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<ul><li>Mode Deactivation Therapy </li></ul>Jack A. Apsche, Ed.D., ABPP
&quot;For every complex problem there is an answer that is clear, simple, and wrong.&quot; H.L. Mencken
Adverse  Childhood Experiences (ACEs) Unbalanced Perceptions Others’ Response to Resident’s Behavior Beliefs Learning & Or...
Evidence Based Treatments EBT’s
<ul><li>RESEARCH THERAPY CLINIC THERAPY </li></ul><ul><li>RECRUITED CASE CLINIC REFERRED </li></ul><ul><li>(Less severe, s...
MDT   Will show us the way!
Where has MDT been shown to be effective?
Demographic data of population treated with MDT, diagnosed disorder and race. Axis I MDT Percentile Conduct Disorder 39 40...
Theoretical Constructs of MDT
Theory of Modes <ul><li>The multiplicity of related symptoms encompassing the cognitive, affective, motivational and behav...
<ul><li>The phenomena of sensitization (“kindling phenomenon”): successive recurrences of a disorder (e.g. Depression) tri...
Theory of Modes <ul><li>Modes are a network of cognitive, affective, motivational, and behavioral components. The modes, c...
Theory of Modes- Activation <ul><li>Charges </li></ul><ul><li>Fear  Avoids Paradigm </li></ul>
Why this is so crucial for our kids <ul><li>Beck (1996) described modes as a network of cognitive, affective, motivational...
Mode Step-by-Step <ul><li>Orienting Schema:  the danger, fear, threat, signal or charge. </li></ul><ul><ul><li>Event:   th...
Mode Step-by-Step <ul><ul><li>Physiological System:   the physical responses to fear, arousal or charges. </li></ul></ul><...
Mode Step-by-Step <ul><ul><li>Motivation Schema:   the signal of the increasing need to escape the fear. </li></ul></ul><u...
Mode De-Activation <ul><li>There are four areas where a mode can be deactivated prior to an aggressive act or other forms ...
Look for the Elevator <ul><li>Beck’s Elevator Phobia: A young man, suffers from an elevator phobia. </li></ul><ul><li>We l...
Adolescent-Onset Personality Disorder <ul><li>Johnson, Cohen, Smailes, Kasen, Oldham, Skodol, Brook (2000) </li></ul><ul><...
Conduct Disorder <ul><li>Conduct Disorder is multi-determined </li></ul><ul><li>Conduct Disorder manifests in multiple way...
Reactive and Proactive Aggression <ul><li>Reactive adolescents had a significant tendency to come from backgrounds of phys...
Reactive and Proactive Aggression  <ul><li>It is possible to identify reliable subgroups of antisocial youngsters based on...
Reactive and Proactive Aggression <ul><li>Reactively violent youngsters (in contrast with the PV group) show a pattern of ...
<ul><li>Cognitive distortions tend to be  highly invalidating </li></ul><ul><li>Attempting to treat the diagnoses, not the...
  MDT CBT DBT FAP Schema Therapy ACT   (Apsche and Ward Baily, 2003) (Beck, et al., 1990) (Linehan, 1993) (Kohlenberg and ...
Collaboration between therapist and client Yes  Yes  No  Yes  Yes  Therapeutic alliance important Yes  Yes  Yes  Yes  Yes ...
Case conceptualization  Yes – ever-evolving and drives treatment  Yes – ever-evolving formulation of the patient’s problem...
<ul><li>MDT  was developed to treat the aberrant typologies of reactive conduct disorder and personality disorders more ef...
Questions?
The MDT Method Case Conceptualization
The MDT Method <ul><li>Therapeutic Alliance </li></ul><ul><li>Complete all assessments </li></ul><ul><ul><li>Typology Surv...
Typology Survey <ul><li>Identifying information </li></ul><ul><li>Family information  </li></ul><ul><li>Substance abuse  <...
Fear Assessment <ul><li>You select the version to administer </li></ul><ul><ul><li>60 question assessment  </li></ul></ul>...
Administering the Fear Assessment <ul><li>Do </li></ul><ul><li>Be relaxed and patient </li></ul><ul><li>Make eye contact w...
Fear Assessments Available <ul><li>Fear Assessment Revised  </li></ul><ul><li>Fear Assessment Pro </li></ul><ul><li>Fear A...
Conglomerate of Beliefs and Behaviors (COBB) <ul><ul><li>209 Question Assessment of Beliefs </li></ul></ul><ul><ul><li>96 ...
The Case Conceptualization:   <ul><li>Hierarchies of Target Behaviors within Target Classes in Outpatient Individual Thera...
The Case Conceptualization:   <ul><li>Personal Reactive-External Fears </li></ul><ul><li>Avoids </li></ul>Remember: &quot;...
Fears and Avoids: FEARS  AVOIDS Failing Trying new behaviors Anger Confrontation, being victim Hurting someone physically ...
The Case Conceptualization:   <ul><li>Personal Reactive-External Fears </li></ul><ul><li>Avoids </li></ul><ul><li>Triggers...
Triggers <ul><li>Trigger 1 (conscious trigger): </li></ul><ul><ul><li>Anything the youth may be aware of that would trigge...
Trigger 1 Conscious Processing Trigger 2 Unconscious processing   Fears Avoids Compound Core Beliefs Unfamiliar situations...
Trigger 1 Conscious Processing Trigger 2 Unconscious processing   Fears Avoids Compound Core Beliefs Pressure situations (...
Compound Core Belief and Corresponding Behavior(s) <ul><li>BORDERLINE PERSONALITY DISORDER </li></ul><ul><ul><li>Everyone ...
<ul><li>BORDERLINE PERSONALITY DISORDER </li></ul><ul><ul><li>When I hurt emotionally, I do whatever it takes to feel bett...
Compound Core Belief and Corresponding Behavior(s) <ul><li>DEPENDENT PERSONALITY DISORDER </li></ul><ul><ul><li>If I am no...
Compound Core Belief and Corresponding Behavior(s) <ul><li>ANTISOCIAL PERSONALITY DISORDER </li></ul><ul><ul><li>Unless yo...
The Case Conceptualization:   <ul><li>Personal Reactive-External Fears </li></ul><ul><li>Avoids </li></ul><ul><li>Triggers...
Situational Analysis <ul><li>Situation: </li></ul><ul><li>Automatic Thought: </li></ul><ul><li>Meaning of Automatic Though...
Questions?
The MDT Method Treatment
Functionally Based Treatment   IDENTIFY NEW BELIEF SYSTEM IDENTIFY HEALTHY ALTERNATIVE THOUGHTS FUNCTIONAL ALTERNATIVE COM...
Functionally Based Treatment   <ul><li>Identify New Belief System </li></ul><ul><li>Identify Healthy Alternative Thoughts ...
Validation: <ul><ul><li>Defined by Linehan (1997) as the therapist communicating to the client that the client’s responses...
Validation: <ul><li>Levels of Validation .  </li></ul><ul><ul><li>Level 1 .   Active Observing.  </li></ul></ul><ul><ul><l...
Redirect: <ul><li>Youth’s belief  Other’s belief or  source of conflict </li></ul><ul><li>Dysregulation </li></ul><ul><li>...
Identify New Belief System Identify Healthy  Alternative Thoughts Functional Alternative Compensatory Strategy Functional ...
Therapeutic Mindfulness <ul><li>Awareness </li></ul><ul><li>Of present experience </li></ul><ul><li>With acceptance </li><...
Mindlessness
Mindfulness Can Help  Us <ul><li>To see and accept things as they are. </li></ul><ul><li>To loosen our preoccupation with ...
Mindfulness of Anxiety <ul><li>Noticing prevalence of anxious thoughts and feelings </li></ul><ul><li>Seeing the component...
The MDT Client Workbook Table of Contents Chapter 1.  Commitment To Treatment- Mindfulness Chapter 2.  Responsibility Chap...
Chapter 1:  Commitment to Treatment <ul><li>What is treatment?____________________________________________________________...
Chapter 1:  Commitment to Treatment <ul><li>Trust Scales </li></ul><ul><li>What does trust mean to you? __________________...
Chapter 1:  Commitment to Treatment <ul><li>MDT DAILY RECORD </li></ul><ul><li>Daily Record </li></ul><ul><li>Use the foll...
Chapter 1:  Commitment to Treatment Daily Record Please rate the individual therapy session:   Not Helpful - 0 1 2 3 4 5 –...
Chapter 2:  Responsibility <ul><li>I am  %  responsible My victim is  %  responsible </li></ul>LIST OF MY RESPONSIBILITY L...
Chapter 3.  Belief Analysis <ul><li>1.  Write down beliefs related to your thoughts (at any given time). </li></ul>2. Writ...
Chapter 3.  Belief Analysis <ul><li>TFAB (Triggers, Fears, Avoids, Beliefs) </li></ul><ul><li>8. The triggers to my fears,...
Chapter 4.  Modes <ul><li>Modes </li></ul><ul><li>What is a Mode? </li></ul><ul><li>A mode is different than your mood.  A...
Chapter 5.  MDT and Reactive Anger, Aggression, and Impulse Control <ul><li>Aggression and Violence </li></ul><ul><li>Ofte...
Chapter 5.  MDT and Reactive Anger, Aggression, and Impulse Control <ul><li>MDT and Reactive Anger, Aggression and Impulse...
Chapter 6.  Beliefs and Problem Behaviors <ul><li>Core Belief Balancing Exercise </li></ul><ul><li>Balancing beliefs is ab...
Chapter 6.  Beliefs and Problem Behaviors SUPPORT OF COMPOUND CORE BELIEF SUPPORT OF NEW BALANCED BELIEF % Of Belief of Ol...
Chapter 6.  Beliefs and Problem Behaviors <ul><li>Beliefs, Feelings, and Behaviors Worksheet </li></ul><ul><li>At the begi...
Chapter 7.  Problem Behaviors and MDT <ul><li>Problem Behaviors and MDT </li></ul><ul><li>You will now learn how to apply ...
Chapter 7.  Problem Behaviors and MDT T1 T2 F A B
Chapter 8.  Substance Abuse <ul><li>Drugs, Alcohol, Substances </li></ul><ul><li>If you were involved in drinking, smoking...
Chapter 8.  TFAB  (TRIGGERS, FEARS, AVOIDS, BELIEFS) <ul><li>Which Triggers, Fears, Avoids and Beliefs relate to substance...
Chapter 9.  Developing Empathy <ul><li>There are many types of abuse or neglect that can change the course of your life.  ...
Chapter 9.  Developing Empathy <ul><li>Introduction :  This section presents six interviews with young males who were abus...
Chapter 10.  Becoming a Survivor <ul><li>Use a cassette tape recorder (obtain one from your advocate or therapist) and tel...
Chapter 10.  Becoming a Survivor <ul><li>Treatment Goal </li></ul><ul><li>Now your victim work has only begun.  With your ...
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  • Transcript of "MDT Brief Training"

    1. 1. <ul><li>Mode Deactivation Therapy </li></ul>Jack A. Apsche, Ed.D., ABPP
    2. 2. &quot;For every complex problem there is an answer that is clear, simple, and wrong.&quot; H.L. Mencken
    3. 3. Adverse Childhood Experiences (ACEs) Unbalanced Perceptions Others’ Response to Resident’s Behavior Beliefs Learning & Organic Problems Triggers (Unconscious) (T 2 s) Triggers ( Conscious) (T 1 s) Avoids (Things that make me feel bad- I do anything to avoid) Fears Temperament (Mood)
    4. 4. Evidence Based Treatments EBT’s
    5. 5. <ul><li>RESEARCH THERAPY CLINIC THERAPY </li></ul><ul><li>RECRUITED CASE CLINIC REFERRED </li></ul><ul><li>(Less severe, study volunteers) (More severe, some coerced) </li></ul><ul><li>Homogeneous Heterogeneous </li></ul><ul><li>Lab or school settings Multi-problem focus </li></ul><ul><li>Researchers/Assistants Clinics or Hospitals </li></ul><ul><li>Small caseloads Clinicians </li></ul><ul><li>Pre-therapy preparation Large caseloads </li></ul><ul><li>Focused treat-ment method Little Preparation </li></ul><ul><li>Behavioral Multi-method, eclectic </li></ul><ul><li>Pre-planned, Non-behavioral </li></ul><ul><li>Highly Structured Flexible, adjustable </li></ul><ul><li>( manual, close monitoring of therapists) </li></ul>
    6. 6. MDT Will show us the way!
    7. 7. Where has MDT been shown to be effective?
    8. 8. Demographic data of population treated with MDT, diagnosed disorder and race. Axis I MDT Percentile Conduct Disorder 39 40.2% Oppositional Defiant Disorder 10 10.3% Post Traumatic Stress Disorder 25 25.8% Major Depression 17 17.5% Other Axis I Disorder 6 6.2% Axis II Mixed Personality Disorder 22 55% Borderline Personality Traits 12 30% Narcissistic/ Antisocial Personality Traits 6 15% Dependent Personality Traits 0 0 Avoidant Personality Traits 0 0 Race African American 97 77.8% European American 38 20.9% Hispanic/Latino American 6 .05% Other 2 Total 142 Average Age 16.2
    9. 9. Theoretical Constructs of MDT
    10. 10. Theory of Modes <ul><li>The multiplicity of related symptoms encompassing the cognitive, affective, motivational and behavioral domains in psychopathological conditions. </li></ul><ul><li>Evidence of systematic biases across many domains suggesting that a more global ad complex organization of schemas is involved in intense psychological reaction </li></ul><ul><li>The findings of a specific vulnerability (or diathesis) to specific stressors that are congruent with particular disorder. </li></ul><ul><li>The great variety of “normal” psychological reactions evoked by the myriad of life’s circumstances. </li></ul><ul><li>The relation of content, structure and function in personality. </li></ul><ul><li>Observations of the variations in the intensity of an individuals’ specific reaction to a given set of circumstances over time. </li></ul><ul><li>Beck, A.T. (1996) </li></ul>
    11. 11. <ul><li>The phenomena of sensitization (“kindling phenomenon”): successive recurrences of a disorder (e.g. Depression) triggered by progressively less intense experiences. </li></ul><ul><li>The remission of symptoms by either pharmacotherapy or psychotherapy. </li></ul><ul><li>The apparent continuity of many psychopathological phenomena with personality. </li></ul><ul><li>The relevance of the model to normal “moods.” </li></ul><ul><li>The relationship among consciousness and unconscious processing of information. </li></ul><ul><li>Beck, A.T. (1996) </li></ul>Theory of Modes
    12. 12. Theory of Modes <ul><li>Modes are a network of cognitive, affective, motivational, and behavioral components. The modes, consisting of integrated sectors or sub-organizations of personality, are designed to deal with specific demands or problems. </li></ul>
    13. 13. Theory of Modes- Activation <ul><li>Charges </li></ul><ul><li>Fear  Avoids Paradigm </li></ul>
    14. 14. Why this is so crucial for our kids <ul><li>Beck (1996) described modes as a network of cognitive, affective, motivational and behavioral components. He suggests that modes are consisting of integrated sectors of sub-organizations of personality that are designed to deal with specific demands to problems. They are the sub-organization that help individuals adopt to solve problems such as, the adaptation of adolescents to strategies of protection and mistrust when they have been abused. </li></ul>
    15. 15. Mode Step-by-Step <ul><li>Orienting Schema: the danger, fear, threat, signal or charge. </li></ul><ul><ul><li>Event: the actual situation that takes place that produces the fear experienced. </li></ul></ul><ul><ul><li>Anticipated Event: the unconscious process of anticipating a fear evoking event. </li></ul></ul><ul><ul><li>Preconscious Processing: the cognitive unconscious based on the experiences of danger charged fears. </li></ul></ul><ul><ul><li>Perception Fear: the sense of fear that fully charges the mode system. </li></ul></ul>
    16. 16. Mode Step-by-Step <ul><ul><li>Physiological System: the physical responses to fear, arousal or charges. </li></ul></ul><ul><ul><li>Activation: the process of the cognitive schemas processing of fear evoked beliefs or thoughts. </li></ul></ul><ul><ul><li>Meaning Assignments , Memories, Beliefs: the activation of the Compound Core beliefs. </li></ul></ul><ul><ul><li>Affective Schema: the emotional component. </li></ul></ul><ul><ul><li>Behavioral Schemas: the behavior that is evolved. </li></ul></ul>
    17. 17. Mode Step-by-Step <ul><ul><li>Motivation Schema: the signal of the increasing need to escape the fear. </li></ul></ul><ul><ul><li>Attack: the response to eliminate the threat by aggression. </li></ul></ul><ul><ul><li>Avoid: the escape from the fear in a non-contact form. </li></ul></ul>
    18. 18. Mode De-Activation <ul><li>There are four areas where a mode can be deactivated prior to an aggressive act or other forms of emotional dysregulation. </li></ul><ul><ul><li>Orienting Schema </li></ul></ul><ul><ul><li>Perception </li></ul></ul><ul><ul><li>Physiological System </li></ul></ul><ul><ul><li>Avoids </li></ul></ul>
    19. 19. Look for the Elevator <ul><li>Beck’s Elevator Phobia: A young man, suffers from an elevator phobia. </li></ul><ul><li>We look for the elevator in each adolescent and MDT helps identify their elevator </li></ul>
    20. 20. Adolescent-Onset Personality Disorder <ul><li>Johnson, Cohen, Smailes, Kasen, Oldham, Skodol, Brook (2000) </li></ul><ul><ul><li>Of 12 categories of DSM-IV Personality Disorder (PD) symptoms, 10 were associated with childhood neglect </li></ul></ul><ul><ul><li>Family instability and lack of parental affection and supervision were found to predict dependent and passive-aggressive PDs. </li></ul></ul><ul><ul><li>Persons who experienced childhood abuse or neglect are considerably more likely to have PDs or elevated PD symptoms. </li></ul></ul><ul><ul><li>Sexual abuse seems related to BPD. </li></ul></ul><ul><ul><li>Physical abuse seems related to antisocial PD. </li></ul></ul><ul><li>Johnson, Cohen, Brown, Smailes and Bernstein (1999) </li></ul><ul><ul><li>Abuse as associated with elevated borderline P.D. symptom and neglect was associated with elevated symptoms of antisocial, avoidant, borderline, narcissistic, and passive aggressive P.D. </li></ul></ul>
    21. 21. Conduct Disorder <ul><li>Conduct Disorder is multi-determined </li></ul><ul><li>Conduct Disorder manifests in multiple ways </li></ul>
    22. 22. Reactive and Proactive Aggression <ul><li>Reactive adolescents had a significant tendency to come from backgrounds of physical abuse and harsh discipline. </li></ul><ul><li>41% of all children that had been identified as physically abused in the first 5 years of life, met criteria of RA 4 years later…in contrast with only 15% of non-abused youngsters. </li></ul>Dodge, Lochman, Harnish, Bates & Pettit, 1997
    23. 23. Reactive and Proactive Aggression <ul><li>It is possible to identify reliable subgroups of antisocial youngsters based on the type of aggressive behavior </li></ul><ul><li>These reactive children display aggressive behavior that appears to be related to developmental histories and abuse that results in information processing pattern of antisocial beliefs and behaviors. </li></ul><ul><li>Reactive Conduct Disorder, like ADHD, was found to be strongly related to attention problems and impulsivity. </li></ul>
    24. 24. Reactive and Proactive Aggression <ul><li>Reactively violent youngsters (in contrast with the PV group) show a pattern of emotional dysregulation that includes </li></ul><ul><ul><li>somatization, depressive symptoms, sleep disorder symptoms, and personality disorders </li></ul></ul><ul><ul><li>. </li></ul></ul><ul><li>Dodge et.al. findings are consistent with the hypothesis that, these reactive disorders, such as chronic violence have their origins in early life experiences </li></ul><ul><ul><li>(such as early traumas of parental rejection, exposure to family violence, and family instability). </li></ul></ul>
    25. 25. <ul><li>Cognitive distortions tend to be highly invalidating </li></ul><ul><li>Attempting to treat the diagnoses, not the underlying issues </li></ul>Why not use CBT?
    26. 26.   MDT CBT DBT FAP Schema Therapy ACT   (Apsche and Ward Baily, 2003) (Beck, et al., 1990) (Linehan, 1993) (Kohlenberg and Tsai, 1993) (Young et al., 2003) (Hayes et al., 1999) Designed for Adolescents Yes No No No No Yes Goal oriented treatment Yes Yes Yes Yes Yes Yes Focus of treatment Present, in-vivo work in session Initially present focused Present Present Present Present Session structure Yes, but flexible Yes Yes Yes Yes Yes Session Limitation Aims to be time limited Aims to be time limited Cognition Unconscious and Conscious Conscious Conscious Conscious Conscious Conscious Goals for therapy Yes – Empower patient to modify underlying beliefs to thereby change moods and behaviours (deactivate modes). Yes – Uses variety of techniques to change thinking, moods, and behaviours Yes – Skills training to better manage symptoms Yes – Uses within-session contingencies to change behaviour Yes – Identify and modify maladaptive mode schemas
    27. 27. Collaboration between therapist and client Yes Yes No Yes Yes Therapeutic alliance important Yes Yes Yes Yes Yes Yes Addresses resistance Yes No – Assumes patients will comply with treatment Yes No Yes No Empowers client to be own therapist Yes Yes No No Yes No Thoughts/beliefs as dysfunctional No – Beliefs are not thought of as dysfunctional, which invalidates the patient’s experience. Beliefs are validated as being created out of a patient’s experience, then are balanced to deactivate modes. Yes – Teach patient to identify, evaluate, and respond to their dysfunctional thoughts and beliefs with schema assumptions (scanning) Yes – Balance through change and acceptance. Yes Yes – Maladaptive mode schemas Yes Clear, direct and concrete session for adolescent Yes No - Uses cognitive distortion and adult oriented No - Uses esoteric and skills training for adult mindfulness No No - Adult oriented No - Uses metaphors and Jargon Cognitive distortions No – thoughts/beliefs are not distortions since they are based on past experience Yes No Yes Yes – Maladaptive mode schemas No Dialectical thinking Yes – Focus on balancing No Yes – Focus on the dialectical pattern/process No No No
    28. 28. Case conceptualization Yes – ever-evolving and drives treatment Yes – ever-evolving formulation of the patient’s problems in cognitive terms Yes – important Yes – case formulation Yes Yes Case conceptualisation is specific typology driven Yes No No No No No Acceptance and validation in the moment Yes No Yes No No Yes Modes Yes – Perceptions trigger physiological cues, which trigger beliefs (entire process is mode activating) No No No No No Triggers important Yes – Learning the triggers is key to preventing activation of modes No - Learned behaviors Client’s perceptions important Yes – Perceptions trigger modes No – Perceptions are distorted Yes – Perceptions are based on past experiences No No No Reducing anxiety, addressing trauma Yes – Uses exposure to fear cue to decrease perception of fear No – Focuses on thought feeling- behaviors connection No No No No Fear _ avoids paradigm Yes No No No No No Data suggest - evidenced based effectiveness with adolescent males Yes No No No No No
    29. 29. <ul><li>MDT was developed to treat the aberrant typologies of reactive conduct disorder and personality disorders more effectively than traditional CBT strategies….by offering a new script to the client. </li></ul>
    30. 30. Questions?
    31. 31. The MDT Method Case Conceptualization
    32. 32. The MDT Method <ul><li>Therapeutic Alliance </li></ul><ul><li>Complete all assessments </li></ul><ul><ul><li>Typology Survey </li></ul></ul><ul><ul><li>Fear Assessment </li></ul></ul><ul><ul><li>CCBQ (Compound Core Belief Questionnaire) </li></ul></ul>Remember: &quot;For every complex problem there is an answer that is clear, simple, and wrong.&quot;
    33. 33. Typology Survey <ul><li>Identifying information </li></ul><ul><li>Family information </li></ul><ul><li>Substance abuse </li></ul><ul><li>Medical </li></ul><ul><li>Educational </li></ul><ul><li>Emotional </li></ul><ul><li>Physiological </li></ul><ul><li>Interpersonal Relationship/ Social </li></ul><ul><li>Offenses </li></ul><ul><li>History of Physical and Sexual Abuse </li></ul><ul><li>History of other Abuse </li></ul><ul><li>Expectations of Treatment </li></ul><ul><li>Across three strata: </li></ul><ul><ul><li>The client </li></ul></ul><ul><ul><li>The parent </li></ul></ul><ul><ul><li>The referral source </li></ul></ul>
    34. 34. Fear Assessment <ul><li>You select the version to administer </li></ul><ul><ul><li>60 question assessment </li></ul></ul><ul><ul><li>5 subcategories of beliefs </li></ul></ul><ul><li>Explain the types of questions you will be asking </li></ul><ul><li>Ascertain the youth’s definition of words like “trust” or “retaliation.” </li></ul><ul><ul><li>Use real life examples and/or scenarios, etc. Use the skills you have to use this exercise as a rapport/ trust building tool. </li></ul></ul>
    35. 35. Administering the Fear Assessment <ul><li>Do </li></ul><ul><li>Be relaxed and patient </li></ul><ul><li>Make eye contact when appropriate </li></ul><ul><li>Be observant </li></ul><ul><li>Give scenarios </li></ul><ul><li>Be supportive </li></ul><ul><li>Don’t </li></ul><ul><li>Read the assessment verbatim </li></ul><ul><li>Move to fast through the assessment </li></ul><ul><li>Answer for the individual </li></ul><ul><li>Lead the individual to answer </li></ul>
    36. 36. Fear Assessments Available <ul><li>Fear Assessment Revised </li></ul><ul><li>Fear Assessment Pro </li></ul><ul><li>Fear Assessment Pro-II </li></ul><ul><li>Difficulty Assessment Revised </li></ul><ul><li>Difficulty Assessment Pro </li></ul><ul><li>Difficulty Assessment Pro-II </li></ul>
    37. 37. Conglomerate of Beliefs and Behaviors (COBB) <ul><ul><li>209 Question Assessment of Beliefs </li></ul></ul><ul><ul><li>96 Question Assessment of Beliefs (Short Version) </li></ul></ul><ul><li>Assesses the underlying cognitive belief structure of the client’s mode. </li></ul><ul><li>Closest we come to a traditional schema focus </li></ul>
    38. 38. The Case Conceptualization: <ul><li>Hierarchies of Target Behaviors within Target Classes in Outpatient Individual Therapy (Linehan, M.M. (1995). Treating borderline personality disorder: The dialectical approach. New York, NY: Guilford Press.) </li></ul><ul><li>Suicidal behaviors: </li></ul><ul><li>Therapy-interfering behaviors: </li></ul><ul><li>Quality-of-life interfering behaviors: </li></ul><ul><li>Increasing behavioral skills: </li></ul>
    39. 39. The Case Conceptualization: <ul><li>Personal Reactive-External Fears </li></ul><ul><li>Avoids </li></ul>Remember: &quot;For every complex problem there is an answer that is clear, simple, and wrong.&quot;
    40. 40. Fears and Avoids: FEARS AVOIDS Failing Trying new behaviors Anger Confrontation, being victim Hurting someone physically Relationships, trust Feelings Close relationships
    41. 41. The Case Conceptualization: <ul><li>Personal Reactive-External Fears </li></ul><ul><li>Avoids </li></ul><ul><li>Triggers </li></ul>Remember: &quot;For every complex problem there is an answer that is clear, simple, and wrong.&quot;
    42. 42. Triggers <ul><li>Trigger 1 (conscious trigger): </li></ul><ul><ul><li>Anything the youth may be aware of that would trigger or activate the fear, avoidance, and compound core beliefs. Trigger 1 is the experiential, which manifests in what the youth avoids. </li></ul></ul><ul><li>Trigger 2 (unconscious trigger): </li></ul><ul><ul><li>Anything the youth is not aware of, but can be identified through observable behaviors to trigger or activate the fear, avoidance, compound core beliefs. Trigger 2 is the information processing (cognitive component) of what the youth avoids. Unconscious triggers are many times what the youth avoids. </li></ul></ul>
    43. 43. Trigger 1 Conscious Processing Trigger 2 Unconscious processing Fears Avoids Compound Core Beliefs Unfamiliar situations Situations that trying, (failing) vulnerable Failing Trying new Behaviors I am inadequate; I will do whatever I must to hide it. Trust versus betrayal Situations of trust or counting on someone (vulnerability) Hurting someone physically Relationships-trust If I trust someone today, they will betray me later. Disrespect Vulnerability My Anger Confrontation Being a victim Whenever I hurt emotionally, I do whatever it takes it feel better. When I am angry, my emotions are extreme and out of control
    44. 44. Trigger 1 Conscious Processing Trigger 2 Unconscious processing Fears Avoids Compound Core Beliefs Pressure situations (confrontation, consequences, anything that triggers victim stuff) Trust (Victim) No one will believe me Trusting others Everyone betrays my trust. In relationships, if the other person is not with me, then they are against me. Showing weaknesses Emotions (hurt, betrayal) Vulnerability Something is wrong with me Showing emotions (especially hurt and anger) I try to control my feelings and not show my grieving, loss, sadness; but it eventually comes out in a rush of emotions
    45. 45. Compound Core Belief and Corresponding Behavior(s) <ul><li>BORDERLINE PERSONALITY DISORDER </li></ul><ul><ul><li>Everyone betrays my trust…always. </li></ul></ul><ul><ul><li>If I trust someone today, they will betray me later…always. </li></ul></ul><ul><ul><li>Whenever I hope, I will become disappointed…always. </li></ul></ul><ul><ul><li>When I am angry, my emotions are extreme and out of control…always, </li></ul></ul><ul><li>Behavior(s) </li></ul><ul><li>Doesn’t trust people or engage in relationships. </li></ul><ul><li>Reserved, distanced, and blunted in relationships. </li></ul><ul><li>Gives up and becomes negative at any “bump” or disappointment. </li></ul><ul><li>Dysregulates, displays anger quickly. </li></ul>
    46. 46. <ul><li>BORDERLINE PERSONALITY DISORDER </li></ul><ul><ul><li>When I hurt emotionally, I do whatever it takes to feel better…always. </li></ul></ul><ul><ul><li>Life at times feels like an endless series of disappointments followed by pain…always. </li></ul></ul><ul><ul><li>I try to control my feelings and not show my grieving, loss, sadness, but eventually it comes out in a rush of emotions…always. </li></ul></ul><ul><ul><li>In relationships, if the other person is not with me, then they are against me…always. </li></ul></ul><ul><li>Behavior(s) </li></ul><ul><li>Dysregulates, displays anger quickly. </li></ul><ul><li>Will clown or “mess around,” or disengage. </li></ul><ul><li>Feels and acts depressed. </li></ul><ul><li>After disturbing family phone calls, becomes angry and aggressive. </li></ul><ul><li>Vacillates through all or nothing thinking. </li></ul>
    47. 47. Compound Core Belief and Corresponding Behavior(s) <ul><li>DEPENDENT PERSONALITY DISORDER </li></ul><ul><ul><li>If I am not loved, I am unhappy…always. </li></ul></ul><ul><ul><li>I am helpless and cannot make it on my own…always </li></ul></ul><ul><li>AVOIDANT PERSONALITY DISORDER </li></ul><ul><ul><li>I am inadequate; I will do whatever I must to hide it…always. </li></ul></ul><ul><ul><li>I would rather do anything to avoid failing because I cannot succeed…always. </li></ul></ul><ul><li>Behavior(s) </li></ul><ul><li>Emotion vacillates, between extremes of idealization and devaluation.. </li></ul><ul><li>Sadness, anger </li></ul><ul><li>Distances self, anger and aggression. </li></ul><ul><li>Anger, outbursts, emotional dysregulation. </li></ul><ul><li>(but accepts responsibility for his sexual offending behaviors). </li></ul>
    48. 48. Compound Core Belief and Corresponding Behavior(s) <ul><li>ANTISOCIAL PERSONALITY DISORDER </li></ul><ul><ul><li>Unless you have a videotapes of me, you cannot prove I did it….always. </li></ul></ul><ul><ul><li>If he/she can’t take care of themselves, they get what they deserve…always. </li></ul></ul><ul><li>HISTRIONIC PERSONALITY DISORDER </li></ul><ul><ul><li>I am so exciting, others want to be around me…always. </li></ul></ul><ul><ul><li>When I am bored, I need to become the center of attention…always. </li></ul></ul><ul><ul><li>If I act silly and entertain people, they won’t notice my weakness…always. </li></ul></ul><ul><li>Behavior(s) </li></ul><ul><li>Denial of small areas of responsibilities. </li></ul><ul><li>High opinion of self. </li></ul><ul><li>Anger, silliness. </li></ul><ul><li>Silly in groups and other tense situations. </li></ul>
    49. 49. The Case Conceptualization: <ul><li>Personal Reactive-External Fears </li></ul><ul><li>Avoids </li></ul><ul><li>Triggers </li></ul><ul><li>Situational Analysis </li></ul>Remember: &quot;For every complex problem there is an answer that is clear, simple, and wrong.&quot;
    50. 50. Situational Analysis <ul><li>Situation: </li></ul><ul><li>Automatic Thought: </li></ul><ul><li>Meaning of Automatic Thought: </li></ul><ul><li>Physiological: </li></ul><ul><li>Emotions: </li></ul><ul><li>Behaviors: </li></ul>
    51. 51. Questions?
    52. 52. The MDT Method Treatment
    53. 53. Functionally Based Treatment IDENTIFY NEW BELIEF SYSTEM IDENTIFY HEALTHY ALTERNATIVE THOUGHTS FUNCTIONAL ALTERNATIVE COMPENSATORY STRATEGY FUNCTIONAL REINFORCING BEHAVIOR(S) SPECIFIC FUNCTIONAL TREATMENT INDIVIDUAL THERAPY TO MILIEU VALIDATE/ CLARIFY/ REDIRECT (VCR) I can trust some people some times. I am adequate. I can balance myself. When I hurt emotionally I can balance myself. My anger can be balanced. If others disagree, they may not be against me. I can take a risk to feel. I can balance my pain. I can deactivate my anger. I will take small steps and measure others…trust level. I accept others’ faults; they accept mine. Practice rational thought and balance. Identify physiological triggers, rank – identify cognitions and anticipated events. Work on scales of trust with therapist to develop alliance. Work on balance of belief scales. Identify my balance thoughts. Practice through imagined exposure to all physiological & cognitive triggers Try to trust one staff, Ms. Margaret. Pick one issue and take a risk one step at a time, in group. Identify issues that cause pain and practice balance. Practice mode activation with staff in vivo. Identify when physiological triggers initiate. Identify continuum of fear activation. Identify when beliefs go out of balance. It’s okay to not trust some people at times, identify one person he does trust some of the time and use scale of trust to measure trust daily It’s okay to make mistakes, help him identify areas of adequacy and use belief scales to balance It’s okay to feel overwhelmed by emotions, identify thoughts/ beliefs to balance emotions It’s okay to feel angry, identify physiological system and beliefs to slow down, prevent, or reduce escalation Use belief scales to balance beliefs
    54. 54. Functionally Based Treatment <ul><li>Identify New Belief System </li></ul><ul><li>Identify Healthy Alternative Thoughts </li></ul><ul><li>Functional Alternative Compensatory Strategies </li></ul><ul><li>Functional Reinforcing Behaviors </li></ul><ul><li>Specific Functional Treatment, Individual Therapy to Milieu </li></ul><ul><li>Validate/ Clarify/ Redirect (VCR) </li></ul>
    55. 55. Validation: <ul><ul><li>Defined by Linehan (1997) as the therapist communicating to the client that the client’s responses make sense and are understandable within the client’s current life context or situation. The therapist has to uncover the validity within the client’s response, sometimes amplify it, and then reinforce it. Linehan goes further to note this importance of understanding that validation is about acknowledging that which is valid and that something may be valid even if it is not scientific or empirical. The focus is on the client’s experience. Balance the validation of truth with the possibility of the other person’s truth. </li></ul></ul>
    56. 56. Validation: <ul><li>Levels of Validation . </li></ul><ul><ul><li>Level 1 . Active Observing. </li></ul></ul><ul><ul><li>Level 2 . Reflecting the Observed. </li></ul></ul><ul><ul><li>Level 3 . Articulating the Unobserved. </li></ul></ul><ul><ul><li>Level 4 . Validating in Terms of the Past or of Biology. </li></ul></ul><ul><ul><li>Level 5 . Validation in Terms of the Present. </li></ul></ul>
    57. 57. Redirect: <ul><li>Youth’s belief Other’s belief or source of conflict </li></ul><ul><li>Dysregulation </li></ul><ul><li>Youth’s belief #1 Youth’s belief #2 </li></ul><ul><li>Dysregulation </li></ul><ul><li>Dichotomous belief </li></ul>
    58. 58. Identify New Belief System Identify Healthy Alternative Thoughts Functional Alternative Compensatory Strategy Functional Reinforcing Behavior(s) Specific Functional Treatment Individual Therapy to Milleu Validate/ Clarify/ Redirect (VCR) I can trust some people some times. If others disagree, they may not be against me. I will take small steps and measure others… trust level. Work on scales of trust with therapist to develop alliance. Try to trust one staff, Ms. Margaret. It’s okay to not trust some people at times, identify one person he does trust some of the time and use scale of trust to measure trust daily I am adequate. I can balance myself. I can take a risk to feel. I accept others’ fault; they accept mine Work on balance of belief scales. Pick one issue and take a risk one step at a time, in group. It’s okay to make mistakes, help him identify areas of adequacy and use belief scales to balance.
    59. 59. Therapeutic Mindfulness <ul><li>Awareness </li></ul><ul><li>Of present experience </li></ul><ul><li>With acceptance </li></ul><ul><li>Each component supports the other (like a three legged stool, if you remove one the it will fail.) </li></ul>
    60. 60. Mindlessness
    61. 61. Mindfulness Can Help Us <ul><li>To see and accept things as they are. </li></ul><ul><li>To loosen our preoccupation with “self”. </li></ul><ul><li>To experience the richness of the moment . </li></ul><ul><li>To become free to act skillfully. </li></ul>
    62. 62. Mindfulness of Anxiety <ul><li>Noticing prevalence of anxious thoughts and feelings </li></ul><ul><li>Seeing the component parts </li></ul><ul><li>Noticing future-oriented catastrophizing </li></ul><ul><li>Noticing aversion responses </li></ul><ul><li>Staying with experience is exposure treatment </li></ul>
    63. 63. The MDT Client Workbook Table of Contents Chapter 1. Commitment To Treatment- Mindfulness Chapter 2. Responsibility Chapter 3. Belief Analysis (Compound Core Beliefs) Chapter 4. Modes Chapter 5. MDT and Reactive Anger, Aggression and Impulse Control Chapter 6. Beliefs and Problem Behaviors Chapter 7. Problem Behaviors and MDT Chapter 8. Substance Abuse Chapter 9. Developing Empathy Chapter 10. Becoming a Survivor
    64. 64. Chapter 1: Commitment to Treatment <ul><li>What is treatment?_________________________________________________________________________ </li></ul><ul><li>Rate your level of commitment to treatment using the following scale: 1-100% (1%=no commitment; 100%=total commitment). Rate your level of commitment on a __________ basis (this will be determined by your therapist). </li></ul>DAY/ DATE LEVEL OF COMMITMENT DAY/ DATE LEVEL OF COMMITMENT
    65. 65. Chapter 1: Commitment to Treatment <ul><li>Trust Scales </li></ul><ul><li>What does trust mean to you? __________________________________________________________________________________________ </li></ul><ul><li>__________________________________________________________________________________________ </li></ul><ul><li>Rate your level of trust for three significant people in your life (identified with your therapist) using the following scale: 1-10 (1=no trust; 10=total trust). Rate your level of trust for each person on a __________ basis (this will be determined by your therapist). </li></ul>Level of Trust Person # 1 Name: Person #2 Name: Person #3 Name: Day Date rate Why? rate Why? rate Why?
    66. 66. Chapter 1: Commitment to Treatment <ul><li>MDT DAILY RECORD </li></ul><ul><li>Daily Record </li></ul><ul><li>Use the following scale to rate each of the categories: </li></ul><ul><li>Never/or Not Intense - 0 1 2 3 4 5 - Always/or Intense </li></ul><ul><li>Rate Daily </li></ul><ul><li> </li></ul>Day/ Date Re-Offend Y/N Hurt Some-one Y/N Urges Y/N Hurt or Pain Y/N Afraid Y/N Angry Y/N Other Feeling Truth Y/N Used Relaxa-tion Skill Sets Y/N Helped Y/N
    67. 67. Chapter 1: Commitment to Treatment Daily Record Please rate the individual therapy session: Not Helpful - 0 1 2 3 4 5 – Very Helpful Use the scale to the right Before the session: How helpful did you think the session would be? After the session: How helpful was the session? Please list beliefs that have been activated this week:
    68. 68. Chapter 2: Responsibility <ul><li>I am % responsible My victim is % responsible </li></ul>LIST OF MY RESPONSIBILITY LIST OF MY VICTIM’S (OR OTHER’S) RESPONSIBILITY Example: I accept responsibility for provoking my peer. My peer should have ignored me, rather than assaulting me.
    69. 69. Chapter 3. Belief Analysis <ul><li>1. Write down beliefs related to your thoughts (at any given time). </li></ul>2. Write in the space below your beliefs and behaviors at any given time. THOUGHTS BELIEFS BELIEFS BEHAVIORS
    70. 70. Chapter 3. Belief Analysis <ul><li>TFAB (Triggers, Fears, Avoids, Beliefs) </li></ul><ul><li>8. The triggers to my fears, worries, anxieties are as follows (complete with your therapist): </li></ul>Trigger 1(T1) Things you know that make you anxious or scared. Trigger 2 (T2) Things you don’t know (but others identify) that make you anxious or scared. This is often what you avoid. Fears
    71. 71. Chapter 4. Modes <ul><li>Modes </li></ul><ul><li>What is a Mode? </li></ul><ul><li>A mode is different than your mood. A mood is how you feel. It is your emotions and feelings. A mode is your entire self. It includes your thoughts, feelings, beliefs and underlying physiological self. </li></ul><ul><li>A mode includes the total of all of your life experiences that create part of how you understand life. These experiences create a – or way you see, interpret and understand life. These experiences create an unconscious interpretation of life’s events. </li></ul><ul><li>So, you mood is only one aspect of your mode. </li></ul>
    72. 72. Chapter 5. MDT and Reactive Anger, Aggression, and Impulse Control <ul><li>Aggression and Violence </li></ul><ul><li>Often teenagers and adults say, “I just got mad – it just happened, I got real angry and hit him.” </li></ul><ul><li>YET EVERYTHING YOU DO STARTS WHEN YOUR MODES ARE ACTIVATED. </li></ul><ul><li>There are two types of aggression: </li></ul><ul><li>planned way ahead AND </li></ul><ul><li>2) thought created on-the-spot (or short-thoughted). </li></ul>
    73. 73. Chapter 5. MDT and Reactive Anger, Aggression, and Impulse Control <ul><li>MDT and Reactive Anger, Aggression and Impulse Control </li></ul><ul><li>What were your activated beliefs? </li></ul><ul><li>1._______________________________________________________________________________________________________________________ </li></ul><ul><li>2_______________________________________________________________________________________________________________________ </li></ul><ul><li>Now, were these beliefs tied to past experiences? </li></ul><ul><li>________________________________________________________________________________________________________________________ </li></ul><ul><li>How were these beliefs related to your memories of past events in your life? </li></ul><ul><li>________________________________________________________________________________________________________________________ </li></ul>
    74. 74. Chapter 6. Beliefs and Problem Behaviors <ul><li>Core Belief Balancing Exercise </li></ul><ul><li>Balancing beliefs is about accepting what is there and learning to balance, not change your beliefs. First identify your compound core belief, then balance it. </li></ul><ul><li>Compound Core Belief: </li></ul><ul><li>________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ </li></ul><ul><li>New Balanced Belief: </li></ul><ul><li>________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ </li></ul>
    75. 75. Chapter 6. Beliefs and Problem Behaviors SUPPORT OF COMPOUND CORE BELIEF SUPPORT OF NEW BALANCED BELIEF % Of Belief of Old Compound Core Belief % % Of Belief of Alternative Belief %
    76. 76. Chapter 6. Beliefs and Problem Behaviors <ul><li>Beliefs, Feelings, and Behaviors Worksheet </li></ul><ul><li>At the beginning of a session, your therapist will prompt you to discuss beliefs, feelings, and behaviors. </li></ul><ul><li>Your therapist will help you identify how compound core beliefs can produce self-defeating feelings, leading to self-destructive behaviors. </li></ul><ul><li>Complete the form based on the previous event/ discussion. </li></ul><ul><li>Continue the session using the previous example to demonstrate how the process works. </li></ul><ul><li>Homework – Complete the new form based on the results of the session. </li></ul>Beliefs Feelings Behaviors
    77. 77. Chapter 7. Problem Behaviors and MDT <ul><li>Problem Behaviors and MDT </li></ul><ul><li>You will now learn how to apply MDT to your problem behaviors. </li></ul><ul><li>Use your completed work from your Mode Chapter (Chapter 4), as well as your Problem Behavior Compound Core Beliefs (Chapter 3). </li></ul><ul><li>Review your TFAB from the previous chapter: </li></ul>
    78. 78. Chapter 7. Problem Behaviors and MDT T1 T2 F A B
    79. 79. Chapter 8. Substance Abuse <ul><li>Drugs, Alcohol, Substances </li></ul><ul><li>If you were involved in drinking, smoking, snorting, shooting, huffing….or whatever method you use/used to get high. Drugs and addictions involve many pathways to get high. We are going to address your use of addiction from the MDT methodologies. This is considered a support to your other substance abuse therapy, not a substitution. </li></ul><ul><li>Let’s begin by examining your drug of choice. Please list the substances that you have taken. </li></ul><ul><li>________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ </li></ul>
    80. 80. Chapter 8. TFAB (TRIGGERS, FEARS, AVOIDS, BELIEFS) <ul><li>Which Triggers, Fears, Avoids and Beliefs relate to substances? Please use the CD column to write down your ideas. </li></ul>T1 T2 FEARS AVOIDS CCB CD
    81. 81. Chapter 9. Developing Empathy <ul><li>There are many types of abuse or neglect that can change the course of your life. Abuses such as the following; sexual abuse, physical abuse, emotional abuse, neglect, and bullying and intimidation. </li></ul><ul><li>Each of these types of abuse has similarities and some difference. Any or all of these abuses hurts you and changes how you think, feel and see the world. </li></ul><ul><li>Victims of abuse go through three separate periods of adjustment – immediate, intermediate and long-term – in which each period has a set of painful problems. </li></ul>Empathy
    82. 82. Chapter 9. Developing Empathy <ul><li>Introduction : This section presents six interviews with young males who were abused in different ways. They includes victims of sexual abuse, emotional abuse, physical abuse, and bullying. Listen to the interview with each victim and respond to the questions in the exercises which follow them. When you read and listen to these interviews, use the empathy skills that you are developing. Listen as if it were you were the victim telling the story – putting yourself in the victim’s place. </li></ul>Interviews
    83. 83. Chapter 10. Becoming a Survivor <ul><li>Use a cassette tape recorder (obtain one from your advocate or therapist) and tell your story. Use your work in the Empathy chapter and the “tellings” as your guide. Talk about your life, as you remember, prior to your victimization(s). Try to discuss the particulars of your problem behavior. Include information such as: your perpetrator, how old you were, who you could or could not tell, how you held things inside of yourself, how learned to shut down your emotions, your anger, how your problem behavior led to your perpetration. </li></ul>
    84. 84. Chapter 10. Becoming a Survivor <ul><li>Treatment Goal </li></ul><ul><li>Now your victim work has only begun. With your therapist you need to develop a treatment goal, and in individual and group therapy you need to continue work on your treatment. </li></ul><ul><li>Examine your TFAB and with your therapist, understand how your fears were developed from your victimization. Your fears are responses to trauma that was inflicted on you by your abuser. </li></ul>
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