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James B. Hanson, M.Ed. Texas Association of School Psychologists Fall Conference 2012.

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1 James B. Hanson, M.Ed. Texas Association of School Psychologists Fall Conference 2012

2  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  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  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  Acceptance  Mindfulness  Radical Acceptance  Validation  Change  Problem Solving  Cognitive Behavioral  Goals and Contingencies

6  Reciprocal  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

7  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

8  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

9  Emotional Regulation (labile, anger)  Interpersonal Regulation (chaotic, abandoned)  Self Regulation (identity, emptiness)  Behavioral Regulation (suicide, cutting, impulsive)  Cognitive Regulation (black and white thinking)

10 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

11  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)

12  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

13  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  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

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

16 Mindfulness Problem Solving (CBT, FBA) Distress Tolerance Emotional Regulation Interpersonal Effectiveness

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

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

19  Goal Setting  Chain Analysis (Functional Behavioral Analysis)  Stinking Thinking

20  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  Activities  Contribute  Compare  Emotional Opposite  Push Away (Bracket)  Thought Change  Sensation Change

22  Self-Soothe Kits  Vision  Hearing  Taste  Smell  Touch  Movement

23  FEAR-Hide- Approach  ANGER-Attack- Gently Avoid  SAD-Withdraw-Get Active  GUILT-Avoid-Face

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

25  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

26  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  What’s Your Objective?-DIG  Relationship-GIVE  Your Goals-RAN  Self Respect-FAST

28  All of the Five Areas  Validation  Obstacles to skillful behavior  Contingencies  Emotional regulation

29  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)

30  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

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


33 33


35 Student Work and Progress Monitoring Formative and Summative Assessment Pre- and Post- Testing Standardized Checklists School Records Data from Attendance Credit Earned G.P.A. Measuring Attitudes, Beliefs, Behaviors Written Reflections and Portfolio Work Samples Performance of Oregon State Health Standards Skills


37  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.

38 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 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. 39

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


43  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  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  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

48  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  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

50  “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

51  School Psychologist  School Nurse  School Social Work Intern  School Psychology Practicum Student and School Psychology Intern  School Counselor  School Counseling Intern

52  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

53  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  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  Five cohorts:  2009Girl’s Group, Closed, Semester  2010Mixed Group, Closed, Semester  2010Mixed Group, Open, Year-Long  2011Mixed Group, Closed, Year-Long  2012Mixed Group, Closed, Semester

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

57  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  “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  “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  Slight increases in attendance and bigger increases in GPA  Modest decreases in Anger Control, Anxiety

61  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 +.10 (2/8 Students -.8, most other students gained about +.4)  Attendance dropped by 10 days per year

62  “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.”

63  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  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)


66  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  “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  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  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 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  Syllabus  Administrative and parent buy-in  Tier Two and Tier Three  School Improvement Plan  Health Action Network Funds  District support

72  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

73  And It Ain’t Bad  Jim Hanson, M.Ed.   (503) 916-6087

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