Transcript Women’s History Month Presentation

Janet L. Strolle, MSW and Dani McCutcheon-Needham
Service Alternatives, Inc.
SOC Conference, July 27, 2011
Dialectical Behavioral Therapy
with Adolescents
in a Community based
Residential Setting.
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)
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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 Structure
Dani McCutheon,
Skills Trainer,
Area Manager
Jan Strolle,
Skills Trainer
Training Director
Program Manager
6-10 staff
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2 supervisors
Case Manager
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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
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milieu.
Program Components
Training 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.
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Egregious Behavior Protocol
Purpose 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
• Running
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Egregious Behavior Protocol
1) 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 Schedule
Sunday
Monday
Tuesday
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
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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
•
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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!
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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 workbook
Wise mind is the integration of rational and emotional mind
Rational Mind
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Emotional
Mind
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Wise Mind Game
Participants 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 she
Denies 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?
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Distress tolerance:
Surviving a crisis without
making it worse.
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Fix it, survive it, make it worse game
1) 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!
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Fix it, survive it, make it worse game
3) 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 regulation
training: 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.
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Describing Emotions: Joy
Words 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
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beliefs.
Objective Effectiveness: DEAR MAN
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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
60
50
40
30
Series1
20
10
0
June
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July
August
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Incidents of swearing/slang for AM
35
30
25
20
Series1
15
10
5
0
June
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July
August
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Incidents of Running from Group Home for
AM
4.5
4
3.5
3
2.5
Series1
2
1.5
1
0.5
0
June
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July
August
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Incidents of not following house rules
18
16
14
12
10
Series1
8
6
4
2
0
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June
July
August
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Challenges in Implementation of DBT
Program
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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….
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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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Resources
Linehan, 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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