Presentation on theme: "Dialectical Behavioral Therapy in the Public Schools"— Presentation transcript:
1Dialectical Behavioral Therapy in the Public Schools James B. Hanson, M.Ed.Texas Association of School PsychologistsFall Conference 2012
2Outline What is DBT? Core Components Adaptation to School Settings Why Did Lincoln High School Choose DBT?How was DBT implemented?Research ResultsSupports and Challenges to School Implementation
3What 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).
4Examples 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.
5Core Dialectic of DBT Acceptance Change Mindfulness Problem Solving Radical AcceptanceValidationChangeProblem SolvingCognitive BehavioralGoals and ContingenciesGestalt Therapy: Paradoxical Nature of Change
6Therapist’s Style Reciprocal Irreverent Responsive SeriousAppropriate Self- DisclosureWarm EngagementRadical GenuinenessIrreverentUnorthodox ReframingPlunging In-HumorConfrontationCalling The BluffOmnipotence and ImpotenceIntensity and SilenceBoth 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.
7Who developed DBT? Marsha Linehan, University of Washington Attempts at traditional Cognitive Behavioral Therapy with suicidal and self-injurious clients did not workDialectical Behavioral Therapy with Suicidal Adolescents (2007). Alec Miller, Jill Rathaus, Marsha Linehan. New York: The Guilford PressMontefiore Medical Center 1995-teen researchCBT as a base for DBTGestalt Therapy and ABA
8Who is it for? Multi-diagnosed BPD (Borderline Personality Disorder) PTSDPara-suicidal Behavior in Teens (cutting)Eating Disorders (bulimia and binge eating)Antisocial PersonalityDepression in Elderly, Emergent in Teens33% of Teens who attempt have BPDComorbidity is the rule, not the exception
10What’s in a name?Results: Accounting for known confounders, victims of peer bullying had an increased risk of BPD symptoms according toself-report (OR, 2.82; 95% CI, 2.13–3.72);mother report (OR, 2.43; 95% CI, 1.86–3.16); andteacher 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– 855BPD and PTSD Care in criteria
11Efficacy Research with Teens Dialectical Behavioral Therapy with Suicidal Adolescents (2007)12-16 week treatments instead of 1 yearSuicidal 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
12Research Studies Rathaus & Miller (2002)-Adolescents Lower hospitalization (TAU 13% versus DBT 0%)Higher retention (TAU 40% versus DBT 62%)Fellows (1998)-AdolescentsTreatment group went from 539 inpatient hospital days pretreatment to 51 days post treatmentLinehan (1991, 2006)-Adults: Lower attempts, cutting, inpatient, anger. Inpatient, medical risk from cutting.Higher GAF, social adjustment, retention
13School 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)
14Biosocial Theory of Behavior Biological, Genes, Emotional VulnerabilitiesExecutive Functions, Abilities, Sensory Functions, MedicalInvalidating Environment(e.g., chronic stress, chaos, perfectionism, inconsistency)Can occur outside the family settingBiosocial TheoryImportant for Teens to know
15Creating a Life Worth Living Increasing Behavioral SkillsDecreasing Quality-of-Life Interfering BehaviorDecreasing Therapy-Interfering BehaviorDecreasing Life Threatening Behaviors
16Interpersonal Effectiveness MindfulnessProblem Solving(CBT, FBA)Distress ToleranceEmotional RegulationInterpersonal EffectivenessCore DBT Units
17Dialectics Black and white? Seeing polarities “Both/and” not “either/or”A life worth living has positive and negative aspectsGetting unstuck
18Mindfulness Full awareness Present Moment Wise Mind (Emotional & Logical)What: Observe, Describe, Participate,How: Don’t Judge, Focus, Do What WorksHalf Smile
19Solving Problems Goal Setting Chain Analysis (Functional Behavioral Analysis)Stinking ThinkingAll Or Nothing: If you’re not perfect, you’re a total loserDisqualifying 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.
20Distress Tolerance Pain is a part of life Pain versus suffering Some things you can’t changeIf you act impulsively, you can hurt yourself, others, and your goals
22Distress Tolerance Self-Soothe Kits Vision Hearing Taste Smell Touch Movement
23Opposite to Emotion Action FEAR-Hide- ApproachANGER-Attack- Gently AvoidSAD-Withdraw-Get ActiveGUILT-Avoid-Face
24Emotional Regulation Radical Acceptance Acknowledge, Recognize, Endure Myths: It’ll Change if I Wait, It’ll Kill Me, It’ll Last Forever
25Emotional Regulation RIDING THE WAVE You are not the wave Don’t avoid itDon’t judge itDon’t make it bigger or smallerDon’t hold on to itYou are not the feelingYou don’t need to act on itRemember times when you have felt differentlyInvite it home for dinner.
26Positive Events and Validation Pleasant Events ScheduleReducing emotional vulnerabilitySEEDS Skills (sleep, eating, exercise, drugs, sickness)Mastery: doing something you’re good atCheerleadingChecking the factsChoices about intensity
27Interpersonal Effectiveness What’s Your Objective?-DIGRelationship-GIVEYour Goals-RANSelf Respect-FASTValidation does not mean that you agree with the statement, it means you understand themGENTLE, INTERESTED, VALIDATE, EASY MANNERFAST-FAIR, no APOLOGIES, STICK TO VALUES, TRUTHFUL
28Parent Skills All of the Five Areas Validation Obstacles to skillful behaviorContingenciesEmotional regulation
29Lincoln High School, Portland OR 1550 studentsMiddle to high socio-economic status100 Best High Schools in United StatesSuicide was leading cause of deathAbout 20 parent meetings/year for cutting, suicidal ideation or attempt (record year high was 45)Meetings required by district Child Find policy
30Lincoln StatisticsHigh 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 suicidesBefore DBT: two to three placements into Portland Public School’s day treatment classroom per year, since DBT one placement2007 Oregon Healthy Teens Survey (11th graders)
31Assets-Lincoln High School CDC Coordinated School Health ModelPBISRESPONSE suicide preventionStudent & Staff Anti-BullyingReconnecting YouthSchool Improvement Plan with Mental Health goals
35Data collected each Area, each Tier Data from Attendance Credit Earned G.P.A.School RecordsMeasuring Attitudes, Beliefs, BehaviorsPre- and Post-Testing Standardized ChecklistsWritten Reflections and Portfolio Work SamplesStudent Work and Progress MonitoringPerformance of Oregon State Health Standards SkillsFormative and Summative AssessmentBASC-2 for DBT, Social Skills Rating System for SSDL, Reconnecting Youth, Coordinated Surveys
37Oregon and PPS Health Class Standards Explain how to build and maintain healthy relationshipsClassify personal stressors at home, in school, peersDescribe how social environments affect well-beingIdentify resources at home, school, and in the community for managing family and relationship problemsPractice strategies for managing and reducing stress, anger and conflictDemonstrate the ability to take the perspective of others in a conflict situationIdentify influences that contribute to positive and negative self-imageDemonstrate pro-social communication skillsDemonstrate the steps in problem solving, anger management and impulse control.These are the basis for all Lincoln SEL IEPS
38IEP ExampleOregon 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.
39School 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.
40DBT 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 trainingWeekly DBT providers team meeting
41Class Format Mindfulness exercise Homework New Skill Discussion and examplesFBA if emerging pattern of not doing homework, coming late, or other therapy- interfering behavior
43Individual Coaching 20-30 minutes a week Diary card driven (events, thoughts, feelings, and skills)Personalized diary cardsMini-FBA if late, if haven’t filled out diary cardNo 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 workingAccommodation in IEP or 504 to come to the counseling center to see their DBT coachCommunicated to teachers if not on IEP/504See the student before target behavior occursDo not see the student for 24 or 48 hours after target behavior occursShaping appropriate help-seeking
47DBT Team MeetingsPurpose: “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 programSimultaneously client an therapistSame hierarchy as DBT
48Parent EveningsEffectiveness research shows clearly that parent evenings are crucialEmphasis on validation, behaviorism, and communicationStudents whose parents come are the students who make the best gainsBeyond the nuclear family
49Adopt 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 therapistsFidelity Matters. Koerner, Dimeff, and Swenson DBT in Clinical Practice (2007)Population: look at research, evaluate outcomes Step DownGreat Advantage: It’s the school setting where a lot of the stress happens, failing of traditional DBT to address school
50Adaptations“Advanced Health” on transcript; DBT is an elective credit classMaterials from Portland DBT Teen ProgramLincoln Staff/Teacher TrainingConsultation with community providersFidelity checks from Portland DBT ProgramDBT in International Baccalaureate “Theory of Knowledge” classes and or Health ClassesClass has homeworkParents have HomeworkPhone calls to Community Therapist
51DBT Team Members School Psychologist School Nurse School Social Work InternSchool Psychology Practicum Student and School Psychology InternSchool CounselorSchool Counseling InternThis doesn’t include 9 years of Gestalt training and our core training in FBA, other SP skills
52Team TrainingCore Team Training: 6 Days, Portland DBT Readings: Miller (2007) Linehan (1993)Leader Training for School Psychologist:6 Days, Portland DBT6 Days per year, Behavioral Tech10 Years, Portland Gestalt Training InstituteABA
53StudentsSelf-referral from one-day preview of DBT skills in general education health classesPBIS: Universal screenerPBIS: Students who did not do well enough in Reconnecting Youth or mentoring programIEP: Students identified with social/emotional needsStudents in day treatment classroom who have collaborative problem solving skill baseTier Two or Tier Three classification depends on student
54Inclusion 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 therapyStep down or “graduates” from LHS DBT, other programs, community DBT, and PPS day treatment as appropriateNo requirement to quit other therapy: consultation with community providerIdentifiable “target behavior”
56Measures BASC-2 Pre and Post (Student, Parent, Teacher Versions) AttendanceGrade Point AverageWritten ReflectionProgress Monitoring: Daily Diary Cards
572009 Girl’s GroupBASC-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
58Girls’ 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.”
59Girls’ 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.”
602010 Mixed Cohort-Semester Slight increases in attendance and bigger increases in GPAModest decreases in Anger Control, Anxiety
612010 Mixed Group, Year-LongAll but one student on IEP or Safety Plan for suicide attempt/serious suicidal ideationBASC-2 ESI < 10, Internalizing < 4, Depression < 9, Anxiety < 4Grade Point Average (2/8 Students -.8, most other students gained about +.4)Attendance dropped by 10 days per yearGreater sense of self developed; more parental conflict in individuation
62Student 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.
632011 Mixed Group, Year Long Average increase in GPA = + .76 11 of 12 students increased GPAAverage increase in attendance = + 4%Attendance not interpretable, 5/12 students decreased attendance slightly, 1 student significantly increased
642011 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  to +2)For one student, DBT as delivered did not work. For the vast majority of students, DBT worked very well.
662012 Group, Semester Long Average increase in GPA = .27 Average increase in attendance = -4% (+7 to -10%, majority of students no changeBASC-2 Internalizing Problems average decrease = 5
67Student 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.”
68Other results: No suicides since REPONSE, RY, and DBT One placement in more restrictive settingSavings to district: $350,000Day treatment classroom at Lincoln with Collaborative Problem Solving model: teaching to other teachers
69Whom we did not help ADHD not medicated Depersonalization Disorder Students with parent who did not attend parent classesNarcissistic traits: difficulty with group formatWhat’s up with lower attendance rates and higher GPA’s?
70Lincoln ResearchAlthough 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)
71Supports Syllabus Administrative and parent buy-in Tier Two and Tier ThreeSchool Improvement PlanHealth Action Network FundsDistrict support
72Challenges Time constraints for class New block schedule lessens flexibilityScheduling individual appointments for students not in SPEDTime intensity for programTraining new staff every yearParent group: have had to modify formatChanging special education administrationPerception of “therapy” versus “counseling”Research parametersStudents were less concerned about getting credit for the class, but it really helped.Special Education Director was familiar with DBT and its efficacy
73It’s Not a Walk on the Beach And It Ain’t BadJim Hanson, M.Ed.(503)