Preventing Suicide in Schools: Implementing CBC of ......DBT Skills Training in Schools: Skills Training for Emotional Problem Solving for Adolescents (STEPS-A). Guilford Press. Do

Preventing Suicide in Schools: Implementing DBT at Universal, Indicated and Targeted

Levels of InterventionPresenter and Co-author:

Alycia Dadd, Ph.DAssistant Director of Consultation Consultation Services

CBC of Westchester and Manhattan

Alec Miller, Psy.D.Clinical Director and Co-Founder

Cognitive & Behavioral Consultants, LLP White Plains and Manhattan, NY

Kelly Graling, Ph.D.Assistant Clinical Director

Director of School ConsultationCognitive & Behavioral Consultants, LLP

White Plains and Manhattan, NY

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Outline

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1. Identify and describe School-Based DBT using a tiered intervention model

2. Preliminary outcome data relating to DBT in schools

3. Current Status of DBT in schools

Do not reproduce, present or distribute without written permission from CBC of Westchester and Manhattan. © CBC 2019

Adolescent Suicide: The Problem (CDC, 2016)

In the previous year nationwide, 9th-12th graders reported…

• 17% seriously considered suicide

• 14.3% made a plan for how to commit suicide

• 9.6% attempted suicide

• 2.7% made SA requiring medical attention

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Do not reproduce, present or distribute without written permission from CBC of Westchester and Manhattan. © CBC

2019

1 male and 2 females may have attempted suicide in the past year

American Association of SuicidologySource: King (1997, p.66)

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In a Typical High School Classroom…


2019

In any given year in the United States…

• 25% of children and adolescents suffer from an anxiety disorder

– 8.7% suffer from phobias

– 6.8% suffer from social anxiety disorder

– 3.5% suffer from Post-traumatic stress disorder

– 1% suffer from general anxiety

– 2.7% suffer from panic disorder

– 1% suffer from obsessive compulsive disorder

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2019

Suicide IdeationNSSISuicide AttemptETOH/DrugsBinge/PurgeSchool or Task avoidanceWithdrawal from peers

THE PROBLEM TO BE SOLVED

CUESIntolerableAversive Emotional State

TEMPORARY RELIEF

AVOIDANCE OR ESCAPE

6Do not reproduce, present or distribute without written permission from CBC of Westchester and Manhattan. © CBC

2019

What is DBT?

• DBT is a PRINCIPLE driven treatment, NOT a manualized intervention

– Principles guide you in figuring out what to do next.

– Principles are needed with complex, multi-diagnostic and/or axis II patients who do not respond to traditional treatment.


Teach Skills to Replace Problems

Problem Areas

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Skills

1. Reduced awareness and focus/Confusion about self and feelings

4. Interpersonal chaos, fears of abandonment

2. Impulsivity, hitting, suicide threats, self-harm

3. Emotion Regulation

2. Distress Tolerance

1. Mindfulness

3. Mood swings, inappropriate expressions of anger

4. Interpersonal Effectiveness

5. Non-dialectical thinking and acting 5. Walking the Middle Path


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Why DBT in Schools?

•DBT Targets Emotion Regulation

•Emotion Regulation underlies mental health disorders AND problem behaviors

•Even High Risk problem behaviors:

•Suicidal Ideation

•Self-Harm

•It Teaches Concrete Skills!9


2019

Why DBT in Schools?• Mounting pressure to keep students within District

– Costs District from $42,000-$120,000/per student per year when sent out of District for specialized programs.

• Transdiagnostic Approach to treating kids– Can treat multiple disorders with the same treatment

• Schools often urge staff to send students to ER when suicidal thinking or self-harm is reported.

• ERs are flooded with visits from students who do not necessarily need hospitalization.

• Sending students to ER may reinforce problem (escape/avoidance) behaviors.

• May Prevent BPD 10

DBT: Starting upstream

DBT STEPS-AComprensive

DBT in Schools

Outpatient DBT

Residential Treatment +

DBTHospitalization +

DBT

IOP/PHP + DBT

Program Evaluation and Research

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DBT in Schools (two types)•Targeted/Selected Intervention (School-Based DBT)

• Comprehensive DBT model within schools • Rathus JH & Miller, AL, (2015) DBT Skills Manual for Adolescents. Guilford Press

•Universal Intervention (STEPS-A)• Mazza, JJ, Dexter-Mazza, ET, Miller, AL, Rathus, JH, & Murphy,

HE, (2016). DBT Skills Training in Schools: Skills Training for Emotional Problem Solving for Adolescents (STEPS-A). Guilford Press.

12Do not reproduce, present or distribute without written permission from CBC of Westchester and

Manhattan. © CBC 2019

Functions of a Comprehensive Model

1) DBT targets motivation

2) DBT works to enhance the child’s skills

3) DBT promotes generalization to the environment

4) DBT structures the environment

5) DBT enhances the staff’s skills and motivation to use the most effective interventions

16Do not reproduce, present or distribute without written permission from CBC of Westchester and Manhattan. © CBC 2019

Modes of Comprehensive School DBT• Individual counseling

• Skills group

• Consultation Team

• Inter-Session Coaching

• Classroom

• Hallway

• Office

• Bus

• Cafeteria


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Structure of the Program


Who Needs Comprehensive DBT

▪Higher Tier Intervention

▪ Takes more time, training, and support

▪When Tier 1 intervention isn’t enough

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Data from Schools• Preliminary results from an open trial at Ardsley

High School (Mason, Catucci, Lusk, and Johnson, 2011)

– Reduced referrals to assistant principal

– Reduced cutting class, detentions and suspensions

– Anecdotal reduction in depression, anxiety, NSSI

– Requires change of culture re: how schools manage problem behavior

17Do not reproduce, present or distribute without written permission from CBC of Westchester

and Manhattan. © CBC 2019

Data from Schools• Preliminary results from an open trial at

Pleasantville HS (Dadd, 2015, unpublished dissertation)

– Comprehensive school-DBT program•Reductions in depression and social stress as measured by BASC, 2nd edition

•Increases in adaptive coping skills, in particular mindfulness skills

•Increases in ability to tolerate distressing situations and reduction in maladaptive coping

– Requires change of culture re: how schools manage problem behavior

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Lincoln High School, Portland, OR


Lincoln HS Statistics

• 1720 students

• Middle to high socio-economic status

• 100 Best High Schools in United States

• High stress and anxiety (OHTS 2008: 13% of students considered suicide in last twelve months; 2012: 8.4%)

• About 20 parent meetings/year for cutting, suicidal ideation or attempt (record year high was 45)

• Suicide was leading cause of death until SB-DBT

– Jim Hanson, 201524

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Lincoln HS StatisticsHanson, 2015

• Identified at-risk youth (ie, NSSI ,SI, attempts) and provided Comprehensive DBT to 56 HS students.

• Results:– Before DBT: one to two suicides per year, since

starting DBT in school 9 years ago there have been no suicides

– Before DBT: two placements into Portland Public School’s day treatment classroom per year, since DBT one placement in nine years

• Statistically significant improvements in GPA from pre- to post-intervention


7-YEAR SUMMARYJim Hanson, 2015


Take away…• DBT for Adolescents is effective on an

outpatient basis

• School data shows that DBT is effective to increase school functioning (spending time in classroom, less referrals to AP

• Mental Health outcomes improve

• DBT changes the culture of the school

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Tier 1: DBT STEPS-A Research


Schools Implementing DBT during 2018-2019 School Year

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• CBC is Working with 32 districts• Consulting to 51 teams• Running approximately 153 skills

group

18%

82%




DBT in Schools (School-Based DBT)

• Far Rockaway, NY, High School (2001-2002)• Lincoln HS, Portland Oregon (2007-present) Jim Hanson• Ardsley School District, (2008-present)• Presented data at conferences (Catucci et al.; Mason et al)• PS 8 Elementary School Bronx, NY/Montefiore School Health (2002-2012)• Pleasantville Union Free School District, NY (2009-present)• Mamaroneck Union Free School District, NY (2010-present)• Rockland County BOCES, NY (2012 – Present)• Riverview High School, NY (2012-Present)• Hilltop Elementary School, NY (2012-Present)• City School District of New Rochelle, NY (2012 – Present) • Florida Union Free School District, NY(2013 – Present)• Briarcliff Manor Union Free School District, NY (2013- 2016)• Astor School Child and Adolescent Day Treatment Programs (2013-present)• Robert Louis Stevenson HS, NYC (2015-present)• Westport, CT, Staples High School (2015-present)• Southern Westchester BOCES HS, White Plains NY (2015-present)



• Harrison City School District, NY (2016-present)• Mount Vernon City School District, NY(2016-present)• White Plains City School District, NY (2016-present)• Yorktown Central School District, NY (2016-present)• IDEAL School of Manhattan, NYC (2016-present)• Katonah-Lewisboro Union Free School District (2016-present)• Bronxville Union Free School District (2016-present)- COMBINED• Hendrick Hudson Central School District (2016-present)• Lakeland Central School District (2016-present)• Ramapo Central School District (2017-present)• Washingtonville Central School District (2017-present)• St. Christopher’s School (2017-present)• Trumbull Public Schools, CT (2017-present)• Fairfield Public Schools, CT (2017-present)• Dobbs Ferry School District, NY (2017-present)• Mt Pleasant (2018)

DBT in Schools Continued

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• Norwalk, CT 2018• Haldane, NY 2018• Garrison, NY 2018• Pocantico Hills, NY 2018• Tarrytown, NY 2018• Pelham, NY 2018• Monroe-Woodbury, NY 2018

Beginning 2019-2020-Cabarrus, North Carolina-CITI-BOCES: Mexico, NY 2019-Ridgefield, CT -New Rochelle, NY

DBT in Schools Continued



Adolescent DBT Books/Manuals• Miller, Rathus, & Linehan (2007). DBT with Suicidal

Adolescents. Guilford Press.• Rathus & Miller (2015). DBT Skills Manual with

Adolescents. Guilford Press.• Mazza, JJ, Dexter-Mazza, ET, Murphy, HE, Miller, AL, &

Rathus, JH (2016). DBT Skills in Schools: Skills Training for Emotional Problem Solving for Adolescents (STEPS-A). Guilford Press.

For more treatment and training information:

www.cognitivebehavioralconsultants.comAlycia Dadd, Ph.D.

Assistant Director of Consultation Services

(914) 385-1150 ext. [email protected] 30

Documents

Preventing Suicide in Schools: Implementing CBC of ......DBT Skills Training in Schools: Skills Training for Emotional Problem Solving for Adolescents (STEPS-A). Guilford Press. Do