James B. Hanson, M.Ed.

CHSD218 INSPiRE Clinic

Grand Rounds

September 29, 2016

Chicago, IL
 Learn the 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 multi-
tiered system of support.
 Examine concrete program elements and supports for SB-
DBT including practitioner training, supervision, student and
family orientation protocols, and fidelity.
 A comprehensive Dialectics: Two opposite
intervention system ideas can be true at the
based on: Behaviorism, same time, and when
Mindfulness, Dialectics 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
 Dialectical Behavior Therapy in
Public Schools

 Emotional Regulation (labile, anger)

 Interpersonal Regulation (chaotic, abandoned)

 Self Regulation (identity, emptiness)

 Behavioral Regulation (suicide, cutting, impulsive)

 Cognitive 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. Alcohol and drug use
2. Relationships with peer, family, and romantic
3. Self-harming behavior
4. Suicidal behavior
5. Bullying victimization and perpetration
6. Antisocial behavior
7. 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,
self-harming 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) Less self-medicating
b) Less use of alcohol and drugs
c) Less risky sexual behavior and students feeling
pressured to have sex
d) Less self-harming behavior
e) Less suicidal behavior
f) Less bullying
g) Less conduct problems and thus less suspensions and
expulsions
h) Less school dropout, better academic success measure
through GPA, homework, etc.
Mazza, 2015
 Dialectical Behavior Therapy
PRINCIPLES

Acceptance Change

 Mindfulness  Problem Solving

 Radical Acceptance  Cognitive Behavioral
 Validation  Goals and Contingencies
 Dialectical Behavior Therapy
PRINCIPLES

 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

Reciprocal Irreverent
 Responsive  Unorthodox Reframing
 Serious  Plunging In-Humor
 Appropriate Self-  Confrontation
Disclosure  Calling The Bluff
 Warm Engagement  Omnipotence and
 Radical Genuineness Impotence
 Intensity and Silence
 Dialectical Behavior Therapy
THEORY

 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
 DBT
Creating
a Life Worth Treatment
Living
Adaptive Hierarchy
Functioning Increasing
Behavioral Skills

Decreasing Quality-of-Life
Interfering Behavior

Decreasing Therapy-Interfering
Behavior

Decreasing Life Threatening Behaviors

 Dialectical Behavior Therapy
ASSUMPTIONS

 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 DBT Therapy

Curriculum in Schools

TIER I TIER II & III

Health Teacher School Psychologist

Trained Teacher School Counselor
School Psychologist 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” Parent Group

DBT

Individual Therapy *Skills Group

Consultation Team for

Mindfulness
Therapists
Distress Tolerance

Middle Path* Emotion Regulation

(Dialectics, CBT) 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% Tier III

Indicated Using MTSS model

10-15% Tier II
Selected Population

80-85% 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
Tier V
Tier III Residential
SB-DBT Indicated treatment

Tier IV
Tier II Outpatient
Selected Population DBT for Adolescents

STEPS-A Tier I Mazza, 2015

Universal Population
 DBT: Starting upstream

STEPS-A
School-based DBT
+ STEPS-A

Program
Evaluation Outpatient DBT
and
Research

IOP/PHP + DBT
Residential
Treatment +
DBT
Hospitalization +
Miller & Mazza, 2014
DBT
 Dialectical Behavior Therapy in
Public Schools

Class structure

Each class is structured similarly (80 minutes)

a) Mindfulness (3-5 minutes)

b) Homework Review (15-30 minutes)
c) Teaching new lesson (30-45 minutes)
d) Lesson summary and assignment of homework
(5-7 minutes)
 Dialectical Behavior Therapy in
Public Schools
Curriculum Structure– Recommended Sequence

Mindfulness

Interpersonal Distress
Effectiveness Tolerance

Mindfulness Mindfulness

Emotion Middle
Regulation Mindfulness Path
Mazza, 2015
 Dialectical Behavior Therapy in
Public Schools
Mazza, 2015
Curriculum Structure
STEPS-A & SB-DBT
CURRICULUM
Interpersonal
Mindfulness Distress Tolerance Emotion Regulation Effectiveness

1. Wise Mind 1. ACCEPTS 1. Observe/Identifying 1. Ranking Priorities

2. Observe 2. Self-Soothe Emotions 2. DEAR MAN
3. Describe 3. Pros & Cons 2. Wave Skills 3. GIVE
4. Participate 4. IMPROVE 3. Opposite Action 4. FAST
5. Non-judgmental 5. Radical Acceptance 4. ABC 5. Evaluating
6. One-mindfully 6. Turning the Mind 5. PLEASE/SEEDS Options
7. Effectively
 Dialectical Behavior Therapy in
Public Schools Mazza, 2015

Core Mindfulness (STEPS-A and SB-DBT)

Mindfulness

1. Balance between emotion mind and reasonable mind

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

Distress Tolerance (STEPS-A and SB-DBT)

Distress Tolerance

1. Pros & Cons 1. Evaluating strategy balancing pro’s/con’s of the decision & lack of the
2. ACCEPTS decision
3. IMPROVE 2. Distract with ACCEPTS -Activities, Contributing, Comparisons, Emotions,
4. Self-Soothe Pushing away, Thoughts, Sensations
5. TIP 3. Imagery, Meaning, Prayer, Relaxation, One thing in the moment, Vacation,
Encouragement
6. Radical
4. Self-soothe through the 5 senses
Acceptance 5. Changing body chemistry- Temperature, Intensive exercise, & Progressive
7. Turning the Mind muscle relax
8. Half Smile & 6. Freedom from suffering requires acceptance (acceptance ≠ approval)
Willing hands 7. Turning the mind to the acceptance road
9. Willingness 8. Changing your emotions by changing your physical expressions
9. 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 1. Learning to recognize how emotions feel within your body

Emotions 2. Learning the different words to describe emotions and what
2. Describing words to use when that emotion is elevated or low
Emotions 3. Acting opposite to your current emotion action urge
3. Opposite Action 4. Before making any decisions, checking the actual facts
4. Check the facts 5. Accumulate, Build mastery (do things you are good at) Cope
5. ABC ahead (rehearse a plan ahead of time
6. PLEASE/SEEDS 6. reduce PhysicaL 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 1. Objectives, relationship, self-respect

Priorities 2. Describe, Express, Assert, Reinforce – Mindful, Appear confident,
2. DEAR MAN Negotiate
3. GIVE 3. Gentle, Interested, Validate, Easy manner
4. FAST 4. be Fair, no Apologies, Stick to your values, be Truthful
5. Evaluating 5. Low or high intensity for asking or saying No
Options
 Dialectical Behavior Therapy in
Public Schools

Walking the Middle Path (SB-DBT) Additional Unit

Walking the
Middle Path

1. Dialectics 1. Two seeming opposite position can both be true, Dialectial

2. Thinking Dilemmas
Mistakes 2. “Stinking Thinking” Mindful, Name, Claim, Tame
3. What’s Typical? 3. What’s typical and what’s cause for concern?
4. Validation 4. Validating self and other; Validation doesn’t mean agreement
5. Behavior Change 5. Ways to Increase, Positive Reinforcement; Ways to Decrease;
Extinction and Punishment

Mazza, 2015
 Dialectical Behavior Therapy in
Public Schools

STEPS-A = Skills Group/Large Class

SB-DBT = All Five Components/Small Class

“Phone Calls” Parent Group

DBT

Individual Therapy *Skills Group

Consultation Team for

Mindfulness
Therapists
Distress Tolerance

Middle Path* Emotion Regulation

(Dialectics, CBT) Interpersonal
Effectiveness
 Dialectical Behavior Therapy in
Public Schools

 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 other therapy-interfering behavior
 Dialectical Behavior Therapy in
Public Schools

 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

 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

 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

 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

 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
 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.”
 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
 • 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
 • 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
1600 SW Salmon St, Portland, OR 97205
RTI & PBIS Accountability

PBIS and SEL

Coordinated Based on School
School Health Improvement
Model Oregon State Plan
Health Standards

Support Elements
58
MTSS
60
1. Explain how to build and maintain healthy relationships
2. Classify personal stressors at home, in school, peers
3. Describe how social environments affect well-being
4. Identify resources at home, school, and in the community
for managing family and relationship problems
5. Practice strategies for reducing stress, anger, and conflict
6. Demonstrate ability to take perspectives of others in
conflict situations
7. Identify contributions to positive and negative self-image
8. Demonstrate pro-social communication skills
9. Demonstrate the steps in problem solving, anger
management and impulse control
 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)
 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)
 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)
 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?

 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
 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 other therapy: consultation
with community provider
 Identifiable “target behavior”
 Student commitment; parent involvement
 Orientation Checklist
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.
74
 “Advanced 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)
 Syllabus
 Page numbers on handouts
 Orientation checklist (district support)
 Administrative and parent buy-in
 School Improvement Plan
 Health Action Network Funds
 https://cfhan.org/
 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 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
 2013 Two Mixed Groups, Closed, Semester
 2014 Three Mixed Groups, Closed, Semester
 2015 Three Mixed Groups, Closed, Semester
 2016 Two Mixed Groups, Open, Year-Long
 2017 Two Groups, Mixed, Semester
 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
• School • Pre- and
Records Post-Testing
Standardized
Checklists

Data from Measuring

Attendance Attitudes,
Credit Earned Beliefs,
G.P.A. Behaviors

Performance of
Written
Oregon State
Reflections and
Health
Portfolio Work
Standards
Samples
Skills
• Formative • Student Work
and and Progress
Summative Monitoring
Assessment
 “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.”
How to implement an evidence-based
therapy in a new setting (e.g., schools)
 Acceptability
 Adoption
 Appropriateness
 Cost
 Feasibility
 Fidelity
 Penetration
 Sustainability
  And It Ain’t Bad

SB-DBT STEPS-A
JIM HANSON, M.ED. JAMES MAZZA, PH.D.
JABRHANSON@YAHOO.COM MAZZA@UW.EDU
(503) 916-6087 (206) 616.6373