The Association of Student Assistance Professionals of New Jersey (ASAP-NJ)

February 27-28, 2014

Faiga Pessie Reches, LSW, MSW

What is DBT?

Core Components

How can DBT be implemented in schools –What can we learn from others who are currently implementing or have implemented DBT in their school?

Research Results

Supports and Challenges to School Implementation

A synthesis of:

Behaviorism

Mindfulness

Dialectics

Dialectics: “A means of finding fluidity and balancing acceptance and change in the face of rigidity and impasse” (Miller et. al 2007).

The understanding that two opposing views, ideas, beliefs, etc. can both be true at the same time.

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.

Acceptance

Mindfulness

Radical Acceptance

Validation

Change

Problem Solving Cognitive Behavioral Goals and

Contingencies

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

Marsha Linehan, University of Washington

Attempts at traditional Cognitive Behavioral Therapy with suicidal and self-injurious clients did not work. Clients expressed frustration with the lack of acceptance they perceived in CBT’s emphasis on Cognitive Restructuring.

Dialectical Behavioral Therapy with Suicidal Adolescents (2007). Alec Miller, Jill Rathaus, Marsha Linehan. New York: The Guilford Press

New Release – Dialectical Behavior Therapy for At-Risk Adolescents (2013). Pat Harvey, Brit Rathbone. New Harbinger Publications

Multi-diagnosed – Comorbidity is the rule, not the exception.

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

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 – bulimia and/or binge-eating)

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

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

Creating a

Life Worth

Living

Increasing

Behavioral Skills

Decreasing Quality-of-Life

Interfering Behavior

Decreasing Therapy-Interfering

Behavior

Decreasing Life Threatening Behaviors

Emotional Regulation (labile, anger)

Interpersonal Regulation (chaotic, abandoned)

Self Regulation (identity, emptiness)

Behavioral Regulation (suicide, cutting, impulsive)

Cognitive Regulation (black and white thinking)

Mindfulness

Problem

Solving

(CBT, BCA)

Distress

Tolerance

Emotional

Regulation

Interpersonal

Effectiveness

Black and white thinking

Seeing polarities

“Both/and” not “either/or”

A life worth living has positive and negative aspects

Getting unstuck

Full awareness

Present Moment

Wise Mind (Emotional & Logical)

What: Observe, Describe, Participate,

How: Don’t Judge, Focus, Do What Works

Pain is a part of life

Pain versus suffering

Some things you can’t change

Willingness to accept the situation as it is. Not as you wish it to be.

Activities

Contribute

Compare

Emotional Opposite

Push Away (Bracket)

Thought Change

Sensation Change

Vision

Hearing

Taste

Smell

Touch

Movement

Imagery

Meaning

Prayer

Relaxation

One-Mindfully

Vacation

Encouragement

Pros of using skills versus Cons of using skills.

Pros of not using skills versus Cons of not using skills.

Pros Cons

Using skills

Not usingskills

Understanding Emotions

Emotion Model

Myths: It’ll Change if I Wait, It’ll Kill Me, It’ll Last Forever

A: Accumulate positive experiences, events (safety net)

B: Build mastery (competence)

C: Cope ahead for emotional situations

PLEASE: Take care of your body

Be mindful of the emotion

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

FEAR-Hide-Approach

ANGER-Attack-Gently Avoid

SAD-Withdraw-Get Active

GUILT-Avoid-Face

What’s Your Objective?

Need – DEAR MAN

Relationship-GIVE

Self Respect-FAST

Growing concern about coping skills of at-risk students

Strategy needed to provide the best support to the greatest number of students given limited and shrinking resources

DBT is successful when at-risk students receive outside DBT treatment

Need for additional clinical support services without any prerequisites - No IEP needed

Teaching a class is a more efficient use of time for clinicians

Ability to fit within the school day

Lincoln Sudbury Regional High School (Sudbury, MA) - Examination of MetroWest Adolescent Health Survey

Data from LSRHS

In 2006, students reported the following behaviors:

29% life being very stressful

20% feeling sad/hopeless almost everyday for at least 2 weeks

15% hurting or injuring themselves on purpose

10% considered suicide in the past year

Lincoln High School (Portland, OR)

Suicide was leading cause of death

About 20 parent meetings/year for cutting, suicidal ideation or attempt (record year high was 45)

2007 Oregon Healthy Teens Survey (11th graders)

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

Tier Three:

3 – 5% of the student body. In need

of outside treatment for mental

health challenges. (i.e. suicidal

ideation, self-harm, eating

disorders, etc.)

Tier Two:

10-15% of the student body. Students are

achieving far below their potential in school

because of emotional interference. (i.e.

depression, anxiety, early signs of eating

disorders, substance use etc.)

Tier One:

Universal student body. Students are struggling with day to

day life. No particular issues on the table.

PreventionTargeting Tier One and/or Tier Two students

TreatmentTargeting Tier Three students –Schools are not equipped to provide evidence-based TREATMENT. Tier Three student should be referred to outside mental health providers with collaboration from school.

What are our resources?What is our time frame? (semester?)

Is there a specific grade we want to target?

Whom do we want to target?1. The entire student body/grade –

Tier One

2. Tier Two students

Weekly Skills Classes with 2 co-facilitators

Weekly individual therapy – Diary Cards

Phone coaching

Weekly Consultation Team Meeting

How are these components implemented in a school

system?

Ex: Lincoln High School (Portland, OR)

Academic elective course or taught in Health Class as part of the curriculum for all students

2 General Education credits

On student’s transcript, the class reads “Skills for Well-being” versus Dialectical Behavior Therapy.

LINCOLN HIGH SCHOOL

Department of Health Education

COURSE INFORMATION

Title: Health Skills (Advanced) CRN# 0803 (1/2 credit), Grade Levels: 9,10,11,12

Location: Counseling Center

Instructors: Timm Goldhammer M.S., M.Ed., Ph.D. (supervising teacher), James B. Hanson,

M.Ed., School Psychologist, Instructor, Mary Johnson, RN, BSN, School Nurse

Phone/Email: Jim Hanson 503-916-6087 (Lincoln) or jimhanson@pps.net

Tutorial: 20-35 minutes weekly, individual, as arranged. Parent group once a month

Required Text/ Readings:

1. Portland DBT Teen Program (2006) adaptation of Miller, Rathus, & Landsman’s

(1999) adaptation of Linehan (1993) Dialectical Behavioral Skills Training

University of Washington

2. Portland DBT Parent Training (2008) adaptation of Linehan (1993a and 1993b)

3. Selected readings provided in class.

PHILOSOPHY OF MENTAL HEALTH EDUCATION

The Lincoln High School Dialectical Behavioral Skills Training Class and Parent training

is designed to provide students additional training and application in five core skills: mindfulness

(health related self-care skills), problem solving (cognitive-behavioral approaches to examining

and correcting self-defeating thoughts and actions), distress tolerance (improve emotional and

behavioral functioning in adverse situations that cannot be immediately changed), emotional

regulation (managing positive and negative mood states), and interpersonal effectiveness

(establishing and maintaining healthy peer, teacher, and parent relationships).

GENERAL COURSE INFORMATION

Description: Advanced health skills (Dialectical Behavioral Skills Training, or DBT) is by

application only. Teachers, school counselors, the school nurse, and parents may nominate

students for this group. Nomination is based upon students’ desires and need for establishing

good habits for managing stress, anxiety, and depression. Students may also nominate

themselves, after hearing a preview of the skills in health class. Many students who enroll are

intelligent and academically skilled, yet they are usually experiencing anxiety, depression, or

stress. Each student and parent must sign a contract for permitting their participation in the group

and its activities. Students meet for 90 minutes on Wednesdays or Thursdays as a small group.

During the class, students learn specific skills to manage thoughts and emotions. Students do not

spend time talking about the issues in their lives because the curriculum is quite specifically skills

training. However, students do relate the skills they are learning to issues that they experience at

school and at home. Class rules include making a commitment to confidentiality of what other

students say during class time. Students are assigned homework that relates to practicing the

skills they learned in class. Each student also attends a 20 minute tutoring session every week

with either one the course co-facilitators (the School Psychologist, School Nurse or School Social

Work Intern) who has been trained in DBT. During the individual sessions,

Ex: Lincoln Sudbury High School (Sudbury, MA)

Excel Program

Mandatory course with history credits.Excel is a special education program for students with

significant emotional issues which impact their ability to be successful at school – either getting through the day or even getting to school.

All 11th and 12th graders take a two year Excel Psychology class which includes a full year of high school Psychology, a semester of DBT skills, a quarter of Cognitive Behavioral Therapy, and a weekly therapy group. In addition, each student has a daily “skills” block with the special educator, and individual counseling.

Weekly or Twice Weekly Skills Class with two co-facilitators (students receive passes to attend DBT class)

Weekly Individual Sessions (with counselors or school psychologist)

“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

Class Format:

Mindfulness exercise

Homework

New Skill

Discussion and examples

BCA if emerging pattern of not doing homework, coming late, or other therapy-interfering behavior

20-30 minutes a week

Diary card driven (events, thoughts, feelings, and skills)

Personalized diary cards

Mini-BCA if late, if haven’t filled out diary card

No reinforcement (conversation, warmth) before diary card is filled out

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

Evenings for Parents

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

Format

Video, letters and skill sheets.

Who is your client? Family or Child

Working with Tier Two

Only student is taught skills

Family skills group – Student with at least one parent

Student groups and separate Parent groups

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

School Psychologist

School Nurse

School Social Work Intern

School Psychology Practicum Student and School Psychology Intern

School Counselor

School Counseling Intern

Littles – Kindergarten through FifthTaught rudimentary mindfulness with some

Distress Tolerance and Emotion Regulation.

Make it Fun!

Incorporates Multi-Family Groups

Middles – Junior High – Sixth through EighthAdd Interpersonal Effectiveness skills

Parent Evenings

Bigs – High SchoolAll modules

Parent Evenings

Self-referral from one-day preview of DBT skills in general education health classes

IEP: Students identified with social/emotional needs

Assessment by school counselor for Tier Two

If suicidal, not included – Tier Three – refer to outside mental health agency

If suicidal ideation, self-harm or eating disorder is serious, referral to outside DBT or other mental health program.

Step down or “graduates” from outside DBT, other programs, and outside day treatment as appropriate.

No requirement to quit other therapy: consultation with community provider

Identifiable “target behavior”

To prevent escalation to Tier Three!

Most schools lose funding through Tier Two students who have many absences and do not do well in school due to emotional interference.

Assessment of student placement in Tier is critical! DBT skills training for a student in need of TREATMENT (Tier Three) will probably not be effective.

Target population – same as research?

Comprehensive DBT – all components?

Setting – finances, time, structure?

Professional training – skill set, credentials?

“Gold Standard” Five functions – skills, generalization, and environment of clients; capabilities and motivation of therapists

Ex: Lincoln High School (Portland, OR)

2009-2012 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

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

Slight increases in attendance and bigger increases in GPA

Modest decreases in Anger Control, Anxiety

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

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)

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

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

“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.”

“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.”

“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.”

“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.”

No suicides since DBT

One placement in more restrictive setting

Savings to district: $350,000

Collaborative Problem Solving model: teaching to other teachers

ADHD not medicated

Depersonalization Disorder

Students with parent who did not attend parent classes

Narcissistic traits: difficulty with group format

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)

Syllabus

Administrative and parent buy-in

Tier Two and Tier Three

School Improvement Plan

Health Action Network Funds

District support

Time constraints for class Scheduling individual appointments for

students with counselors 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