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Dialectical Behavioral Therapy in the Public Schools

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Presentation on theme: "Dialectical Behavioral Therapy in the Public Schools"— Presentation transcript:

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

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)

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