I hardly know where to begin. This was one of the most incredible experiences of my career. The learning curve was phenomenal. *Apologies for the information overload, SO much to share from this week!
Contact: CBC – Cognitive Behavioral Consultants
Emma at CBC offices in White Plains NY
As discussed on their website, CBC is a private psychology clinic located in Manhattan and Westchester New York, that supports both adolescents and adults in mental health treatment. Founders Alec L. Miller and Lata K. McGinn have international recognition for DBT and CBT respectively. Alec Miller, co-author of DBT Skills Manual for Adolescents and DBT Skills in Schools (STEPS-A) (pictured below) is the leading DBT researcher and clinician in DBT for Adolescents. He literally wrote THE books. By spending the week with his team and joining them for their own DBT Team Consultation meetings, it is clear to me that there is no better evidence-based, peer supported team that I have seen. From executive level down, this team exemplifies DBT constructs that clarity, precision and compassion are of the utmost importance and that treatment providers need support.
I was extraordinarily impressed with the professionalism, depth of knowledge and support that I saw in this team. For this post, I will focus on what a DBT Consultation Team Meeting looks like and the schools that I visited with the CBC consultants and learning gleaned from those settings.
The consultants I shadowed were:
- Kelly Graling Clinical Psychologist and Director of Consultation Services
- Chad Brice Psychologist and Director of Training
- Amy Walker Psychologist and Associate Director of Training
- Casey O’Brien Clinical Psychologist and Coordinator of Group Programs
The CBC consultants that I shadowed are employed by schools or school districts, to come in as external providers and deliver initial DBT training to teachers and then provide fortnightly/monthly DBT Team Consultation meetings (which is primarily what I was observing). These meetings offer a chance for the staff (teachers/ school psychologists) implementing the programs to come together, discuss difficult cases and gain guidance from the group and CBC consultant in how to troubleshoot areas where they are experiencing difficulty. NB: Some of the schools had Comprehensive DBT programs (Full DBT therapy), some where using the DBT STEPS-A skills based program and some were using both.
DBT Consultation Meeting Behavioural Agreements and Roles
Members agree to do the following:
- remain compassionate, non-judgmental, mindful and dialectical,
- be engaged in team and not be silent observers or only focused on their own work,
- treat the meeting as vital to the DBT process and to avoid distractions or cancellations,
- do homework and come prepared,
- give advice even to those with more clinical experience,
- have humility to admit mistakes,
- assess problems before giving solutions,
- call out the “elephant in the room”,
- be willing to undergo chain analysis for one’s own problem behaviors,
- ask for permission, prepare for and repair after, when missing team,
- speak up when concerned or frustrated by the process,
- carry on even when feeling burnt out, frustrated, tired, overworked, under-appreciated, hopeless, ineffective
Roles during DBT Consultation Team Meetings
Members agree to assume any one of these roles (as needed) at each meeting.
- Meeting Leader – manages the agenda and how time is spent. Although teams may have a member who is considered a leader based on DBT experience, the role of meeting leader is rotated.
- Observer – is mindful of deviations from Team Agreements and other ineffective behaviors during the meeting. Brings the team’s attention to those as they arise.
- Note Taker – takes notes on the content of the meeting, including issues brought for consultation and advice given by the team.
- Member – Actively participates in assessment of issues brought for consultation, including defining the problem behaviorally and helping to formulate solution strategies.
Behavioural Agreements and Roles above retrieved from https://dbt-lbc.org/index.php?page=101147
DBT Consultation Meeting Agenda
- Mindfulness activity
The meeting always starts with a mindfulness activity lead by one of the staff (alternating each week). The mindfulness starts with 3 bell chimes (on Tibetan Singing Bowl) to start the mindfulness practice and then 1 chime to conclude.
2. Team agreement revised
Each team has a set of team agreements (like group expectations). One member picks an agreement that they revise and have prominent in their minds for that session. Eg. “Consistency Agreement: Because change is a natural life occurrence, we agree to accept diversity and change as they naturally come about. This means that we do not have to agree with each others’ positions about how to respond to specific patients nor do we have to tailor our own behaviour to be consistent with everyone else’s. ”
An example agreement by Behavioral Tech can be found here.
3. Repair
An opportunity for team members to repair to the group where necessary eg. if they missed a meeting
4. Burnout Rating
Group members go around the room and rank their own personal burn-out rating from 1-5 (5= BURNT OUT). If a rating is 3 or more, after everyone has given their rating, the group checks in with the 3+ rating people to support and discuss what’s happening for them
5. Case consultation
Group members are asked to submit (ahead of time) agenda items that they would like to talk about as well as what they need support with, how long they expect to talk for and the urgency (1-5). So an agenda item submission could be something like “A. Smith, 16yrs old, Need problem solving support for therapy interfering behaviour – 15mins, 4=urgency”. The group then collaborative discusses the issues at hand to support the DBT practitioner. This is supposed to be brief and very succinct so ideally members would offer a short context to the case and then ask the team directly what exactly they are wanting support from the team for.
The team meetings I observed were 1 hour in length.
Schools Context
I visited 8 schools in the New York State area and even 1 in Connecticut:
Bronxville School Team had a discussion about Diary Cards and finding a way to make them palatable to their students for compliance. It was indicated that 2 targets for younger children and 3 targets for adolescents was appropriate and that it can be helpful to involve some positive goals so that the student gets positive reinforcement eg. play with friends outside could be a target. In addition, it was discussed that it is also vital to reiterate the value that Diary Cards can have for the student through using it as a tool to track what happens and see how you’re doing better over time. If students have not completed diary card before individual session, then they are to complete during the individual session. If students really resist the diary card, they can be asked to complete some/ part of the card but every attempt is made to encourage them to complete it. An idea to help facilitate this are by using a stop watch initially to see how fast they can fill it out and record the time on the sheet.
Application of Knowledge to Australian Context
Diary Cards are supposed to be QUICK and INDIVIDUALISED. However, from this meeting, it became clear that it is normal to expect push back on completing diary cards which is understandable, especially initially, if students are used to coming to see the SC and being able to talk about whatever they want and then suddenly you’re asking them to have some sort of structure that closely resembles (and is sometimes named) homework.
Diary Cards can be incredibly useful tools in tracking progress, introducing and tracking skill use and structuring individual sessions.
This team discussed how to advertise the roll out of the STEPS-A program in their Middle School to their parents. The school has the program already running in their High School. One tip that they came up with was to call the program a “Wellness” or “Social/Emotional Skills Program” instead of DBT as there was some stigma in their schools about this therapy. The team then discussed which students such a wellness program would be most suitable for by examining 5 problem areas:
- Lack of awareness
– difficulty maintaining attention, meeting goals and deadlines
– confusion about what emotion they are feeling
– instead of their emotions and mind controlling them, those who need to learn how to control their mind - Up and down mood
– Struggles with mood eg. pervasively low or high, frequent fluctuations - Difficulty keeping and maintaining friends and difficulty set limits with friends
– continually caught up in the “drama” - Act implusively
– those who don’t think through consequences - Conflict with peers/parents
– common thinking of black/white
– stuck in polarised views
Application of Knowledge to Australian Context
As you may be thinking… what adolescent doesn’t experience at least one of these problem areas?! EXACTLY! Thus, this type of program has such a great reach for all high school students. Now let’s look at these problem areas again with a DBT lens….
- Lack of awareness (Mindfulness Skills deficit)
- Up and down mood (Emotional Regulation Skills deficit)
- Difficulty keeping and maintaining friends and difficulty set limits with friends (Interpersonal Effectiveness Skills deficit)
- Act impulsively (Distress Tolerance Skills deficit)
- Conflict with peers/parents (Walking the Middle Path skills – more than one way to see the problem)
Further tips in presenting the program to parents:
– highlighting that this is the strength based program
– outline pros and cons of the course eg. if student says that they don’t want to do it because they will miss electives and parents don’t want to upset them – highlight that it is their choice and that the program is voluntary. Can also discuss that the student could do the program in Yr8 when the course load is less demanding, alternatively, if the student does not receive support, they may experience escalations in their problematic behaviour which may be in a more strenuous academic year.
– Highlight proactive nature of this program
In this team, there were 6 school psychologists and 4 social workers. This school is a special needs setting catering for students from Kindergarten to 21yrs (similar to Redbank School). All students in this high school receive DBT intervention, groups are held twice a week, with students receiving individual therapy with their respective psych. This is an example of their agenda.
| Therapist | Student | Time needed | Urgency (1-5) | |
| Target | ||||
| Burnout | ||||
| Case consult | ||||
This meeting had combined staff from the Elementary and Middle School.
The Elementary school staff have modified the adolescent curriculum for elementary school age students
Francheska Perepletchikova, PhD delivered training to Hilltop School staff for DBT for children. She is said to be working on a Child DBT manual that should be published in the next year.
This meeting was for DBT clinicians that (unusually for the US), work as the only school psychologist in their settings, thus they have a combined meeting with other school psychs from a multitude of schools to help support them in their individual school implementation.
Application of Knowledge to Australian Context
As this is a similar model to Australia, I can see this working for the implementation of DBT where SCs could form a DBT consultation team with other SCs/ School Psychs in their area who they can meet with fortnightly (maybe on the alternate Fridays to our SPE meetings or after school).
This school is an alternative setting for students with emotional, behavioural and learning challenges. This is one of the only schools that had a low socio-economic demographic. Due to the student challenges eg. externalised behaviour, high turnover of students, the STEPS-A program and Comprehensive DBT was quite challenging to implement.
Application of Knowledge to Australian Context
For schools that have significant behavioural difficulties, it may be beneficial to run more targeted groups as opposed to whole grade programs. When I consider the curriculum of DBT, I can also see that significant modifications may need to be made to suit students from non English Speaking Backgrounds, those with learning difficulties or other disorders as Autism.
This team discussed dialectical dilemmas.
Aasen, P. (2014) Dialectical Dilemmas retrieved from https://www.slideserve.com/cheche/dialectical-behavior-therapy
The following definitions retrieved from: https://www.7cups.com/forum/BorderlinePersonalityDisorderSupportCommunity_81/DBTSkilloftheWeek_1304/NEWDBTSkilloftheWeekDialecticalDilemmas_55533/
Dilemma 1: Emotional Vulnerability vs. Self-Invalidation
Emotional Vulnerability refers to extreme sensitivity to emotional stimuli. This sensitivity leads to strong emotional reactions to even small events. People who are emotionally vulnerable have trouble modulating facial expressions, aggressive action, and obsessive worries.
Self-invalidation refers to discounting one’s own emotional experiences and looking to others to provide accurate reflections of reality and over-simplifying problems and their solutions. This can make it difficult to achieve goals and lead to extreme shame, self, criticism, and punishment when goals are not met.
Dilemma 2: Active Passivity vs. Apparent Competence
Active Passivity is the tendency to appear and act helpless in the face of life’s problems. When stressed, instead of solving problems by his or her self, the individual will demand that the environment or other people solve this problem for them. When struggling with active passivity a person gives up, quits, or becomes suicidal.
Apparent Competence is the ability to hand many everyday life problems with skill. With *apparent competence, an individual acts like they have it all together and don’t need any help. These competencies though are inconsistent and depend on circumstances.
Dilemma 3: Unrelenting Crisis vs. Inhibited Grieving
Unrelenting Crisis consists of the inability to recover from repetitive stressful events before another one occurs. It occurs as if bad things are always happening to you, and can result in urgent behaviours such as suicide attempts, self-harm, drinking, spending money and other impulsive behaviours.
Inhibited Grieving is the tendency to avoid painful emotional reactions. Constant crisis leads to trauma and painful emotions, which the individual frantically attempts to avoid. During inhibited grieving the individual tries to overly control emotions, refusing to express how he or she feels to others.
In this group, I got to see how a repair worked. A member was late to the previous session so she bought a small treat for the rest of the team and was able to apologise. I know this may sound fairly trivial, but I really saw how something as simple as building in a “repair” agenda item can engender positive regard for fellow members of the group. It also allowed the person to formally apologies and give recognition of the importance of the other members time. Similarly, the “burnout” section of the agenda is assists in putting self care at the forefront of clinician’s minds (so commonly overlooked in team meetings). I was personally surprised at how candid some members were when giving their rating. I got the sense that though some members toed the line with “2.5” scores (knowing that you are asked to share if it is 3+, when members did give a 3+ response, they were able to again, highlight that they are under incredible pressure for various reasons and at times, apologies to other members if they hadn’t completed proposed work. It really allowed those who may be having trouble, a chance to be heard and hopefully understood/supported.
This group was in the beginning stages of establishing DBT in their school. They were discussing which students to target for a 8 person group of Comprehensive DBT as well as which grades would benefit best from a whole cohort DBT STEPS-A program. They were considering:
- Parent/teacher referrals,
- Open information nights for parents/staff,
- How to help staff identify possible candidates eg. 3/5 problem areas (discussed above).
Application of Knowledge to Australian Context
It was really interesting to see a program in such beginning stages. It also allowed me to see how much work needs to go into establishing such a program:
- making it relevant to the individual school context
- suiting the purpose that your school is looking for eg. is it that there are a smaller group of students that are in crisis and need this kind of support or in your setting, is there benefits in running a whole grade program?
- considering parental involvement
- this may be completely valid in some settings and completely unattainable in others. The schools that I have seen have a variety of approaches in engaging parents in the program from full DBT parent groups to no parent involvement other than consent
- Considering who will run the program eg. teachers? Welfare/Wellbeing teachers? and logistically where and when (and if) sufficient time will be allowed for session preparation, data collection through pre/post and ongoing measures and team consultation meetings.
Resources
- Adolescent Skills Training Handouts Miller, A.L., Rathus, J.H., Landsman, (1997). DBT Multifamily Skills Training for Suicidal Adolescents. Adapted from Marsha M. Linehan’s Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1992.
- Rathus, J.H., Miller, A.L. (2002). Dialectical Behavior Therapy adapted for suicidal adolescents. Suicide and Life-Threatening Behavior, 32(2), 146-157.
- Trupin, E.W., Stewart, D.G., Beach B., Boesky, L. (2002). Effectiveness of a dialectical behavior therapy program for incarcerated female juvenile offenders. Child and Adolescent Mental Health, 7, 121-127.
Quote of the day:
Sign in office at Mildred E. Strang Middle School
DBT in Schools - Emma Sue San 