PowerPoint presen - National Association of School Psychologists

Report
James B. Hanson, M.Ed.
NASP Convention 2012
Philadelphia, PA
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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
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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).
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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.
 Acceptance
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Mindfulness
Radical Acceptance
Validation
 Change
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Problem Solving
Cognitive Behavioral
Goals and
Contingencies
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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
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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
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Emotional Regulation (labile, anger)
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Interpersonal Regulation (chaotic, abandoned)
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Self Regulation (identity, emptiness)
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Behavioral Regulation (suicide, cutting, impulsive)
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Cognitive Regulation (black and white thinking)
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Individual Emotional
Regulation Problems
Biological, Genes,
Emotional
Vulnerabilities
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Invalidating
Environment
(e.g., Chronic stress,
chaos, perfectionism,
inconsistency)
Learning:
Observational,
Operant, Respondent
Mindfulness
Interpersonal
Effectiveness
Emotional
Regulation
Problem
Solving
(CBT, FBA)
Distress
Tolerance
Creating a
Life Worth
Living
Increasing
Behavioral Skills
Decreasing Quality-of-Life
Interfering Behavior
Decreasing Therapy-Interfering
Behavior
Decreasing Life Threatening Behaviors
 Reciprocal
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Responsive
Serious
Appropriate SelfDisclosure
Warm Engagement
Radical Genuineness
 Irreverent
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Unorthodox Reframing
Plunging In-Humor
Confrontation
Calling The Bluff
Omnipotence and
Impotence
Intensity and Silence
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Dialectical Behavioral Therapy with Suicidal
Adolescents (2007)
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12-16 week treatments instead of 1 year
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Suicidal ideation, depression, and anxiety
(perfectionism)
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Six problem areas (violence, drinking, drugs,
smoking, risky sexual behavior, disturbed
eating)
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Rathaus & Miller (2002)-Adolescents
◦ Lower hospitalization (TAU 13% versus DBT 0%)
◦ Higher retention (TAU 40% versus DBT 62%)
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Fellows (1998)-Adolescents
◦ Treatment group went from 539 inpatient hospital
days pretreatment to 51 days post treatment
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Target population – same as research?
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Comprehensive DBT – all components?
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Setting – amenable finances, time, structure?
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Professional training – skill set, credentials?
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“Gold Standard” Five functions – skills,
generalization, and environment of clients;
capabilities and motivation of therapists
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
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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
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CDC Coordinated School Health Model
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PBIS
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RESPONSE suicide prevention
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Student & Staff Anti-Bullying
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Reconnecting Youth
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School Improvement Plan with Mental
Health goals
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Character Traits: Respect, Understanding,
Integrity, Community, Purpose
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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
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STUDENT ACHIEVEMENT GOAL (SMART GOAL):
1.Students will increase healthy habits and reduce
alcohol, tobacco and drug use.
2.Students will increase knowledge of human
diversity and develop interpersonal skills to
counter bullying, harassment and conflict.
3.Students will develop mindfulness, distress
tolerance, and emotional regulation skills,
recognize the signs of
anxiety/depression/suicide, and access
appropriate support services when needed.
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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
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“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
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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
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“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
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If suicidal, not the only counseling service
If cutting or eating disorder is serious,
referral to Portland DBT or other communitybased 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”
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Student will use social/emotional and
behavioral skills to improve her scores on
measures of Sense of Inadequacy, Anxiety,
Depression, Atypicality and Withdrawal BASC2 scales from the clinically significant to the
average range on parent, teacher, and selfreport
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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 problemsolving and emotional regulation skills.
Evaluation Procedures: transcript for GPA,
school attendance, Advanced Health class
attendance/homework, diary card, FBA,
BASC-2.
Mindfulness
Interpersonal
Effectiveness
Emotional
Regulation
Problem
Solving
(CBT, FBA)
Distress
Tolerance
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Mindfulness exercise
Homework
New Skill
Discussion and examples
FBA if emerging pattern of not doing
homework, coming late, or other therapyinterfering behavior
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Black and white?
Seeing polarities
“Both/and” not
“either/or”
A life worth living
has positive and
negative aspects
Getting unstuck
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Full awareness
Present Moment
Wise Mind (Emotional
& Logical)
Observe, Describe,
Participate, Don’t
Judge, Focus, Do What
Works
Half Smile
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Goal Setting
Chain Analysis
(Functional
Behavioral Analysis)
Stinking Thinking
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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
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Act
Contribute
Compare
Emotional Opposite
Push Away (Bracket)
Thought Change
Sensation Change
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Self-Soothe Kits
Vision
Hearing
Taste
Smell
Touch
Movement
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FEAR-HideApproach
ANGER-AttackGently Avoid
SAD-Withdraw-Get
Active
GUILT-Avoid-Face
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Radical Acceptance
Acknowledge,
Recognize, Endure
Myths: It’ll Change,
It’ll Kill Me, It’ll Last
Forever
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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
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What’s Your
Objective?-DIG
Relationship-GIVE
Your Goals-RAN
Self Respect-FAST
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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
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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
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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).
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“Group therapy for therapists”
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Integral part of DBT program
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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
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Five cohorts:
2009
2010
2010
2011
2012
Girl’s Group, Closed, Semester
Mixed Group, Closed, Semester
Mixed Group, Open, Year-Long
Mixed Group, Closed, Year-Long
Mixed Group, Closed, Semester
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BASC-2 Pre and Post
(Student, Parent, Teacher Versions)
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Attendance
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Grade Point Average
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Written Reflection
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Progress Monitoring: Daily Diary Cards
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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
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“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.”
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“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.”
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Slight increases in attendance and bigger
increases in GPA
Modest decreases in Anger Control, Anxiety
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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
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“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.”
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Average increase in GPA = + .76
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11 of 12 students increased GPA
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Average increase in attendance = + 4%
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Attendance not interpretable, 5/12 students
decreased attendance slightly, 1 student
significantly increased
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BASC-2 Self Report t-scores
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Anxiety: average decrease 13.9 (-35 to +6)
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Depression: average decrease 18.7 (-40 to 4)
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Internalizing: average decrease 15.2 (-37 to +4)
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ESI: average decrease 16.0 (-33 [2] to +2)
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ADHD not medicated
Depersonalization Disorder
Students with parent who did not attend
parent classes
Narcissistic traits: difficulty with group format
What’s up with lower attendance rates and
higher GPA’s?
Syllabus
 Administrative and parent buy-in
 Tier Two and Tier Three
 School Improvement Plan
 Health Action Network Funds
 District support
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No suicides since REPONSE, RY, and DBT
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One placement in more restrictive setting
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Savings to district: $350,000
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Day treatment classroom at Lincoln with
Collaborative Problem Solving model:
teaching to other teachers
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Time constraints for class
New block schedule lessens flexibility
Scheduling individual appointments for
students not in SPED
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
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But It Ain’t Bad
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Jim Hanson, M.Ed.
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[email protected]
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(503) 916-6087

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