Dialectical Behavioral Therapy in the Public Schools

1. Dialectical Behavioral Therapy in the Public Schools James B. Hanson, M.Ed. NASP Convention 2012 Philadelphia, PA

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, but 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 • Mindfulness • Radical Acceptance • Validation • Change • Problem Solving • Cognitive Behavioral • Goals and Contingencies

6. 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

7. 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

8. 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)

9. Biosocial Theory of Behavior • Individual Emotional Regulation Problems • Biological, Genes, Emotional Vulnerabilities • Invalidating Environment (e.g., Chronic stress, chaos, perfectionism, inconsistency) • Learning: Observational, Operant, Respondent

10. Core DBT Units

12. Therapist’s Style • 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

13. 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)

14. 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

15. 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

16. Lincoln High School, Portland OR • 1400 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

17. 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

18. 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

19. CDC Coordinated School Health

21. Character Traits: Respect, Understanding, Integrity, Community, Purpose

22. 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 .

24. School Improvement Plan

25. 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

26. 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 • Possible inclusion of DBT curriculum for general education health classes: University of Washington, James Mazza developed curriculum

27. Syllabus

28. Students • Self-referral from one-day preview of DBT skills in general education health classes • 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 who have collaborative problem solving skill base • Tier classification depends on student

29. Advance Health Skills/Dialectical Behavioral Skills Signed Contract • “I am familiar with the assumptions and theory of DBT” • “I agree to participate in DB Skills Training Class and individual coaching” • Parents agree to monthly parent meeting • BASC-2 teacher, parent, & self: pre and post • Diary card: basis of individual coaching • FBA as part of the coaching: Target Behavior

30. Inclusion Criteria • If suicidal, not the only counseling service • If 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”

31. Sample IEP • Student will use social/emotional and behavioral skills to improve her scores on measures of Sense of Inadequacy, Anxiety, Depression, Atypicality and Withdrawal BASC-2 scales from the clinically significant to the average range on parent, teacher, and self-report

32. IEP Goals • Student will demonstrate the steps in problem solving, anger management, and impulse control by completing readings, discussion, and 100% of homework, including functional behavioral analysis, on problem-solving and emotional regulation skills. • Evaluation Procedures: transcript for GPA, school attendance, Advanced Health class attendance/homework, diary card, FBA, BASC-2.

33. Core DBT Units

34. 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

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

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

37. Solving Problems • Goal Setting • Chain Analysis (Functional Behavioral Analysis) • Stinking Thinking

38. 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

39. Distress Tolerance: ACCEPTS • Act • Contribute • Compare • Emotional Opposite • Push Away (Bracket) • Thought Change • Sensation Change

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

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

42. Emotional Regulation • Radical Acceptance • Acknowledge, Recognize, Endure • Myths: It’ll Change, It’ll Kill Me, It’ll Last Forever

43. 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

44. Interpersonal Effectiveness • What’s Your Objective?-DIG • Relationship-GIVE • Your Goals-RAN • Self Respect-FAST

45. Individual Coaching • Share more deeply than in the class • Class does not allow sharing of examples that have to do with cutting, suicidal ideation, or other matters that might trigger other students • Diary card guides the session • If diary card isn’t done, then student must complete then and there, and have less time to talk to coach

48. “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

49. 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

50. Lincoln’s Experience • Who has been a member of Lincoln’s DBT Team: • School Psychologist, School Nurse, School Social Work Intern, School Psychology Practicum Student, School Counselor, School Counseling Intern • 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