Dialectical Behavioral Therapy in the Public Schools . James B. Hanson, M.Ed. Texas Association of School Psychologists Fall Conference 2012. Outline . What is DBT? Core Components Adaptation to School Settings Why Did Lincoln High School Choose DBT? How was DBT implemented?
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Dialectical Behavioral Therapy in the Public Schools James B. Hanson, M.Ed. Texas Association of School Psychologists Fall Conference 2012
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
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).
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.
Core Dialectic of DBT • Acceptance • Mindfulness • Radical Acceptance • Validation • Change • Problem Solving • Cognitive Behavioral • Goals and Contingencies
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
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
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
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)
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., SchreierA., 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
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)
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
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)
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
Dialectics • Black and white? • Seeing polarities • “Both/and” not “either/or” • A life worth living has positive and negative aspects • Getting unstuck
Mindfulness • Full awareness • Present Moment • Wise Mind (Emotional & Logical) • What: Observe, Describe, Participate, • How: Don’t Judge, Focus, Do What Works • Half Smile
Solving Problems • Goal Setting • Chain Analysis (Functional Behavioral Analysis) • Stinking Thinking
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
Distress Tolerance: ACCEPTS • Activities • Contribute • Compare • Emotional Opposite • Push Away (Bracket) • Thought Change • Sensation Change
Distress Tolerance • Self-Soothe Kits • Vision • Hearing • Taste • Smell • Touch • Movement
Opposite to Emotion Action • FEAR-Hide-Approach • ANGER-Attack-Gently Avoid • SAD-Withdraw-Get Active • GUILT-Avoid-Face
Emotional Regulation • Radical Acceptance • Acknowledge, Recognize, Endure • Myths: It’ll Change if I Wait, It’ll Kill Me, It’ll Last Forever
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
Positive Events and Validation • Cheerleading • Checking the facts • Choices about intensity • Pleasant Events Schedule • Reducing emotional vulnerability • SEEDS Skills (sleep, eating, exercise, drugs, sickness) • Mastery: doing something you’re good at
Interpersonal Effectiveness • What’s Your Objective?-DIG • Relationship-GIVE • Your Goals-RAN • Self Respect-FAST
Parent Skills • All of the Five Areas • Validation • Obstacles to skillful behavior • Contingencies • Emotional regulation
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)
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
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
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 .
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.
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
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
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
“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
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
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
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
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