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DBT Training 2 Day Workshop
 

DBT Training 2 Day Workshop

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DBT Training 2 Day Workshop DBT Training 2 Day Workshop Presentation Transcript

  • Dialectical Behavior Treatment (DBT) “ The Basics”
  • DBT IS A COGNITIVE BEHAVIORAL TREATMENT APPROACH • Dialectical Behavior Treatment (DBT) is a cognitive-behavioral treatment approach with two key characteristics: a behavioral, problem-solving focus blended with acceptance-based strategies, and an emphasis on dialectical processes.
  • DBT IS LISTED IN THE NATIONAL REGISTRY OF EVIDENCEBASED PROGRAMS AND PRACTICES • DBT is recommended by the National Registry of Evidence-based Programs and Practices for psychosocial treatment, cooccurring disorders, and mental health inpatient treatment. It is the number one evidence-based treatment for suicide prevention.
  • NREPP Criteria for Rating Quality of Research • • Each reviewer independently evaluates the quality of Research for an intervention's reported results using the following six criteria: 1. Reliability 2. Validity 3. Intervention Fidelity 4. Missing Data and Attrition 5. Potential Confounding Variable 6. Appropriateness of analysis Reviewers use a scale of 0.0 to 4.0, with 4.0 being the highest rating given.
  • Quality of Research Ratings by Criteria (0.0-4.0 scale) Outcome Reliability Validity Fidelity Missing Data /Attrition Confounding Variables Data Analysis Overall Rating 1.Suicide attempts 3.8 3.8 4.0 3.5 3.0 4.0 3.7 2.Nonsuicidal self- 3.8 3.8 3.3 2.9 2.6 3.7 3.3 4.0 4.0 3.0 3.2 2.7 3.7 3.4 4.0 4.0 3.7 2.5 2.7 3.8 3.4 3.6 3.6 3.5 2.8 2.8 3.5 3.3 3.6 3.6 3.0 2.3 2.8 4.0 3.2 injury 3.Psychosocial adjustment 4.Treatment retention 5.Drug use 6.Symptoms of eating disorders
  • PURPOSE • DBT teaches people how to use their strengths to manage their emotions and to think, behave, and function in life more effectively to create a life they love… “ A LIFE WORTH LIVING”
  • TREATMENT STRUCTURE • Describes who on the team does what and when. Mode Purpose Person When 1. Commitment, Participation, Practice, and Generalization Accept self and others as they are and the environment as it is and create a more effective way of being. Individual, Partner, Client, Patient As often as possible 2. Medication Support 3. Individual Therapy 4. Family Therapy 5. Group Therapy Assess, dispense, monitor medications Assess and address the underlying issues relating to Client’s behavior Psychiatrist Nurse Social Worker/ Therapist/ Intern As Scheduled 1-2x’s/wk 2-4x’s/mo 1x/wk 6. DBT Skills Training and Practice 7. Skills Generalization Teach and practice effective coping skills Co-lead groups. Coach Client’s on the floor RT/RT Aide MHRS MHW 4-7x’s/wk Daily
  • DBT Targets Pre-Treatment: Develop a relationship Orient to treatment Elicit a commitment to change 4. 5. 7. Stage 1: 1. 2. 3. Decrease life-threatening behaviors to self and others. Decrease treatment destroying/interfering behaviors (e.g. non-med compliance, nonattendance, non-participation) Decrease quality of life interfering behaviors such as substance abuse/dependence, that contribute to functional impairments in life. Increase effective behavioral skills in areas of: a. Core mindfulness b. Distress tolerance c. Emotion regulation d. Interpersonal effectiveness e. Self-management 8. Decrease post-traumatic stress and/or underlying symptoms that lead to behaviors that contribute to functional impairments in life. 6. Stage 2: Stage 3: 9. Increase, strengthen, and generalize self-validation and problem solving skills. 10. Achieve individual goals.
  • DIALECTICAL • Dialectical simply means looking at both sides – your side and my side – in search of a side we both can work on to attain our goal - “our side”.
  • What is this? Who Is Right?
  • DIALECTICAL STRATEGIES • Effective use of dialectical strategies ensure that the provider is never trapped in an argument but free to assist the client to move out of their rigid and ineffective positions. They are designed to help clients move closer to their goals with the least amount of resistance.
  • PROVIDER CHARACTERISTICS A Nurturing Unwavering Centeredness C C C E H P A T N A G N E C E Compassionat e Flexibility Benevolent Demanding
  • DBT ASSUMPTIONS • Assumptions are beliefs that are acted out on purpose. DBT assumptions are not true or false, right or wrong, they just work better according to the research.
  • DBT ASSUMPTIONS • People Need To Feel Safe and Significant: Our personal well being is enhanced when we feel safe and significant. • Dignity And Respect Are Basic Human Rights That Are Given Freely And Not Earned. The best way to create respect is to genuinely express it to ourselves and others. • People Are Perfect, Whole, And Complete. There is nothing wrong . There never has been, and there never will be. People respond naturally to their own DNA, life development, and environment.
  • DBT ASSUMPTIONS • People Can Create New Ways Of Being. We do not have to be slaves to our past. We have the option, if we choose, to create our present reality out of possibilities from our future and become the conscious authors of our own life stories. • Change Requires Acceptance. A focus on both acceptance and change are necessary for either to occur. The first step towards creating something new is to accept what is. • People Are Doing The Best They Can. Based upon our genetic code, life development, and the influence of our environment since birth, our behaviors make perfect sense. “Shoulding” on self or others is rarely effective.
  • DBT ASSUMPTIONS • People Want To Improve. If we could do better we would. People want the best out of life even if they do not know how to get it. • People Can Do Better, Try Harder, And Be More Committed To Create. There is no substitute for hard work, practice, and perseverance in order to achieve mastery. • Although People May Not Have Caused All Of Their Problems, It Is Up To Them To Accept Them And/Or Solve Them. To search for blame is futile. Although we may not be able to change on our own, it is ultimately up to us to take full responsibility for our own thoughts, feelings, and actions.
  • DBT ASSUMPTIONS • Pain And Stress Are Inevitable Parts Of Life. Accepting pain and stress as inevitable parts of life relieves us from emotional suffering. • The Present Moment Is All That Exists. Our past and future do not exist in the present and never have. Right now is the only time and place you can learn from your past, create from your future, and do what works. • Thoughts Are Nothing From Which Everything Is Created. All I know is that I know nothing. It is from nothing that everything is created. • Emotions Can Be Regulated. Harness the energy of you emotions and you can be at peace, in love, and full of joy even if you live in hell.
  • DBT ASSUMPTIONS • People Can Create New Habits In All Relative Contexts. The most effective way to change an old habit is to create a new one to take its place. • People Cannot Fail. If something didn’t work we have simply not found the best way to make it happen. • People Need Support. Effectively supporting one another involves capitalizing on each others strengths and compensating for each others weaknesses.
  • DIALECTIC STRATEGIES “KEEPING A BALANCE” • • • • • • • Entering The Paradox. The “And” vs. “But” Response. The Use of Metaphor. The “It’s like…” Response. The Devil’s Advocate Technique. The “Are you sure?” Response Extending. The “Wow, that’s pretty serious!” Response Activating “Wise Mind”. The “Let’s look at what is.” Response. Making Lemonade Out of Lemons. The “That’s great!” Response. Allowing Natural Change. The “That was then, this is now.” Response.
  • STYLISTIC STRATEGIES: “HOW TO PROVIDE TREATMENT” • RECIPROCAL: Join – – – – Responsive Self-Disclosing Warm Engagement Unconditional Positive Regard – Authentic – Genuine • IRREVERENT: Unbalance – – – – – – – Unorthodox Reframing Plunging In Confrontational Tone Calling The Bluff Intensity vs. Silence Omnipotence vs. Impotence Confront, Challenge, Confuse
  • CORE STRATEGIES “WHAT TO DO” • VALIDATION – – – – – – – – – – Radical Acceptance Reflecting/Understanding Clarifying/Summarizing Probing/Questioning Reassuring/Cheerleading Cognitive Validation Emotion Validation Behavior Validation Genetic Validation Environmental Validation • PROBLEM SOLVING • Orienting & Commitment • Behavior Analysis – Insight – Didactic • Change Procedures: – – – – Contingency Management Skills Training Cognitive Restructuring Exposure – – – Create Adaptive Solutions Rehearse Troubleshoot • Solution Analysis
  • CASE MANAGEMENT “WHY WE PROVIDE TREATMENT” • INTERVENE IN THE ENVIRONMENT – Observing Limits – Conditions Mandating Intervention – Providing Information Independently Of Client – Client Advocacy – To Give Assistance When Most Needed • CONSULTATION TO THE CLIENT – Rationale And Spirit – The “Treatment Team” Vs. “Everyone Else” – Orient To The Approach – How To Manage Other Professionals – How To Handle Family And Friends
  • DBT SKILLS MODULES SKILL Core Mindfulness: Distress Tolerance: Emotion Regulation: Interpersonal Effectiveness: PURPOSE To get in and stay in the moment in order to make a wise choice. To stay in the moment without making matters worse. To gain mastery over the response to my emotions so that they do not determine my behavior. To get what I want while demonstrating respect for relationships and for myself.
  • PROVIDER CONSULTATION • Scheduled opportunities for providers to review strategies and skills, exchange information, and give and receive support in an effort to avoid burnout, strengthen unity, increase skills, and maintain adherence to the DBT model.
  • PROVIDER CONSULTATION AGREEMENTS • Consistency Agreement: We agree to present a unified treatment approach while at the same time acknowledge that each provider has a unique style and use of self. We agree that the job of the treatment team is not to provide a stress-free environment for clients. Mix-ups and inconsistencies will inevitably occur and are expected; they are seen as opportunities for clients and providers to practice skills taught in DBT. • Training Towards Mastery Agreement: We agree to learn and practice DBT Strategies and Skills and apply them to our clients, colleagues, and ourselves on a daily basis while focusing on effective mastery. We agree to be coachable and take direction from our supervisors and other DBT coaches.
  • PROVIDER CONSULTATION AGREEMENTS • Dialectical Agreement: We agree to practice a dialectical philosophy. We agree to assume that no one has a corner on the “truth”, and therefore we agree to keep an open mind to discover what works best in the moment. When strong differences of opinion arise, we agree to work towards clarifying the outcome to be achieved, validate all perspectives as “what is” and search for the synthesis that will assist us in realizing our desired outcome. • Consultation to the Client Agreement: We agree to consult with our clients on how to interact with other providers and milieu staff rather than tell other providers and staff how to interact with our clients. We agree to coach our clients to use effective skills that will empower them to resolve any issues they may have and not to solve their problems for them.
  • PROVIDER CONSULTATION AGREEMENTS • Radical Acceptance Agreement: We agree to radically accept without judgment our client’s and each other’s behavior. We agree to the fundamental assumption that we are all trying our best and want to improve. When one or more of us is unable to come up with such an interpretation, other team members agree to assist in doing so, while validating the others. • Fallibility Agreement: We agree to apply the principles of DBT to our clients, to one another, and to ourselves. We also assume that all providers are fallible and that we will all inevitably violate one or more of our agreements at one time or another. When this occurs, we agree to take responsibility for our violation of agreement, repair any damage caused, and seek a more effective behavior.
  • DBT Training Opportunities
  • BASIC STRATEGIES TRAINING once per quarter that teach and practice • Six training topics held basic ways to accept others and solve problems that everyone on the team can use. 1. ORIENTATION: People do better if they first have an idea of where they are going and what is expected of them. The intent of orientation is to describe the road to be traveled then get a commitment to take the trip. 2. VALIDATION STRATEGIES: How to genuinely hear another person’s point of view and accept them just the way they are without judgment. 3. DIALECTICAL STRATEGIES: How to help others move closer to their goals with the least amount of resistance. 4. ORIENTING AND COMMITMENT STRATEGIES: How to get a commitment from the person you are working with to do what it takes to make a life change. 5. CONTINGENCY MANAGEMENT STRATEGIES: Contingency simply means if you do “a”, you will often get “b”. Contingency management strategies teach you how to change behaviors in yourself and others. 6. SKILLS TRAINING STRATEGIES: How to teach and practice
  • SKILLS COACHING • Six training sessions held once per quarter that teach and practice how to teach, coach, provide practice, and document DBT and other adaptive skills. 1. MINDFULNESS: How to use your whole brain to get present to the moment and make a wise choice and do what works. 2. DISTRESS TOLERANCE: How to stay in the moment without making it worse. 3. EMOTION REGULATION: How to manage your emotions so they don’t manage you. 4. INTERPERSONAL EFFECTIVENESS: How to get what you want while keeping respect of self and others.
  • ADVANCED STRATEGIES TRAINING • You guessed it! Six training sessions held once per quarter that teach and practice advanced ways to go about accepting others and solving problems. 1. COGNITIVE RESTRUCTURING STRATEGIES: How to help someone change the way they think. 2. EXPOSURE STRATEGIES: How to help someone overcome fear of just about anything. 3. BEHAVIOR ANALYSIS STRATEGIES: How to help someone to see things as they are without judgment. 4. SOLUTION ANALYSIS STRATEGIES: How to help others to create and practice what works best for them. 5. STYLE STRATEGIES: How to say or do something in ways that get the results you want. 6. CASE MANAGEMENT & CONSULTATION STRATEGIES: How to coach others to care for themselves while providing ways to support and encourage each other.
  • INSTRUCTORS TRAINING • Pre-requisites are the completion of the Basic & Advanced courses. Instructor training certificates will be issued to those who assist and lead in both training courses under the supervision of a master trainer.
  • DBT Treatment Overview 1. Complete assessment and behavioral analysis and review as a 2. 3. 4. 5. 6. 7. treatment team. (Therapists, Interns) Provide weekly skills and rehearsal groups as a requisite of therapeutic services. (Trainers) Complete additional behavior analysis as new problem behaviors arise and rehearse created solutions. (Therapists, Interns) Provide ongoing skills coaching during everyday life. (All Staff) Address PTSD and/or underlying symptoms that contribute to functional impairments (Therapists, Interns) All interactions focus on Increasing, strengthening and reinforcing self-validation and problem solving skills achieve individual goals (All staff) Provide regular Provider Consultation.
  • COMMUNICATION & VALIDATION • Validation and problem-solving strategies form the core of DBT. All other strategies are built around them. • Validation strategies are the most obvious and direct acceptance strategies in DBT. • They are designed to engage the Client in trying to understand his actions, emotions, and thoughts or implicit rules. • The Provider communicates to the Client that his responses are understandable and that they make sense in light of his history and/or current life context or situation. • The Provider accepts the Client and communicates this acceptance by taking the Client’s responses seriously and not discounting or trivializing them.
  • COMMUNICATION & VALIDATION ACCEPTANCE HIGH FACILITATIVE RESPONSES VALIDATION 5. Reassuring/Cheerleading “I believe in you…I know you can do it.” “You have everything it takes to make this happen.” “I believe in you whether you do or not.” 6. Interpreting/Analyzing “What do you see going on here?” “What does this mean to you?” “What is it about this that makes you upset?” 7. Advising/Evaluating “If I were you… I would” “The way I see it is...” “From my perspective...” 8. Commanding/Directing “Please…” “I need you to…” “I want you to…Stop…Come…Be quiet…etc.” CHANGE LOW FACILITATIVE RESPONSES PROBLEM SOLVING
  • COMMUNICATION & VALIDATION ACCEPTANCE CHANGE HIGH FACILITATIVE RESPONSES VALIDATION 1. Radical Acceptance “That makes perfect sense to me.” “Of course how could you feel any other way?” “Anyone would have done the same thing.” 2. Reflecting/Understanding "You seem disappointed." "You're upset right now and you want to leave the group." "You’re proud of what you’ve done!" 3. Clarifying/Summarizing "Let me see if I got what you are trying to say..." "Is what you’re saying...?” “So what you’re saying is…” 4. Probing/Questioning “Tell me about your day…” "What was going on before everything ‘hit the fan’?” LOW FACILITATIVE RESPONSES “Tell me what happened…” PROBLEM SOLVING
  • HIGH & LOW FACILITATIVE RESPONSES • No single response can be classified as good or bad, right or wrong. All of the above responses may be effective at one time or another. The goal is to be aware of the effectiveness of the responses you are using as you are using them. • Treatment that focuses only on change may lead the Client to mistrust and invalidate their responses to events, thus resulting in an avoidance to change. • A treatment that focuses only on unconditional acceptance and validation of the Client’s behaviors may lead to reinforcing the Client’s problems, resulting in the Client giving up hope in the possibility of change. • Thus, the primary focus of DBT is teaching the Client to both validate himself and to change.
  • LEVELS OF VALIDATION • Active Observing • Reflection • Direct Validation
  • Active Observing • The essence is that the Provider is awake enough to observe what the Client is thinking, feeling, and doing while letting go of any previously known history, evaluations, or comments made about the Client. • Push away distractions; make eye contact; use body language get on the same level; knee-toknee, shoulder to shoulder; and use voice tones that demonstrate to the Client that he is acknowledged and being heard
  • Reflection • Accurately and non-judgmentally summarize, clarify, understand, and mirror the Client’s own thoughts, feelings, assumptions, and behaviors. • Provide accurate emotional empathy; understanding of (but not necessarily agreement with) beliefs, expectations, or assumptions. “You look disappointed” (Reflecting and Understanding) • Provide the Client a chance to say that the Provider is wrong and he or she is not right until the Client agrees. “So what I hear you saying is…” (Clarifying and Summarizing) • In reflecting, the Provider often states what the Client observes but is afraid to say or admit. This simple act of “saying it first”, can be a powerful act of validation. • Find the wisdom or kernel of truth/motivation, in the behavior. “I can see why you did that. Am I right in saying you wanted to fit in?”
  • Direct Validation • Find the stimuli in the current environment that support the Client’s behavior. • Even though information regarding all the relevant causes may not be available, communicate that the Client’s thoughts, feelings, and actions make perfect sense in the context of the Client’s current experience and life to date. • Reflect the wisdom or validity of the Client’s response, and communicate that the response is understandable. (e.g. physiology, brain chemistry, drug use, culture, rules, etc.) • Behavior is adaptive to the context in which it occurs, and the Provider must find the wisdom of that adaptation. In other words, there is a legitimate underlying reason and/or purpose for every behavior in every specific situation.
  • Direct Validation • Do not be blinded by the dysfunctional nature of a Client’s response but, instead, attend to those aspects of the response that may be either reasonable or appropriate to the context. • Search the Client’s responses for their inherent accuracy, appropriateness, or reasonableness before considering their more dysfunctional characteristics. Even if only a small part of the response is valid, search out that portion of the behavior and respond to it. • It is this third level that takes the most searching by the Provider and that defines validation most clearly. By finding the validity in the Client’s response, the Provider can honestly support the Client in validating himself. “It makes sense that you would want to escape from that ….and using drugs has worked for you before.”
  • EMOTION VALIDATION STRATEGIES • • • • • Validate Primary and Secondary emotions. Provide Opportunities For Emotional Expression. Teach Emotion, Observation, And Labeling Skills. Read And Clarify Emotions. Communicate The Validity Of Emotions. • Anti-DBT Tactics: – Insist on your own perception of Client’s feelings. – Criticize Client’s feelings. – Label feelings as irrational or distorted without acknowledging the kernel of truth. – Respond to painful emotions as something to get rid of. – Express only discomfort with Client’s painful emotions.
  • BEHAVIORAL VALIDATION STRATEGIES • Teach Behavior Observation And Labeling • • • • Skills. Identify The “SHOULD”. Counter The “SHOULD”. “It Is What It Is.” Accept The “SHOULD”. Validate The Client’s Disappointment In His Behavior. • Anti-DBT Tactics: – Impose your own behavioral preferences as absolute “shoulds” – Communicate that Client should feel, act, think differently than he does. – Communicate that others should be different.
  • COGNITIVE VALIDATION STRATEGIES • • • • • Elicit And Reflect Thoughts And Assumptions. Discriminate Facts From Interpretations. Find the “Kernel Of Truth”. Acknowledge “Wise Mind”. Respect Differing Values. • Anti-DBT Tactics: – Push a particular set of values or philosophical position on reality and truth. – Present a rigid view of events. – Unable to see reality from the perspective of the Client.
  • CHEERLEADING STRATEGIES • • • • • • • Assume the Best Provide Encouragement Focus On Capabilities And Strengths Modulate External Criticism Provide Praise and Reassurance Have Realistic Expectations And Deal Directly With Fears Of Insincerity Stay near in a crisis • Anti-DBT Tactics: – Over generalize, or overestimate Client’s capabilities. – Use cheerleading to “get rid” of Client. – Call Client a “manipulator”, or accuse him of “playing games”, “splitting”, and “not trying” either to his face or to other providers.
  • VALIDATING COMMUNICATION 1. Ask an open question–Validates the Story – Tell me what’s going on? 2. Clarify the response–Validates Reason Mind – So what I hear you say is… 3. Empathize the emotion–Validates Emotion Mind – So are you feeling…? 4. Radically accept-Validates the Being – That makes sense…of course…got it.
  • DIALECTIC STRATEGIES • The primary dialectical strategy is the balanced use of specific strategies and therapeutic positions by the Provider during interactions with the Client. Constant attention to combining acceptance with change, flexibility with stability, nurturing with challenging, and a focus on capabilities with a focus on limitations and deficits is the essence of this strategy. The Provider must respond to the Client just where he is and then be able to move quickly from strategy to strategy, alternating acceptance with change, control with letting go, confrontation with support, the carrot with the stick, a hard edge with softness, and so on in rapid succession.
  • DIALECTIC STRATEGIES • Clients tend to move away and thus change thoughts, responses, behaviors, etc. from whichever position the Provider tends to take. “Whichever side the Provider aligns himself with, the Client will usually feel impelled to leave.” Sherman (1961, pg 55) • The key idea guiding the Provider’s behavior is that for any point, an opposite or complementary position can be held. Thus, change may be facilitated by emphasizing acceptance and acceptance by emphasizing change. The idea is to keep the Client sufficiently off balance so that he cannot find a secure foothold to maintain his previous behavioral, emotional, and cognitive rigidity.
  • DIALECTIC STRATEGIES • Compared to the “Teeter-totter”: Move back (opposing the Client’s position) and the Client moves back (to validate his position) – move forward (validating the Client’s position) and the Client moves forward (to change his position) – by carefully moving back and forth between change and acceptance the Client and Provider will eventually find themselves in the middle of the teeter-totter and a new dialectic will present itself. • Compared to playing a game of “Chicken”: The one who moves with the most confidence and resolve forces the other to “change direction”. • Extremes and rigid behavior patterns are signals that a dialectic has not been achieved.
  • DIALECTIC STRATEGIES (How to position yourself on any side of a conversation and move someone to change.) • P - Entering The P aradox. The “And” vs. “But” Response • M - The Use of M etaphor. The “It’s like…” Response • D - The D evil’s Advocate Technique. The “Are you sure?” Response • E - E xtending. The “Wow, that’s pretty serious!” Response • A - A ctivating “Wise Mind”. The “Let’s look at what is.” Response • L - Making L emonade. The “That’s great!” Response • N - N atural Change. The “That was then, this is now.” Response
  • Entering The Paradox The “And” vs. “But” Response. • Both-and” is offered as an alternative to “either-or”. Both sides are accepted as valid. Behavior is simply seen as a way to solve problems. We either solve the problem, attempt solutions, make it worse, or accept it as it is. Forces Client and Provider to let go of rigid positions and inflexible ways, rules, regulations, and patterns of actions. – “You are perfect just the way you are and you must change if life is going to be different.” – “What you did worked very well for the moment and it caused more problems later on.” – “It makes perfect sense that you did what you did and you must learn a new way to avoid making things worse.”
  • The Use of Metaphor The “It’s like…” Response. • Simple analogies, anecdotes, parables, myths, or stories, are extremely important in DBT. They are usually more interesting and easier to remember than lecturing or instruction alone. When constructed properly, metaphors can be less threatening to the individual. Points can be made indirectly, in a way that softens their impact. Allow the Client to use the story in their own way, for their own purposes. Metaphor uses something the Client is familiar with to assist in understanding what is unfamiliar. – – “Emotions are like waves…they come…and they go.” “Using wise mind helps you find the calm inside the storm.” “Like riding a bike – you just “get it”. – “I am like a guide or coach. I will do my best to show you the way but I cannot walk the trail for you.”
  • Devil’s Advocate The “Are you sure?” Response. • Used best to counteract oppositional patterns. Used in the first several sessions to elicit a strong commitment to change. The Provider argues against change and commitment to therapy, because change is painful and difficult; this method is effective if it moves the Client to take the oppositional position in favor of change and commitment. The Provider argues in favor of the irrational belief, questioning why the Client does not agree. – – – “Are you sure you want to work that hard? “I mean, this isn’t going to be easy you know.” “Do you think you have what it takes?”
  • Extending The “Wow, that’s pretty serious!” Response. • The Provider takes extreme emotional expression literally and extends it further, taking the Client more seriously than he/she takes himself/herself. The emotional equivalent of the devil’s advocate strategy. The term “extending” is borrowed from martial arts. Extending allows the movements of a challenger to reach their natural completion, then extends the end point of the movement slightly further than it would go naturally leaving the challenger off balance and vulnerable to shift direction. First “blend” – accept or join or move with the client’s energy flow the direction it is going. Go to the natural conclusion of the response. Then “extend” – use the momentum to move the client further than he expected. – “Wow, if your going to kill somebody, I better get you to a hospital right away. We can’t have you going to jail for murder.” – “Wow, if you can’t control your behavior and none of these skills work, we need to get you to a more controlled facility.” – “These clothing rules are not fair! “You’re absolutely right we should start wearing uniforms so we all look exactly alike.”
  • Activating “Wise Mind” • The “Let’s look at what is.” Response. A person is in “reasonable mind” when he is approaching knowledge intellectually, is thinking rationally and logically, attends to empirical facts, is planful in his behavior, focuses attention, and is “cool” in his approach to problems. A person is in “emotion mind” when thinking and behavior are controlled primarily by his current emotional state. In “emotion mind,” reasonable, logical thinking is difficult and behaviors can be amplified to be congruent with current emotion. “Wise mind” is the integration of “emotion mind” and “reasonable mind”; Wise mind” must rule over the other two and Clients must be convinced that they are capable of doing this. – “All humans have “wise mind” in the same way we have hearts. Just because I cannot see my heart does not mean it does not exist. What does your wise mind say?” – “I’m not interested in what you think or feel to be true, I want to know what you “know” to be true. – “Knowing what you know, and knowing what you feel, what does your “wise mind” tell you to do?
  • Making Lemonade The “That’s great!” Response. • Take a problem and make it into an asset. The more difficult a Client acts in therapy, the better it is. After all, if problems didn’t show up in treatment, how could the Provider be helpful? Problems in life are opportunities to learn and practice new skills. Persistence in resisting change is exactly what will keep him going until he finds the “right” path. The skill is in finding the silver lining without denying that the cloud is indeed black. Making good tasting lemonade requires a fair amount of sugar. – Client: “I’m stuck here for six months”. Provider: “That’s great! That will give us a chance to learn all kinds of new skills and ways of being that you never could have learned if you had not ended up here!”
  • Allow Natural Change. The “That was then, this is now.” Response. • Change occurs naturally in many instances. One consistent reality of life is that it constantly changes. The Provider does not try to create the perfect environment with the perfect people doing all the right things so that the Client can learn. The Provider uses natural change as opportunity to learn, reinforce, and experience effective skills that help the Client to adapt. – Client: “I liked it better before! I hate the way it is now!” – Provider: “It did seem easier then. Now that then no longer exists and all there is now, what skills can you use now that will work?”
  • ORIENTING • The purpose of orienting is to provide precise information about what is to be learned before each instance of new learning, as well as a clarification of the conceptual model within which the learning will take place.
  • ORIENTING • It is important to provide information about the treatment process, explain DBT Agreements, procedures that will be employed, or requirements necessary in implementing a specific solution.
  • ORIENTING STRATEGIES • Orienting to the task at hand must be conducted • repeatedly during treatment as a general first step in repeated recommitments to treatment, to specific therapeutic procedures, and to implementation of previously agreed-upon behavioral solutions. Orienting is like shining a light down the unknown path of change.
  • Orienting to Roles, Responsibilities & Reason ROLES RESPONSIBILITIES Provider = Teach, Practice, Model, Coach/Teacher/Guide Document Client = Learn, Practice, Generalize Player/Student/Explorer REASON To create a life I love…a life worth living!
  • COMMITMENT • Client commitment is both a prerequisite for treatment and a goal. Commitment is not assumed. It is viewed as itself a behavior, which can be elicited, learned and reinforced. It is the Provider’s task to figure out ways to help this process along.
  • COMMITMENT • Throughout treatment, the Provider can expect that the Client will need reminding of the commitments made, as well as assistance in refining, expanding, and remaking behavioral commitments.
  • COMMITMENT • A failure in commitment should be one of the first things assessed, but not assumed, when a problem in treatment arises. Before moving to solve the problem, the Provider should go back with the Client, assess commitment, and use the most effective commitment strategies.
  • COMMITMENT • Once recommitment is made, both can proceed with addressing the problem at hand. Commitment creates the internal energy required to let go of old, ineffective behaviors and create new more effective ones.
  • ORIENTATION & COMMITTMENT • The skillful use of orientation and commitment strategies will reduce Client anxiety, increase forward momentum, and significantly increase the probability that change will indeed occur.
  • ORIENTATION & COMMITTMENT • Describe the road to be traveled then get a commitment to the trip, to take the first step, and to continue on until Clients are confident it will lead to their desired destination and they can walk on their own.
  • COMMITMENT STRATEGIES • • • • 3 Levels of Commitment Commitment & Recommitment The Need for Flexibility Commitment Strategies
  • LEVELS OF COMMITMENT Level 1: Intention-A desire to change ineffective behaviors. Level 2: Practice-A commitment to practice effective behaviors. – Take medications and attend and participate in therapy and groups. Level 3: Generalize-A commitment to apply new behavioral solutions in everyday living.
  • LEVELS OF COMMITMENT • There must be at least a level two commitment in order to begin therapy. • If a level two commitment has not been obtained, the primary treatment target will be to elicit one.
  • COMMITMENT & RECOMMITMENT • One of the chief reasons many treatments fail and/or end • • in early termination is inadequate commitment by the Client, the Provider, or both. Commitments may not be strong enough to begin with or reduced by events during treatment. Client commitment is both a prerequisite for treatment and a goal. Commitment is not assumed. It is viewed as itself a behavior, which can be elicited, learned and reinforced. It is the Provider’s task to figure out ways to help this process along.
  • COMMITMENT & RECOMMITMENT • Throughout treatment, the Provider can expect that the • • Client will need reminding of the commitments he has made, as well as assistance in refining, expanding, and remaking behavioral commitments. A failure in commitment should be one of the first things assessed, but not assumed, when a problem in treatment arises. Before moving to solve the problem, the Provider should go back with the Client, assess his commitment, and use the most effective commitment strategies. Once recommitment is made, both can proceed with addressing the problem at hand.
  • COMMITMENT & RECOMMITMENT • Sometimes the uncommitted partner is the Provider, not • the Client. The Client may be demanding resources that the Provider does not have, or has not yet made available. The Client’s progress may be so slow that the Provider becomes frustrated or loses interest. There may be value clashes, or the Provider may find that he or she simply does not like the Client. Treating the Client may no longer be rewarding. The most appropriate arena for the Provider to examine his or her commitment and recommitment is in the Consultation Teams and Clinical Supervision.
  • THE NEED FOR FLEXIBILITY • Avoid being judgmental about the Client’s choice of • • • goals and/or commitments. Be careful not to impose your own goals or treatment procedures on the Client when the Consultation and Treatment Team does not dictate such goals or procedures. Eliciting a commitment from a Client may involve a number of steps. The Provider is often functioning like a good salesperson.
  • THE NEED FOR FLEXIBILITY • The product being sold is treatment strategies or skills, new behavior, a renewed effort to change, or sometimes life itself. All of the strategies below may be needed when the task requires great effort on the part of the Client; when effort must be sustained over a long period or in the face of adversity or during attempts by others to dissuade the Client; when the Client feels hopeless about his capacity to change; or when what is required is something the Client fears greatly.
  • THE NEED FOR FLEXIBILITY • At other times, only a request for the verbal commitment may be needed, and other tactics can be discarded. • Feel free to move back and forth among the various strategies as needed.
  • COMMITMENT STRATEGIES • Highlight The Pros And Cons • Play The Devil’s Advocate • Foot In The Door/Door In The Face • Connect To Commitments • Highlight Freedom To Choose • Use Principles Of Shaping • Generate Hope: Cheerlead • Agree To Homework • Two Rules • “You Are Your Word”
  • • • • • • Highlight The Pros And Cons in better than those they do People keep commitments they believe not believe in. When one or more action plans have been proposed, engage the Client in a discussion of the pros and cons of actually making a commitment to a specific plan or solution. Rehearse the good points of the action to be taken. Highlight the benefits to the Client and his life. Provide counterarguments to reservations the Client might have for not taking action. The more you can realistically paint the picture of how taking action will benefit the Client and how not taking action will lead to misery the better. Sometimes selling the “pro” of an action to be taken is simply highlighting that it is the best action between two undesirable possibilities.
  • Highlight The Pros And Cons
  • Playing The Devil’s Advocate • Use when you think the Client’s commitment may not be strong • • • • enough to stand up during future adversity. Helpful in enhancing the Client’s sense of choice and control. When a tentative commitment is made, pose arguments against it. The secret here is to make sure that the counterarguments are slightly weaker than the Client’s arguments for commitment. If the counterarguments are too strong, the Client may capitulate and retract his initial commitment. If this happens, back down slightly and reinforce the arguments for commitment, and then revert back once more to the devil’s advocate position. Example: “I’m wondering if you are strong enough to do this kind of work?”
  • Foot-In-The-Door • Terms come from research on door-to-door canvassing • • for charities. Enhances compliance with requests and previously made commitments. Foot-In-The-Door: Make an easier first request followed by a more difficult request.
  • Door-In-The-Face • Door-In-The-Face: Request something much larger • • than the Client expects, and then request something easier. Combined: Ask for something very hard, then move to something very easy, and progressively ask for something harder. Most successful in eliciting commitments to engage in homework practice or to try new behaviors. “I want you to try using all your skills everyday.” “How about committing to using one skill each day.”
  • Steps: • Present a goal of treatment, procedure, or task somewhat vaguely • • • • • and in a favorable light, omitting discussion of how hard the goals will be to reach, so that almost anyone would agree. Elicit the Client’s commitment to reach the goal. Re-describe the goal, presenting more specifics and highlighting the difficulties a bit more. Elicit another commitment to reach the goal. “Up the ante” by presenting goals as very difficult to reach, perhaps more difficult than anything the Client has ever attempted (and more difficult than it may actually be)-but attainable if the Client wants to try. Elicit another commitment to reach goal.
  • • Remind and/or clarify previous commitment and reinforce current commitment. • Used when the strength of a commitment seems to be fading or when the Client’s behavior is incongruent with his previous commitments. Example: “I thought you agreed to…”
  • Highlighting Freedom To Choose & The Absence Of Alternatives • Commitment and adherence are enhanced both when people believe that • • • they have chosen a commitment feely and when they believe that there are no alternative paths to their goals. Highlighting the freedom to choose behaviors while stressing the negative consequences of failure to make a particular commitment can strengthen both a commitment and the likelihood of follow-through on the agreement. Stress the fact that the Client can simply change his goals. Stress that in choosing a new goal he must also be prepared to accept the consequences. When providing consequences, speak in a matter of fact manner. Avoid embellishing or adding negative consequences that you know may not occur as this amounts to threatening and may move the Client completely away from your goal of getting a commitment. Example: “You can choose to solve your problem with ____ by violence, stealing, arguing, etc. and the consequence is that you may have to stay in treatment longer.”
  • Using Principles Of Shaping • Commitments often have to be creatively shaped larger or smaller to just – noticeable differences in order to stick. • Must be done in a way that does not make the Client look like a failure. • Do not be afraid to experiment and change until it works.
  • Generating Hope: Cheerleading • Client’s often have a lack of any hope that they can • • change their ways and put more effective solutions into practice, or that their attempts will not end in failure and humiliation. Commitment without hope of keeping the commitment is extremely difficult. Acknowledge all the times the Client has succeeded thus far. Reinforce even the smallest progress, letting him know that it was his power that produced it – it came from him – know one else. Example: “You have everything it takes to overcome your problems no matter what they are.”
  • Agreeing On Homework • Put the assignment in writing. • Explain thoroughly how to complete the • • • assignment. Check to ensure that he “gets it”. Set up a support person who can provide help. Get a commitment to bring homework results to the next session.
  • • • • Works well before beginning a skills group. This process increases the Client’s own sense of personal power. Before beginning any instruction, explain the purpose and the importance of the material being taught in session and how important it is that you be allowed to teach in the most effective manner possible. • Let the group know that in order to accomplish this task, you have only two rules that each participant must commit to if they are to stay in group: – Listen to what I say, and – Follow my directions. • Clarify that it is completely up to them to choose to accept these rules. If they agree they will receive the tremendous benefit of learning something new and effective for their life. • Clarify to those who ask, that they are certainly free to not commit to these rules, and in that case will be asked to sit outside the group.
  • The “Two Rules” Method • Obtain a commitment from each participant. It is preferable that the • • • commitment is verbal, but you may at times just want a show of hands. The importance of the verbal commitment is connected to the power that every participant has available to them-the power to keep his own word. During group, if a Client refuses to follow directions, or does not appear to be listening, remind him immediately of his previous commitment and ask if he would please do what he promised to do. Clients will often claim that you coerced them into committing to the two rules. Remind them that you did not hold a gun to their head and that they made the choice with their own power, and that you respect the power of their word. This technique helps Clients to experience the very real power their words can have if they decide to give those words the power to follow through with their promise.
  • • • • • CONTINGENCY MANAGEMENT PROCEDURES Contingency simply refers to “if/then” scenarios. “If you do ____ then ____ will probably happen.” Every response within an interpersonal interaction, whether intended or not, is a potential reinforcement, punishment, or extinction. Getting across accurate information about how learning works is crucial if the Client is to collaborate in discovering the forces controlling his own behavior.
  • Orient To Contingency Management • Discuss the differences among intentions, behavioral planning, purpose, and consequences as they influence how individuals respond or act in the world. – The intent of their behaviors is frequently unrelated to at least some of the outcomes, including outcomes that reinforce the behaviors. – Many consequences are in fact unintended. Just because a consequence strengthens behavior does not mean that it was intended or wanted. Unintended consequences can and frequently do reinforce behavior.
  • Orient To Contingency Management • Discuss the automatic nature of most learning. – Infant and animal learning is usually unconscious. – Reinforced consequences cause chemical change in the brain. Neural circuits are changed.
  • Orient To Contingency Management • Discuss the automatic nature of most learning. – Infant and animal learning is usually unconscious. – Reinforced consequences cause chemical change in the brain. Neural circuits are changed.
  • Orient To Contingency Management • Consequences can affect behavior without a person’s awareness. – Most of us are not aware of how and when behavioral consequences influence our behavior. – The feeling that we are doing something for one reason or purpose does not mean that this reason or purpose is actually influencing our behavior. – All humans tend to construct reasons for their own behavior when causes are not apparent.
  • Orient To Contingency Management – Research has shown that stimulating certain reward centers in the brain increases the frequency of any behavior preceding the stimulation. The effect is so powerful that an animal or human can be made to engage in a “rewarded behavior” so frequently that it will not stop to eat, even when food deprived. – In humans, any time the reward center in the brain is stimulated, the preceding behavior becomes more reinforced. – We may attribute why we do things to other reasons when in fact it may be something unknown to us that actually stimulates the reinforced behavior.
  • Orient To Contingency Management • When a person figures out what is truly influencing his behavior, this is called insight. – Do not assume that intent, consequences and reinforcement go hand in hand. – Do not assume that feelings, or beliefs about causes, without supporting data, are the best information about what is really influencing behavior. – You must be careful to observe and identify the actual contingent relationships that influence behavior.
  • Orient To Contingency Management • Give a lesson on the effects of extinction on behavior. – Maladaptive behaviors may temporarily increase in frequency or intensity after the removal of reinforcement. (Extinction burst) – Understanding these effects sometimes helps with the pain associated with the removal of usual reinforcers. – The Foot-In-The-Door technique can be used to help the Client make a commitment to tolerating the painful aspects of changing contingencies. • Review the principals of punishment. – Helps Client to drop punishment as a self-control technique. – Self-punishment is often the only self-control procedures used.
  • Reinforce Target-Relevant Adaptive Behavior • A central principle of DBT is that Providers • should reinforce target-relevant adaptive behaviors when they occur. The Provider must at all times pay attention to what the Client is doing, whether the Client’s behavior is targeted for increase, decrease or is irrelevant to goals, how the Provider responds to the Client’s behaviors and if the response is reinforcing behaviors that represent progress.
  • Reinforce Target-Relevant Adaptive Behavior • Timing of Reinforcement. – Immediate reinforcement is far more powerful than delayed reinforcement. – Many behaviors are extraordinarily difficult to decrease because they result in short-term, immediate reinforcement. These same behaviors often lead to long-term negative or punishing outcomes. – Addictive behaviors are a good example here. The immediate reinforcing effects of drugs, alcohol, gambling, food, and suicidal behaviors, strengthen the behaviors far more effectively than long-term aversive consequences weaken them. – Thus, the Provider must reinforce improved/desired behavior as soon as possible. – Be alert to improved behaviors in your presence so that you may reinforce them immediately.
  • Reinforce Target-Relevant Adaptive Behavior • Scheduling of Reinforcement. – At the beginning of therapy, continuous reinforcement may be needed fading gradually as the behavior occurs more often. – Behaviors that are intermittently reinforced are far more resistant to extinction.
  • Reinforce Target-Relevant Adaptive Behavior • Validation, Responsiveness, and Non-demanding Attentiveness as Reinforcers. For some Clients, expressions of warmth and closeness are very effective; for others, such expressions are so threatening that the effects are just the opposite of that which is intended. For most Clients, the following relationship activities are reinforcing; – Expressions of Providers approval, care, concern, or interest; – Behaviors that communicate liking or admiring the Client, wanting to work with him, and wanting to interact with him; – Behaviors that reassure that the Provider and therapy is secure; – Almost any validating response (except, at times, cheerleading); – Behaviors that are responsive to the Clients requests/inputs; – Attention from or contact with the Provider.
  • Reinforce Target-Relevant Adaptive Behavior • Jackpots. – One extremely useful technique with any reinforcement, for animals or people, is the jackpot. The jackpot is a reward that is much bigger, maybe ten times bigger, than the normal reinforcer, and one that comes a s surprise to the subject. – A jackpot may be used to mark a sudden breakthrough. – Paradoxically, a single jackpot may also be effective in improving the response of a recalcitrant, fearful, or resistant subject that is offering no desirable behavior at all.
  • Reinforce Target-Relevant Adaptive Behavior • Conditioned Reinforcers. A conditioned reinforcer is some initially meaningless signal-a sound, a light, a motionthat is deliberately presented before or during the delivery of a reinforcer. – Effective teachers often arrive at some such ritualized and carefully rationed word of commendation-“That’s fine” or “Very good”-for which their students anxiously work and want. – Before the start of training, while the subject is doing nothing in particular, teach them to understand the significance of the conditioned reinforcer by pairing it with food, positive statements, or other real reinforcers.
  • Reinforce Target-Relevant Adaptive Behavior – With the establishment of a conditioned reinforcer, you have a real way of communicating exactly what you like in the subject’s behavior. I.e. Statements of praise, points, tickets, money, clickers, are examples of a conditioned reinforcers. – The conditioned reinforcer bridges the stimulus between earning the reward and getting the reward. – A positive conditioned reinforcer says, “What you are doing now is good and will gain you something, so do it some more.”
  • Reinforce Target-Relevant Adaptive Behavior – The conditioned reinforcer constitutes an “event marker”. It identifies to the trainee exactly what behavior is being reinforced. It puts control in the hands of the learner. After a while the subject no longer just repeats the behavior; the subject exhibits intention. “Hey! I made you (click, say yes, etc.) watch me, I’m going to do it again!” Clicker trainers speak of that shift as the moment when “the light bulb goes on.” This moment is extremely reinforcing for the trainer and trainee alike. – Pair the conditioned reinforcer with several real reinforcers.
  • Reinforce Target-Relevant Adaptive Behavior – Once you have established a conditioned reinforcer, you must be careful not to throw it around meaninglessly or you will dilute its force. Validate everything; demonstrate radical acceptance, empathy and unconditional positive regard at all times. However, reserve praise, specifically, as a conditioned reinforcer, to a real adaptive behavior. False or meaningless praise, is soon resented, and loses any power to reinforce.
  • Extinguish Target-Relevant Maladaptive Behaviors • Behavioral responses are extinguished when the • reinforcers that maintain the behavior are removed. The Provider must determine what reinforcers are maintaining a maladaptive behavior pattern, and then withhold those reinforcers following the behavior. Remember that not all behaviors are maintained by their consequences (Operant Behaviors). Some behaviors are elicited automatically by prior events (Respondent Behaviors).
  • Extinguish Target-Relevant Maladaptive Behaviors • There is no substitute for a good behavioral analysis to • • determine what is maintaining a maladaptive behavior. Client’s problem behaviors often function quite effectively. If a helpless stance or out-of-control emotionality leads the Provider to pay more attention to, or give more help to the Client than when he asks for what he wants directly and competently, the Provider reinforces the helplessness and emotionality that he or she is trying to reduce.
  • Extinguish Target-Relevant Maladaptive Behaviors • By not reinforcing maladaptive behaviors, the Client’s behavior is put on an extinction schedule. – Although, in time, behavior can be expected to increase, there will be a “behavioral burst” near the beginning of extinction and intermittently thereafter. – If the behavior previously functioned to meet an important need, and if the Client has no other behaviors that worked as well as this one, the Client’s general behavior can become disorganized, intense, or chaotic.
  • Extinguish Target-Relevant Maladaptive Behaviors • Factors that increase the likelihood of a Provider breaking the extinction schedule: – Client wears out the Provider – Provider is unsure of treatment plan – Provider feels guilty about not giving the Client what he needs or wants – Provider feels threatened by Client’s behavior
  • Extinguish Target-Relevant Maladaptive Behaviors • An extinction schedule should be aimed at the targeted behavior, not at the Client himself. The aim is to break the relationship between the targeted behavior and the reinforcing consequences. – Find another response to reinforce. – Get the Client to engage in an acceptable replacement behavior that can be reinforced. – Soothe the Client. – Acknowledge how difficult the therapy process is. – The problem rarely is in what the Client wants or needs, but how he goes about getting it.
  • Extinguish Target-Relevant Maladaptive Behaviors • Combine extinction with a heavy dose of soothing and kindness. – First, find the courage and commitment to stick to an extinction schedule. – Second, help the Client find more adaptive behaviors that will function as well or better and be sure to reinforce those behaviors. – Third, be kind and soothing to the Client. Extinction is not a means of punishing Clients.
  • Determining the Potency of Consequences • Praise as a Reinforcer. – Borderline and suicidal individuals are often both eager for praise and very afraid of it. – Clients often fear being left on their own, having to be independent of the Provider and self-reliant before they are able or ready. – The Provider must anticipate negative effects of praise and move to counteract them. – Generally, the inability to accept appropriate praise should be viewed as a therapy-interfering behavior and analyzed and treated as such.
  • Determining the Potency of Consequences – The Provider should discuss the consequences of an inability to accept praise. The strategy is to continue praising following progress or positive change. But for this to work, the Provider must stay close to the Client and not appear as if he is leaving the Client because the Client is doing better. – The continued exposure to praise in an atmosphere that does not reinforce fear, shame, or anger should in the long run change the valence of praise from negative to neutral and eventually to positive. – A person who is either punished by praise or neutral to it is at a distinct disadvantage.
  • Determining the Potency of Consequences • Further Comments on Relationship Contingencies. – The key here, as in all contingency management, is to keep a close eye on the effects of interpersonal warmth and attachment on the Client’s behavior. – Example from set point theory from the field of weight regulation; each individual has a set point range of intimacy that he or she is comfortable with and will defend that range. When over their set point, people will push away and attempts at greater intimacy will be experienced as aversive. When under their set point, people will reach out for intimacy. Warmth and closeness from others will be experienced as reinforcing; coolness and distancing behaviors will be experienced as aversive.
  • Determining the Potency of Consequences – The attached Client, once placed in a secure, bonded, and warm relationship for long enough, will eventually relax and stop clinging. The butterfly patient, if given enough room to move, not punished for frequently flying out of the Provider’s hand, and not punished when he returns, will in time become more attached. – The potency of any reinforcer depends on whether the individual has already received the desired or needed level of the reinforcer. The question to ask is this: Is the person already sated on what is being offered? Food is not likely to be a good reinforcer for a person who has just finished a large meal. The secret is “just enough”. – There is no substitute for trial and error and close observation to determine just enough for any particular Client.
  • Use Natural Over Arbitrary Consequences • Whenever possible, natural rather than arbitrary • • • consequences should be applied. Natural consequences are those that flow from and are characteristic outcomes of a behavior in everyday life. Smiling, moving closer, and nodding are natural consequences of someone’s saying something we like; Giving and m & m, or a ticket is an example of arbitrary reinforcement.
  • Principles of Shaping • In shaping, gradual approximations to the target behaviors are reinforced. • Shaping requires the Provider to break the desired behavior down into small • • • steps and teach these steps sequentially. Trying to extract an adaptive behavior without reinforcing small steps on the way is like promising a hiker a sumptuous banquet if he can get to the other side of a high mountain, and then refusing to feed him during the ten day journey. If expectations of the environment are too high for the abilities of the Client, progress is often punished because it does not come up to expectations rather than reinforced because it represents an improvement over past behavior. If a behavior represents progress, the Provider should reinforce it. If not, the Provider should ignore it or punish it and if necessary teach a new behavior.
  • The 10 Laws of Shaping 1. Raise criteria in increments small enough that the subject always has a realistic chance for reinforcement. 2. Train one aspect of any particular behavior at a time; don’t try to shape for two criteria simultaneously. 3. During shaping, put the current level of response onto a variable schedule of reinforcement before adding or raising the criteria. 4. When introducing a new criterion, or aspect of the behavioral skill, temporarily relax the old ones. 5. Stay ahead of your subject: Plan your shaping program completely so that if the subject makes sudden progress, you are aware of what to reinforce next.
  • The 10 Laws of Shaping 6. Don’t change trainers in midstream; you can have several trainers per trainee, but stick to one shaper per behavior. 7. If one shaping procedure is not eliciting progress, find another; there are as many ways to get behavior as there are trainers to think them up. 8. Don’t interrupt a training session gratuitously; that constitutes punishment. 9. If behavior deteriorates, “go back to kindergarten”; quickly review the whole shaping process with a series o easily earned reinforcers. 10.End each session on a high note, if possible, but in any case, quit while you are ahead.
  • Anti-DBT Tactics: • Provider “gave in” to Clients demands and reinforced • • • behaviors well below Client’s capabilities when more capable behavior is required in the situation at hand. Provider was inconsistent in use of contingency management procedures. Provider was punitive in use of aversive consequences. Provider required behaviors beyond Client’s capabilities before reinforcing behavioral attempt.
  • OBSERVING-LIMITS PROCEDURES • Observing limits is essential to DBT. It addresses limit-relevant behaviors and functionally related behaviors of the Client that push or cross Providers own personal limits. These behaviors differ from Provider to Provider.
  • OBSERVING-LIMITS PROCEDURES • The responsibility for taking care of the Provider’s limits • • • in DBT belongs to the Provider not to the Client. The Provider must be aware of which Client behaviors he or she is able and willing to tolerate and which are unacceptable. This information should be given to the Client in a timely fashion before it’s too late. The Provider must also specify which behaviors he or she can accept only temporarily and which are acceptable over the long haul, as well as which Client behaviors are likely to lead to Provider burnout and which are not.
  • OBSERVING-LIMITS PROCEDURES • Client behaviors that cross Provider’s limits are a special • type of therapy-interfering behaviors; thus, limit-relevant behaviors are second only to life threatening behaviors as a target of therapy. They are therapy threatening because they interfere with the Provider’s ability or willingness to continue treatment. It’s crucial for a Provider not to ignore such behaviors; otherwise they will sooner or later lead to burnout, early termination of therapy, or otherwise harm the Client.
  • OBSERVING-LIMITS PROCEDURES • In observing limits, the Provider takes care for the Client • • by taking care of him or herself. Observing limits in DBT, is concerned with preserving the personal limits of the Provider – the Provider’s sense of self as it were. It is important that each Provider understands his or her own limits and communicates these clearly to each Client. The goal of DBT is to teach Clients how to interact productively and happily within these natural interpersonal limits.
  • OBSERVING-LIMITS PROCEDURES • The following are guidelines for effectively observing limits with borderline Clients: 1. Monitor Limits. Be aware of warning signs of feelings of discomfort, anger, and frustration. The idea is to catch yourself before your limits are crossed. The consultation team can be useful here. 2. Be Honest About Limits. A Provider’s limits are presented for the good of the Provider, not for the Client. Avoid explaining limits that are for the good of the Client when they really are for your own benefit.
  • OBSERVING-LIMITS PROCEDURES 3. Temporarily Extend Limits When Needed. Observing limits is not a license to be uncaring or unresponsive to important Client needs. Nor is it permission to be chaotic in responses to Client requests and demands. It is necessary for Providers at times to push their own limits, extend themselves, and give what they do not want to give. Similarly, when a Provider is about to reach his or her limits, and the Client’s life is in danger, the appropriate strategy is to involve other professionals in the provision of care. The dialectic here, is between pushing limits when necessary, and observing limits when necessary.
  • OBSERVING-LIMITS PROCEDURES 4. 5. Be Consistently Firm. Use the broken record strategy Clients are taught in interpersonal skills training: Over and over and over the Provider states her position calmly, clearly, and firmly and restates frequently that the observation of these limits will benefit the Client in the end. Combine Soothing, Validating, and Problem Solving With Observing Limits. The importance of soothing and validating the Client while simultaneously observing limits cannot be overstated.
  • EIGHT BEHAVIORAL SHAPING METHODS Method 1: Approach Advantage Elimination Kill, Incarcerate, Place a 7 Day, Isolate, Fire, Quit, Divorce, End the Relationship, etc. This always works. By removing the person or yourself from the situation, the unwanted behavior is gone. Sometimes necessary. Disadvantage No new behavior is learned. Using this method could cause you to have to “go away” also.
  • EIGHT BEHAVIORAL SHAPING METHODS Method 2: Approach Advantage Punishment Torture, Hit, Spank, Scold, Dock Pay, Give Fines, Take Something Away, Threaten Prompt punishment may stop an ongoing behavior. As long as you remain present. Punisher usually feels better. Disadvantage No new behavior is learned or modified. Subject may resort to hiding; develop fear, anger, and resentment. Could escalate to Method #1 for both of you.
  • EIGHT BEHAVIORAL SHAPING METHODS Method 3: Negative Reinforcement Approach Provide an Aversive Stimulus or something people want to avoid (Stop Everything, Frown, Warning Glance, Scream, Electric Shock, Ignore, Inflict Pain or Discomfort) until the behavior changes and then stop the stimulus. A change in behavior must make the stimulus go away. Advantage Can be effective if used consistently, every time-without fail. Works really well to keep cows in their fields (electric fences). Disadvantage When it works it reinforces the one providing the aversive so that nagging, prodding, etc. escalates. If not done consistently subjects unwanted behavior becomes reinforced intermittently.
  • EIGHT BEHAVIORAL SHAPING METHODS Method 4: Approach Extinction Advantage Applies well to verbal behavior. Whining, quarreling, teasing, bullying. By ignoring the behavior with ignoring the person, you can extinguish many disagreeable displays because they have no result, good or bad. Disadvantage If you or someone else slips and provides a reaction-good or bad-you intermittently reinforced the subject’s unwanted behavior. I.e. Whining child in the store with mom who tries to ignore and finally gives in. Provide no response, (positive or negative) until the unwanted behavior ceases for lack of reinforcement, like a burnt out candle. Ignore, Show no signs of acknowledgement.
  • EIGHT BEHAVIORAL SHAPING METHODS Method 5: Train An Incompatible Behavior Approach Engage, Orient, and get a commitment to teach, practice, generalize and reinforce an acceptable and incompatible behavior and connect it to the same stimulus that triggered the unwanted behavior reinforce, practice, reinforce, practice. ”What DBT Skills could you use in this situation?” “Shape it until they make it.” Advantage Provides subject with the skills to control their own consequences. Teaches how to fish instead of just feeding fish. Works well to counteract emotional states. Opposite Action, HalfSmile, etc. Sometimes takes more time, effort, and patience. Disadvantage
  • EIGHT BEHAVIORAL SHAPING METHODS Method 6: Put The Unwanted Behavior On Cue Approach Choose a time to do the unwanted behavior at your command (cue), reinforce doing the behavior only when asked and then don’t ask for it. Advantage When a behavior is brought under stimulus controlthat is when the subject learns to offer the behavior in response to some kind of cue-the behavior tends to extinguish in the absence of the cue. Disadvantage Too much fun.
  • EIGHT BEHAVIORAL SHAPING METHODS Method 7: Positive Reinforcement Approach Reinforce everything but the unwanted behavior. Catch them in the act of doing things well. Praise at least 4 times more than you punish. Advantage Smoother, easier, more positive work environment so you can have some energy left for your family when you get home. Energizes the residents and staff. Disadvantage If not done properly, it could become to costly and other behaviors such as stealing, or counterfeiting could occur.
  • EIGHT BEHAVIORAL SHAPING METHODS Method 8: Attend To The Motivation Approach Get clear on their motivation: P-hysical Health; L-eisure; E-at; A-ltering Drugs; S-leep; E-xercise Be-like others A-ttention/Contact; W-ithdrawl/Break; A-utonomy/Power; R-evenge/Protection; E-xcitment/Challenge Meet their need or collaborate to create a healthier, more effective motivation. Reiss Personality Profile. Advantage Disadvantage Provides the most natural behavioral shapers of all. PLEASE, Mastery and self-management, self-validation, and self-problem solving. Requires close observation as to what is really reinforcing the behavior rather than just what the trainer and/or the subject think the reinforcer is.
  • SKILLS TRAINING • Skills are abilities including cognitive, emotional, and overt behavioral responses necessary for effective performance. In DBT, almost any desired behavior can be thought of as a skill and thus can be acquired, strengthened and generalized.
  • SKILLS TRAINING • Skills training procedures are necessary when a problem solution requires skill not currently in the Client’s behavioral repertoire. The aim of DBT is to replace ineffective, maladaptive, or non-skilled behaviors with skillful responses.
  • SKILLS TRAINING • Skill acquisition . Instructions, modeling • Skill strengthening . Behavioral rehearsal, feedback • Skill generalization . Homework assignments, discussion of similarities and differences in situations, use of the skill in the context that it is needed.
  • Orienting and Committing to Skills Training: Task Overview • Skills training can only be accomplished if the person • • actively collaborates with the treatment program. Some Clients both have skill deficits and are fearful about acquiring new skills. It can be pointed out that learning a new skill does not mean the Client actually has to use it. Much like the fear of flying: The Client does not want to reduce his fears because then he might have to fly. Point out that the skills being taught have helped others and myself.
  • Orienting and Committing to Skills Training: Task Overview • The most important point to make, and to repeat • • as often as necessary, is that learning new skills requires practice, practice, practice, and that practice has to occur in situations where the skills are needed. If these points do not get through to the Client, there is not much hope that they will actually learn anything new. Give a rationale before teaching any new skill.
  • Orienting and Committing to Skills Training: Task Overview SKILLS MODULE PURPOSE/RATIONALE MINDFULNESS To get in and stay in the moment in order to make a wise choice. DISTRESS TOLERANCE To stay in the moment without making matters worse. EMOTION REGULATION INTERPERSONAL EFFECTIVENESS To gain mastery over the response to my emotions so that they do not master me. To get what I want while demonstrating respect for self and others.
  • 1. Assess Abilities • Is the Client incapable of learning a new skill, or is he emotionally inhibited • or constrained by environmental factors? Emotionally dysregulated Clients often confuse being afraid of doing something with not being able to do it. – Some may fear that if they learn the skill, the Therapist will think they no longer need treatment and discharge them prematurely. – Some may fear that just because they can perform the skill in treatment the Therapist will assume they can perform it in all contexts. – Some Clients may feel hopeless and ask, “What’s the point? I’m probably not going to use this skill when I go home!” – Some don’t like the feelings of vulnerability that comes with learning a new skill and looking foolish or silly. – All of the above scenarios will just contribute to one more failure and reinforce that he is a “loser” and nothing can help.
  • 1. Assess Abilities • Avoid getting stuck on either side of the following assumptions: – The Client can do anything if he wants to with the right amount of coaching; advice, and a swift kick in the pants. Therefore, if he is not learning, he must not want to reach his goals. OR… – The poor Client is too fragile and can’t be expected to learn such difficult tasks. He needs tons of acceptance, nurturance and for me to structure his environment so he doesn’t have to experience the shame and embarrassment that will ultimately come if he is placed in a vulnerable situation. – Usually there is one Provider representative for each side on the treatment team. Not surprisingly, the Client will capitalize on the dichotomy and “staff splitting” will often arise.
  • 1. Assess Abilities • To assess the Client’s skill repertoire, observe the Client in as many contexts as possible, perform a BCA, or use role-play. – To assess Mindfulness Skills, ask the Client to demonstrate getting focused and observe his thoughts, feelings, and actions. – To assess Distress Tolerance, ask the Client to demonstrate a skill or skills he uses when in a stressful situation so as not to make the matter worse. – To assess Emotion Regulation Skills, ask the Client about something to trigger an emotion and then ask the Client to change his emotional state. – To assess Interpersonal Effectiveness, ask the Client to think of something he really wants and then ask you for it effectively, and/or for the ability to say yes or no to something when asked.
  • 2. Provide Instruction On How To Do The Skills • Specify necessary behaviors in concrete terms • • • that the Client understands. Break each skill taught down into easy-to-follow steps. Begin with simple tasks the Client can readily demonstrate and precede to more difficult tasks. Provide examples of the skill to be learned.
  • 3. Provide Instruction On How To Do The Skills • Use aids and techniques that stimulate the visual, auditory and kinesthetic (experiential) learner: – Visual: Use handouts that are easy to read and simply describe the skill; use a large white board or chalkboard; write large enough for the person furthest away to see clearly; refer to posters on the walls, use power point; overhead projector; etc. – Auditory: Speak clearly and concisely; avoid unnecessary words; use music, rhythms, acronyms, metaphors, stories; etc. – Kinesthetic: Involve students in creating posters; have them role-play and act out scenarios; use structured movement; etc.
  • 4. Model The Skills • • • • • • Role-Play Use skilled behavior in interacting with the Client Describe what skills you are using out loud as you use them Disclose how you use the skills in everyday life Tell stories that illustrate how to use the skill. Point out people in the environment that use the skills being taught for the Client to observe; People the Client knows, public figures, books, movies, etc.
  • SKILL STRENGTHENING PROCEDURES 1. Rehearse The Skills – – – Role-Play Guide the Client in-session to practice Guide the Client in practice imagining the skill step by step (see it happen in your mind) – For emotion regulation, practice facial expressions, closed fists to open hands, muscle tension to relaxation, etc. – Encourage the Client to practice in vivo (in a real life situations) with issues that come up during practice or outside of session.
  • SKILL STRENGTHENING PROCEDURES 2. Reinforce The Skills – The most powerful reinforcer available to strengthen the Clients skill and probability of using that skill in other contexts as well as increase the Client’s self esteem and confidence is YOUR APPROVAL! Use it liberally! If they agree to practice-reinforce with your approval-O.K. great!; Way to go!; Well done! ; If they start to get it- reinforce with your approval!; Catch them using it in session and throughout the day and- reinforce with your approval!
  • SKILL STRENGTHENING PROCEDURES 3. Give Feedback and Coaching – Keep your feedback focused on the Client’s performance rather than his motives – Be behaviorally specific and tell the Client exactly what he is doing and what he needs to do to improve the skill – Avoid telling the Client he is manipulating, expressing a need to control, overreacting, clinging, or acting outit is simply not helpful and can cause the Client to give up practice.
  • SKILL STRENGTHENING PROCEDURES – Give positive feedback. Focus on what they did well and instead of commenting on what they didn’t do well; say something like, “You did this part really well! Now I want you to try ____! – Do not be afraid to give negative feedback as long as you describe the effect of the behavior clearly without judging the Client personally. – Limit your feedback to only one or two items that need improvement rather than overwhelming them with every little thing they did wrong, and of coursereinforce with your approval!
  • SKILL STRENGTHENING PROCEDURES – Coaching is combining clear behavioral feedback with clear behavioral instructions. Clinical practice suggests that the “permission” to behave in certain ways that is implicit in coaching may be all that is needed to accomplish changes in behavior.
  • SKILL GENERALIZATION PROCEDURES 1. Generalization Programming. – – – – Structure milieu to encourage generalization. Teach a variety of skilled responses to each situation. Vary training situations that Client practices skills in. Duplicate within the Provider/Client relationship important characteristics of interpersonal relationships Client has outside of therapy.
  • SKILL GENERALIZATION PROCEDURES 2. Between-Session Consultation – Assist Client in applying skills in between sessions, by phone or on the floor – “What skills can you use right now to help you….?” – Watch for opportunities to “Catch the client in the act” of behaving skillfully and effectively. – Highlight patterns, cheerlead, and reinforce effective skills with genuine praise. – Look for opportunities to “Coach In The Moment”: • When the Client is vulnerable to act out an old response, • When he presents with a stimulus that may trigger a maladaptive response, • Has repeated an ineffective pattern. • Ask Client, “What skills can you use right now….?”
  • SKILL GENERALIZATION PROCEDURES 3. Provide Session Tapes For Review 4. Provide In Vivo Behavioral Rehearsal Assignments – Therapist and Skills Trainer gives Client specific tasks to practice with Support Staff. – Support Staff rehearse and reinforce skills. – Provide assignments based on Client’s needs and capabilities using principles of shaping.
  • SKILL GENERALIZATION PROCEDURES 5. Create an environment that reinforces skilled behaviors. – Teach how to recruit reinforcement from the natural community. – Teach behaviors that fit the natural contingencies in Client’s environment. – Teach self-management skills, especially how to structure her environment. – Schedule regular family meetings to teach and practice new skills, teach and practice reinforcement techniques and reduce punishment of adaptive behaviors. – Fade reinforcement procedures to intermittent as the environment and Client reinforcement increase.
  • ADVANCED STRATEGIES TRAINING 1. COGNITIVE RESTRUCTURING STRATEGIES: How to help someone change the way they think. 2. EXPOSURE STRATEGIES: How to help someone overcome fear of just about anything. 3. BEHAVIOR ANALYSIS STRATEGIES: How to help someone to see things as they are without judgment. 4. SOLUTION ANALYSIS STRATEGIES: How to help others to create and practice what works best for them. 5. STYLE STRATEGIES: How to say or do something in ways that get the results you want. 6. CASE MANAGEMENT & CONSULTATION: How to coach others to care for themselves while providing ways to support and encourage each other.
  • COGNITIVE RESTRUCTURING • Ways of helping the Client change both the style and content of his thinking. Change can be initiated by verbally challenging current thinking and biases; by offering alternative theories, explanations, and descriptions; and by examining the effectiveness of the Clients current rules and labels.
  • COGNITIVE RESTRUCTURING • Cognitive theories of emotions and emotional disorders suggest that an individual’s cognitive appraisals of events are primary determinants of emotional responses. Help the Client to restructure his style and content of thought and the behavior attached to his emotional response will also change.
  • Cognitive Constructs • Cognitive constructs are that help the client receive, process, store, and use information in a way that changes the cognitive map.  None of the constructs below are intended to considered “true” or “right” ways of thinking. If a particular way of thinking isn’t working for you, try another way.
  • Constructivist Theory • Since the moment you acquired language your brain has taken in sensory information and has interpreted in a way that makes sense for you in that moment. This theory suggests that all of our interpretations and meanings since language have been created or “constructed” and thus can be “reconstructed”
  • Cognitive Restructuring How to help someone think differently • • • • • • • • • DBT Assumptions Thoughts vs. Reality Meaning is Created My Story vs. What Happened What I Know Letting Go of Being Right My Probable Almost Certain Future Possibility vs. Expectation The Language of Change vs. Transformation
  • DBT Assumptions • Every assumption is valid. They can not be proven right or wrong, good or bad. DBT assumptions are ideas or beliefs that I choose to act out on purpose because they work better. What you think about yourself and others has a great effect on how you treat yourself and others. It is important to assess your assumptions of yourself, others, and the world to determine their effect.
  • Thoughts vs. Reality • Thoughts Are Not Real. To demonstrate this idea, picture in your mind a horse. If you have a difficult time picturing things in your mind, draw a horse on a piece of paper. Next, imagine that the horse’s legs turn into car tires (or draw tires on top of the horse’s legs). Now look at your own legs and turn them into tires. Notice that your thoughts can be changed in an instant, and that no matter how hard you try, your legs will never turn into tires. This is because your legs are real and your thoughts are not. If a thought is not working for you, think one that does.
  • Meaning Is Created • You will never find the meaning of life on top of a mountain, in the desert, or buried in the earth. This is because meaning is created by humans in reason mind. Life itself has no meaning other than that which you create. Someone else might have created some of your meanings in life. However, you are the one that chose to accept them. So, if you don’t like the meaning of something, make it mean something else that works better for you.
  • My Story vs. What Happened • Consider that everything you have experienced in life is based on your interpretation and that nobody truly knows what really happened. All we can really know is what we perceive and interpret. It is our life story as we perceive it. We experience trouble in life when we start to believe that our life story actually is what happened and then act as if it is true.
  • What I Know
  • Letting Go of Being Right • If all I have ever experience is my perception of what • • • • • happens, then I can never say my way is the “right” way. However, I often deceive myself into believing that I am right. I pretend that my “right” is from sainthood and another person’s “right” is from psychosis. By insisting on being right I do get certain payoffs: I get to be right and comfort myself that others are wrong. I get to judge others and justify myself. I get to dominate others before they can dominate me. I get to feel superior rather than inferior. The cost of being right is love, joy, connectedness, and well being.
  • My Probable, Almost Certain Future • If I live in my past, I am destined to recreate it until I die. In order to free myself from my past, I must put it where it belongs and radically accept it as my past. Only then can I create a different future. Project My Past Into My Future
  • Possibility vs. Expectation If you expect something and it doesn’t happen, you become disappointed. You can avid disappointment if you see something as a possibility instead of an expectation. If the possibility doesn’t happen, it’s still a possibility. Disappointment Possibility Expectation Possibility
  • The Language of Change vs. Transformation CHANGE TRANSFORMATION Occurs inside of the system Creates a new system More, Better, Different, Comparative, Descriptive, Complex, Becoming, Someday Perfect, Whole, Complete, Possible, Declaration, Simple, Being, Now, Past-Based Future-Based Your words fit your world Your words create your world 1st Order Change 2nd Order Change
  • Exposure How to help someone overcome trauma • Tame the PAPER tiger. • Present Trigger • Accept The Affect • Prevent Maladaptive Response • Empower • Repeat Often & Longer Until the Story Loses it’s Power
  • BEHAVIOR ANALYSIS How to hear the story without judgment • • • • • • • • • • • • 1. Orient To Process 2. Elicit A Commitment 3. Define the Problem 4 Describe Context 5. Describe Behavior 6. Describe Thoughts 7. Describe Emotions 8. Define Trigger 9. Determine Vulnerabilities 10. Determine Motivation 11. Describe Result 12. Describe Intended Result
  • SOLUTION ANALYSIS • • • • • • • • • • • • How to help someone find more effective responses 1. Create A Possibility Of Being 2. Highlight Patterns 3. Interrupt The Pattern 4. Decrease Vulnerabilities 5. Same Context, Trigger, Emotions 6. Create New Thoughts 7. Shape New Behaviors 8. Rehearse New Ways of Being 3 Times 9. Regulate Emotions 10. Identify Goals Aligned With Being 11. Correct And Over Correct 12. Generalize Behavior
  • STYLISTIC STRATEGIES How to help someone change by keeping them off balance Reciprocal Style  Be Responsive  Self-Disclose  Express Warm Engagement  Be Genuine And Authentic Irreverent Style  Unorthodox Reframing  Plunging In  Confrontational Tone  Calling The Bluff  Intensity vs. Silence  Omnipotence vs. Impotence  Be Genuine and Authentic
  • CASE MANAGEMENT How to teach someone to fish not give them one Intervention in the Environment Consultation to the Client   When client is unable to act Orient client and other and the outcome is professionals to the important. approach.   When the environment is Consult client on how to intransigent or high in power. interact with other  To save client’s life or avoid professionals.  high risk to others. Do not intervene to adjust  Provide need-to-know client’s treatment information to other environment.  professionals. Consult how to respond to family and friends about therapy.
  • Feedback • Tim Bradley, Clinical Director Aacres, CA LLC 310-327-7842 timbr@aacresllc.com