1. Dialectical Behavioral Therapy in the Public Schools
James B. Hanson, M.Ed.
Texas Association of School Psychologists
Fall Conference 2012

2. Outline What is DBT? Core Components Adaptation to School Settings
Why Did Lincoln High School Choose DBT?
How was DBT implemented?
Research Results
Supports and Challenges to School Implementation

3. What is DBT? A synthesis of: Behaviorism Mindfulness Dialectics
Dialectics: “A means of finding fluidity and balancing acceptance and change in the fact of rigidity and impasse” (Miller et. al 2007).

4. Examples of Teen Dialectics
There is no absolute truth; everyone has something to offer.
I am doing the best I can and I can do better.
I am tough and I am gentle.
I may not have caused all of my problems, and I’m responsible for working on them.
A life worth living has happiness, sadness, anger, and calm, and all of these things are valuable and necessary.

5. Core Dialectic of DBT Acceptance Change Mindfulness Problem Solving
Radical Acceptance
Validation
Change
Problem Solving
Cognitive Behavioral
Goals and Contingencies
Gestalt Therapy: Paradoxical Nature of Change

6. Therapist’s Style Reciprocal Irreverent Responsive
Serious
Appropriate Self- Disclosure
Warm Engagement
Radical Genuineness
Irreverent
Unorthodox Reframing
Plunging In-Humor
Confrontation
Calling The Bluff
Omnipotence and Impotence
Intensity and Silence
Both are what teens respond to. Self-disclosure: DBT is good for adults and students. As soon as you’re fixed, the environment will break you again because nothing is static. We made creative adjustments to a changing universe and those adjustments are intelligence.

7. Who developed DBT? Marsha Linehan, University of Washington
Attempts at traditional Cognitive Behavioral Therapy with suicidal and self-injurious clients did not work
Dialectical Behavioral Therapy with Suicidal Adolescents (2007). Alec Miller, Jill Rathaus, Marsha Linehan. New York: The Guilford Press
Montefiore Medical Center 1995-teen research
CBT as a base for DBT
Gestalt Therapy and ABA

8. Who is it for? Multi-diagnosed BPD (Borderline Personality Disorder)
PTSD
Para-suicidal Behavior in Teens (cutting)
Eating Disorders (bulimia and binge eating)
Antisocial Personality
Depression in Elderly, Emergent in Teens
33% of Teens who attempt have BPD
Comorbidity is the rule, not the exception

9. BPD Reconceptualized Emotional Regulation (labile, anger)
Interpersonal Regulation (chaotic, abandoned)
Self Regulation (identity, emptiness)
Behavioral Regulation (suicide, cutting, impulsive)
Cognitive Regulation (black and white thinking)
Every teen?

10. What’s in a name?
Results: Accounting for known confounders, victims of peer bullying had an increased risk of BPD symptoms according to
self-report (OR, 2.82; 95% CI, 2.13–3.72);
mother report (OR, 2.43; 95% CI, 1.86–3.16); and
teacher report (OR, 1.95; 95% CI, 1.34–2.83).
Children who reported being chronically bullied (OR, 5.44; 95% CI, 3.86–7.66) or experienced combined relational and overt victimization (OR, 7.10; 95% CI, 4.79–10.51) had highly increased odds of developing BPD symptoms.
Wolke, D., Schreier A., Zanarini, M. and Winsper C. (2012) Bullied by peers in childhood and borderline personality symptoms at 11 years of age: A prospective study. Journal of Child Psychology and Psychiatry 53:8, pp. 846– 855
BPD and PTSD Care in criteria

11. Efficacy Research with Teens
Dialectical Behavioral Therapy with Suicidal Adolescents (2007)
12-16 week treatments instead of 1 year
Suicidal ideation, depression, and anxiety (perfectionism)
Six problem areas (violence, drinking, drugs, smoking, risky sexual behavior, disturbed eating)
277.3 % Higher Risk with all 6 factors, each factor adds upon itself

12. Research Studies Rathaus & Miller (2002)-Adolescents
Lower hospitalization (TAU 13% versus DBT 0%)
Higher retention (TAU 40% versus DBT 62%)
Fellows (1998)-Adolescents
Treatment group went from 539 inpatient hospital days pretreatment to 51 days post treatment
Linehan (1991, 2006)-Adults: Lower attempts, cutting, inpatient, anger. Inpatient, medical risk from cutting.
Higher GAF, social adjustment, retention

13. School Research James, Taylor, Winmill and Alfoadari (2008)
James, Winmill, Anderson, and Alfoadari (2011)
Katz, Cox, Gunasekara, and Miller (2004)
Nelson-Gray and colleagues (2006)
Sunseri (2004)
Dialectical behavior therapy skills groups in schools: A review of empirical findings at: From Science to Practice, July 2012 (/division- 16/publications/newsletters/science/2012/07/index.aspx)

14. Biosocial Theory of Behavior
Biological, Genes, Emotional Vulnerabilities
Executive Functions, Abilities, Sensory Functions, Medical
Invalidating Environment
(e.g., chronic stress, chaos, perfectionism, inconsistency)
Can occur outside the family setting
Biosocial Theory
Important for Teens to know

15. Creating a Life Worth Living
Increasing Behavioral Skills
Decreasing Quality-of-Life Interfering Behavior
Decreasing Therapy-Interfering Behavior
Decreasing Life Threatening Behaviors

16. Interpersonal Effectiveness
Mindfulness
Problem Solving
(CBT, FBA)
Distress Tolerance
Emotional Regulation
Interpersonal Effectiveness
Core DBT Units

17. Dialectics Black and white? Seeing polarities
“Both/and” not “either/or”
A life worth living has positive and negative aspects
Getting unstuck

18. Mindfulness Full awareness Present Moment
Wise Mind (Emotional & Logical)
What: Observe, Describe, Participate,
How: Don’t Judge, Focus, Do What Works
Half Smile

19. Solving Problems Goal Setting
Chain Analysis (Functional Behavioral Analysis)
Stinking Thinking
All Or Nothing: If you’re not perfect, you’re a total loser
Disqualifying the Positive: The good stuff doesn’t count because the rest of your life is a miserable pile of doo-doo.
Jumping to Conclusions: You suddenly become a psychic mind reader and know exactly what everyone really thinks.
Emotional Reasoning: You start thinking emotions are facts. I feel like she hates me, so she does.

20. Distress Tolerance Pain is a part of life Pain versus suffering
Some things you can’t change
If you act impulsively, you can hurt yourself, others, and your goals

21. Distress Tolerance: ACCEPTS
Activities
Contribute
Compare
Emotional Opposite
Push Away (Bracket)
Thought Change
Sensation Change
Wise Mind Accepts

22. Distress Tolerance Self-Soothe Kits Vision Hearing Taste Smell Touch
Movement

23. Opposite to Emotion Action
FEAR-Hide- Approach
ANGER-Attack- Gently Avoid
SAD-Withdraw-Get Active
GUILT-Avoid-Face

24. Emotional Regulation Radical Acceptance Acknowledge, Recognize, Endure
Myths: It’ll Change if I Wait, It’ll Kill Me, It’ll Last Forever

25. Emotional Regulation RIDING THE WAVE You are not the wave
Don’t avoid it
Don’t judge it
Don’t make it bigger or smaller
Don’t hold on to it
You are not the feeling
You don’t need to act on it
Remember times when you have felt differently
Invite it home for dinner.

26. Positive Events and Validation
Pleasant Events Schedule
Reducing emotional vulnerability
SEEDS Skills (sleep, eating, exercise, drugs, sickness)
Mastery: doing something you’re good at
Cheerleading
Checking the facts
Choices about intensity

27. Interpersonal Effectiveness
What’s Your Objective?-DIG
Relationship-GIVE
Your Goals-RAN
Self Respect-FAST
Validation does not mean that you agree with the statement, it means you understand them
GENTLE, INTERESTED, VALIDATE, EASY MANNER
FAST-FAIR, no APOLOGIES, STICK TO VALUES, TRUTHFUL

28. Parent Skills All of the Five Areas Validation
Obstacles to skillful behavior
Contingencies
Emotional regulation

29. Lincoln High School, Portland OR
1550 students
Middle to high socio-economic status
100 Best High Schools in United States
Suicide was leading cause of death
About 20 parent meetings/year for cutting, suicidal ideation or attempt (record year high was 45)
Meetings required by district Child Find policy

30. Lincoln Statistics
High stress and anxiety (OHTS 2008: 13% of students considered suicide in last twelve months; 2012: 8.4%)
Before DBT: one to two suicides per year, since DBT no suicides
Before DBT: two to three placements into Portland Public School’s day treatment classroom per year, since DBT one placement
2007 Oregon Healthy Teens Survey (11th graders)

31. Assets-Lincoln High School
CDC Coordinated School Health Model
PBIS
RESPONSE suicide prevention
Student & Staff Anti-Bullying
Reconnecting Youth
School Improvement Plan with Mental Health goals

33. CDC Coordinated School Health
NASP Model for Comprehensive and Integrated School Psychological Services (2010a) Seventh Doman: Family-School Collaboration Services

35. Data collected each Area, each Tier
Data from Attendance Credit Earned G.P.A.
School Records
Measuring Attitudes, Beliefs, Behaviors
Pre- and Post-Testing Standardized Checklists
Written Reflections and Portfolio Work Samples
Student Work and Progress Monitoring
Performance of Oregon State Health Standards Skills
Formative and Summative Assessment
BASC-2 for DBT, Social Skills Rating System for SSDL, Reconnecting Youth, Coordinated Surveys

37. Oregon and PPS Health Class Standards
Explain how to build and maintain healthy relationships
Classify personal stressors at home, in school, peers
Describe how social environments affect well-being
Identify resources at home, school, and in the community for managing family and relationship problems
Practice strategies for managing and reducing stress, anger and conflict
Demonstrate the ability to take the perspective of others in a conflict situation
Identify influences that contribute to positive and negative self-image
Demonstrate pro-social communication skills
Demonstrate the steps in problem solving, anger management and impulse control .
These are the basis for all Lincoln SEL IEPS

38. IEP Example
Oregon State Standard: Demonstrate the ability to take the perspective of others in a conflict situation DBT Skill: In classroom settings, Mary will use “validation” skills to repeat or reframe what a peer has said before she uses assertion and negotiation skills. This skillful behavior will occur 3/5 days as measured by her diary card (self-report) and 2 or fewer school discipline referrals per month. Mary’s use of validation skills will result in a DBT post-test score decrease (to 59 or lower) on teacher BASC-2 Aggression scale and an increase (to 41 or higher) on self-report BASC -2 Interpersonal Relations scale.

39. School Improvement Plan
LEARNER-CENTERED PROBLEM (What are your students struggling to learn or to be able to do?):
Students at Lincoln often struggle with depression, anxiety, stress, self harm, drugs and alcohol, suicide, and bullying are not aware of existing levels of prejudice (racism, classism, misogyny, sexual minorities).
STUDENT ACHIEVEMENT GOAL (SMART GOAL):
Students will develop mindfulness, distress tolerance, and emotional regulation skills, recognize the signs of anxiety/depression/suicide, and access appropriate support services when needed.
Measures include Oregon Health Teens, Health Class Surveys, etc.

40. DBT Core Components Weekly Skills Class with two co-facilitators
Weekly Individual Sessions
“Phone Calls” (consultation to student in the counseling center for emergencies during the day when coaching on skills and reassurance is needed)
Parent training
Weekly DBT providers team meeting

41. Class Format Mindfulness exercise Homework New Skill
Discussion and examples
FBA if emerging pattern of not doing homework, coming late, or other therapy- interfering behavior

42. Syllabus

43. Individual Coaching 20-30 minutes a week
Diary card driven (events, thoughts, feelings, and skills)
Personalized diary cards
Mini-FBA if late, if haven’t filled out diary card
No reinforcement (conversation, warmth) before diary card is filled out

46. “Telephone Consultation”
Every student has the chance to receive immediate consultation during the week if trying to use skills and they aren’t working
Accommodation in IEP or 504 to come to the counseling center to see their DBT coach
Communicated to teachers if not on IEP/504
See the student before target behavior occurs
Do not see the student for 24 or 48 hours after target behavior occurs
Shaping appropriate help-seeking

47. DBT Team Meetings
Purpose: “To allow therapists to discuss their difficulties providing treatment in a nonjudgmental and supportive environment that helps improve their motivation and capabilities” (Miller, et. al., 2007).
“Group therapy for therapists”
Integral part of DBT program
Simultaneously client an therapist
Same hierarchy as DBT

48. Parent Evenings
Effectiveness research shows clearly that parent evenings are crucial
Emphasis on validation, behaviorism, and communication
Students whose parents come are the students who make the best gains
Beyond the nuclear family

49. Adopt or Adapt? Target population – same as research?
Comprehensive DBT – all components?
Setting – amenable finances, time, structure?
Professional training – skill set, credentials?
“Gold Standard” Five functions – skills, generalization, and environment of clients; capabilities and motivation of therapists
Fidelity Matters. Koerner, Dimeff, and Swenson DBT in Clinical Practice (2007)
Population: look at research, evaluate outcomes Step Down
Great Advantage: It’s the school setting where a lot of the stress happens, failing of traditional DBT to address school

50. Adaptations
“Advanced Health” on transcript; DBT is an elective credit class
Materials from Portland DBT Teen Program
Lincoln Staff/Teacher Training
Consultation with community providers
Fidelity checks from Portland DBT Program
DBT in International Baccalaureate “Theory of Knowledge” classes and or Health Classes
Class has homework
Parents have Homework
Phone calls to Community Therapist

51. DBT Team Members School Psychologist School Nurse
School Social Work Intern
School Psychology Practicum Student and School Psychology Intern
School Counselor
School Counseling Intern
This doesn’t include 9 years of Gestalt training and our core training in FBA, other SP skills

52. Team Training
Core Team Training: 6 Days, Portland DBT Readings: Miller (2007) Linehan (1993)
Leader Training for School Psychologist:
6 Days, Portland DBT
6 Days per year, Behavioral Tech
10 Years, Portland Gestalt Training Institute
ABA

53. Students
Self-referral from one-day preview of DBT skills in general education health classes
PBIS: Universal screener
PBIS: Students who did not do well enough in Reconnecting Youth or mentoring program
IEP: Students identified with social/emotional needs
Students in day treatment classroom who have collaborative problem solving skill base
Tier Two or Tier Three classification depends on student

54. Inclusion Criteria If suicidal, not the only counseling service
If suicidal ideation, cutting or eating disorder is serious, referral to Portland DBT or other community-based therapy
Step down or “graduates” from LHS DBT, other programs, community DBT, and PPS day treatment as appropriate
No requirement to quit other therapy: consultation with community provider
Identifiable “target behavior”

55. 2009-2012 Student Groups Five cohorts:
2009 Girl’s Group, Closed, Semester
2010 Mixed Group, Closed, Semester
2010 Mixed Group, Open, Year-Long
2011 Mixed Group, Closed, Year-Long
2012 Mixed Group, Closed, Semester

56. Measures BASC-2 Pre and Post (Student, Parent, Teacher Versions)
Attendance
Grade Point Average
Written Reflection
Progress Monitoring: Daily Diary Cards

57. 2009 Girl’s Group
BASC-2 Scores – Decreases in Anxiety (8), Depression (12) and Social Stress (7)
Attendance - Increases up to 30%
Grade Point Average – from no increase to 1.43, Average .80

58. Girls’ voices:
“This group rocked. I learned a lot and you were pretty tough on me. You know that, right?”
“All those chain analyses. They laid it all right out, like, ‘Girl, this is your life.’ It helped me quit smoking and I’m not cutting on myself anymore.”

59. Girls’ Voices:
“Now I like myself. After group ended, a relationship failed. I did ‘accepting myself rehab’ and it worked.”
“This is kind of messed up, but how the other girls handled their problems reminded me that I was actually better at using the skills than many of them were. That’s a ‘comparison’ skill.”

60. 2010 Mixed Cohort-Semester
Slight increases in attendance and bigger increases in GPA
Modest decreases in Anger Control, Anxiety

61. 2010 Mixed Group, Year-Long
All but one student on IEP or Safety Plan for suicide attempt/serious suicidal ideation
BASC-2 ESI < 10, Internalizing < 4, Depression < 9, Anxiety < 4
Grade Point Average (2/8 Students -.8, most other students gained about +.4)
Attendance dropped by 10 days per year
Greater sense of self developed; more parental conflict in individuation

62. Student Voices:
“The Mindfulness skill allowed me to heighten my awareness of my limits. I’m more aware of when I’m overworked, or over emotional and I know what triggers the overload.”
“My experience here with DBT has been truly life changing. I’ve developed skills that will help me the rest of my life.”
Parent Group was video, letters and skill sheets. Better outcomes with parent group.

63. 2011 Mixed Group, Year Long Average increase in GPA = + .76
11 of 12 students increased GPA
Average increase in attendance = + 4%
Attendance not interpretable, 5/12 students decreased attendance slightly, 1 student significantly increased

64. 2011 Mixed Group BASC-2 Self Report t-scores
Anxiety: average decrease 13.9 (-35 to +6)
Depression: average decrease 18.7 (-40 to 4)
Internalizing: average decrease 15.2 (-37 to +4)
ESI: average decrease 16.0 (-33 [2] to +2)
For one student, DBT as delivered did not work. For the vast majority of students, DBT worked very well.

65. Example of BASC-2 SRP

66. 2012 Group, Semester Long Average increase in GPA = .27
Average increase in attendance = -4% (+7 to -10%, majority of students no change
BASC-2 Internalizing Problems average decrease = 5

67. Student Voices
“Staying in logical mind and using emotional regulation, I have been able to stay rational and calm and get what I need.”
“The number one skill that I used was DEAR MAN, especially with my mother. I basically sat down and thought about how I could use each element of DEAR MAN in a conversation with her. DEAR MAN in combination with…just about everything else.”

68. Other results: No suicides since REPONSE, RY, and DBT
One placement in more restrictive setting
Savings to district: $350,000
Day treatment classroom at Lincoln with Collaborative Problem Solving model: teaching to other teachers

69. Whom we did not help ADHD not medicated Depersonalization Disorder
Students with parent who did not attend parent classes
Narcissistic traits: difficulty with group format
What’s up with lower attendance rates and higher GPA’s?

70. Lincoln Research
Although the results have not been published in a peer-reviewed journal, Lincoln High School in Portland, OR reported initially promising results with ongoing skills groups (Hanson, 2012). The school developed a DBT program for course credit that included weekly group skills classes and individual sessions, as well as parent training and telephone consultation for the adolescents. The treatment included the four core modules of DBT and was offered in semester or year-long options. The treatment team consisted of the school psychologist, counselor, social worker, nurse, practicum students, and interns. Students in the five groups that have been completed were assessed pre- and post-intervention with the Behavior Assessment System for Children, Second Edition (BASC-2); results suggested that students experienced decreased anxiety, depression, social stress, and anger control, and demonstrated increased school attendance and GPA. Although this treatment was more comprehensive than skills-groups alone, it offers a treatment format that can be replicated and evaluated in future studies. Dialectical behavior therapy skills groups in schools: A review of empirical findings at: From Science to Practice, July 2012 (/division- 16/publications/newsletters/science/2012/07/index.aspx)

71. Supports Syllabus Administrative and parent buy-in
Tier Two and Tier Three
School Improvement Plan
Health Action Network Funds
District support

72. Challenges Time constraints for class
New block schedule lessens flexibility
Scheduling individual appointments for students not in SPED
Time intensity for program
Training new staff every year
Parent group: have had to modify format
Changing special education administration
Perception of “therapy” versus “counseling”
Research parameters
Students were less concerned about getting credit for the class, but it really helped.
Special Education Director was familiar with DBT and its efficacy

73. It’s Not a Walk on the Beach
And It Ain’t Bad
Jim Hanson, M.Ed.
(503)