Regulating the Co-Occurring Adolescent & Young Adult through the Application of DBT Skills Erin Goodhart, LPC, CAADC, ACRPS, CCS, CSAT candidate Clinical Director of Womens Continuum at Caron Treatment Centers Cheryl Knepper, LPC, ATR-BC, ICCDPD, CSAT-S, CMAT VP Clinical Services, Caron Treatment Centers 800.678.2332 I www.caron.org Goal of Workshop The goal of this presentation is to provide a workshop format
that offers the attendee the opportunity to learn and practice DBT skills that can be utilized with the adolescent and young adult co-occurring populations. The goal is for each attendee to have a basic understanding of the theory and practice of DBT. 800.678.2332 I www.caron.org Educational Objectives The participant will: be able to cite research regarding the use of DBT with the co-occurring adolescent and young adult populations Demonstrate through practice the use of mindfulness, diary cards and behavioral chain analysis
Understand the complexity of treating co-occurring addiction and mental health disorders commonly found in adolescence and young adulthood Understand the Bio-psych-social model of treating behavioral health disorders Present skill and then practice skill with other workshop attendees, design a treatment plan that includes DBT interventions Identify the Basic principles of DBT Apply multiple skills including distress tolerance, interpersonal skills, mindfulness and emotional regulation with co-occurring disordered young people 800.678.2332 I www.caron.org Dialectical Behavioral Therapy
800.678.2332 I www.caron.org So What is DBT? Dialectical Behavioral Therapy-skills based approach Marsha Linehan-1993, evidence based and well researched BioSocial Theory that the problem behaviors often seen in individuals stem from a combination of biological and environmental factors Bio- predisposition, vulnerable to high sensitivity and reactivity, intense emotion and difficulty regulating example-Alcoholic Family
Social-learned in the environment, home, school, peers Skills training for adolescents-(2015) Jill Rathus and Alec Miller-DBT skills Manual for Adolescents 800.678.2332 I www.caron.org Why DBT for Adolescents and young adults struggling with Co-occurring Disorders? Evidence based intervention Provides specific coping skills For triggers to use To shorten relapse if it occurs
Overlaps with 12 step approaches when treating co-existing addictions 6 800.678.2332 I www.caron.org Who benefits from DBT Skills ? Young people who engage in self-harm behaviors such as: Substance Use Disorder and Behavioral addictions Suicidal acts Suicidal thoughts
Cutting, burning and other self-injurious activities Eating disordered behavior 800.678.2332 I www.caron.org DBT Functions-the Big 5 1. 2. 3. 4. 5. Enhancing Capabilities
Improving motivation to change Assuring generalization to environment Structuring the environment Enhancing therapist capabilities and motivation to treatWe are an agent of proactive change-own supervision 800.678.2332 I www.caron.org DBT Basic Assumptions 1. 2. 3. 4. 5.
6. 7. 8. Patients are doing the best that they can Patients want to improve Patients need to do better, try hard, and be more motivated to change Patients may not have caused all their own problems but they have to solve them anyway The lives of suicidal, borderline individuals are unbearable as they are currently being lived Patients must learn new behaviors in all relevant contexts Patients cannot fail in treatment Therapists treating patients need support 800.678.2332
I www.caron.org DBT Directly Addresses these Factors: Increasing the teen and teens families capabilities by teaching specific skills for self regulation Improving interpersonal effectiveness Increase distress tolerance Improve balanced thinking and acting rather than reacting Structure the environment to assist in motivation, reinforcement Patient centered approach to individualized use of skills 800.678.2332 I
www.caron.org Modules Skills based approach that offers 4 sets of skills plus one specific to Adolescents (Miller) 1. Mindfulness-awareness of self and others, make wise decisions, focus, avoid judgements 2. Distress Tolerance- 2 subsets, Crisis Survival and Accepting reality-coping through difficult situations without doing harm and change what you can and accept what you cannot change 3. Emotion Regulation-emotional awareness, balance, confidence building 4. Interpersonal Effectiveness-communication and relationship skills, assertiveness, healthy relationship building and increase self respect in relationships 5. WALKING THE MIDDLE PATH
800.678.2332 I www.caron.org Dialectical dilemmas in adolescent DBT Making Making light light of of problems problems behaviors
behaviors Too loose Forcing Forcing independence independence Too strict Fostering Fostering independence independence Making Making too
too much much of of typical typical adolescent adolescent behavior behavior 800.678.2332 I www.caron.org Adolescent DBT Treatment Cycle
Skill Building Distress Tolerance Mindfulness Mindfulness Mindfulness Walking the Middle path Interpersonal Effectiveness Mindfulness Mindfulness Emotion Regulation 800.678.2332
I www.caron.org Mindfulness Module: requires daily practice! 800.678.2332 I www.caron.org DBT conceptualizes the emotionally dysregulated adolescent Self dysregulation---------------------DBT Skill Core Mindfulness a)identity confusion/difficulties
b)sense of emptiness c)lack of awareness of thought/emotion/behavior 800.678.2332 I www.caron.org When we are Mindful, we can: Notice our thoughts without being overwhelmed by them Make planned decisions & avoid impulsivity Be focused on, appreciate and enjoy the fun times Feel more calm within your mind and body-even during stressful times Act effectively and feel better
800.678.2332 I www.caron.org Mindfulness is opposite of Mindlessness. When we are mindless, we: Dont notice our thoughts and get overwhelmed easily, increasing anxiety, depression and anger
Are less likely to think about decisions and act impulsively Are more likely to miss out on enjoyment and having fun because of worry or distraction Increase impact of stress Might not be able to use skills to assist self when you really need them 800.678.2332 I www.caron.org Mindfulness Skills List What Skills: Observe Describe
Participate How Skills: *Non-Judgmental Stance *One-Mindfully * Effectively 800.678.2332 I www.caron.org Mindfulness: Three states of Mind Reasonable Mind
W I S E M I N D Emotional Mind 800.678.2332 I
www.caron.org Mindfulness Activities 800.678.2332 I www.caron.org Are You Mindfulness allows for us to be in the moment because it is the only moment we have. In using skills
such as DBT, 12-steps, life-skills, addictionrecovery skills, we only have this moment in which to use them effectively and skillfully. 800.678.2332 I www.caron.org Three states of mind drawing 800.678.2332
I www.caron.org Three States of Mind Practical Application Introduce the three states Activity: Stressful Event-individual or group activity Give an example of a stressful event (walking down the hallway) How would you respond Split into 2 groups and write pros/cons of the reaction Emotional mind laughing and distracted. Reasonable mind right to business Start each group with where found themselves in the last week
800.678.2332 I www.caron.org Observe, Describe & Participate Activity: Mystery Bags-group activity Discussion questions: What was it like to use observe and describe? What did you learn about yourself or your environment? What was it like to participate without acting on urges? How do you think this could be helpful? How could you use Observe, Describe & Participate in your day to day tasks and interactions? 800.678.2332
I www.caron.org Distress Tolerance Module 800.678.2332 I www.caron.org DBT conceptualizes the emotionally dysregulated adolescent Behavioral dysregulation---------DBT Skill Distress Tolerance
a)Para suicidal/ suicidal behavior b)impulsive behaviors including: ED behavior, alcohol/drug use behavior, risky sexual behavior 800.678.2332 I www.caron.org Distress Tolerance Skills Help tolerate emotional pain not remove the pain 2 types of skills Crisis Survival: Situation cannot be avoided Goal is not to make the situation worse
Acceptance: Goal is to accept painful situations rather than avoid or fight them 800.678.2332 I www.caron.org Distress
Toleran ce: Distr a Rate current level of distress A: Activities C: Contributing C: Comparisons E: Emotions P: Pushing Away T: Thoughts S: Sensations
ct with W ise Mind 800.678.2332 I www.caron.org Distress Tolerance Module Skills List Crisis Survival Skills: Wise Mind Accepts Self-soothe Improve the Moment Half Smile Creative outlet
Accepting Reality Skills: Pros & Cons Radical Acceptance Turn the Mind Willingness 800.678.2332 I www.caron.org Distress Tolerance Activities 800.678.2332
I www.caron.org Distress Tolerance: Self-Soothe Skills Vision Hearing Smell Taste Touch Movement-Kinetic Activity: Develop a Self-Soothe kit 800.678.2332
I www.caron.org Distress Tolerance Skills Activity: Imagery My Happy Place Design a collage through cutting out pictures or gather from pre cut images that represent a place that is happy and pleasant Discuss what elements make this place safe and happy, post collage in a place that will be a reminder 800.678.2332 I
www.caron.org Distress Tolerance Skills Activity: One Thing at a Time One thing at a time skill helps improve the moment by focusing on only one step at a time Jenga game with questions related to tolerance and destressing-focus on one piece at a time and waiting turn, in turn focusing 800.678.2332 I www.caron.org
Emotional Regulation Module 800.678.2332 I www.caron.org DBT conceptualizes the emotionally dysregulated adolescent Emotional Dysregulation---------------DBT skill Emotion Regulation a)emotional vulnerability b)affective lability c)problems with anger d)Steady negative emotional states
800.678.2332 I www.caron.org Emotional Regulation Goal is to reduce emotional suffering not get rid of emotions 800.678.2332 I www.caron.org
Emotional Regulation: What do Emotions do for Us ? Emotions give us information Emotions communicate to, and influence, others Emotions motivate and prepare us for action 800.678.2332 I www.caron.org Emotional Regulation: Check the Facts What is the emotion I want to change? What is the prompting event for my emotional reaction? Describe the prompting events
Look for extremes and judgements and rewrite the facts What are interpretations about the facts? List as many other possible interpretations of the facts 800.678.2332 I www.caron.org Check the Facts (cont.) Am I assuming threat? List as many other possibilities as possible Whats the catastrophe, even if the outcome I am worrying about does occur? Describe ways to cope Does my emotions fit the fact?
What did you do the check the facts? 800.678.2332 I www.caron.org Emotion Regulation Activities 800.678.2332 I www.caron.org Emotion Regulation
Activities in this module are intended to evoke emotions so that clients can learn how to improve their ability to identify, experience and express emotions. These activities are often paired with distress tolerance activities so that when difficult emotions surface the individual is able to work through the emotion in a health non harming manner. 800.678.2332 I www.caron.org Emotion Regulation Activities Activity: Emotions Ball The goal of this activity is to observe and describe emotions
Using a soccer ball and sharpie write feelings words on the edges of the ball prior to activity Write the following ?s on a white board: 1. Share a time when you experience this emotion 2. What did you notice about your body or thoughts 3. When was the last time you had this emotion 4. What is it like to have someone else around you express this emotion 5. How do you think observing and describing emotions could be helpful in your daily life 800.678.2332 I www.caron.org
Interpersonal Effectiveness 800.678.2332 I www.caron.org DBT conceptualizes the emotionally dysregulated adolescent Interpersonal dysregulation------------DBT Skill Interpersonal Effectiveness a)chaotic/unstable relationships b)chronic family disturbance c)social isolation
800.678.2332 I www.caron.org Interpersonal Effectiveness Activities Activity: Cheerleading Statements 1. Give courage to do things when times are tough 2. Make you stronger and ready for action 3. Fight off untrue thoughts I am ok! I can do it! I am Strong! I will be ok! This is my Choice!
800.678.2332 I www.caron.org Interpersonal Effectiveness Activities
Activity: Communication-Dear Man (art negotiation) D-describe, list the facts, pit into words E-express, talk about feelings, I statements, What you want what you want A-assert, Say exactly what you want and accept NO sometimes R-reinforce. Use examples and what will the other person get out of the deal M-Be mindful, focus, clear calm approach, listen, be present A-appear confident-eye contact, speak clearly, do not beat around the bush N-negotiate, discuss options, be open to others suggestions, be willing to give to get. Have other ideas in mind 800.678.2332 I www.caron.org
Interpersonal Effectiveness Activities Activity: How to Keep a Good Relationship (Give Chart) 1. Be Gentle 2. Act Interested 3. Validate (role play) 4. Use and Easy Manner 800.678.2332 I www.caron.org Walking the Middle Path
800.678.2332 I www.caron.org DBT conceptualizes the emotionally dysregulated adolescent Cognitive dysregulation and family conflict--- DBT Skill Walking the Middle Path a)chronic invalidation of self and others b)pervasive non-dialectical thinking c)poor conflict resolution 800.678.2332
I www.caron.org Middle Path Skills Adolescent Specific skills These skills bridge the gap between acceptance and change These skills focus on 3 core areas: Dialectics Validation Behavior change 800.678.2332 I
www.caron.org Invalidating Environment An environment that pervasively negates or dismisses behavior independent of the actual validity of the behavior (often well-meaning)-family members, teachers, healthcare pro----------discontentment, irritability and hopelessness Characteristics: 1. Indiscriminately rejects communication of private experiences and selfinitiated behaviors-persons experiences are trivialized, not validated or punished 2. Intermittently reinforces escalation of emotional responses-removing demands after an incident-codependent 3. Over-simplifies ease of problem solving rather emphasizing the need to control emotional expressiveness-intolerant of displays of negative affectacting in or acting out 800.678.2332
I www.caron.org Consequences of Invalidation Environment does not teach individual to: - label private experience in a normative fashion (self-validate) - to effectively regulate emotions - to trust experiences as valid - accurately express emotions - communicate pain effectively - tolerate distress - solve difficult problems in living (resolve family conflict) - use shaping and other behavioral strategies
to effectively regulate own behavior 800.678.2332 I www.caron.org Invalidating Environment Environment does teach the individual to: - actively self invalidate - oscillate between emotional inhibition and extreme emotional displays - respond with high negative arousal to to failure - form unrealistic goals and expectations - hold perfectionistic standards
800.678.2332 I www.caron.org Key points in deciding which DBT skills to teach 1. Develop skills curriculum with the right focus and fit for the length of stay and target population 2. Skills taught should target the behaviors that typically lead to the inpatient/residential admission 3. Whatever skills are chosen, teach them twice 4. Staff should learn the skills and practice them themselves in order to be able to provide
5. Effective coaching 800.678.2332 I www.caron.org Steps to Planning a Skills Curriculum 1. Determine how much time you have to teach based on length of stay 2. Decide who you want to include in the skills training (teens only/family and teens/family only) 3. Multiple family groups/ parents taught separately 4. Decide which skills you want to teach 5. Decide which handouts and worksheets you want to use
800.678.2332 I www.caron.org Providing Feedback & Coaching Be behaviorally specific! Focus on client's performance, not motives Do not remove cue when client is over-sensitive to feedback Balance negative feedback with positive feedback Use shaping to encourage successive approximations Identify client's patterns of skill use over time 800.678.2332
I www.caron.org The Goal of DBT for the Young person is a Life Worth Living! 800.678.2332 I www.caron.org 800.678.2332
I www.caron.org 800.678.2332 I www.caron.org Thank You Follow us on social media! @CaronTreatment Facebook.com/Caron
YouTube.com/Caron 800.678.2332 I www.caron.org References Abney-Cunningham, G. (2012) Getting to the Heart of the Problem: Targeting, Assessing, and solving problem behaviors. (Power point presentation). Dimeff, L. & Koerner, K. (2007) Dialectical behavior Therapy in Clinical Practice: Applications across disorders and settings. New York: The Guildford Press Dimeff, L. & Reynolds, S. (2007) Dialectical Behavior Therapy: Intensive training course. (Power point presentation). Eells, T.D. (1997) Handbook of Psychotherapy Case Formulation, Chapter 13: Case
Formulation in Dialectical Behavior Therapy; p. 340-367 Koerner, K (2012) Doing Dialectical Behavior Therapy p.111-138. New York: The Guilford Press 800.678.2332 I www.caron.org References Kelly, J.F., Brown, S.A., Abrantes, A., Kahler, C., Myers, M.G. (2008). Social recovery model: An 8 year investigation of adolescent 12-step group involvement following inpatient treatment. Alcoholism: Clinical and Experimental Research, 32(8), 1468-1478.doi:10.1111/j.15300277.2008.00712.x. Kelly, J.F., Urbanoski, K. (2012). Youth recovery contexts: the incremental effects of 12-step attendance and involvement on adolescent outpatient outcomes. Alcoholism: Clinical and
Experimental Research, 36(7), 1219-1229. doi: 10.1111/j.1530-0277.2011.01727. 62 800.678.2332 I www.caron.org References Mundt, MP, Parthasarathy, S, Chi, FW, Sterling, S, Campbell, C I. (2012).12-Step participation reduces medical use costs among adolescents with a history of alcohol and other drug treatment. Drug and Alcohol Dependence. 126(1-2), 124-130. doi:10.1016/j drugalcdep2012.05.002 Sussman, S. (2010). A review of Alcoholics Anonymous/Narcotics Anonymous programs for teens. Evaluations of Health Professionals. Doi: 10.1177/0163278709356186
White, W. L. (2008). Recovery management and recovery-oriented systems of care: Scientific rationale and promising practices. Retrieved from http://www.williamwhitepapers.com/papers/ 63 800.678.2332 I www.caron.org References Linehan, M.M. (1993) Cognitive Behavioral Treatment of York: The Guildford Press Borderline Personality Disorder. New
Rathus, J.H. & Miller, A.L. (2015) DBT Skills Manual for Adolescents. New York: The Guildford Press. Swales, M. & Dunkley, C. (2010) Core Components of Dialectical Behaviour Therapy: Conducting a comprehensive behavioral and solution analysis.(Video) Swenson, C.R., Sanderson, C., Dulit, R. & Linehan, M.M. (2001) The application of dialectical behavior therapy for patients with borderline personality disorder on inpatient units. Psychiatric Quarterly, 72, p.307-323 800.678.2332 I www.caron.org Workbooks Dialectical Behavior Skills Training with Adolescents; Jean
Eich PsyD, LP Dialectical Behavior Therapy, Children & Adolescents; Connie Callahan, Ph. D., LPCC, LMFT 800.678.2332 I www.caron.org
The Fear Factor Joann Doyle, MS CCC-SLP SLP Literacy Academies National Reading Panel National Reading Panel and other research has clearly documented the importance of incorporating phonemic awareness, phonics, and fluency in reading instruction.
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