We have the coveted 1.30 after lunchtime. But we're going to try and keep you engaged because this is working in high-intensity settings, treating the fast and furious. So most of us are fast. Maybe only a few of us are furious. But we're going to try to cover a lot of stuff. Leave plenty of time for questions. And I think it's fine with Dr. Sullivan and Dr. Thorteson if we have questions at the time. But we'll also reserve time at the end. All right, so I'm going to do a brief overview of CBT and DBT in high-intensity settings. I'm Bob Friedberg, by the way. Other people on the slide are people that are in my research group who helped me put this together. So I'm going to just give you a brief introduction, talk a little bit about CBT, cognitive behavior therapy in high-intensity milieus, then DBT in high-intensity milieus. And then Dr. Sullivan is going to talk about DBT and CBT in acute inpatient. And Dr. Thorteson will talk about DBT and CBT in intensive outpatient. And they're going to be using their clinical experiences at NYU Bellevue and Children's Hospital of Orange County, respectively. All right, so typical things, as you all know, there's basically sort of three common arms in high-intensity treatment. One is psychopharm. The other is CBT. The third now has the new entry into all of this relatively is DBT. The good news is all of them are effective. Many of them are effective in combination. And most can be effective solo, singular, as a singular treatment. So CBT first in high-intensity milieus. Essentially, most places that use CBT in an inpatient or intensive outpatient or partial hospitalization program do adopt a milieu focus, where everyone on the milieu conceptualizes and intervenes from that same perspective, from either a DBT or a CBT orientation. One of the things that is very helpful in doing a milieu approach is it allows for task shifting so that a lot of low-intensity interventions that are typical in some of these settings, like relaxation or mindfulness or social skills training or communication training, don't require higher levels of degrees, don't require doctoral-level degrees. So they can be shifted off to OTs, RTs, nurse practitioners, et cetera, master's-level practitioners. The key, though, in the milieu is that you have to really make sure that you shepherd it so that everybody's on the same page, both from a conceptual perspective and on a treatment planning and intervention perspective. I put this slide up here because that beautiful place, Mesa Vista Hospital in San Diego, was the first inpatient cognitive behavioral milieu therapy program west of the Mississippi in the 80s, developed by some of you may know this person, Ray Fidelio. This is where I cut my teeth back in 1989, perhaps before some of you might have been born. And that was a... To show you the milieu focus of it, I just want to give one example as to why I call it the granddaddy of them all, because it was an innovative treatment planning procedure in which essentially all the staff and all the patients met on a Tuesday afternoon from 1 to 3, and they were all in the same room, and the patient's progress was discussed, both in the milieu and through the different disciplines. So whoever the leader would be, either myself or Dr. Fidelio, would present the case, check on progress, and then each discipline would weigh in and the milieu, the other patients, also would weigh in, which was a very, very powerful sort of essentially fishbowl experience for the patients. And again, that was sort of a method that Fidelio developed. More recently, UCLA has developed a partial hospitalization called the UCLA ABC program, which, again, kids 6 to 12 have all those presenting complaints, as you would imagine. Their PHP is set five days a week for seven hours a day, and their typical length of stay is reported as somewhere between six and eight weeks. They also have a PHP milieu, CBT milieu, and the reference down there will also kind of describe that for you. What they had is they had two school sessions, and then, of course, they had prototypical groups, and the CBT group, as it says before that, as it says right there, is split into two smaller groups, and they do that to tailor the material. And that is accompanied by daily treatment sessions, parent training, family therapy, and not surprisingly, because of the high acuity, all the patients are on psychotropic meds. It also includes a positive support system and bibliotherapy. The CBT is augmented by bibliotherapy, role play, again, I call bibliotherapy psychoeducation, play worksheets, and discussion. And they have some recent outcome data on this, and for you statistics wonks out there, it's a pretty large effect size of 1.38. Interestingly, what they did is they compared that to the treatment for adolescent depression studies, which was, remember, multi-site, multi-trial for adolescent depression, and again, the effect size is essentially similar. So they've got good success. How about DBT programs? How am I doing on time? How much time do I have? Okay. The DBT program, so one brand new, as you can see, this 2022 program, which is created by Joan Asarnow at UCLA, combines a multisystemic therapy, DBT and CBT, in their approach. And what that does is it combines and integrates the person's sociocultural context, the skills that are missing, their risk and protective factors, and how distressed they are, their level of acuity. It includes work with both the parents and the caregivers, and what they focus in on is essentially acute stress, meaning crisis, which is basically dealt with with safety planning, emotional regulation skills, essentially sort of the meat and potatoes of DBT, distress tolerance, also the meat and potatoes of DBT, mindfulness and hope kits, and again, more specifically, their approach includes psychoeducation, problem solving, behavioral activation, social skills training, communication training, and making their whatever environment they're going back to safe. So they took this safety plan, this safety program, which was initially developed in an outpatient, and they tried to transfer it to intensive outpatient or partial hospitalization. And what they found is in the ER, they migrated to the ER and medical floors, and they found that this safety program actually transfers to those very, very acute situations, and that it allowed them to safely discharge people to much less intense levels of care. Additionally, most importantly, that suicide risk scores were much lower in patients that completed the safety program than in the treatment-as-usual group. And again, you can see most of these new studies here on DBT are very, very recent. Then they did safety with a very diverse patient population. This, again, in Southern California, and you can see that, what, 69% were Hispanic Latinx, 18% African American, 11% Asian, et cetera. Again, similarly to the other program, or the other research protocol, they assigned them either to safety or treatment-as-usual, and what they found was better linkages to lower levels of care and decreased stress for those who were in the safety program. Okay. And what's interesting about, or maybe compelling about this study, is the large number of diverse patients that they had. This is a review article that, again, relatively recent, of DBT in inpatient settings. Basically, again, not surprisingly, this is where they're focusing in on acute safety concerns and very severe life-threatening behavior. What they did to adapt DBT to the inpatient setting was two to three times a week individual therapy. They really emphasized diary cards and behavioral chain analysis throughout. The skills groups were up to nine times a week, so it was a pretty heavy dose of the groups. And what's been found is that very good effects on depression, suicidality, mania, really very impressive decreased behavioral incidence on inpatient units, much less restraints, less aggression. And they actually metricized this data, and you can see that by using the DBT and getting these type of results in the high-intensity settings, they were finding an average yearly cost benefit of almost $120,000 for suicidal behavior, $56,000 for cutting, burning, otherwise non-suicidal self-injury, and about the same for, and exactly the same for aggressive behavior. In the review, all these DBT programs have the same type of components, right? They're mainly, particularly in the high-intensity programs, they're focusing on, again, self-harming behavior. Good, I'm right on it. Increasing generalization, decreasing the amount of interference in quality of life that, again, they have done some studies looking at DBT for reducing readmission and retention. And essentially, the effect sizes are a little bit more rangeable, probably because the data is new. I did say that one of the major outcomes is that there is better patient stabilization, more reduction in suicidal ideation, more reduction in non-suicidal self-injury, and better acquisition of coping skills. And I am almost at time. And that's all I want to say. I want to say I'm right on time. And I want to say thank you to those of my co-authors, Joey Zucker, Megan Neely, Isabella Zee, and Kelly Goodman, for helping kind of prepare the research for that. And now I'm going to turn it over to Dr. Sullivan. And again, any questions or if you want the handouts, please feel free to email me at that address. Hey, everybody. How's everybody doing today? All right. Just curious, by a show of hands, how many folks have worked on an inpatient unit? Excellent. All right. So my name is Paul Sullivan. I'm going to be talking about high-intensity interventions specifically on the inpatient unit. In regards to conflicts of interest, I don't have any. Just a little bit of background on myself. Before graduate school, I worked at McLean Hospital and the OCD Institute for a couple of years. I did my training under the tutelage of Dr. Freeberg at Palo Alto University. Very fortunate to meet Dr. Freeberg and Dr. Thorderson there. Did my pre-doctoral internship at NYU Bellevue. Post-doctoral fellowship at Weill Cornell New York Presbyterian. Came back to Bellevue. I'm currently the unit chief on the adolescent inpatient unit there at Bellevue. And it's a great time. So just in regards to what the structure of the unit looks like, so we have 17 beds there on one of our adolescent inpatient units, 15 maximum. I would say typically our census is around, like, 11 and 12 typically. We have a fair share of, like, do-not cohorts, so patients who cannot tolerate a roommate for aggression reasons, therapy-interfering behaviors who encourage other folks to cut. Low-functioning ASD. LGBTQ. We try to be very mindful about, you know, rooming individuals together. Peer issues, as we know, working with adolescents. Sometimes they just really don't get along. And SAO behavior, sexually acting out. Our primary team has kind of gone over a big shift at Bellevue. Our unit specifically looks different than the other ones, first and foremost because I'm the unit chief. I'm the first unit chief in the child and adolescent department at Bellevue in history, which is very fun. We have one supervising psychiatrist, where the other units usually have two. We have two psychiatric nurse practitioners, two social workers, two creative arts therapists, tours of individuals of behavioral health techs, nursing staff, psych technicians. We have interns. We have externs. We have fellows and adult residents. So we have quite a hodgepodge of folks there during the course of our time. For folks who have been on the inpatient unit, we are kind of talking about... Oh, I'm sorry. That slide, it looks a little bit messed up. We have two categories of behaviorally dysregulated, which are more of those furious. And then we have the emotion dysregulation. So behaviorally dysregulated folks can come in for a lot of different reasons. Psychosis, individuals who are coming off of substances, mania, low-functioning ASD. We're approaching that time of the year where it's like a really hot time on the inpatient unit, the summertime. If you think about the kids who are in school, they have adults looking after them. School ends, there's no one looking after them anymore. There's no structure and routine to their days. So usually it's when they really, really struggle. Individuals with uncontrolled ADHD or just actually misdiagnosed ADHD. Medical comorbidities, we see a fair share of them on the inpatient unit. Individuals with hand injuries, encephalitis. Also intellectual functioning is like a really big key and I think sometimes underappreciated aspect of psychological presentations that we try to always figure out. And then we have the emotion dysregulated, the DBT kids. I'm sure that everybody knows what I mean when I say that. Also folks who are engaging in non-suicidal self-injury and also those who have psychogenic, non-epileptic seizures, which I'll talk a little bit more towards the end of the presentation about how we go about managing those folks because it's a little bit different for everybody. Typically these kids are folks who are kind of more likely to be restrained, more likely to need emergent medications and also higher need for one-to-one staff supervision throughout the course of their time. So how do we treat both of them? So kind of going back to the tenets of CBT, I would say we're a very heavy B on the inpatient unit. This is our reward and point sheet. So every activity that a child does throughout the course of their time on Bellevue, they receive points. So for going to school, for going to groups, for attending their therapy sessions, actively participating, having a tidy room, they can earn points throughout the course of their time there. When I first started at Bellevue about four years ago, we just had daily rewards. So our daily rewards would be iPods in the middle of the day, iPods in the evening. Our unit was the fortunate one to be the COVID-specific unit, so we were just shut down and had all the COVID-positive, psychiatric kids on our unit. They were quite dysregulated. All the iPods got shattered. We replaced the iPods with headphones. All the headphones got shattered. We replaced them with handhelds. They all got shattered. So there was a problem. We had these rewards that the kids weren't earning. We had nothing. So they were earning these points that meant absolutely nothing. So what we did in conjunction with myself and the two creative arts therapists, we created a weekly reward system. So those points in which they earned throughout the course of the week, they can add up, get unit-specific things like stress balls, stress toys, T-shirts, little snacks, things of that nature. And actually, we noticed a pretty significant reduction, well, not only on the day in which they cash out, but also throughout the course of their stay there. Just adolescents love earning things. They really like getting those little prizes throughout the course of the time. There are certain things in which they have to be kept in their property bin. We have really nice tote bags, but we can't let them have the tote bags because we don't want it to be a choking hazard. Crayons, they can become very lovely graffiti there on our unit. So there's some things in which they can have during the course of the day, and then some things like at the end, like a skateboard. It can't be on the unit, not using their skateboard. So we found that was very, very helpful because the kids were motivated, earning their points, and actually those things meant something, and they add a lot of weight, and they would always be checking with the staff, like, why didn't I earn a three? I want to earn a three. So we noticed that there was a big uptick in some behavioral compliance during the course of their stay there. So kind of shifting more to the furious, so those folks who are a little bit more behaviorally dysregulated. I want to talk about one patient who really resonates in my mind when I think about how we go about managing that furious. It's a patient named Karen. She's a 15-year-old female. She was domiciled in a group home. She had multiple previous psychiatric hospitalizations. Her psychiatric diagnosis, we can kind of see sometimes in the inpatient units, like the whole DSM. So just kind of distill down to the main key factors. ADHD, ASD, their intellectual disability, their IQ was around 58, and they were also engaging in a lot of non-suicidal self-injury. Medical history was also notable for pre-diabetes as well, too. The reason in which they came to Bellevue is that they were endorsing a lot of suicidal ideation in the context of a peer conflict, saying that they were gonna cut and hurt themselves. Their medications upon admission, I will let the psychiatrist in the room take a look at those and think about them and critique them as you would like. So Karen had a little bit of an interesting treatment course going back to that idea of the do-not cohorts, so we didn't have any room availability for her. So she was placed on the child unit, which are typically those kids who are about five to 12. 15-year-old female was placed on there. She was specifically placed in one room, which was called the nursery, which was four beds, and they just gave her the nursery and thought that it would be okay. Took about three days for things to kind of hit the fan. She had what we call a behavioral response team where the responders come to restrain individuals. She had found a glass microwave plate. What was it doing on there? I don't know. She found it. She disrobed, she sliced herself. For all the responders who were coming on the unit, she was trying to choke them. If she couldn't get a hold of them, then she started choking herself. So she was then transferred over to our unit, which is a little bit more of an appropriate milieu, having adolescents and not being around five-year-olds. So the question was, how do we go about managing this behavior? For especially, we think about some of the things in which we're working against, the intellectual disability, the ASD. How do we go about thinking about how to get that behavioral compliance in a way that's very appropriate for this patient? So we used the course of visual aids. So we had a very specific behavior plan. I apologize for the photo. Very specific behavior plan for her. If you hit, if you choke yourself, if you disrobe, then quite simply, you're gonna be going to restraints. It's a safety issue. We wanna make sure that she maintains safety. So we had this on her, on her wall in her room. But yet, if you listen, you chill out, you follow directions, go to your room when you're asked to, you get to have music. You can go in the chill-out room and you can watch a movie. So again, we use a lot of visual aids with her because when we were just talking with her, it just wasn't really like hitting, but she really responded well to the visual aids. Also, as we found out through the course of time, you know, being from a group home, she wasn't getting a lot of visits from the group home representatives, nor meetings with her family. So she was very motivated by food. I know the pre-diabetes medical comorbidity, and we were giving McDonald's, sorry about that. But we had to grist to the mill to make sure we had the behavioral compliance. And as probably most folks know, working with adolescents, talkies. If your patient's asking for talkies, it's usually like a red herring for maybe some behavioral dysregulation. But always have them on deck for yourself. They're delicious, try them out. I think they're in the waiting room. They're lovely. Do you know what they are? I don't know what they are. Oh my God, all right. I should have brought talkies for everybody. So again, we had to think about what rewards are gonna get what we want. We're thinking about behavioral compliance here. So over the course of her treatment, she was restrained overall 28 times over approximately 40 days. Her PRN, yeah, I know. Her PRNs were mostly this mixture of the Haldol, the Ativan, and the Benadryl. So kind of the question is, why were there so many restraints? Some of it was attention-seeking. There were definitely staff members in which she really enjoyed and was completely in control. But when certain staff members went on, she would chase after them. And also, I think a part of it, thinking about the ASD core morbidity, I think there was something about the restraints that was kind of actually soothing at times for her. So we tried things like weighted blankets, which had some success, but also not necessarily what we were looking for overall. Her longest course going without a restraint was about six days. And also the question of, with any behavioral system in which we had, there's satiation by rewards. If somebody really likes coffee, I'm giving you a cup of coffee. That first cup of coffee is gonna hit. But after the 15th cup of coffee, you're not necessarily gonna feel as motivated as you did before. Unfortunately for her, due to the fact that she wasn't able to stabilize on the unit, she was referred to state hospital. And her medication's at discharge. You can kind of see that we did quite a few changes to her medication regimen over the course of her stay with us. For folks who maybe are a little bit, don't need as robust of a behavioral system, this is typically one of our kind of go-tos. We have a lot of kids who usually ask for behavioral rewards. And so we usually try to space them out throughout the course of the day so that they're not just waiting for one point throughout the course of the day. So usually around lunch, for this individual, for being safe, following directions, not assaulting anybody, not having any behavioral response teams, get a fidget reward at noon, get the headphones from six to seven, and video games in their room. One thing in which I've kind of noticed throughout the time of doing these things, especially for kids who are from the ACS pre-placement center next door, CPS, group homes, those visiting times are really, really rough on them when everyone else is getting a visit, but they're not. So we usually try to think about how we can go about sliding those rewards in during visiting times, because it'd be really distressing if you're seeing everybody else get a visit and you're not getting a visit. It's not the, it doesn't make you feel good. So changing gears, how do we manage the FAST, those emotionally dysregulated kids? So we're talking about those folks who are engaging in those non-suicidal, self-injurious behaviors, cunning behaviors, what have you. So one of our most intense interventions are group therapies. When I came to Bellevue to work as an attending psychologist, we only had two groups running, a group that was primarily focused on trauma and psychoeducation, and another group that was on substance use, which are, not to say, those are really great things, especially for Bellevue, we have a fair share of folks who come in with a trauma history, but they weren't really getting skills-based programming. So what we started implementing with some training was modular CBT groups, behavioral activation, especially during COVID. There were a lot of kids who were coming in really significantly depressed, not doing anything, so we would think about behavioral activation to kind of get them going. Cognitive restructuring, so kind of thinking about how we go about modifying those automatic thoughts. Anxiety management, we get a fair share of anxious folks in problem solving. And for DBT, which Dr. Thorderson will go into a little bit more in depth, really the big things in which we're looking at are distress tolerance and emotion regulation. So what's gonna help really, really fast, especially when we're at the height of emotion dysregulation, because we think about the kids who usually are an inpatient unit, they're going from zero to 100, they're not using their skills. And we also have a fair share about over-therapetized kids who come in who are very, almost bored by DBT and CBT. So we try to think about, okay, what's that one skill, if you were to walk away, what's something that's gonna help you in those moments in which you're really, really distressed? And also our two amazing creative arts therapists, Mr. Danny and Mr. Day, who are fantastic. They do a fair share of the load on the unit as well, too. For a clinical example, talking about more of the fast, more of the emotionally dysregulated, I wanna talk a little bit about Eric. So Eric is a 12-year-old Caucasian trans male. Their parents are divorced. They came with a psych history of MDD, OCD, and trauma, kind of more of an unspecified trauma. Their medical history wasn't really notable. They were brought in by their dad after endorsing suicide ideation, and once they endorsed that suicide ideation, scratched themselves pretty significantly on their face, pretty significantly on their arms, and the dad had to restrain them and then call EMS and bring them in. Their medication upon admission is there for your look, and their treatment course, when they were admitted, they were automatically put on the one-to-one supervision. Typically, we always ask the kids during that first initial intake, how are you feeling about your safety? Can you contract for safety? Would you be willing to come to a staff member if you're feeling unsafe? And for Eric, they were very ambivalent about coming to the staff. Wouldn't necessarily say that they would contract for safety on the unit, so that usually gets you one-to-one supervision, which is very aversive. You know, you have someone who's going either an arm's length or 10 feet away from you, and they're with you all the time, while you're sleeping, while you're in groups, while you're in school, can be quite aversive. So what was the most effective intervention for them? Ice. So ice is really, really kind of a key component in which we use on the unit, especially for those individuals who do engage in a lot of self-injurious behaviors. One thing that we've been starting to have on the unit with supervision is like ice masks. You know, if we think about the theoretical background behind like the tip skills, you know, going on your vagus nerve, that ice helping you to regulate. Also, just the kids really like holding the ice cubes, like where they were typically self-harm. For Eric specifically, we had to make sure they had gloves, just to kind of block their hands, and also like earning music. So if they were asking to take five, which is like a break, appropriately, they'd be able to go back and listen to music, and then after five minutes, would be able to re-engage in the activities. So it was a lot of really distraction-based skills for them to help bring them down in those moments. As we were getting closer to discharge, you know, Eric's disposition was to go to residential placement. In the interim, the parents really wanted to take them home. So what we did was also like a communication plan. You know, one of Eric's biggest barriers was to disclosing to their parents when they were feeling unsafe. So what we did with them is a little bit like a communication plan, so like a code would represent their safety level. They would have how they're feeling, what they can do for their coping skills, and also for like what the parents are doing. You know, I think sometimes in acute care settings, especially on the inpatient, like the parent component can sometimes be very underappreciated. Because sometimes parents do things which they think are really helpful, but can be invalidating to the child. So we want to think with them, you know, what can your parents do? Should they give you space? Should they not give you space? How long should they check in with you? You want them to check in with you. Should they be offering coping skills? Should they not be talking about school? Should they be, you know, just taking a walk with you? So sometimes it's a very helpful thing because parents just want that kind of like simple to-do in those moments. You know, especially for kids, you know, where they're not the most communicative or they're really struggling in those moments. So this is a little bit of like a clinical example, again, like how am I feeling? And it usually goes up in regards to emotion dysregulation. The skills get a little bit more kind of, a little bit more, they're definitely distraction-based, but a little bit more intense as they go along. And also like the parents' check-ins, usually towards the bottom of like, you know, when they're doing fine, parents can just kind of like sit back and chill. But as they get a little bit more dysregulated, a little bit more safety compromised, then we would notice that there's more check-ins going on or even like contacting their therapist if they can as well too. So Eric, you know, actually responded well to the Unipoint system, was very motivated by rewards, the goal of being off the one-to-one because they just wanted their own space. Very interesting, no episodes of restraint, no episodes of restraint, but also no episodes of self-harm while in the one-to-one, which is, you know, interesting. There's a disposition, again, was to go to residential treatment and their medications at discharge, you know, we just really bumped the searcher lane and added prazosin at night because they were endorsing a lot of nightmares. So that is what the psychiatrist did. So the one last component of the, more of the fast that I wanted to bring about, talking about today, was the psychogenic non-epileptic seizures activity, which is sometimes really kind of quite common on the units. I mean, it really takes a village. You know, what I'll say is that this is a behavioral plan that's enacted after the child has been medically cleared and has been diagnosed that this child is not having a real seizure activity because it's not only just the providers who are their primary team, but also the floor staff who has to really respond in a way that can be quite nerve-wracking because you're allowing someone to kind of writhe on the floor. And, you know, obviously everyone's concerned about any legal ramifications. So it's really a lot of psychoeducation for the staff to say, you know, this is not true seizure activity. Also, when we call pediatric airways, the medical staff gets really pissed at us. So we wanna think about the idea of like our most important resources as providers and as parents, you know, minimizing our attention when they're having that because our staff is very sweet. You know, usually when a child would be having a non-epileptic seizure, they're giving them hugs, they're rubbing their backs, they're giving them glasses of water, which is all very reinforcing, right? Because like, oh, I'm getting this attention. This is really lovely. So we have to pull back on that. And not in like a very, in a very caring way, not in a very cold way, and just kind of helping the individual talk through them. You know, you're safe. When you're ready, I'm here to talk to you. And just kind of like taking a step back and hopefully they'll be re-engaging. And just reminding, you know, just to praise those moments in which there is compliance. You know, we do a really good job of giving attention when things are maybe negative. So just using our attention to praise when they're being safe, when they're engaging. And for giving the attention for safe behavior rather than the behaviors we don't wanna see. So this is my contact information. If anybody has any questions, anything, I'd be more than happy to consult about anything. So I wanna thank everybody very much for your time. I'm gonna change gears. I'm gonna give it over to Dr. Storteson. This is, you know, so we've been out for a little bit over a half hour. Probably a good thing at this point to, are there any questions at this point? I have a couple of questions for Dr. Sullivan. Oh sure, of course. No, maybe that'll break the ice for everybody. So, who all are the staff on your unit? Like during just like the course of like one. One day. Yeah, one day. So like the behavioral techs and the PSAs, they're on tours. So usually it's about three nurses. Usually about four, maybe five staff members depending on how many one-to-ones we have. And then it's myself, the psychiatrist, the two social workers, the creative arts therapist. So usually that's us. Any trainee that's rotating on the unit throughout the course of the day. So it's pretty large during the course of the day and definitely dwindles like after 5 p.m. when everybody goes. And during the day, what's the staff to patient ratio? The staff to patient ratio? I would say, depending on the sentences, I would probably say it might be two-to-one, two staff for every one patient. Two staff to every one patient. And is this breaking, oh great. That's exactly what I wanted. Oh my. And thanks for going to the microphone. Appreciate it. Hi, my name is Tori. I am a rising M4 at VCOM Louisiana. And so from a trainee standpoint, I guess my question is, as I continue to go through training and sometimes we're in institutions or facilities that are under-resourced who may not have all of these different therapy units or different sectors, how do you think that we can maybe create a treatment plan with our resources but also to the best benefit for our patients? That's a really great question. I think in regards to the treatment plan and in regards to patient care, I always kind of harken back to the idea of some therapy is better than no therapy. So even if you can give a patient 10 or 15 minutes, sometimes that's extremely powerful, especially for a lot of, we think about the idea of milieu work, and we have some kids who can't tolerate being in our groups. Like we have one patient right now, very low-functioning ASD, very sexually explicit with all the peers, but we all kind of try to figure out how we can each go and just spend 10 minutes with him or even just pace up and down the hall with him, which is getting our steps in. So trying to figure out the treatment plan, even if from a therapeutic standpoint, even just spending that 10 or 15 minutes is better than nothing. Because for a lot of kids, definitely there's a spectrum of how much therapy they've had. We have kids who have been in comprehensive DBT programs, partial programs, they've gotten so much therapy, and then you have those really naive folks who've never been across from a provider, maybe outside of maybe a school counselor before. So even just as much time as you can spend, especially when you're busy and you probably have several patients that you need to see throughout the course of the day, just trying to find those windows, too. And especially if you do have group therapies, you know, that can sometimes be like the longer reach, you know, and having so many people in one group, like focusing in on like one skill, sometimes that can also be one way to kind of get more bang for your buck in that regard. Especially like during COVID, when it was just myself, one psychiatrist, one social worker, we just really did a lot of groups because we were kind of spread thin. And so we would just have them, everyone's in proper PPE and what have you, but we would have more group programming to kind of get a longer reach rather than just like individual skills, if that makes sense. Yes. And could you go to the... I have two questions here. Oh, yeah, sure. Oh, you've already got it. Hi, thanks for the talk. I'm almost on the flip side of that. In an ideal world, what kind of skills do you really think would make a difference? I feel like sometimes we're limited and we have to stick to a certain set of checkboxes, but like big sky, right? What kind of skills do you think would be helpful? From my experience, like 100% like tip skills and from DBT, like a lot of distress tolerance, you know, especially in like acute care settings, you know, I think it can sometimes be really hard to dive deep, you know, into maybe like trauma or like what kind of, you know, maybe it's an issue that brought them into the inpatient unit. So I think like accept skills, tip skills, you know, the improved skills, behavioral activation, you know, for the folks who are more depressed, I would probably say those like distress tolerance and emotional regulation skills from DBT. I've noticed have like more of the bang for the buck in the setting rather than maybe like a cognitive restructuring. I probably would say cognitive restructuring is maybe like towards the lower end of like need from what I've experienced, but usually those DBT skills I would say is like probably my number one like priority. And how many people are familiar with, Dr. Sullivan keeps using the term tip skills. Show of hands, how many people know what they are? So probably less. Yeah, so it's temperature. So like using ice or like, you know, Dr. Thornton doesn't brag at Golden Horns. So like using temperature to like help regulate emotions, intense physical exercise, progressive muscle relaxation and pace breathing. So they're basically like skills that are for like that tippy top of emotion dysregulation to help kind of swing them down because I think one, you know, one thing that I've noticed is that sometimes kids get into like, well, I did my temperature, but I still feel like crap. It's like, yes, I get that. But you want to like stack your skills. So it's always going to take more than just one. And so I think kind of starting at the top of the emotion dysregulation and then trying to work your way down is probably what I've noticed to be the most effective. And let me just do a quick commercial here for Dr. Thornton that for those of you who don't know what tip skills are and want to know what they are and see how they're done, are your videos freely available now? They are free. They're on a Google drive. So I would have to send a link, which I'm happy to do. And if anybody has an Apple device, I can airdrop videos at the conclusion of my talk. That would, just as a commercial, I took the one of those videos and put it embedded in my class. And they paid much more attention to her video than they did to mine. They're not to be missed because she demonstrates all four tip skill, the temperature, the intense exercise, the progressive muscle relaxation, the paced breathing in fairly good detail. So again, for those of you who want to know more about it, that's what I would suggest. Are there other things that either one of you would suggest for the tip skills to learn them? No, I mean, I think there's a fair amount of information out there for the tip skill in particular. And I think one of the things that really gets a lot of buy-in from kids and families is the way that each of the tip skills, so the TI, the P and the P, they're all targeting parasympathetic nervous systems without having to access logic or reasoning or understanding anything. So these are four different buttons that exist in our brain that can be going and touched to calm down that acute emotion dysregulation. So when you get a kid who comes back and they're like, oh, it doesn't work. And you're like, it literally works because you have a mammal brain. And so let's talk about what's not going well or how you're not doing it as effectively as you possibly could to get the bang for your buck. And they're very concrete and easy to practice together. The video library came from when COVID shut the world down, we created a bunch of videos for skills learning. So it's me standing in my living room, doing my COVID thing. And again, just as a documentation thing for this is that there's brand new research saying these videos are not only effective, but actually really embraced by these kids in distress. Because if they're on video, they can access them 24 seven. So they could do a tip skill at 1 a.m., right? And they don't need to call in or something like that. All right. Okay, so I'm gonna take us in a slightly different direction and really focus on the use of DBT and applying it into an intensive outpatient or IOP setting and then what the successes are and why this is a brilliant idea for you to go out into the world and champion. We are, I think probably anybody in this room who works with kids, we are continuing to experience what some people have called a second pandemic in that the children are not okay, right? And this has been devastatingly documented since late 2020 and the numbers do not improve. Kids are more suicidal, experiencing higher rates of mental health conditions and are just simply more acute. Whatever the flavor of their specific mental health condition, we are just noticing significantly higher levels of acuity. So yay, there's a lot of money out there in our areas that hasn't necessarily been there before. So there's, I guess, a silver lining there. And there's also motivation to build more of these high-intensity approaches so that we can really essentially get some great momentum going with the pathology that the kids are experiencing. And that's what an intensive outpatient really is intended to do. So at an IOP level of care, the goal is to have the child as involved in their natural ecosystems as possible while also getting the most amount of therapeutic support possible so that they can continue to persist. One of the things that's so helpful about this model is that it is a lot easier to generalize the skills that you're learning. When you do inpatient level of care, the kids can demonstrate gains over time, they're in a protected bubble. So they are completely removed from those natural ecosystems. And so the IOP kind of helps provide that step-down transition or divert from an acute hospitalization. So we are teaching them a lot of stuff for about three hours, and then we're sending them back out into the world and like, go do that thing, I'll see you tomorrow. So there's a lot of opportunity for reinforcement of the learning that they're doing in the therapeutic setting. What an IOP looks like varies pretty widely based on institution as well as state of practice because payers vary their minimums and maximums depending on the state you live in. Because that's obviously how we determine treatment benefits, of course. Most commonly, they're about nine to 12 hours. And thinking that this is a billing code that requires three hours, you're thinking like three to four days of treatment a week on average. In an IOP, you need to have group, you need to have some individual, you need to have, for kids, some component of family. But there's not a lot of restrictions around what that looks like. And we love insurance companies who give us very clear definitions of why a kid needs an IOP. And so that is psychopathology that cannot be managed at an outpatient level of care, which is not equally agreed upon depending on which provider you're talking to. Okay. IOP is billed in a day rate, similar to an inpatient code. And one of the things that I think is really helpful for those of us who wanna go out there and lead programs, build new programs, improve access to care, is that IOPs make money. And people who are in positions in power of organizations are like, oh, really? Mental health is something that makes good money? This is fantastic, right? So they don't just make good clinical sense, they also make good business sense. They have to have a medical director on record, and so psychiatry is naturally gonna be tasked to be that medical director. And so you can practice or bill an IOP on a hospital license or off a hospital license. And then that changes the way that medical services or psychiatry services are billed, whether it's included or not. That's some technicalities that you can learn down the line if you're interested. IOP teams are really similar to inpatient teams in the sense that they are very diverse in the population of providers, or the people that are on that team. So you've got a psychiatrist that's required, you've got maybe a psychologist or maybe just master's level providers, like social workers, LMFTs, or LPCCs. Usually, expressive therapies of some sort are included, especially with kids. So if you put kids in a room and try to do nonstop therapy without breaks for three hours, you are going to manifest emotion and behavioral dysregulation, right? So we try to vary the ways that we're getting them to learn and practice these skills, and expressive therapies are fantastic because they're nonverbal ways of applying and learning the skills that they've been doing. Depending on the type of IOP, so the IOP that I practice in specifically targets suicidal behaviors and self-injurious behaviors. But there are IOPs for eating disorders, substance use, OCD. So depending on what it is that your treatment is targeting, you're gonna maybe have nursing involved, nutrition involved, spiritual care can be involved. The most important thing, actually I'll table that. So people in training can also be involved. And when we think about business or fiscal responsibility while also thinking about growing our workforces, right? Because our workforces are not big enough to meet the needs of our population right now. And so when you can include people in training, yes, this is a high acuity of patients, and it's almost exclusively done in group settings. So you can train people up really quickly to be doing high value work with high risk people with not a lot of investment because you're just doing what you would be doing anyways. So it is a way that we have doubled the size of our team without having to double the size of our budget to pay for all of the staffing. While also increasing the referral sources we have in our community, because now I have, whether they stayed at our hospital or not, I've got at least a dozen people out in my county that I can say, hey, go see that person. I know they're gonna do a good job and they're gonna know what we're doing over here too. I know a lot of people are afraid of giving people in training, like lots of responsibility or exposing them to too much risk. And it is, I'm gonna say it's invalid, but that's not very fair of me. There are ways to do this that are very effective. And now we get to kind of the crux of the problem here, right, because IOPs, this isn't new, IOPs exist everywhere. But IOPs and PHPs, but I'm gonna focus exclusively on IOPs, there's not like well-established research about the ways that we apply the fabulous treatments that we have from the RCTs into these novel settings. And because they're often designed by people with business backgrounds, then you get these like, oh, hey, let's do a Google search and like CBT, you know, DBT and like, oh, ACT. These are some things that work well with kids. Let's go do some treatment, go do those things, right? So you don't have a cohesive clinical model and you get people who are just kind of like throwing spaghetti at the wall, they're not well-trained and then it's like, just go do what you think these kids need. So when you can kind of think about, okay, we need to find programs or build programs that have a cohesive treatment approach so that every minute from the moment they walk through that door is an intervention, right? So it's almost like you're creating a microcosm of like an inpatient milieu that is completely safe and protected and you can start billing, right, from the moment that kid walks through the door and everybody's on the same page. Everybody's intervening with the same philosophy, the same prompting, the same skills, the same mindset. It is intensive treatment, even though it is like two months you tell a teen they're gonna be in treatment for two months, like so the rest of my life, right? And it goes by in the blink of an eye. So it's still short-term treatment. So we are not looking at processing traumas or unpacking really gnarly family dynamics. We are stabilizing the emotional and behavioral dysregulation to be able to discharge them to the next level of care where they can do that long-term work. So our goal is not to seek remission, is not to cure people, it is to stabilize and get them this really great set of skills foundation so that they can go and do the harder dysregulating work and still be safe at an outpatient level of care. So to do faithful DBT, DBT has been criticized a lot because it's like, hey, that's a fantastic treatment program that requires a high investment of services, right? And so when we're talking about systems that don't have a ton of resources and are not rich in the sense of their resources, that we get a lot of pushback of like, you want me to do what? And the only way to really achieve training is through this like $10,000 thing. That doesn't make sense for us. So DBT has really been working, like the field of DBT, if you will, has really been working at saying, how do we stop putting up all these barriers to what we know is very good care? And we still need to remain faithful to the model. So to do real DBT, you need to have group skills training. Cool, most of IOP is in a group. You need to have some kind of individual therapy. Awesome, insurance requires that too. You need to have a consult team, which is a non, well, actually there are some insurances that will pay for this, but a consult team is a place where everybody who's involved in treating these patients comes together and talks about how are things going, right? So not just like rounds where we discuss the patient's progress, but how are we doing as providers? Because this is hard work and it burns us out. And if we're not actually paying attention to the ways that we're being reinforced and caring for ourselves, we are less good at our jobs. And it's a little hard to sell to organizations to say, hey, I'm gonna take an hour or two hours of time where we are not seeing patients and we're just talking about how everybody on the team is doing, and it causes tremendous improvements in things like burnout and team cohesion. Because every week, once a week, we are sitting down together and we are connecting and making sure we're all okay. And if you're not okay, we're gonna hold each other accountable. So if you show up to this meeting and you're like, oh, I'm great, and someone else is like, that's your fifth cup of coffee, you are not great today, right? And so we're gonna be held accountable for those kinds of things. To then we go out and it turns out when we take care of ourselves, we do really great work. We are our best versions of ourselves. And so that's what a consult team is, it's required. And then phone coaching is the generalization of skills across settings, which this is the one thing that probably everybody tries to leave out because this means that patients have access to some of their clinical providers outside of scheduled business hours. And that sounds terrifying to most people. And phone coaching is so powerfully reinforcing. First of all, they reach out and they say, hey, I need help, we did a thing today, but I can't remember it, I need to go ask my mom if I can go to this party tomorrow night. And instead of waiting until the next day, because what kind of impulse control do children and teens have? It's about this big, and especially the kids we're treating. So they're not gonna wait to ask you tomorrow, they're gonna go and try and ask their parents and then do the normal maladaptive behavior pattern that emerges in that cycle. Instead, they can hit you up and say, hey, remind me again how to ask for things in an effective way. And then most of the interventions should be 15 minutes or less. And on the data we've collected for our phone coaching on our team, they hover between five and seven minutes. People are worried that it's gonna really ruin their nighttime hours, their wind down time. We've had, in the course of five years, I think two calls after midnight. And those are calls you want, honestly, right? Those are the things that, yeah, two calls in five years after midnight, I will take that. By and large, they come in while the kids are at school, so between 12 and two in particular, so like lunchtime hours or right after. And then also in the one or two hours after school that they're not coming to program. So that's when we're all working anyways. So it's not that big of a deal to take a very quick message and respond to a need for a kid. Then they can also give you good news and say, hey, I did a skill and it really worked. That's reinforcing for us as well. And so the vast majority of kids and teens use it incredibly effectively for very brief moments in time and they're doing things that are gonna be a lot more helpful and they help us do our job better. It's not to replace crisis services. This doesn't mean I'm on call and I'm gonna get back to you the second you text me 24-7, but it is an incredibly useful intervention. So we took the 16-week DBT treatment manual that is designed to be led and then repeated. So a lot of kids do DBT for about six to 12 months if they're doing the standard treatment package. We took 16 weeks and we smooshed it all into eight weeks. And what we did was we made sure that we were gonna take advantage of the fact that we had them for three hours and we were gonna make them do everything that we were teaching. So you give kids and teens just enough information that they know what they're supposed to do and then you're like, now go do it. And you're gonna do it right now. Which means that we also stress our kids out fairly often because we need to see that emotion dysregulation. I don't want panic attacks all day every day and I need to see you getting a little frustrated, getting a little anxious, getting a little sad. Because then, right in that moment, the kids can do the things they need to do and they gain relief and there is nothing more potent than that experiential learning. That saying, oh holy cow, this thing that everybody's been telling me, it works. We do have individual, we stretch our group time by 15 minutes and that makes sure that we don't have to actually be like, oh you got here 10 minutes late so now we have to do something to not be doing like insurance fraud, right? And billing for 170 minutes when I have to have 180. And then everyone on the team is trained in DBT or even if they're not trained in DBT, they're in all of our meetings. So they're hearing the lingo, they're exposed to all these things. Which again, makes our entire job easier. Insurance authorizations are done by non-clinical folks. Concurrent reviews are done by non-clinical folks. We have less than five peer-to-peer calls a year authorizing IOPs because this stuff is really easy to learn. That's what makes it a really great treatment approach so that our administrative folks, the people who are answering the phones when people call in, they can say two or three things about the program and the clinical quality and then parents can understand it and then they're excited to come and then the kids are excited to come, which is really weird, right? Like kids excited to come to three hours of therapy after a whole day of school, that is actually pretty unusual. But I think because we are so cohesive, it really makes it seem like, wow, everybody on this team is bought into this and then when I go see my psychiatrist and I'm like, oh, well, IOP's fine and then your psychiatrist is saying, okay, so what skills are you using? And then the kid is like, wait, I have to tell you things you know? And so then same thing, they check in and they look really shaky and our admin folks don't know the skills necessarily, but they know if that kid looks not okay, they say, hey, what skill can you use right now? You look like you're not okay. Now, they're also gonna message us on the side, like, hey, get out of here, you got a kid who's like about to freak out and that kid is already getting those prompts, those cues from the entire environment to be using the treatment that they are learning. So what a typical day looks like for us is we have check-in procedures, right? So they're doing those diary cards, which are a wealth of data for, again, our whole treatment team. If you haven't seen a diary card, they're basically rating their suicidal ideation and behaviors, non-suicidal self-injury, urges and behaviors, if they're using substances, if they're attending school, if they're taking their meds, the intensity of the emotions they've experienced all day and then what skills have they practiced. So every single day, they're being cued to be paying attention to the things that we know, if they know, they're gonna do better at therapy with, right? So they're doing that diary card, they're giving us an emotion rating, so we are making them focus on or doing these mini emotional exposures constantly. So every day, they're doing it at least three times where they're saying, how am I feeling right now? Every one of our providers, if they pull out a kid, our psychiatrists, our master's level clinicians, everybody says, okay, give me an emotion rating because that's gonna be the cue to help you better understand what you need and then me also to better understand what you need. We do mindfulness, we do a skills group, we have our break, we take the kids for walks around the neighborhood. The first time I told our risk management officer that we were gonna take a group of suicidal kids walking through the neighborhood, we work right off of a freeway, she looked at me and she was like, I know you're joking. And then I told her, look, if they're at an IOP level of care, I don't need to be afraid that they're gonna jump out onto the freeway. That's not my level of care. That's Dr. Sullivan over there, right? And if that's what we're worried about, then we're not doing good treatment. We need to send them to the appropriate treatment where they are. And so why would I wanna take them for a walk? Well, first of all, we had to give the rooms like a break of air, this all started during COVID and we had to do cleaning procedures, but also what happens when you take kids for walks? What happens to their mood? Oh, wow, they feel better. It's weird. They say, I don't have any energy to walk. And we say, great, that means you definitely need to walk today. And then we take energy or mood ratings throughout the course of the walk. And by the end, they're like, well, I don't know if it was the walk, it's just, you know, I was so excited to be done with it or something like that. And who cares? Whatever their words are saying, they're getting that lived experience that like, wow, when I get up and move my body, even when I feel terrible, I actually end up feeling better at the end of it. We feed them because hangry teens are not fun to be around. And we wanna teach them that that's an important vulnerability to be addressing. We also let them have that unstructured socializing often. And this is kind of that milieu approach, but it doesn't mean that they get to talk about anything they want or whenever they want or however they want. It means that all of the people who are on the team who are paid associates or trainees, that they are gonna step in and say, we're not gonna talk about that here. And it's just these little tiny prompts to redirect the kids. Sometimes it requires lots of them. And we're still shaping that behavior of, hey, how do you effectively socialize with other kids? And it is very effective. And then we wrap up with art therapy. The art therapy is done completely cohesively with DBT. So there are some skills that we only teach in art because they're gonna learn them there and then practice them there. You don't need a separate skills group. This is just a skills group that happens to have art in it, right? So really maintaining that cohesion of the clinical approach. And it works, right? There are lots of successes. So our clinical outcomes have demonstrated medium to large effect sizes both on overall distress as well as critical item subscales. This is for both teen and parent report. More complicated statistical analysis has revealed that we actually are getting very meaningful results within the first four weeks of treatment and they keep getting better after the next four weeks of treatment. So there's a great argument when we're working with our payers to say, no, you really do wanna authorize the entire dose of treatment because this is gonna really help save money for you. One IOP program, so that's 32 visits for us, costs the same as a three-day inpatient stay. And that's assuming that kid is only there for the legal hold. So financially it makes sense for a lot of different stakeholders involved to make sure that they are investing in these higher levels of care. And then we also have large reductions in the subscales of the areas or domains that all the things that we're treating with DBT are hoping to improve. So emotion dysregulation, interpersonal conflict, confusion about identity and impulsivity. So holy cow, treatment works and in such a short period of time. I presented a poster on some of the statistical data last year and people were like, wait, this treatment that we usually take six to 12 months with works in four to eight weeks? Wow, right? Super fun. Revenue generation, as I said, we make great money. The first year was a little wonky because of the way that our system does billing and insurances like to take three to six months to pay things. But once you hit that first 12 months, our administrators were very, very happy with our program. And that is with a facility that does not discharge our kids even if we get insurance denials. So if insurance says, well, they haven't attempted suicide in the past 24 hours, so they can probably go to outpatient. And we say, cool, we do our denials and appeals, they don't always work, but our system does not then discharge. Sorry, insurance said this. And we are still making good money, right? We are also thoughtful about the way that we do admissions. So if we've got two kids who are, we're having a hard time wrangling something like substance use in our milieu, we're gonna table a kid who's at medium risk to wait a couple weeks so that we can get these kids in order because otherwise your entire milieu is contaminated. And now these kids are doing that thing where they learn the unhealthy things from each other. So we're making our best clinical choices and we are still making a lot of money. It can be done, right? And we are a really, really robust training clinic. So we have psychology externs, interns, and postdoctoral fellows. We have pediatrics residents who rotate through our clinic for two to four weeks each year. We have psychiatry fellows who come through. Our admin teams come and sit and shadow our program so that they can be better at talking to the people who are calling from the community. And we have a scaffolded training model. So this is all done in group anyways. So the first round, you watch me do it and then I'll watch you do it until I say, okay, cool, you're good to go. And you're never alone anyways because it's this really heavy team-based approach. So essentially, IOPs are super doable and having that cohesive approach is vital because I think that's one of the things that we hear time and again from our patient population and their parents is they have had so much exposure to therapy and this is the first time they're getting a full evidence-based treatment package that is just one approach, right? DBT is a great fit because it's concrete, it's easy to learn, and kids get benefit quickly. And it's an awesome opportunity for training. BehavioralTech.org is one of the best training resources. So they've got connections to, you have to pay for them, but videos and other training programs. But they also have lists of research trials, diagnoses and age groups and different cultural identities that DBT is evidence-based for. So if you're interested in learning more, you can check out that website and then I can also airdrop anybody who wants my slightly embarrassing Google Drive videos. But that is all for me. So I'm concluding our panel. So I'll take questions, but I will also open it up for our whole panel. Thank you. Yes, thank you all. Super helpful presentation. I was hoping you could talk a little bit more about the experiential experiences after you teach the DBT skills. That would be So for example, I'll pick an art group because sometimes I think people don't believe me when I say art can be done like theoretically cohesively. So the module skills distress tolerance is something that we've been talking about. So those are the skills you use when your emotions get super loud or when life just super sucks, right? And so we have the kids fold origami projects for the first five minutes. First of all, origami is really hard. So they start with their origami project and then after about five minutes some of the kids have already gotten too frustrated and so we pause and have them engage in one of those skills to bring that emotion down and then as soon as it does come down they have to go back to building their frog. And then we say, okay cool, now you have to put your dominant hand in the air and sit on it. So you have one hand to then continue working on your origami project to evoke that distress and then pause and then they have other pieces of paper that they can take and tear up. We put like a beach picture on the screen so that they can use an imagery skill and just kind of envision that they're in this beautiful beach and not in this stupid origami project. And then we also say you can ask for help, but you need to ask us. So we're not going to come and rescue you. You need to adaptively seek support. So that would be one example. Sir? Yeah, good afternoon. Thank you for your presentations. My name is Bill Arroyo and I'm from the Los Angeles area. First couple things relate to the services at CHOC and I was curious if you do drug testing for those youth who come from home for their care. Number one. Number two, I have a concern about accommodating insurances and curbing what is a proven 16-week intervention curbing it to eight weeks. What happens if the insurance carrier in two months says, you know, eight weeks or six weeks is too low. We'll approve two weeks. Will you consider contracting the 16-week proven intervention to two weeks? You know, it's a very slippery slope from my perspective, and I guess I also would like to see any related published data that the eight-week is as good as a 16-week DBT. Yeah, so quickly on the substance drug testing. So we do not do drug testing standard. So drug testing, a lot of our kids will own up to that. Most of them smoke weed. Yay. But we, there isn't evidence that substance use testing actually prevents or is therapeutic in any way, shape, or form. So if a kid comes and they seem intoxicated and we say, hey, you look intoxicated and they're like, no, I'm not. It's like, great, then we're gonna test you. And then they can kind of figure that out. And we have standing orders in the chart and can walk them down to the urgent care if we need to. We just don't often need to. So we don't do drug testing as a regular thing. We can cheat a little bit in the sense that about half of our kids come from within our own system. So the emergency department and the inpatient center do do tox screenings. And it hasn't shown to be any different for those kids that we know who have been using versus the kids who we don't know have been using. And then for the the model of care, so we didn't pick eight weeks based on the insurance. We took the 16 week and given the fact that they are getting about 13 hours of treatment a week, we kind of reconfigured rather than 90 minutes of treatment a week for 16 weeks. They're getting 180 times, anyways, math, right? 180 for four days a week. So it's, they're not losing anything in the treatment. What they're losing is the spacing of the information. And so what we think is, and our data seems to be supporting it, is that we balance the spacing that helps with learning with the experiential components. So it's the experience that's heightening and really making that learning possible in that shortened period of time. And then I'm sure our phone coaching also helps to to generalize some of those things as well. Can you talk a little bit about the phone, for people who may not be familiar with DBT, could you say a little bit more about the phone coaching? Yeah, so phone coaching, so as I mentioned, access to clinicians outside of scheduled clinic hours. And so that could be texts or phone calls. And this is done differently by each clinic. So some clinics say you have a cutoff at 10. Some clinics say it can only be texting. The way that our consent is, is that we are not guaranteed to respond, and we probably will. So it's reliable expectation. And we will take texts, phone calls. I've had kids FaceTime me. And our consent does say that this interaction may and may not be HIPAA compliant, and the parents are consenting and aware of that. I had to do all these focus groups with parents, and they were like, why do you think we care if it's HIPAA compliant? Please help our children, right? So it's interesting the way we think about things from a systems versus, you know, the people that we're serving and the way they think about those things. If I may just follow up, so I'm aware of one study that relates directly to contingency management program for youth who use cannabis, who use a lot of cannabis. So that's one thing. The other thing is that in California, and I'm saying this because I advise the state on the Medicaid plan for California. And I'm involved also more directly with the Children's Medicaid plan in California as an advisor to the state. And that is that there is a new contingency management program that is primarily targeting stimulants, so meth and other stimulants, that was instituted sometime in the past year. That program is under the auspices of every county's behavioral health division of their county government, so just FYI. I'm going to take advantage right now. Our state insurances will not pay for an IOP level of care, so if you have their ear and want to plug, hey, IOPs can be helpful, it would be super appreciative. Great talks. So I'm Jamal. I work at Penn State Hershey's eating disorder partial hospitalization program. I started as a program director there a few years ago. It was an existing kind of eclectic PHP, and I was really interested in bringing an exposure-oriented cognitive behavioral therapy model. And I ran into a few speed bumps with trying to come in with all these ideas for the staff who were already working in kind of this eclectic program. It's gotten better over the years, but I still think there's ways for me to figure out how to be more effective at increasing that cohesion. I'm just curious to see if any of you had any similar issues. I don't know if you've built these programs from the ground up, so everybody was already on board, or if you had similar struggles with trying to bring in a model that was maybe incompatible with the way that staff were already operating, and if that created issues, and how you address that. Go ahead. I'm, oh, you go ahead, then I'll go ahead. I'm sure. I mean, I think this is a very common issue at Bellevue, because like our staff, they're actually frankly just not trained. They are hired, they're given these roles, like they're trained in restraints, they're trained in, you know, just kind of doing their Q15s on their little iPhones, but we do a lot of in-services. So about once a month, we'll do an in-service about working with individuals who have eating disorders, you know, because a lot of things can get misconceptualized, kids just being very oppositional. It's like, no, they're like profoundly depressed, they're having trauma triggers. So we do at least like once monthly in-services for, I guess, the disorder du jour, whatever's going on in the unit, and some will come, you know, just like anything, you know, some folks are more interested than others, but definitely that is something that is a whiz. I feel like I'm beating the drum to try to get more training there. Jamal, I have passing knowledge of the culture at Penn State, that you're hitting on really one of the core things that is sort of the leitmotif of all of what everyone is saying is in order for these programs to really be robust and effective, you have to have staff on board who are of the same mind. Otherwise, the program and the patients themselves gets fragmented. So one of the things that I learned way back when from Dr. Fidelio and have been doing when I've been in these situations is to build in both a didactic and an experiential component to the staff training, to where they can share their reservations and, you know, arguments or whatever about that, and that we really kind of work through the, again, any exposures to their new paradigm. And sometimes that takes a long time. And then what the hard part of that is, is what do you do if people are intractable, right? Then it becomes an issue of how do you manage that? Do they still have a place on that unit, or does the integrity of the unit take priority? And that becomes an issue. But you're hitting right on it is that it's good if you go on into an existing program and everybody's on board. With a startup, you have to train everybody up on the ground floor, shift paradigms perhaps, and that's not an easy task. It's a slog, just to be honest. Is there a question in the back? Go ahead. Yeah, I had a couple of questions. So one question was around keeping therapists that are trained at DVT, an outpatient program that's a big challenge, both burnout and private pay, so I had a question about that. The other question is related to burnout, and I'm around that as burnout because I feel like maybe IOP could be less burnout, just talking about your experiences with that. Another question is how you interact with, once they leave the program, do you guys continue to offer individuals in DVT? Maybe I missed how you talked about how you do therapy in this program, but I'm curious about that and how it works once you leave the program, if there's any interaction. So burnout, getting really great training in DVT and then being able to leave and charge a very beautiful amount of money for private practice is definitely something that we have heard a lot in when we were collaborating with other hospitals about IOPs. Some people, there are different ways of going about it, so you can hire all part-time clinicians who then already have their private practice, so that you're saying, look, we'll bring you in, we'll do the training to make your other thing more lucrative, and my experience with those hospitals was they just had kind of written off their staff, was that they were already assuming that they were going to leave. Another hospital I worked for had a contract, so if you got invested in for the DVT training, you owed a year or two of service, otherwise you had to pay back the cost of the training. While my sample size is very small, so it's just the six people on my team, I wonder how much of that becomes a self-fulfilling prophecy, that when we anticipate someone's going to leave because they could make more money elsewhere, so we treat them like they're going to leave, which, I mean, then they leave, but we don't have any of those contracts, we give a lot of flexibility to our clinicians, and because we generate the revenue from program, we don't then also say, so you need an outpatient caseload for the first half of your day, so that people are running from individual into the program, but they can actually spend that time doing our evals, our notes, documentation, all the different things, supervision for all of our training needs, but then their main focus is that clinical program, and so we've had one person leave in five years, and people are excited to be with us, so I think there may be some selection bias, and you're looking for people who want to be on a team, and that may be one of those things, and figuring out how do you, like, invest in people, make them feel invested in, and I will say, consult team is a game-changer, and our administrative folks, because they're not clinicians, have the option to attend consult team, and they all do, so these are non-clinical people who adore getting a chance to sit down and hear from each other how we're doing, and just because they're not clinicians doesn't mean they don't have to talk about how they're coping with their days, so they're accountable for saying, okay, well, here's what I'm doing, and I think that that can help with that, like, fidelity issue of, if we're going to sit down and talk, I don't, yeah, you don't have to do these skills outside of here, but you need to use the language, you need to be held accountable for the way that you're coping, like, practice what you preach, basically, and then it kind of infuses back into that milieu and the clinical approach, so that's the burnout one, I forgot, yeah, our system, our hospital is relatively new on the mental health side, which I think is kind of a weird way of saying that, so we've had psychiatry and psychology forever, but only in the context of medical conditions, and so our program is one of the newest, like, just mental health things, and they chose to invest on the acute end of the spectrum, rather than on the lower end of the spectrum, so we have now an inpatient center, and then an IOP, and we have an emergency department psychiatric triage team, and we're going to continue building out IOPs and PHBs, rather than having that discharge. I have written a proposal to get an outpatient DVT clinic, so that we could then hand them off into individual within our system, and it is not currently being spotlit for funding, so it is hard, for sure. Do you hand off to individual DVT therapists, or just whatever individual therapists you find? I didn't catch that. Could you say it a little, could you say it a little louder? Do you hand off to DVT therapists, or just whatever therapists that you had before, or whatever you find? Yeah, we have maybe six or seven regional clinics that do really good care that we'll hand off to, but we kind of have to be thoughtful about, can the family pay for those clinics, and then some of them have, you know, nine-month wait lists, which seems a little counterintuitive to some degree, so we hand off to people who are willing to see high-risk kids. We try to find behaviorally-based treatments, too, so that they're at least getting skills, but it's definitely a deficit. And in regard to the inpatient side of things, at Bellevue, like, we have a partial hospital program. We have our outpatient clinic, which has turned into more of a high-risk outpatient clinic, and we're actually trying to get an IOP instilled at Bellevue as well, too, so that there is more of a continuum of services, but I think similarly to what Dr. Thorderson was mentioning, you know, just there's such a significant barrier for folks who just don't have resources, especially for our folks who come from, on the inpatient side of things, CPS, ACS. They're really just mostly going to a lot of teletherapy, to be quite honest, because they're on these long wait lists for our DVT programs when they ideally could use them, but we also try to be very mindful about the spots in which we have for our partial hospital programs. If families can't afford, you know, a robust DVT program, we would ideally refer them out to that and save our spots for the folks who are maybe Medicaid-based and what have you. I think somebody in the back, and then in front. Hi there. My name is Wolf Klotz. I'm a psychiatrist down in San Diego with the Navy. A little bit of an older population, but maybe you're 16-ish-year-olds at the start of the pandemic who now are junior Marines and have the advantage of having automatic weapon and high explosives, so that makes it fun. I'm definitely not as staffed up as you guys are, but the DVT skills instruction and kind of milieu setting of having a company like that is actually something that translates, I think, really well. What I was hoping you might be able to address is given some do's and don'ts or some anecdotes about things that you're encouraging, the peer-to-peer kind of teaching, skills development, boundaries there for what you're entrusting kids to teach each other or what to start to pull back and make sure you're getting oversight on when they leave your program or leave your hospital. I'm going to organize my thoughts. So my favorite thing about DVT is the way that it's packaged in really concrete, easy-to-understand ways, and so you get these refrains, right? What skills are you going to use? Where are your emotions at? Those are things that, because they're refrains, they're not necessarily like clinical interventions, although we could get into a whole rabbit hole there. Those are easy things to train peers to do with each other, right? And so when our kids graduate, they will often develop group chats within the more skillful groups of them, and they will coach each other on, like, what's your emotion rating? So what skill do you need? And the kids are just asking the questions. The other kids are the ones who are generating the responses. Oh, I need this. Oh, I need that. But it's because they have that shared foundation of learning. So that could absolutely be like almost like a graduate model or like a leader model where the kids or the junior Marines who have gone through some of the training and have stabilized and learned some of the stuff can take more of a leader or mentor type role within the milieu and just be, I mean, you're capitalizing on the sense that they're selling the product for you. I don't really have to even work that hard because our milieu, we get new kids every two weeks. So, yeah, we're standing in the front of the room doing the teaching, but it's the other kids in the room who are saying, I know mindfulness is so stupid, but it helps so much. And so that's where they're really kind of capitalizing on some of that peer-to-peer learning. Yes, we have supervision. I would be okay. I mean, then we also teach them the limits. They may not express suicidal ideation to each other. They may not talk about self-harm or send each other pictures. And so that the kids understand if that comes up, they come to us and tell us, hey, Paul sent me a picture of his cuts last night. And then we have a conversation, not about like bad Paul, but in the sense of, hey, you just made that really unsafe for that person. And so where could you have instead? And there are interventions called a behavior chain analysis where you can walk them through and then they figure out where did they go wrong, what could they have done differently at multiple steps along the way. Kind of piggybacking off that. I mean, definitely like one don't that we recommend for all the kids. Like, you know, the idea of, this is like the term that's being thrown around, like trauma dumping. You know, a lot of talking about what they've experienced that brought them into the hospital because it can be re-traumatizing to the folks who are in there with them. Also, we've had kids who've become quite symbiotic where they're not just like teaching each other like helpful skills, but also like hoarding, like this is dash packets for some reason were really big on our units to like hoard for like cutting and what have you. So we actually did what we call like a reverse room plan. So we would basically split the unit. So we would have group A, group B, and we would split those folks into two separate sides of the unit. So people in the day room would be group A to split that one patient and group B to split the other patient. And we would be very clear with them, you know, this relationship, you know, we're really happy that you're in a milieu where you can make someone that you feel connected to and also it's becoming more toxic for both of you. So sometimes we do have the staff and the capability to do that. We would all create basically group A and group B, which we've had to do several times, especially for the folks who are very encouraging of one another to self-harm. The do's is always like practicing, you know, like we really praise the practice. Like when we're seeing people ask for ice, using their skills, using like their fidgets, even asking for therapy sessions, like always praising those things and trying to redirect or notice anything that's getting past the point of therapeutic, like talking about self-injury, talking about, you know, really significant trauma in that way. It's tricky. And I think we have time for the last two questions. So one and two. Hi. Brian Markum, also with the Navy, but I'm a child out in Guam. So a little jet lag, but I'll try to speak inherently. I did my training at Hopkins and I was curious. We had a day program and it was a little different because it was a PHP, so it was a six-hour program. But I was just curious, what does your wait list look like? How big are the actual cohorts? And then how do you reintegrate? Because it's like rolling, right? You have some new kids popping in, some popping out. How do you manage that transition? Yeah, we have new kids starting every two weeks. Hold on, I forgot the first half of that. Wait list. Wait list. Oh, our goal for services was to never have kids wait more than the two weeks to the next admission point. Other than the winter holiday season of COVID-2020, we've been able to stick with that. And so it kind of seems like, I don't know, a weird way of it just works. But the new kids start every two weeks and then that's because some kids have graduated. And so the kids are present at the graduation. We include graduation criteria. You have to serve as a leader in the community within the last four weeks, at least once a week. So we're incentivizing them taking ownership of the skills. And it is very interesting to see the way that the kids step up. I mean, even we just graduated a kid who is 14 on the spectrum, very immature, obsessed with Legos. And most of our milieu is 16 and 17 right now. And when he hit his four-week mark, he was like, I need to be a leader. It is my turn and I have to help everybody here. And so he, ironically, also had significant gains in the second four versus the first four. So I think there's a lot of merit to a stratified community. Do you only admit on a certain day of the week so you don't have people popping in here and there throughout the week? We do. We only admit on a week, on one day a week. And we've gone back and forth in talks with other hospitals that say we admit any day. We're the only structured curriculum out of the hospitals that we've talked to so that there is a lesson plan, essentially. There are some times where a kid will bail on an admit spot and so we'll offer the admission to another kid. And then we say, to get in, you have to go watch these four videos. And then when they show up for their first day, they've already made up the learning from the day before. So that's the wiggle room we have there. But other than that, we're pretty firm. It creates really beautiful cohorts. So it's like, I wouldn't like these three people if I met them on the street. But they're basically like my blood brothers because we all started at the same time. So it's pretty cute. All right. And last question, because I know you all have other sessions to go to. Thank you for sticking around to answer our questions. I know you touched on this a little bit earlier, but I'm wondering what your staff training model looks like for DBT skills learning and how you account for the fact that you're using trainees, so they rotate out. And what that looks like with your training model. Yeah, for me specifically on the inpatient unit, because my training is also with the social workers, too, who happen to know DBT skills training. It's weekly, so what I do is get everybody in the room and we go through a skill together. We do didactic training. So if we're learning about distractions, usually like accepts doing an activity, we all do an activity like reading our moods before and after. So it's very experiential. But I would say for the social workers, it's weekly. Also the psychology trainees as well, too. But also like ad hoc supervision whenever they need it as well, too. So absolutely on a weekly basis. Our clinicians that get paid are intensively trained. So they are required to complete what is now an online training that I think takes about six months to complete. But they are also, and our trainees, when they get started, they are learning as they go. And it really speaks to how quickly you can. Also, if you've done any kind of therapy at all, this makes sense. If you've never done therapy, it also makes sense. So it's just really easy to kind of connect the dots. And then, oh, I think I missed. Groups are up to eight kids in a room at a time. And then we have basically two groups running at any given point in time. So we can have up to 16 kids at snack. And we do blend them. And then we scramble the groups every day so that the kids are not making some of those unhealthy connections. Or so that we can split them. But what that means is we can take somebody, so like a PEDS resident, right? They don't get to come to the prep time. So the PEDS resident comes. They sit in on skills group one. And then they teach 15 minutes of skills group two. And it's just like that. And it actually works really well. And remember, you've got the safety net because there's another person in the room with you. So if you totally mess something up, that person just says, oh, hey, got that one wrong. The P is for whatever, right? And so it's really easy to kind of pick up and make sense. It's all pretty logical and grounded in really good science. So that's kind of how we use that. Great. Well, I want to thank everybody for hanging around a little bit after 3 o'clock. And really want to thank you for being so interactive with us. And hope this was a helpful session. And we'll see you rest of the conference. Thank you. Thanks.

Cognitive Behavioral Therapy

Dialectical Behavior Therapy

high-intensity settings

inpatient units

intensive outpatient units

Dr. Bob Friedberg

Mesa Vista Hospital

behaviorally dysregulated adolescents

structured environment

emotion dysregulation

experiential learning

clinical outcomes

patient acuity