treatment implementation collaborative - bharp...dbt skills training manual: pp 416-450 dbt skills...

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Core Skills in DBT ©TIC 2017-18 of 1

Treatment Implementation Collaborative

March 2, 2018 To: Registered Participants for Master Class: Core Skills in Dialectical Behavior Therapy©

16 weeks/hours with Annie McCall, MA, LMHC

From: Cindy Best ([email protected]) Thank you for registering for our Master Class: Core Skills in DBT©. This course is available through the TIC website (www.ticllc.org) until May 31, 2018. Part I: 12 hours available on demand Part II: 4 hours available on demand Access Instructions:

1. Visit the TIC website Registration page - https://www.ticllc.org/registration.html 2. Scroll down to the “Core Skills in DBT” section and click on the red “Login (paid registrants only”

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3. The Login button will take you to the list of recorded sessions in our WebEx account. Click on the

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Please note that these are for our own personal use and should not be distributed or shared with others.

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Master Class: Core Skills in DBT Annie McCall, MA, LMHC

© 2017 Treatment Implementation Collaborative, LLC :: www.ticllc.orgDo not copy/use without permission.

CORE SKILLS

of Dialectical Behavior Therapy©

12 Hours On Demand

with Annie McCall, MA, LMHC

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Core Skills of DBT with Annie McCall, MA, LMHC

www.ticllc.org :: © TIC 2011-2017 :: Slide 2

Week 1: Mindfulness 1

Intro to Mindfulness: Why Bother, States of Mind

DBT Skills Training Manual: pp 151-199

DBT Skills Training Handouts & Worksheets: pp 45-59 Both books by Marsha M. Linehan, Second Edition 2015



The Core Mindfulness Skills





Dialectics

Acceptance Change



Goals for Mindfulness Practice

Mindfulness is….

living life fully,

without self-consciousness

and with awareness

moment by moment.



▪ Mindfulness

▪ Mindfulness Skills

▪ Mindfulness Practice

Explaining the Definitions





Mindfulness Practice v. Mindful Experiencing

Helping clients live a mindful life by presenting

them with ways to practice mindfulness



The goal of mindfulness practice is mindfulness practice.

Relaxation

Calming

Soothing

Just breathing

Religious experiencing

Mindfulness practice does not have a goal of:



▪ Feet on the floor

▪ “Open” position of hands

▪ Back straight but not rigid

▪ Head held slightly tilted

▪ Position that is not slumping but can

be held without moving

▪ Eyes open unless told otherwise

Mindfulness Posture

http://4.bp.blogspot.com/_bsyuacXiuFk/SW1_I7StIVI/AAAAAAAAAHo/IVNc2LBrXQE/s1600-h/Sitting+in+a+chair+meditation.JPG





Opening the Mind

Focusing the Mind

Mindfulness



1. Orient/name the practice

2. Link the practice to a real life example using self

disclosure

3. Explain the practice. Make sure it does not have

multiple steps

4. Tell what to do if participants’ minds wander or

judgments arise

5. Ask if anyone has questions

6. Ring bell 3 times

7. Leader participates in mindfulness with participants

8. Ring bell once

9. Ask people to state what they observed (using describe

skills)

Leading Mindfulness Practice



From: Linehan, M. M. (1993). Skills Training Manual for Borderline Personality Disorder. New York: Guilford Press.

Three States of Mind (Cm 1)

WISEMIND

ReasonableMind

EmotionMind





Week 2: Mindfulness 2

Mindfulness What’s and How’s


DBT Skills Training Handouts & Worksheets: pp 60-63

(worksheets pp 78-93)Both books by Marsha M. Linehan, Second Edition 2015



1. Pause, stop or slow down

2. Observe: notice without words

3. Describe: put labels on the experience without adding

4. Participate: fully engage without self-consciousness

These skills are linear with Participation as the goal.

The “What” Skills (CM 2)



1. Non-judgmentally: let go of evaluating

2. One-Mindfully: focus attention on the present moment,

doing one thing at a time

3. Effectively: focus on doing what needs to be done, despite

the principle or what you think is fair or unfair

These skills are designed to be used with all of the

mindfulness skills.

The “How” Skills (CM 3)





▪ Spiritual Practices—Wise Mind from a spiritual perspective

(CM 7, p.68)

▪ Loving Kindness (CM 8, p. 70)

▪ Doing Mind v. Being Mind (CM 9, p. 71)

▪ Walking the Middle Path (CM 10, p.74)

Supplemental CM Skills:

Other Perspectives on Mindfulness



Week 3: Distress Tolerance 1

Changing the Body: TIPP, Self-Soothe


DBT Skills Training Handouts & Worksheets: pp 328-329, 334

(worksheets pp 374-376, 382, 386)Both books by Marsha M. Linehan, Second Edition 2015



Dialectics

Acceptance Change





Two Types of Distress Tolerance Skills

Crisis Survival Skills

• Short term pain

• Urges

• Impulses

Acceptance Skills

• Long term pain



Change your physiological response to a situation/emotion through

TIP. This skill works best when you do the steps in order.

TIP Skills (DT 6, p. 329)

• TemperatureT

• Intense ExerciseI

• Paced Breathing/Paired Muscle RelaxationP



Self-Soothing:

Using your senses to calm your body and your mind

Self-Soothing (DT 8, p. 334)

VISION HEARING SMELL

TASTE TOUCH






Changing the Mind: Pros/Cons, ACCEPTS,

IMPROVE


DBT Skills Training Handouts & Worksheets: pp 333, 336




Dialectics

Acceptance Change



Making wise mind decisions about responses to high

emotion, high urge situations

Pros and Cons (DT5, p. 328)

Pros Cons

ToleratingThe Distress

Not Tolerating the distress





Distracting (putting your attention on something else)

with Wise Mind ACCEPTS

Distracting (DT 7, p.333)

• ActivitiesA

• ContributingC

• ComparisonsC

• Emotions (that are different from the ones you are experiencing)E

• Pushing AwayP

• ThoughtsT

• Sensations S



Replacing negative events with more positive ones using IMPROVE

Improving the Moment (DT 9, p. 336)

• ImageryI

• MeaningM

• PrayerP

• RelaxationR

• One thing at a timeO

• VacationV

• Encouragement E




Reality Acceptance


DBT Skills Training Handouts & Worksheets: pp 342, 345-353






Dialectics

Acceptance Change



Reality Acceptance

Radical Acceptance, (DT 11, p. 342)

Turning the mind(DT 12, p. 345)

Willingness vs. willfulness(DT 13, p, 346)

Half Smiling & Willing Hands (DT 14, p. 347)



Change your posture and breathing to make you more accepting

Distress Tolerance: Acceptance Skills (DT 14)

Breathing skills

Awareness

Half-smile





▪ Observe thoughts

▪ Don’t suppress or magnify thoughts

▪ Allow thoughts to come and go

▪ Play with your thoughts

Mindfulness of Current Thoughts (DT 15, p. 350)




Addiction Skills






▪ Dialectical Abstinence (DT 17, p. 357)

▪ Clear Mind (DT 18, p. 359)

▪ Community Reinforcement (DT 19, p. 361)

▪ Burning Bridges and Building New Ones (DT 20, p. 362)

▪ Alternate Rebellion (DT 21, p. 363)

▪ Adaptive Denial (DT 21, p. 363)

Skills for Addictions





Week 7: Interpersonal Effectiveness I

DEAR MAN



(worksheets pp 174)Both books by Marsha M. Linehan, Second Edition 2015



Dialectics

Acceptance Change



Getting your objective with DEAR

Guidelines for Getting What You Want (IE 5, p. 125)

• Describe the facts of the situation (when needed)D

• Express your feelings and opinions about the situationE

• Assert what you want/say noA

• Reinforce the person ahead of time R





Guidelines for Getting Your Objectives (continued)

• (stay) MindfulM

• Appear confidentA

• NegotiateN



▪ Suggestions for Interpersonal Effectiveness Practice

▪ In session practice

▪ Round robin

▪ Directed role plays (demonstration with rehearsal)

▪ Role play with leader

▪ Role play with each other

▪ “Clash of the Titans”

Getting People to Practice

Interpersonal Effectiveness Skills



Week 8: Interpersonal Effectiveness 2

GIVE, FAST








Dialectics

Acceptance Change



Guidelines for Relationship Effectiveness:

Keeping the Relationship (IE 6, p. 128)

• (be) GentleG

• (act) InterestedI

• ValidateV

• (use an) Easy MannerE



Guidelines for Self-Respect Effectiveness:

Keeping Respect for Yourself (IE 7, p. 130)

•(be) FairF

•(no) ApologiesA

•Stick to valuesS

•(be) TruthfulT





Options—use wise mind to determine intensity

If not, use factors to determine intensity

(the dime game)

Options for Intensity of Asking/Saying No (IE8, p. 131)



▪ Finding and getting people to

like you (IE 11, p. 140)

▪ Mindfulness of Others

(IE 12, p. 143)

▪ Ending Relationships

(IE 13, p. 145)

Supplemental IE Skills:

Building Relationships and Ending Destructive Ones



Week 9: Interpersonal Effectiveness 3

Dialectics and Behaviorism


DBT Skills Training Handouts & Worksheets: pp 149-151, 161-163

(worksheets pp 189-191, 194-195)Both books by Marsha M. Linehan, Second Edition 2015





Dialectics

Acceptance Change



▪ Dialectics (IE 15, p. 150)

▪ Validation (IE 17, p. 155)

▪ Recovering from invalidation (IE 18, p. 158)

▪ Increasing the Probability of Behaviors You Want (IE 20, p. 161)

Supplemental IE Skills: Walking the Middle Path



Week 10: Emotion Regulation 1

Model of Emotion, Checking the Facts


DBT Skills Training Handouts & Worksheets: pp 205, 213, 228

(worksheets pp 281-282, 285-286)Both books by Marsha M. Linehan, Second Edition 2015





Dialectics

Acceptance Change



1. Understand and name emotions

2. Decrease the frequency of

unwanted emotions

3. Decrease emotional vulnerability

4. Decrease emotional suffering

Goals of Emotion Regulation (ER1, p. 205)



Model of Emotions (ER 5, p. 213)





▪ Check the Facts (ER 8, p. 228)

▪ Opposite Action and Problem Solving: Deciding Which to Use

(ER 9, p.230)

▪ Opposite Action (ER 10, p. 231)

▪ Problem Solving (ER 12, p. 241)

Changing Emotional Responses




Opposite Action & Problem-solving


DBT Skills Training Handouts & Worksheets: pp 230-231, 241




Dialectics

Acceptance Change





▪ Check the Facts (ER 8, p. 228)

▪ Opposite Action and Problem Solving: Deciding Which to Use

(ER 9, p.230)

▪ Opposite Action (ER 10, p. 231)

▪ Problem Solving (ER 12, p. 241)

Changing Emotional Responses



Know the emotion. Know the action urge.

Fully engage in the opposite of the action

Change Your Emotion: Opposite Action (ER 10)

•do what is prompting the emotionFear

•engage in meaningful activity, behaviorally activateSadness

•engage in the behavior over and over (don’t apologize)Guilt

•disclose what you are hiding Shame

•approach, pick up, make contact with cue Disgust

•count your blessingsEnvy

•wish the bestJealousy

•stop driving by, calling, texting, etc.Love

• compassion, empathy, do something kind, gently avoidAnger




Coping Ahead &The Wave


DBT Skills Training Handouts & Worksheets: pp 256, 264

(worksheets pp 301, 311)Both books by Marsha M. Linehan, Second Edition 2015





Dialectics

Acceptance Change



▪ Accumulating Positive Emotions: Short Term (ER 15, p. 248)

▪ Accumulating Positive Emotions: Long Term (ER 17, p. 252)

▪ Values and Priorities List (ER 18, p. 253)

▪ Build Mastery and Cope Ahead (ER 19, p. 256)

▪ PLEASE (ER 20, p. 257)

Reducing Vulnerability to Emotion Mind –

Building a Life Worth Living



Accept Your Emotion: Mindfulness to Current Emotion

(ER 22)

”THE WAVE”

▪ Experience your emotion as a wave

without avoiding or

amplifying

▪ Pay attention to your physical

sensations





www.ticllc.org

TIC as a Resource

Helen Best, M.Ed.

President, TIC

[email protected]

(206)251-5134

Shari Manning, Ph.D.

Chief Executive Officer, TIC

DBT-Linehan Board Certified Clinician

[email protected]

(803)479-4545

Cindy Best

Chief Operating Officer, TIC

[email protected]

Annie McCall, MA, LMHC

Trainer & Advisor, TIC


[email protected]

MASTER CLASS: Core Skills in DBTPart Two: How to Structure and Run Skills Training Groups©

Presented by: Annie McCall, MA, LMHC

Dates: June 7 and 14, 2017


MASTER CLASS: Core Skills in DBT

Part II: How to Structure and

Run Skills Training Groups©



Treatment Implementation Collaborative, LLC


Enhancing Capability: DBT Skills Group


▪ Lack of skill; not knowing what to do or how to do it

▪ High emotion

▪ Thoughts: “I can’t do this.” “Nothing will change.” “This isn’t

my fault--I shouldn’t have to do this.”

▪ Failure to generalize across contexts (ex. more skillful at work

than at home)

▪ Willfulness

▪ Contingencies: old, problematic behavior works better than

new, more effective behavior at solving problems (reducing

emotion, getting help, distracting the mind)

Things that Interfere with Capability

Page 1 of 19






▪ Addresses capability problems: Clients do not have behaviors

in their behavioral repertoire (Skills Acquisition)

▪ Model new behaviors

▪ Teach new behaviors

▪ Increase learning of skills (Skills Strengthening)

▪ Rehearse new skills in group

▪ Reinforce new skills when they occur

▪ Give feedback on skills use (don’t reinforce incorrect practice)

▪ Make sure skills are used outside of group (Skills

Generalization)

▪ Homework assignments

▪ Homework review

The Purpose of Skills Training


Therapy Destroying Behaviors (Examples)

Behavioral Skills (Core Mindfulness, Emotion Regulation,

Distress Tolerance, Interpersonal Effectiveness)

Therapy Interfering Behaviors

Skills Training Targets


Interlocking Core Paradigms

DialecticsAcceptance Change

Your current behavior

is understandable and

inevitable.

Your behavior needs to

change in order to meet

your goals.

Page 2 of 19






Using the Skills Training

Manual(s)


▪ Determine your population

▪ Determine the length of your skills training program

▪ Review the schedules in the DBT Skills Training Manual (pgs.

110-122, Linehan, 2015)

▪ Choose a curriculum that matches your program

▪ Either give clients a copy of the DBT Skills Training Handouts

and Worksheets (Linehan, 2015) or make copies

Choosing a Schedule


▪ The Handouts with stars are the core skills

▪ Divided into main handouts and

supplementary handouts

▪ Multiple Worksheets for each skill

The Skills Training Handouts and Worksheets

Page 3 of 19






▪ To address a specific problem (11 week Emotion Regulation)

▪ With a less out of control (Stage 3) population

▪ With non-DBT individual therapy

▪ With intensive, structured case management

REMEMBER: Skills alone is NOT recommended for clients with

repeated or chronic life threatening (suicidal, self-harm, assaultive

and homicidal) behaviors or people too dysregulated to tolerate

group without 1:1 DBT therapy

When Might You Do Skills Alone?


▪ Who manages crises? Who creates and maintains the crisis

plan?

▪ Who has clinical responsibility?

▪ Who treats therapy-interfering behavior related to group (ex.

not attending, not doing homework, conflict with other

members)

▪ Who manages contingencies related to group attendance?

▪ Who helps clients generalize skills from the skills training

room to real life?

Issues to Consider in Offering Skills Alone


Leadership in Skills Training Group:

Each group requires a leader and a co-leader

Page 4 of 19






In order to be an effective

skills trainer you must

believe in the power of

skills to change lives.

The best way to do that is

to learn and use skills in

your own life.


▪ Participate in a skills training course

▪ Co-lead or observe a skills class where you work and do the

homework

▪ Read and practice from the manual

▪ Teach your team and others skills

▪ Keep a skills diary card for yourself

How to Learn the Skills Yourself


The Leader:

▪ Plans lessons (w co-leader)

▪ Leads mindfulness

▪ Leads homework review

▪ Teaches new skills

▪ Provides coaching and

feedback

▪ Rotates no more often than

1x per module

Leader and Co-leader

The Co-Leader:

▪ Helps with time management

▪ Manages TIB w/ proximity

and facial expression

▪ Adds questions, examples

based on observing members

▪ Coaches clients who leave

▪ Calls missing members

▪ Observes behavioral shaping

Page 5 of 19






Setting Up Your Skills Training Group


Getting the Right People in the Room:

Orientation and Commitment in DBT


DBT is a voluntary treatment.

Page 6 of 19






▪ Use DBT commitment strategies

▪ Uncover goals and link DBT skills to achieving them

▪ Orient to roles (skills trainers v. individual therapists/case

managers)

▪ Skills v. process therapy

▪ Homework/practice/diary card

▪ Throwing yourself in and participating (no ”tourists”)

▪ Schedule and attendance, including 4-miss rule

Core DBT Strategies: Orientation and Commitment


▪ Clients have dropped out of therapy if they miss 4 of any

MODE of treatment in a row, e.g. 4 individual sessions OR 4

group sessions in a row

▪ No “excused” or “unexcused” absences

▪ If clients drop out, they may not request to return until after

the end of their current contracted period of treatment and

then they must start over with assessment, intake, etc.

▪ Even in skills alone, consider the 4-miss rule with the non-

DBT therapist as a contingency to keep people in skills group.

The Four Miss Rule in DBT


▪ Classroom setting

▪ Tables vs. comfy chairs

▪ Whiteboard/flip chart

▪ Classroom supplies: pens, extra paper, extra copies of all materials

▪ Each client gets a notebook with all materials in it, including a

syllabus with page numbers

▪ Mindfully shape norms for your group that promote practicing

vs. processing

Creating a Learning Environment

Page 7 of 19






▪ Greeting

▪ Mindfulness Practice (5-10 minutes)

▪ Homework Review (45 minutes -1 hour)

▪ Break (5-10 minutes)

▪ Teaching new lesson (45-50 minutes)

▪ Homework assignment (5 minutes)

▪ Closing mindfulness practice (usually an observe and describe)

Standard Skills Training Format: 2-2.5 hours


▪ Read the teaching notes

▪ Think about how to “sell” clients on the skill. Why do THESE

people need THIS skill right NOW?

▪ Choose worksheets (or other means of recording practice)

▪ Determine which mindfulness practice to begin group

▪ Which WHAT skill and HOW skills will it focus on? Why?

▪ Plan personal stories, metaphors, analogies, etc. to make the

skill vivid and appealing

▪ Plan live practices

Lesson-planning for Your DBT Skills Group


▪ Stand up (at least periodically)

▪ Manage the room with your presence

▪ Write on the whiteboard

▪ Light touch

▪ Humor (irreverence will keep people coming)

▪ Self-disclosure

Teaching Tips

Page 8 of 19






▪ Identify a WHAT and at least one HOW skill that needs

practice

▪ Possibly link the practice to the module you’re on (e.g.

Mindfulness of Others, a “brain teaser” to model the “T” in

ACCEPTS, listen to evocative music to cue sensation for a

”wave” practice)

▪ Talk as little as possible once the practice starts

▪ Over time, balance active participation practices with quiet

observation practices

The Opening Mindfulness Practice


1. Orient/name the practice

2. Link the practice to a real life example using self

disclosure

3. Explain the practice. Make sure it does not have

multiple steps

4. Tell what to do if participants’ minds wander or

judgments arise

5. Ask if anyone has questions

6. Ring bell 3 times

7. Leader participates in mindfulness with participants

8. Ring bell once

9. Ask people to state what they observed (using describe

skills)

Leading Mindfulness Practice


▪ Begin with what people know. Ask a question that draws on

their experience and starts a discussion.

▪ Does your mind ever get stuck on something and you can’t let it go?

▪ Anybody ever stay mad even when they don’t want to be mad

anymore?

▪ Introduce the lesson. Link to last week’s learning.

▪ Build a case for how they (perhaps all people) have a problem,

and the skill is a solution

▪ Don’t read the handout word-for-word.

▪ Explain HOW to do the skill (i.e. what to DO with their body

and/or their thoughts)

Tips for Teaching the New Skill

Page 9 of 19






Generalizing Skills to the Natural Environment


▪ The end of each group—don’t rush

▪ Write it on the board and show the sheet

▪ No more than two practices

▪ Make sure participants understand (ask if there are questions)

▪ Get a verbal commitment from each member

▪ If anyone says “no,” assess, validate, clarify and re-sell, try again

for commitment.

Assigning Homework


▪ Half of group time is mindfulness and homework review; the other half is

new teaching and live practice.

▪ Divide time evenly across attendees.

▪ Get help from your co-leader or a timer if necessary.

▪ Ask group to remind you what the assignment was

▪ No passes (except in extreme cases)

▪ Ask questions that shape discussion of SKILL use, not the story or failures

▪ Make corrections. Give productive feedback

▪ Reinforce any practice, even if it was wrong

▪ Watch for dysregulation and move in with validation

Reviewing Homework

Page 10 of 19






▪ Very quick, round robin review where everyone says

something

▪ Pick a random person from each family

▪ Divide adolescents and adults and everyone does review

Reviewing Homework

in Multi-Family Skills Training Groups: Options


▪ With very few exceptions, NO ONE passes

▪ Make sure that the client gets as much time as everyone else

▪ Do Missing Links Analysis

▪ Whenever possible, get them to do the skill in the moment:

▪ DEAR MAN you to move to the next person

▪ Non-judgmentally describe how they didn’t do the homework

▪ Imaginal practice/cope ahead to practice this week. Get

commitment and troubleshoot.

“I didn’t do the homework.”


▪ Are you sure you didn’t do it? Practicing vs. writing it down

▪ Did you understand the skill and/or the assignment? Did you

intend to do it when you said “yes?”

▪ Did you remember that you were supposed to practice?

▪ What got in the way of doing the homework?

▪ Emotion: Hopelessness? Fear? Shame?

▪ Thoughts: What’s the point? Skills don’t work?

▪ Contingencies: More reinforcing to watch tv, other people interfered

▪ Willfulness

Missing Links Analysis

Page 11 of 19






▪ Says skills don’t work

▪ Passes or refuses to talk

▪ Tells long stories

▪ Consistently shows up after

homework review

▪ Did the skill wrong

▪ Talks exclusively their about skillful

behavior in one context

Provide Coaching and Feedback when the Client…


▪ Did s/he do the effective skill?

▪ Did s/he do it accurately?

▪ Did s/he do it sufficiently?

▪ Did s/he do it mindfully?

▪ Did judgments, hopelessness or other cognitions or emotions

interfere?

When the Skills “Don’t Work”


▪ I’m seeing what looks like shame to me, and I wonder if it’s shown

up because you didn’t do the homework perfectly.

▪ Shame is only effective when it protects us from being rejected.

▪ Your shame isn’t effective in skills group because we don’t want you

to go away because you didn’t do the homework.

▪ Your shame will come down if you drop your shoulders, get your

chin up, and look at me, and look around the room.

▪ What’s happening in your body while you do that? You’re doing

great!

Coaching Opposite Action for Shame

Page 12 of 19






▪ Would YOU attend your group? Is it engaging, interesting, and

fun? Is it a good interpersonal experience?

▪ Link skills to LWGs: Why do THESE people need THIS skill

right NOW?

▪ Live practice in every session

▪ Tailor homework practices to be relevant to LWLGs

Remember: SKILLS themselves are not reinforcing until they

work; in the short term, SKILLS GROUP must be reinforcing.

Improving Homework Completion and Attendance


Dealing with Behaviors

that Interfere with Learning


Remember the Skills Training Targets

Page 13 of 19






Therapy Destroying Behaviors (Examples)

Behavioral Skills

(Core Mindfulness, Emotion Regulation,

Distress Tolerance, Interpersonal Effectiveness)


Skills Training Targets


Therapy Destroying Behaviors

▪ Clients will quit coming to

group

▪ Therapists will quit coming to

group

▪ Presence of threat

▪ Group can’t be conducted

▪ DBT will get discontinued

Determining Therapy Destroying v.



▪ Annoying

▪ Distracting

▪ Interfere more with personal

learning than the learning of

others (e.g. sleeping)

▪ If not addressed, could escalate

into TDB over time


▪ Criticizing, making fun of other members

▪ Bringing a knife

▪ Interrupting repeatedly

▪ Crying

▪ Sleeping

▪ Picking at scabs

▪ Threatening another group member

▪ Leaving the room

Which are Therapy Interfering and

Which are Therapy Destroying?

Page 14 of 19






Reciprocal/Vulnerable Irreverent/Confrontational

TIB TDB

Ignore Face/Body Request Demand EBPlanguage Coaching happens here

Managing Group TIB vs. TDB


▪ Non-judgmentally describe the behavior to the client

▪ Quickly validate the behavior, the emotion behind it, or the

urge to do the behavior

▪ Instruct and coach the client in the behavior you want

▪ Reinforce when they do the new behavior

▪ Avoid power struggles and a scolding, “teacherly” tone (“You

need to… “I need you to...”)

▪ Work VERY HARDto keep people in the room vs. asking or

allowing them to leave

Managing Therapy-Interfering Behavior in Skills Group


▪ Genuinely understanding the individual’s thoughts, feelings,

behaviors, etc. in a nonjudgmental way

▪ Conveying that understanding to the individual so he or she

feels understood

▪ Validation is essential to coaching and maintaining

relationships.

▪ Individuals are more likely to use skills and accept coaching IF

they think the the coach “gets” them.

Remember to Validate!

Used with permission from Jennifer Eaton, M.S.

Page 15 of 19






▪ Leader asks client to stop behavior, gently or irreverently

▪ Leader uses the relationship as a contingency (e.g. “Help me

out and...”)

▪ Leader or co-leader uses proximity and facial expression to

manage behavior (i.e. The Teacher Face)

▪ Leader uses moment for a practice: “let’s do a mindfulness

skill here to make sure we are doing one thing in the

moment.”

Therapy Interfering Behavior


▪ Done by the co-leader

▪ The goal is to get them back in the room; it is NOT therapy in

the hallway

▪ Get a brief explanation of the problem

▪ Genuinely validate what has sent them from the room

▪ Coach skillful behavior that will help them to get regulated

enough to participate and learn in group

▪ Reinforce participating in coaching and coming back

▪ If the person does not collaborate, go back to group

Coaching a Client Who Has Left Group


▪ When there is conflict, distress, too much talking, or

generalized low affect

▪ Use mindfulness as an irreverent/unexpected intervention

▪ Choose practices strategically to quiet or activate a group

▪ Choose practices to build connection and decrease

“outsiderness”

▪ Consider a group mindfulness practice if you yourself become

dysregulated in group

Using Mindfulness to Address Whole-group TIB

Page 16 of 19






▪ Often done in consultation-to-client approach (i.e. client tells

leaders what to look for and how to respond

▪ Leaders loudly get client’s attention and coach them to:

▪ Get up and move around the room

▪ Do wall sits, stand on a balance board, stand on one foot

▪ Hold ice

▪ Throw themselves into group-–take notes, ask questions, interact with

other members

TIB of Dissociation


Using mindfulness to treat group TIB

Up-regulating

GroupIndividual

Down-regulating


▪ Leader-directed observing

▪ Shoe mindfulness

▪ Build-a-body

▪ “Twist and Shout”

▪ Sound ball

▪ Non-dominant writing of “Everything is perfect as it is.”

▪ Mindful walking

Mindfulness Practice Examples

Page 17 of 19






▪ If you want one behavior to STOP, you must identify what

behavior you want to START in its place.

▪ e.g. What is the behavior of “waiting your turn” or “not interrupting”?

▪ Make sure you reinforce the new, functional behavior

Remember…


▪ Stop them in the moment

▪ Use language of skills

▪ Discuss behavior with client outside of group

▪ Attend to group members’ reactions if

necessary

▪ Individual therapist (if available) targets in

therapy

▪ Egregious Behavior Protocol

Therapy Destroying Behaviors


▪ An aversive contingency designed to STOP therapy destroying

behaviors

▪ Client cannot return to group until the plan is approved

▪ Client determines harm that was done by behavior (to other

clients, staff, facilities, etc.)

▪ Client determines how to repair/correct harm

▪ Client determines how to over-repair/correct harm

▪ Client implements the plan

The Egregious Behavior Protocol

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Punishment, e.g. egregious behavior protocol,

only works while you are doing it, therefore you

want to REINFORCE any new functional

behavior no matter how small it is.

Remember Principles of Reinforcement


www.ticllc.org

TIC as a Resource

Helen Best, M.Ed.

President, TIC

[email protected]

(206)251-5134

Shari Manning, Ph.D.

Chief Executive Officer, TIC


[email protected]

(803)479-4545

Cindy Best

Chief Operating Officer, TIC

[email protected]

Annie McCall, MA, LMHC

[email protected]

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treatment implementation collaborative - bharp...dbt skills training manual: pp 416-450 dbt skills...

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