Good afternoon, welcome everyone. Thank you so much for joining our presentation. I'm really excited today to introduce you to a wonderful multidisciplinary team that I work with here, or work with at Children's National in Washington, D.C. So our presentation today is about creating a life worth living, so implementing dialectical behavior therapy, DBT, on an acute inpatient unit for both children and adolescents. So our first presenter, who's gonna be talking about implementing DBT from a trainee perspective, is Dr. Alex Yoon. She's finishing, wrapping up her first year as a Child and Adolescent Psychiatry Fellow at Children's, and she'll be the incoming chief. She completed her undergraduate in Chemistry and History from the College of William and Mary, and received her medical degree from Eastern Virginia Medical School. She was also a resident at GW University, which is where I first got to meet Dr. Yoon. And she has a lot of experience working with community leaders, especially in the Korean American community. And she is also very interested, besides DBT, in psychoanalytic psychotherapy, and completed both the Child and Adult Psychoanalytic Fellowships. So she's also very passionate about working with minority populations, transitional age youth, and women and their families. So thank you very much, and I'll turn it over to Dr. Yoon. Thank you, Dr. Z. So we are going to talk about how we can implement DBT therapeutic milieu in the acute care settings, especially we are gonna focus on inpatient units at Children's National, on the child and adolescent units. So disclosure, I do not have any relevant financial relationships with any commercial interests. So start with off, what is DBT? It's short for Dialectical Behavioral Therapy. It's a type of CBT that was originally invented by Dr. Marsha Linehan. It was for individuals with chronic suicidality, and especially people with borderline personality disorder. So when Dr. Linehan was studying for the efficacy of dialectical behavioral therapy, she targeted for these individuals, like who usually we, as providers, we think that it's really difficult and challenging the treatment types because of some chronic suicidality here. And DBT has been expanded and now used for many different types of psychiatric disorders, including substance use disorder, eating disorders, treatment-resistant depression and anxiety, and there are different modified versions of DBT that can be applied to many different mental health disorders. It can be also used in many different settings, not just in the outpatient setting, that can be used in the schools, residential type of treatment settings, in IOP, PHP, and inpatient units as well. So DBT uses a bio-social model, and the bio part of the bio-social is that people who are born with biological vulnerability, they have the genetic influences, and they have some cortical limbic dysfunction, so they are more vulnerable to the environmental changes. And because of that, when they are put in the high-risk environment, such as lots of invalidation and inadequate guide from the guardians, and there are negative reinforcements that are repeated, then it is very likely these individuals may develop emotional dysregulation. And this type of emotion dysregulation can be a cause of many different mental health issues. So dialectics, one specific behavior that is interrelated in the environment. So it considers that is one specific behavior can be interrelated to the larger whole system, like the culture, situations in the world, or immediate social settings. So it sees that the learning one skill is difficult without learning others, because using skills can be hard without understanding these types of environments. So dialectical behavior therapy helps people with extreme thinking, behavior, emotions, who think usually in the black and white thinking, all or nothing thinking, and help them recognize emotions, thoughts, and behaviors, and help them validate these. So when they are validated in their emotions and how to regulate them, they feel more empowered and have less emotion dysregulation. And the most important thing is that we work on the workable dialectical goals so that we can also help them reach each step. So this is the DBT House of Treatment. So we tend to build up from the most emergency immediate level that we'd like to focus on and build up from there. So this is what we think about, the workable, reachable goals. So the first level is some severe behavioral and emotion dysregulation, and help them reach that level. And once that they reach this stability, then they can go up to the next step and the next step above that, and the eventual goal is creating a life worth living, which is the title of the presentation we are doing together. So there are five DBT skills modules for children and adolescents. The fifth one is added for the teens, adolescents especially. The first is mindfulness, interpersonal effectiveness, emotion regulation, distress tolerance. And the fifth one is really important for children and adolescents especially, because it helps teens to talk with their, communicate with their guardians or the family members so that they can come up with the middle ground. So why is it important for us to know about DBT? So rates of suicide have increased considerably for the past 10 to 15 years. The rates increased by 56% for children age from 10 to 19 year olds from 2017 to 2016. And this is based on the CDC Youth Risk Behavior Study from 2017, and we are focusing on DC area because we are talking about the DC population in a children's national, 17.2% of the high, this is a national adversity, 17.2% of high school students seriously consider suicide. And in DC, 11.1% was male middle school students, 11.8% male high school, and 20.4% female, and 19.1% female high school students. And 8.6 reported a past suicide attempt. And the 2.2% reported having received medical care for a suicide attempt, which is very, there's a discrepancy between the people who reported past suicide attempts and who received actual medical care. And 7.3% engaged in non-suicidal self-injurious behaviors. And the meta-analysis showed this rate to be as high as 22.9%. So the DBT can be a good option to help with these individuals with chronic suicidality, non-suicidal self-injurious behaviors. In adolescent inpatient psychiatric hospitalizations, as you know, that suicidal ideation, suicide attempts are one of the most common presentations to the acute hospital settings. And psychiatric hospitalizations account for about 15% of all pediatric hospitalizations. From 2006 to 2011, there was a 50% increase in hospitalizations for all mental health conditions in children between 10 and 14 years old. And inpatient psych hospitalization increased by 104% for children and adolescents. For SI, self-injury, misbehaviors, and from 10 to 14, this number increased by even higher, 151%. So just to explain more how we implemented DBT in our acute settings, I would like to introduce our Children's National Hospital. So we are a freestanding children's hospital and a non-profit organization in Washington, D.C. We provide care for Tri-States, D.C., Maryland, Virginia, and we have two psychiatric units. So 10 or 12-bed co-ed child unit, depending on the quarantine COVID, the COVID quarantine status or the behavioral issues that concern for the co-ed, the roommate situations, and for youth age below 14 years old, and 13 or 14-bed co-ed adolescent unit for youth age between 14 and 17 years old. So we have a multidisciplinary treatment team. One that is comprised of one full-time attending psychiatrist certified in child and adolescent psychiatry, two to three psychiatric residents or child and adolescent fellows on each unit, one full-time licensed psychologist supervising one to two psychology trainees at post-doc level, one family therapist on each unit, and three registered nurses per shift on each unit, three to four mental health workers per shift each unit. So this is how it actually looks like in our units. Dr. Z took the wonderful photos over here. We see approximately 1,000 patients per year on average. Average length of stay is something between five and seven days. There could be something longer, something shorter. The most common presentation is for suicide attempts or serious suicidal ideation with plans. We see a lot of diverse population in terms of socioeconomic status, geographic locations. We sometimes see international patients because of the location in the nation, race, ethnicity, and sexual and gender identity. Each patient has a primary clinician assigned to them, psychiatry and or psychology trainees attendings, has a family meeting with our family therapist who is a social worker at least once during their hospital stay. Patients attend community meetings, unit school, therapy skills group, and group recreational activities, and nurses, child psych specialists, and child life specialists. They provide frontline care and milieu support to patients. So these are steps that we took to implement DBT therapeutic milieu in our hospital. So in February 2019, we started on the units and started leading DBT skills groups two per week on the unit and provided consultation to trainees so that they can learn skills and apply that to a patient in practice. In the spring of 2019, we started introducing nursing and child psychiatric specialist staff to DBT principles or skills so that they can be also well-versed in DBT and they have knowledge and have the one-hour DBT orientation to all new staff. And going on, all patients started receiving a diary card, which is also essential in us to check on whether they are applying their DBT skills daily and checking would be easy to do with staff and trainees as well. In September 2019, we started a parent DBT group as we saw in the fifth module, the parental and the family involvement for DBT therapy is very important as well, and all psychiatric mental health disorders in children and adolescents. In October 2019, a multidisciplinary group from inpatient unit participated in the behavioral tech year-long intensive DBT training with expert consultation for a year. So we have a consultation team as well. In July 2020, we started a weekly DBT didactics for all trainees on the unit as a QI project and DBT skills group expanded like four to five times per week taught by the psychology extern and social workers who attended behavior tech training. And with more groups, patients received skills from all five modules. The one we had the overview in the beginning and in January 2021, group of nursing and frontline staff became DBT champions that they attended by monthly skills training in January 2022. So we formed the consultation team with the frontline staff. And in the fall, we started a coping card with helping with the distress tolerance and mindfulness skills. And in the following fall, in the next year, we were approved for a postdoc position like 2.5 days per week starting July 2022. And in October 22, we implement DBT caregiver groups, which was also done virtually. So five essential modules and functions of DBT. So these are different like five modes and functions of comprehensive DBT. The first one is improve patient motivation for change, which is a very important part of the treatment that the patient motivation and intention are very important. And generalization of new behaviors that they can get the support from the unit staff, the DBT champions, a coping card and enhance the patient capabilities and that capabilities with like motivation, consultation team, the whole multidisciplinary team providing the structure environment so that they can improve as a comprehensive part. And this is a summary how we got the DBT integration into the acute care setting that we have started with the foundation of the principles and then expanded to the individual level and then involve the family so that we can also address from the comprehensive part and the therapeutic milieu, which is all encompassing multidisciplinary team. So observations from DBT implementation, we found out that increased DBT language in nursing notes that was actually showing that people are using those skills and think about these DBT skills and increased validation, less judgmental, more common language spoken by staff and patients too, especially the environment that has a high impact on patient and increased interest in learning more about DBT on all levels, like from patient level, family level and the staff level. Current psychiatry residency training, so jumping onto like how it does look like right now in the nation average wise. So there's a ACGME requirement and at the same time there's little data available for effective ways to teach this psychotherapy and for most psychiatry residency programs, the trainees, especially below PGY-3 level relatively have little psychotherapy training and rarely receive psychotherapy training in medical school. So what our training does to help with the psychotherapy training during the trainee years, medical school or residency training is that it's led by the unit attending psychologist. It's one hour weekly that starts with five minute mindfulness and then go through the skills and end up with the real time consultation that happens on the unit, the real patients that we see on the units. And we learn skills education, do the role playing and the homework so that we can follow up in the following month. So from trainee perspective, it has been really beneficial. That's how I felt like I felt like I can provide the comprehensive care when I didn't have like little psychotherapy training in the beginning of my PGY-2 year. I felt like I benefited a lot. I could learn psychotherapy, medication management, family interventions with that fifth module walking the middle path. And I felt more confident in treating patients with acute suicide ideation, self injury behaviors and real time consultation really helped me a lot because when I felt stuck, I had someone to go to and ask questions and get recommendations. And working with the multidisciplinary team members who are also trained in DBT so that we can provide a comprehensive care over there. And this is actually the research results that we saw in our own training system that we saw a lot of improvement on the knowledge and test percent correct. It was a little about the same pre and post training we think that that's probably because that we haven't encompassed all DBT knowledge in a few number of questions. And they're having a little bit of challenges there too because of the core structure and the many different trainees rotating around that we could not get the comprehensive learning of all DBT modules and difficult to manage schedules at times be given the acuity of the inpatient unit. So take a message, DBT has shown efficacy and effectiveness in reducing suicidal ideation and attempts. And it has been shown improvement in the acute setting as well. And modified shorter version also can make impact and changes in multidisciplinary team treatment support is essential in the DBT implementation in the acute setting. Thank you so much, Dr. Yoon. And I realized I didn't introduce myself. I'm Deborah Zlanik. I'm the psychologist on the inpatient units who kind of started the DBT program. And excuse me, next I'm gonna introduce Reggie Bannerman. He's the director of the Division of Psychiatry inpatient behavioral science and is a nurse. And he has over 30 years of experience in the healthcare field. He did his undergraduate and graduate degrees from the Johns Hopkins University School of Nursing and Business. And he's been with Children's National for over 15 years. Oh, he's getting calls. He's a very important person. Yeah, he's leading the unit, even from here. So he specializes in the area of reduction of the use of restraints and seclusions. And he's been working with the Children's National for over 15 years. And he does this within our hospital, but he's also been helpful with the Behavioral Health Task Force system-wide in helping to integrate a suicide screen for the whole hospital as well as a behavioral emergency response team as well. He's also presented his work both nationally and internationally. And we're just also gonna ask that we save all the questions and comments till the end and we'll have an opportunity for questions and discussion. So Reggie, thank you so much for being here. Thank you very much, Dr. Slotnick, for the introduction. And I sincerely apologize. That's the unit calling. So as soon as I finish my presentation, I may step out just to contact them. So I don't have any financial disclosures to make. So I'm gonna talk to you guys more about from a nursing perspective and how we've been able to collaborate with Dr. Slotnick since she's joined our team almost four to five years now. On the inpatient unit, typically for new staff members, we have a 1.5 hours DBT overview that is delivered by Dr. Slotnick. The main components that we're looking at is validation, positive reinforcement, dialectical thinking, and walking the middle path. And I can tell you that one of the ones that I've seen a lot, is the two that I've seen a lot when I'm on the inpatient unit, is the positive reinforcement and validation. You know, staff is also invited, you know, to observe DBT groups to see skills. So when she's running groups on the unit, staff is allowed to come in to actually see in real time how that is, some of the skills are being utilized. We also have a DBT champion. That's a little bit more involved if you think about it, and it takes a bit of training. So I'll go a little bit more into details as we go on. So just some outcomes that we wanted to share with you guys. As you can see, this is our seclusion and restraints. We don't do much of restraints, the way our unit are set up, but we do do seclusions quite a bit. And as you can see the numbers, as we've implemented, we don't have calendar year 2022. We're still putting the data together, but through 21, in the midst of COVID, as you've seen our numbers actually, 2018 went up through 19, and then begin to descend quite a bit. And we believe that DBT has something to do with that. So we're really excited. And we've used different approaches, collaborative problem solving. We've used that in the past, and at CBT and many others that we've used in the past. But I think right now we all agree that DBT will be the right way to go. And we're really excited to have someone of our doctor's stature to work with our team. The DBT champions are unit-based registered nurses that are on the unit and frontline staff. So all of our, most people call them techs, we don't call them techs. These are child psychiatric specialists, we call them. They all have a four-year college degree or higher for the job that they do. And they spend a lot of time with the kids in the frontline, also with the staff. It's not, there's a bit of a challenge because a lot of times when we've gotten people where we need them to do, because of career progression. Some of them are going to nursing school, the CPSs. Some of them are going to, I have a guy actually going to medical school, social work school, psychology school. So it's a little bit of challenge when we think we finally have our team together. But we're also excited for these folks because they're getting a second degree and career. And I think that, but that's really worth it. But again, very in-depth training that Dr. Zlotnick offers. Their goal is to coach distressed kids utilizing DBT skills that they've learned through this champion program. And the concepts and skills are critical in the practice that we have to continue to mitigate and also make sure that the milieu is well-managed and seamless. The DBT champions participate in consultative team meeting twice a month, as Dr. Yoon mentioned before. And I think it's very critical. If you want to put a line on that, there's a word, safe space. As a director for the department, I'm not even in those meetings. I think the meetings are run by Dr. Zlotnick. And it offers people the opportunity to speak up in terms of the things that they are seeing, what is working, what is not working, be able to confide in her. And Dr. Zlotnick will sometimes come to me and say, hey, these are some of the things that we're seeing, how can we work them out? And I think it's really valuable. But that safe space is critical if you're gonna build a program for people to be able to express how they feel about the care that is being provided and the challenges that are on the unit. We know, for example, short staffing and through COVID, I mean, there've been times that we've had a lot of short staffing. And sometimes that's really very difficult on staff, not having the number of staff or someone has already worked a 12-hour shift and then they may have to stay for a few more hours to help out. And one can imagine after a long day, this job also sometimes can be very stressful. They also explore how to further incorporate DBT on the unit, develop techniques to decrease burnout and improve staff or unit morale, as I've mentioned. DBT champions apply DBT skills on the unit as a role model, common language. I call it therapeutic platform that is built, framework, which also aligns with male lead management. How safe do you want your male lead to be and how seamless do you want the male lead to be managed? I think those are critical elements. So I'm not gonna label you guys by going through each and every one. I'll just highlight a few of them for you all. But what is validation? Validation communicates to another person that his or her feelings, thoughts and actions make sense and are understandable to you in a particular situation, right? And that's one thing that I think is very, very critical. A kid coming out of a family meeting upset, right? The behavior is that, yes, they took a chance through it, but we also have to understand that as a human being, they went in there hoping to have a good meeting. It didn't turn out that way. They're in a state that they have a feeling we have to accept that, accept the feelings that they're going through and how do we work with them to manage? And then we can talk about their behaviors later on. It does benefit in terms of validation to improve relationships, right? De-escalation, and I'm also a senior trainer for crisis prevention intervention. For those of you that may be aware of CPI, and I'll go a little bit into that in the next few slides. But de-escalation in terms of conflict and then intense emotions. When we do the CPI, de-escalation is a critical component because if you can de-escalate a child, the likelihood of acting out behaviors and having to intervene physically, whether through seclusion or putting them in a restraint, is highly diminished. And also through our behavior emergency response team, Dr. Zlotnick is also part of that team. We see this when we go to the inpatient units, when we're visiting, helping the medical units, patients with psychiatric history that are there for medical issues sometimes. And then what to validate. Validate someone feeling upset after a family meeting, as I mentioned. I think that is critical, right? The yelling that may have come out of that, yes, it's a behavior because they're upset. And we're not validating the fact that they're yelling, we're validating the feelings that they have. And I think that's very, very critical. So, you know, validate patient's behavior is normal and expected based on their history and their life experiences. I mean, a lot of our kids, I'm not saying all of them, come from inner city DC, very, very tough background. I've heard kids that say, my mom told me if someone hits me, I hit them right back, right? So this is the tough kid, tough mentality. You know, yes, when they're upset with someone, we're not gonna make threats. Can we talk about what the issues are? Yes, me too, if I'm in your situation and someone called me a name, I'll be upset about it. But let's talk about how we can manage that feeling so that there's a safe space for people. We're not here to get into fights. And I think that, again, some of these kids, this is how they've grown up in very tough, difficult situation. Respond to show that you're taking them seriously, right? Radical, generous engagement, I think this is critical. You know, someone is crying, do you offer them something, you know, like a napkin or a tissue, you know, and be there with them. Sometimes you gotta give them space. And when they are ready, sometimes they are not ready, but, you know, you offer yourself when they are ready, you engage and try to help de-escalate them, validate their feelings and whatnot. So some of the key elements that our nurses, you know, when they are working in child psychiatric specialists, you know, pay attention, look interested, you know, listen and observe. I call it look, listen and feel, right? You know, from that perspective. You know, make an eye contact, no multitasking, you know, stay focused. We should also be very mindful of our nonverbal and verbal reactions, the way we come off in our interaction. Accurately reflect what you heard with our judgment, show that you understand. Again, validating someone for what they're going through doesn't mean that you agree with the behavior necessarily, but you're validating the feeling that they're going through, putting yourself into a patient's shoes. And this is available. We also will provide our information if people are interested, but these are some of the common languages that one may use for validation. I'm so sorry what happened. I'm so glad you're here, right? This must be difficult for you. You know, I hear what you're saying. You know, there's a few of them just to go over, but we have this in the presentation. I'm going to go ahead and introduce myself. I'm going to push us back into the CPI crisis, prevention intervention, and this is where I try to bring that into my CPI training too when I'm training. And I train for the whole hospital, right? So CPI, this is our model. You know, care means empathy, support, and being nonjudgmental. Welfare, emotional state that the individual and physical support that may be given in the best interest of the patients. And we want to get to a place where there's a level of independence. Safety, you're talking about protecting rights, safeguarding vulnerable people. We all know the population that we work with. Some of them are very vulnerable, and we have to be there to safeguard them. Security, maintaining safe and harmonious therapeutic relationship based on collaboration. The collaborative process, working together to achieve our common goals. So this is, for those of you that are not quite familiar, but this is the CPI crisis model. On the left side is for the kids, and then on the right side is for the staff, right? So you talk about anxiety, what the individual is going through, and then we have to be supportive. From a defensive perspective, we have to be directive, right? Set some limits, you know, and whatnot. Acting out behaviors, they're at a point where they're actually acting out. So that means that we physically have to intervene because, you know, they endanger to themselves and others. Typically, that's not where we want to be, but we also know that in this field, this does happen sometimes. And then you have attention reduction, you know, and therapeutic rapport. We must learn from the past what has happened. We debrief with the patients. Are there things that we could have done better? We typically ask three questions. Did we do everything that we set out to do? Number one, were we successful in what we were trying to achieve? And if we have to do it again, how would we approach the same scenario? And we've tried to put this in a little bit more of a... I like this a lot because even if you don't remember, you know, the anxiety and the supportive, this is a little bit visual, right? So for our emergency team that we use going to the medical units, for example, we tell them that early signs of anxiety, we want you to call us, right? Because we have more room to de-escalate, you know, the situation. They are still escalating, right? And then they get into crisis, you know, the cliche, what goes up must come down. They plateau, you know, they use all their energy, begin to descend again, tension reduction, and then, you know, of course, the debrief. So back into DBT again, right? Positive reinforcement increases behaviors you want to see, you know, so providing them a place. And this is one thing I see on our unit quite a bit, providing praises, you know, giving them rewards, stickers. We have a child life, Lena. She's not here, but she gets a big shout out for me because she's always looking for stuff for the kids to make sure that, you know, they're being rewarded stickers and whatnot, special activities. Positive reinforcement benefits, you know, teaches patients to engage in desirable behaviors. What are the behaviors that we want to see, right? And that's an effective way to create behavior change. Shaping, reinforcing small steps that lead towards a bigger goal, like for example, some kids don't even want to go to groups at all. So when they go to one group, how do we praise them, right? So one step at a time, you know, let's get them through one group and then we'll figure out what tomorrow holds, right? Behavior plans, we do use them not as much, but we do use them once in a while. And again, because of shift work, sometimes it's good when you have a behavior plan so that there's a level of consistency, predictability in terms of the care that is being provided. Label praise can increase positive behaviors by specifically praising the desired behaviors. Thank you, Bobby, example for cleaning up after yourself. Jada, you did a great job providing support to your peers. The more you catch patients or staff doing the right thing, giving them praises, the more you see that behavior. And, you know, I know that things are tough for all institutions across the country from a financial perspective. You know, so, you know, just saying to a staff member, I know today was a very tough day, but we appreciate you for your service, right? That's validation. I'm not giving them any monetary value per se, but I'm there to tell them I appreciated everything that they did today. And that goes a long way for staff. Some of the positive reinforcement on the inpatient unit that we're using, group participation, opening up, and safely expressing feelings, using coping skills, cleaning up after themselves, unit rules. We all know how, you know, especially teenagers feel about unit rules. And then being respectful in our interactions. Even in disagreement, we have to always be respectful. Taking turns, you know, raising your hands when they're in group, completing therapeutic assignments that Dr. Zlotnick would give them when they come in, the DBT forms to be filled out so that when the treatment team meets with them in the morning, they can go over it, and then validating their peers. So the negative behaviors that we don't want to see have clear rules and expectations, and that goes to the consistency and predictability that I mentioned before on the unit. Also, from a CPI perspective, and bringing it back into DBT, consequences for behaviors, right? So we have to set some limits from that perspective. And the bigger picture we have to look at, is it everything that a kid does or a teenager does that you're going to get in their face and get into an argument with them, or call them out on it? You know, there are opportunities. Some of the things, you know, I call it the bigger fishes, right? Some are really egregious. That is not acceptable. And some are things that we can talk about it, but at the right time or the right moment. How do we continue to reinforce desired positive behaviors? Because the goal is to reinforce those behaviors, and then it becomes more of what we're seeing. And then validating feelings whenever possible, rather than engaging in power struggle. We all know where power struggle leads us to, right? Bumping of the heads, I call it. You know, you don't do this, it's gonna happen. Okay, watch me, right? And then the next thing, somebody says, well, okay, you're not doing it. Okay, let's call security, right? So you know the trajection that is going. So from my perspective, being the director of the department, inpatient unit, nursing, working closely with Dr. Slotnick, it's been a privilege of mine to have as a team member, someone who is very solid in this work, and we look forward to building many more bridges, and hopefully grow this program as the year goes on. So thank you for having me. Thank you. Yes, thank you. It's hard to believe that Reggie is in San Francisco, and still running the unit, and making sure everything is safe. And I think just speaking to what Reggie was saying, just the importance of a team approach, and having people from multidiscipline, all the different disciplines kind of bought in to the program is super, super important. So next I want to introduce Dr. Pinto, who is going to be speaking today about applications of DBT within an acute care setting. And Dr. Stefania Pinto is currently a psychology postdoctoral fellow with us in the mood disorders program at Children's, and she was also a psychology intern, so I got to know her at that time. She currently provides care to youth in both inpatient and outpatient settings. She obtained her doctorate degree from University of Florida, where she specialized in working with pediatric populations. Her clinical interests include the cultural adaptations of evidence-based treatments to inform patient-centered care. And she is an expert in DBT and trauma as well. So I'll turn it over now to Dr. Pinto. All right, so I came to my position with quite a breadth of DBT experience and lots of DBT knowledge. So my experience from a trainee perspective would be different than that of other folks who are just learning DBT. I too have no financial relationships to disclose. And my goal today is to convince you that adapting mental health care interventions to race, ethnicity, or culture of the target group or patient can actually enhance the acceptance and effectiveness of that treatment. And this is especially true of DBT, which is principle-driven, which means that it tends really, really well to the adaptation across different cultural contexts. It's also especially true considering that both psychopathology and treatment have been conceptualized historically using a Western lens. So thinking about ways that we can use these evidence-based treatments to adapt them to different areas across intersectionality when you're working with vulnerable patient populations is really important. So these are a number of different domains that, oh my goodness, that's much louder. These are a number of different domains in which the research suggests that you can actually adapt DBT quite well. So I'll be going through them just briefly. First one being language. So naturally, DBT was created in English by Dr. Marshall Linehan, and a lot of the materials are, there's a breadth of resources online, and they're all in English, and they have been translated in other languages, but not all of them, right? So ideally, it would be great if we had these resources, these handouts, these skills in different languages, especially to non-English languages to be able to provide those to patients, language of origin, right? Additionally, it would be ideal if the person's providing the treatment, their ethnic and linguistic matches, language matches their patient, right? So again, in an ideal world, that would be a really great way to adapt DBT and consider these things culturally. When we get into how do we change how we're providing this therapy, use of metaphors is actually really, really key here. So I can provide a treatment and use metaphors that are relevant to me because it makes sense as the clinician, but they're not gonna translate over to the patient that I'm speaking to, especially someone who's an adolescent or a teenager, right? So trying to use patient-derived metaphors, use of imagery that prioritizes cultural familiarity, stories, descriptions, all of that can be quite helpful. And similarly with being considerate of the content of the therapy that we're providing, right? So Dr. Yoon mentioned there's a number of different skills modules. Within those skills modules in DBT, there's a number of different skills, right? And all of them have different uses. All of them may be relevant or not relevant to a child. So being strategic with which skills you wanna highlight versus which skills maybe you wanna omit or de-emphasize depending on the child's presentation or their culture, their cultural references, right? An example of this may be omitting assertiveness modules if that's not in line with the patient's culture or adding new material, like the discussion of cross-cultural differences, acknowledgement of racism and community stigma and how that might be playing a role in the patient's presentation. And drawing parallels between core DBT concepts and skills and their values. Values-based work, I would say, is the most important adaptation of the DBT in general when it comes to thinking about different things that are important to adapt culturally. And I think, lastly, it's really important when you think about content, how historically skills, even therapeutic skills, can be used, can be weaponized, right? So a big skill that's used in DBT is something called check the facts, which is very similar to cognitive restructuring, right? You're trying to identify a thought that is problematic or is not helpful, but inadvertently you're telling a patient that it's wrong. And you know what? It might not be wrong depending on their lived experience, their cultural context, right? So even though it may be, from our perspective, something that we see that's wrong within a Western lens, that might just be what their belief system is. So again, trying to be aware of our own thoughts and beliefs and how that impacts the way that we provide care is really, really important. And being skillful and intentional about the content that we're giving therapeutically is also really important. And moving on from their goal setting, making sure that they're client-derived. So being collaborative with setting goals in therapy, again, is super-duper important. The goals of the patient might not be the same goals as yours. So it's important that there's overlap in the goals that are being set. And this is especially true within the context of an inpatient unit. Because our goal might be their safety and readiness for discharge. And their goal might be having their parent allow them to go somewhere, right? So it really, being able to come to a middle path in terms of goal setting is really important to get to the point where you both want to be, which is safe discharge. And then lastly, another way to adapt DBT is to think about context. And this is broader on a systems level in terms of addressing barriers to treatment that are imposed by systemic racism, right? So this includes treatment delivery, the educational literacy of a family, stigma that they might be facing, transportation barriers, right? All of these are ways in which we can adapt as clinicians the delivery of the treatment in order to address some of these things that might come up for families. So now I'll go over some ways that we've tried to address the adaptation of DBT from like a cultural lens, right? So broadly we've been trying to address the context domain, so that last domain I just talked about, by offering a virtual skills group for caregivers on the inpatient unit that discusses a number of different topics and utilizes a seminar format. So how the skills group typically goes is that I'll start with leading it. We always start off with mindfulness, a mindfulness activity that takes about 5 to 10 minutes depending on how long. And then I use a modular approach on a rotating basis. So first, these are all the topics that you see there that we discuss. So there's one module on mindfulness and interpersonal effectiveness. One module on the bio-social model and validation. Another on dialectics. And then the last one is skills, crisis skills and distress tolerance. And these rotate. So I'll do four weekly sessions and then I'll start over again, right? Because the idea is that it's offered to the caregivers of teens that are on both of the inpatient units. So the idea is that they're not there that long where they're restarting the modules. And this is what you see here is our flyer that's given to the families with all of their admission documents. So they're able to register online or they're able to register by telling the staff whenever they call for updates. Some of the challenges that we face here are truthfully recruitment efforts, getting the word out that this is something that we're offering, something that we really struggled at first because it was just brand new. So that involved like orienting staff to make sure that they were advertising it appropriately. And then inconsistent participation and engagement from caregivers, right? We have to keep in mind that these are caregivers of teens who are going through a really acute moment in their lives and they might not have the bandwidth to fully participate. So I've had to be really flexible with how I'm delivering the intervention, right? I've had some parents participate in this virtual group from their car as they're on their way to work. I've had some parents not want to have their camera on or be completely muted the whole time because they have five other kids that they're taking care of behind the scenes, right? So being really flexible with the treatment delivery has been something that I've had to really consider with this intervention. That being said, we're offering at the very end of the group I send out a survey to see how satisfied parents are. Our preliminary data is that everyone is satisfied. They're just so glad to receive this information. So as we continue to implement this we'll get more data and see how we can improve this approach. So to illustrate additional ways in that we've attempted to address some of these cultural domains I'll also be discussing a case example. And I'll be talking about a 14-year-old North African female that was admitted on our adolescent unit following an aborted suicide attempt and worsening suicidal ideation. Some demographics about the patient. She lives with her parents and older sister. She came to us with a history of depression, suicidality, potential trauma, and I'll explain a little bit more about what that means. She had been recently prescribed fluoxetine and had ongoing stressors and vulnerabilities. Specifically family context or family conflict she was using self-harm as a form of punishment towards herself. And she was experiencing developmentally appropriate sexual curiosity but because sex wasn't something that was discussed in their family she felt that it was completely abnormal. And that was contributing to a lot of the self-harm that she was engaging in. Additional cultural factors to consider. The parents were from Ethiopia and were completely monolingual, spoke only Amharic. So we had to rely on interpreters that were our interpreter services specifically for Amharic were hit or miss. A lot of them seeing some nods were hit or miss a lot of the time. And we knew this because our patient would participate in the meetings and verbally call out the interpreters by saying that's wrong you're not translating it right. So that was a challenge. The family also practiced orthodox oriental faith which was relevant to the patient's symptom presentation because a lot of this was contributing to how she viewed her developmentally appropriate sexual curiosity. A lot of this were things that she felt she couldn't disclose to her family members. And then when she did she was told to pray about it. And again all of these were normal kind of developmentally appropriate urges. She was YouTubing videos of people kissing to understand what that was like. She had curiosities that were related. But she believed all of these were sinful in nature and led to a lot of shame and guilt that was contributing to her suicidality. And again all of this was kind of like a reinforcement loop because of her family's religious orientation. They weren't communicating in the most validating or supportive way whenever the patient would disclose these things. Lastly I'll mention that the family had some views surrounding methods of discipline that were really different than Western views. So there had been prior involvement with child protective services for corporal punishment. So this was a conversation that we had to have as well when the patient came to the unit. So the patient was in our unit for a longer hospitalization than typical. Dr. Yoon mentioned our kids are typically on the units for five to seven days. That's plus or minus. This kid was on the plus side. At the beginning of her hospitalization we focused a lot on the conceptualization of her psychopathology, which again was part of why she had a longer hospitalization than typical. And we really wanted to spend some time accounting for, okay, what is culturally relevant versus what is something that we can pathologize. So again the main domain, to bring this back to the cultural domains I talked about, the main domain that we were looking to address was goal setting in this moment. She initially, we gave her a diagnosis of PTSD because she reported an unclear sexual trauma. But then by working on rapport building she eventually disclosed that the trauma that she was referring to was that she watched two individuals out in public have a very sort of like romantic kiss. And because she thought that that was inherently sinful, she was having lots of intrusive memories of it. And then whenever she experienced a memory of it she felt like hurting herself. So it wasn't quite what we would label a sexual trauma given diagnostic criteria, but to her it was something that really impacted her. It was highly distressing and triggering a lot of her SI and triggering a lot of her self-injury. Eventually we diagnosed her with generalized anxiety disorder and major depressive disorder because we felt like those were more appropriate in terms to conceptualize her presentation. Her anxiety was about worries about being perfect for her parents to really adhere to their religious ideals. She had lots of fears about being reprimanded, expectations for herself of being the perfect religious person, praying frequently, getting perfect grades, speaking only when spoken to, following house rules, not sharing negative emotions because that was not appropriate in their family. And what this resulted in was interrupted sleep, lots of nightmares, lots of family conflict and just high distress all the time. And then her depression was triggered by high distress so her feelings of worthlessness and hopelessness were a lot related to her anxiety. I'll explain part of the reason why she had a longer hospitalization as well is that her behavior on the unit initially was quite bizarre. She had moments where she was completely flat, not engaging with any of her providers and then those were offset by moments where she was quite tearful and then laughing inappropriately to topics being discussed. And it all was because her anxiety was so high that she didn't really know how to respond to the clinical interventions being delivered. She also expressed suicidal ideation a lot. She refused to engage in meetings with her family members. She refused to eat at certain points in time. And then she required a one-to-one constant observation staff member to be with her due to safety concerns because she engaged in self-harm when staff weren't looking and had to wear a hospital gown for the first week of her admission because she was using either eating utensils offered on the unit or other things to harm herself. At this point in time some helpful DBT concepts that we implemented were using a behavior chain and I'll show you all what that looks like. And then as we've discussed validation, dialectics, mindfulness, all things to improve rapport because she was quite shut off at this point in time. This is an example of on the left you'll notice an emotion wheel which offered her a plethora of different emotion words which she had no idea existed because emotions weren't really discussed in her home. So it put words to the emotions and feelings that she was feeling which she found super helpful. And then on the right you'll see a worksheet of a chain analysis where this is the form I really like to use with teens especially when they're engaging in a behavior that we're naming as unhelpful. I try to stay away from words like bad or good and just call it an unhelpful behavior. So for her it was self-harm and then talk about okay what was the prompting event? What was something that triggered this? And then let's talk about the thoughts, body sensations, and emotions that you felt during that moment in time which led to the behavior, right? Because you didn't just self-harm for no reason. Lots of times teens will see you and they'll be like I don't know why I cut myself. And they do know. So we have to break it down a little bit more for them once we talk about the different things that happened that led to them there. And then once you have that oh my goodness isn't that evidence to validate them, right? Like I can totally see why you felt such intense emotions and why it led you to feel like the only solution you had was to harm yourself because look at how complex everything going on in your body was, right? And that's the validating piece that Reggie was talking about earlier. You validate what got them there. You don't validate the behavior, right? And then you talk about short-term positive consequences which are important because we all engage in unhelpful behaviors for one reason or a multitude of reasons but there's usually a positive consequence to the unhelpful behavior. For me if I procrastinate it's that I don't have to deal with it in the moment, right? If I for her if she self-harmed is that the intensity of her emotion decreased, right? So there's always something that we can acknowledge that's positive because that's what's perpetuating the unhelpful behavior. However, to get by and to change the behavior we got to think long-term. And more times than not there's a long-term negative consequence. For me if I procrastinate my long-term negative consequences that I put it off to the last minute and then it takes a long time. For her if she continued to self-harm it would lead to either more hospitalizations or eventually death and it's okay to talk to get to that point, right? We want to really emphasize the point that worst-case scenario you're not here anymore so all the things you care about they're not there anymore because you're not here anymore, right? And then that leads us to our behavioral solutions which is where we implement skills. Then through I'm going to refer to this as like the turning point in therapy. Once we had built enough rapport we focused on content and context as main modes of implementing culture or adapting different the intervention culturally. We collaborated a lot with staff to be able to maintain skills application which is really truly so important because I can provide an intervention for one hour right during the day but the staff is there for the remainder of the hours in a day. So if I'm doing something that's not being reinforced by the rest of the staff then you know it's only half the work being done, half of the intervention, not even half the intervention being delivered whereas if I'm really collaborating with the staff and nursing staff the CPSs, the psychiatry team, right? That's all systems go and the intervention is going to there's likelier that it's going to succeed. The patient then became more willing to discuss triggers to self-harm. That's when she eventually disclosed that a lot of them were related to the sexual urges she was having. We started using goal setting for parent for family meetings. We also started holding family meetings twice weekly because that was a big turning point that when she saw that her family was engaged and wanting to talk to her about these things that were like prohibited before then she had some buy-in as well because she started noticing that they in her brain, in her mind she perceived them as caring, right? And that's not withstanding the fact that there were continued challenges because we had to rely on interpreter services to communicate with the families. We were only able to try to reach them a couple of times a day. And then if they weren't available then we just weren't able to speak. Because when they called the unit back we had to get in touch with interpreters. So just logistical issues that came about. And like I said earlier, the interpreter competency. On the right you'll find different skills modules that we implemented that were really helpful and the specific skills within them. So emotion regulation, distress tolerance, interpersonal effectiveness and then specific skills within those modules that were especially helpful during this time. And then the very end of her hospital stay, so she stayed for 18 days, we worked again on adapting content to be more culturally relevant to this family. So we worked on coming to a middle path between the patient's more acculturated values versus her parents' more traditional Ethiopian values. We also tried to come to a middle path in terms of emotion expression versus not speaking about emotions whatsoever. We got buy-in from her parents because we showed them, you know, if we don't talk about your child's feelings then she holds them in. And what you all don't want is for her to come back here or worse. So we got buy-in from the family just within the blink of an eye. Because our goal was similar, was that this child had a life worth living and that wasn't possible if she wasn't talking about her emotions. We had to meet her halfway. And a lot of that came with incorporating values-based work to acknowledge those cultural differences and just kind of put them out there, right. And then we created a safety plan with the family and shared it with them which included things like warning signs of a crisis that they could physically see to know when their child, even when she was having a really hard time communicating, when she was feeling like she was in crisis, using coping skills that she identified were helpful and then other ways that her parents could help and other supportive people. And what you see on the right side is another example of the DBT house that Dr. Yoon shared earlier that I actually brought to her room and had her draw her own so that it was applicable to her. So all in all, my general takeaways for you are that pathology and treatment are often conceptualized using a Western lens, which means that we have to continuously work on our own self-awareness and our own implicit and explicit biases so that we're able to acknowledge them and then find ways that we can either stop perpetuating stigma or stop weaponizing our treatments, right. Because we have to acknowledge the fact that the treatments that were developed that are evidence-based aren't always necessarily evidence-based for all. And then as far as the other takeaways that you can take from this is that rapport building is really, really important to increase patient buy-in and a way to learn more about cultural differences and that can help you adapt treatment as you go. And additionally, using a patient-derived approach, a patient-centered approach can help you get there as well. Taking a nonjudgmental stance when providing psychoeducation about emotional expression or disciplining techniques to different cultures is also really important. And other ways that you can be more inclusive are, as I mentioned before, language, shifting treatment content in order to prioritize what's relevant to the family, and addressing sociocultural barriers to treatment. And that's it for me. Thank you so much, Dr. Pinto. And we're going to wrap up by talking about the implementation of DBT on our unit, some of the barriers that we've seen, lessons learned, and future directions. And after that, we'll have time for questions and comments. I also do not have any financial disclosures. And I'll start by talking a little bit about some of the barriers. I think one is that on an inpatient unit, DBT is not effective for all patients. So when we have patients that are there for psychosis or mania, they might not really be able to take in the skills that we're teaching in skills groups or therapy. And so they might not be benefiting from that and still might have some of the aggressive behavior or difficult behavior for the milieu to manage. I do still think it is helpful for our staff, though, to interact with these patients using the same principles. And I think that can often help de-escalate some conflicts, even if those patients aren't in a place at that time necessarily to take in the skills that we're teaching. Another difficult part of implementing DBT is the kind of large number of staff and providers to train. So given that, as Reggie was talking about, we have a lot of young staff that are going on to nursing school or psychology or medical school, and there's also high burnout. There is a lot of turnover of our frontline staff, and for our trainees, there's a lot of turnover as well. We have residents that come on the unit for between one and four months. We have medical students every six weeks. We have psychology interns that are there for three months. So we have a lot of different rotators and at different times. So it's really hard to find what is the kind of sweet spot for actually training everybody and having people have all of the information. So that can be difficult, but we can try to find ways around it, and nothing is going to be perfect, of course. It's also really difficult to ensure implementation and consistency. So we are 24-7, and the kind of team here is usually here mostly Monday through Friday, typical business hours. So you're not really able to ensure that people are using the principles that we're talking about and teaching in the evening hours and weekends, and you're not able to observe everything all the time anyway. So I think there are issues that come up related to consistency and implementation of, like, using diary cards, for example. That's been an ongoing challenge of how do we make sure every patient is getting diary cards consistently when there's constantly new patients. So little things like that really take a lot of time. And it's also difficult, as I mentioned, to find time for training due to shift work and also the changing of trainees as well. And there's staff burnout. These kids, it kind of goes in waves, I would say, of the acuity of the milieu. But when the milieu is really acute and there's a lot of patients that are aggressive and things like that, staff emotions come out and it can be hard to remember, oh, right, I'm supposed to validate first. And so that is a real challenge, of course. And I think really helping support staff and validating staff that they are humans and this is really difficult work and figuring out kind of ways to, even when the unit milieu is really high, to still kind of focus on DBT skills and maybe letting someone know that you need a break, kind of being what we would call paying attention to our emotion mind and trying to get into wise mind when we're working with difficult patients. So now I'm gonna talk a little bit about some of the lessons learned. So I think this panel here really speaks to that. DBT implementation takes a team approach. That's so, so important. So coming and starting this position about four and a half years ago, being one of the only people knowing DBT, it was super important getting kind of buy-in from the rest of the team, other people that are trained through behavioral tech as well so that other people are kind of speaking the same language and also kind of championing DBT as well. Super important, making big programmatic changes in a system takes time. So, you know, Rome wasn't built in a day. We have to be patient. I had, you know, came into lots of ideas. I met with Reggie and I'm like, we're gonna do this, we're gonna do this. We've done a lot of that, but it kind of took time, one step at a time. You can't make changes in a system that is, you know, 24-7 right away. And so being patient is super, super important. Collaborating with other institutions is also super important. I'm on a listserv for acute care, inpatient, and residential psychologists, and it's super helpful to kind of send questions or ideas and kind of learn from what other programs are doing. Of course, also going to conferences like this, we were just at a panel of other institutions, inpatient, IOPs who are implementing DBT, and it was really helpful to hear some of the ideas that they had and the challenges that they had as well. Also, creating training opportunities for psychology in other disciplines is super important. So as, you know, I started as the only, well, I still am the only full-time psychologist on the unit, but creating opportunities for other psychology trainees, so having externs leading group, having interns leading group, having postdoctoral students leading groups for parents and the patients on the unit really makes it much more feasible and makes the program much more robust. So that's super important to kind of expand people who are able to deliver the treatment, especially with fidelity. Also, asking for and applying for opportunities and grants. So DBT behavioral tech training is quite expensive. It's about $10,000, but it really, really makes a huge difference. So not being afraid to use the DBT skill of dear man, which is asking for what you want, being open to know, but luckily, the powers that be have said yes, and so we were able to do that. And so it's really helpful to be able to get that higher level of training. I also applied for a grant to get coping materials for the unit, so things like that are really important to kind of go for. The importance of leadership investment in DBT, so helping support those endeavors like the behavioral tech training and things like that, bringing on a postdoctoral fellow, all of that requires the buy-in from leadership to see that this is a really important initiative and helping to invest in that. And then the importance of repetition and continuous training, because there's constantly new providers and staff, I might be kind of saying the same thing, but it's a different group and I have to remember that. It's probably not boring to them or too repetitive for them because there's new people, it's new material. You have to kind of keep things moving, and so that DBT becomes part of our, like the backbone, our DNA of the unit. So some of the future directions that we are kind of hoping to move in, because as I said, it's kind of everything takes time, really trying to increase consistency of DBT on the unit. So having everyone speak that language more often, and we have a new group of DBT champions who I think will really be helpful in championing that for the unit. Wanting to increase behavioral principles and positive reinforcements. So thinking about things such as a token economy or more privileges that can be used for those that are engaging in the behaviors that desirable behaviors that we wanna see, going to groups, being respectful, following the unit rules, things like that. So we have some natural reinforcers like discharge and things like that, but we also wanna have kind of more opportunities for built-in reinforcers. We wanna have opportunities to expand DBT groups on the unit, so we're expanding our number of psychology externs next year, which will help with that. Wanna implement a egregious behavioral protocol. So if there is an episode of aggression or self-injury, we have a more systematic way for patients to do a behavior chain and repair and kind of think about what skills they could have used instead before returning to the typical unit programming. So that's something that I'd like to implement as well. And really wanting to increase all staff knowledge and comfort with DBT skills to provide in vivo skills coaching so that when a kid is in crisis, they feel like they have a lot of different skills that they could help support and walk the patients through. I think that is some of the staff I think feel very comfortable and others don't. So kind of having it be so that everyone feels quite comfortable with a range of skills is definitely important. And then also increasing availability of DBT resources in other languages. So we do have worksheets and things like that in Spanish. We're in the process of trying to get some recorded caregiver DBT groups in Spanish as well so we could have that same resource for Spanish-speaking families. Additionally, the work on an inpatient unit is with patients that can be very difficult, aggressive with high acuity. And so the consultation team for all staff is gonna be something that we are striving for. So right now, the group that kind of self-selected that are particularly interested in getting more experience in DBT, the DBT champions have a consultation team. But we want to expand that so anyone on the unit who feels like they need more support and kind of using the DBT model can join consultation team. We have diary cards for all patients which have some of the skills, but we want to have kind of individualized coping cards and kind of coping plans so that everyone has a plan. If they're in distress, what can they do? And have a very kind of on an index card that they can walk around with. So that's kind of a next step. Having more DBT visuals on the unit so they can see kind of are you in your wise mind kind of art and things like that on the walls. That's my idea, we'll get there. So just having a little bit more kind of reminders of the skills around. Also, we sometimes have patients who are stuck on our unit for a long period of time. And as you would imagine, if you're going to skills groups on repeat that are kind of similar, it gets maybe a little boring potentially. So having some specialized DBT programming kind of like a graduate group or things like that for longer term patients. So that's another project that I want to work on. We're also expanding our resources to other hospital units. So sometimes we have patients who are COVID positive on medical units or patients with eating disorders. And we've started an opportunity for those patients to zoom into the groups on the inpatient unit so that they can get some of those skills as well. So that's another area that we're starting to expand. And then we've been doing this for a while. So kind of is DBT effective? So we've seen like some of the changes in restraints and seclusions, but we haven't done more formalized research on kind of which elements of our DBT program are helpful and for which patients and what are the mechanisms. So that would be something really important to continue researching as well. So I want to thank you all. And this is our contact information. And also on the app, it does have all of these slides as well if you wanted to reference those. So thank you for your time. And I wanted to turn it over to the audience and see if anybody has any questions for our panel here. Thank you. Thank you very much for your presentation. I'm John Cheem. I'm from Toronto, Canada. I had a question about how you've worked with, I work on an inpatient unit as well. And so a lot of our more dysregulated youth have significant learning disabilities, sometimes even intellectual disabilities and also autism spectrum disorder. And so we're wondering what adaptations you've had to implement specifically with regards to working around these individuals because they'll have different learning abilities within these group formats, for example, sometimes don't even handle group formats very well. So just wondering what kind of adaptations you've used to deal with individuals with those kinds of issues. Yeah, great, thank you so much. That's a great question. So maybe I'll start out and then see if other people have things to add. So sometimes the DBT manual worksheets and things like that are very dense and can be really overwhelming for really a wide variety of people. And so I really think taking certain skills and concepts and adapting them for a kind of differing developmental levels and cognitive levels and things like that. So different things you could do is kind of using just kind of visuals. So it's kind of taking the language out and kind of really, like for the example, the tip skills about temperature and intense exercise, progressive muscle relaxation and paced breathing. So you might not worry about the words. You might kind of just show pictures of each of those things and actually really model and practice. So I think kind of the stop skill is one that can be really helpful, just kind of pausing before moving on. So you probably are gonna think about tailoring the skills and kind of focusing more on the distress tolerance skills and kind of taking some of the language out and making it as visual as possible. But I'll see what other, go ahead. Something else that we've done quite a bit of is emotion words are hard and that's especially hard for a kiddo that's really emotionally dysregulated. So trying to put, use it like a color system. So similar to a stoplight, like a green, yellow, red. And I also add blue because blue can be like low energy emotions. So sadness or boredom or sleepiness, right? And then having these colors be directly related to like the intensity of how they're feeling. And since these kids get their own rooms, what I end up doing is just creating different zones in their rooms with different colors. So if they feel red, then they're going to the red corner. And then that's like an easier way for them to communicate than telling me I feel angry because, right? So trying to tailor to the bandwidth that they can handle and being collaborative in that way. In addition to what Dr. Z mentioned as far as using like pictures instead of just words. Also just to add to what was said, good old validation, right? I know that works quite a bit because recently, just to tell you, we had a situation where a bunch of the kids were acting out over the weekend, right? I mean, so typically you're like, hey, why are you guys acting out? And this is wrong. Everybody, the first thing Dr. Zlotnick and I spoke and said, we've got to go in there and validate their feelings, right? Because some of the behaviors, yes, they are inappropriate, but there is something that is causing them to behave that way. So how do we validate them, try to figure out what the issues are and then begin to work through the issues. Whereas pre-DBT, you know what you did is so wrong, time out, you're going to lose all your privileges, right? It was more just a reactionary perspective versus saying, hey, I know you're acting out, but I know there's a reason maybe behind it. So can I hear you, what the issues are? And we were able to have a dialogue with them. You know, they felt some of the staff were a little bit too tough on them. You know, the staff, for example, one quick example, they didn't think that groups were happening on time, right? And then, so that means that they had to spend more time in their room. But guess what, when some of them are acting out, the same staff that have to run the groups are the same time people are trying to put out the fire. So we have to have a dialogue and say, hey, we appreciate your feedback. We want groups to start on time. But that means that in return, then we want to see certain behaviors so that we're not also spending time trying to put out this virus, but we're engaging and trying to make sure that groups can start on time. So that validation goes a long way. I think for me, that's just a starting point. Validate what they're going through, try to figure out what the issues are. And then the next question is, how do we work through them? So that would be one of the ways I would manage that. Totally, I agree. Like piggyback on everyone, so like going back to bio-social model of DBT, biological part that we can definitely use, like simple, modified, visual DBT skills to help with that biological hyper-arousal. And the social part with the more validating environment, Reggie said, and also have the staff who are well-versed in that DBT supportive setting that actually helps the patient whenever they have difficulties, challenging situations going on. I suspect that the density of your staffing and the level of expertise is much higher than is the case for the average psychiatric unit. And so therefore, how exportable do you believe that the kinds of skills that you've described are? And are there components that you think you would emphasize if a particular unit can't be as comprehensive as yours but would still like to work with the concepts? Yes, I think that having the DBT skills, even if you're not able to, at the time, go to the behavioral tech training, there's a lot of research to show skills-only DBT has a lot of efficacy. So I think if it's a child and adolescent unit, there's a book that you could read it and it tells you how to teach the skills. So it's by Miller and Rathus. And having that manual and having someone who's maybe tasked to get well-versed in those skills, or even there's much shorter-term skills trainings that can be much less expensive than the full comprehensive training. So having someone really well-versed in the skills who could then train everyone can be super important. I think that not that many people knew DBT before I came. So having at least one person well-trained can really, as long as you're kind of being consistent and continuing the training, can really make a really big difference. So it is worth investing, even if it's just in the manual and tasking someone to really get to know that manual. So that's my thought. Yeah, and to add to that, I think it's really relevant to have the stakeholders at the table. Because one thing that Dr. Zlotnick, when she started, she and I sat down and we looked at the program and where we wanted to go with the program. So engaging your stakeholders at the very beginning makes a big difference, right? It's similar to the work that we've done with seclusion and other areas throughout, you know, over the years. When the stakeholders are at the table, you're right. When you look at a budget, 10,000, wow, you know, that's a lot of money. But what you're gonna benefit by investing is worth more than you just looking at the 10,000, right? So, but Dr. Zlotnick is now the one that is training everybody. So yeah, this 10,000, I think is money well spent. Back then, when you look at the budget, you're like, oh my God, 10 more thousand dollars we have to spend. But I think it's worth every dime. So engage the leaders of your team, whether they're medical director or, you know, the nursing counterpart, whoever it may be, the psychiatrist, you have to get some buy-in, any program that we start, right? Because if you don't have buy-in, you know, it's really difficult to make sure that the program can continue to grow. So that would be my advice to you. Just to add to that in terms of the finances, the research on programs that have implemented DBT, it saves about $250,000 because they're spending less money on like constant observation and things like that. So there is a cost-saving benefit to the hospital. Hi, thank you for the chat. I'm Dr. Tam, I'm from Singapore. I do see a fair bit of adolescents in the clinic and sometimes the biggest challenge I face is when there is a personality trait, like a conduct disorder or an oppositional defiant disorder where they're very, very volatile. So can I find out from the experts that in an acute setting, will DBT be able to help this group of patients where they're so volatile, the patients are so hostile, the parents have given up? Can DBT be helpful in those situations? I think yes. I think you kind of wanna kind of tailor the treatment specifically to those patients, but we definitely on our unit have those patients as well who are very aggressive towards staff frequently. And so sometimes we wanna kind of adapt and have a behavior plan for those patients. So I did mention we don't have a general kind of unit wide one, but we'll make a specific one and find out for that patient, what do they want? What's reinforcing for them? How can, what's their motivation? Is there a motivation to discharge? Do they wanna go to foster care? Do they wanna, what is it that they want and trying to kind of think about what are their values and kind of how are these behaviors kind of taking them toward their values or away from their values and tailoring treatment around that. And sometimes you wanna find out what's, we don't have that much to work with on an inpatient unit, but maybe they're really reinforced by going to free time and socializing with their peers, but they're not paying like any attention in skills groups. So you might kind of tie it like contingency management. So if you wanna go to free time, we have to make sure we're learning one new skill today and kind of opening up with the treatment team. So you could kind of figure out what they are incentivized by and try and kind of work that with kind of what our goals are. So that's kind of one way, but we definitely have had success with a lot of aggressive patients who are quite, we'll say in DBT, willful. And I'll say to add to that, lots of times the behavior plans are quite simple, right? Like an example might be keeping yourself safe, keeping others safe. So safe hands, safe feet, safe mouth. And that's it. That's the bare expectation for the first couple of days. And then we add on to that, attend groups, talk to your doctors, right? Being as simple as you possibly can to build up. And then once they start to check mark all of those things on the behavior plan, then they're engaging in therapy. So using a lot of some of the adaptations that I mentioned about like figuring out what got them there, right? We get lots of kids on the unit with ODD and lots of them. And initially they see you as similar to all of their invalidating environment, right? So you have to invest in the relationship that you have with them in order to see some change. And then once they're engaging, you have that little bit of engagement, you're able to create a therapeutic bond or a therapeutic relationship to be able to let them know, okay, I hear you. I see why you're here. I see why you feel like everyone is not listening. Let me be the one person that you feel like is listening to you so that we can work on your value system to make sure that you're still engaging, still applying. Like let's tailor these skills to be something that you can work on. My thing about ODD is, I know everything said here is great, but we do see we're inner city DC. So we do see our share. I mean, like in terms of really tough case to manage, I mean, it doesn't get any better. I mean, that's what I say, but we manage them. And some of them, you know, you'd be surprised their first few days there, the hostility. And then when you look at them, right? Like in a week, a week and a half, they're ready to go. I remember there was a young lady just recently. I mean, I walked in there and the barrage of the names, right? And then I go in there a week later, she's like, Mr. Reggie, I need to talk to you. You know, guess what? I'm going home tomorrow, right? Someone that didn't even want to engage anyone, didn't want to talk to anyone, right? Very, very tough. But now they have this soft side of them that they're able to actually tell you, hey, you know, things have worked out and they're gonna go home, you know? But yeah, Washington DC, we do see a share without a doubt. Thank you, any other questions? Well, thank you so much for attending and enjoy the rest of the conference. Thank you.

Dialectical Behavior Therapy

DBT

acute inpatient unit

children and adolescents

Children's National

Washington D.C.

emotional dysregulation

multidisciplinary approach

behavioral principles

cultural adaptation

psychiatric care

patient outcomes