Amy Hoch, Psy.D. David Rubenstein, Psy.D., MSW Rowan University

Amy Hoch, Psy.D. David Rubenstein, Psy.D., MSW Rowan University

In College Counseling Centers, an increase in frequency and severity of: Depression Suicidal ideation Self injury Eating disorders Substance abuse Trauma (Benton, et al., 2003; Hunt and Eisenberg, 2010; Kitzrow, 2003)

Most Recent Survey of American Universities College Counseling Center Directors Reported Clients with Presenting Concerns (7/1/10-8/31/11): 37.18% Depression 40.94% Anxiety 15.92% Suicidal Thoughts/Behavior 9.22% Engaging in Self-Injury 10.80% Alcohol Abuse/Dependence 7.63% Substance Abuse/Dependence 6.88% Eating Disorders (2011 AUCCDSurvey)

60% 50% 40% 30% 20% >1,500 1501-2500 2,501-5,000 5,001-7,500 7,501-10K 10,001-15K 15,001-20K 20,001-25K 25,001-30K 30,001-35K 35,001+ 10% 0% Depression Anxiety Suicidal Thoughts/Behaviors Engaging in Self- Injury Alcohol Abuse Substance Abuse Eating Disorders

Question: What percent of your client would be classi_ied as severe (e.g. severe mood disorders, post traumatic stress, substance dependence, psychotic disorders, etc.): 20.39% Question: Is the number of students with signi_icant psychological problems a growing concern in your center or on your campus? Of the 374 responders: Yes: 346 (93%) No: 28

Total Number of Students: 11, 816 (10, 438 Undergraduates & 1,378 Graduate) Minority Enrollment: 22.6% More than half of Rowan's 2011 enrolled freshmen ranked in the top quarter of their high school class.

3,837 students live on campus in 8 residence halls and 5 apartment complexes. 121 total clubs and organizations (97 campus clubs and organizations, 24 Greek Life organizations) 8 men s and 10 women s varsity sports. Rowan competes within NCAA Division III

Percentage Reporting Psychiatric Condition: 3.6% Academic Impacts: Stress: 23.8% Anxiety: 17.4% Depression: 10.7% Alcohol Use: 3.9% Drug Use: 1.2%

Mental Health (Any time in last 12 months) Hopelessness: 46.1% Felt so depressed it was dif_icult to function: 31.3% Felt overwhelming anger: 40.2% Seriously considered suicide: 4.9% Intentionally cut, burned, bruised or otherwise injured self: 5.1% Percentage of students reporting at least 3 situation that was traumatic or dif_icult to handle: 46.5% More than average stress: 41.6%

Alcohol and Drug Use: Alcohol Use in Last 30 Days: 69.5% (18.3% reported 7 or more drinks last socialized; 32.1% reported doing something they later regretted; 1.9% seriously considered suicide) Drug Use in Last 30 Days: 14.6% (Respondents: 1435; 13% of Student Population)

StafLing 1 FTE Director (Doctoral Level Psychologist) 4 FTE Doctoral Level Psychologists 1 FTE Social Work Clinician 1 FTE Licensed Substance Abuse Counselor 1 Half- Time Psychiatrist Rotating Psychiatry Resident (Substance Abuse Program: 1 day per week) 2 Full- Time Psychology Interns; 1 One- Day Per Week Psych. Intern 2 Doctoral Level Practicum Students (2 days per week, each) 2 Masters Level Practicum Students (2 days per week, each) 2 ½ FTE equiv. Secretaries 1 Graduate Learning Coordinator 1 Undergraduate Student Worker

DBT has been developed for use with suicidal ideation and self- injurious behaviors and has been adapted for use with substance abuse disorders, eating disorders and adolescents. (Linehan, 1993; Linehan et. al., 1999; Safer, Telch and Chen, 2009; Miller, Rathus, & Linehan, 2007)

Empirical Support for Treatment of: Symptoms of Borderline Personality Disorder Self- Injury Suicidal Behavior Depression Substance Use Disorders Eating Disorders

Increase in severity of mental health issues nationally, on college campuses. Types, rates and acuity of mental health issues on our campus. Empirical support for DBT in addressing these types of symptoms.

Needs to develop and ef_icacious program aimed at reducing these problematic symptoms and behaviors on campus. Studying and disseminating the ef_icacy of treatment. Development of regional and national efforts at developing DBT programs on college campuses.

Stage of Pre- Implementation Reviewed of rates of mental health issues, problems, symptoms and behaviors on college campuses and our own campus. Reviewed empirically supported treatment approaches aimed at addressing these mental health issues. Reviewed existing resources: staf_ing, expertise, programmatic, and _inancial. Reviewed issues with administration and sought administrative support in principal and then _inancial support for development and implementation of program.

Stage of Pre- Implementation Hiring of an expert in DBT who was certi_ied and had foundational and intensive training, with experience in program development. Developed an outline of a DBT Program that could be modi_ied to work within a college campus.

Stage of Preparation and Beginning Implementation Didactic Training for Staff: 1) 1- hour inservice trainings 2) 3- hour inservice trainings 3) Day- long external trainings 3) 2- Day Workshops 4) Week- long Foundational Trainings

Stage of Implementation The development of a DBT Consultation Team for staff members. The development of a DBT Skills Group for students engaging in risky behaviors, concomitant to individual therapy. The development of a DBT- ED Group for students with Eating Disorders. The integration of Substance Abuse Services into Counseling and Psychological Services Center and Substance Abuse Counselor joining DBT Consultation Team. Involvement of counseling center trainees in implementation of this program

Stage of Dissemination Applied and received IRB approval to study ef_icacy of DBT interventions on target behavior. Decision to disseminate efforts at implementing a DBT Program: Hosted 2 mid- atlantic regional consortium meetings.

Stage of Dissemination Submitted paper for publication on these efforts. Preparing additional papers to submit for publication. Looking at external support (grants, etc.) aimed at larger program support, implementation and study. Presented initial work at the American College Health Association, May 2012.

Programmatic and Clinical Implementation of a DBT Program in a University Counseling Center Setting

Adult DBT Outpatient Weekly Individual Therapy Weekly Skills Group 6 months x 2 Distress Tolerance Emotion Regulation Core Mindfulness Interpersonal Effectiveness Phone Coaching Consultation Team Adolescent DBT Outpatient weekly individual therapy Weekly Multifamily Skills Group 20 weeks All Skill Modules +Walking the Middle Path Phone Coaching Consultation Team

Weekly Individual Therapy 12- Week Skill Group Emotion Regulation 4 weeks Distress Tolerance 4 weeks Core Mindfulness 1 week/weekly practice Interpersonal Effectiveness 2 weeks Walking the Middle Path 1 week Phone Consultation Consultation Team

T R A U M A

Sensitive Reacts intensely Slow to return to baseline Dif_iculty identifying feelings Looks for external soothing Dif_iculty with interpersonal relatedness Behavior problems

VALIDATION

Outpatient Individual Psychotherapy Outpatient Group Skills Training Telephone Consultation Therapists Consultation Meeting Uncontrolled Ancillary Treatments Pharmacotherapy Acute- Inpatient Psychiatric

Client Agreements Decreasing suicidal behaviors and thoughts Decreasing self- harmful behaviors/thoughts Decreasing behaviors interfering with the quality of life Attendance at all individual sessions Decreasing any therapy interfering behaviors Building a life worth living Participation in Skills Training Class

Therapist Agreements To make every reasonable effort I can to conduct therapy effectively To conduct therapy in an ethical manner Attendance as scheduled or rescheduling To communicate when behaviors stretch my limits beyond my comfort zone Con_identiality To seek consultation

Life threatening behaviors Suicidal/self- injury Therapy interfering behaviors Absences, no paging, no homework Quality of life behaviors Substance abuse, risky sex, aggression Skills Trauma Processing

Identify triggers and consequences Identify places where coping skills can be used Opportunity for mindfulness practice Opportunity for behavioral rehearsal

Vulnerability: PMS Told him to Boyfriend says get out I m _lirting with others Mad, shame Thought: No one will ever love me Bfriend yells back Yells at bfriend I ll show you who s psycho Thought: He thinks I m a slut. Maybe I am. Thought: I m a psycho! At least I m not crazy! Sad, alone Thought: I can cut Shame Relief, in control Hits bfriend Mad, ashamed What if I do! You do it too! Go upstairs to room and get razor Cut myself

Confusion about Self Mindfulness Interpersonal Problems Interpersonal Effectiveness Emotional Instability Impulsivity (Family Dilemmas) Emotion Regulation Distress Tolerance Walking the Middle Path

Mindfulness States of Mind Reasonable Mind Wise Mind Emotional Mind

Identifying and Labeling Emotions Identifying Obstacles to Changing Emotions Reducing Vulnerability to Emotion Mind Increasing Positive Emotional Events Increasing Mindfulness to Emotions Taking Opposite Action

Understand Emotions You Experience Identify and understand emotions Reduce Emotional Vulnerability Decrease negative vulnerability Increase positive emotions Decrease Emotional Suffering Let go of pain through mindfulness Change pain through opposite action

Treat PhysicaL Illness Balance Eating Avoid mood- Altering drugs Balance Sleep Get Exercise Build MASTERy

Emo$on Regula$on: Opposite Ac$on Feeling/Urge Opposite Ac2on Fear = Avoid Guilt or Shame (When Jus$fied) = Hide Sadness = Withdraw Anger = ADack Approach Repair and Let Go Get Ac$ve Gently Avoid/Be Nice

Pros of Cutting Cons of cutting Pros of using skills Cons of using skills

Temperature Change Warm shower with lavender Ice Intense Exercise Paced Breathing Progressive Relaxation

Acceptance of a situation you can t change REJECT ACCEPT

Honoring and acknowledging one s feelings Verbal and nonverbal NOT about trying to change the feeling

Dialectics Thinking Mistakes Family Dilemmas

Support for clinical team Decreases burnout/vicarious trauma Increases communication across group and individual modalities Reinforcement of adherence to model

Clinician is a coach Relationship is key Reinforcement of coping skills Not a time for processing Not allowed if client engages in self- destructive behavior Every clinician has his/her own limits

Standard, adult, comprehensive DBT package vs. optimized TAU for suicidal students Three 8- week groups covering all adult skills across one school year 30 hours of training for therapists DBT found superior in reducing suicidality, depression, # of parasuicidal gestures, BPD criteria and use of medication

10/14 students completed pre and post measures Beck Depression Inventory II (BDI- II) Beck Anxiety Inventory (BAI) Life Problems Inventory Dif_iculties in Emotion Regulation Scale (DERS) 80% had decrease in depression symptoms 60% had decrease in anxiety symptoms 80% had decrease in life problems No difference in pre/post emotion regulation

Questionnaire Item I have learned mindfulness skills and am able to implement them I have learned skills that help me tolerate distress without engaging in impulsive behavior I have better understanding of my emotions and more comfortable with dif_icult emotions I feel more comfortable handling crisis situations I am able to be more assertive in relationships with others Group 2/3 Mean Likert Scale Rating (1-7) 5.8/6.0 6.3/6.0 6.0/5.3 6.5/5.5 5.0/5.0

6 months/20 weeks of skills into 12 weeks Fidelity Open or closed group Consultation team in training Commitment Drop Outs Inconsistent phone consultation

More comprehensive research Regional Consortium ABCT Special Interest Group ListSERV Skills groups vs. Comprehensive DBT