2. 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.
3. 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.
4. 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.
6. 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”
7. 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
8. 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.
9. 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”.
11. 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.
13. 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.
14. 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.
15. 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.
16. 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.
17. 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.
18. 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.
19.
20.
21. 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.
22. 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
24. 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
25. 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.
26. 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.
27. 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.
28. 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.
29. 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.
31. 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
32. 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.
33. 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.
34. 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.
35. 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.
36. 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.
37. 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
38. 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
39. 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.
41. 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
42. 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?”
43. 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.
44. 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.”
45. 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.
46. 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.
47. 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.
48. 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.
49. 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.
50. 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.
51. 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.
52. 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.
53. 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
54. 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.”
55. 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.”
56. 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?”
57. 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.”
58. 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?
59. 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!”
60. 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?”
61. 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.
62. 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.
63. 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.
64. 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!
65. 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.
66. 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.
67. 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.
68. 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.
69. 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.
70. 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.
72. 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.
73. 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.
74. 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.
75. 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.
76. 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.
77. 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.
78. 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.
79. 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.
80. 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”
81. •
•
•
•
•
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.
83. 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?”
84. 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.
85. 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.”
86. 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.
87. • 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…”
88. 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.”
89. 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.
90. 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.”
91. 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.
92. •
•
•
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.
93. 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.
94. •
•
•
•
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.
95. 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.
96. 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.
97. 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.
98. 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.
99. 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.
100. 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.
101. 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.
102. 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.
103. 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.
104. 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.
105. 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.
106. 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.
107. 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.
108. 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.”
109. 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.
110. 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.
111. 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).
112. 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.
113. 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.
114. 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
115. 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.
116. 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.
117. 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.
118. 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.
119. 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.
120. 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.
121. 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.
122. 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.
123. 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.
124. 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.
125. 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.
126. 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.
127. 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.
128. 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.
129. 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.
130. 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.
131. 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.
132. 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.
133. 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.
134. 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.
135. 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.
136. 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.
137. 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
138. 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.
139. 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.
140. 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.
141. 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.
142. 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.
143. 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.
144. 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.
145. 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.
146. 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.
147. 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.
148. 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.
149. 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.
150. 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.
151. 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.
152. 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.
153. 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.
154. 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!
155. 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.
156. 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!
157. 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.
158. 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.
159. 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….?”
160. 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.
161. 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.
162. 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.
163. 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.
164. 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.
165. 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.
166. 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”
167. 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
168. 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.
169. 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.
170. 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.
171. 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.
173. 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.
174. 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
175. 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
176. 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
177. 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
178. 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
179. 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
180. 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
181. 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.
