Dialectical Behavioral Therapy in the Public Schools James

Dialectical Behavioral Therapy in the Public Schools James B. Hanson, M. Ed. CHSD 218 INSPi. RE Clinic Grand Rounds September 29, 2016 Chicago, IL

Learning Objectives � Learn theory, assumptions, and principles associated with SB-DBT � Learn skills associated with all five modules of SB-DBT � Explain what systems and supports must be in place to implement SB-DBT with fidelity and how SB-DBT operationalizes mental health interventions within a multitiered system of support. � Examine concrete program elements and supports for SBDBT including practitioner training, supervision, student and family orientation protocols, and fidelity.

What is DBT? � A comprehensive intervention system based on: Behaviorism, Mindfulness, Dialectics: Two opposite ideas can be true at the same time, and when considered together, can create a new truth and a new way of viewing the situation. There’s always more than one way to think about a situation. (Rathus & Miller, 2015)

Dialectical Behavior Therapy in Public Schools From Student Handouts, Rathus & Milller (2015) • • • DBT is an effective treatment for people who have difficulty controlling their emotions and behaviors DBT aims to replace problem behaviors with skillful behaviors DBT skills help people experience a range of emotions without necessarily acting on them DBT skills help teens navigate relationships with family, school, and peers DBT helps people create a life worth living

NASP

Dialectical Behavior Therapy in Public Schools BPD Re-conceptualized � Emotional Regulation (labile, anger) � Interpersonal � Self Regulation (chaotic, abandoned) Regulation (identity, emptiness) � Behavioral � Cognitive Regulation (suicide, cutting, impulsive) Regulation (black and white thinking)

Dialectical Behavior Therapy in Public Schools Why apply DBT skills to schools DBT skills focus on coping strategies and decision-making abilities (esp. emotionally difficult situations) Where could adolescents use these skills? 1. 2. 3. 4. 5. 6. 7. Alcohol and drug use Relationships with peer, family, and romantic Self-harming behavior Suicidal behavior Bullying victimization and perpetration Antisocial behavior Academic pressures Mazza, 2015

Dialectical Behavior Therapy in Public Schools Outcomes for Community-Based DBT For Adults reduction in suicidal behavior, self harming behavior, PTSD, depression, substance dependence, impulsivity, & BPD For adolescents Reduction in suicidal thoughts and attempts, selfharming behavior & depression (Miller et al. , 2010; Neacsiu et al. , 2010)

Dialectical Behavior Therapy in Public Schools Examples of outcomes for School Based (SB)-DBT Ardsley High School, NY (9 years) -improved school attendance -50% reduction in disciplinary referrals Lincoln High School, OR (10 years) -BASC-2 significant reductions in anxiety, depression, social stress, anger control - increased GPA (Miller et al. , 2014)

Dialectical Behavior Therapy in Public Schools Potential Outcomes a) b) c) d) e) f) g) h) Less self-medicating Less use of alcohol and drugs Less risky sexual behavior and students feeling pressured to have sex Less self-harming behavior Less suicidal behavior Less bullying Less conduct problems and thus less suspensions and expulsions Less school dropout, better academic success measure through GPA, homework, etc. Mazza, 2015

Dialectical Behavior Therapy PRINCIPLES Core Dialectic of DBT �Acceptance � � � Mindfulness Radical Acceptance Validation �Change � � � Problem Solving Cognitive Behavioral Goals and Contingencies

Dialectical Behavior Therapy PRINCIPLES Examples of Teen Dialectics 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. �

Dialectical Behavior Therapy PRINCIPLES 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

Dialectical Behavior Therapy THEORY Biosocial Theory of Behavior Biological, Genes, Emotional Vulnerabilities � Invalidating Environment (e. g. , chronic stress, chaos, perfectionism, inconsistency) that can occur inside or outside the family setting (e. g. , school can be an invalidating environment) � Interaction of biology and environmental factors (e. g. , highly emotional student in a rigid classroom) can create a vicious downward spiral of vulnerability and invalidation �

Creating a Life Worth Living Adaptive Functioning DBT Treatment Hierarchy Increasing Behavioral Skills Decreasing Quality-of-Life Interfering Behavior Decreasing Therapy-Interfering Behavior Decreasing Life Threatening Behaviors

Dialectical Behavior Therapy ASSUMPTIONS Rathus & Miller, 2015 � � � � People are doing the best they can People want to improve People need to try harder, do better, and be more motivated to change You have to play the hand you’re dealt Not learning new ways to cope means remaining in pain Skills are for using in all environments There is no absolute truth Teens and families can’t fail in DBT.

DBT Skills and Therapy Continuum of Services STEPS-A Curriculum DBT Therapy in Schools TIER II & III Health Teacher Trained Teacher School Psychologist School Counselor Social Worker Mazza, 2015

Dialectical Behavior Therapy in Public Schools STEPS-A = Skills Group/Large Class SB-DBT = All Five Components/Small Class “Phone Calls” DBT Individual Therapy Parent Group *Skills Group Consultation Team for Therapists Mindfulness Distress Tolerance Middle Path* (Dialectics, CBT) Emotion Regulation Interpersonal Effectiveness

Dialectical Behavior Therapy in Public Schools STEPS-A is a universal program; selective if used with an at-risk population SB-DBT is an indicated program; selective if used with students identified at risk and if used as RTI 5 -10% 10 -15% 80 -85% Tier III Indicated Using MTSS model Tier II Selected Population Tier I Universal Population Mazza, 2015

Emotional Problem Solving for Adolescents: Introduction to the STEPS-A Curriculum If DBT in Schools doesn’t work, then outpatient DBT for adolescents (Miller, Rathus, & Linehan, 2008) would be the next logical tier Hospitalization Tier VI SB-DBT Tier III Indicated Tier II Selected Population STEPS-A Tier I Universal Population Tier V Residential treatment Tier IV Outpatient DBT for Adolescents Mazza, 2015

DBT: Starting upstream STEPS-A School-based DBT + STEPS-A Program Evaluation and Research Outpatient DBT Residential Treatment + DBT Miller & Mazza, 2014 Hospitalization + DBT IOP/PHP + DBT

Dialectical Behavior Therapy in Public Schools Class structure Each class is structured similarly (80 minutes) a) b) c) d) Mindfulness (3 -5 minutes) Homework Review (15 -30 minutes) Teaching new lesson (30 -45 minutes) Lesson summary and assignment of homework (57 minutes)

Curriculum

Syllabus

Agenda

Dialectical Behavior Therapy in Public Schools Curriculum Structure– Recommended Sequence Mindfulness Distress Tolerance Interpersonal Effectiveness Mindfulness Emotion Regulation Mindfulness Middle Path Mazza, 2015

Dialectical Behavior Therapy in Public Schools Mazza, 2015 Curriculum Structure STEPS-A & SB-DBT CURRICULUM Mindfulness 1. 2. 3. 4. 5. 6. 7. Wise Mind Observe Describe Participate Non-judgmental One-mindfully Effectively Distress Tolerance 1. 2. 3. 4. 5. 6. ACCEPTS Self-Soothe Pros & Cons IMPROVE Radical Acceptance Turning the Mind Interpersonal Effectiveness Emotion Regulation 1. Observe/Identifying Emotions 2. Wave Skills 3. Opposite Action 4. ABC 5. PLEASE/SEEDS 1. 2. 3. 4. 5. Ranking Priorities DEAR MAN GIVE FAST Evaluating Options

Dialectical Behavior Therapy in Public Schools Mazza, 2015 Core Mindfulness (STEPS-A and SB-DBT) Mindfulness 1. 2. 3. 4. 5. 6. 7. Wise Mind Observe Describe Participate Non-judgmental One-mindfully Effectively 1. 2. 3. 4. 5. Balance between emotion mind and reasonable mind Observe – just notice the experience (component of the How skills) Describe – put words on the experience (How skills) Participate – throw yourself completely into it (How skills) Non-judgmental – see but don’t evaluate, just the facts (What skills) 6. One-mindfully – be completely present (What skills) 7. Effectively – Focus on what works (What skills)

Dialectical Behavior Therapy in Public Schools Mazza, 2015 Distress Tolerance (STEPS-A and SB-DBT) Distress Tolerance 1. 2. 3. 4. 5. 6. Pros & Cons ACCEPTS IMPROVE Self-Soothe TIP Radical Acceptance 7. Turning the Mind 8. Half Smile & Willing hands 9. Willingness 1. 2. 3. 4. 5. 6. 7. 8. 9. Evaluating strategy balancing pro’s/con’s of the decision & lack of the decision Distract with ACCEPTS -Activities, Contributing, Comparisons, Emotions, Pushing away, Thoughts, Sensations Imagery, Meaning, Prayer, Relaxation, One thing in the moment, Vacation, Encouragement Self-soothe through the 5 senses Changing body chemistry- Temperature, Intensive exercise, & Progressive muscle relax Freedom from suffering requires acceptance (acceptance ≠ approval) Turning the mind to the acceptance road Changing your emotions by changing your physical expressions Playing the cards that you were dealt and doing what works – opposite of willfulness

Dialectical Behavior Therapy in Public Schools Mazza, 2015 Emotion Regulation (STEPS-A and SB-DBT) Emotion Regulation 1. Observe/Identifying Emotions 2. Describing Emotions 3. Opposite Action 4. Check the facts 5. ABC 6. PLEASE/SEEDS 1. Learning to recognize how emotions feel within your body 2. Learning the different words to describe emotions and what words to use when that emotion is elevated or low 3. Acting opposite to your current emotion action urge 4. Before making any decisions, checking the actual facts 5. Accumulate, Build mastery (do things you are good at) Cope ahead (rehearse a plan ahead of time 6. reduce Physica. L Illness, balance Eating, Avoid drugs, balanced Sleep, Exercise daily or SEEDS: Sleep, Exercise, Eating, Drugs, and Sickness

Dialectical Behavior Therapy in Public Schools Mazza, 2015 Interpersonal Effectiveness (STEPS-A and SB-DBT) Interpersonal Effectiveness 1. Ranking Priorities 2. DEAR MAN 3. GIVE 4. FAST 5. Evaluating Options 1. Objectives, relationship, self-respect 2. Describe, Express, Assert, Reinforce – Mindful, Appear confident, Negotiate 3. Gentle, Interested, Validate, Easy manner 4. be Fair, no Apologies, Stick to your values, be Truthful 5. Low or high intensity for asking or saying No

Dialectical Behavior Therapy in Public Schools Walking the Middle Path (SB-DBT) Additional Unit Walking the Middle Path 1. Dialectics 2. Thinking Mistakes 3. What’s Typical? 4. Validation 5. Behavior Change 1. Two seeming opposite position can both be true, Dialectial Dilemmas 2. “Stinking Thinking” Mindful, Name, Claim, Tame 3. What’s typical and what’s cause for concern? 4. Validating self and other; Validation doesn’t mean agreement 5. Ways to Increase, Positive Reinforcement; Ways to Decrease; Extinction and Punishment Mazza, 2015

Practice Skill-Mindfulness

Observe and Describe

Practice Skill-Distress Tolerance

Practice Skill-Middle Path

Practice Skill-Emotional Regulation

Practice Skill-Emotional Regulation

Practice Interpersonal Effectiveness

Dialectical Behavior Therapy in Public Schools STEPS-A = Skills Group/Large Class SB-DBT = All Five Components/Small Class “Phone Calls” DBT Individual Therapy Parent Group *Skills Group Consultation Team for Therapists Mindfulness Distress Tolerance Middle Path* (Dialectics, CBT) Emotion Regulation Interpersonal Effectiveness

Dialectical Behavior Therapy in Public Schools Individual Counseling Format 20 -30 minutes a week � Diary card driven (Progress Monitoring) � Share at deeper level � FBA if emerging pattern of not doing homework, coming late, or otherapy-interfering behavior �

Diary Card Side One

Diary Card Side Two

Dialectical Behavior Therapy in Public Schools “Telephone Consultation” � � � � Every student has the chance to receive immediate consultation during the day if trying to use skills and they aren’t working Accommodation in IEP or 504 to come to the counseling center or nurses office to see their DBT coach (top three coaches, wait) Communicated to teachers if not on IEP/504 Short (<5 minutes) coaching until next skills class or appointment Student asks for help before target behavior occurs Therapist does not see the student for 24 or 48 hours after target behavior occurs Shapes appropriate help-seeking and self-reliance

Dialectical Behavior Therapy in Public Schools 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 �

Dialectical Behavior Therapy in Public Schools SB-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” � Team supervises each other � Team may hire a consultant to provide supervision � Integral part of DBT program �

Dialectical Behavior Therapy in Public Schools SB-DBT Team Members School Psychologist � School Nurse � School Social Work Intern � School Psychology Practicum Student and School Psychology Intern � School Counselor � School Counseling Intern � Portland DBT Institute Therapist (participant, fidelity) � Private DBT Practitioner (consultant, fidelity) �

Dialectical Behavior Therapy in Public Schools. Team SB-DBT Training Core Team Training: 6 Days, Portland DBT Institute � Required readings: � Miller et al. (2007) DBT with Suicidal Adolescents � Rathus & Miller (2015) DBT Skills Manual for Adolescents � Linehan (1993) CBT of Borderline Personality Disorder � Dimeff & Koerner (2007) DBT in Clinical Practice (optional) � Leader Training for School Psychologist: � 6 Days, Portland DBT (initial training) � 6 Days per year, Behavioral Tech (continuing education) �

DBT in Action in the Schools

NASP � The National Association of School Psychologists Practice Model Domain 4 indicates, “School psychologists have knowledge of. . . evidence-based strategies to promote social– emotional functioning and mental health. ” � NASP “Principles for Professional Ethics” (2010) Standard II. 3. 9 states that preference for intervention selection is given to interventions described in the peer-reviewed professional research literature and found to be efficacious. ”

NASP

NASP

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, motivation, generalization, and environment change of clients; capabilities and motivation of therapists � Koerner, Dimeff, and Swenson (2007) DBT in Clinical Practice

DBT in Schools(Comprehensive &/or STEPS-A) • Ulster County HS Health Class Curriculum (1999) • Salley et al, (2002) �Far Rockaway HS • Hanson (2007 -present) �Lincoln HS, Oregon • Perepletchikova et al, (2010) • • �New Haven Elementary School/Yale University Lander, Miller, Edwards et al, (2009 -2012) �PS 8 Bronx, NY/Albert Einstein College of Medicine Ardsley School District, NY- Elementary, MS, and HS (2008 present) �Presented data at conferences (Catucci et al. ; Mason et al) Pleasantville, NY School District- MS and HS (2009 -present) Mamaroneck, NY School District (2010 -present) Miller & Mazza, 2014

DBT in Schools(Comprehensive &/or STEPS-A) • • • BOCES Rockland County (2012 – Present) New Rochelle School District (2012 – Present) Mastery Charter School, Philadelphia, PA HS (2013 -present) University of Washington, MS & HS Education Golden Hill Elementary, Florida, NY (2013 – Present) Irvington Elementary, Middle, and High Schools, NY (2013 present) Hasting on Hudson Elementary, Middle, and High Schools, NY (2013 - present) Briarcliff Elementary, Middle, and High Schools, NY (2013 - present) Manteca MS & MS, CA (2014 -present) Oakland, MS & CA (2014 -present) Project GRAD, LA (2014 -present) Aloha HS, Beaverton SD, OR (2015 -present) Miller & Mazza, 2014

Lincoln High School, Portland, OR

Support Elements

ASCD/CDC Model 58

MTSS

School Improvement Plan 60

Counseling Center Brochure

Student Information Team

SB-DBT Goals via Oregon DOE Health Standards 1. 2. 3. 4. 5. 6. 7. 8. 9. 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 reducing stress, anger, and conflict Demonstrate ability to take perspectives of others in conflict situations Identify contributions to positive and negative self-image Demonstrate pro-social communication skills Demonstrate the steps in problem solving, anger management and impulse control

Syllabus

Lincoln HS Statistics 1720 students � Middle to high socio-economic status � 100 Best High Schools in United States � Suicide was leading cause of death until SB-DBT � About 20 parent meetings/year for cutting, suicidal ideation or attempt (record year was this year: 57) �

Lincoln HS Statistics � High stress and anxiety (OHTS 2014: 13% of students considered suicide in last twelve months; 2% attempted) Not unusual for Oregon & Portland schools � Before DBT: one to two suicides per year; since DBT no suicides � Before DBT: two placements into Portland Public School’s day treatment classroom per year; since DBT one placement in nine years (student returned in two weeks)

Referral � Self-referral from one-day preview of DBT skills in general education health classes � Building-wide mental health screening � MTSS/RTI: Students who did not do well enough in Reconnecting Youth or mentoring program � IEP: Students identified social/emotional needs � Students in Lincoln’s day treatment who have Collaborative Problem Solving (three years) � Child Find meetings � (Tier classification depends on student)

Career Pathways Screening � Adversity, health issues, personal problems and stress can challenge all of us. Are there issues that you are dealing with which might impact your academic success? � Would it be helpful to talk with your school counselor about any of the issues you mentioned in the previous question? � Next year: Social and Emotional Health Survey?

Child Find Meetings Suicide attempts, hospitalization, serious ideation (plan), pattern of self-injury (cutting, burning, etc. ) � Immediate Special Education Evaluation Team meeting (parents, student, school counselor & psychologist) � Suicide screening form completed � Examine community-based resources � Examine school-based resources � • MTSS • Safety plan • Mental health referrals • Special education assessment

Inclusion Criteria � If suicidal, not the only counseling service. If suicidal ideation or eating disorder is serious, referral to Portland DBT Institute or other community-based therapy � Step down or “graduates” from LHS SB-DBT, other programs, community DBT, and PPS day treatment as appropriate � No requirement to quit otherapy: consultation with community provider � Identifiable “target behavior” � Student commitment; parent involvement � Orientation Checklist

Orientation Checklist

Scheduling

IEP Example-Little RTI 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.

School Improvement Plan Big RTI (Program Evaluation) 74

Adaptations Health” on transcript; elective credit class � Monthly, not weekly parent training � Lincoln Staff/Teacher Training (environmental) � Consultation with students’ community providers � Not only MH service for students with suicidal ideation � Weekly fidelity checks from Portland DBT Institute � Memo of Understanding (2015) with Portland DBT Institute for individual therapist (they bill insurance); allows us to serve students more impacted by mental health issues � STEPS-A in health classes (Tier One) and International Baccalaureate “Theory of Knowledge classes (Tier Two) � “Advanced

Supports �Syllabus �Page numbers on handouts �Orientation checklist (district support) �Administrative and parent buy-in �School Improvement Plan �Health Action Network Funds �https: //cfhan. org/

Challenges � Scheduling class � Scheduling individual appointments for students not in SPED or support classes � Time intensity for program � Training new staff every year � Parent group � Changing special education administration � Perception of “therapy” versus “counseling” � Research (time, partners)

2009 -2017 Student Groups 2009 � 2010 � 2011 � 2012 � 2013 � 2014 � 2015 � 2016 � 2017 � Girl’s Group, Closed, Semester Mixed Group, Open, Year-Long Mixed Group, Closed, Semester Two Mixed Groups, Closed, Semester Three Mixed Groups, Closed, Semester Two Mixed Groups, Open, Year-Long Two Groups, Mixed, Semester

Measures � BASC-2 Pre and Post Measure (Student, Parent, sometimes Teacher Versions) � Attendance � Grade Point Average � Final test � Written reflection on students’ self-chosen Oregon DOE health standard goals � Progress Monitoring: daily diary cards

Data • School Records • Formative and Summative Assessment • Pre- and Post -Testing Standardized Checklists Data from Attendance Credit Earned G. P. A. Measuring Attitudes, Beliefs, Behaviors Performance of Oregon State Health Standards Skills Written Reflections and Portfolio Work Samples • Student Work and Progress Monitoring

Students’ 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. ” � “Now I like myself. After group ended, a relationship failed. I did ‘accepting myself rehab’ and it worked. ”

� “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. ”

Example of BASC-2 SRP

7 -YEAR SUMMARY

EBPs on a Budget

Implementation Research Article How to implement an evidence-based therapy in a new setting (e. g. , schools) � Acceptability � Adoption � Appropriateness � Cost � Feasibility � Fidelity � Penetration � Sustainability

It’s Not a Walk on the Beach � And It Ain’t Bad SB-DBT JIM HANSON, M. ED. STEPS-A JAMES MAZZA, PH. D. JABRHANSON@YAHOO. COM MAZZA@UW. EDU (503) 916 -6087 (206) 616. 6373