Dialectical Behavioral Therapy in the Schools

Report
James B. Hanson, M.Ed.
Texas Association of School Psychologists
Fall Conference 2012
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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,
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
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Mindfulness
Radical Acceptance
Validation
 Change
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Problem Solving
Cognitive Behavioral
Goals and
Contingencies
 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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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)
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., Schreier A., 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
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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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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 (/division16/publications/newsletters/science/2012/07/index.aspx)
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Biological, Genes,
Emotional
Vulnerabilities
Executive Functions,
Abilities, Sensory
Functions, Medical
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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
Mindfulness
Interpersonal
Effectiveness
Emotional
Regulation
Problem
Solving
(CBT, FBA)
Distress
Tolerance
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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)
What: Observe,
Describe, Participate,
How: 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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Activities
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
if I Wait, 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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Pleasant Events
Schedule
Reducing emotional
vulnerability
SEEDS Skills (sleep,
eating, exercise,
drugs, sickness)
Mastery: doing
something you’re
good at
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Cheerleading
Checking the facts
Choices about
intensity
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What’s Your
Objective?-DIG
Relationship-GIVE
Your Goals-RAN
Self Respect-FAST
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All of the Five Areas
Validation
Obstacles to skillful
behavior
Contingencies
Emotional
regulation
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)
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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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Lincoln High School
1600 SW Salmon St, Portland, OR 97205
RTI & PBIS Accountability
Coordinated
School Health
Model
PBIS and SEL
Based on
Oregon State
Health Standards
School
Improvement
Plan
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•School Records
•Formative and
Summative
Assessment
•Pre- and PostTesting
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
(**No Immediate Safety Threat**)
Social or Emotional Issues
Academic
Attendance
(e.g. depression, anxiety, drugs, outbursts, etc.)
(e.g. not passing, can’t sit still, etc. )
(e.g. skipping, often ill, etc.)
Counselor
Nurse
Social Work
Intern
Counselor
Counselor
Administrative
Vice Principal
Student Support Team (SST) and Tier Three Student Achievement Resource Meetings
Administrative and Curriculum Vice Principals, Counselors, Teachers, Nurse, School Psychologist, School Resource Officer
Staffing:
Student, Parent(s), Counselor,
Administrative Vice Principal
Options
Conference
(District/Private)
Academic Plan
(Green Sheet,
FLEX Schedule)
Credit Recovery Plan
(Night/Summer School,
On-Line Courses, etc.)
Change of Schedule
(Reduction of classes,
alt level)
Building Screening Committee (BSC):
Student, Parent(s), Teacher(s),
Counselor, Nurse, Spec. Ed. Teacher
and/or School Psychologist
Special Ed
Team
Student, Parent,
Spec.Ed. Staff,
General Ed.
Teacher, School
Psychologist,
Nurse,
Speech Language
Pathologist,
Motor Team, (as
needed)
504 Team
Student,
Parent,
Teachers,
Counselor,
Curriculum
Vice Principal,
School
Psychologist,
Nurse (as
needed)
Mental Health Referral:
Parent, Counselor, Nurse,
Social Work Intern, School
Psychologist
Create Safety Plan
Student, Parent,
Counselor,
Social Work Intern,
School Psychologist
Referral to:
Social Work Intern,
PPS Safe Schools,
Community Counselor/
Therapist, Primary Care
Physician Etc.
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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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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.
LEARNER-CENTERED PROBLEM (What are your students struggling to learn
or to be able to do?):
Students at Lincoln often struggle with depression, anxiety, stress, self
harm, drugs and alcohol, suicide, and bullying are not aware of existing
levels of prejudice (racism, classism, misogyny, sexual minorities).
STUDENT ACHIEVEMENT GOAL (SMART GOAL):
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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Mindfulness exercise
Homework
New Skill
Discussion and examples
FBA if emerging pattern of not doing
homework, coming late, or other therapyinterfering behavior
LINCOLN HIGH SCHOOL
Department of Health Education
COURSE INFORMATION
Title:
Location:
Instructors:
Health Skills (Advanced) CRN# 0803 (1/2 credit), Grade Levels: 9,10,11,12
Counseling Center
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 [email protected]
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,
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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
Lincoln High School DBT Program
DIARY CARD
Name:
&
Day
Sadness
Date
(0-5)
Date Range:
Shame
(0-5)
Anger
(0-5)
Fear
(0-5)
Joy
(0-5)
Peace
(0-5)
RATING SCALE FOR EMOTIONS AND SELF-HARM URGES:
0= None
1= Minimal
2= Mild
4= Strong
Additional Homework:
Additional
Wisdom/
Self-Harm
Suicidal
Goal
or Target HomeAccomplishUrges/
Thoughts/
ment
(0- Actions (0- Actions
(0work
5)
5)
5)
5= Intense
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Notes:
Interpersonal
Effectiveness
Emotion
Regulation
Distress
Tolerance
Problem
Solving
Mindfulness
Instructions: Circle the days you worked on each skill.
1
Mindfulness and Wise Mind
Mon
Tues
Wed
Thur
Fri
Sat
2
WHAT: Observe, Describe, Participate
Mon
Tues
Wed
Thur
Fri
Sat
3
HOW: Don't Judge, Stav Focused, Do What W orks
Mon
Tues
Wed
Thur
Fri
Sat
4
Breathing, Half Smile, and Dialectics
Mon
Tues
Wed
Thur
Fri
Sat
5
What Happens Next? Applied Behavioral Analysis
Mon
Tues
Wed
Thur
Fri
Sat
6
Stopping Stinknig Thinking
Mon
Tues
Wed
Thur
Fri
Sat
7
The Four Questions/The Turnaround
Mon
Tues
Wed
Thur
Fri
Sat
8
ACCEPTS
Mon
Tues
Wed
Thur
Fri
Sat
9
Self Soothe Kit
Mon
Tues
Wed
Thur
Fri
Sat
10
Pros and Cons
Mon
Tues
Wed
Thur
Fri
Sat
11
Radical Acceptance, Willing Hands, Turning the Mind
Mon
Tues
Wed
Thur
Fri
Sat
12
Riding the Wave
Mon
Tues
Wed
Thur
Fri
Sat
13
SEEDS (Sleep, Eat, Exercise, Drugs, Sickness)
Mon
Tues
Wed
Thur
Fri
Sat
14
Checking the Facts/Opposite to Emotion Action
Mon
Tues
Wed
Thur
Fri
Sat
15
Pleasant Events
Mon
Tues
Wed
Thur
Fri
Sat
16
DIG (Determine Interaction Goal)
Mon
Tues
Wed
Thur
Fri
Sat
17
DEAR MAN or RAN (Reinforce, Assert, Negotiate)
Mon
Tues
Wed
Thur
Fri
Sat
18
GIVE (Gentle, Interested, Validate, Easy Manner)
Mon
Tues
Wed
Thur
Fri
Sat
19
FAST (Fair, no Apologies, Stick to Values, Truthful)
Mon
Tues
Wed
Thur
Fri
Sat
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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).
“Group therapy for therapists”
Integral part of DBT program
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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
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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
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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
DBT in International Baccalaureate “Theory of
Knowledge” classes and or Health Classes
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School
School
School
School
School
School
School
Psychologist
Nurse
Social Work Intern
Psychology Practicum Student and
Psychology Intern
Counselor
Counseling Intern
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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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Self-referral from one-day preview of DBT
skills in general education health classes
PBIS: Universal screener
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 classroom who
have collaborative problem solving skill base
Tier Two or Tier Three classification depends
on student
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If suicidal, not the only counseling service
If suicidal ideation, 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”
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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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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
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“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.”
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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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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?
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 (/division16/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
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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

And It Ain’t Bad

Jim Hanson, M.Ed.
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[email protected]
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(503) 916-6087

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