DBT Training 2 Day Workshop

Dialectical Behavior Dialectical Behavior Treatment (DBT)Treatment (DBT)

““The Basics”The Basics”

DBT IS A COGNITIVE BEHAVIORAL DBT IS A COGNITIVE BEHAVIORAL TREATMENT APPROACHTREATMENT APPROACH

• Dialectical Behavior Treatment (DBT) Dialectical Behavior Treatment (DBT) is a cognitive-behavioral treatment is a cognitive-behavioral treatment approach with two key approach with two key characteristics: a behavioral, characteristics: a behavioral, problem-solving focus blended with problem-solving focus blended with acceptance-based strategies, and an acceptance-based strategies, and an emphasis on dialectical processes.emphasis on dialectical processes.

DBT IS LISTED IN THE DBT IS LISTED IN THE NATIONAL REGISTRY OF EVIDENCE-NATIONAL REGISTRY OF EVIDENCE-

BASED BASED PROGRAMS AND PRACTICESPROGRAMS AND PRACTICES

• DBT is recommended by the National DBT is recommended by the National Registry of Evidence-based Programs Registry of Evidence-based Programs and Practices for psychosocial and Practices for psychosocial treatment, co-occurring disorders, and treatment, co-occurring disorders, and mental health inpatient treatment. It is mental health inpatient treatment. It is the number one evidence-based the number one evidence-based treatment for suicide prevention.treatment for suicide prevention.

NREPP Criteria for Rating NREPP Criteria for Rating Quality of ResearchQuality of Research• Each reviewer independently evaluates the Each reviewer independently evaluates the

quality of Research for an intervention's reported quality of Research for an intervention's reported results using the following six criteria:results using the following six criteria:

1.1. Reliability Reliability

2.2. Validity Validity

3.3. Intervention FidelityIntervention Fidelity

4.4. Missing Data and AttritionMissing Data and Attrition

5.5. Potential Confounding Variable Potential Confounding Variable

6.6. Appropriateness of analysisAppropriateness of analysis

• Reviewers use a scale of 0.0 to 4.0, with 4.0 Reviewers use a scale of 0.0 to 4.0, with 4.0 being the highest rating given.being the highest rating given.

Quality of Research Ratings by Quality of Research Ratings by CriteriaCriteria

(0.0-4.0 scale)(0.0-4.0 scale) OutcomeOutcome

ReliabilitReliabilityy

ValiditValidityy

FidelityFidelity Missing Missing DataData

/Attrition/Attrition

ConfoundinConfoundinggVariablesVariables

DataDataAnalysiAnalysiss

OveralOveralllRatingRating

1.1.Suicide Suicide attempts attempts

3.8 3.8 3.8 3.8 4.0 4.0 3.5 3.5 3.0 3.0 4.0 4.0 3.73.7

2.2.Nonsuicidal Nonsuicidal self-injuryself-injury

3.8 3.8 3.8 3.8 3.3 3.3 2.9 2.9 2.6 2.6 3.7 3.7 3.33.3

3.3.Psychosocial Psychosocial adjustment adjustment

4.0 4.0 4.0 4.0 3.0 3.0 3.2 3.2 2.7 2.7 3.7 3.7 3.43.4

4.4.Treatment Treatment retention retention

4.0 4.0 4.0 4.0 3.7 3.7 2.5 2.5 2.7 2.7 3.8 3.8 3.43.4

5.5.Drug use Drug use 3.6 3.6 3.6 3.6 3.5 3.5 2.8 2.8 2.8 2.8 3.5 3.5 3.33.3

6.6.Symptoms of Symptoms of eating eating disordersdisorders

3.6 3.6 3.6 3.6 3.0 3.0 2.3 2.3 2.8 2.8 4.0 4.0 3.23.2

PURPOSEPURPOSE

• DBT teaches people how to use their DBT teaches people how to use their strengths to manage their emotions strengths to manage their emotions and to think, behave, and function in and to think, behave, and function in life more effectively to create a life life more effectively to create a life they love…they love…

““A LIFE WORTH LIVING”A LIFE WORTH LIVING”

TREATMENT STRUCTURETREATMENT STRUCTURE

• Describes who on the team does what and when.Describes who on the team does what and when.

ModeMode PurposePurpose PersonPerson WhenWhen1. Commitment, 1. Commitment,

Participation, Participation, Practice, and Practice, and GeneralizationGeneralization

Accept self and others as Accept self and others as they are and the they are and the environment as it is and environment as it is and create a more effective create a more effective way of being.way of being.

Individual, Individual, Partner, Partner, Client, Client, PatientPatient

As often As often as as possiblepossible

2. Medication 2. Medication SupportSupport

Assess, dispense, monitor Assess, dispense, monitor medications medications

PsychiatristPsychiatristNurseNurse

As As ScheduleSchedule

dd

3. Individual 3. Individual TherapyTherapy

4. Family Therapy4. Family Therapy5. Group Therapy5. Group Therapy

Assess and address the Assess and address the underlying issues relating underlying issues relating to Client’s behaviorto Client’s behavior

Social Social Worker/Worker/Therapist/Therapist/InternIntern

1-2x’s/1-2x’s/wkwk

2-4x’s/2-4x’s/momo

1x/wk1x/wk

6. DBT Skills 6. DBT Skills Training and Training and PracticePractice

Teach and practice Teach and practice effective coping skillseffective coping skills

RT/RT AideRT/RT AideMHRSMHRS

4-7x’s/4-7x’s/wkwk

7. Skills 7. Skills GeneralizationGeneralization

Co-lead groups. Coach Co-lead groups. Coach Client’s on the floorClient’s on the floor

MHWMHW DailyDaily

DBT TargetsDBT TargetsPre-Treatment:Pre-Treatment:

1.1. Develop a relationshipDevelop a relationship2.2. Orient to treatmentOrient to treatment3.3. Elicit a commitment to changeElicit a commitment to change

Stage 1:Stage 1:4.4. Decrease life-threatening behaviors to self and others. Decrease life-threatening behaviors to self and others. 5.5. Decrease treatment destroying/interfering behaviors (e.g. non-med Decrease treatment destroying/interfering behaviors (e.g. non-med

compliance, non-attendance, non-participation)compliance, non-attendance, non-participation)6.6. Decrease quality of life interfering behaviors such as substance Decrease quality of life interfering behaviors such as substance

abuse/dependence, that contribute to functional impairments in life.abuse/dependence, that contribute to functional impairments in life.7.7. Increase effective behavioral skills in areas of:Increase effective behavioral skills in areas of:

a.a. Core mindfulness Core mindfulness b.b. Distress tolerance Distress tolerance c.c. Emotion regulation Emotion regulation d.d. Interpersonal effectiveness Interpersonal effectiveness e.e. Self-management Self-management

Stage 2:Stage 2:8.8. Decrease post-traumatic stress and/or underlying symptoms that lead to Decrease post-traumatic stress and/or underlying symptoms that lead to

behaviors that contribute to functional impairments in life.behaviors that contribute to functional impairments in life.Stage 3:Stage 3:

9.9. Increase, strengthen, and generalize self-validation and problem solving Increase, strengthen, and generalize self-validation and problem solving skills.skills.

10.10. Achieve individual goals.Achieve individual goals.

DIALECTICALDIALECTICAL

• Dialectical simply means looking at Dialectical simply means looking at both sides – your side and my side – both sides – your side and my side – in search of a side we both can work in search of a side we both can work on to attain our goal - “our side”. on to attain our goal - “our side”.

What is this?What is this?

Who Is Right?Who Is Right?

DIALECTICAL STRATEGIESDIALECTICAL STRATEGIES

• Effective use of dialectical strategies Effective use of dialectical strategies ensure that the provider is never ensure that the provider is never trapped in an argument but free to trapped in an argument but free to assist the client to move out of their assist the client to move out of their rigid and ineffective positions. They rigid and ineffective positions. They are designed to help clients move are designed to help clients move closer to their goals with the least closer to their goals with the least amount of resistance.amount of resistance.

PROVIDER CHARACTERISTICS PROVIDER CHARACTERISTICS

A

C

C

E

P

T

A

N

C

E

Compassionate Flexibility

Benevolent

Demanding

C

H

A

N

G

E

Unwavering Centeredness

Nurturing

DBT ASSUMPTIONSDBT ASSUMPTIONS

• Assumptions are beliefs that are Assumptions are beliefs that are acted out on purpose. DBT acted out on purpose. DBT assumptions are not true or false, assumptions are not true or false, right or wrong, they just work better right or wrong, they just work better according to the research.according to the research.


• People Need To Feel Safe and Significant: People Need To Feel Safe and Significant: Our personal well being is enhanced when we feel Our personal well being is enhanced when we feel safe and significant.safe and significant.

• Dignity And Respect Are Basic Human Dignity And Respect Are Basic Human Rights That Are Given Freely And Not Rights That Are Given Freely And Not Earned. Earned. The best way to create respect is to The best way to create respect is to genuinely express it to ourselves and others.genuinely express it to ourselves and others.

• People Are Perfect, Whole, And Complete. People Are Perfect, Whole, And Complete. There is nothing wrongThere is nothing wrong. There never has . There never has been, and there never will be. People respond been, and there never will be. People respond naturally to their own DNA, life development, and naturally to their own DNA, life development, and environment. environment.

DBT ASSUMPTIONSDBT ASSUMPTIONS• People Can Create New Ways Of Being. People Can Create New Ways Of Being. We do We do

not have to be slaves to our past. We have the not have to be slaves to our past. We have the option, if we choose, to create our present reality out option, if we choose, to create our present reality out of possibilities from our future and become the of possibilities from our future and become the conscious authors of our own life stories.conscious authors of our own life stories.

• Change Requires Acceptance.Change Requires Acceptance. A focus on both A focus on both acceptance and change are necessary for either to acceptance and change are necessary for either to occur. The first step towards creating something occur. The first step towards creating something new is to accept what is.new is to accept what is.

• People Are Doing The Best They Can. People Are Doing The Best They Can. Based Based upon our genetic code, life development, and the upon our genetic code, life development, and the influence of our environment since birth, our influence of our environment since birth, our behaviors make perfect sense. “Shoulding” on self behaviors make perfect sense. “Shoulding” on self or others is rarely effective. or others is rarely effective.

DBT ASSUMPTIONSDBT ASSUMPTIONS• People Want To Improve. People Want To Improve. If we could do better If we could do better

we would. People want the best out of life even if we would. People want the best out of life even if they do not know how to get it.they do not know how to get it.

• People Can Do Better, Try Harder, And Be People Can Do Better, Try Harder, And Be More Committed To Create.More Committed To Create. There is no There is no substitute for hard work, practice, and perseverance substitute for hard work, practice, and perseverance in order to achieve mastery.in order to achieve mastery.

• Although People May Not Have Caused All Of Although People May Not Have Caused All Of Their Problems, It Is Up To Them To Accept Their Problems, It Is Up To Them To Accept Them And/Or Solve Them.Them And/Or Solve Them. To search for blame is To search for blame is futile. Although we may not be able to change on futile. Although we may not be able to change on our own, it is ultimately up to us to take full our own, it is ultimately up to us to take full responsibility for our own thoughts, feelings, and responsibility for our own thoughts, feelings, and actions. actions.

DBT ASSUMPTIONSDBT ASSUMPTIONS• Pain And Stress Are Inevitable Parts Of Life. Pain And Stress Are Inevitable Parts Of Life.

Accepting pain and stress as inevitable parts of life relieves Accepting pain and stress as inevitable parts of life relieves us from emotional suffering.us from emotional suffering.

• The Present Moment Is All That Exists. The Present Moment Is All That Exists. Our past and Our past and future do not exist in the present and never have. Right future do not exist in the present and never have. Right now is the only time and place you can learn from your now is the only time and place you can learn from your past, create from your future, and do what works.past, create from your future, and do what works.

• Thoughts Are Nothing From Which Everything Is Thoughts Are Nothing From Which Everything Is Created. Created. All I know is that I know nothing. It is from All I know is that I know nothing. It is from nothing that everything is created.nothing that everything is created.

• Emotions Can Be Regulated. Emotions Can Be Regulated. Harness the energy of you Harness the energy of you emotions and you can be at peace, in love, and full of joy emotions and you can be at peace, in love, and full of joy even if you live in hell.even if you live in hell.


• People Can Create New Habits In All Relative People Can Create New Habits In All Relative Contexts.Contexts. The most effective way to change an The most effective way to change an old habit is to create a new one to take its place.old habit is to create a new one to take its place.

• People Cannot Fail.People Cannot Fail. If something didn’t work we If something didn’t work we have simply not found the best way to make it have simply not found the best way to make it happen.happen.

• People Need Support. People Need Support. Effectively supporting Effectively supporting one another involves capitalizing on each others one another involves capitalizing on each others strengths and compensating for each others strengths and compensating for each others weaknesses.weaknesses.

DIALECTIC STRATEGIESDIALECTIC STRATEGIES“KEEPING A BALANCE”“KEEPING A BALANCE”

• Entering The Paradox. TheEntering The Paradox. The “And” vs. “But” “And” vs. “But” ResponseResponse..

• The Use of Metaphor. TheThe Use of Metaphor. The “It’s like…” “It’s like…” ResponseResponse..• The Devil’s Advocate Technique. The The Devil’s Advocate Technique. The “Are you “Are you

sure?”sure?” Response Response• Extending.Extending. The The “Wow, that’s pretty serious!”“Wow, that’s pretty serious!”

ResponseResponse• Activating “Wise Mind”. The Activating “Wise Mind”. The “Let’s look at what is.”“Let’s look at what is.”

Response.Response.• Making Lemonade Out of Lemons. The Making Lemonade Out of Lemons. The “That’s “That’s

great!”great!” Response. Response.• Allowing Natural Change. The Allowing Natural Change. The “That was then, this “That was then, this

is now.” is now.” Response.Response.

STYLISTIC STRATEGIES: STYLISTIC STRATEGIES: “HOW TO PROVIDE “HOW TO PROVIDE

TREATMENT”TREATMENT”• RECIPROCAL: RECIPROCAL: JoinJoin

– ResponsiveResponsive– Self-DisclosingSelf-Disclosing– Warm EngagementWarm Engagement– Unconditional Positive Unconditional Positive

RegardRegard– AuthenticAuthentic– GenuineGenuine

• IRREVERENT: IRREVERENT: UnbalanceUnbalance– Unorthodox ReframingUnorthodox Reframing– Plunging InPlunging In– Confrontational ToneConfrontational Tone– Calling The BluffCalling The Bluff– Intensity vs. SilenceIntensity vs. Silence– Omnipotence vs. Omnipotence vs.

ImpotenceImpotence– Confront, Challenge, Confront, Challenge,

ConfuseConfuse

CORE STRATEGIESCORE STRATEGIES“WHAT TO DO”“WHAT TO DO”

• VALIDATIONVALIDATION– Radical AcceptanceRadical Acceptance– Reflecting/UnderstandingReflecting/Understanding– Clarifying/SummarizingClarifying/Summarizing– Probing/QuestioningProbing/Questioning– Reassuring/CheerleadingReassuring/Cheerleading– Cognitive ValidationCognitive Validation– Emotion ValidationEmotion Validation– Behavior ValidationBehavior Validation– Genetic ValidationGenetic Validation– Environmental ValidationEnvironmental Validation

• PROBLEM SOLVINGPROBLEM SOLVING• Orienting & CommitmentOrienting & Commitment• Behavior Analysis Behavior Analysis

– InsightInsight– DidacticDidactic

• Change Procedures:Change Procedures:– Contingency ManagementContingency Management– Skills TrainingSkills Training– Cognitive RestructuringCognitive Restructuring– ExposureExposure

• Solution AnalysisSolution Analysis – Create Adaptive SolutionsCreate Adaptive Solutions– RehearseRehearse– TroubleshootTroubleshoot

CASE MANAGEMENTCASE MANAGEMENT“WHY WE PROVIDE “WHY WE PROVIDE

TREATMENT”TREATMENT”• INTERVENE IN THE INTERVENE IN THE

ENVIRONMENT ENVIRONMENT – Observing LimitsObserving Limits– Conditions Mandating Conditions Mandating

InterventionIntervention– Providing Information Providing Information

Independently Of ClientIndependently Of Client– Client AdvocacyClient Advocacy– To Give Assistance To Give Assistance

When Most NeededWhen Most Needed

• CONSULTATION TO CONSULTATION TO THE CLIENTTHE CLIENT– Rationale And SpiritRationale And Spirit– The “Treatment Team” The “Treatment Team”

Vs. “Everyone Else”Vs. “Everyone Else”– Orient To The ApproachOrient To The Approach– How To Manage Other How To Manage Other

ProfessionalsProfessionals– How To Handle Family How To Handle Family

And FriendsAnd Friends

DBT SKILLS MODULESDBT SKILLS MODULES

To gain mastery over the To gain mastery over the response to my emotions response to my emotions so that they do not so that they do not determine my behavior. determine my behavior.

Emotion Regulation:Emotion Regulation:

To get what I want while To get what I want while demonstrating respect for demonstrating respect for relationships and for relationships and for myself. myself.

Interpersonal Interpersonal Effectiveness:Effectiveness:

To stay in the moment To stay in the moment without making matters without making matters worse. worse.

Distress Tolerance:Distress Tolerance:

To get in and stay in the To get in and stay in the moment in order to make a moment in order to make a wise choice. wise choice.

Core Mindfulness:Core Mindfulness:

PURPOSEPURPOSESKILLSKILL

PROVIDER CONSULTATIONPROVIDER CONSULTATION

• Scheduled opportunities for providers to Scheduled opportunities for providers to review strategies and skills, exchange review strategies and skills, exchange information, and give and receive information, and give and receive support in an effort to avoid burnout, support in an effort to avoid burnout, strengthen unity, increase skills, and strengthen unity, increase skills, and maintain adherence to the DBT model. maintain adherence to the DBT model.

PROVIDER CONSULTATION PROVIDER CONSULTATION AGREEMENTSAGREEMENTS

• Consistency Agreement:Consistency Agreement: We agree to present a We agree to present a unified treatment approach while at the same time unified treatment approach while at the same time acknowledge that each provider has a unique style acknowledge that each provider has a unique style and use of self. We agree that the job of the and use of self. We agree that the job of the treatment team is not to provide a stress-free treatment team is not to provide a stress-free environment for clients. Mix-ups and environment for clients. Mix-ups and inconsistencies will inevitably occur and are inconsistencies will inevitably occur and are expected; they are seen as opportunities for clients expected; they are seen as opportunities for clients and providers to practice skills taught in DBT. and providers to practice skills taught in DBT.

• Training Towards Mastery Agreement: Training Towards Mastery Agreement: We We agree to learn and practice DBT Strategies and agree to learn and practice DBT Strategies and Skills and apply them to our clients, colleagues, and Skills and apply them to our clients, colleagues, and ourselves on a daily basis while focusing on ourselves on a daily basis while focusing on effective mastery. We agree to be coachable and effective mastery. We agree to be coachable and take direction from our supervisors and other DBT take direction from our supervisors and other DBT coaches. coaches.


• Dialectical Agreement:Dialectical Agreement: We agree to practice a We agree to practice a dialectical philosophy. We agree to assume that no dialectical philosophy. We agree to assume that no one has a corner on the “truth”, and therefore we one has a corner on the “truth”, and therefore we agree to keep an open mind to discover what works agree to keep an open mind to discover what works best in the moment. When strong differences of best in the moment. When strong differences of opinion arise, we agree to work towards clarifying the opinion arise, we agree to work towards clarifying the outcome to be achieved, validate all perspectives as outcome to be achieved, validate all perspectives as “what is” and search for the synthesis that will assist “what is” and search for the synthesis that will assist us in realizing our desired outcome.us in realizing our desired outcome.

• Consultation to the Client Agreement:Consultation to the Client Agreement: We agree We agree

to consult with our clients on how to interact with to consult with our clients on how to interact with other providers and milieu staff rather than tell other other providers and milieu staff rather than tell other providers and staff how to interact with our clients. providers and staff how to interact with our clients. We agree to coach our clients to use effective skills We agree to coach our clients to use effective skills that will empower them to resolve any issues they that will empower them to resolve any issues they may have and not to solve their problems for them.may have and not to solve their problems for them.


• Radical Acceptance Agreement:Radical Acceptance Agreement: We agree to We agree to radically accept without judgment our client’s and radically accept without judgment our client’s and each other’s behavior. We agree to the each other’s behavior. We agree to the fundamental assumption that we are all trying our fundamental assumption that we are all trying our best and want to improve. When one or more of us best and want to improve. When one or more of us is unable to come up with such an interpretation, is unable to come up with such an interpretation, other team members agree to assist in doing so, other team members agree to assist in doing so, while validating the others.while validating the others.

• Fallibility Agreement: Fallibility Agreement: We agree to apply the We agree to apply the principles of DBT to our clients, to one another, and principles of DBT to our clients, to one another, and to ourselves. We also assume that all providers are to ourselves. We also assume that all providers are fallible and that we will all inevitably violate one or fallible and that we will all inevitably violate one or more of our agreements at one time or another. more of our agreements at one time or another. When this occurs, we agree to take responsibility When this occurs, we agree to take responsibility for our violation of agreement, repair any damage for our violation of agreement, repair any damage caused, and seek a more effective behavior.caused, and seek a more effective behavior.

DBT DBT Training Training OpportunitiesOpportunities

BASIC STRATEGIES BASIC STRATEGIES TRAININGTRAINING• Six training topics held once per quarter that teach and practice Six training topics held once per quarter that teach and practice

basic ways to accept others and solve problems that everyone basic ways to accept others and solve problems that everyone on the team can use. on the team can use.

1.1. ORIENTATION: ORIENTATION: People do better if they first have an idea of where People do better if they first have an idea of where they are going and what is expected of them. The intent of they are going and what is expected of them. The intent of orientation is to describe the road to be traveled then get a orientation is to describe the road to be traveled then get a commitment to take the trip.commitment to take the trip.

2.2. VALIDATION STRATEGIES: VALIDATION STRATEGIES: How to genuinely hear another How to genuinely hear another person’s point of view and accept them just the way they are person’s point of view and accept them just the way they are without judgment.without judgment.

3.3. DIALECTICAL STRATEGIES: DIALECTICAL STRATEGIES: How to help others move closer to How to help others move closer to their goals with the least amount of resistance.their goals with the least amount of resistance.

4.4. ORIENTING AND COMMITMENT STRATEGIES: ORIENTING AND COMMITMENT STRATEGIES: How to get a How to get a commitment from the person you are working with to do what it commitment from the person you are working with to do what it takes to make a life change.takes to make a life change.

5.5. CONTINGENCY MANAGEMENT STRATEGIES:CONTINGENCY MANAGEMENT STRATEGIES: Contingency Contingency simply means if you do “a”, you will often get “b”. Contingency simply means if you do “a”, you will often get “b”. Contingency management strategies teach you how to change behaviors in management strategies teach you how to change behaviors in yourself and others.yourself and others.

6.6. SKILLS TRAINING STRATEGIES:SKILLS TRAINING STRATEGIES: How to teach and practice How to teach and practice Personal Power Skills with others.Personal Power Skills with others.

SKILLS COACHING SKILLS COACHING • Six training sessions held once per quarter that teach and Six training sessions held once per quarter that teach and

practice how to teach, coach, provide practice, and practice how to teach, coach, provide practice, and document DBT and other adaptive skills. document DBT and other adaptive skills.

1.1. MINDFULNESS: MINDFULNESS: How to use your whole brain to get present How to use your whole brain to get present to the moment and make a wise choice and do what works.to the moment and make a wise choice and do what works.

2.2. DISTRESS TOLERANCE: DISTRESS TOLERANCE: How to stay in the moment without How to stay in the moment without making it worse.making it worse.

3.3. EMOTION REGULATION: EMOTION REGULATION: How to manage your emotions so How to manage your emotions so they don’t manage you.they don’t manage you.

4.4. INTERPERSONAL EFFECTIVENESS:INTERPERSONAL EFFECTIVENESS: How to get what you How to get what you want while keeping respect of self and others.want while keeping respect of self and others.

ADVANCED STRATEGIES ADVANCED STRATEGIES TRAININGTRAINING

• You guessed it! Six training sessions held once per quarter that You guessed it! Six training sessions held once per quarter that teach and practice advanced ways to go about accepting others teach and practice advanced ways to go about accepting others and solving problems. and solving problems.

1.1. COGNITIVE RESTRUCTURING STRATEGIES:COGNITIVE RESTRUCTURING STRATEGIES: How to How to help someone change the way they think.help someone change the way they think.

2.2. EXPOSURE STRATEGIES:EXPOSURE STRATEGIES: How to help someone How to help someone overcome fear of just about anything.overcome fear of just about anything.

3.3. BEHAVIOR ANALYSIS STRATEGIES: BEHAVIOR ANALYSIS STRATEGIES: How to help How to help someone to see things as they are without judgment.someone to see things as they are without judgment.

4.4. SOLUTION ANALYSIS STRATEGIES: SOLUTION ANALYSIS STRATEGIES: How to help others How to help others to create and practice what works best for them.to create and practice what works best for them.

5.5. STYLE STRATEGIES:STYLE STRATEGIES: How to say or do something in How to say or do something in ways that get the results you want.ways that get the results you want.

6.6. CASE MANAGEMENT & CONSULTATION STRATEGIES:CASE MANAGEMENT & CONSULTATION STRATEGIES: How to coach others to care for themselves while How to coach others to care for themselves while providing ways to support and encourage each other.providing ways to support and encourage each other.

INSTRUCTORS TRAININGINSTRUCTORS TRAINING

• Pre-requisites are the completion of Pre-requisites are the completion of the Basic & Advanced courses. the Basic & Advanced courses. Instructor training certificates will be Instructor training certificates will be issued to those who assist and lead issued to those who assist and lead in both training courses under the in both training courses under the supervision of a master trainer. supervision of a master trainer.

DBT Treatment OverviewDBT Treatment Overview1.1. Complete assessment and behavioral analysis and review as a Complete assessment and behavioral analysis and review as a

treatment team. (Therapists, Interns) treatment team. (Therapists, Interns)

2.2. Provide weekly skills and rehearsal groups as a requisite of Provide weekly skills and rehearsal groups as a requisite of therapeutic services. (Trainers)therapeutic services. (Trainers)

3.3. Complete additional behavior analysis as new problem Complete additional behavior analysis as new problem behaviors arise and rehearse created solutions. (Therapists, behaviors arise and rehearse created solutions. (Therapists, Interns) Interns)

4.4. Provide ongoing skills coaching during everyday life. (All Staff)Provide ongoing skills coaching during everyday life. (All Staff)

5.5. Address PTSD and/or underlying symptoms that contribute to Address PTSD and/or underlying symptoms that contribute to functional impairments (Therapists, Interns) functional impairments (Therapists, Interns)

6.6. All interactions focus on Increasing, strengthening and All interactions focus on Increasing, strengthening and reinforcing self-validation and problem solving skills achieve reinforcing self-validation and problem solving skills achieve individual goals (All staff)individual goals (All staff)

7.7. Provide regular Provider Consultation.Provide regular Provider Consultation.

COMMUNICATION & COMMUNICATION & VALIDATION VALIDATION • Validation and problem-solving strategies form the core of DBT. Validation and problem-solving strategies form the core of DBT.

All other strategies are built around them. All other strategies are built around them.

• Validation strategies are the most obvious and direct acceptance Validation strategies are the most obvious and direct acceptance strategies in DBT. strategies in DBT.

• They are designed to engage the Client in trying to understand They are designed to engage the Client in trying to understand his actions, emotions, and thoughts or implicit rules. his actions, emotions, and thoughts or implicit rules.

• The Provider communicates to the Client that his responses are The Provider communicates to the Client that his responses are understandable and that they make sense in light of his history understandable and that they make sense in light of his history and/or current life context or situation. and/or current life context or situation.

• The Provider accepts the Client and communicates this The Provider accepts the Client and communicates this acceptance by taking the Client’s responses seriously and not acceptance by taking the Client’s responses seriously and not discounting or trivializing them.discounting or trivializing them.

COMMUNICATION & COMMUNICATION & VALIDATIONVALIDATION

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 & COMMUNICATION & VALIDATIONVALIDATION

ACCEPTANCE 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 beforeeverything ‘hit the fan’?”

“Tell me what happened…”

CHANGE LOW FACILITATIVE RESPONSES PROBLEM SOLVING

HIGH & LOW FACILITATIVE HIGH & LOW FACILITATIVE RESPONSESRESPONSES

• No single response can be classified as good or bad, right or 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 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 another. The goal is to be aware of the effectiveness of the responses you are using as you are using them.responses you are using as you are using them.

• Treatment that focuses only on change may lead the Client to Treatment that focuses only on change may lead the Client to mistrust and invalidate their responses to events, thus resulting in mistrust and invalidate their responses to events, thus resulting in an avoidance to change. an avoidance to change.

• A treatment that focuses only on unconditional acceptance and A treatment that focuses only on unconditional acceptance and validation of the Client’s behaviors may lead to reinforcing the validation of the Client’s behaviors may lead to reinforcing the Client’s problems, resulting in the Client giving up hope in the Client’s problems, resulting in the Client giving up hope in the possibility of change. possibility of change.

• Thus, the primary focus of DBT is teaching the Client to both Thus, the primary focus of DBT is teaching the Client to both validate himself and to change.validate himself and to change.

LEVELS OF VALIDATIONLEVELS OF VALIDATION

•Active ObservingActive Observing

•ReflectionReflection

•Direct ValidationDirect Validation

Active ObservingActive Observing• The essence is that the Provider is awake The essence is that the Provider is awake

enough to observe what the Client is enough to observe what the Client is thinking, feeling, and doing while letting go thinking, feeling, and doing while letting go of any previously known history, evaluations, of any previously known history, evaluations, or comments made about the Client. or comments made about the Client.

• Push away distractions; make eye contact; Push away distractions; make eye contact; use body language get on the same level; use body language get on the same level; knee-to-knee, shoulder to shoulder; and use knee-to-knee, shoulder to shoulder; and use voice tones that demonstrate to the Client voice tones that demonstrate to the Client that he is acknowledged and being heard that he is acknowledged and being heard

ReflectionReflection• Accurately and non-judgmentally summarize, clarify, Accurately and non-judgmentally summarize, clarify,

understand, and mirror the Client’s own thoughts, feelings, understand, and mirror the Client’s own thoughts, feelings, assumptions, and behaviors. assumptions, and behaviors.

• Provide accurate emotional empathy; understanding of (but not Provide accurate emotional empathy; understanding of (but not necessarily agreement with) beliefs, expectations, or necessarily agreement with) beliefs, expectations, or assumptions. “You look disappointed” (Reflecting and assumptions. “You look disappointed” (Reflecting and Understanding) Understanding)

• Provide the Client a chance to say that the Provider is wrong 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 and he or she is not right until the Client agrees. “So what I hear you saying is…” (Clarifying and Summarizing) hear you saying is…” (Clarifying and Summarizing)

• In reflecting, the Provider often states what the Client observes In reflecting, the Provider often states what the Client observes but is afraid to say or admit. This simple act of “saying it first”, but is afraid to say or admit. This simple act of “saying it first”, can be a powerful act of validation. can be a powerful act of validation.

• Find the wisdom or kernel of truth/motivation, in the behavior. 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 “I can see why you did that. Am I right in saying you wanted to fit in?”fit in?”

Direct ValidationDirect Validation

• Find the stimuli in the current environment that support the Find the stimuli in the current environment that support the Client’s behavior. Client’s behavior.

• Even though information regarding all the relevant causes may Even though information regarding all the relevant causes may not be available, communicate that the Client’s thoughts, not be available, communicate that the Client’s thoughts, feelings, and actions make perfect sense in the context of the feelings, and actions make perfect sense in the context of the Client’s current experience and life to date. Client’s current experience and life to date.

• Reflect the wisdom or validity of the Client’s response, and Reflect the wisdom or validity of the Client’s response, and communicate that the response is understandable. (e.g. communicate that the response is understandable. (e.g. physiology, brain chemistry, drug use, culture, rules, etc.) physiology, brain chemistry, drug use, culture, rules, etc.)

• Behavior is adaptive to the context in which it occurs, and the Behavior is adaptive to the context in which it occurs, and the

Provider must find the wisdom of that adaptation. In other Provider must find the wisdom of that adaptation. In other words, there is a legitimate underlying reason and/or purpose words, there is a legitimate underlying reason and/or purpose for every behavior in every specific situation. for every behavior in every specific situation.

Direct ValidationDirect Validation• Do not be blinded by the dysfunctional nature of a Client’s Do not be blinded by the dysfunctional nature of a Client’s

response but, instead, attend to those aspects of the response but, instead, attend to those aspects of the response that may be either reasonable or appropriate to response that may be either reasonable or appropriate to the context. the context.

• Search the Client’s responses for their inherent accuracy, Search the Client’s responses for their inherent accuracy, appropriateness, or reasonableness before considering appropriateness, or reasonableness before considering their more dysfunctional characteristics. Even if only a their more dysfunctional characteristics. Even if only a small part of the response is valid, search out that portion small part of the response is valid, search out that portion of the behavior and respond to it. of the behavior and respond to it.

• It is this third level that takes the most searching by the It is this third level that takes the most searching by the Provider and that defines validation most clearly. By Provider and that defines validation most clearly. By finding the validity in the Client’s response, the Provider finding the validity in the Client’s response, the Provider can honestly support the Client in validating himself. “It can honestly support the Client in validating himself. “It makes sense that you would want to escape from that makes sense that you would want to escape from that ….and using drugs has worked for you before.” ….and using drugs has worked for you before.”

EMOTION VALIDATION EMOTION VALIDATION STRATEGIESSTRATEGIES

• Validate Primary and Secondary emotions.Validate Primary and Secondary emotions.• Provide Opportunities For Emotional Expression.Provide Opportunities For Emotional Expression.• Teach Emotion, Observation, And Labeling Skills.Teach Emotion, Observation, And Labeling Skills.• Read And Clarify Emotions.Read And Clarify Emotions.• Communicate The Validity Of Emotions.Communicate The Validity Of Emotions.

• Anti-DBT Tactics:Anti-DBT Tactics:– Insist on your own perception of Client’s feelings.Insist on your own perception of Client’s feelings.– Criticize Client’s feelings.Criticize Client’s feelings.– Label feelings as irrational or distorted without acknowledging Label feelings as irrational or distorted without acknowledging

the kernel of truth.the kernel of truth.– Respond to painful emotions as something to get rid of.Respond to painful emotions as something to get rid of.– Express only discomfort with Client’s painful emotions.Express only discomfort with Client’s painful emotions.

BEHAVIORAL VALIDATION BEHAVIORAL VALIDATION STRATEGIESSTRATEGIES

• Teach Behavior Observation And Labeling Skills.Teach Behavior Observation And Labeling Skills.• Identify The “SHOULD”.Identify The “SHOULD”.• Counter The “SHOULD”. “It Is What It Is.”Counter The “SHOULD”. “It Is What It Is.”• Accept The “SHOULD”.Accept The “SHOULD”. • Validate The Client’s Disappointment In His Validate The Client’s Disappointment In His

Behavior.Behavior.

• Anti-DBT Tactics:Anti-DBT Tactics:– Impose your own behavioral preferences as absolute “shoulds”Impose your own behavioral preferences as absolute “shoulds”– Communicate that Client should feel, act, think differently than Communicate that Client should feel, act, think differently than

he does.he does.– Communicate that others should be different.Communicate that others should be different.

COGNITIVE VALIDATION COGNITIVE VALIDATION STRATEGIESSTRATEGIES

• Elicit And Reflect Thoughts And Assumptions.Elicit And Reflect Thoughts And Assumptions.• Discriminate Facts From Interpretations.Discriminate Facts From Interpretations.• Find the “Kernel Of Truth”.Find the “Kernel Of Truth”.• Acknowledge “Wise Mind”.Acknowledge “Wise Mind”.• Respect Differing Values.Respect Differing Values.

• Anti-DBT Tactics:Anti-DBT Tactics:– Push a particular set of values or philosophical position on Push a particular set of values or philosophical position on

reality and truth.reality and truth.– Present a rigid view of events.Present a rigid view of events.– Unable to see reality from the perspective of the Client.Unable to see reality from the perspective of the Client.

CHEERLEADING CHEERLEADING STRATEGIESSTRATEGIES

• Assume the BestAssume the Best• Provide EncouragementProvide Encouragement• Focus On Capabilities And StrengthsFocus On Capabilities And Strengths• Modulate External Criticism Modulate External Criticism • Provide Praise and ReassuranceProvide Praise and Reassurance• Have Realistic Expectations And Deal Directly With Have Realistic Expectations And Deal Directly With

Fears Of InsincerityFears Of Insincerity• Stay near in a crisis Stay near in a crisis

• Anti-DBT Tactics:Anti-DBT Tactics:– Over generalize, or overestimate Client’s capabilities.Over generalize, or overestimate Client’s capabilities.– Use cheerleading to “get rid” of Client.Use cheerleading to “get rid” of Client.– Call Client a “manipulator”, or accuse him of “playing games”, Call Client a “manipulator”, or accuse him of “playing games”,

“splitting”, and “not trying” either to his face or to other “splitting”, and “not trying” either to his face or to other providers. providers.

VALIDATING VALIDATING COMMUNICATIONCOMMUNICATION

1.1. Ask an open question–Validates the StoryAsk an open question–Validates the Story– Tell me what’s going on?Tell me what’s going on?

2.2. Clarify the response–Validates Reason MindClarify the response–Validates Reason Mind– So what I hear you say is…So what I hear you say is…

3.3. Empathize the emotion–Validates Emotion Empathize the emotion–Validates Emotion MindMind– So are you feeling…?So are you feeling…?

4.4. Radically accept-Validates the BeingRadically accept-Validates the Being– That makes sense…of course…got it.That makes sense…of course…got it.

DIALECTIC STRATEGIESDIALECTIC STRATEGIES

• The primary dialectical strategy is the balanced use The primary dialectical strategy is the balanced use of specific strategies and therapeutic positions by the of specific strategies and therapeutic positions by the Provider during interactions with the Client. Provider during interactions with the Client. Constant attention to combining acceptance with Constant attention to combining acceptance with change, flexibility with stability, nurturing with change, flexibility with stability, nurturing with challenging, and a focus on capabilities with a focus challenging, and a focus on capabilities with a focus on limitations and deficits is the essence of this on limitations and deficits is the essence of this strategy. The Provider must respond to the Client strategy. The Provider must respond to the Client just where he is and then be able to move quickly just where he is and then be able to move quickly from strategy to strategy, alternating acceptance from strategy to strategy, alternating acceptance with change, control with letting go, confrontation with change, control with letting go, confrontation with support, the carrot with the stick, a hard edge with support, the carrot with the stick, a hard edge with softness, and so on in rapid succession.with softness, and so on in rapid succession.

DIALECTIC STRATEGIESDIALECTIC STRATEGIES

• Clients tend to move away and thus change thoughts, Clients tend to move away and thus change thoughts, responses, behaviors, etc. from whichever position the responses, behaviors, etc. from whichever position the Provider tends to take. “Whichever side the Provider Provider tends to take. “Whichever side the Provider aligns himself with, the Client will usually feel impelled aligns himself with, the Client will usually feel impelled to leave.” Sherman (1961, pg 55)to leave.” Sherman (1961, pg 55)

• The key idea guiding the Provider’s behavior is that The key idea guiding the Provider’s behavior is that for any point, an opposite or complementary position for any point, an opposite or complementary position can be held. Thus, change may be facilitated by can be held. Thus, change may be facilitated by emphasizing acceptance and acceptance by emphasizing acceptance and acceptance by emphasizing change. The idea is to keep the Client emphasizing change. The idea is to keep the Client sufficiently off balance so that he cannot find a secure sufficiently off balance so that he cannot find a secure foothold to maintain his previous behavioral, foothold to maintain his previous behavioral, emotional, and cognitive rigidity.emotional, and cognitive rigidity.

DIALECTIC STRATEGIESDIALECTIC STRATEGIES• Compared to the “Teeter-totter”: Move back Compared to the “Teeter-totter”: Move back

(opposing the Client’s position) and the Client moves (opposing the Client’s position) and the Client moves back (to validate his position) – move forward back (to validate his position) – move forward (validating the Client’s position) and the Client moves (validating the Client’s position) and the Client moves forward (to change his position) – by carefully moving forward (to change his position) – by carefully moving back and forth between change and acceptance the back and forth between change and acceptance the Client and Provider will eventually find themselves in Client and Provider will eventually find themselves in the middle of the teeter-totter and a new dialectic will the middle of the teeter-totter and a new dialectic will present itself. present itself.

• Compared to playing a game of “Chicken”: The one Compared to playing a game of “Chicken”: The one who moves with the most confidence and resolve who moves with the most confidence and resolve forces the other to “change direction”.forces the other to “change direction”.

• Extremes and rigid behavior patterns are signals that Extremes and rigid behavior patterns are signals that a dialectic has not been achieved.a dialectic has not been achieved.

DIALECTIC STRATEGIESDIALECTIC STRATEGIES(How to position yourself on any side of a conversation and move someone to (How to position yourself on any side of a conversation and move someone to

change.)change.)

• P - Entering The P - Entering The PParadox.aradox. The The “And” vs. “But” “And” vs. “But” ResponseResponse

• M - The Use of M - The Use of MMetaphor.etaphor. The The “It’s like…” “It’s like…” ResponseResponse

• D - The D - The DDevil’s Advocate Technique.evil’s Advocate Technique. The The “Are you sure?”“Are you sure?” ResponseResponse

• E - E - EExtending. xtending. The The “Wow, that’s pretty serious!”“Wow, that’s pretty serious!” Response Response

• A - A - AActivating “Wise Mind”.ctivating “Wise Mind”. The The “Let’s look at what is.”“Let’s look at what is.” ResponseResponse

• L - Making L - Making LLemonade. emonade. The The “That’s great!”“That’s great!” Response Response

• N - N - NNatural Change.atural Change. The The “That was then, this is now.” “That was then, this is now.” ResponseResponse

Entering The ParadoxEntering The ParadoxThe “And” vs. “But” Response.The “And” vs. “But” Response.

• Both-and” is offered as an alternative to “either-or”. Both Both-and” is offered as an alternative to “either-or”. Both sides are accepted as valid. Behavior is simply seen as a sides are accepted as valid. Behavior is simply seen as a way to solve problems. We either solve the problem, way to solve problems. We either solve the problem, attempt solutions, make it worse, or accept it as it is. attempt solutions, make it worse, or accept it as it is. Forces Client and Provider to let go of rigid positions and Forces Client and Provider to let go of rigid positions and inflexible ways, rules, regulations, and patterns of actions. inflexible ways, rules, regulations, and patterns of actions.

– ““You are perfect just the way you are You are perfect just the way you are andand you must you must change if life is going to be different.”change if life is going to be different.”

– ““What you did worked very well for the moment What you did worked very well for the moment andand it it caused more problems later on.”caused more problems later on.”

– ““It makes perfect sense that you did what you did It makes perfect sense that you did what you did andand you must learn a new way to avoid making things you must learn a new way to avoid making things worse.”worse.”

The Use of MetaphorThe Use of MetaphorThe “It’s like…” Response.The “It’s like…” Response.

• Simple analogies, anecdotes, parables, myths, or stories, Simple analogies, anecdotes, parables, myths, or stories, are extremely important in DBT. They are usually more are extremely important in DBT. They are usually more interesting and easier to remember than lecturing or interesting and easier to remember than lecturing or instruction alone. When constructed properly, metaphors instruction alone. When constructed properly, metaphors can be less threatening to the individual. Points can be can be less threatening to the individual. Points can be made indirectly, in a way that softens their impact. Allow made indirectly, in a way that softens their impact. Allow the Client to use the story in their own way, for their own the Client to use the story in their own way, for their own purposes. Metaphor uses something the Client is familiar purposes. Metaphor uses something the Client is familiar with to assist in understanding what is unfamiliar.with to assist in understanding what is unfamiliar.

– ““Emotions are like waves…they come…and they go.” Emotions are like waves…they come…and they go.” – ““Using wise mind helps you find the calm inside the Using wise mind helps you find the calm inside the

storm.” “Like riding a bike – you just “get it”.storm.” “Like riding a bike – you just “get it”.– ““I am like a guide or coach. I will do my best to show 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.”you the way but I cannot walk the trail for you.”

Devil’s Advocate Devil’s Advocate The “Are you sure?” Response.The “Are you sure?” Response.• Used best to counteract oppositional patterns. Used in Used best to counteract oppositional patterns. Used in

the first several sessions to elicit a strong commitment to the first several sessions to elicit a strong commitment to change. The Provider argues against change and change. The Provider argues against change and commitment to therapy, because change is painful and commitment to therapy, because change is painful and difficult; this method is effective if it moves the Client to difficult; this method is effective if it moves the Client to take the oppositional position in favor of change and take the oppositional position in favor of change and commitment. The Provider argues in favor of the commitment. The Provider argues in favor of the irrational belief, questioning why the Client does not irrational belief, questioning why the Client does not agree.agree.

– ““Are you sure you want to work that hard?Are you sure you want to work that hard?– ““I mean, this isn’t going to be easy you know.”I mean, this isn’t going to be easy you know.”– ““Do you think you have what it takes?”Do you think you have what it takes?”

ExtendingExtendingThe “Wow, that’s pretty serious!” The “Wow, that’s pretty serious!”

Response.Response.• The Provider takes extreme emotional expression literally and The Provider takes extreme emotional expression literally and extends it further, taking the Client more seriously than he/she extends it further, taking the Client more seriously than he/she takes himself/herself. The emotional equivalent of the devil’s takes himself/herself. The emotional equivalent of the devil’s advocate strategy. The term “extending” is borrowed from advocate strategy. The term “extending” is borrowed from martial arts. Extending allows the movements of a challenger to martial arts. Extending allows the movements of a challenger to reach their natural completion, then extends the end point of the reach their natural completion, then extends the end point of the movement slightly further than it would go naturally leaving the movement slightly further than it would go naturally leaving the challenger off balance and vulnerable to shift direction. First challenger off balance and vulnerable to shift direction. First “blend” – accept or join or move with the client’s energy flow the “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. direction it is going. Go to the natural conclusion of the response. Then “extend” – use the momentum to move the client further Then “extend” – use the momentum to move the client further than he expected.than he expected.

– ““Wow, if your going to kill somebody, I better get you to a 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 hospital right away. We can’t have you going to jail for murder.”murder.”

– ““Wow, if you can’t control your behavior and none of these Wow, if you can’t control your behavior and none of these skills work, we need to get you to a more controlled facility.”skills work, we need to get you to a more controlled facility.”

– ““These clothing rules are not fair! “You’re absolutely right we These clothing rules are not fair! “You’re absolutely right we should start wearing uniforms so we all look exactly alike.”should start wearing uniforms so we all look exactly alike.”

Activating “Wise Mind”Activating “Wise Mind”The “Let’s look at what is.” The “Let’s look at what is.”

Response.Response.• A person is in “reasonable mind” when he is approaching A person is in “reasonable mind” when he is approaching knowledge intellectually, is thinking rationally and logically, knowledge intellectually, is thinking rationally and logically, attends to empirical facts, is planful in his behavior, focuses attends to empirical facts, is planful in his behavior, focuses attention, and is “cool” in his approach to problems. A person is attention, and is “cool” in his approach to problems. A person is in “emotion mind” when thinking and behavior are controlled in “emotion mind” when thinking and behavior are controlled primarily by his current emotional state. In “emotion mind,” primarily by his current emotional state. In “emotion mind,” reasonable, logical thinking is difficult and behaviors can be reasonable, logical thinking is difficult and behaviors can be amplified to be congruent with current emotion. “Wise mind” is amplified to be congruent with current emotion. “Wise mind” is the integration of “emotion mind” and “reasonable mind”; Wise the integration of “emotion mind” and “reasonable mind”; Wise mind” must rule over the other two and Clients must be mind” must rule over the other two and Clients must be convinced that they are capable of doing this. convinced that they are capable of doing this.

– ““All humans have “wise mind” in the same way we have All humans have “wise mind” in the same way we have hearts. Just because I cannot see my heart does not mean it hearts. Just because I cannot see my heart does not mean it does not exist. What does your wise mind say?” does not exist. What does your wise mind say?”

– ““I’m not interested in what you think or feel to be true, I want I’m not interested in what you think or feel to be true, I want to know what you “know” to be true.to know what you “know” to be true.

– ““Knowing what you know, and knowing what you feel, what Knowing what you know, and knowing what you feel, what does your “wise mind” tell you to do?does your “wise mind” tell you to do?

Making Lemonade Making Lemonade The “That’s great!” Response.The “That’s great!” Response.

• Take a problem and make it into an asset. The more Take a problem and make it into an asset. The more difficult a Client acts in therapy, the better it is. After all, difficult a Client acts in therapy, the better it is. After all, if problems didn’t show up in treatment, how could the if problems didn’t show up in treatment, how could the Provider be helpful? Problems in life are opportunities to Provider be helpful? Problems in life are opportunities to learn and practice new skills. Persistence in resisting learn and practice new skills. Persistence in resisting change is exactly what will keep him going until he finds change is exactly what will keep him going until he finds the “right” path. The skill is in finding the silver lining the “right” path. The skill is in finding the silver lining without denying that the cloud is indeed black. Making without denying that the cloud is indeed black. Making good tasting lemonade requires a fair amount of sugar.good tasting lemonade requires a fair amount of sugar.

– Client: “I’m stuck here for six months”. Provider: “That’s Client: “I’m stuck here for six months”. Provider: “That’s great! That will give us a chance to learn all kinds of new 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 skills and ways of being that you never could have learned if you had not ended up here!”you had not ended up here!”

Allow Natural Change.Allow Natural Change. The “That was then, this is now.” The “That was then, this is now.”

Response.Response.• Change occurs naturally in many instances. One Change occurs naturally in many instances. One

consistent reality of life is that it constantly changes. The consistent reality of life is that it constantly changes. The Provider does not try to create the perfect environment Provider does not try to create the perfect environment with the perfect people doing all the right things so that with the perfect people doing all the right things so that the Client can learn. The Provider uses natural change as the Client can learn. The Provider uses natural change as opportunity to learn, reinforce, and experience effective opportunity to learn, reinforce, and experience effective skills that help the Client to adapt.skills that help the Client to adapt.

– Client: “I liked it better before! I hate the way it is Client: “I liked it better before! I hate the way it is now!”now!”

– Provider: “It did seem easier then. Now that Provider: “It did seem easier then. Now that thenthen no no longer exists and all there islonger exists and all there is now now, what skills can you , what skills can you use use nownow that will work?” that will work?”

ORIENTINGORIENTING

• The purpose of orienting is to provide The purpose of orienting is to provide precise information about what is to precise information about what is to be learned before each instance of be learned before each instance of new learning, as well as a new learning, as well as a clarification of the conceptual model clarification of the conceptual model within which the learning will take within which the learning will take place. place.

ORIENTINGORIENTING

• It is important to provide information It is important to provide information about the treatment process, explain about the treatment process, explain DBT Agreements, procedures that DBT Agreements, procedures that will be employed, or requirements will be employed, or requirements necessary in implementing a specific necessary in implementing a specific solution. solution.

ORIENTING STRATEGIESORIENTING STRATEGIES

• Orienting to the task at hand must be Orienting to the task at hand must be conducted repeatedly during treatment as conducted repeatedly during treatment as a general first step in repeated a general first step in repeated recommitments to treatment, to specific recommitments to treatment, to specific therapeutic procedures, and to therapeutic procedures, and to implementation of previously agreed-upon implementation of previously agreed-upon behavioral solutions. behavioral solutions.

• Orienting is like shining a light down the Orienting is like shining a light down the unknown path of change.unknown path of change.

Orienting to Orienting to Roles, Responsibilities & Roles, Responsibilities &

ReasonReasonROLES RESPONSIBILITIES

Provider = Coach/Teacher/Guide

Teach, Practice, Model, Document

Client = Player/Student/Explorer

Learn, Practice, Generalize

REASON

To create a life I love…a life worth living!

COMMITMENTCOMMITMENT

• Client commitment is both a Client commitment is both a prerequisite for treatment and a prerequisite for treatment and a goal. Commitment is not assumed. goal. Commitment is not assumed. It is viewed as itself a behavior, It is viewed as itself a behavior, which can be elicited, learned and which can be elicited, learned and reinforced. It is the Provider’s task to reinforced. It is the Provider’s task to figure out ways to help this process figure out ways to help this process along. along.


• Throughout treatment, the Provider Throughout treatment, the Provider can expect that the Client will need can expect that the Client will need reminding of the commitments reminding of the commitments made, as well as assistance in made, as well as assistance in refining, expanding, and remaking refining, expanding, and remaking behavioral commitments. behavioral commitments.


• A failure in commitment should be one A failure in commitment should be one of the first things assessed, but not of the first things assessed, but not assumed, when a problem in treatment assumed, when a problem in treatment arises. Before moving to solve the arises. Before moving to solve the problem, the Provider should go back problem, the Provider should go back with the Client, assess commitment, with the Client, assess commitment, and use the most effective and use the most effective commitment strategies. commitment strategies.


• Once recommitment is made, both Once recommitment is made, both can proceed with addressing the can proceed with addressing the problem at hand. Commitment problem at hand. Commitment creates the internal energy required creates the internal energy required to let go of old, ineffective behaviors to let go of old, ineffective behaviors and create new more effective ones.and create new more effective ones.

ORIENTATION & ORIENTATION & COMMITTMENTCOMMITTMENT

• The skillful use of orientation and The skillful use of orientation and commitment strategies will reduce commitment strategies will reduce Client anxiety, increase forward Client anxiety, increase forward momentum, and significantly momentum, and significantly increase the probability that change increase the probability that change will indeed occur. will indeed occur.

ORIENTATION & ORIENTATION & COMMITTMENTCOMMITTMENT

• Describe the road to be traveled then Describe the road to be traveled then get a commitment to the trip, to take get a commitment to the trip, to take the first step, and to continue on the first step, and to continue on until Clients are confident it will lead until Clients are confident it will lead to their desired destination and they to their desired destination and they can walk on their own.can walk on their own.

COMMITMENT COMMITMENT STRATEGIESSTRATEGIES

• 3 Levels of Commitment3 Levels of Commitment

• Commitment & RecommitmentCommitment & Recommitment

• The Need for FlexibilityThe Need for Flexibility

• Commitment StrategiesCommitment Strategies

LEVELS OF COMMITMENTLEVELS OF COMMITMENTLevel 1:Level 1: Intention-A desire to change Intention-A desire to change

ineffective behaviors. ineffective behaviors.

Level 2:Level 2: Practice-A commitment to Practice-A commitment to practice effective behaviors. practice effective behaviors. – Take medications and attend and Take medications and attend and

participate in therapy and groups.participate in therapy and groups.

Level 3:Level 3: Generalize-A commitment to Generalize-A commitment to apply new behavioral solutions in apply new behavioral solutions in everyday living.everyday living.

LEVELS OF COMMITMENTLEVELS OF COMMITMENT

• There must be at least a level two There must be at least a level two commitment in order to begin commitment in order to begin therapy.therapy.

• If a level two commitment has not If a level two commitment has not been obtained, the primary been obtained, the primary treatment target will be to elicit one.treatment target will be to elicit one.

COMMITMENT & COMMITMENT & RECOMMITMENTRECOMMITMENT

• One of the chief reasons many treatments fail One of the chief reasons many treatments fail and/or end in early termination is inadequate and/or end in early termination is inadequate commitment by the Client, the Provider, or both. commitment by the Client, the Provider, or both. Commitments may not be strong enough to begin Commitments may not be strong enough to begin with or reduced by events during treatment.with or reduced by events during treatment.

• Client commitment is both a prerequisite for Client commitment is both a prerequisite for treatment and a goal. treatment and a goal.

• Commitment is not assumed. It is viewed as Commitment is not assumed. It is viewed as itself a behavior, which can be elicited, learned itself a behavior, which can be elicited, learned and reinforced. It is the Provider’s task to figure and reinforced. It is the Provider’s task to figure out ways to help this process along.out ways to help this process along.

COMMITMENT & COMMITMENT & RECOMMITMENTRECOMMITMENT• Throughout treatment, the Provider can expect that Throughout treatment, the Provider can expect that

the Client will need reminding of the commitments the Client will need reminding of the commitments he has made, as well as assistance in refining, he has made, as well as assistance in refining, expanding, and remaking behavioral commitments.expanding, and remaking behavioral commitments.

• A failure in commitment should be one of the first A failure in commitment should be one of the first things assessed, but not assumed, when a problem things assessed, but not assumed, when a problem in treatment arises.in treatment arises.

• Before moving to solve the problem, the Provider Before moving to solve the problem, the Provider should go back with the Client, assess his should go back with the Client, assess his commitment, and use the most effective commitment, and use the most effective commitment strategies. Once recommitment is commitment strategies. Once recommitment is made, both can proceed with addressing the made, both can proceed with addressing the problem at hand.problem at hand.

COMMITMENT & COMMITMENT & RECOMMITMENTRECOMMITMENT

• Sometimes the uncommitted partner is the Provider, Sometimes the uncommitted partner is the Provider, not the Client. The Client may be demanding not the Client. The Client may be demanding resources that the Provider does not have, or has not resources that the Provider does not have, or has not yet made available. The Client’s progress may be so yet made available. The Client’s progress may be so slow that the Provider becomes frustrated or loses slow that the Provider becomes frustrated or loses interest. There may be value clashes, or the Provider interest. There may be value clashes, or the Provider may find that he or she simply does not like the may find that he or she simply does not like the Client. Treating the Client may no longer be Client. Treating the Client may no longer be rewarding.rewarding.

• The most appropriate arena for the Provider to The most appropriate arena for the Provider to examine his or her commitment and recommitment examine his or her commitment and recommitment is in the Consultation Teams and Clinical Supervision.is in the Consultation Teams and Clinical Supervision.

THE NEED FOR THE NEED FOR FLEXIBILITYFLEXIBILITY

• Avoid being judgmental about the Client’s choice Avoid being judgmental about the Client’s choice of goals and/or commitments. of goals and/or commitments.

• Be careful not to impose your own goals or Be careful not to impose your own goals or treatment procedures on the Client when the treatment procedures on the Client when the Consultation and Treatment Team does not Consultation and Treatment Team does not dictate such goals or procedures.dictate such goals or procedures.

• Eliciting a commitment from a Client may involve Eliciting a commitment from a Client may involve a number of steps.a number of steps.

• The Provider is often functioning like a good The Provider is often functioning like a good salesperson.salesperson.


• The product being sold is treatment strategies or The product being sold is treatment strategies or skills, new behavior, a renewed effort to change, skills, new behavior, a renewed effort to change, or sometimes life itself. All of the strategies below or sometimes life itself. All of the strategies below may be needed when the task requires great may be needed when the task requires great effort on the part of the Client; when effort must effort on the part of the Client; when effort must be sustained over a long period or in the face of be sustained over a long period or in the face of adversity or during attempts by others to adversity or during attempts by others to dissuade the Client; when the Client feels dissuade the Client; when the Client feels hopeless about his capacity to change; or when hopeless about his capacity to change; or when what is required is something the Client fears what is required is something the Client fears greatly.greatly.


• At other times, only a request for the At other times, only a request for the verbal commitment may be needed, verbal commitment may be needed, and other tactics can be discarded. and other tactics can be discarded.

• Feel free to move back and forth Feel free to move back and forth among the various strategies as among the various strategies as needed. needed.

COMMITMENT COMMITMENT STRATEGIESSTRATEGIES

• Highlight The Pros And ConsHighlight The Pros And Cons

• Play The Devil’s AdvocatePlay The Devil’s Advocate

• Foot In The Door/Door In The Face Foot In The Door/Door In The Face

• Connect To Commitments Connect To Commitments

• Highlight Freedom To ChooseHighlight Freedom To Choose

• Use Principles Of ShapingUse Principles Of Shaping

• Generate Hope: CheerleadGenerate Hope: Cheerlead

• Agree To HomeworkAgree To Homework

• Two RulesTwo Rules

• ““You Are Your Word”You Are Your Word”

Highlight The Pros And Highlight The Pros And ConsCons

• People keep commitments they believe in better than those People keep commitments they believe in better than those they do not believe in. When one or more action plans have they do not believe in. When one or more action plans have been proposed, engage the Client in a discussion of the pros been proposed, engage the Client in a discussion of the pros and cons of actually making a commitment to a specific plan and cons of actually making a commitment to a specific plan or solution.or solution.

• Rehearse the good points of the action to be taken. Highlight Rehearse the good points of the action to be taken. Highlight the benefits to the Client and his life.the benefits to the Client and his life.

• Provide counterarguments to reservations the Client might Provide counterarguments to reservations the Client might have for not taking action.have for not taking action.

• The more you can realistically paint the picture of how taking The more you can realistically paint the picture of how taking action will benefit the Client and how not taking action will action will benefit the Client and how not taking action will lead to misery the better.lead to misery the better.

• Sometimes selling the “pro” of an action to be taken is simply Sometimes selling the “pro” of an action to be taken is simply highlighting that it is the best action between two undesirable highlighting that it is the best action between two undesirable possibilities.possibilities.

Highlight The Pros And Highlight The Pros And ConsCons

Playing The Devil’s Playing The Devil’s AdvocateAdvocate

• Use when you think the Client’s commitment may not be strong Use when you think the Client’s commitment may not be strong enough to stand up during future adversity.enough to stand up during future adversity.

• Helpful in enhancing the Client’s sense of choice and control.Helpful in enhancing the Client’s sense of choice and control.

• When a tentative commitment is made, pose arguments against When a tentative commitment is made, pose arguments against it.it.

• The secret here is to make sure that the counterarguments are The secret here is to make sure that the counterarguments are slightly weaker than the Client’s arguments for commitment. slightly weaker than the Client’s arguments for commitment.

• If the counterarguments are too strong, the Client may capitulate If the counterarguments are too strong, the Client may capitulate and retract his initial commitment. If this happens, back down and retract his initial commitment. If this happens, back down slightly and reinforce the arguments for commitment, and then slightly and reinforce the arguments for commitment, and then revert back once more to the devil’s advocate position.revert back once more to the devil’s advocate position.

Example: “I’m wondering if you are strong Example: “I’m wondering if you are strong enough to do this kind of work?”enough to do this kind of work?”

Foot-In-The-DoorFoot-In-The-Door

• Terms come from research on door-to-door Terms come from research on door-to-door canvassing for charities.canvassing for charities.

• Enhances compliance with requests and Enhances compliance with requests and previously made commitments.previously made commitments.

• Foot-In-The-Door:Foot-In-The-Door: Make an easier first request Make an easier first request followed by a more difficult request.followed by a more difficult request.

Door-In-The-FaceDoor-In-The-Face

• Door-In-The-Face:Door-In-The-Face: Request something much Request something much larger than the Client expects, and then request larger than the Client expects, and then request something easier.something easier.

• Combined: Ask for something very hard, then Combined: Ask for something very hard, then move to something very easy, and progressively move to something very easy, and progressively ask for something harder.ask for something harder.

• Most successful in eliciting commitments to Most successful in eliciting commitments to engage in homework practice or to try new engage in homework practice or to try new behaviors. “I want you to try using all your skills behaviors. “I want you to try using all your skills everyday.” “How about committing to using one everyday.” “How about committing to using one skill each day.”skill each day.”

Steps:Steps:

• Present a goal of treatment, procedure, or task somewhat Present a goal of treatment, procedure, or task somewhat vaguely and in a favorable light, omitting discussion of how vaguely and in a favorable light, omitting discussion of how hard the goals will be to reach, so that almost anyone would hard the goals will be to reach, so that almost anyone would agree.agree.

• Elicit the Client’s commitment to reach the goal. Elicit the Client’s commitment to reach the goal.

• Re-describe the goal, presenting more specifics and Re-describe the goal, presenting more specifics and highlighting the difficulties a bit more.highlighting the difficulties a bit more.

• Elicit another commitment to reach the goal.Elicit another commitment to reach the goal.

• ““Up the ante” by presenting goals as very difficult to reach, Up the ante” by presenting goals as very difficult to reach, perhaps more difficult than anything the Client has ever perhaps more difficult than anything the Client has ever attempted (and more difficult than it may actually be)-but attempted (and more difficult than it may actually be)-but attainable if the Client wants to try.attainable if the Client wants to try.

• Elicit another commitment to reach goal.Elicit another commitment to reach goal.

• Remind and/or clarify previous Remind and/or clarify previous commitment and reinforce current commitment and reinforce current commitment.commitment.

• Used when the strength of a Used when the strength of a commitment seems to be fading or commitment seems to be fading or when the Client’s behavior is when the Client’s behavior is incongruent with his previous incongruent with his previous commitments. commitments.

Example: Example: “I thought you agreed to…”“I thought you agreed to…”

Highlighting Freedom To Highlighting Freedom To Choose & The Absence Of Choose & The Absence Of

AlternativesAlternatives• Commitment and adherence are enhanced both when people believe that Commitment and adherence are enhanced both when people believe that

they have chosen a commitment feely and when they believe that there they have chosen a commitment feely and when they believe that there are no alternative paths to their goals.are no alternative paths to their goals.

• Highlighting the freedom to choose behaviors while stressing the Highlighting the freedom to choose behaviors while stressing the negative consequences of failure to make a particular commitment can negative consequences of failure to make a particular commitment can strengthen both a commitment and the likelihood of follow-through on the strengthen both a commitment and the likelihood of follow-through on the agreement.agreement.

• Stress the fact that the Client can simply change his goals.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 Stress that in choosing a new goal he must also be prepared to accept the consequences. When providing consequences, speak in a matter of the consequences. When providing consequences, speak in a matter of fact manner. Avoid embellishing or adding negative consequences that fact manner. Avoid embellishing or adding negative consequences that you know may not occur as this amounts to threatening and may move you know may not occur as this amounts to threatening and may move the Client completely away from your goal of getting a commitment. the Client completely away from your goal of getting a commitment.

Example: Example: “You can choose to solve your problem with ____ by violence, “You can choose to solve your problem with ____ by violence, stealing, arguing, etc. and the consequence is that you may have to stay stealing, arguing, etc. and the consequence is that you may have to stay in treatment longer.”in treatment longer.”

Using Principles Of Using Principles Of ShapingShaping

• Commitments often have to be Commitments often have to be creatively shaped larger or smaller to creatively shaped larger or smaller to just –noticeable differences in order just –noticeable differences in order to stick.to stick.

• Must be done in a way that does not Must be done in a way that does not make the Client look like a failure.make the Client look like a failure.

• Do not be afraid to experiment and Do not be afraid to experiment and change until it works.change until it works.

Generating Hope: Generating Hope: CheerleadingCheerleading

• Client’s often have a lack of any hope that they can Client’s often have a lack of any hope that they can change their ways and put more effective solutions change their ways and put more effective solutions into practice, or that their attempts will not end in into practice, or that their attempts will not end in failure and humiliation. Commitment without hope failure and humiliation. Commitment without hope of keeping the commitment is extremely difficult.of keeping the commitment is extremely difficult.

• Acknowledge all the times the Client has Acknowledge all the times the Client has succeeded thus far.succeeded thus far.

• Reinforce even the smallest progress, letting him Reinforce even the smallest progress, letting him know that it was his power that produced it – it know that it was his power that produced it – it came from him – know one else. came from him – know one else.

Example: Example: “You have everything it takes to “You have everything it takes to overcome your problems no matter what they are.”overcome your problems no matter what they are.”

Agreeing On HomeworkAgreeing On Homework

• Put the assignment in writing.Put the assignment in writing.

• Explain thoroughly how to complete the Explain thoroughly how to complete the assignment.assignment.

• Check to ensure that he “gets it”.Check to ensure that he “gets it”.

• Set up a support person who can provide Set up a support person who can provide help.help.

• Get a commitment to bring homework Get a commitment to bring homework results to the next session.results to the next session.

• Works well before beginning a skills group. Works well before beginning a skills group.

• This process increases the Client’s own sense of personal power.This process increases the Client’s own sense of personal power.

• Before beginning any instruction, explain the purpose and the Before beginning any instruction, explain the purpose and the importance of the material being taught in session and how important importance of the material being taught in session and how important it is that you be allowed to teach in the most effective manner it is that you be allowed to teach in the most effective manner possible.possible.

• Let the group know that in order to accomplish this task, you have only 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 two rules that each participant must commit to if they are to stay in group: group: – Listen to what I say, andListen to what I say, and– Follow my directions.Follow my directions.

• Clarify that it is completely up to them to choose to accept these rules. 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 If they agree they will receive the tremendous benefit of learning something new and effective for their life.something new and effective for their life.

• Clarify to those who ask, that they are certainly free to not commit to 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.these rules, and in that case will be asked to sit outside the group.

The “Two Rules” MethodThe “Two Rules” Method

• Obtain a commitment from each participant. It is preferable that the Obtain a commitment from each participant. It is preferable that the commitment is verbal, but you may at times just want a show of commitment is verbal, but you may at times just want a show of hands. The importance of the verbal commitment is connected to the hands. The importance of the verbal commitment is connected to the power that every participant has available to them-the power to keep power that every participant has available to them-the power to keep his own word.his own word.

• During group, if a Client refuses to follow directions, or does not During group, if a Client refuses to follow directions, or does not appear to be listening, remind him immediately of his previous appear to be listening, remind him immediately of his previous commitment and ask if he would please do what he promised to do.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 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 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 that they made the choice with their own power, and that you respect the power of their word.the power of their word.

• This technique helps Clients to experience the very real power their 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 words can have if they decide to give those words the power to follow through with their promise.through with their promise.

CONTINGENCY CONTINGENCY MANAGEMENT MANAGEMENT PROCEDURESPROCEDURES

• Contingency simply refers to “if/then” scenarios. Contingency simply refers to “if/then” scenarios.

• ““If you do ____ then ____ will probably happen.”If you do ____ then ____ will probably happen.”

• Every response within an interpersonal Every response within an interpersonal interaction, whether intended or not, is a interaction, whether intended or not, is a potential reinforcement, punishment, or potential reinforcement, punishment, or extinction. extinction.

• Getting across accurate information about how Getting across accurate information about how learning works is crucial if the Client is to learning works is crucial if the Client is to collaborate in discovering the forces controlling collaborate in discovering the forces controlling his own behavior.his own behavior.

Orient To Contingency Orient To Contingency ManagementManagement

• Discuss the differences among intentions, Discuss the differences among intentions, behavioral planning, purpose, and consequences behavioral planning, purpose, and consequences as they influence how individuals respond or act as they influence how individuals respond or act in the world.in the world. – The intent of their behaviors is frequently unrelated The intent of their behaviors is frequently unrelated

to at least some of the outcomes, including to at least some of the outcomes, including outcomes that reinforce the behaviors. outcomes that reinforce the behaviors.

– Many consequences are in fact unintended. Just Many consequences are in fact unintended. Just because a consequence strengthens behavior does because a consequence strengthens behavior does not mean that it was intended or wanted. not mean that it was intended or wanted. Unintended consequences can and frequently do Unintended consequences can and frequently do reinforce behavior.reinforce behavior.


• Discuss the automatic nature of Discuss the automatic nature of most learning.most learning.– Infant and animal learning is usually Infant and animal learning is usually

unconscious.unconscious.– Reinforced consequences cause Reinforced consequences cause

chemical change in the brain. Neural chemical change in the brain. Neural circuits are changed.circuits are changed.


• Discuss the automatic nature of Discuss the automatic nature of most learning.most learning.– Infant and animal learning is usually Infant and animal learning is usually

unconscious.unconscious.– Reinforced consequences cause Reinforced consequences cause

chemical change in the brain. Neural chemical change in the brain. Neural circuits are changed.circuits are changed.


• Consequences can affect behavior Consequences can affect behavior without a person’s awareness.without a person’s awareness.– Most of us are not aware of how and when Most of us are not aware of how and when

behavioral consequences influence our behavior.behavioral consequences influence our behavior.– The feeling that we are doing something for one The feeling that we are doing something for one

reason or purpose does not mean that this reason reason or purpose does not mean that this reason or purpose is actually influencing our behavior.or purpose is actually influencing our behavior.

– All humans tend to construct reasons for their own All humans tend to construct reasons for their own behavior when causes are not apparent. behavior when causes are not apparent.


– Research has shown that stimulating certain reward Research has shown that stimulating certain reward centers in the brain increases the frequency of any centers in the brain increases the frequency of any behavior preceding the stimulation. The effect is so behavior preceding the stimulation. The effect is so powerful that an animal or human can be made to powerful that an animal or human can be made to engage in a “rewarded behavior” so frequently that it engage in a “rewarded behavior” so frequently that it will not stop to eat, even when food deprived.will not stop to eat, even when food deprived.

– In humans, any time the reward center in the brain is In humans, any time the reward center in the brain is stimulated, the preceding behavior becomes more stimulated, the preceding behavior becomes more reinforced.reinforced.

– We may attribute why we do things to other reasons We may attribute why we do things to other reasons when in fact it may be something unknown to us that when in fact it may be something unknown to us that actually stimulates the reinforced behavior.actually stimulates the reinforced behavior.


• When a person figures out what is truly When a person figures out what is truly influencing his behavior, this is called insight.influencing his behavior, this is called insight.– Do not assume that intent, consequences and Do not assume that intent, consequences and

reinforcement go hand in hand.reinforcement go hand in hand.– Do not assume that feelings, or beliefs about Do not assume that feelings, or beliefs about

causes, without supporting data, are the best causes, without supporting data, are the best information about what is really influencing information about what is really influencing behavior.behavior.

– You must be careful to observe and identify the You must be careful to observe and identify the actual contingent relationships that influence actual contingent relationships that influence behavior.behavior.


• Give a lesson on the effects of extinction on behavior.Give a lesson on the effects of extinction on behavior.– Maladaptive behaviors may temporarily increase in frequency or Maladaptive behaviors may temporarily increase in frequency or

intensity after the removal of reinforcement. (Extinction burst)intensity after the removal of reinforcement. (Extinction burst)– Understanding these effects sometimes helps with the pain Understanding these effects sometimes helps with the pain

associated with the removal of usual reinforcers.associated with the removal of usual reinforcers.– The Foot-In-The-Door technique can be used to help the Client The Foot-In-The-Door technique can be used to help the Client

make a commitment to tolerating the painful aspects of make a commitment to tolerating the painful aspects of changing contingencies.changing contingencies.

• Review the principals of punishment.Review the principals of punishment.– Helps Client to drop punishment as a self-control technique.Helps Client to drop punishment as a self-control technique.– Self-punishment is often the only self-control procedures used.Self-punishment is often the only self-control procedures used.

Reinforce Target-Reinforce Target-Relevant Adaptive Relevant Adaptive

BehaviorBehavior• A central principle of DBT is that Providers A central principle of DBT is that Providers

should reinforce target-relevant adaptive should reinforce target-relevant adaptive behaviors when they occur. behaviors when they occur.

• The Provider must at all times pay attention to The Provider must at all times pay attention to what the Client is doing, whether the Client’s what the Client is doing, whether the Client’s behavior is targeted for increase, decrease or behavior is targeted for increase, decrease or is irrelevant to goals, how the Provider is irrelevant to goals, how the Provider responds to the Client’s behaviors and if the responds to the Client’s behaviors and if the response is reinforcing behaviors that response is reinforcing behaviors that represent progress.represent progress.


BehaviorBehavior• Timing of Reinforcement.Timing of Reinforcement.

– Immediate reinforcement is far more powerful than delayed Immediate reinforcement is far more powerful than delayed reinforcement. reinforcement.

– Many behaviors are extraordinarily difficult to decrease because Many behaviors are extraordinarily difficult to decrease because they result in short-term, immediate reinforcement. These same they result in short-term, immediate reinforcement. These same behaviors often lead to long-term negative or punishing behaviors often lead to long-term negative or punishing outcomes. outcomes.

– Addictive behaviors are a good example here. The immediate Addictive behaviors are a good example here. The immediate reinforcing effects of drugs, alcohol, gambling, food, and suicidal reinforcing effects of drugs, alcohol, gambling, food, and suicidal behaviors, strengthen the behaviors far more effectively than behaviors, strengthen the behaviors far more effectively than long-term aversive consequences weaken them.long-term aversive consequences weaken them.

– Thus, the Provider must reinforce improved/desired behavior as Thus, the Provider must reinforce improved/desired behavior as soon as possible.soon as possible.

– Be alert to improved behaviors in your presence so that you may Be alert to improved behaviors in your presence so that you may reinforce them immediately.reinforce them immediately.


BehaviorBehavior• Scheduling of Reinforcement.Scheduling of Reinforcement.

– At the beginning of therapy, continuous At the beginning of therapy, continuous reinforcement may be needed fading reinforcement may be needed fading gradually as the behavior occurs more gradually as the behavior occurs more often. often.

– Behaviors that are intermittently Behaviors that are intermittently reinforced are far more resistant to reinforced are far more resistant to extinction.extinction.


BehaviorBehavior• Validation, Responsiveness, and Non-demanding Validation, Responsiveness, and Non-demanding Attentiveness as Reinforcers. Attentiveness as Reinforcers. For some Clients, expressions of For some Clients, expressions of warmth and closeness are very effective; for others, such warmth and closeness are very effective; for others, such expressions are so threatening that the effects are just the opposite expressions are so threatening that the effects are just the opposite of that which is intended. For most Clients, the following of that which is intended. For most Clients, the following relationship activities are reinforcing;relationship activities are reinforcing;– Expressions of Providers approval, care, concern, or interest;Expressions of Providers approval, care, concern, or interest;– Behaviors that communicate liking or admiring the Client, Behaviors that communicate liking or admiring the Client,

wanting to work with him, and wanting to interact with him;wanting to work with him, and wanting to interact with him;– Behaviors that reassure that the Provider and therapy is secure;Behaviors that reassure that the Provider and therapy is secure;– Almost any validating response (except, at times, cheerleading);Almost any validating response (except, at times, cheerleading);– Behaviors that are responsive to the Clients requests/inputs;Behaviors that are responsive to the Clients requests/inputs;– Attention from or contact with the Provider.Attention from or contact with the Provider.


BehaviorBehavior• Jackpots.Jackpots.

– One extremely useful technique with any One extremely useful technique with any reinforcement, for animals or people, is the jackpot. reinforcement, for animals or people, is the jackpot. The jackpot is a reward that is much bigger, maybe The jackpot is a reward that is much bigger, maybe ten times bigger, than the normal reinforcer, and one ten times bigger, than the normal reinforcer, and one that comes a s surprise to the subject.that comes a s surprise to the subject.

– A jackpot may be used to mark a sudden A jackpot may be used to mark a sudden breakthrough.breakthrough.

– Paradoxically, a single jackpot may also be effective Paradoxically, a single jackpot may also be effective in improving the response of a recalcitrant, fearful, in improving the response of a recalcitrant, fearful, or resistant subject that is offering no desirable or resistant subject that is offering no desirable behavior at all.behavior at all.


BehaviorBehavior• Conditioned Reinforcers. Conditioned Reinforcers. A conditioned reinforcer is A conditioned reinforcer is

some initially meaningless signal-a sound, a light, a some initially meaningless signal-a sound, a light, a motion-that is deliberately presented before or during the motion-that is deliberately presented before or during the delivery of a reinforcer.delivery of a reinforcer.– Effective teachers often arrive at some such ritualized Effective teachers often arrive at some such ritualized

and carefully rationed word of commendation-“That’s and carefully rationed word of commendation-“That’s fine” or “Very good”-for which their students anxiously fine” or “Very good”-for which their students anxiously work and want.work and want.

– Before the start of training, while the subject is doing Before the start of training, while the subject is doing nothing in particular, teach them to understand the nothing in particular, teach them to understand the significance of the conditioned reinforcer by pairing it significance of the conditioned reinforcer by pairing it with food, positive statements, or other real reinforcers.with food, positive statements, or other real reinforcers.


BehaviorBehavior– With the establishment of a conditioned reinforcer, With the establishment of a conditioned reinforcer,

you have a real way of communicating exactly what you have a real way of communicating exactly what you like in the subject’s behavior. I.e. Statements you like in the subject’s behavior. I.e. Statements of praise, points, tickets, money, clickers, are of praise, points, tickets, money, clickers, are examples of a conditioned reinforcers. examples of a conditioned reinforcers.

– The conditioned reinforcer bridges the stimulus The conditioned reinforcer bridges the stimulus between earning the reward and getting the between earning the reward and getting the reward. reward.

– A positive conditioned reinforcer says, “What you A positive conditioned reinforcer says, “What you are doing now is good and will gain you something, are doing now is good and will gain you something, so do it some more.”so do it some more.”


BehaviorBehavior– The conditioned reinforcer constitutes an “event The conditioned reinforcer constitutes an “event marker”. It identifies to the trainee exactly what marker”. It identifies to the trainee exactly what behavior is being reinforced. It puts control in the behavior is being reinforced. It puts control in the hands of the learner. After a while the subject no hands of the learner. After a while the subject no longer just repeats the behavior; the subject longer just repeats the behavior; the subject exhibits intention. “Hey! I made you (click, say yes, exhibits intention. “Hey! I made you (click, say yes, etc.) watch me, I’m going to do it again!” Clicker etc.) watch me, I’m going to do it again!” Clicker trainers speak of that shift as the moment when trainers speak of that shift as the moment when “the light bulb goes on.” This moment is extremely “the light bulb goes on.” This moment is extremely reinforcing for the trainer and trainee alike.reinforcing for the trainer and trainee alike.

– Pair the conditioned reinforcer with several real Pair the conditioned reinforcer with several real reinforcers.reinforcers.


BehaviorBehavior– Once you have established a conditioned Once you have established a conditioned

reinforcer, you must be careful not to throw it reinforcer, you must be careful not to throw it around meaninglessly or you will dilute its around meaninglessly or you will dilute its force. Validate everything; demonstrate force. Validate everything; demonstrate radical acceptance, empathy and unconditional radical acceptance, empathy and unconditional positive regard at all times. However, reserve positive regard at all times. However, reserve praise, specifically, as a conditioned reinforcer, praise, specifically, as a conditioned reinforcer, to a real adaptive behavior. False or to a real adaptive behavior. False or meaningless praise, is soon resented, and meaningless praise, is soon resented, and loses any power to reinforce.loses any power to reinforce.

Extinguish Target-Extinguish Target-Relevant Maladaptive Relevant Maladaptive

BehaviorsBehaviors• Behavioral responses are extinguished when the Behavioral responses are extinguished when the

reinforcers that maintain the behavior are reinforcers that maintain the behavior are removed. The Provider must determine what removed. The Provider must determine what reinforcers are maintaining a maladaptive reinforcers are maintaining a maladaptive behavior pattern, and then withhold those behavior pattern, and then withhold those reinforcers following the behavior.reinforcers following the behavior.

• Remember that not all behaviors are maintained Remember that not all behaviors are maintained by their consequences (Operant Behaviors). by their consequences (Operant Behaviors). Some behaviors are elicited automatically by Some behaviors are elicited automatically by prior events (Respondent Behaviors). prior events (Respondent Behaviors).


BehaviorsBehaviors• There is no substitute for a good behavioral There is no substitute for a good behavioral

analysis to determine what is maintaining a analysis to determine what is maintaining a maladaptive behavior.maladaptive behavior.

• Client’s problem behaviors often function quite Client’s problem behaviors often function quite effectively. effectively.

• If a helpless stance or out-of-control emotionality If a helpless stance or out-of-control emotionality leads the Provider to pay more attention to, or leads the Provider to pay more attention to, or give more help to the Client than when he asks give more help to the Client than when he asks for what he wants directly and competently, the for what he wants directly and competently, the Provider reinforces the helplessness and Provider reinforces the helplessness and emotionality that he or she is trying to reduce. emotionality that he or she is trying to reduce.


BehaviorsBehaviors• By not reinforcing maladaptive behaviors, the By not reinforcing maladaptive behaviors, the

Client’s behavior is put on an extinction Client’s behavior is put on an extinction schedule.schedule.– Although, in time, behavior can be expected to Although, in time, behavior can be expected to

increase, there will be a “behavioral burst” near the increase, there will be a “behavioral burst” near the beginning of extinction and intermittently beginning of extinction and intermittently thereafter.thereafter.

– If the behavior previously functioned to meet an If the behavior previously functioned to meet an important need, and if the Client has no other important need, and if the Client has no other behaviors that worked as well as this one, the behaviors that worked as well as this one, the Client’s general behavior can become disorganized, Client’s general behavior can become disorganized, intense, or chaotic.intense, or chaotic.


BehaviorsBehaviors• Factors that increase the likelihood of Factors that increase the likelihood of

a Provider breaking the extinction a Provider breaking the extinction schedule:schedule:– Client wears out the ProviderClient wears out the Provider– Provider is unsure of treatment planProvider is unsure of treatment plan– Provider feels guilty about not giving the Provider feels guilty about not giving the

Client what he needs or wantsClient what he needs or wants– Provider feels threatened by Client’s Provider feels threatened by Client’s

behaviorbehavior


BehaviorsBehaviors• An extinction schedule should be aimed at the An extinction schedule should be aimed at the

targeted behavior, not at the Client himself. The aim targeted behavior, not at the Client himself. The aim is to break the relationship between the targeted is to break the relationship between the targeted behavior and the reinforcing consequences. behavior and the reinforcing consequences. – Find another response to reinforce. Find another response to reinforce. – Get the Client to engage in an acceptable replacement Get the Client to engage in an acceptable replacement

behavior that can be reinforced. behavior that can be reinforced. – Soothe the Client. Soothe the Client. – Acknowledge how difficult the therapy process is. Acknowledge how difficult the therapy process is. – The problem rarely is in what the Client wants or needs, The problem rarely is in what the Client wants or needs,

but how he goes about getting it. but how he goes about getting it.


BehaviorsBehaviors• Combine extinction with a heavy dose of Combine extinction with a heavy dose of

soothing and kindness.soothing and kindness.– First, find the courage and commitment to First, find the courage and commitment to

stick to an extinction schedule.stick to an extinction schedule.– Second, help the Client find more adaptive Second, help the Client find more adaptive

behaviors that will function as well or better behaviors that will function as well or better and be sure to reinforce those behaviors.and be sure to reinforce those behaviors.

– Third, be kind and soothing to the Client. Third, be kind and soothing to the Client. Extinction is not a means of punishing Extinction is not a means of punishing Clients.Clients.

Determining the Potency Determining the Potency of Consequencesof Consequences

• Praise as a Reinforcer.Praise as a Reinforcer.– Borderline and suicidal individuals are often both Borderline and suicidal individuals are often both

eager for praise and very afraid of it.eager for praise and very afraid of it.– Clients often fear being left on their own, having to Clients often fear being left on their own, having to

be independent of the Provider and self-reliant be independent of the Provider and self-reliant before they are able or ready.before they are able or ready.

– The Provider must anticipate negative effects of The Provider must anticipate negative effects of praise and move to counteract them.praise and move to counteract them.

– Generally, the inability to accept appropriate praise Generally, the inability to accept appropriate praise should be viewed as a therapy-interfering behavior should be viewed as a therapy-interfering behavior and analyzed and treated as such.and analyzed and treated as such.


– The Provider should discuss the consequences of an The Provider should discuss the consequences of an inability to accept praise. The strategy is to continue inability to accept praise. The strategy is to continue praising following progress or positive change. But for praising following progress or positive change. But for this to work, the Provider must stay close to the Client this to work, the Provider must stay close to the Client and not appear as if he is leaving the Client because and not appear as if he is leaving the Client because the Client is doing better.the Client is doing better.

– The continued exposure to praise in an atmosphere The continued exposure to praise in an atmosphere that does not reinforce fear, shame, or anger should that does not reinforce fear, shame, or anger should in the long run change the valence of praise from in the long run change the valence of praise from negative to neutral and eventually to positive.negative to neutral and eventually to positive.

– A person who is either punished by praise or neutral A person who is either punished by praise or neutral to it is at a distinct disadvantage.to it is at a distinct disadvantage.


• Further Comments on Relationship Contingencies.Further Comments on Relationship Contingencies.– The key here, as in all contingency management, is to The key here, as in all contingency management, is to

keep a close eye on the effects of interpersonal warmth keep a close eye on the effects of interpersonal warmth and attachment on the Client’s behavior.and attachment on the Client’s behavior.

– Example from set point theory from the field of weight Example from set point theory from the field of weight regulation; each individual has a set point range of regulation; each individual has a set point range of intimacy that he or she is comfortable with and will intimacy that he or she is comfortable with and will defend that range. When over their set point, people will defend that range. When over their set point, people will push away and attempts at greater intimacy will be push away and attempts at greater intimacy will be experienced as aversive. When under their set point, experienced as aversive. When under their set point, people will reach out for intimacy. Warmth and closeness people will reach out for intimacy. Warmth and closeness from others will be experienced as reinforcing; coolness from others will be experienced as reinforcing; coolness and distancing behaviors will be experienced as aversive.and distancing behaviors will be experienced as aversive.


– The attached Client, once placed in a secure, bonded, and The attached Client, once placed in a secure, bonded, and warm relationship for long enough, will eventually relax and warm relationship for long enough, will eventually relax and stop clinging. The butterfly patient, if given enough room to stop clinging. The butterfly patient, if given enough room to move, not punished for frequently flying out of the Provider’s move, not punished for frequently flying out of the Provider’s hand, and not punished when he returns, will in time become hand, and not punished when he returns, will in time become more attached.more attached.

– The potency of any reinforcer depends on whether the The potency of any reinforcer depends on whether the individual has already received the desired or needed level of individual has already received the desired or needed level of the reinforcer. The question to ask is this: Is the person the reinforcer. The question to ask is this: Is the person already sated on what is being offered? Food is not likely to 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 be a good reinforcer for a person who has just finished a large meal. The secret is “just enough”.meal. The secret is “just enough”.

– There is no substitute for trial and error and close observation There is no substitute for trial and error and close observation to determine just enough for any particular Client.to determine just enough for any particular Client.

Use Natural Over Use Natural Over Arbitrary ConsequencesArbitrary Consequences

• Whenever possible, natural rather than arbitrary Whenever possible, natural rather than arbitrary consequences should be applied. consequences should be applied.

• Natural consequences are those that flow from Natural consequences are those that flow from and are characteristic outcomes of a behavior in and are characteristic outcomes of a behavior in everyday life. everyday life.

• Smiling, moving closer, and nodding are natural Smiling, moving closer, and nodding are natural consequences of someone’s saying something we consequences of someone’s saying something we like; like;

• Giving and m & m, or a ticket is an example of Giving and m & m, or a ticket is an example of arbitrary reinforcement. arbitrary reinforcement.

Principles of ShapingPrinciples of Shaping

• In shaping, gradual approximations to the target behaviors are In shaping, gradual approximations to the target behaviors are reinforced. reinforced.

• Shaping requires the Provider to break the desired behavior down Shaping requires the Provider to break the desired behavior down into small steps and teach these steps sequentially. into small steps and teach these steps sequentially.

• Trying to extract an adaptive behavior without reinforcing small steps Trying to extract an adaptive behavior without reinforcing small steps on the way is like promising a hiker a sumptuous banquet if he can 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 get to the other side of a high mountain, and then refusing to feed him during the ten day journey. him during the ten day journey.

• If expectations of the environment are too high for the abilities of the 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 Client, progress is often punished because it does not come up to expectations rather than reinforced because it represents an expectations rather than reinforced because it represents an improvement over past behavior.improvement over past behavior.

• If a behavior represents progress, the Provider should reinforce it. If 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 not, the Provider should ignore it or punish it and if necessary teach a new behavior.new behavior.

The 10 Laws of ShapingThe 10 Laws of Shaping1.1. Raise criteria in increments small enough that the Raise criteria in increments small enough that the

subject always has a realistic chance for reinforcement.subject always has a realistic chance for reinforcement.

2.2. Train one aspect of any particular behavior at a time; Train one aspect of any particular behavior at a time; don’t try to shape for two criteria simultaneously.don’t try to shape for two criteria simultaneously.

3.3. During shaping, put the current level of response onto a During shaping, put the current level of response onto a variable schedule of reinforcement before adding or variable schedule of reinforcement before adding or raising the criteria.raising the criteria.

4.4. When introducing a new criterion, or aspect of the When introducing a new criterion, or aspect of the behavioral skill, temporarily relax the old ones.behavioral skill, temporarily relax the old ones.

5.5. Stay ahead of your subject: Plan your shaping program Stay ahead of your subject: Plan your shaping program completely so that if the subject makes sudden completely so that if the subject makes sudden progress, you are aware of what to reinforce next.progress, you are aware of what to reinforce next.

The 10 Laws of ShapingThe 10 Laws of Shaping6.6. Don’t change trainers in midstream; you can have Don’t change trainers in midstream; you can have

several trainers per trainee, but stick to one shaper several trainers per trainee, but stick to one shaper per behavior.per behavior.

7.7. If one shaping procedure is not eliciting progress, find If one shaping procedure is not eliciting progress, find another; there are as many ways to get behavior as another; there are as many ways to get behavior as there are trainers to think them up.there are trainers to think them up.

8.8. Don’t interrupt a training session gratuitously; that Don’t interrupt a training session gratuitously; that constitutes punishment.constitutes punishment.

9.9. If behavior deteriorates, “go back to kindergarten”; If behavior deteriorates, “go back to kindergarten”; quickly review the whole shaping process with a quickly review the whole shaping process with a series o easily earned reinforcers.series o easily earned reinforcers.

10.10.End each session on a high note, if possible, but in End each session on a high note, if possible, but in any case, quit while you are ahead.any case, quit while you are ahead.

Anti-DBT Tactics:Anti-DBT Tactics:

• Provider “gave in” to Clients demands and Provider “gave in” to Clients demands and reinforced behaviors well below Client’s reinforced behaviors well below Client’s capabilities when more capable behavior is capabilities when more capable behavior is required in the situation at hand.required in the situation at hand.

• Provider was inconsistent in use of contingency Provider was inconsistent in use of contingency management procedures.management procedures.

• Provider was punitive in use of aversive Provider was punitive in use of aversive consequences.consequences.

• Provider required behaviors beyond Client’s Provider required behaviors beyond Client’s capabilities before reinforcing behavioral attempt.capabilities before reinforcing behavioral attempt.

OBSERVING-LIMITS OBSERVING-LIMITS PROCEDURESPROCEDURES

• Observing limits is essential to DBT. Observing limits is essential to DBT. It addresses It addresses limit-relevantlimit-relevant behaviors and functionally related behaviors and functionally related behaviors of the Client that push or behaviors of the Client that push or cross Providers own personal limits. cross Providers own personal limits. These behaviors differ from Provider These behaviors differ from Provider to Provider.to Provider.


• The responsibility for taking care of the Provider’s The responsibility for taking care of the Provider’s limits in DBT belongs to the Provider not to the Client. limits in DBT belongs to the Provider not to the Client.

• The Provider must be aware of which Client behaviors The Provider must be aware of which Client behaviors he or she is able and willing to tolerate and which are he or she is able and willing to tolerate and which are unacceptable. unacceptable.

• This information should be given to the Client in a This information should be given to the Client in a timely fashion before it’s too late. timely fashion before it’s too late.

• The Provider must also specify which behaviors he or The Provider must also specify which behaviors he or she can accept only temporarily and which are she can accept only temporarily and which are acceptable over the long haul, as well as which Client acceptable over the long haul, as well as which Client behaviors are likely to lead to Provider burnout and behaviors are likely to lead to Provider burnout and which are not. which are not.


• Client behaviors that cross Provider’s limits are a Client behaviors that cross Provider’s limits are a special type of therapy-interfering behaviors; special type of therapy-interfering behaviors; thus, limit-relevant behaviors are second only to thus, limit-relevant behaviors are second only to life threatening behaviors as a target of therapy. life threatening behaviors as a target of therapy. They are therapy threatening because they They are therapy threatening because they interfere with the Provider’s ability or willingness interfere with the Provider’s ability or willingness to continue treatment.to continue treatment.

• It’s crucial for a Provider not to ignore such It’s crucial for a Provider not to ignore such behaviors; otherwise they will sooner or later lead behaviors; otherwise they will sooner or later lead to burnout, early termination of therapy, or to burnout, early termination of therapy, or otherwise harm the Client. otherwise harm the Client.


• In observing limits, the Provider takes care for the In observing limits, the Provider takes care for the Client by taking care of him or herself. Observing Client by taking care of him or herself. Observing limits in DBT, is concerned with preserving the limits in DBT, is concerned with preserving the personal limits of the Provider – the Provider’s personal limits of the Provider – the Provider’s sense of self as it were. sense of self as it were.

• It is important that each Provider understands his It is important that each Provider understands his or her own limits and communicates these clearly or her own limits and communicates these clearly to each Client. to each Client.

• The goal of DBT is to teach Clients how to interact The goal of DBT is to teach Clients how to interact productively and happily within these natural productively and happily within these natural interpersonal limits. interpersonal limits.


• The following are guidelines for effectively observing The following are guidelines for effectively observing limits with borderline Clients:limits with borderline Clients:

1.1. Monitor Limits.Monitor Limits. Be aware of warning signs of Be aware of warning signs of feelings of discomfort, anger, and frustration. The feelings of discomfort, anger, and frustration. The idea is to catch yourself before your limits are idea is to catch yourself before your limits are crossed. The consultation team can be useful crossed. The consultation team can be useful here.here.

2.2. Be Honest About Limits. Be Honest About Limits. A Provider’s limits are A Provider’s limits are presented for the good of the Provider, not for the presented for the good of the Provider, not for the Client. Avoid explaining limits that are for the Client. Avoid explaining limits that are for the good of the Client when they really are for your good of the Client when they really are for your own benefit.own benefit.


3.3. Temporarily Extend Limits When Needed.Temporarily Extend Limits When Needed. Observing limits is not a license to be uncaring or Observing limits is not a license to be uncaring or unresponsive to important Client needs. Nor is it unresponsive to important Client needs. Nor is it permission to be chaotic in responses to Client permission to be chaotic in responses to Client requests and demands. It is necessary for Providers requests and demands. It is necessary for Providers at times to push their own limits, extend themselves, at times to push their own limits, extend themselves, and give what they do not want to give. Similarly, and give what they do not want to give. Similarly, when a Provider is about to reach his or her limits, and when a Provider is about to reach his or her limits, and the Client’s life is in danger, the appropriate strategy the Client’s life is in danger, the appropriate strategy is to involve other professionals in the provision of is to involve other professionals in the provision of care. The dialectic here, is between pushing limits care. The dialectic here, is between pushing limits when necessary, and observing limits when when necessary, and observing limits when necessary.necessary.


4.4. Be Consistently Firm.Be Consistently Firm. Use the broken record Use the broken record strategy Clients are taught in interpersonal skills strategy Clients are taught in interpersonal skills training: Over and over and over the Provider training: Over and over and over the Provider states her position calmly, clearly, and firmly states her position calmly, clearly, and firmly and restates frequently that the observation of and restates frequently that the observation of these limits will benefit the Client in the end.these limits will benefit the Client in the end.

5.5. Combine Soothing, Validating, and Combine Soothing, Validating, and Problem Solving With Observing Limits.Problem Solving With Observing Limits. The importance of soothing and validating the The importance of soothing and validating the Client while simultaneously observing limits Client while simultaneously observing limits cannot be overstated.cannot be overstated.

EIGHT BEHAVIORAL EIGHT BEHAVIORAL SHAPING METHODSSHAPING METHODS

Method 1: Elimination

Approach Kill, Incarcerate, Place a 7 Day, Isolate, Fire, Quit, Divorce, End the Relationship, etc.

Advantage 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.


Method 2: PunishmentApproach Torture, Hit, Spank, Scold, Dock Pay, Give

Fines, Take Something Away, Threaten

Advantage 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.


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.


Method 4: Extinction

Approach 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.

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.


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, Half-Smile, etc.

Disadvantage Sometimes takes more time, effort, and patience.


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 control-that 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.


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.


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-xerciseBe-like othersA-ttention/Contact; W-ithdrawl/Break; A-utonomy/Power; R-evenge/Protection; E-xcitment/ChallengeMeet their need or collaborate to create a healthier, more effective motivation. Reiss Personality Profile.

Advantage Provides the most natural behavioral shapers of all. PLEASE, Mastery and self-management, self-validation, and self-problem solving.

Disadvantage 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 TRAININGSKILLS TRAINING

• Skills are abilities including cognitive, Skills are abilities including cognitive, emotional, and overt behavioral emotional, and overt behavioral responses necessary for effective responses necessary for effective performance. In DBT, almost any performance. In DBT, almost any desired behavior can be thought of desired behavior can be thought of as a skill and thus can be acquired, as a skill and thus can be acquired, strengthened and generalized.strengthened and generalized.


• Skills training procedures are Skills training procedures are necessary when a problem solution necessary when a problem solution requires skill not currently in the requires skill not currently in the Client’s behavioral repertoire. The Client’s behavioral repertoire. The aim of DBT is to replace ineffective, aim of DBT is to replace ineffective, maladaptive, or non-skilled behaviors maladaptive, or non-skilled behaviors with skillful responses.with skillful responses.


• Skill acquisitionSkill acquisition. Instructions, . Instructions, modelingmodeling

• Skill strengtheningSkill strengthening. Behavioral . Behavioral rehearsal, feedbackrehearsal, feedback

• Skill generalizationSkill generalization. Homework . Homework assignments, discussion of similarities assignments, discussion of similarities and differences in situations, use of the and differences in situations, use of the skill in the context that it is needed.skill in the context that it is needed.

Orienting and Committing Orienting and Committing to Skills Training: Task to Skills Training: Task

OverviewOverview• Skills training can only be accomplished if the person Skills training can only be accomplished if the person

actively collaborates with the treatment program. actively collaborates with the treatment program.

• Some Clients both have skill deficits and are fearful Some Clients both have skill deficits and are fearful about acquiring new skills. It can be pointed out that about acquiring new skills. It can be pointed out that learning a new skill does not mean the Client actually learning a new skill does not mean the Client actually has to use it. Much like the fear of flying: The Client has to use it. Much like the fear of flying: The Client does not want to reduce his fears because then he does not want to reduce his fears because then he might have to fly. might have to fly.

• Point out that the skills being taught have helped Point out that the skills being taught have helped others and myself. others and myself.

Orienting and Committing Orienting and Committing to Skills Training: Task to Skills Training: Task

OverviewOverview• The most important point to make, and to The most important point to make, and to

repeat as often as necessary, is that learning repeat as often as necessary, is that learning new skills requires practice, practice, practice, new skills requires practice, practice, practice, and that practice has to occur in situations and that practice has to occur in situations where the skills are needed. where the skills are needed.

• If these points do not get through to the If these points do not get through to the Client, there is not much hope that they will Client, there is not much hope that they will actually learn anything new. actually learn anything new.

• Give a rationale before teaching any new skill.Give a rationale before teaching any new skill.

Orienting and Committing Orienting and Committing to Skills Training: Task to Skills Training: Task OverviewOverview

SKILLS MODULE PURPOSE/RATIONALE

MINDFULNESSTo 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

To gain mastery over the response to my emotions so that they do not

master me.

INTERPERSONAL EFFECTIVENESS

To get what I want while demonstrating respect for self and

others.

1.1.Assess AbilitiesAssess Abilities

• Is the Client incapable of learning a new skill, or is he emotionally Is the Client incapable of learning a new skill, or is he emotionally inhibited or constrained by environmental factors? inhibited or constrained by environmental factors?

• Emotionally dysregulated Clients often confuse being Emotionally dysregulated Clients often confuse being afraidafraid of doing of doing something with something with not being ablenot being able to do it. to do it.– Some may fear that if they learn the skill, the Therapist will think Some may fear that if they learn the skill, the Therapist will think

they no longer need treatment and discharge them prematurely. they no longer need treatment and discharge them prematurely. – Some may fear that just because they can perform the skill in Some may fear that just because they can perform the skill in

treatment the Therapist will assume they can perform it in all treatment the Therapist will assume they can perform it in all contexts. contexts.

– Some Clients may feel hopeless and ask, “What’s the point? I’m Some Clients may feel hopeless and ask, “What’s the point? I’m probably not going to use this skill when I go home!” probably not going to use this skill when I go home!”

– Some don’t like the feelings of vulnerability that comes with learning Some don’t like the feelings of vulnerability that comes with learning a new skill and looking foolish or silly. a new skill and looking foolish or silly.

– All of the above scenarios will just contribute to one more failure and All of the above scenarios will just contribute to one more failure and reinforce that he is a “loser” and nothing can help.reinforce that he is a “loser” and nothing can help.

1.1. Assess AbilitiesAssess Abilities

• Avoid getting stuck on either side of the following assumptions:Avoid getting stuck on either side of the following assumptions:– The Client can do anything if he wants to with the right amount 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 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…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 The poor Client is too fragile and can’t be expected to learn such difficult tasks. He needs tons of acceptance, nurturance such difficult tasks. He needs tons of acceptance, nurturance and for me to structure his environment so he doesn’t have to and for me to structure his environment so he doesn’t have to experience the shame and embarrassment that will ultimately experience the shame and embarrassment that will ultimately come if he is placed in a vulnerable situation.come if he is placed in a vulnerable situation.

– Usually there is one Provider representative for each side on the Usually there is one Provider representative for each side on the treatment team. Not surprisingly, the Client will capitalize on treatment team. Not surprisingly, the Client will capitalize on the dichotomy and “staff splitting” will often arise.the dichotomy and “staff splitting” will often arise.

1.1. Assess AbilitiesAssess Abilities• To assess the Client’s skill repertoire, observe the Client in as To assess the Client’s skill repertoire, observe the Client in as

many contexts as possible, perform a BCA, or use role-play.many contexts as possible, perform a BCA, or use role-play.– To assess Mindfulness Skills, ask the Client to demonstrate To assess Mindfulness Skills, ask the Client to demonstrate

getting focused and observe his thoughts, feelings, and getting focused and observe his thoughts, feelings, and actions.actions.

– To assess Distress Tolerance, ask the Client to demonstrate To assess Distress Tolerance, ask the Client to demonstrate a skill or skills he uses when in a stressful situation so as not a skill or skills he uses when in a stressful situation so as not to make the matter worse.to make the matter worse.

– To assess Emotion Regulation Skills, ask the Client about To assess Emotion Regulation Skills, ask the Client about something to trigger an emotion and then ask the Client to something to trigger an emotion and then ask the Client to change his emotional state.change his emotional state.

– To assess Interpersonal Effectiveness, ask the Client to think To assess Interpersonal Effectiveness, ask the Client to think of something he really wants and then ask you for it of something he really wants and then ask you for it effectively, and/or for the ability to say yes or no to effectively, and/or for the ability to say yes or no to something when asked.something when asked.

2.2. Provide Instruction On Provide Instruction On How To Do The SkillsHow To Do The Skills

• Specify necessary behaviors in concrete Specify necessary behaviors in concrete terms that the Client understands.terms that the Client understands.

• Break each skill taught down into easy-to-Break each skill taught down into easy-to-follow steps.follow steps.

• Begin with simple tasks the Client can Begin with simple tasks the Client can readily demonstrate and precede to more readily demonstrate and precede to more difficult tasks.difficult tasks.

• Provide examples of the skill to be Provide examples of the skill to be learned.learned.

3. Provide Instruction 3. Provide Instruction On On

How To Do The SkillsHow To Do The Skills• Use aids and techniques that stimulate the visual, auditory Use aids and techniques that stimulate the visual, auditory

and kinesthetic (experiential) learner:and kinesthetic (experiential) learner:– Visual: Visual: Use handouts that are easy to read and simply Use handouts that are easy to read and simply

describe the skill; use a large white board or chalkboard; describe the skill; use a large white board or chalkboard; write large enough for the person furthest away to see write large enough for the person furthest away to see clearly; refer to posters on the walls, use power point; clearly; refer to posters on the walls, use power point; overhead projector; etc.overhead projector; etc.

– Auditory: Auditory: Speak clearly and concisely; avoid Speak clearly and concisely; avoid unnecessary words; use music, rhythms, acronyms, unnecessary words; use music, rhythms, acronyms, metaphors, stories; etc.metaphors, stories; etc.

– Kinesthetic: Kinesthetic: Involve students in creating posters; have Involve students in creating posters; have them role-play and act out scenarios; use structured them role-play and act out scenarios; use structured

movement; etc.movement; etc.

4. Model The Skills4. Model The Skills

• Role-PlayRole-Play

• Use skilled behavior in interacting with the ClientUse skilled behavior in interacting with the Client

• Describe what skills you are using out loud as you Describe what skills you are using out loud as you use themuse them

• Disclose how you use the skills in everyday life Disclose how you use the skills in everyday life

• Tell stories that illustrate how to use the skill. Tell stories that illustrate how to use the skill.

• Point out people in the environment that use the Point out people in the environment that use the skills being taught for the Client to observe; skills being taught for the Client to observe; People the Client knows, public figures, books, People the Client knows, public figures, books, movies, etc.movies, etc.

SKILL STRENGTHENING SKILL STRENGTHENING PROCEDURESPROCEDURES

1.1. Rehearse The SkillsRehearse The Skills– Role-PlayRole-Play– Guide the Client in-session to practiceGuide the Client in-session to practice– Guide the Client in practice imagining the skill step Guide the Client in practice imagining the skill step

by step (see it happen in your mind)by step (see it happen in your mind)– For emotion regulation, practice facial expressions, For emotion regulation, practice facial expressions,

closed fists to open hands, muscle tension to closed fists to open hands, muscle tension to relaxation, etc.relaxation, etc.

– Encourage the Client to practice Encourage the Client to practice in vivo (in a real in vivo (in a real life situations)life situations) with issues that come up during with issues that come up during practice or outside of session.practice or outside of session.


2.2. Reinforce The SkillsReinforce The Skills– The most powerful reinforcer available to The most powerful reinforcer available to

strengthen the Clients skill and probability of using strengthen the Clients skill and probability of using that skill in other contexts as well as increase the that skill in other contexts as well as increase the Client’s self esteem and confidence is Client’s self esteem and confidence is YOUR YOUR APPROVAL!APPROVAL! Use it liberally! If they agree to Use it liberally! If they agree to practice-practice-reinforce with your approval-O.K. reinforce with your approval-O.K. great!; Way to go!; Well done!great!; Way to go!; Well done!; If they start to ; If they start to get it-get it- reinforce with your approval!; reinforce with your approval!; Catch Catch them using it in session and throughout the day them using it in session and throughout the day and- and- reinforce with your approval!reinforce with your approval!


3.3. Give Feedback and Coaching Give Feedback and Coaching – Keep your feedback focused on the Client’s Keep your feedback focused on the Client’s

performance rather than his motivesperformance rather than his motives– Be behaviorally specific and tell the Client Be behaviorally specific and tell the Client

exactly what he is doing and what he needs to exactly what he is doing and what he needs to do to improve the skilldo to improve the skill

– Avoid telling the Client he is manipulating, Avoid telling the Client he is manipulating, expressing a need to control, overreacting, expressing a need to control, overreacting, clinging, or acting out-it is simply not helpful clinging, or acting out-it is simply not helpful and can cause the Client to give up practice.and can cause the Client to give up practice.


– Give positive feedback. Focus on what they did Give positive feedback. Focus on what they did well and instead of commenting on what they well and instead of commenting on what they didn’t do well; say something like, “You did this didn’t do well; say something like, “You did this part really well! Now I want you to try ____!part really well! Now I want you to try ____!

– Do not be afraid to give negative feedback as Do not be afraid to give negative feedback as long as you describe the effect of the behavior long as you describe the effect of the behavior clearly without judging the Client personally.clearly without judging the Client personally.

– Limit your feedback to only one or two items that Limit your feedback to only one or two items that need improvement rather than overwhelming need improvement rather than overwhelming them with every little thing they did wrong, and them with every little thing they did wrong, and of course-of course- reinforce with your approval! reinforce with your approval!


– Coaching is combining clear Coaching is combining clear behavioral feedback with clear behavioral feedback with clear behavioral instructions. behavioral instructions. Clinical Clinical practice suggests that the practice suggests that the “permission” to behave in certain “permission” to behave in certain ways that is implicit in coaching ways that is implicit in coaching may be all that is needed to may be all that is needed to accomplish changes in behavior.accomplish changes in behavior.

SKILL GENERALIZATION SKILL GENERALIZATION PROCEDURESPROCEDURES

1.1. Generalization Programming. Generalization Programming. – Structure milieu to encourage generalization.Structure milieu to encourage generalization.– Teach a variety of skilled responses to each Teach a variety of skilled responses to each

situation.situation.– Vary training situations that Client practices Vary training situations that Client practices

skills in.skills in.– Duplicate within the Provider/Client Duplicate within the Provider/Client

relationship important characteristics of relationship important characteristics of interpersonal relationships Client has outside interpersonal relationships Client has outside of therapy.of therapy.


2.2. Between-Session ConsultationBetween-Session Consultation– Assist Client in applying skills in between sessions, by phone Assist Client in applying skills in between sessions, by phone

or on the floor – “What skills can you use right now to help or on the floor – “What skills can you use right now to help you….?”you….?”

– Watch for opportunities to “Watch for opportunities to “Catch the client in the act” of Catch the client in the act” of behaving skillfully and effectivelybehaving skillfully and effectively. .

– Highlight patterns, cheerlead, and reinforce effective skills Highlight patterns, cheerlead, and reinforce effective skills with genuine praise. with genuine praise.

– Look for opportunities to “Coach In The Moment”:Look for opportunities to “Coach In The Moment”:• When the Client is vulnerable to act out an old response, When the Client is vulnerable to act out an old response, • When he presents with a stimulus that may trigger a When he presents with a stimulus that may trigger a

maladaptive response, maladaptive response, • Has repeated an ineffective pattern.Has repeated an ineffective pattern.• Ask Client, “What skills can you use right now….?”Ask Client, “What skills can you use right now….?”


3.3. Provide Session Tapes For ReviewProvide Session Tapes For Review

4.4. Provide In Vivo Behavioral Rehearsal Provide In Vivo Behavioral Rehearsal AssignmentsAssignments– Therapist and Skills Trainer gives Client Therapist and Skills Trainer gives Client

specific tasks to practice with Support Staff.specific tasks to practice with Support Staff.– Support Staff rehearse and reinforce skills.Support Staff rehearse and reinforce skills.– Provide assignments based on Client’s needs Provide assignments based on Client’s needs

and capabilities using principles of shaping.and capabilities using principles of shaping.


5.5. Create an environment that reinforces skilled Create an environment that reinforces skilled behaviors. behaviors. – Teach how to recruit reinforcement from the natural Teach how to recruit reinforcement from the natural

community.community.– Teach behaviors that fit the natural contingencies in Teach behaviors that fit the natural contingencies in

Client’s environment.Client’s environment.– Teach self-management skills, especially how to structure Teach self-management skills, especially how to structure

her environment.her environment.– Schedule regular family meetings to teach and practice Schedule regular family meetings to teach and practice

new skills, teach and practice reinforcement techniques new skills, teach and practice reinforcement techniques and reduce punishment of adaptive behaviors.and reduce punishment of adaptive behaviors.

– Fade reinforcement procedures to intermittent as the Fade reinforcement procedures to intermittent as the environment and Client reinforcement increase.environment and Client reinforcement increase.

ADVANCED STRATEGIES ADVANCED STRATEGIES TRAININGTRAINING

1.1.COGNITIVE RESTRUCTURING STRATEGIES:COGNITIVE RESTRUCTURING STRATEGIES: How How to help someone change the way they think.to help someone change the way they think.

2.2.EXPOSURE STRATEGIES:EXPOSURE STRATEGIES: How to help someone How to help someone overcome fear of just about anything.overcome fear of just about anything.

3.3.BEHAVIOR ANALYSIS STRATEGIES: BEHAVIOR ANALYSIS STRATEGIES: How to help How to help someone to see things as they are without judgment.someone to see things as they are without judgment.

4.4.SOLUTION ANALYSIS STRATEGIES: SOLUTION ANALYSIS STRATEGIES: How to help How to help others to create and practice what works best for others to create and practice what works best for them.them.

5.5.STYLE STRATEGIES:STYLE STRATEGIES: How to say or do something in How to say or do something in ways that get the results you want.ways that get the results you want.

6.6.CASE MANAGEMENT & CONSULTATION:CASE MANAGEMENT & CONSULTATION: How to How to coach others to care for themselves while providing coach others to care for themselves while providing ways to support and encourage each other.ways to support and encourage each other.

COGNITIVE COGNITIVE RESTRUCTURINGRESTRUCTURING

• Ways of helping the Client change both Ways of helping the Client change both the style and content of his thinking. the style and content of his thinking. Change can be initiated by verbally Change can be initiated by verbally challenging current thinking and challenging current thinking and biases; by offering alternative theories, biases; by offering alternative theories, explanations, and descriptions; and by explanations, and descriptions; and by examining the effectiveness of the examining the effectiveness of the Clients current rules and labels.Clients current rules and labels.

COGNITIVE COGNITIVE RESTRUCTURINGRESTRUCTURING

• Cognitive theories of emotions and Cognitive theories of emotions and emotional disorders suggest that an emotional disorders suggest that an individual’s cognitive appraisals of individual’s cognitive appraisals of events are primary determinants of events are primary determinants of emotional responses. Help the Client to emotional responses. Help the Client to restructure his style and content of restructure his style and content of thought and the behavior attached to thought and the behavior attached to his emotional response will also his emotional response will also change.change.

Cognitive ConstructsCognitive Constructs

• Cognitive constructs are that help the Cognitive constructs are that help the client receive, process, store, and use client receive, process, store, and use information in a way that changes the information in a way that changes the cognitive map. None of the constructs cognitive map. None of the constructs below are intended to considered below are intended to considered “true” or “right” ways of thinking. If a “true” or “right” ways of thinking. If a particular way of thinking isn’t working particular way of thinking isn’t working for you, try another way.for you, try another way.

Constructivist TheoryConstructivist Theory• Since the moment you acquired Since the moment you acquired

language your brain has taken in language your brain has taken in sensory information and has sensory information and has interpreted in a way that makes sense interpreted in a way that makes sense for you in that moment. This theory for you in that moment. This theory suggests that all of our interpretations suggests that all of our interpretations and meanings since language have and meanings since language have been created or “constructed” and been created or “constructed” and thus can be “re-constructed”thus can be “re-constructed”

Cognitive RestructuringCognitive RestructuringHow to help someone think differentlyHow to help someone think differently

• DBT AssumptionsDBT Assumptions

• Thoughts vs. RealityThoughts vs. Reality

• Meaning is CreatedMeaning is Created

• My Story vs. What HappenedMy Story vs. What Happened

• What I KnowWhat I Know

• Letting Go of Being RightLetting Go of Being Right

• My Probable Almost Certain FutureMy Probable Almost Certain Future

• Possibility vs. ExpectationPossibility vs. Expectation

• The Language of Change vs. The Language of Change vs. TransformationTransformation

DBT AssumptionsDBT Assumptions

• Every assumption is valid. They can not be Every assumption is valid. They can not be proven right or wrong, good or bad. DBT proven right or wrong, good or bad. DBT assumptions are ideas or beliefs that I assumptions are ideas or beliefs that I choose to act out on purpose because they choose to act out on purpose because they work better. What you think about work better. What you think about yourself and others has a great effect on yourself and others has a great effect on how you treat yourself and others.how you treat yourself and others. It is It is important to assess your assumptions of important to assess your assumptions of yourself, others, and the world to yourself, others, and the world to determine their effect. determine their effect.

Thoughts vs. RealityThoughts vs. Reality

• Thoughts Are Not Real. To demonstrate this idea, Thoughts Are Not Real. To demonstrate this idea, picture in your mind a horse. If you have a difficult picture in your mind a horse. If you have a difficult time picturing things in your mind, draw a horse on a time picturing things in your mind, draw a horse on a piece of paper. Next, imagine that the horse’s legs piece of paper. Next, imagine that the horse’s legs turn into car tires (or draw tires on top of the horse’s turn into car tires (or draw tires on top of the horse’s legs). Now look at your own legs and turn them into legs). Now look at your own legs and turn them into tires. Notice that your thoughts can be changed in tires. Notice that your thoughts can be changed in an instant, and that no matter how hard you try, an instant, and that no matter how hard you try, your legs will never turn into tires. This is because your legs will never turn into tires. This is because your legs are real and your thoughts are not. If a your legs are real and your thoughts are not. If a thought is not working for you, think one that does.thought is not working for you, think one that does.

Meaning Is CreatedMeaning Is Created

• You will never find the meaning of life on top of a You will never find the meaning of life on top of a mountain, in the desert, or buried in the earth. mountain, in the desert, or buried in the earth. This is because meaning is created by humans in This is because meaning is created by humans in reason mind. Life itself has no meaning other reason mind. Life itself has no meaning other than that which you create. Someone else might than that which you create. Someone else might have created some of your meanings in life. have created some of your meanings in life. However, you are the one that chose to accept However, you are the one that chose to accept them. So, if you don’t like the meaning of them. So, if you don’t like the meaning of something, make it mean something else that something, make it mean something else that works better for you.works better for you.

My Story vs. What My Story vs. What HappenedHappened

• Consider that everything you have experienced in Consider that everything you have experienced in life is based on your interpretation and that life is based on your interpretation and that nobody truly knows what really happened. All we nobody truly knows what really happened. All we can really know is what we perceive and can really know is what we perceive and interpret. It is our life story as we perceive it. We interpret. It is our life story as we perceive it. We experience trouble in life when we start to believe experience trouble in life when we start to believe that our life story actually is what happened and that our life story actually is what happened and then act as if it is true.then act as if it is true.

What I KnowWhat I Know

Letting Go of Being RightLetting Go of Being Right• If all I have ever experience is my perception of If all I have ever experience is my perception of

what happens, then I can never say my way is the what happens, then I can never say my way is the “right” way. However, I often deceive myself into “right” way. However, I often deceive myself into believing that I am right. I pretend that my “right” believing that I am right. I pretend that my “right” is from sainthood and another person’s “right” is is from sainthood and another person’s “right” is from psychosis. By insisting on being right I do get from psychosis. By insisting on being right I do get certain payoffs:certain payoffs:

• I get to be right and comfort myself that others are wrong. I get to be right and comfort myself that others are wrong.

• I get to judge others and justify myself. I get to judge others and justify myself.

• I get to dominate others before they can dominate me. I get to dominate others before they can dominate me.

• I get to feel superior rather than inferior.I get to feel superior rather than inferior.

• The cost of being right is love, joy, connectedness, and well The cost of being right is love, joy, connectedness, and well being.being.

My Probable, Almost Certain My Probable, Almost Certain FutureFuture• If I live in my past, I am destined to If I live in my past, I am destined to

recreate it until I die. In order to free recreate it until I die. In order to free myself from my past, I must put it myself from my past, I must put it where it belongs and radically accept where it belongs and radically accept it as my past. Only then can I create it as my past. Only then can I create a different future.a different future.

Project My Past Into My Future

Possibility vs. ExpectationPossibility vs. Expectation

Expectation Possibility

Disappointment

Possibility

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.

The Language of Change vs. The Language of Change vs. TransformationTransformation

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

ExposureExposureHow to help someone overcome traumaHow to help someone overcome trauma

• Tame the PAPER tiger.Tame the PAPER tiger.

•Present TriggerPresent Trigger

•Accept The AffectAccept The Affect

•Prevent Maladaptive ResponsePrevent Maladaptive Response

•Empower Empower

•Repeat Often & Longer Until the Repeat Often & Longer Until the Story Loses it’s PowerStory Loses it’s Power

BEHAVIOR ANALYSISBEHAVIOR ANALYSISHow to hear the story without judgmentHow to hear the story without judgment

• 1. Orient To Process1. Orient To Process

• 2. Elicit A Commitment2. Elicit A Commitment

• 3. Define the Problem3. Define the Problem

• 4 Describe Context4 Describe Context

• 5. Describe Behavior 5. Describe Behavior

• 6. Describe Thoughts6. Describe Thoughts

• 7. Describe Emotions7. Describe Emotions

• 8. Define Trigger8. Define Trigger

• 9. Determine Vulnerabilities9. Determine Vulnerabilities

• 10. Determine Motivation10. Determine Motivation

• 11. Describe Result11. Describe Result

• 12. Describe Intended Result12. Describe Intended Result

SOLUTION ANALYSISSOLUTION ANALYSISHow to help someone find more effective How to help someone find more effective

responsesresponses• 1. Create A Possibility Of Being1. Create A Possibility Of Being

• 2. Highlight Patterns2. Highlight Patterns

• 3. Interrupt The Pattern3. Interrupt The Pattern

• 4. Decrease Vulnerabilities4. Decrease Vulnerabilities

• 5. Same Context, Trigger, Emotions5. Same Context, Trigger, Emotions

• 6. Create New Thoughts6. Create New Thoughts

• 7. Shape New Behaviors7. Shape New Behaviors

• 8. Rehearse New Ways of Being 3 Times8. Rehearse New Ways of Being 3 Times

• 9. Regulate Emotions 9. Regulate Emotions

• 10. Identify Goals Aligned With Being10. Identify Goals Aligned With Being

• 11. Correct And Over Correct11. Correct And Over Correct

• 12. Generalize Behavior12. Generalize Behavior

STYLISTIC STRATEGIESSTYLISTIC STRATEGIESHow to help someone change by keeping How to help someone change by keeping

them them off balanceoff balance

Reciprocal Style Irreverent Style

Be Responsive Self-Disclose Express Warm Engagement Be Genuine And Authentic

Unorthodox Reframing Plunging In Confrontational Tone Calling The Bluff Intensity vs. Silence Omnipotence vs. Impotence Be Genuine and Authentic

CASE MANAGEMENT CASE MANAGEMENT How to teach someone to fish not give them How to teach someone to fish not give them

oneoneIntervention in the Environment Consultation to the Client

When client is unable to act and the outcome is important.

When the environment is intransigent or high in power.

To save client’s life or avoid high risk to others.

Provide need-to-know information to other professionals.

Orient client and other professionals to the approach.

Consult client on how to interact with other professionals.

Do not intervene to adjust client’s treatment environment.

Consult how to respond to family and friends about therapy.

FeedbackFeedback

• Tim Bradley, Clinical DirectorTim Bradley, Clinical Director

Aacres, CA LLCAacres, CA LLC

310-327-7842310-327-7842

[email protected]@aacresllc.com

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