Dialectical Behavioral Therapy with Adolescents

in a Community based Residential Setting.

Janet L. Strolle, MSW and Dani McCutcheon-Needham

Service Alternatives, Inc.SOC Conference, July 27, 2011

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What is Dialectical Behavioral Therapy (DBT)?

• DBT is a cognitive-based treatment strategy that was initially created by Marsha Linehan, PhD. to treat suicidal individuals.

• DBT is an evidenced based practice for treating Borderline Personality Disorder (BPD) and is being evaluated for other mental health diagnoses as well as chemical dependency.

• DBT treats BPD as a disorder of emotional regulation.

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Elements of DBT (Linehan)

• Outpatient Individualized Psychotherapy.

• Outpatient Group Skills Training.• Telephone Consultation• Therapist Consultation Meeting• Uncontrolled Ancillary Treatments:

• Pharmacotherapy• Acute-Inpatient Hospitalization

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Background: Service Alternatives (SA)

• SA serves children with high behavioral needs in residential settings throughout Washington State.

• We have a commitment to implementing evidence based practices.

• We chose DBT because of its focus on skills training, as well as the opportunity to used therapeutic milieu to support skills acquisition.

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Program StructureJan Strolle,

Skills TrainerTraining Director

Dani McCutheon,

Skills Trainer,Area Manager

Program Manager

Case Manager2 supervisors6-10 staff

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Staff roles Related to DBT• Dani McCutcheon: Area manager

(Oversees residential programs) DBT Skills Group Facilitator, Provides monthly DBT in-service training.

• Jan Strolle: Agency Training Director. DBT Skills Group Facilitator. Provides monthly DBT in-service training. Consultation.

• Program Manager: Oversees program, supervises staff around implementation of DBT in milieu.

• Case Manager: Writes individualized goals for ISTPs that are based on DBT skills.

• Shift supervisors, staff: Implementation of DBT in milieu.

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Program ComponentsTraining

and consultation to staff

Egregious behavior protocol

Individualized skills coaching

Individualized programming and case management

Structure of Therapeutic Milieu

Skills Training

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Overview of Program Components

• Skill Training group: Provided 11/2 hours skills training per week. Mindfulness each week. Homework each week. Reinforcement strategies for participation.

• Structure of milieu: Scheduling provides daily opportunities to practice and reinforcement.

• Individualized programming and case management: Case manager devises individualized goals which address targets and skills development.

• Staff skills coaching: Staff use DBT language and coach to skills on an ongoing basis. Children receive bonus points for using skills.

• Egregious behavior protocol: Use of chain analysis when significant behavioral problems occur.

• Consultation and training to staff: Dani and Jan provide monthly in service training to staff in all DBT skills and consult around implementation in milieu.7/27/2011

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Egregious Behavior ProtocolPurpose of protocol• Post-vention teaching allows residents to learn

from a crisis. When a girl engages in egregious behavior, we can best address these behaviors by implementing chain analysis as a teaching tool. This supports the resident in learning alternative behaviors. 

• Phoenix defines egregious behavior as the following behaviors:

• Assault• Property destruction• Self harm• Running7/27/2011

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Egregious Behavior Protocol1) Within 24 hours of egregious behavior,

staff will perform a chain analysis with staff.

2) At daily practice meeting, the child will present chain analysis to group.

3) Overcorrection: The child determines overcorrection with case manager.

4) Return to normal activities: The child is considered to be off program until all steps of this protocol have been completed.

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DBT ScheduleSunday Monda

yTuesday

Wed Thus Friday Saturday

Goal Hour:Mindfulness and skills

Goal Hour:Mindfulness and skills

Goal Hour:Mindfulness and skills

Goal Hour:Mindfulness and skills

Goal Hour:Mindfulness and skills

Goal Hour:Mindfulness and skills

Goal Hour:Mindfulness and skills

1/1 time:Process individual skills use,

1/1 time:Process individual skills use

1/1 time:Process individual skills use

1/1 time:Process individual skills use

1/1 time:Process individual skills use

1/1 time:Process individual skills use

1/1 time:Process individual skills use

Wrap up group

DBT skills group.

DBT art project

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Program Targets• Reduce client aggression and assault.• Reduce client self harm behaviors.• Reduce impulsive behaviors.• Increase pro social behaviors• Increase ability to tolerate distress.• Increase ability to regulate behavior.• Increase quality of life.

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DBT skills groups• We meet weekly for 11/2 hours.• We teach 1 -2 new skills per week.• We teach a module every 8 – 10 weeks.• Children lead mindfulness activities each

week.• We review homework each week.• We reinforce participation with tickets

which earn prizes. • We try to make it interactive and fun!• We have a party at the end of each

module!7/27/2011

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Example of individualized target/goal• SL will identify a maximum of 3 DBT skills

that help her survive crises and avoid turning to physical aggression.

• SL will practice specific DBT skill of opposite action.

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Mindfulness

Participating in each moment of life with

awareness.

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Mindfulness page 113 – 116 of

workbookWise mind is the integration of rational and emotional mind

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Wise Mind GameParticipants pick a card which represents a

situation they may encounter. Peers represent

emotional mind,rational mind and wise mind. Dialogue.

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Wise mind game situation You come home from school and find that

your Personal shampoo is missing. You are sure

that your room mate took it. When you confront her

sheDenies that she did anything. You are very

upset. What would emotional mind say, do?What would rational mind say, do?What would wise mind say, do?7/27/2011

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Distress tolerance: Surviving a crisis without making it

worse.

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Fix it, survive it, make it worse game1) You get in an argument with your

boyfriend/girlfriend and they tell you that they are going to leave you. You are upset with yourself and want to cut yourself.

2) You work really hard on a school assignment and get a B. You wish you had gotten an A, but you are basically OK with this.

 

Survive it!7/27/2011

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Fix it, survive it, make it worse game3) You are living in a foster home and you

find out that your real mother has gone to prison and you probably won’t be able to see her for a long time. You are devastated.

4) Your foster parent tells you that they are disappointed with you because you did not do your chores. You feel that they are being unfair so you ignore them and go to your room.

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Crisis Survival Strategies:Wise mind accepts:• Activities• Contributing• Comparisons• Emotions• Pushing away• Thoughts• Sensations

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Twilight Deconstructed• Pick a picture that represents a distress

tolerance technique. • The facilitator will show a scene from

Twilight which represents a scene that may cause distress. Participant will visualize using their technique and then describe to group how/if it worked.

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Emotional Regulation

Many of the children we serve have difficulties with emotional and behavioral dysregulation:

-Intense emotions-Painful emotions

-Difficulty returning to baseline-Behavioral difficulties

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Goals of emotional regulationtraining: Linehan

• To understand emotions you experience:• Identify (observe and describe)

emotions.• Understand what emotions do for you.

• To reduce emotional vulnerability:• To decrease negative vulnerability• Increase positive emotions

• To decrease emotional suffering:• To let go of painful emotions through

mindfulness• Change painful emotions through

opposite action.7/27/2011

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Describing Emotions: JoyWords for joy: amusement, bliss,

cheerfulness, delight, elation, excitement, glee, happiness…

Prompting events for joy: beings successful, receiving a surprise, being accepted, belonging, receiving love…

Interpretations that prompt feelings of joy: Experiencing emotion of joy: Feeling excited,

feeling like giggling.Expressing and acting on joy: smiling,

hugging people, jumping up and down, saying positive things…

Aftereffects of joy: doing nice things for other people, having a positive outlook.

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Interpersonal Effectiveness Goals Linehan

• Objective effectiveness: Getting your goals met includes obtaining your legitimate rights, getting another to do something, resolving conflict, and getting your opinion taken seriously.

• Relationship effectiveness: getting or keeping a good relationship includes acting in ways that the other person likes and respects you.

• Self respect effectiveness: Keeping and improving your self respect or liking yourself includes respecting your own values and beliefs.

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Objective Effectiveness: DEAR MAN

• Describe the current situation.• Express your feelings and opinions• Assert yourself by asking for what you

want.• Reinforce the person ahead of time for

considering your request. • Be Mindful of your objectives.• Appear confident• Negotiate.

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Incidents of threatening to harm self by AH

June July August0

10

20

30

40

50

60

Series1

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Incidents of swearing/slang for AM

June July August0

5

10

15

20

25

30

35

Series1

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Incidents of Running from Group Home for AM

June July August0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Series1

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Incidents of not following house rules

June July August0

2

4

6

8

10

12

14

16

18

Series1

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Challenges in Implementation of DBT Program

• Failure to attend group due to detention stays or runs.

• Right level of reinforcement• The fact that DBT is “required” can alter

motivation• Girls have different developmental levels.• Staffing shortages and turnover • Multiple roles for facilitators• Refining staff role during group.• Staff’s ability to know and “coach” to skills in

milieu. • Time management around homework….7/27/2011

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Challenges in implementing DBT in SOC

• Non group care staff , foster parents often have limited knowledge of DBT skills.

• When children leave our settings for less restrictive care, they are not supported in maintaining skills.

• Case workers often don’t see need to continue practicing and learning skills to continue success in new settings.

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Behavioral Tech

Web site:

www.behavioraltech.com

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ResourcesLinehan, M. (1993). Skills Training Manual

for Treating Borderline Personality Disorder. New York: Guilford Press.

Miller, A., Rathus, J., and Linehan, M. (2006). Dialectical Behavior Therapy and Suicidal Adolescents. New York: Guilford Press

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