out of the clinical need and the programming that we created for that clinical piece. And we knew that we wanted a caregiver component, so we developed them to happen concurrently both with kids and with caregivers at the same time, to really give them that coaching ability to work with their kids once the group was done.
Keith Sutton, PsyD: (05:17)
Yeah.
Rebecca C. Shaffer, PsyD: (05:18)
And then that has just kind of grown from there. So we developed this clinical program. We did a chart review and wrote up the data from the kiddos who had done it clinically. I received an internal grant to do a pilot with kids with autism specifically because our clinical program is a bit broader, for mixed diagnoses. And then that data was published, and I was awarded a Department of Defense clinical trial award, and that is in process right now. And then just earlier this year, I was also awarded a grant from the NIH to do a canine assisted version of this intervention. So we're doing it with therapy dogs starting this summer.
Keith Sutton, PsyD: (06:06)
Oh, that's great. I actually haven't been in the office since the pandemic, but I actually have a dog that comes with me to the office, and it's great with the kids. That's wonderful that you're including that in the research too, which is perfect.
Rebecca C. Shaffer, PsyD: (06:19)
Yeah, we're really excited about it.
Keith Sutton, PsyD: (06:21)
Nice. And I really love the family piece because my kind of grounding is in family systems. I also trained in cognitive behavioral therapy, and so I kind of integrate the family within that. So I would love to hear a little bit about…I guess one, just let's hear about the program, and if you could kind of describe that. And then two, I really like that you're involving the parents and having the parents doing the coaching, because that helps prevent relapse, and continuing the gains that are made outside once the therapy is over and between sessions and such. But yeah, tell me a little bit about the program or how it’s structured.
Rebecca C. Shaffer, PsyD: (07:04)
Sure. So Regulating Together is focused on emotion dysregulation for kids with autism and with broader diagnoses. So our clinical program is a mixed diagnostic group. And it is a group intervention, so we have about 6–8 kids in a group at a time.
Keith Sutton, PsyD: (07:22)
Mm-hmm.
Rebecca C. Shaffer, PsyD: (07:23)
And it meets for an hour and a half, twice a week for five weeks. So it is an intensive push, but it's for a small amount of time so families are usually able to do that level of intensity for five weeks.
Keith Sutton, PsyD: (07:35)
Uh huh.
Rebecca C. Shaffer, PsyD: (07:36)
So like I said, there is a kid group that is run by two leaders, and then there is a caregiver group that happens at the same time with one leader, which is typically a social worker or a psychologist. And the intervention really focuses on a progression of skills, starting with relaxation. So they learn a lot about deep breathing and muscle relaxation.
Keith Sutton, PsyD: (08:03)
Mm-hmm.
Rebecca C. Shaffer, PsyD: (08:03)
Then that progresses into understanding our triggers, understanding our body signs when we're upset, and then being able to rate our emotion on a five-point scale.
Keith Sutton, PsyD: (08:14)
Uh huh.
Rebecca C. Shaffer, PsyD: (08:15)
Being able to problem solve. So different options for problem solving. And then just a little bit of radical acceptance. So talking about how sometimes we can't solve our problems, and we have to decide whether we're going to let it go or let it bother us.
Keith Sutton, PsyD: (08:30)
Yeah.
Rebecca C. Shaffer, PsyD: (08:31)
And move past that problem. And then we talk about cognitive flexibility. So our kids with autism are often quite rigid and struggle with changes in their routines. So we are able to incorporate that flexibility piece within the group. We talk about sizes of the problem as well when we're doing problem sizes. So how big of a problem is this? Is my reaction fitting the size of the problem? So there's a lot of CBT techniques for this.
Rebecca C. Shaffer, PsyD: (09:00)
There's also quite a bit of mindfulness. So we're teaching the early relaxation skills, but then we're teaching some mindfulness strategies along the way, and those are practiced every single session that we see the kids.
Keith Sutton, PsyD: (09:11)
Oh, great. I'm wondering a little bit too about the cognitive behavioral therapy skills. So I don't do a lot of work with autism. I've had occasional clients that are on the spectrum. Sometimes they're coming to me for other things like OCD or I do a lot of work with ADHD and such. And I think that's one of the tough things with the cognitive therapy, because of the rigidity and the concreteness, that it's oftentimes difficult to think from a different perspective or how someone else might think about it because they're like, well, this is just how it is. Tell me a little bit about your thoughts on that or how you work with that.
Rebecca C. Shaffer, PsyD: (09:48)
Yeah. So we attempt to make things as concrete as possible because that is often an easier way to learn the material. So when it's really abstract, it gets a lot more difficult.
Keith Sutton, PsyD: (10:00)
Yeah.
Rebecca C. Shaffer, PsyD: (10:01)
So often we teach the material in, really, a Socratic method. So we're going to give you the information, and then when you have a question, we're going to bounce that back to the group at large to see how the rest of the group would respond, and see if they can answer it. And then we do activities that are specifically focused on reinforcing that material on an individual level.
Keith Sutton, PsyD: (10:25)
Mm-hmm.
Rebecca C. Shaffer, PsyD: (10:26)
So they're often using their own examples to apply the material, whether that be something about positive and negative thoughts, or whether it's about problem solving, but really applying it more specifically to themselves in that moment.
Keith Sutton, PsyD: (10:41)
Uh huh.
Rebecca C. Shaffer, PsyD: (10:42)
And so I think there's this thought in the field, maybe, that CBT doesn't work with kids with autism, and that's just really not true. It just takes more time sometimes. So, you know, we're reinforcing material quite a bit. I think that's where the caregiver component is so incredibly important. Because we can cover it, you know, for an hour and a half in group, but the parents are going to be the ones that are with their kids when this dysregulation is really occurring.
Keith Sutton, PsyD: (11:12)
Mm-hmm. So kind of coach through?
Rebecca C. Shaffer, PsyD: (11:16)
Yep. So everything the kids learn, the caregivers are learning as well. So they are learning the same material, and then they're learning specific coaching strategies to implement it at home and really keep that progress going. Parents also learn prevention strategies to behavior, how to handle a crisis, as well as reinforcement systems. So some basic behavior management in addition to the skills that they're learning, that their children are learning. So I really think it's the combo of the family having the same language, being in the treatment together, really getting all of that material together, and then also making it concrete and giving lots of opportunities to practice in group and at home that really helps that CBT component to be successful.
Keith Sutton, PsyD: (12:09)
Yeah. And they're practicing in reflection? Or are you having them do something together and then noticing what's happening in the moment? Or is it like talking about what happened at school that day, or like something that's happening right now with the other kid and them?
Rebecca C. Shaffer, PsyD: (12:24)
Yeah, so it's a little bit of both. So we're definitely reflecting, coming up with examples of things that happened at school earlier in the day, but also the group is structured in a way that we have the opportunity to see some of those social dysregulation things happening in vivo. So there's a snack period where they're encouraged to talk to each other, and then there's free time at the end of the group that they earn. So they have a reinforcement plan that they're following throughout the group. They earn the free time at the end, and we have activities there for them to do that pull for interaction.
Keith Sutton, PsyD: (13:04)
Oh okay.
Rebecca C. Shaffer, PsyD: (13:04)
So playing games together, following rules of games together, often are times when dysregulation occurs. And so when it happens in the moment, we're able to address it and talk them through it and help them to use their skills.
Keith Sutton, PsyD: (13:19)
Yeah. Okay. That's great. Wonderful. So yeah, with the parents, a little bit about what that looks like if their child is having a moment of extreme dysregulation at home or something. What are the tools that you're giving to the parents or kind of guidance for that coaching in those moments?
Rebecca C. Shaffer, PsyD: (13:43)
You know, it's a great question, and I think that caregivers have such a hard time when their kids are dysregulated, right? Like, it is really overwhelming. And it's hard to know what to do in the moment. So one of the pieces of the program that I think is incredibly helpful for caregivers is we're really encouraging them to have their own mindfulness practice, and they are also practicing relaxation in each session. Then their role as coach is really reinforced, that when your child is upset and they become very dysregulated, it's incredibly important for you to stay calm.
Keith Sutton, PsyD: (14:22)
Yeah.
Rebecca C. Shaffer, PsyD: (14:22)
Because that co-regulation piece is so important.
Keith Sutton, PsyD: (14:27)
Yeah, exactly.
Rebecca C. Shaffer, PsyD: (14:28)
Yeah. So really giving them some suggestions of ways to take care of themselves in the moment and some really clear ways to respond. So the tools that we use are quite concrete. We have this five-point scale where they're identifying how they're feeling, and we're giving the caregiver prompts on how to use that in the moment when they notice their child starting to get upset.
Keith Sutton, PsyD: (14:48)
Uh huh.
Rebecca C. Shaffer, PsyD: (14:49)
As well as breathing strategies to use with their kids, ways to talk about problems as they're happening, in order to prevent those outbursts from happening. So I tell caregivers all the time, this isn't a crisis management group. If we're in crisis, a lot of times, you know, we're not rational, and we have to calm down and get to the other side of that before we can talk about it. So we're giving them some crisis management tips in the moment to get through it.
Keith Sutton, PsyD: (15:23)
Mm-hmm. Yeah.
Rebecca C. Shaffer, PsyD: (15:23)
If that's what's occurring. But really the goal is to prevent us from getting there to begin with.
Keith Sutton, PsyD: (15:28)
Sure. Kind of like seeing the signs of it coming and being able to circumvent it.
Rebecca C. Shaffer, PsyD: (15:33)
Yep, exactly. And really using, you know, these skills of mindfulness and relaxation along the way so that our kid can stay at a more stable baseline period instead of shooting into those dysregulated periods quite so fast. Or the other thing that we hear from families is, you know, he's still having outbursts, but they're not lasting as long. They're not as severe. So he's able to calm faster and get to the other side of it faster. So I think those are positive things. We're not staying upset for as long.
Keith Sutton, PsyD: (16:05)
Definitely. Yeah. That's great. It reminds me of, I think, Ross Green's work with The Explosive Child – kind of identifying those situations and times and kind of understanding so you can potentially see it coming and be more prepared for those scenarios. So love what you're talking about because one of my specialties is with oppositional defiant disorder. I do a lot of work with ADHD, and there's a huge overlap. And oftentimes what we talk about with the parents is we're starting off teaching them co-regulation because sometimes the rules and consequences in a typical behavioral system doesn't work if the parent is kind of escalated and going into a power struggle. And so that idea of helping them stay grounded. I actually interviewed Deb Dana around her work on polyvagal and was kind of struck by that idea of helping get to that vagal state to kind of calm one's nervous system because our nervous systems play off each other and kind of…
Rebecca C. Shaffer, PsyD: (17:04)
Yeah, absolutely.
Keith Sutton, PsyD: (17:06)
…helping that parent to get that, because that's also another way. Just like when a baby's crying, if you start taking deep breaths and relaxing your body while you're kind of soothing them, they kind of sync up. So I'm interested in what you suggest in those crisis moments because I have a similar thing with those types of clients I work with because sometimes helping the parents understand, right, that there's not much learning that's going on in that moment. Like having the conversation or so on. Sometimes the kids are like a pit bull with their jaw locked at that moment or like backed into a corner. So lecturing or explaining or something is not really going to…so it's finding some way to de-escalate and get back to a grounded place to reengage. What techniques or what kind of suggestions do you give for parents in those crisis situations?
Rebecca C. Shaffer, PsyD: (17:56)
Yeah. So, you know, what you said in terms of you can't give a lecture during that time, right? I mean, parents really kind of want to lecture during that period. So really emphasizing the importance of silence or using less words in that moment is incredibly powerful. Sometimes silence is our most powerful tool.
Keith Sutton, PsyD: (18:17)
Yeah.
Rebecca C. Shaffer, PsyD: (18:18)
When we just calm ourselves and take a step back, especially for our kids with autism who have some communication difficulties. So if they're struggling with receptive language or expressive language, and we just keep firing off questions at them or statements that they may not be fully understanding, often escalating instead of de-escalating. We also talk a lot about proximity, so where I’m at in relation to you. Some kids are going to do better if you're closer and you're touching, whereas other kids are going to be better if you take a step back and give them some space.
Keith Sutton, PsyD: (18:54)
Yeah.
Rebecca C. Shaffer, PsyD: (18:55)
We talk about this idea of hurdle help. So we're going to do what we can to help you get over the hurdle of the task that's here. So can I get you started so you can finish it, or if you get started, can I step in and help you finish it? So that we can move on past this task. So not taking away demands necessarily, but just giving you the assistance to accomplish it.
Keith Sutton, PsyD: (19:19)
Yeah. So not kind of reinforcing an avoidant pattern or something. You're so upset, so we won't do it. Instead, kind of scaffolding and coming in to help persist despite the reactivity.
Rebecca C. Shaffer, PsyD: (19:32)
Yeah, absolutely. And then we use a lot of visuals in autism, so thinking about, you know, if there's been a visual of a relaxation or counting down. So like, starting with five and when I get to one, we're going to be done, and we'll go take a break away from each other. So really thinking about how you can communicate in a really concrete visual way in that moment that might be easier to understand.
Keith Sutton, PsyD: (19:55)
Yeah. Okay. Great. And what are your thoughts on time-outs or so on, as kind of a way of parent regulating child or helping with regulation? Do you have any thoughts on that? I know different people have different ideas about time-outs and time-ins and so on.
Rebecca C. Shaffer, PsyD: (20:16)
Yeah. So we don't really use time-outs in the program. We really focus a lot more on positive reinforcement. So how are we reinforcing the behavior we want to see versus really focusing in on the things that we don't want to see.
Keith Sutton, PsyD: (20:30)
Sure. Sure.
Rebecca C. Shaffer, PsyD: (20:31)
So, you know, we're not teaching any strategies for those consequences. The consequences are really just that you don't receive the reinforcement, whatever we're focusing on at this point. That being said, time away is actually helpful for some of our kids with autism. It's helpful to have a break and to step away so we talk a lot about the use of breaks.
Keith Sutton, PsyD: (20:54)
Yeah. Yeah.
Rebecca C. Shaffer, PsyD: (20:55)
Not necessarily as a consequence or, you know, removing attention. But this is helpful to you, so we're both going to just take a break away from the child right now and come back when we're ready.
Keith Sutton, PsyD: (21:05)
Yeah. That's kind of the way that I think about time-outs. It's a pattern interrupt and space to regulate rather than a punishment. It's not supposed to be painful, necessarily, it's more just to get into a safe space where the child can re-regulate and so on, to that peace. Actually, that leads me to another question because the same family I'm working with, we were talking and the mother also had a behaviorist coming into the home and helping them out. She was saying that it was solely reinforcement based, and so there were not any type of consequences or so on. So in part, she was kind of struggling with that because she was trying to re-regulate, but the other son has ADHD so it was a bit of a single parent and things would be a handful. Can you tell me a little bit about that? Is that kind of particular to autism, to working with kids with autism or, and again, I know we need to rely on that positive reinforcement and parent management training out reinforcing the target behaviors. But yeah, sometimes having some consequence piece…but I don't know, is that kind of a perspective at all in the…
Rebecca C. Shaffer, PsyD: (22:27)
You know, it's interesting. I do think that within the autism world, there has been quite a bit of a shift in terms of focusing a lot more on that positive reinforcement side, probably in the last like 10 years.
Keith Sutton, PsyD: (22:39)
Ah.
Rebecca C. Shaffer, PsyD: (22:40)
So really that focus has been there. I would just say like, as I work with kids who have emotion dysregulation, both with autism and without, oftentimes the consequence or taking away a reward is such a trigger in and of itself that we're maybe actually causing some harm instead of correcting the behavior in that moment.
Keith Sutton, PsyD: (23:02)
Yeah.
Rebecca C. Shaffer, PsyD: (23:02)
So really thinking about, does this behavior system, is it going to escalate it instead of actually addressing and changing the behavior? And then, is the behavior occurring because this is like an intentional negative behavior, or is it truly like this kid is dysregulated and so overwhelmed and they don't know how to handle it?
Keith Sutton, PsyD: (23:26)
Mm-hmm.
Rebecca C. Shaffer, PsyD: (23:26)
And, you know, I have a hard time using a consequence when there's a lack of skills on the kid's part, and they don't know what they're supposed to be doing.
Keith Sutton, PsyD: (23:35)
Yeah. Yeah. Definitely. Yeah. I worked at a number of residential treatment programs prior to grad school – four different ones actually – and they all had their different behavioral systems, and they found the ones that were earning rather than taking away tended to have a significantly different effect than the others, where oftentimes the kids were angry because they got something take away and were feeling like they should have everything, but then something gets taken away away rather than the reinforcement system where they get, you know, for the positive behaviors and earning.
Rebecca C. Shaffer, PsyD: (24:11)
Yeah, I had the same experience working in residential facilities and just seeing how those negative systems, or those point systems where they lose points and can get into the negative points. Like that doesn't really help in the long run.
Keith Sutton, PsyD: (24:28)
Yeah. Yeah. Definitely. Yeah. It just kind of creates almost more resentment because they end up feeling entitled to everything, and then it's being taken away rather than actually we’re earning. Something you were talking about too with the crisis situations is kind of interesting. I don't know how you think about this or work with the parents, but even with my own children when they were young and going through tantrums, you know, trying to be there and give them a hug or trying to regulate. And it wasn't until I read – I'm blanking on her name, from UCSF – The Emotional Life of the Toddler. But she talks about how sometimes the children just need to go to the depths of their emotion and then come out of it, and there's nothing the parent can do to, you know, make that stop or to soothe it or so on. They just kind of need to be there and make sure the kid doesn't hurt themselves, but they will kind of come out of it. And later as now I’ve learned more about exposure work and sitting with anxiety and riding that wave, you know, it's kind of a similar aspect.
Rebecca C. Shaffer, PsyD: (25:33)
Yep. Absolutely. We talk about that in session one with the caregivers, that if we're thinking about arousal and escalation, it's a wave exactly like we talk about with anxiety. And when we get to the height of it like that, we lose that rational control. But we have to come down. Our bodies can't stay in that heightened state. Thinking back to the nervous system and what you were talking about earlier, our bodies just aren't built for that so we're going to top out at some point and come back down. I think it's helpful for caregivers to hear that.
Keith Sutton, PsyD: (26:06)
Yeah.
Rebecca C. Shaffer, PsyD: (26:07)
To know that it's not going to last forever, but we might just have to sit with it for a little bit until, you know, this kiddo's body is done with whatever is happening at this escalation stage. But they will come back down, and as they're coming back down, here are the tools that you can use to coach them through coming back down.
Keith Sutton, PsyD: (26:26)
Yeah.
Rebecca C. Shaffer, PsyD: (26:27)
And getting to the other side of it.
Keith Sutton, PsyD: (26:28)
Great. Yeah. Oh, I think it was Alicia Lieberman's work. Um, wonderful. And so tell me a little bit about – what's your experience or what do you notice with the kids as they are internalizing some of those affect regulation skills? Because I think that is one of the hardest things and, and especially doing a lot of work with folks with ADHD, it's like the person knows what the skill is, but in the moment it's hard to put in. I mean, even adults have that difficulty, like knowing to breathe and so on. But then in the moment when they're at an 8 out of 10, it's kind of all out the window. What are your thoughts on that?
Rebecca C. Shaffer, PsyD: (27:08)
Yeah, so we talk a lot with caregivers about how this isn't going to happen overnight. They have developed these patterns for when they're dysregulated. So we're really changing that pattern and assisting with some new strategies. So don't expect them to implement it every single time when they're in that moment. But the caregiver-as-coach is incredibly important there too, right? So talking them through, where are you at on the five-point scale? We talk to them about – so five is fully escalated. When you get to a three, that's when you need to use your skills. If we wait until we get to a five, it's going to be too late. So really giving the kids some markers and some body signs of when they use the skill and not waiting until we're so overwhelmed that we can't think about it and do it.
Keith Sutton, PsyD: (27:57)
Yeah.
Rebecca C. Shaffer, PsyD: (27:59)
And then really having visuals available, making it part of the culture of their home. So encouraging caregivers to have other kids in the home practicing the skills too. They're good for everybody. And making it more part of their daily lives. Because if we're practicing relaxation daily on a regular basis, then we're more likely to use it in the moment. We've built that muscle memory to be able to actually implement it.
Keith Sutton, PsyD: (28:25)
Yeah.
Rebecca C. Shaffer, PsyD: (28:26)
And then I think the other piece of this too, is we run into a lot, and I'm sure you see this too, when you're in individual therapy trying to get kids to do new skills or to practice relaxation, sometimes they just refuse, right?
Keith Sutton, PsyD: (28:41)
Like take some deep breaths. I don't want to. Yeah, yeah.
Rebecca C. Shaffer, PsyD: (28:45)
I've already done that before. It doesn't work. Yeah.
Keith Sutton, PsyD: (28:46)
Yeah.
Rebecca C. Shaffer, PsyD: (28:47)
Right. So I think the group environment is incredibly powerful in this certain part. So there's some natural peer peer pressure that happens.
Keith Sutton, PsyD: (28:57)
Positive peer pressure.
Rebecca C. Shaffer, PsyD: (28:58)
Yep. If all of the other kids around me are practicing, I'm probably more likely to do it myself. So we see some of those more resistant kids who won't try new things being more likely to do it in the group setting.
Keith Sutton, PsyD: (29:11)
Mm-hmm.
Rebecca C. Shaffer, PsyD: (29:12)
Because they see everyone else doing it. And then if we're practicing it in group, we're getting it there. They're practicing it as part of their homework at home. We're encouraging the family to practice it together. We slowly get to that point where we can see it implemented a little bit more in the moment.
Keith Sutton, PsyD: (29:28)
Oh, great. Yeah. Sometimes I talk with clients – it’s almost like learning karate or something like that. They practice, practice, practice. So if they're in a bad situation, they don't have to think about it. Right. It just becomes natural.
Rebecca C. Shaffer, PsyD: (29:38)
Yeah, exactly.
Keith Sutton, PsyD: (29:39)
But yeah. Only trying to use it in the moment, right, it's not going to come to you.
Rebecca C. Shaffer, PsyD: (29:42)
Never works.
Keith Sutton, PsyD: (29:44)
Yeah. Yeah. Oh, great. Tell me about your thoughts on – there's been a lot of research on children with anxiety, and also oftentimes when a caregiver has anxiety too, the caregiver’s anxiety is not addressed and sometimes there's much more relapse. It sounds great because you're teaching them these skills in the goal of helping manage their children. But I imagine that the parents are also kind of being able to shift their own relationship with anxiety through this process. Are you seeing that or is that explicit at all? Or is anybody kind of speaking to that?
Rebecca C. Shaffer, PsyD: (30:32)
So we've definitely anecdotally heard that from families, that it really helped me a lot in my own life to be practicing relaxation or having a mindfulness practice. I've been able to use these skills myself to stay calm, not only with my kid, but just being able to stay calm in general. We do talk about how having a kid with autism with dysregulation can be really hard. And so making sure you take care of yourself is important. So encouraging them to seek out their own therapy if that makes sense. But we also know that caregivers are really busy and it's hard to make everything work. So hopefully we can give them some skills in the group to start to address it, even if they don't make it to their own therapy right away. We're starting to look at this in the Department of Defense funded trial right now. Caregivers are completing their own mindfulness measures as they enter. They're also filling out measures about themselves in terms of their stress level.
Keith Sutton, PsyD: (31:36)
Mm-hmm.
Rebecca C. Shaffer, PsyD: (31:37)
And where they're at in terms of that. And then we also collect family diagnostic history, so any diagnosis in caregivers, and really we hope at the end of this that we'll be able to look at some of those caregiver factors and see how they impact outcomes for kids.
Keith Sutton, PsyD: (31:54)
Definitely. Yeah, because I'd be interested too also about if the parent filled out a questionnaire and was meeting criteria for anxiety disorder. At the end of the treatment, would there be a change there, a difference or so on?
Rebecca C. Shaffer, PsyD: (32:09)
Yeah. Yeah. We're definitely very interested in that. We believe that there's probably some sort of impact there, right? Like there's no way that if the caregiver is struggling on their own, that that's not going to impact outcomes in general. So what can we do to kind of start to look at that? We're hopeful to see that. We also have a focus in that Department of Defense trial really thinking about diversity and how we're creating access to this intervention.
Keith Sutton, PsyD: (32:39)
Yeah.
Rebecca C. Shaffer, PsyD: (32:40)
So we're doing a few things as part of the study: We're providing mileage reimbursement and then childcare for siblings, which is like a huge need for these families. Like where do they put their other kids while they're in group? So we are offering that and then we're doing some qualitative interviews after the group to talk through barriers and facilitators’ and caregivers’ experience in the group. And, you know, what that was like for them. So we're also hopeful that we're going to learn more about caregivers and their experience through these interviews at the end of the study.
Keith Sutton, PsyD: (33:16)
Mm-hmm. Wonderful. Tell me a little bit about the parents’ coaching through the cognitive therapy and noticing the thoughts. I'd just be interested in how that goes. Some parents as they're trying to help out their kids – I don't know if it would necessarily be the topic in this population – but they're like, oh gosh, you know, everybody at school hates me or something like that. Right? Then the parents take the other side and say, no, they don't hate you. What about this person or that person? Kind of like, you know, from theory of motivational interviewing – the more that one takes one side of the ambivalence, they're sometimes eliciting the other side. Then the kid says, no, no, and it kind of sometimes can go back and forth and parents get frustrated. Everybody kind of gets frustrated in that scenario. I imagine that's going to be even a little harder, right, with parents trying to bring in a different perspective with the kids with autism who might have even more concreteness and less openness, maybe, to various perspectives. How does that work?
Rebecca C. Shaffer, PsyD: (34:14)
Yeah, that's a really great question and I think it's so incredibly tricky, right?
Keith Sutton, PsyD: (34:20)
Mm-Hmm.
Rebecca C. Shaffer, PsyD: (34:20)
Caregivers want to step in and fix it. They want to make things better and provide perspectives that are going to fix it, but that doesn't always help. And so we're really encouraging them to really get their kids just to talk about it. So having them come up with their own examples and not stepping in and providing the answer. The problem solving model that we use provides several options for the kid. But then sometimes, like I said, they're left with this choice of let it bother me or accept it and move on and do the next thing to help me get past it. So really we're coaching caregivers to not jump in and give the option. Can't solve the problem. We have to allow them the space to start to solve the problem. You know, caregivers of kids with autism often spend a lot of time managing the world for their kid.
Keith Sutton, PsyD: (35:21)
Yeah.
Rebecca C. Shaffer, PsyD: (35:22)
So like, really thinking of all the things that can go wrong and making a backup plan and having all of that ready for their kids. So we're really encouraging them to kind of take a step back from that. Let your child be involved in the backup plan. Let them think of those things. Because if we don't help them just start to build those skills, they're not going to be able to do it independently in the future.
Keith Sutton, PsyD: (35:47)
Sure, sure. And I imagine for some parents it might feel just easier. It's like, you know, it's like doing the dishes yourself rather than trying to teach the child to do the dishes, and they may break them, so it's like, ah, I'll just do it anyway. But yeah. Especially if they’re busy maybe. And so I like that though, that kind of, they're already doing this, and so more including and collaborating with kids,
Rebecca C. Shaffer, PsyD: (36:08)
Let's do it together.
Keith Sutton, PsyD: (36:10)
Yeah. Yeah. That's great. Yeah. Sometimes the way I think about it too is, as the parents are trying to help the kids with the problems, I always like Brene Brown's little video with a bear that goes down the hole, and talking about empathy and how to truly empathize, we have to connect with the part of ourselves that's felt that same feeling. And so if the parent is connecting with the child, you know, oftentimes they get dysregulated, so they try to give the other side and what about this, what about that? Rather than sitting with the kids and their emotions and going to that kind of dark place with them of like, nobody likes me or whatever it might be, and just sitting with them there. Because oftentimes from there, right, the kids kind of start to problem solve or can kind of come out of that. But yeah, this sounds like it's really great and really kind of helping to shift not only things for the kid, but the family system, and I imagine creating more lasting effects.
Rebecca C. Shaffer, PsyD: (37:05)
Yeah. That's our hope. And we definitely see in our outcomes from our pilot trials that the families have the most amount of change at about 10 weeks post intervention. And so I think that really speaks to the fact that the caregivers are keeping things going. It also probably speaks to the fact that dysregulation takes a little a while to change, right? It doesn't change right away. But that caregiver component, I don't have the data to say it, but I truly believe that we wouldn't see change at 10 weeks if caregivers didn't have the knowledge and the ability to coach their kids in continuing to use those skills.
Keith Sutton, PsyD: (37:45)
Yeah. Have you done a group just for the kids and no parents versus kids and parents?
Rebecca C. Shaffer, PsyD: (37:52)
So we haven't. We've certainly talked about it. Because I feel so strongly about the caregiver group, it's hard for me to think about providing that to kids and potentially not giving them the best intervention possible. But I do think that is a potential study down the line. Does it make sense to…and I also wonder about caregiver only, right? So like, if we just provide this to caregivers, do we see some of the change for some of our milder kids?
Keith Sutton, PsyD: (38:22)
Yeah.
Rebecca C. Shaffer, PsyD: (38:22)
Is that all that's necessarily needed? Maybe.
Keith Sutton, PsyD: (38:24)
Yeah. It's like Eli Lebowitz’s work, you know, just doing the work to address anxiety, but only working with the parents and not even with the kids and having the same results as individual CBT. And I think it would be great because I think that the parent component is often left out in practice at least, at least in our area. You know the therapists are usually working with the kids individually. And there's been some research and they’ve done some stuff with a coping cat and coping koala, with kind of no parents parents, but that it's still, I think, not widely really understood how significantly it can help increase change. And also, you know, create more lasting change and prevent relapse.
Rebecca C. Shaffer, PsyD: (39:11)
Yeah, for sure. I think that maintenance and generalization piece, and preventing the relapse, is just so incredibly important. So if we can show that we're doing that, I think that's even better for the field. It helps direct where we're going and definitely a future research idea. We're definitely interested in that down the road.
Keith Sutton, PsyD: (39:31)
Yeah, definitely. Now have you thought about or is there any kind of looking at applying this also to different populations? Because I imagine, right, kids with anxiety, oppositional, kind of other dysregulation, kids with trauma, you know all these kinds of things could be…this sounds like this could be really applicable.
Rebecca C. Shaffer, PsyD: (39:52)
Yeah, we are very interested in doing that. So, like I said, our clinical program is a mixed diagnosis group. We see kids come through with lots of different diagnoses. So it is something that I would be happy to partner with people who are interested in doing it in ADHD and anxiety. You know, we're focused on autism right now. I am part of a study that's getting ready to happen, though, where they're implementing it for kids with tuberous sclerosis, so TSC, and doing that virtual model because it's such a rare disorder. They're able to see more kids if they do it virtually. So really thinking about… The other thing that I'm incredibly passionate about and thinking about is developing it down for some of our lower functioning kids with autism who may not have as much language or as high of IQ. So how do we really tailor it to a lower IQ group and think about how we do that. We also have a study going right now that's on our inpatient unit where we're thinking about how do we start to build some of these skills while kids are in the hospital so that once they're out, they're ready to engage in another therapy and be able to be a little bit more regulated in the moment.
Keith Sutton, PsyD: (41:08)
Mm-hmm.
Rebecca C. Shaffer, PsyD: (41:09)
So yeah, I mean, I think it could be helpful. I believe it could be helpful. I think these things aren't specific to autism and yeah, it's definitely an interest for the future.
Keith Sutton, PsyD: (41:22)
Great. And I know they've got it at UCSF and I don't know… Do you know, is it kind of being widely adopted or is it… For folks that are listening, I don't know how they might get this program going. Do they get a manual and kind of do it? Or is there kind of a training through your group? Or…
Rebecca C. Shaffer, PsyD: (41:43)
Yeah. So we are in the process of publishing it. It's not available yet, but hopefully within the next year it'll be available for purchase. But for right now, if clinicians are interested, they can access it through training with our site. So we do training with groups. That's a bit of a discount if you have a lot of people joining from your institution. And then individuals can also join the training. It's a two-day training. The intervention is slightly different between children and teens. So we teach the curriculum for the 8–12 year olds on day one. We teach the intervention for the teenagers on day two. And then when you do the training, you also have access to me as a consultant afterwards. So I actually just met with UCSF this morning to talk through some issues that had popped up. So we've done training across the country for institutions. We've done it at Michigan and Georgetown University, UCSF, Maine. And so quite a few groups have done the training so far, and they're implementing it. Some of the groups are implementing it as a once-a-week model instead of a twice-a-week model. So I do think that's an option. We don't have data to support that yet, but I think it probably works in a once-a-week format.
Keith Sutton, PsyD: (43:01)
Sure. Definitely. Well, that's wonderful. Well, great. Well, you know, anything else that you think is important for folks to know about this population, this program that you're doing? I want to make sure we get all the pieces you think that would be helpful for our listeners to know about.
Rebecca C. Shaffer, PsyD: (43:19)
Yeah, I mean, I think that we covered a lot of stuff. I would also say if anyone is in training right now and they're interested in this population, we frequently take postdocs at our site for additional training. So please feel free to reach out if you're interested in getting further experience. But it's an amazing experience to work with these kids and to help them learn how to regulate. And it's certainly my passion, and I love doing it.
Keith Sutton, PsyD: (43:48)
Great. Well, thank you so much for all this great information and just the amazing work that you're doing. It sounds wonderful, and it's always nice to hear from a parent that went through it, of my own client, saying how effective it was. So it really is great. Thank you so much for taking the time today. I really appreciate it.
Rebecca C. Shaffer, PsyD: (44:06)
Thank you so much.
Keith Sutton, PsyD: (44:08)
Okay. Bye-bye. Thank you for joining us. If you're wanting to use this podcast to earn continuing education credits, please go to our website at https://therapyonthecuttingedge.com. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, providing in-person and remote therapy in the San Francisco Bay Area. IAP provides training for licensed clinicians through our in-person and online programs, as well as our treatment for children, adolescents, families, couples, and individual adults. For more information, go to https://sfiap.com or call (415) 617-5932. Also, we really appreciate feedback and if you have something you're interested in, something that's on the cutting edge of the field of therapy and think clinicians should know about it, send us an email or call us. We're always looking for the advancements in the field of psychotherapy to help in creating lasting changes for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up-to-date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the Director of the Institute for the Advancement of Psychotherapy. Today, I'll be speaking with Dr. Rebecca Schafer who is a clinical psychologist and serves as an associate professor of pediatrics at Cincinnati Children's Hospital, and she also has an affiliate appointment at the University of Cincinnati. Rebecca is the director of the Psychological Services for the Cincinnati Fragile X Center, where she oversees the assessment and treatment of individuals with Fragile X syndrome. Rebecca and her team have created an emotional dysregulation treatment program for children with autistic spectrum disorders called Regulating Together. Regulating Together treats emotional dysregulation, especially with reactivity and irritability, in a group setting with concurrent caregiver training. She currently leads several research studies, as well as publications, focused on the development and efficacy of this program. She also serves as a primary investigator of the Simons Foundation Powering Autism Research SPARK study at Cincinnati Children's and other ASD-specific studies. Rebecca has had numerous publications and trains clinicians in Regulating Together throughout the country. Let's listen to the interview. Well, hi Rebecca. Welcome. Thanks for coming in.
Rebecca C. Shaffer, PsyD: (01:50)
I'm so happy to be here. Thanks for inviting me.
Keith Sutton, PsyD: (01:53)
Yes, definitely. So I heard about the program Regulating Together from one of my clients. I'm actually working with a younger brother, but the older brother had gone through this program and the parent had said that it was really helpful. I think they're doing it at UCSF here, University of California, San Francisco. So, yeah, I would love to hear more about it. Before we even kind of get into that, I always like to hear about folks’ trajectory, of the things they've done and how they got to do what they're doing and the evolution of their thinking. So, yeah. Take it away.
Rebecca C. Shaffer, PsyD: (02:33)
Sure. All right. So, I knew that I wanted to be a psychologist for a long time, from a pretty young age, and I knew I wanted to work with children. So I got my doctorate at a program at Chestnut Hill College in Philadelphia that had a fairly generalist program. So I definitely got experience with adults and with kids, but it had a family-based component to it or a track. And so I was very interested in working with families in general, really wanted to make sure that I had skills to be able to work with caregivers and with kids both. So I had gotten lots of kid experience in internship, got lots of kid experience on an inpatient residential program.
Rebecca C. Shaffer, PsyD: (03:16)
And then realized that a gap in my training was within autism. So I really sought out a fellowship program that was going to give me some more experience with autism specifically. And then I fell in love with the autistic population and really enjoyed working with the kids and with their families. I was at Indiana University Riley Hospital for Children in Indianapolis and got a really nice experience with kids with autism both in individual therapy and in group therapy. So then started faculty at Cincinnati Children's Hospital, and there was a real gap in our service line. So we have an inpatient hospitalization here that serves kids with developmental disabilities and autism. And then we have a really great outpatient program. But there is a gap in between. So there were kids that needed a step down from inpatient, or they needed a higher level of care, but weren't really at the point where they needed a hospitalization.
Keith Sutton, PsyD: (04:18)
Sure.
Rebecca C. Shaffer, PsyD: (04:19)
And so I was asked to create this intensive outpatient model for these kids. And so we started off with some curriculums that were available, but once we got into it, we really realized it's not really attacking or addressing what we wanted within emotion dysregulation, and there just really weren't any interventions available that were going to tackle it for our kids with autism. So we ended up writing it ourselves as we did it. The research line really came out of the clinical need and the programming that we created for that clinical piece. And we knew that we wanted a caregiver component, so we developed them to happen concurrently both with kids and with caregivers at the same time, to really give them that coaching ability to work with their kids once the group was done.
Keith Sutton, PsyD: (05:17)
Yeah.
Rebecca C. Shaffer, PsyD: (05:18)
And then that has just kind of grown from there. So we developed this clinical program. We did a chart review and wrote up the data from the kiddos who had done it clinically. I received an internal grant to do a pilot with kids with autism specifically because our clinical program is a bit broader, for mixed diagnoses. And then that data was published, and I was awarded a Department of Defense clinical trial award, and that is in process right now. And then just earlier this year, I was also awarded a grant from the NIH to do a canine assisted version of this intervention. So we're doing it with therapy dogs starting this summer.
Keith Sutton, PsyD: (06:06)
Oh, that's great. I actually haven't been in the office since the pandemic, but I actually have a dog that comes with me to the office, and it's great with the kids. That's wonderful that you're including that in the research too, which is perfect.
Rebecca C. Shaffer, PsyD: (06:19)
Yeah, we're really excited about it.
Keith Sutton, PsyD: (06:21)
Nice. And I really love the family piece because my kind of grounding is in family systems. I also trained in cognitive behavioral therapy, and so I kind of integrate the family within that. So I would love to hear a little bit about…I guess one, just let's hear about the program, and if you could kind of describe that. And then two, I really like that you're involving the parents and having the parents doing the coaching, because that helps prevent relapse, and continuing the gains that are made outside once the therapy is over and between sessions and such. But yeah, tell me a little bit about the program or how it’s structured.
Rebecca C. Shaffer, PsyD: (07:04)
Sure. So Regulating Together is focused on emotion dysregulation for kids with autism and with broader diagnoses. So our clinical program is a mixed diagnostic group. And it is a group intervention, so we have about 6–8 kids in a group at a time.
Keith Sutton, PsyD: (07:22)
Mm-hmm.
Rebecca C. Shaffer, PsyD: (07:23)
And it meets for an hour and a half, twice a week for five weeks. So it is an intensive push, but it's for a small amount of time so families are usually able to do that level of intensity for five weeks.
Keith Sutton, PsyD: (07:35)
Uh huh.
Rebecca C. Shaffer, PsyD: (07:36)
So like I said, there is a kid group that is run by two leaders, and then there is a caregiver group that happens at the same time with one leader, which is typically a social worker or a psychologist. And the intervention really focuses on a progression of skills, starting with relaxation. So they learn a lot about deep breathing and muscle relaxation.
Keith Sutton, PsyD: (08:03)
Mm-hmm.
Rebecca C. Shaffer, PsyD: (08:03)
Then that progresses into understanding our triggers, understanding our body signs when we're upset, and then being able to rate our emotion on a five-point scale.
Keith Sutton, PsyD: (08:14)
Uh huh.
Rebecca C. Shaffer, PsyD: (08:15)
Being able to problem solve. So different options for problem solving. And then just a little bit of radical acceptance. So talking about how sometimes we can't solve our problems, and we have to decide whether we're going to let it go or let it bother us.
Keith Sutton, PsyD: (08:30)
Yeah.
Rebecca C. Shaffer, PsyD: (08:31)
And move past that problem. And then we talk about cognitive flexibility. So our kids with autism are often quite rigid and struggle with changes in their routines. So we are able to incorporate that flexibility piece within the group. We talk about sizes of the problem as well when we're doing problem sizes. So how big of a problem is this? Is my reaction fitting the size of the problem? So there's a lot of CBT techniques for this.
Rebecca C. Shaffer, PsyD: (09:00)
There's also quite a bit of mindfulness. So we're teaching the early relaxation skills, but then we're teaching some mindfulness strategies along the way, and those are practiced every single session that we see the kids.
Keith Sutton, PsyD: (09:11)
Oh, great. I'm wondering a little bit too about the cognitive behavioral therapy skills. So I don't do a lot of work with autism. I've had occasional clients that are on the spectrum. Sometimes they're coming to me for other things like OCD or I do a lot of work with ADHD and such. And I think that's one of the tough things with the cognitive therapy, because of the rigidity and the concreteness, that it's oftentimes difficult to think from a different perspective or how someone else might think about it because they're like, well, this is just how it is. Tell me a little bit about your thoughts on that or how you work with that.
Rebecca C. Shaffer, PsyD: (09:48)
Yeah. So we attempt to make things as concrete as possible because that is often an easier way to learn the material. So when it's really abstract, it gets a lot more difficult.
Keith Sutton, PsyD: (10:00)
Yeah.
Rebecca C. Shaffer, PsyD: (10:01)
So often we teach the material in, really, a Socratic method. So we're going to give you the information, and then when you have a question, we're going to bounce that back to the group at large to see how the rest of the group would respond, and see if they can answer it. And then we do activities that are specifically focused on reinforcing that material on an individual level.
Keith Sutton, PsyD: (10:25)
Mm-hmm.
Rebecca C. Shaffer, PsyD: (10:26)
So they're often using their own examples to apply the material, whether that be something about positive and negative thoughts, or whether it's about problem solving, but really applying it more specifically to themselves in that moment.
Keith Sutton, PsyD: (10:41)
Uh huh.
Rebecca C. Shaffer, PsyD: (10:42)
And so I think there's this thought in the field, maybe, that CBT doesn't work with kids with autism, and that's just really not true. It just takes more time sometimes. So, you know, we're reinforcing material quite a bit. I think that's where the caregiver component is so incredibly important. Because we can cover it, you know, for an hour and a half in group, but the parents are going to be the ones that are with their kids when this dysregulation is really occurring.
Keith Sutton, PsyD: (11:12)
Mm-hmm. So kind of coach through?
Rebecca C. Shaffer, PsyD: (11:16)
Yep. So everything the kids learn, the caregivers are learning as well. So they are learning the same material, and then they're learning specific coaching strategies to implement it at home and really keep that progress going. Parents also learn prevention strategies to behavior, how to handle a crisis, as well as reinforcement systems. So some basic behavior management in addition to the skills that they're learning, that their children are learning. So I really think it's the combo of the family having the same language, being in the treatment together, really getting all of that material together, and then also making it concrete and giving lots of opportunities to practice in group and at home that really helps that CBT component to be successful.
Keith Sutton, PsyD: (12:09)
Yeah. And they're practicing in reflection? Or are you having them do something together and then noticing what's happening in the moment? Or is it like talking about what happened at school that day, or like something that's happening right now with the other kid and them?
Rebecca C. Shaffer, PsyD: (12:24)
Yeah, so it's a little bit of both. So we're definitely reflecting, coming up with examples of things that happened at school earlier in the day, but also the group is structured in a way that we have the opportunity to see some of those social dysregulation things happening in vivo. So there's a snack period where they're encouraged to talk to each other, and then there's free time at the end of the group that they earn. So they have a reinforcement plan that they're following throughout the group. They earn the free time at the end, and we have activities there for them to do that pull for interaction.
Keith Sutton, PsyD: (13:04)
Oh okay.
Rebecca C. Shaffer, PsyD: (13:04)
So playing games together, following rules of games together, often are times when dysregulation occurs. And so when it happens in the moment, we're able to address it and talk them through it and help them to use their skills.
Keith Sutton, PsyD: (13:19)
Yeah. Okay. That's great. Wonderful. So yeah, with the parents, a little bit about what that looks like if their child is having a moment of extreme dysregulation at home or something. What are the tools that you're giving to the parents or kind of guidance for that coaching in those moments?
Rebecca C. Shaffer, PsyD: (13:43)
You know, it's a great question, and I think that caregivers have such a hard time when their kids are dysregulated, right? Like, it is really overwhelming. And it's hard to know what to do in the moment. So one of the pieces of the program that I think is incredibly helpful for caregivers is we're really encouraging them to have their own mindfulness practice, and they are also practicing relaxation in each session. Then their role as coach is really reinforced, that when your child is upset and they become very dysregulated, it's incredibly important for you to stay calm.
Keith Sutton, PsyD: (14:22)
Yeah.
Rebecca C. Shaffer, PsyD: (14:22)
Because that co-regulation piece is so important.
Keith Sutton, PsyD: (14:27)
Yeah, exactly.
Rebecca C. Shaffer, PsyD: (14:28)
Yeah. So really giving them some suggestions of ways to take care of themselves in the moment and some really clear ways to respond. So the tools that we use are quite concrete. We have this five-point scale where they're identifying how they're feeling, and we're giving the caregiver prompts on how to use that in the moment when they notice their child starting to get upset.
Keith Sutton, PsyD: (14:48)
Uh huh.
Rebecca C. Shaffer, PsyD: (14:49)
As well as breathing strategies to use with their kids, ways to talk about problems as they're happening, in order to prevent those outbursts from happening. So I tell caregivers all the time, this isn't a crisis management group. If we're in crisis, a lot of times, you know, we're not rational, and we have to calm down and get to the other side of that before we can talk about it. So we're giving them some crisis management tips in the moment to get through it.
Keith Sutton, PsyD: (15:23)
Mm-hmm. Yeah.
Rebecca C. Shaffer, PsyD: (15:23)
If that's what's occurring. But really the goal is to prevent us from getting there to begin with.
Keith Sutton, PsyD: (15:28)
Sure. Kind of like seeing the signs of it coming and being able to circumvent it.
Rebecca C. Shaffer, PsyD: (15:33)
Yep, exactly. And really using, you know, these skills of mindfulness and relaxation along the way so that our kid can stay at a more stable baseline period instead of shooting into those dysregulated periods quite so fast. Or the other thing that we hear from families is, you know, he's still having outbursts, but they're not lasting as long. They're not as severe. So he's able to calm faster and get to the other side of it faster. So I think those are positive things. We're not staying upset for as long.
Keith Sutton, PsyD: (16:05)
Definitely. Yeah. That's great. It reminds me of, I think, Ross Green's work with The Explosive Child – kind of identifying those situations and times and kind of understanding so you can potentially see it coming and be more prepared for those scenarios. So love what you're talking about because one of my specialties is with oppositional defiant disorder. I do a lot of work with ADHD, and there's a huge overlap. And oftentimes what we talk about with the parents is we're starting off teaching them co-regulation because sometimes the rules and consequences in a typical behavioral system doesn't work if the parent is kind of escalated and going into a power struggle. And so that idea of helping them stay grounded. I actually interviewed Deb Dana around her work on polyvagal and was kind of struck by that idea of helping get to that vagal state to kind of calm one's nervous system because our nervous systems play off each other and kind of…
Rebecca C. Shaffer, PsyD: (17:04)
Yeah, absolutely.
Keith Sutton, PsyD: (17:06)
…helping that parent to get that, because that's also another way. Just like when a baby's crying, if you start taking deep breaths and relaxing your body while you're kind of soothing them, they kind of sync up. So I'm interested in what you suggest in those crisis moments because I have a similar thing with those types of clients I work with because sometimes helping the parents understand, right, that there's not much learning that's going on in that moment. Like having the conversation or so on. Sometimes the kids are like a pit bull with their jaw locked at that moment or like backed into a corner. So lecturing or explaining or something is not really going to…so it's finding some way to de-escalate and get back to a grounded place to reengage. What techniques or what kind of suggestions do you give for parents in those crisis situations?
Rebecca C. Shaffer, PsyD: (17:56)
Yeah. So, you know, what you said in terms of you can't give a lecture during that time, right? I mean, parents really kind of want to lecture during that period. So really emphasizing the importance of silence or using less words in that moment is incredibly powerful. Sometimes silence is our most powerful tool.
Keith Sutton, PsyD: (18:17)
Yeah.
Rebecca C. Shaffer, PsyD: (18:18)
When we just calm ourselves and take a step back, especially for our kids with autism who have some communication difficulties. So if they're struggling with receptive language or expressive language, and we just keep firing off questions at them or statements that they may not be fully understanding, often escalating instead of de-escalating. We also talk a lot about proximity, so where I’m at in relation to you. Some kids are going to do better if you're closer and you're touching, whereas other kids are going to be better if you take a step back and give them some space.
Keith Sutton, PsyD: (18:54)
Yeah.
Rebecca C. Shaffer, PsyD: (18:55)
We talk about this idea of hurdle help. So we're going to do what we can to help you get over the hurdle of the task that's here. So can I get you started so you can finish it, or if you get started, can I step in and help you finish it? So that we can move on past this task. So not taking away demands necessarily, but just giving you the assistance to accomplish it.
Keith Sutton, PsyD: (19:19)
Yeah. So not kind of reinforcing an avoidant pattern or something. You're so upset, so we won't do it. Instead, kind of scaffolding and coming in to help persist despite the reactivity.
Rebecca C. Shaffer, PsyD: (19:32)
Yeah, absolutely. And then we use a lot of visuals in autism, so thinking about, you know, if there's been a visual of a relaxation or counting down. So like, starting with five and when I get to one, we're going to be done, and we'll go take a break away from each other. So really thinking about how you can communicate in a really concrete visual way in that moment that might be easier to understand.
Keith Sutton, PsyD: (19:55)
Yeah. Okay. Great. And what are your thoughts on time-outs or so on, as kind of a way of parent regulating child or helping with regulation? Do you have any thoughts on that? I know different people have different ideas about time-outs and time-ins and so on.
Rebecca C. Shaffer, PsyD: (20:16)
Yeah. So we don't really use time-outs in the program. We really focus a lot more on positive reinforcement. So how are we reinforcing the behavior we want to see versus really focusing in on the things that we don't want to see.
Keith Sutton, PsyD: (20:30)
Sure. Sure.
Rebecca C. Shaffer, PsyD: (20:31)
So, you know, we're not teaching any strategies for those consequences. The consequences are really just that you don't receive the reinforcement, whatever we're focusing on at this point. That being said, time away is actually helpful for some of our kids with autism. It's helpful to have a break and to step away so we talk a lot about the use of breaks.
Keith Sutton, PsyD: (20:54)
Yeah. Yeah.
Rebecca C. Shaffer, PsyD: (20:55)
Not necessarily as a consequence or, you know, removing attention. But this is helpful to you, so we're both going to just take a break away from the child right now and come back when we're ready.
Keith Sutton, PsyD: (21:05)
Yeah. That's kind of the way that I think about time-outs. It's a pattern interrupt and space to regulate rather than a punishment. It's not supposed to be painful, necessarily, it's more just to get into a safe space where the child can re-regulate and so on, to that peace. Actually, that leads me to another question because the same family I'm working with, we were talking and the mother also had a behaviorist coming into the home and helping them out. She was saying that it was solely reinforcement based, and so there were not any type of consequences or so on. So in part, she was kind of struggling with that because she was trying to re-regulate, but the other son has ADHD so it was a bit of a single parent and things would be a handful. Can you tell me a little bit about that? Is that kind of particular to autism, to working with kids with autism or, and again, I know we need to rely on that positive reinforcement and parent management training out reinforcing the target behaviors. But yeah, sometimes having some consequence piece…but I don't know, is that kind of a perspective at all in the…
Rebecca C. Shaffer, PsyD: (22:27)
You know, it's interesting. I do think that within the autism world, there has been quite a bit of a shift in terms of focusing a lot more on that positive reinforcement side, probably in the last like 10 years.
Keith Sutton, PsyD: (22:39)
Ah.
Rebecca C. Shaffer, PsyD: (22:40)
So really that focus has been there. I would just say like, as I work with kids who have emotion dysregulation, both with autism and without, oftentimes the consequence or taking away a reward is such a trigger in and of itself that we're maybe actually causing some harm instead of correcting the behavior in that moment.
Keith Sutton, PsyD: (23:02)
Yeah.
Rebecca C. Shaffer, PsyD: (23:02)
So really thinking about, does this behavior system, is it going to escalate it instead of actually addressing and changing the behavior? And then, is the behavior occurring because this is like an intentional negative behavior, or is it truly like this kid is dysregulated and so overwhelmed and they don't know how to handle it?
Keith Sutton, PsyD: (23:26)
Mm-hmm.
Rebecca C. Shaffer, PsyD: (23:26)
And, you know, I have a hard time using a consequence when there's a lack of skills on the kid's part, and they don't know what they're supposed to be doing.
Keith Sutton, PsyD: (23:35)
Yeah. Yeah. Definitely. Yeah. I worked at a number of residential treatment programs prior to grad school – four different ones actually – and they all had their different behavioral systems, and they found the ones that were earning rather than taking away tended to have a significantly different effect than the others, where oftentimes the kids were angry because they got something take away and were feeling like they should have everything, but then something gets taken away away rather than the reinforcement system where they get, you know, for the positive behaviors and earning.
Rebecca C. Shaffer, PsyD: (24:11)
Yeah, I had the same experience working in residential facilities and just seeing how those negative systems, or those point systems where they lose points and can get into the negative points. Like that doesn't really help in the long run.
Keith Sutton, PsyD: (24:28)
Yeah. Yeah. Definitely. Yeah. It just kind of creates almost more resentment because they end up feeling entitled to everything, and then it's being taken away rather than actually we’re earning. Something you were talking about too with the crisis situations is kind of interesting. I don't know how you think about this or work with the parents, but even with my own children when they were young and going through tantrums, you know, trying to be there and give them a hug or trying to regulate. And it wasn't until I read – I'm blanking on her name, from UCSF – The Emotional Life of the Toddler. But she talks about how sometimes the children just need to go to the depths of their emotion and then come out of it, and there's nothing the parent can do to, you know, make that stop or to soothe it or so on. They just kind of need to be there and make sure the kid doesn't hurt themselves, but they will kind of come out of it. And later as now I’ve learned more about exposure work and sitting with anxiety and riding that wave, you know, it's kind of a similar aspect.
Rebecca C. Shaffer, PsyD: (25:33)
Yep. Absolutely. We talk about that in session one with the caregivers, that if we're thinking about arousal and escalation, it's a wave exactly like we talk about with anxiety. And when we get to the height of it like that, we lose that rational control. But we have to come down. Our bodies can't stay in that heightened state. Thinking back to the nervous system and what you were talking about earlier, our bodies just aren't built for that so we're going to top out at some point and come back down. I think it's helpful for caregivers to hear that.
Keith Sutton, PsyD: (26:06)
Yeah.
Rebecca C. Shaffer, PsyD: (26:07)
To know that it's not going to last forever, but we might just have to sit with it for a little bit until, you know, this kiddo's body is done with whatever is happening at this escalation stage. But they will come back down, and as they're coming back down, here are the tools that you can use to coach them through coming back down.
Keith Sutton, PsyD: (26:26)
Yeah.
Rebecca C. Shaffer, PsyD: (26:27)
And getting to the other side of it.
Keith Sutton, PsyD: (26:28)
Great. Yeah. Oh, I think it was Alicia Lieberman's work. Um, wonderful. And so tell me a little bit about – what's your experience or what do you notice with the kids as they are internalizing some of those affect regulation skills? Because I think that is one of the hardest things and, and especially doing a lot of work with folks with ADHD, it's like the person knows what the skill is, but in the moment it's hard to put in. I mean, even adults have that difficulty, like knowing to breathe and so on. But then in the moment when they're at an 8 out of 10, it's kind of all out the window. What are your thoughts on that?
Rebecca C. Shaffer, PsyD: (27:08)
Yeah, so we talk a lot with caregivers about how this isn't going to happen overnight. They have developed these patterns for when they're dysregulated. So we're really changing that pattern and assisting with some new strategies. So don't expect them to implement it every single time when they're in that moment. But the caregiver-as-coach is incredibly important there too, right? So talking them through, where are you at on the five-point scale? We talk to them about – so five is fully escalated. When you get to a three, that's when you need to use your skills. If we wait until we get to a five, it's going to be too late. So really giving the kids some markers and some body signs of when they use the skill and not waiting until we're so overwhelmed that we can't think about it and do it.
Keith Sutton, PsyD: (27:57)
Yeah.
Rebecca C. Shaffer, PsyD: (27:59)
And then really having visuals available, making it part of the culture of their home. So encouraging caregivers to have other kids in the home practicing the skills too. They're good for everybody. And making it more part of their daily lives. Because if we're practicing relaxation daily on a regular basis, then we're more likely to use it in the moment. We've built that muscle memory to be able to actually implement it.
Keith Sutton, PsyD: (28:25)
Yeah.
Rebecca C. Shaffer, PsyD: (28:26)
And then I think the other piece of this too, is we run into a lot, and I'm sure you see this too, when you're in individual therapy trying to get kids to do new skills or to practice relaxation, sometimes they just refuse, right?
Keith Sutton, PsyD: (28:41)
Like take some deep breaths. I don't want to. Yeah, yeah.
Rebecca C. Shaffer, PsyD: (28:45)
I've already done that before. It doesn't work. Yeah.
Keith Sutton, PsyD: (28:46)
Yeah.
Rebecca C. Shaffer, PsyD: (28:47)
Right. So I think the group environment is incredibly powerful in this certain part. So there's some natural peer peer pressure that happens.
Keith Sutton, PsyD: (28:57)
Positive peer pressure.
Rebecca C. Shaffer, PsyD: (28:58)
Yep. If all of the other kids around me are practicing, I'm probably more likely to do it myself. So we see some of those more resistant kids who won't try new things being more likely to do it in the group setting.
Keith Sutton, PsyD: (29:11)
Mm-hmm.
Rebecca C. Shaffer, PsyD: (29:12)
Because they see everyone else doing it. And then if we're practicing it in group, we're getting it there. They're practicing it as part of their homework at home. We're encouraging the family to practice it together. We slowly get to that point where we can see it implemented a little bit more in the moment.
Keith Sutton, PsyD: (29:28)
Oh, great. Yeah. Sometimes I talk with clients – it’s almost like learning karate or something like that. They practice, practice, practice. So if they're in a bad situation, they don't have to think about it. Right. It just becomes natural.
Rebecca C. Shaffer, PsyD: (29:38)
Yeah, exactly.
Keith Sutton, PsyD: (29:39)
But yeah. Only trying to use it in the moment, right, it's not going to come to you.
Rebecca C. Shaffer, PsyD: (29:42)
Never works.
Keith Sutton, PsyD: (29:44)
Yeah. Yeah. Oh, great. Tell me about your thoughts on – there's been a lot of research on children with anxiety, and also oftentimes when a caregiver has anxiety too, the caregiver’s anxiety is not addressed and sometimes there's much more relapse. It sounds great because you're teaching them these skills in the goal of helping manage their children. But I imagine that the parents are also kind of being able to shift their own relationship with anxiety through this process. Are you seeing that or is that explicit at all? Or is anybody kind of speaking to that?
Rebecca C. Shaffer, PsyD: (30:32)
So we've definitely anecdotally heard that from families, that it really helped me a lot in my own life to be practicing relaxation or having a mindfulness practice. I've been able to use these skills myself to stay calm, not only with my kid, but just being able to stay calm in general. We do talk about how having a kid with autism with dysregulation can be really hard. And so making sure you take care of yourself is important. So encouraging them to seek out their own therapy if that makes sense. But we also know that caregivers are really busy and it's hard to make everything work. So hopefully we can give them some skills in the group to start to address it, even if they don't make it to their own therapy right away. We're starting to look at this in the Department of Defense funded trial right now. Caregivers are completing their own mindfulness measures as they enter. They're also filling out measures about themselves in terms of their stress level.
Keith Sutton, PsyD: (31:36)
Mm-hmm.
Rebecca C. Shaffer, PsyD: (31:37)
And where they're at in terms of that. And then we also collect family diagnostic history, so any diagnosis in caregivers, and really we hope at the end of this that we'll be able to look at some of those caregiver factors and see how they impact outcomes for kids.
Keith Sutton, PsyD: (31:54)
Definitely. Yeah, because I'd be interested too also about if the parent filled out a questionnaire and was meeting criteria for anxiety disorder. At the end of the treatment, would there be a change there, a difference or so on?
Rebecca C. Shaffer, PsyD: (32:09)
Yeah. Yeah. We're definitely very interested in that. We believe that there's probably some sort of impact there, right? Like there's no way that if the caregiver is struggling on their own, that that's not going to impact outcomes in general. So what can we do to kind of start to look at that? We're hopeful to see that. We also have a focus in that Department of Defense trial really thinking about diversity and how we're creating access to this intervention.
Keith Sutton, PsyD: (32:39)
Yeah.
Rebecca C. Shaffer, PsyD: (32:40)
So we're doing a few things as part of the study: We're providing mileage reimbursement and then childcare for siblings, which is like a huge need for these families. Like where do they put their other kids while they're in group? So we are offering that and then we're doing some qualitative interviews after the group to talk through barriers and facilitators’ and caregivers’ experience in the group. And, you know, what that was like for them. So we're also hopeful that we're going to learn more about caregivers and their experience through these interviews at the end of the study.
Keith Sutton, PsyD: (33:16)
Mm-hmm. Wonderful. Tell me a little bit about the parents’ coaching through the cognitive therapy and noticing the thoughts. I'd just be interested in how that goes. Some parents as they're trying to help out their kids – I don't know if it would necessarily be the topic in this population – but they're like, oh gosh, you know, everybody at school hates me or something like that. Right? Then the parents take the other side and say, no, they don't hate you. What about this person or that person? Kind of like, you know, from theory of motivational interviewing – the more that one takes one side of the ambivalence, they're sometimes eliciting the other side. Then the kid says, no, no, and it kind of sometimes can go back and forth and parents get frustrated. Everybody kind of gets frustrated in that scenario. I imagine that's going to be even a little harder, right, with parents trying to bring in a different perspective with the kids with autism who might have even more concreteness and less openness, maybe, to various perspectives. How does that work?
Rebecca C. Shaffer, PsyD: (34:14)
Yeah, that's a really great question and I think it's so incredibly tricky, right?
Keith Sutton, PsyD: (34:20)
Mm-Hmm.
Rebecca C. Shaffer, PsyD: (34:20)
Caregivers want to step in and fix it. They want to make things better and provide perspectives that are going to fix it, but that doesn't always help. And so we're really encouraging them to really get their kids just to talk about it. So having them come up with their own examples and not stepping in and providing the answer. The problem solving model that we use provides several options for the kid. But then sometimes, like I said, they're left with this choice of let it bother me or accept it and move on and do the next thing to help me get past it. So really we're coaching caregivers to not jump in and give the option. Can't solve the problem. We have to allow them the space to start to solve the problem. You know, caregivers of kids with autism often spend a lot of time managing the world for their kid.
Keith Sutton, PsyD: (35:21)
Yeah.
Rebecca C. Shaffer, PsyD: (35:22)
So like, really thinking of all the things that can go wrong and making a backup plan and having all of that ready for their kids. So we're really encouraging them to kind of take a step back from that. Let your child be involved in the backup plan. Let them think of those things. Because if we don't help them just start to build those skills, they're not going to be able to do it independently in the future.
Keith Sutton, PsyD: (35:47)
Sure, sure. And I imagine for some parents it might feel just easier. It's like, you know, it's like doing the dishes yourself rather than trying to teach the child to do the dishes, and they may break them, so it's like, ah, I'll just do it anyway. But yeah. Especially if they’re busy maybe. And so I like that though, that kind of, they're already doing this, and so more including and collaborating with kids,
Rebecca C. Shaffer, PsyD: (36:08)
Let's do it together.
Keith Sutton, PsyD: (36:10)
Yeah. Yeah. That's great. Yeah. Sometimes the way I think about it too is, as the parents are trying to help the kids with the problems, I always like Brene Brown's little video with a bear that goes down the hole, and talking about empathy and how to truly empathize, we have to connect with the part of ourselves that's felt that same feeling. And so if the parent is connecting with the child, you know, oftentimes they get dysregulated, so they try to give the other side and what about this, what about that? Rather than sitting with the kids and their emotions and going to that kind of dark place with them of like, nobody likes me or whatever it might be, and just sitting with them there. Because oftentimes from there, right, the kids kind of start to problem solve or can kind of come out of that. But yeah, this sounds like it's really great and really kind of helping to shift not only things for the kid, but the family system, and I imagine creating more lasting effects.
Rebecca C. Shaffer, PsyD: (37:05)
Yeah. That's our hope. And we definitely see in our outcomes from our pilot trials that the families have the most amount of change at about 10 weeks post intervention. And so I think that really speaks to the fact that the caregivers are keeping things going. It also probably speaks to the fact that dysregulation takes a little a while to change, right? It doesn't change right away. But that caregiver component, I don't have the data to say it, but I truly believe that we wouldn't see change at 10 weeks if caregivers didn't have the knowledge and the ability to coach their kids in continuing to use those skills.
Keith Sutton, PsyD: (37:45)
Yeah. Have you done a group just for the kids and no parents versus kids and parents?
Rebecca C. Shaffer, PsyD: (37:52)
So we haven't. We've certainly talked about it. Because I feel so strongly about the caregiver group, it's hard for me to think about providing that to kids and potentially not giving them the best intervention possible. But I do think that is a potential study down the line. Does it make sense to…and I also wonder about caregiver only, right? So like, if we just provide this to caregivers, do we see some of the change for some of our milder kids?
Keith Sutton, PsyD: (38:22)
Yeah.
Rebecca C. Shaffer, PsyD: (38:22)
Is that all that's necessarily needed? Maybe.
Keith Sutton, PsyD: (38:24)
Yeah. It's like Eli Lebowitz’s work, you know, just doing the work to address anxiety, but only working with the parents and not even with the kids and having the same results as individual CBT. And I think it would be great because I think that the parent component is often left out in practice at least, at least in our area. You know the therapists are usually working with the kids individually. And there's been some research and they’ve done some stuff with a coping cat and coping koala, with kind of no parents parents, but that it's still, I think, not widely really understood how significantly it can help increase change. And also, you know, create more lasting change and prevent relapse.
Rebecca C. Shaffer, PsyD: (39:11)
Yeah, for sure. I think that maintenance and generalization piece, and preventing the relapse, is just so incredibly important. So if we can show that we're doing that, I think that's even better for the field. It helps direct where we're going and definitely a future research idea. We're definitely interested in that down the road.
Keith Sutton, PsyD: (39:31)
Yeah, definitely. Now have you thought about or is there any kind of looking at applying this also to different populations? Because I imagine, right, kids with anxiety, oppositional, kind of other dysregulation, kids with trauma, you know all these kinds of things could be…this sounds like this could be really applicable.
Rebecca C. Shaffer, PsyD: (39:52)
Yeah, we are very interested in doing that. So, like I said, our clinical program is a mixed diagnosis group. We see kids come through with lots of different diagnoses. So it is something that I would be happy to partner with people who are interested in doing it in ADHD and anxiety. You know, we're focused on autism right now. I am part of a study that's getting ready to happen, though, where they're implementing it for kids with tuberous sclerosis, so TSC, and doing that virtual model because it's such a rare disorder. They're able to see more kids if they do it virtually. So really thinking about… The other thing that I'm incredibly passionate about and thinking about is developing it down for some of our lower functioning kids with autism who may not have as much language or as high of IQ. So how do we really tailor it to a lower IQ group and think about how we do that. We also have a study going right now that's on our inpatient unit where we're thinking about how do we start to build some of these skills while kids are in the hospital so that once they're out, they're ready to engage in another therapy and be able to be a little bit more regulated in the moment.
Keith Sutton, PsyD: (41:08)
Mm-hmm.
Rebecca C. Shaffer, PsyD: (41:09)
So yeah, I mean, I think it could be helpful. I believe it could be helpful. I think these things aren't specific to autism and yeah, it's definitely an interest for the future.
Keith Sutton, PsyD: (41:22)
Great. And I know they've got it at UCSF and I don't know… Do you know, is it kind of being widely adopted or is it… For folks that are listening, I don't know how they might get this program going. Do they get a manual and kind of do it? Or is there kind of a training through your group? Or…
Rebecca C. Shaffer, PsyD: (41:43)
Yeah. So we are in the process of publishing it. It's not available yet, but hopefully within the next year it'll be available for purchase. But for right now, if clinicians are interested, they can access it through training with our site. So we do training with groups. That's a bit of a discount if you have a lot of people joining from your institution. And then individuals can also join the training. It's a two-day training. The intervention is slightly different between children and teens. So we teach the curriculum for the 8–12 year olds on day one. We teach the intervention for the teenagers on day two. And then when you do the training, you also have access to me as a consultant afterwards. So I actually just met with UCSF this morning to talk through some issues that had popped up. So we've done training across the country for institutions. We've done it at Michigan and Georgetown University, UCSF, Maine. And so quite a few groups have done the training so far, and they're implementing it. Some of the groups are implementing it as a once-a-week model instead of a twice-a-week model. So I do think that's an option. We don't have data to support that yet, but I think it probably works in a once-a-week format.
Keith Sutton, PsyD: (43:01)
Sure. Definitely. Well, that's wonderful. Well, great. Well, you know, anything else that you think is important for folks to know about this population, this program that you're doing? I want to make sure we get all the pieces you think that would be helpful for our listeners to know about.
Rebecca C. Shaffer, PsyD: (43:19)
Yeah, I mean, I think that we covered a lot of stuff. I would also say if anyone is in training right now and they're interested in this population, we frequently take postdocs at our site for additional training. So please feel free to reach out if you're interested in getting further experience. But it's an amazing experience to work with these kids and to help them learn how to regulate. And it's certainly my passion, and I love doing it.
Keith Sutton, PsyD: (43:48)
Great. Well, thank you so much for all this great information and just the amazing work that you're doing. It sounds wonderful, and it's always nice to hear from a parent that went through it, of my own client, saying how effective it was. So it really is great. Thank you so much for taking the time today. I really appreciate it.
Rebecca C. Shaffer, PsyD: (44:06)
Thank you so much.
Keith Sutton, PsyD: (44:08)
Okay. Bye-bye. Thank you for joining us. If you're wanting to use this podcast to earn continuing education credits, please go to our website at https://therapyonthecuttingedge.com. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, providing in-person and remote therapy in the San Francisco Bay Area. IAP provides training for licensed clinicians through our in-person and online programs, as well as our treatment for children, adolescents, families, couples, and individual adults. For more information, go to https://sfiap.com or call (415) 617-5932. Also, we really appreciate feedback and if you have something you're interested in, something that's on the cutting edge of the field of therapy and think clinicians should know about it, send us an email or call us. We're always looking for the advancements in the field of psychotherapy to help in creating lasting changes for our clients.