.
James B. Hanson, M.Ed.
New York Association of
School Psychologists
October 22nd, 2015
Verona, NY
Dialectical Behavior Therapy in
Public Schools
What is DBT?
Comprehensive cognitive –behavioral treatment
developed to treat problems caused by pervasive
emotion dysregulation:
a) Chronic suicidal behaviors
b) Non-suicidal self-injury
Balances teaching acceptance-based and changebased skills
Dialectical Behavior Therapy in
Public Schools
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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)
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
Dialectical Behavior Therapy in
Public Schools
Outcomes for 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
What is a Dialectic?
Balance of polar opposites
1. Thesis, Antithesis, Synthesis
2. Actions, emotions, cognitions
Acceptance & Change
Dialectical Behavior Therapy in
Public Schools
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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 in
Public Schools
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Biological, Genes, Emotional Vulnerabilities
Invalidating Environment
(e.g., chronic stress, chaos, perfectionism,
inconsistency)
Can occur inside or outside the family setting
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 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.
DBT Skills and Therapy
Continuum of Services
STEPS-A
Curriculum
DBT Therapy
in Schools
TIER I
TIER II & III
Health Teacher
Trained Teacher
School Psychologist
School Psychologist
School Counselor
Social Worker
Dialectical Behavior Therapy in
Public Schools
Components of STEPS-A = Skills Group/Large Class
Components of SB-DBT = All Five Functions/Small Class
“Phone Calls”
DBT
Individual Therapy
Parent Group
*Skills Group
Consultation Team for
Therapists
Mindfulness
Distress Tolerances
Emotion Regulation
Interpersonal
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 gauging RTI
5-10%
10-15%
80-85%
Tier III
Indicated
Tier II
Selected Population
Tier I
Universal Population
Using MTSS model
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
When In Wise Mind
Behavioral
Regulation
Emotion
Regulation
Interpersonal
Regulation
Cognitive
Regulation
Self
Regulation
Dialectical Behavior Therapy in
Public Schools
Curriculum Structure– Recommended Sequence
Mindfulness
Interpersonal
Effectiveness
Distress
Tolerance
Mindfulness
Mindfulness
Emotion
Regulation
Dialectical Behavior Therapy in
Public Schools
Curriculum Structure
STEPS-A and 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.
ACCEPTS
Pros & Cons
IMPROVE
Radical Acceptance
Turning the Mind
Interpersonal
Effectiveness
Emotion Regulation
1. Observe/Identifying
Emotions
2. Describing
Emotions
3. Opposite Action
4. ABC
5. PLEASE
1.
2.
3.
4.
5.
Ranking Priorities
DEAR MAN
GIVE
FAST
Evaluating
Options
Dialectical Behavior Therapy in
Public Schools
Core Mindfulness
Mindfulness
1.
2.
3.
4.
5.
Wise Mind
Observe
Describe
Participate
Nonjudgmental
6. One-mindfully
7. 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
Distress Tolerance
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
Emotion Regulation
Emotion Regulation
1. Observe/Identifying
Emotions
2. Describing
Emotions
3. Opposite Action
4. Check the facts
5. ABC
6. PLEASE
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 PhysicaL Illness, balance Eating, Avoid drugs,
balanced Sleep, Exercise daily
Dialectical Behavior Therapy in
Public Schools
Interpersonal Effectiveness
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
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
(5-7 minutes)
Dialectical Behavior Therapy in
Public Schools
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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
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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
Dialectical Behavior Therapy in
Public Schools
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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
Dialectical Behavior Therapy in
Public Schools
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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
Dialectical Behavior Therapy in
Public Schools
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School Psychologist
School Nurse
School Social Work Intern
School Psychology Practicum Student and School
Psychology Intern
School Counselor
School Counseling Intern
Dialectical Behavior Therapy in
Public Schools
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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
DBT in Action in the Schools
Piloting School-Based DBT with Tier II &
III students
1. Lincoln High School – Portland, Oregon
2. Battle Ground School District – Battle Ground, Washington
3. Mastery Charter Schools – Philadelphia, Pennsylvania
4. Oakland Unified School District – Oakland, California
5. Aloha High School – Beaverton, Oregon
5. BOCES Rockland County – New York
7. Pleasantville School District (MS & HS) – Pleasantville, New York
8. Ardsley School District (MS & HS) - Ardsley, New York
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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
Koerner, Dimeff, and Swenson DBT in Clinical Practice (2007)
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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 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 placements into Portland Public
School’s day treatment classroom per year, since DBT
one placement in nine years
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“Advanced Health” on transcript; SB-DBT elective credit class
Materials from Miller & Rathaus (reproducible)
Monthly, not weekly parent training
Lincoln Staff/Teacher Training (environmental contingencies)
Consultation with community providers-not only MH service
Weekly fidelity checks from Portland DBT Institute Program
Memo of Understanding (2015) with Portland DBT Institute for
individual therapist (they bill insurance); allows us to work with
students that are more impacted by mental health issues
STEPS-A in health classes (Tier One) and International
Baccalaureate “Theory of Knowledge classes (Tier Two)
+
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
40
MTSS
42
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Self-referral from one-day preview of DBT skills in general
education health classes
MTSS/RTI: 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
Child Find meetings
Tier classification depends on student
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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”
Parent involvement
Orientation Checklist
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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?
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Suicide Attempts, Hospitalization, Serious Ideation
(plan), pattern of self-injury
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
•
•
•
•
•
•
•
•
•
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 selfimage
Demonstrate pro-social communication skills
Demonstrate the steps in problem solving, anger management and
impulse control
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.
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2009
2010
2010
2011
2012
2013
2014
2015
2016
Girl’s Group, Closed, Semester
Mixed Group, Closed, Semester
Mixed Group, Open, Year-Long
Mixed Group, Closed, Year-Long
Mixed Group, Closed, Semester
Two Mixed Groups, Closed, Semester
Three Mixed Groups, Closed, Semester
Three Mixed Groups, Closed, Semester
Two Mixed Groups, Open, Year-Long
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BASC-2 Pre and Post
(Student, Parent, Teacher Versions)
Attendance
Grade Point Average
Written Reflection
Progress Monitoring: Daily Diary Cards
• 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

BASC-2 Scores – Decreases in Anxiety (n=8),
Depression (n=12) and Social Stress (n=7)
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Attendance - Increases up to 30%
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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.”
“Now I like myself. After group ended, a relationship
failed. I did ‘accepting myself rehab’ and it worked.”
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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
11 of 12 students increased GPA
Average increase in attendance = + 4%
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
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Syllabus
Administrative and parent buy-in
School Improvement Plan
Health Action Network Funds
District support
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Scheduling class
Scheduling individual appointments for students not in
SPED
Time intensity for program
Training new staff every year
Parent group
Changing special education administration
Perception of “therapy” versus “counseling”
Research

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