Supporting Individuals with Developmental Disabilities, Mental Illness,

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• Supporting Individuals with Developmental
  Disabilities, Mental Illness,
• Challenging Behaviors
• using
• Dialectical Behavior Therapy (DBT) Ted Ryle,
  MSW, MA

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Who am I?

• Ted Ryle, LICSW, MSW, MA,
• I have taught practiced DBT
• As a clinical intern in an inpatient psychiatric
  unit with the Ohio Department of Corrections
• As a group counselor at the Puget Sound Hospital
  MICA Unit (Mentally Ill, Chemically Addicted)
• As a DBT therapist/consultant with Aacres Allvest
  in Tacoma, and consultant trainer with other
  residential programs around the state.
• As Clinical Training Administrator with the
  Washington State Juvenile Rehabilitation
  Administration

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DBT in a Nutshell

• DBT is a research-based Cognitive Behavioral
  Therapy that was developed Marsha Linehan from
  the UW for people with para-suicidal behavior and
  other extremes of emotional and behavioral
  dys-regulation many with Borderline Personality
  Disorder (BPD).
• Cognitive Treatment Recognizing how thinking
  patterns cause symptoms- change your
  thinking/change your life
• Behavioral Treatment Analyzing situational
  reactions, practicing problem solving and
  calming/relaxation strategies
• Radical Behaviorist Principles of teaching,
  learning and reinforcing behaviors.
• DBT assumes that BPD is an Emotion-Driven
  Disorder,
• DBT reframes para-suicidal behavior (and some
  other target behaviors) as a maladaptive problem
  solving strategy
• DBT assumed the problem is often intense
  emotional pain, and the solution, in the eyes of
  the person with BPD, is self injury or other
  problem behaviors.
• the problem emotional pain
• the solution self-harm behavior

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Emotion Vulnerability
Average Emotional Experience
Major
Stressors
Medium
Minor
Borderline Emotional Experience
Major
Medium
Stressors
Minor
Time
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InvalidatingEnvironments

• Invalidating environments (families, schools,
  institutions, residential providers) may not
  understand or may be overwhelmed by the intensity
  and the frequency of emotional outbursts and may
  communicate that the person should not be feeling
  what they are feeling, that what their feeling
  doesnt make sense, that they should be able to
  get over it and get it together, or they may be
  inconsistent in how they respond to the persons
  emotions. As a result the person may learn not to
  trust their own emotions.
• I dont understand why you are making such a big
  deal out of this.
• Just pull yourself together.
• Youre just trying to get attention.
• There is no need for you to be so ..
• As a result of constant emotional and behavior
• dys-regulation, combined with the difficulties
  in the environment, the person with BPD may
• Learn not to trust own emotions
• Invalidate themselves and their feelings
• Have a difficult time trusting others
• Intense fear of abandonment

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Emotions are like Heat
Hot
Warm
The GIVE Zone
Cool
Cold
Who controls the thermostat?
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• Persons with Borderline Personality Disorder are
  like Emotional Burn Victims
• People who work with them must be Emotion Experts
  with a high level of
• Awareness
• Tolerance
• Acceptance
• Competence

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Emotion Experts

• Awareness What are my reactions? Hot Buttons?
  Boundaries? Judgments? Assumptions?
• Tolerance Am I able, and/or willing to tolerate
  the intensity?
• Acceptance Can I accept this client exactly
  where she is right now? Her disability? Her
  behavior?
• Competence Do I have, or am I willing to gain
  skills to support and coach the client AND
  manage myself in the midst of challenging hot
  situations?

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The house ison Fire!

• Staff is burning up and burning out from the
  intense emotional heat
• Everyone is doing the best they can under the
  circumstances
• AND.
• They dont believe this and that is part of what
  is lighting up the place
• And this is why the first assumption of DBT is
  ..

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DBT Assumption 1

• Clients are doing the
• best they can.
• We have a choice
• Choose Assumption A Clients are doing the best
  they can
• Choose Assumption B Clients know better and
  are deliberately trying to manipulate staff
• How would each assumption influence our behavior?
• How would our behavior, operating from each
  assumption, in turn influence client behavior?
• Remember, assumptions are not facts.
• Choose your assumptions wisely.

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DBT Assumption 2

• Clients WANT to improve.
• We have a choice
• Choose Assumption A Clients want to improve
• Choose Assumption B Clients are not motivated to
  change and do not want to improve their lives
• How would each assumption influence our behavior?
• How would our behavior, operating from each
  assumption, in turn influence client behavior?
• Choose your assumptions wisely

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DBT Assumptions

• Assumption 3
• Clients Need to do better, try harder, and be
  more motivated to change
• Clients are doing the best they can AND it may
  not be good enough.
• Assumption 4
• Clients may not have caused all of their own
  problems, AND they have to solve them anyway
• The therapist/staff/program cant save the
  client. They are going to have to change their
  behavior in order to change their life.

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DBT Assumptions

• Assumption 5
• The lives of suicidal, borderline individuals
  are unbearable as they are currently being lived
• The frequently voiced dissatisfaction with their
  lives is valid. They are in a living hell. The
  only solution is to change their lives.
• Assumption 6
• Clients have to learn behaviors in all relevant
  contexts
• The clients behavior is often mood dependent.
  Times of stress are the times to learn new ways
  of coping.
• Assumption 7
• Clients cannot fail as long as they are in
  treatment (in-program)
• If the treatment program is being applied
  according to protocol, and the clients still does
  not improve, the failure is in the treatment, not
  the client

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DBT Assumptions

• Assumption 8
• People who work with/treat Borderline clients
  need support
• Treatment providers (therapists, direct care
  staff, skills trainers, program directors,
  administrators) WILL make mistakes.
• We often get stuck between wanting to relieve
  immediate, intense pain, and what we need to do
  to support long-term cure. It is VERY DIFFICULT
  to remain therapeutic with Borderline clients.
• If you are going to effectively support these
  clients, you will need to provide members of the
  treatment team with a high level of training,
  consultation, support, and frequent
  non-judgmental communication and reinforcement.

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The Dialectical Dance between Acceptance Change

• There are 2 sides to every coin. Just because
  you cant see the other side does not mean it
  isnt there.
• Dialectics stresses the fundamental
  interrelatedness or wholeness of reality
• Reality is not static, but is made up of internal
  opposing forces or tensions.
• The fundamental nature of reality is change and
  process rather than content and structure.
• The Primary Dialectic in treatment is with
  Acceptance Change.
• Effective use of skills, strategies and
  structure can support the continuous dialectical
  continuously dance with acceptance and change.

Acceptance Change
Acceptance Change
Acceptance Change
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Hints for practicing a dialectical worldview

• Practice seeing other points of view, looking
  through the eyes of another. There are usually
  multiple sides to a situation.
• Move away from either-or thinking to both-and
  thinking. Avoid words like always and never.
• Remember no one has the absolute truth.
• Say I think and I feel, instead of You are
  this way or that way or Thats just the way it
  is
• EMBRACE CHANGE (and acceptance!)

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Acceptance Change (the dance)

• Treatment providers must balance the clients
  capabilities deficiencies
• Treatment providers must balance nurturing and
  supporting strategies change demanding
  strategies
• This requires infinite patience and . .
• ACCEPTANCE of REALITY
• Radical Acceptance of both clients and our
  selves, exactly as we are in the moment.
• Ability to turn the mind back toward acceptance
  moment to moment.
• Willingness to find the inherent wisdom and
  goodness of the current moment . . .
• Without judgment, blame or manipulation

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We are all Coaches

• All of us, regardless of our position,
  credential, or education can use every
  interaction with a client as an opportunity to
  coach and reinforce skillful behavior
• The 3 Ss of Coaching can help all of us to coach
  consistently and effectively
• Structure (Client Meaningful Goals Activities,
  Agreements Expectations, Skills Training and
  therapy
  Staff Training, Behavior Support Plans, Team
  communication, support, and consultation, open
  feedback loop, modeling from top down
• Skills (Focus, Coping, Emotion Management,
  Relationship Building Skills for staff
  Mindful non-judgmental, GIVE, Radical
  Acceptance,
• Strategies (Staff interventions-coaching,
  validation, reinforcement, engagement and
  motivation,
• acceptance change

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Increasing Skillful BehaviorCoaching Strategies

• TELL
• (Describe and define) To do Willing Hands,
  You unclench your fists and open your hands with
  your palms up, and take a nice relaxed breath.
• SHOW
• (Demonstrate the skill) Watch me do it. I
  will show you what it looks. See how my hands
  look? Hear me breathing?
• DO
• (Have the client practice with you or another
  client) OK, now lets do it together. Were
  waiting for our ride to get here and they are
  late and we are frustrated. We are coping with
  our frustration using Willing Hands Were
  opening our hands. Were breathing.
• REVIEW
• (Constructive non-judgmental descriptions/feedbac
  k of what worked and what didnt, or of attempts
  that are on the money, or off the mark) You did
  a really good job. Try holding your hands open a
  little bit longer
• HIGHLIGHT
• (Point out when the client uses a skill,
  especially when the client isnt aware he was
  doing it) I just noticed you being mindful
  there, when you hesitated and took a breath
  before reacting.
• SHAPE
• (Reward attempts, and describe next steps) I
  noticed you tried really hard to use GIVE to be
  gentle with me other staff when you are asking
  us to help you with something. Thank you very
  much. A great next step would be to use it with
  us when we are trying to solve a problem
  together.

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DBT Strategies Validation

• Communicating that a persons thoughts, feelings,
  beliefs and behaviors are understandable
• Finding the wisdom or kernel of truth in
  behavior.
• Acknowledging what is valid about a persons
  thoughts, feelings, emotions, beliefs

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DBT Strategies Levels of Validation (1-3)

• Level 1- Paying Mindful Attention, Active
  Observing
• Examples Eye contact, nodding, 1-mindful,
  focused
• Level 2 Paraphrasing, accurately reflecting.
• Examples
• So I heard you say,
• Let me make sure I heard you
• correctly . . .,
• You are saying youre angry
• Level 3- Speaking the unspoken, mind reading
• Examples
• You look sad. Are you feeling down,
• I know you havent said so, but are you feeling
  frustrated?,
• I bet you wanted to storm out of here just
  then. That seemed hard to talk about.

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DBT Strategies Levels of Validation (4-6)

• Level 4-
• Valid given history and past learning
• Examples I am not surprised that you had the
  urge to yell. You have said it works really well
  to get people off of your back.
• Its understandable that you believe you need
  to fight back when you feel threatened, I know
  youve said youve been hurt in the past and you
  want to protect yourself
• Level 5- Valid based on current situation, based
  on biology.
• Examples It makes complete sense that you are
  nervous right now. This is a new place
• I know you are having a hard time focusing
  today. Its not surprising. You are not feeling
  well and did not get much sleep.
• You are thinking this isnt fair and feeling
  frustrated. Thats understandable. I know you
  were really looking forward to going on the
  activity with us.
• Level 6- Radical Genuineness (Keeping it Real)
• Examples I want you to know that even though I
  disagree with what you did yesterday, when you
  assaulted me, I believe in you and I want to help
  you. Were just two ordinary human beings, can we
  just role up our sleeves and work together? We
  both have the same goals of making your life
  better.

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Why Validate?

• To build relationship
• To prevent treatment provider blindness in the
  face of dysfunctional behavior
• To reduce judgment
• To model self-understanding acceptance
• To help clients learn to trust their own
  responses
• To draw out unassertive, less verbal clients
• To calm a client who is too
• dys-regulated to discuss anything else
• To repair therapeutic/relationship errors
• To learn about a clients experiences
• To help the client identify and label authentic
  primary emotions that may underlie learned,
  secondary emotions
• To create a validating context for change

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Validation is
NOT
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Acceptance Change

• We begin treatment by first accepting clients for
  who they are and where they have come from. This
  is Validation.
• Then we motivate and challenge them to change,
• and we reinforce them for accepting themselves
  and changing by rewarding Just Noticeable
  Progress (JNPs). This is called Shaping.

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DBT Skill Modules

• Skills Modules
• Mindfulness
• Interpersonal Effectiveness
• Distress Tolerance
• Emotion Regulation

• Treatment Targets
• Lack of awareness of thoughts feelings,
  Impulsivity
• Aggression, Lack of Relationships, Negative Self
  Image, Self-Centeredness
• Impulsivity, distorted Thinking, Avoidance
• Emotional Avoidance or Intensity, Grief/Shame

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DBT Skills Mindfulness

• What gets in the way of doing what I need to do
  RIGHT NOW? (Being judgmental? Distracted? Caught
  up in being right? Too emotional? Disconnected
  from emotions?)
• How do I overcome these obstacles?
• Mindfulness How Skills
• Non-judgmental (focus on just the facts)
• 1-Mindful (focus on just 1 thing)
• Effective (focus on just what works, get off of
  Im right- youre wrong, or Its not fair)
• What steps do I take to Mindfully do what I need
  to do?
• Mindfulness What Skills
• Observe (what is going on around me and inside of
  me? What is my state of mind?)
• Describe (put words on what I have observed)
• Participate (Choice Participate in this, or
  that? Chose which state of mind makes sense right
  now)

States of Mind
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• Key 1 Reinforcement
• If you want someone to do something more often,
  increase the consequences that are rewarding the
  behavior, or provide some rewarding consequences
  yourself
• Key 2 Extinction
• If you want someone to stop doing something,
  look for the consequences that are rewarding the
  behavior and stop them.
• Key 3 Extinction Burst
• When behavior is being extinguished by removing
  the rewards, expect the behavior to get worse
  temporarily.
• Key 4 Punishment Doesnt Work
• Punishment is the least effective way of
  changing behavior in the long run.
• Key 5 Intermittent Reinforcement
• Rewarding a problem behavior some of the time
  can actually make it more difficult to change the
  behavior.
• Key 6 Timing is Everything
• The timing of a reward is extremely important.
• Key 7 Clients Know the Difference

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Sample DBT ResidentialProgram Structure

Mentoring, Super- vision
Coaching, Pager
Staffing, Meetings, Consults
Ongoing Training
Individual Therapy
Group Skills Training
Consultation Team
Staff
Clients
Skills Trainer
Program Director
Therapist
Family, Administrator, Consultant, Psychiatrist,
DDD Case Manager, Vocational Provider