Dialectical Behavior Therapy Skills Training: Adapted for Special Populations



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Dialectical Behavior Therapy

Skills Training:

Adapted for Special Populations

Eric J. Dykstra, Psy.D.

Developmental Enhancement, PLC


Margaret Charlton, Ph.D., ABPP

Aurora Mental Health Center




Table of Contents


Adapted for Special Populations 1

Eric J. Dykstra, Psy.D. 1

Developmental Enhancement, PLC 1

1


Margaret Charlton, Ph.D., ABPP 1

Table of Contents 2

Sponsors 24

Sponsors 24

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This work has been sponsored in part by 24


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Aurora Mental Health Center 24

Intercept Center 24

Authors’ Note 26

Authors’ Note 26

Chapter 1: Rationale for Psychosocial Skills Training with Clients Who Have Developmental Disabilities 27

Chapter 1: Rationale for Psychosocial Skills Training with Clients Who Have Developmental Disabilities 27

Clinical lore often leads one to believe that psychotherapy for individuals with developmental and/or intellectual disabilities (DD/ID) and mental health concerns is limited to behavior modification in the areas of social skill training, self-injurious behavior, and adaptive functioning. However, there is a growing appreciation that individuals with DD/ID suffer from the same difficulties in life that persons of average intelligence suffer from, such as anxiety, mood disorders, substance abuse, and a range of other mental health concerns, as well as empirical backing for such (Charlton, 2002; Bütz, Bowling, & Bliss, 2000; Nezu & Nezu, 1994). Given this, treatment approaches targeting various symptoms and promoting positive mental health are necessary to enhance the lives of those with co-occurring DD/ID and mental health problems. However, typically-trained clinicians often find themselves at a loss when attempting to provide “typical mental health services” to those with lower cognitive abilities or other neurodevelopmental differences. 27

There are a number of issues that need to be addressed when providing psychotherapy to individuals with DD/ID and mental illness, including but not limited to the level of functioning of the individual, the therapist’s biases and views of psychotherapy and of persons with DD/ID, and the mode of psychotherapy provided (Bütz, Bowling, & Bliss, 2000; Sue & Sue, 1999). As Hurley and colleagues (1996) noted, effective psychotherapy must be adapted according to the idiosyncrasies of the individual a therapist is working with. While this is certainly true when working with those who are more neurotypical, there is a heightened importance of adaptation when working with those with developmental differences. 27

One of the popular and effective psychotherapeutic treatment modalities currently being used in the field is Dialectical Behavior Therapy (DBT). DBT is an empirically validated, comprehensive treatment program addressing skills deficits in emotion regulation, distress tolerance, and interpersonal relationships. This therapeutic intervention was originally developed by Marsha Linehan and is outlined in Cognitive-Behavioral Treatment of Borderline Personality Disorder (1993a) and the accompanying Skills Training Manual for Treating Borderline Personality Disorder (1993b). An overview of standard DBT appears in Chapter 3. Though it was originally developed as a treatment for individuals diagnosed with Borderline Personality Disorder, the treatment’s use has been expanded to address the needs of a wide variety of clients with severe and chronic DSM-IV Axis I and II multiple diagnoses of mental illnesses that are difficult to treat (Manning & Reitz, 2002). We believe that this treatment, in an adapted form, will also be effective in addressing the needs of individuals with DD/ID and mental health problems. 27

The skills that are taught as part of a DBT model are the very skills that people with DD/ID most often struggle with. From impaired impulse control to limited frustration tolerance, individuals with DD/ID and concurrent mental health problems often suffer from an inability to cope with distress, regulate their emotions, effectively self-soothe when upset, and effectively develop and maintain healthy interpersonal relationships. Like those diagnosed with borderline personality disorder, people with DD/ID also have a much higher likelihood of being the victims of trauma than the general population. There is considerable variability in the statistics reported, but estimates of the incidence traumatic episodes among individuals with DD/ID range from 4 to 10 times higher than the general population. Current research in the field of traumatic stress also indicates that people who are the victims of prior traumatic events such as bullying or racial slurs are less likely to be resilient to the effects of trauma. Therefore, it is not surprising that people with DD/ID exhibit a range of difficulties related to trauma exposure and have a relatively low incidence of recovery from traumatic incidents without therapeutic interventions (Charlton, Kliethermes, Tallant, Taverne, & Tishelman, 2004). 27

Dialectical Behavior Therapy appears to be a particularly effective treatment method for persons with DD/ID and mental health difficulties for a number of additional reasons. DBT focuses on strength-based instruction, on concrete skill building with built-in repetition, and on addressing deficits in a range of life domains. The first area, strength-based intervention, is vital when working with individuals with dual diagnoses. The DBT treatment model helps clients use their current skills more effectively by teaching them to use those skills in new ways and/or in new situations. The skill building does not stop there, however. DBT also helps clients add to their repertoire by teaching new skills and how to use the new skills most effectively. As mentioned above, the skills specifically addressed are in the areas of emotion regulation, distress tolerance, and interpersonal effectiveness; mindfulness is also a skill (and way of being) that is trained and incorporated throughout the three modules. Furthermore, the treatment sessions build upon one another and skills already learned are reviewed and further generalized, thus providing the repetitive learning that the persons with dual diagnoses generally benefit from. Finally, DBT skills are naturally generalized, as the skills and skill modules are taught in a group therapy format, reviewed and practiced in individual therapy, and reinforced during interaction with other DBT team member(s). 28

Because of the high level of care that individuals with co-occurring difficulties often need, a multi-disciplinary treatment team is frequently involved. This presents another area in which DBT demonstrates its strength. If one is to start a DBT program, it is recommended that the whole team (broadly defined to include everyone who interacts with the clients – from office manager to program director, case managers, caregivers and therapists) be trained in DBT principles and be kept up-to-date with what is occurring in the skills groups and individual therapy (Fruzzetti, Waltz, & Linehan, 1997; Linehan, 1993a), keeping in mind the ethics of confidentiality. This team approach is effective as the team is unified and using the same language, as well as reinforcing the same use of skills. This provides consistency and an environment that supports new learning, as well as hinders any attempts by clients to use maladaptive ways of getting needs met (e.g. through asking numerous people until getting the answer they want, through “splitting”). Furthermore, the focus of DBT on strength based interventions helps to facilitate problem solving among team members as it discourages judgmental comments and blaming while promoting solution-focused problem-solving. Furthermore, as team members use DBT techniques and engage in the processes of using DBT, they model the skills that are being taught for their clients, as well as become more effective in their own lives (Fruzzetti et al., 1997). 28

Chapter 2: Philosophical and Theoretical Roots of DBT and DBT-SP 29

Chapter 2: Philosophical and Theoretical Roots of DBT and DBT-SP 29

Introduction 29

As mentioned above, DBT was originally developed by Dr. Linehan and outlined in two conjoined texts, Cognitive-Behavioral Treatment of Borderline Personality Disorder (1993a) and Skills Training Manual for Treating Borderline Personality Disorder (1993b). Because of the strong philosophical and theoretical underpinnings of DBT, it is important to understand the core philosophical assumptions. Further, a discussion of core pre-analytic assumptions underlying functional contextualistic interpretive accounts provides the analytic context giving meaning and definition to the behavior-analytic rooted work presented in this manual. The sections below briefly summarize the philosophies and theories that give rise to the DBT model. 29

Radical Behaviorism 29

Radical Behaviorism is a distinct approach within the Behavioral and Cognitive-Behavioral traditions within contemporary mainstream psychology. Radical Behavioral philosophies and theories are primarily rooted in the work of B.F. Skinner, though have been further developed by a range of professionals, including S.C. Hayes, M.M. Linehan, N.S. Jacobson, and numerous others. Radical Behaviorism also gave rise to a variety of interrelated forms of behavioral analysis, including applied behavior analysis (ABA), clinical behavior analysis, organizational behavior management, and so forth. For an excellent account of Radical Behaviorism, consult Chiesa’s Radical Behaviorism: The Philosophy and the Science (1994). In summary, Radical Behaviorism does away with mechanistic accounts and proffers a whole person, contextual view of the person. 29

Functional Contextualism 29

DBT also was greatly influenced by the cognitive-behavioral movement in contemporary psychology, whose leaders are often identified as A. Beck, A. Ellis, and A. Bandura, among others. While avoiding attributing causative power to cognitions, the DBT approach does recognize, acknowledge, and teach the influential role that thoughts have in impacting an individual’s choices and overall functioning. In addition, DBT exemplifies current cognitive-behavioral approaches that focus on changing the relationship with one's cognitions as opposed to directly challenging the content. 29

Recognizing the ubiquity of human suffering, DBT is not aimed at reducing or getting rid of ordinary pain or discomfort, nor on ridding oneself from particular thoughts or feelings, but rather is focused on reducing unnecessary suffering (similar to its “relative” Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) in the behavior analytic tradition). Oftentimes individuals increase their suffering by struggling against that which they cannot change, such as trying to rid themselves of their respective histories. In contrast, the focus of DBT is on reducing unnecessary suffering through skillful means, namely managing urges and emotions in the service of pursuing valued life directions despite feeling pain, experiencing negative emotions, or thinking negative thoughts. In short, the focus is on achieving a balance between changing that which one is able to change and accepting that which is unchangeable, so that the individual can behave effectively in all situations and make progress toward his or her valued life goals – living a life worth living. During the process there is a focus on reducing suffering and particular thoughts and emotions may be altered so they are more pleasant, but this is not guaranteed. The relative concreteness of these ideas makes them accessible enough for many people to understand and utilize them, including persons with DD/ID. In summary, DBT encourages clients to take responsibility for their actions, advancing the dictum that “no matter what, I choose how to act.” 30

Dialectical Philosophy 30

The dialectical perspective is perhaps most parsimoniously described as a focus on the intentional bringing together (synthesis) of two seemingly conflicting sides (thesis and antithesis). This philosophy is founded upon the concept of a non-absolute ‘truth’ model, allows for (seemingly) conflicting perspectives, and sees ‘truth’ as developing, evolving, and constructed over time. This is middle ground between Universalism (‘ABSOLUTE TRUTH’ – this is THE WAY or THE TRUTH) and complete Relativism (‘NO TRUTH’ – its all RELATIVE). This worldview advocates the use of words such as ‘AND’ instead of ‘BUT’ or ‘NOT’ and is intentionally inclusive in nature. From a pragmatic perspective, a dialectical approach weakens dependence on assumptions, biases, and verbal rule-governance while promoting multiple-perspective-taking and facilitating increased openness to varied experiences. In other words, it reduces rigidity, excessive judgment and blame, and ineffective fundamentalism while broadening perspectives and allowing for a sharing of ideas. 30

There are three core principles that underlie this Dialectical Philosophy, including Wholeness and Interrelatedness, Polarity, and Continuous Change. A clear, pragmatic example that elucidates these principles is time. When considering the concept and application of time, it is easily understood that previous moments are clearly connected to this moment … and this moment … and this moment … and so forth. Furthermore, the polarities of past versus the future are synthesized into this moment, yet this moment is only this moment for a short time as it is continuously changing as well. Said otherwise, that which is “the future” becomes “the now” which becomes “the past”; the seemingly opposing forces of past and future are part of the unrelenting and ever-changing present moment. 30

An appreciation for this philosophy allows us to attend to the whole person in-context, understand the push-pull experiences that clients have, and recognize how difficult the change process can be, especially if change is not welcomed. Practically, this philosophy undergirds the working balance between acceptance (validation) and change. This balance, tenuous and ever-changing though it may be, is foundational to effective working with individuals with significant and numerous challenges. 31

Bio-Psycho-Social theory 31

The theory explaining why DBT successfully targeted a specific subset of individuals postulates that some people have a higher-than-typical baseline arousal level, they are highly emotionally reactive to their environments, and they have difficulty returning to a baseline arousal level. Frequently these individuals also have a history of trauma and severe emotional dysregulation, which holds both etiological and exacerbational potential. Oftentimes, these individuals also have skills deficits that inhibit effective coping with such experiences, frequently resulting in crisis-ridden lives characterized by chaotic interpersonal relationships and poor day-to-day functioning. 31

Said otherwise, the interplay between our biology, psychology, and interpersonal/social experiences (among other factors) is the foundation for understanding and working with individuals with numerous long-standing problems. Given the frequent occurrence of brain-based differences, increased amounts of stress in everyday life, and atypical interpersonal experiences for individuals with a range of developmental and intellectual differences, it is clear how this model applies. Furthermore, this highlights the need for individuals with DD/ID and mental health concerns to be involved with a multidisciplinary team that is well-connected and working in a consistent manner toward shared goals. 31

Chapter 3: Brief Overview of the Standard DBT Model 32

Chapter 3: Brief Overview of the Standard DBT Model 32

Working Assumptions (taking a DBT stance) 32

These assumptions were originally published in Linehan’s Cognitive Behavioral Therapy for Borderline Personality Disorder (1993). They are summarized here as adapted for the target population of this manual. 32

Patients are doing the best they can. 32

This is a clearly ‘person-centered’ perspective. This assertion boils down to the appreciation for the fact that everyone is doing the best they can in that moment. This allows for variability in performance and different levels of success in various life domains. It also acknowledges that one’s ability to effectively self-regulate and negotiate interpersonal relationships is fluid and affected by numerous factors in life (e.g. stress, sleep, nutrition, physical health, peer group, and so forth). Especially for those who are more vulnerable to the stressors they experience, it is important to acknowledge the effects of stress and not have rigid and unrealistic expectations. Remember that just because a client performed one way yesterday, it does not mean that the client can do the same today and at the same time we expect that positive change will occur over time. 32

Patients want to improve 32

The majority of people that will be involved in DBT-based treatment recognize that there are problems and they do want to change. Even if the initial desire for change comes from a desire to escape from or avoid negative consequences, most often individuals do acknowledge that something should change – even if it is not themselves. This opens the door to treatment and presents an opportunity to engage in an intentional change process. 32

Patients need to do better, try harder, … 32

Wanting to change is not enough. Patients actually need to improve their performance. In addition, many of the patients we work with are unsuccessful in many of their attempts to help themselves. There are likely many reasons for this yet the fact remains that they are responsible for their lives. Our jobs are to encourage, build skills, maintain & increase motivation, and facilitate success. Balancing skill-based and performance-based perspectives is vital. 32

Patients have not caused all of their problems but they have to solve them anyway 32

This statement tends to hold true for most people. As so much of what happens in the world is out of one’s direct control, many difficulties occur that are unavoidable. However, as human beings we are “response-able” and thus can choose how to respond in the multitude of situations that we face. While initially a seemingly harsh assertion, it really functions to empower clients (really all of us) to solve problems and become effective in many life situations. In addition, it allows us to maintain the stance that as professionals we cannot save people – they must work to save themselves. 32

Patients lives are unbearable as they currently are 33

If we really listen to the life stories of the people we serve, we will realize the living hell their lives have truly been. It may be complaining about the program they are in, “the system” they are a part of, their guardian, the food that they have to eat, their roommate, or even nonspecific grumbling – all of these are indications of dissatisfaction with one’s current life. This ties into the belief that people do want to change as well as needing to work on bettering themselves. While we cannot do the work for them or save them ourselves, we can work alongside to help patients change their lives. 33

Patients must learn new ways of being in all relevant situations 33

When planning for comprehensive treatment there are a couple of questions to ask to help with the generalization of skills. They are: Success in the program is great ~ and what about real life? and Success with some people is great ~ what about the rest? One of the most important measures of successful treatment is evidence that individuals have effectively generalized skills outside of the treatment environment. 33

Patients cannot fail in treatment 33

If we have a comprehensive, consistent, philosophy-to-theory-to-practice approach that doesn’t work … either the treatment failed or the treators failed. This assertion protects against a “blame the patient” tendency that is all too common and is a reminder of our fallability as professionals. While there is no assertion, let alone a guarantee, that DBT-SP – or standard DBT for that matter – will be effective for all patients, the intentional consistency that exists from philosophy through practice provides a measure of confidence in the treatment approach. This also serves as a reminder that treatment should be customized and individualized for clients, even in an intentionally structured approach such as DBT. 33

Treators (everyone on the DBT Team) need assistance and support when working with individuals with intensive problems 33

It is easy to get caught up in the crisis of the week, get burnt out, become judgmental and invalidating, lose perspective, get lost, and otherwise fail. The team is a vital resource that needs to function well in order to protect against burnout, secondary traumatic stress, caregiver fatigue, and generally ineffective working. This is not easy work and we cannot do it alone. 33

DBT Team Agreements 33

Because the function of the team is so critical to the success of the patients we work with, the following agreements, if valued highly and lived reasonably, should provide a good foundation for working together. 33

Dialectical Agreement 33

Because disagreements, differences of opinion, and conflict arise, we agree to search for the synthesis in these situations as opposed to “THE truth.” Just as there is wisdom in all of the actions of our clients, each of us holds a valid perspective. Our job is to work to synthesize the perspectives presented before us. We agree to consider other perspectives and work collaboratively for the best of the clients we serve. 33

Consultation to the Patient 33

This agreement is centered on our role with patients. Just as we cannot “save” the individuals we work with, it is unhelpful to try and solve all of their problems for them. First, we agree to work with clients to use skills in their interactions with others. We help coach them about how to approach various treatment team members and work with them to find skillful ways of relating. Second, we agree to not intervene on their behalf nor tell other professionals how to respond to a client. 34

It should be noted, however, that coaching, teaching, and learning as a team does not conflict with this agreement. Finally, if a team member makes a mistake, we agree to acknowledge this and help clients accept and cope with this. As team members are fallible, so are the people that the clients will interact with in everyday life. We are privileged to have the trust of our patients and we must provide them with experiences that reflect the world that they live in. 34

Consistency Agreement 34

We agree that consistency is important … AND … real life happens. We concurrently agree to help clients cope with failures and inconsistencies. This presents opportunities for all of us (clients and professionals alike) to practice our DBT skills. Said otherwise, we strive to be consistent and we acknowledge that this will not occur 100% of the time. 34

Empathic Orientation 34

In order to be successful in our roles we must be mindfully empathic with those we work with. We agree to search for non-pejorative and non-judgmental interpretations and understandings of clients’ behaviors. We also agree to approach each other in a non-judgmental way and validate each others’ experiences. This is absolutely necessary, as the relationships between team members are as vital as the therapeutic ones between professionals and patients. 34

Fallibility Agreement 34

First, we agree that we are all imperfect and have permission to fail. Without this explicit statement judgment, invalidation, and strife will poison the team. Further, as a team we agree to utilize the DBT framework to help each other remain true to the philosophy and the approach. We agree to keep each other accountable and treat each other gently and with empathy. 34

Chapter 4: Adaptation of the Dialectical Behavior Therapy Model 35

Chapter 4: Adaptation of the Dialectical Behavior Therapy Model 35

Adaptation of DBT for individuals with DD/ID begins with an overall assessment of the philosophy and theory, gauging its applicability to the targeted population. As mentioned previously, it seems that DBT is a “good fit” for persons with DD/ID and mental and behavioral health concerns. Given the often-seen constellation of multiple difficult-to-treat problems, vulnerability to stress, and need for intensive and long-term interventions, the DBT model provides a framework that addresses a number of the core deficit areas. The whole-person, developmentally-informed, comprehensive hierarchy of targets and skills that is found in DBT fits so well for many individuals with concurrent DD/ID and mental health problems. It is also important to note that the skills taught in DBT can serve well as the foundation for further work in the areas of independent living, resolving other mental health concerns, and generally increasing the quality of life for each individual. 35

Because the group skills training material was the most formalized and structured in standard DBT, the early phases of adaptation was focused here. In modifying each of the handouts suggested for use in the DBT group skills modules (Linehan, 1993b) we worked to use language that was accessible to and easily understood by our clients. For example, rather than talking about reducing emotional vulnerability, we focused on understanding how emotions affect us and on making good decisions when experiencing an emotion (Emotional Regulation Handout 1). We also used a visual presentation style that makes it easier for clients with DD/ID to absorb the information. This type of adaptation is illustrated in Emotion Regulation Handouts 3a and 3b, where we reduced the number of interactions we attempted to teach, used more prominent arrows, illustrated the components with different types of shapes to help make them easier to remember, and simplified the language. As “choice” was a main concept we wished to teach in this module, we also added it to this handout to provide an additional repetition. 35

Another example of the type of adaptation is made with regard to the topic of emotional vulnerability. Linehan (1993b) uses the acronym “PLEASE MASTER” in her handout addressing how to reduce vulnerability to negative emotions. We modified this to “SEEDS GROW” and discussed controlling emotions instead of reducing vulnerability (see Emotion Regulation Handout 10). This modification allowed us to use simpler language that was already in our clients’ vocabulary, provided another opportunity to emphasize that we control our emotions—they do not control us, and simplified the visual presentation of the material. 36

Chapter 5: Session Format and Introduction to Skills Training 37

Chapter 5: Session Format and Introduction to Skills Training 37

Check-in 39

Mindfulness Activity 39

Discussion of Mindfulness Skills 39

Review of Homework Assignments 39

Presentation of Skill Training Material 39

Review 40

Chapter 6: Mindfulness Skills 41

Chapter 6: Mindfulness Skills 41

What is Mindfulness? 41

Psychology and Mindfulness Practices 41

Mindfulness in Dialectical Behavior Therapy 42

Session 1 43

Session 2 44

Session 3 45

Mindfulness Exercises 46

Chapter 7: Distress Tolerance Skills 47

Chapter 7: Distress Tolerance Skills 47

Overview of the Module 47

Sessions 1 and 2 49

Just give one simple assignment for each session. Here are a couple of examples, but any assignment that encourages group members to think about the skills that are being taught will be helpful. Then don’t forget to review clients’ success with the assignment next week. 50

Between now and the next session, notice your state of mind. How much time to you spend in emotional mind, rational mind and wise mind. 50

Notice times when you feel distressed. Don’t try to change anything, just notice the feelings. See what happens over time and if anything changes. 50

Session 3 51

Session 4 52

Session 5 54

Session 6 55

Many of our clients have difficulty thinking about the consequences for their behavior when they are experiencing strong emotions. Begin presenting this handout by discussing how difficult it is for some people to think of the different choices they have in situations and what the consequences are for those choices. Elicit examples from group members, or if they have trouble thinking of examples, present a situation in which a person is faced with a few choices and there are consequences (positive or negative) for whatever choice they make. Some ideas may include having to choose between spending time with family vs. friends or a lover vs. friends; having family members dislike one’s chosen romantic partner; apologizing for a perceived mistake vs. being right, and so on. To practice, either have group members fill out the handout according to examples being given in the group or work together on a white board. Sometimes it is fun to see how many different choices (both good and bad) a person could make. Then after considering all the consequences, talk about which of the choices would be the best in this situation. 55

Session 7 56

In order to practice radical acceptance, one first must acknowledge that which exists. Anything but acknowledgment is simply another way to attempt to avoid. Then one must put up with, tolerate, and endure reality. In fact, one practices radical acceptance only when one embraces all experiences, whether they are pleasant or painful. 56

Practicing radical acceptance is counter-intuitive and takes a great deal of effort. Practicing radical acceptance is an effortful choice, one that must be made again and again. Without this repetitive effort, we will naturally turn towards escape and avoidance. Turning your mind towards this choice that needs to be made is the first step towards practicing acceptance. 56

Session 8 58

Session 9 59

Emotions, thoughts, and overt behaviors all have bi-directional influence on each other. While feeling happy often makes people smile, smiling can also help people feel happy. There is some truth to the saying “fake it until you make it.” In order to feel more accepting, adopting a congruent facial expression is helpful. Have group members practice having a scowling facial expression, then no expression, and then a half-smile. The half-smile can feel unnatural at first. A helpful way to teach clients how to relax their facial muscles is to pretend that they are sleeping/falling asleep and gently pick up the corners of their mouth. Elicit feedback from clients regarding their experience with their different facial expressions. Briefly practice the 4 different exercises listed on the handouts during group. 59

Homework: 59

Have group members commit to practicing one of the exercises each day, until your next session. Have the group members report back regarding their success with the exercise. 59

Session 10 60

Chapter 8: Emotion Regulation Skills 61

Chapter 8: Emotion Regulation Skills 61

Overview of the Module 61

In order to teach these skills, group leaders must validate the clients’ experiences, as emotional validation is the foundation for the rest of the skill training. Too often our emotional responses to events and experiences are evaluated as unreasonable and observed in disbelief. Validation is critical to the dialectical process of accepting one’s emotional experiences and responses and responding more effectively in the future. 61

Clients will further resist learning and implementing the skills unless they see benefit in doing so. A way to engage and join with clients around this issue is having them assess how well their current approach is working for them. Though they may get some benefit from having extreme emotional and behavioral displays, most clients will admit that they would like to handle things better. Emotion regulation skills are designed to empower clients so that they are able to choose their responses (to environmental events and their own automatic responses to environmental events) and behave more effectively in difficult situations. 61

Here are specific emotion regulation skills that will be taught: 61

Identifying and Labeling Emotions 61

This can be a difficult skill to learn, especially for those with little experience paying attention to emotions. This skill is much more helpful if one can describe the contexts in which emotions typically occur as well. This includes the ability to observe and describe prompting events, interpretations of events, physiological and psychological correlates of emotions, behavioral expressions related to emotions, and the consequences (effects) of emotions on general functioning. 61

Identifying Obstacles to Changing Emotions 62

In essence, emotions function as modes of communication. First of all, emotions serve as signals to ourselves, informing us about our current environment and motivating us to behave in response to the environment. Second, emotions communicate to others and help influence their behavior. Given the naturally reinforcing qualities of these functions, it is easily understood why emotions are difficult to change. Understanding how emotions work, however, is a good step towards being able to find appropriate ways to change. 62

Reducing Vulnerability to “Emotion Mind” 62

Numerous factors influence the level of reactivity we have to our emotions. Especially for those clients with fewer internal resources to begin with, factors such as lack of sleep, poor nutrition, inconsistent medication adherence, and lack of physical activity can increase emotional lability and ineffective problem solving techniques. In addition, increasing positive activities to reduce one’s emotional reactivity have long term benefits, but often little short term payoff. Engaging in helpful activities requires an active, persistent approach. 62

Increasing Positive Emotional Events 62

One of the core DBT assumptions is that one’s emotional experience is a natural result of environmental experiences. In short, most people have good reasons for feeling bad. The most parsimonious way to counteract feeling bad is to engage in activities that result in more positive feelings. For individuals with DD/ID, this includes working with caregivers to provide daily opportunities for positive experiences and making long term commitments to positive lifestyle changes. 62

Increasing Mindfulness to Current Emotions 62

Many people increase the effects of their negative emotions by attempting to inhibit, deny, or judge them. The focus of this skill is on increasing exposure to primary emotions and blocking ineffective coping strategies, thereby undermining their capability to evoke negative secondary emotions. Basically, clients are taught to increase their willingness to feel emotional pain without feeling guilty, anxious, or angry about it. 62

Taking Opposite Action 62

One of the greatest skill deficits that many individuals with dual diagnoses exhibit is that of behavioral emotional expression. The skill of taking opposite action is simply choosing to behave in a way that is in opposition to or inconsistent with one’s current emotion. This skill has the benefits of decreasing the length of negative emotions and decreasing ineffective behavioral responses. In addition, it should be noted that taking opposite action is more than simply blocking expression of negative emotions; taking opposite action involves actions such as approaching that which one is afraid of and being nice to those one is angry with. 62

Applying Distress Tolerance Techniques 63

As mentioned above, impulsive emotional responding often creates greater negative experiences. Simply tolerating negative emotions can help stop the perpetuation of negative emotions and ineffective coping skills. 63

Sessions 1 and 2 64

Emotion Regulation Handout 1 outlines the overarching goals of the group and serves as an introduction to the basic skills. You will want to spend some time on this sheet as it orients clients to the main focus of the group, but remember the specific skills will be taught in more detail later so you don’t have to describe everything now. 64

Understand your emotions 64

In order to regulate emotions, the first step is to be willing to look at the emotions you are experiencing. Then you need to be able to accurately identify and label those emotions. This task necessitates the use of the mindfulness skill of observing and describing. While there are an infinite number of names for the various nuances of emotions, for individuals with lower cognitive abilities it is helpful to start with five basic emotions: happy, sad, mad, embarrassed, and scared (the five emotions on the check-in sheet discussed in Chapter 4). Later the list of emotions may be expanded, but it is best to start with a brief list of emotions initially. 64

The next aspect of understanding emotions is to understand the function of emotions. Very simply, emotions help prepare people for action. Emotions like scared, embarrassed, and mad prepare the protective “fight or flight” response pattern while both sad and happy can facilitate developing connections with others, among other things. Emphasize the point that emotions are in no way “bad,” but some feel yucky and others feel good. All emotions play a role in our lives and have a useful function – at least when they occur in moderation. 64

Control Your Behavior 64

Many of our clients are subject to their emotions; they lack skill to respond differently or moderate their emotions. Because of the multiple influences on emotions, having insight about or understanding of emotions in isolation has only limited benefit; understanding one’s emotions in the context that they occur will aid in the ability to identify and label the emotions. As you move through this module, leaders will be emphasizing the contextual influences, which include the prompting event, the interpretation/thoughts about the prompting event, the sensations and experiences that occur with the emotion, the emotionally expressive behaviors accompanying the emotion, and the consequences/aftereffects of the emotion. The process of “chaining” events this way enables clients and therapists alike to identify choice points and interventions (skills) that could be used at these choice points. The core of this idea is “no matter what, I choose how to act.” It does not matter what sorts of emotions, thoughts, sensations, and/or perceptions we are experiencing, we all still make choices about how to behave. Certain experiences certainly make it more difficult to respond in a societally appropriate manner, yet appropriate responses are not impossible. As you discuss of how to respond to environmental stimuli appropriately, it is also a great time to validate the emotions that the client is feeling. 64

Stop Feeling Bad All The Time 65

Another way to regulate emotions, reducing one’s vulnerability to them, can be achieved in a number of ways. First of all, by using one’s wise mind, clients will be able to reduce the amount of time spent in emotional mind. Additionally, engaging in activities that increase positive emotions will help clients experience more of the normal range of emotions. Finally, clients will be able to learn how to let go of painful emotions and reduce their suffering by being mindful of their emotions instead of fighting them, avoiding them, or wallowing in them; clients will also learn how to engage in “opposite action” in order to reduce the power that emotions have over them. 65

Homework: 65

Just give one simple assignment for each session. Here are a couple of examples, but any assignment that encourages group members to think about the skills that are being taught will be helpful. Then don’t forget to review their success with the assignment next week. 65

Between now and the next session, notice your state of mind. How much time do you spend in emotional mind, rational mind and wise mind? 65

When you experience emotions, think about how your body feels and try to accurately label the emotion. 65

Session 3 66

Mindfulness Handout 3: Mindfulness: How To Do It 66

Emotion Regulation Handout 2: Lies and Truths About Emotions 66

Overview: 66

Using the session format described in chapter 3, after you have done the mindfulness exercise, introduce the mindfulness concepts found in Mindfulness Handout 3 (for suggestions of what to focus on see chapter 5, session 3). 66

Many of our clients, for a variety of reasons, have ideas about emotions that are incorrect, invalidating, and contribute to their suffering. Emotion Regulation Handout 2 is a way to help clients identify the dysfunctional beliefs that they have about emotions and develop their own counter-statements. You can use this sheet in a variety of ways, depending on the functioning level of the group members. Clients can write in their own truths about emotions individually; the group can work together to develop truths and then individual clients can write the group truths on to their handout; or the group can develop truths together and the group leader can write out the truths and provide copies of the completed handout to the group members. 66

A great way to discuss the lies about emotions is to use the devil’s advocate technique in support of the lies. Using this technique the group leader would state strongly that there is a correct way to feel all the time, using extreme examples, so that the group members can argue against the obvious incorrectness of this position. For example, the leader might proclaim: “Everyone should feel happy all of the time. It is not OK to feel any other way.” Use of this technique will help clients to more strongly identify with the challenges to the lies and hopefully make the truths about emotions concrete and understandable to the clients. Using this technique as you process the handout should also help clients recognize that emotions are not bad and they do not need to be angry, guilty, frustrated, or ashamed about feeling specific emotions. 66

Homework: 66

Notice your emotions between now and the next session and accurately label them. 66

Session 4 67

Materials: 67

Mindfulness Handout 1: States of Mind 67

Emotion Regulation Handout 3a and 3b: Model of Emotions 67

Emotion Regulation Homework Sheets 1-3: Homework Sheet 67

Overview: 67

Emotion Regulation Handout 3 is a very simplified version of Linehan’s (1993b) model for describing emotions. The core components have been retained but some of the more complex nuances have been modified or eliminated in order to make the model easier to understand. Although review of this handout is described as a single session, leaders may find that spending additional sessions on this skill would be helpful depending on the needs of the group members. It may also be helpful to teach this skill to other caregivers who can help by prompting clients to use the skill in other environments outside of the session. 67

Stuff Happens 67

Prompting events for emotions can be located externally (in the environment) or internally (thoughts, behaviors, physiological arousal/calming, or other emotions). While it is quite common for people to focus on the internal prompts for emotions, the emphasis should be balanced between external and internal prompts. Leaders should use both internal and external prompts as examples in discussing this handout with group members. It is also important to note that emotions can occur automatically (without thinking), such as when looking down from a high place or seeing a close friend. 67

I feel my emotion 67

Emotions are complex experiences, made up of many components. These components include: 67

a)Physiological responses or sensations like increased/decreased pulse and respiration, muscle relaxation/contraction or changes in the way the gastrointestinal tract feels; 67

b)Facial expressions like smiles, frowns, widening of the eyes, etc.; 67

c)Brain responses that determine how well and what types of information we can process; and 67

d)Urges to take different types of action. 67

Emotions always occur with physiological correlates, including changes in heart rate, muscle tone (tensing or relaxing), sweating or feeling cold, facial expression, and so on. Some clients will recognize these changes very quickly, while others will not have noticed the relationship between their physical body and their emotions. 67

One way to get clients to associate emotions with their accompanying physical sensations is to have them think of the last time they felt a strong emotion and then lead them through a brief body scan – especially focusing on the stomach, chest, and shoulder areas. Most clients will be able to identify changes in their heart rate and muscle tension, as well as facial expressions. 67

An area that many of our clients have difficulty is with the urges that accompany emotions. Because of the evolutionary function of emotions to prompt action, our bodies get “pumped up” when a strong emotion is present. However, these action urges are often inappropriate for the current cultural setting. The urge to retaliate to verbal aggression makes sense – if survival is on the line, but retaliation may not be the best choice in a less serious situation. Discuss with clients the various urges they experience with a variety of different emotions. 67

Because of the cultural and social pressures to appear “healthy,” many people learn to inhibit the public expression of their emotions – especially facial expressions. However, if clients want people to know how they are feeling, they need to let others know! This is a good time to share with participants the reasons for allowing our faces to express our emotions. It is also a good time to talk about why we do a check-in at the beginning of each session, including that it is great practice in identifying and sharing information about emotions in appropriate ways. 68

An additional area that leaders should consider discussing is that many clients have been told to “stop feeling” whatever it is they are experiencing. Not only is this invalidating, but it is impossible! To demonstrate this, ask the group members to stop feeling their bodies in their chairs or their feet in their shoes. The only way to do this is to distract yourself and divert your attention elsewhere. While sometimes this is easy and it works, other times it is very difficult. Discuss when it is easy to distract ourselves and when it is difficult; group members will likely discover that some individuals find it easier at certain times, and other individuals at other times. 68

I think about what happened 68

While there are some events and situations that automatically evoke emotional responses, many emotions are prompted by the one’s thoughts, interpretations, or appraisals of the event. The key point being emphasized here is that we often respond to our interpretation of the event instead of the event itself. Have the group think of some emotionally evocative events and describe how they might react to them. Help the group to understand that given the same event different people are likely to respond in different ways. In each of these situations, discuss the types of things that people might be thinking that might prompt their behavior. Help the group members to understand that the way a person thinks about an event might be responsible for all the different reactions people have to the same event. Some examples that could be used for discussion include: 68

a)When in the presence of reptiles some people show signs of fear and disgust while others draw closer. 68

b)When meeting a new person, some people are intimidated and are shy while others look forward to and are happy about meeting new people. 68

c)When driving some people experience excitement and exhilaration while others experience fear and trepidation. 68

d)In a conflict with a friend or family member, some people become angry because the other is acting unfriendly while others become afraid that the relationship will never be the same and all of their relationships will end up in shambles. 68

I Make A Choice 68

All components in this model are important, but this one is especially so. Clients may have the most difficult time with this step. Culturally, reasons for behavior are evaluated as more valid if there is an emotional aspect. For example, reasons given in response to questions like “why did you do that?” such as “I was angry” or “I was depressed” are much more acceptable than “I don’t know.” Nonetheless, making choices should be emphasized at this point. Emotions do not cause us to act, they simply prepare us for action. Eliciting examples from the group of times that they have had the urge to do something but resisted will help make this point. 68

There are also numerous choices to make when feeling emotions. These choices include (but are not limited to) expressing the emotion (using body language), sharing the emotion with people (using words), and deciding whether or not to act on the urges associated with the emotion. 69

Homework Sheet 69

After going through each of the individual items on Handout 3: Model of Emotions, use Emotion Regulation Homework Sheet 1 to demonstrate the steps in the emotion process. Take time to review all of the steps, describing a variety of prompting events; what kind of thoughts might occur; the feelings that might be experienced, including how the client’s face might look and body might feel; and finally consider the choices by discussing the urges the client might feel and how they will decide what is the best choice for them at this time. 69

In processing this handout, the leader will be talking about situations that have already occurred. Sometimes the choices made in these situations were not ideal and it is helpful to talk about goals for “Next Time.” This technique provides an opportunity for clients to set goals for themselves and to rehearse positive choices. Sometimes role-play of the situations with rehearsal of the positive choices is a very powerful technique. It is usually best not to allow the role-play of negative choices, because clients generally have plenty of practice with their negative choices. Instead group time and attention should be focused on practicing better ways of handing difficult situations. 69

Homework: 69

Ask clients to take blank copies of Homework Sheet 1 home and to fill it out when they encounter tough emotional situations. Also be sure that caregivers are aware of this sheet and will prompt clients to complete it. The homework sheet can be completed to illustrate successful handling of events, as well as to process situations that were handled in a less than optimal fashion. Working with this sheet should, over time, increase the client’s awareness of his/her emotions and action urges, as well as the results or consequences for his/her actions. 69

Sessions 5-8 70

Materials: 70

Emotion Regulation Handout 4: Words for Emotions: Happy 70

Emotion Regulation Handout 5: Words for Emotions: Mad 70

Emotion Regulation Handout 6: Words for Emotions: Sad 70

Emotion Regulation Handout 7: Words for Emotions: Scared 70

Emotion Regulation Handout 8: Words for Emotions: Embarrassed 70

Emotion Regulation Homework Sheets 1-3 70

Overview: 70

Begin these sessions by asking if anyone in the group used the Homework sheet. If the sheet was used by any of the group members, go over the incident and talk about what lessons were learned by using the homework sheet. If no one used the sheet, talk with group members about incidents that happened during the week where using the homework sheet would have been helpful. If possible, process at least one or two incidents with the group using the homework sheet format to reinforce the connection between prompting events, thoughts, feelings and choices. Be sure that everyone has blank copies of Handout 15 in case they need to use it during the upcoming week. 70

Depending on the group, it may be necessary to spend an entire session on each emotion (happy, mad, sad, scared, embarrassed), or it may be possible to cover more than one emotion in each session. The leader will decide how quickly the group can move through the handouts, depending on the group’s success in completing the goals described for this section. 70

One of the goals for these sessions is to get clients familiar with the many emotional synonyms that can be used in describing basic emotions. These sheets contain samples of the lists of emotion synonyms that the pilot group came up with. However, these are but a few of the words that can be used to describe emotions. Feel free to have your clients add to the list. 70

The bottom of each sheet contains space for clients to identify 5 objects and/or situations that evoke the specified emotion. Depending on your preference, group time can be taken to have each member complete the sheet and share an item/items or the group could work together to generate a number of things that might elicit the specified emotion. It is important to consider that both prompting events and thoughts may elicit various emotions. This activity can be an excellent time for the group members to identify with each other and build empathy for others. Depending on time constraints, leaders may also choose to have clients fill out the bottom section at home. There is some advantage to having some of these assignments done both in group and at home, as working in another environment may help clients to generalize the skills outside the group room and involving other caregivers may help to provide prompts to use the skills in other environments. 70

Additional goals for these sessions are to review the types of sensations that clients associate with these emotions to facilitate accurate identification of emotions. Completion of the bottom portion of the sheet should emphasize the manner in which prompting events and/or thoughts are related to the feelings we experience. Depending on the leader’s evaluation of the group members’ retention, it may be helpful to revisit Emotion Regulation Handout 3 to talk again about the connections between prompting events, thoughts, feelings and the choices we eventually make. 70

Homework: 71

Ask clients to take blank copies of the homework sheets home and to fill it out when they encounter tough emotional situations. Also be sure that caregivers are aware of this sheet and will prompt clients to complete. It can be completed to illustrate successful handling of events, as well as to process situations that were handled in a less than optimal fashion. Working with this sheet should, over time, increase the client’s awareness of his/her emotions and action urges, as well as the results or consequences for his/her actions. 71

71


Session 9 72

Materials: 72

Emotion Regulation Handout 9: What Good Are Emotions? 72

Overview: 72

This handout explains why we have emotions. The basic functions of emotions are to communicate and to prepare for action. As shown in the model for emotions, emotions occur in reaction to something and prepare us to respond to that event. This seems to be an important key to survival, especially when competing for life necessities such as safety, food, and shelter. Given this vital function, it is not surprising that emotions are so difficult to change. If emotions were less important, they would have less effect on us and would be much easier to change. 72

Emotions Communicate to Others 72

Facial expressions, one of the most visible components of emotions, are quick, efficient means of communicating. Additionally, many facial expressions evoke automatic reactions from others, such as smiling when you see someone smile at you or feeling bad when you see someone crying. The non-verbal expression of emotions can also say to people “don’t mess with me,” “I need help,” and “I care for you,” among others. Emotionally expressive factors such as tone of voice, volume, posture, and facial expressions are all very powerful communicators. 72

The nonverbal communication of emotion is often stronger than any verbal expression of emotion. Thus, if someone is scowling and says that there is nothing wrong, those around him/her will probably not believe that there is nothing wrong or going on with the scowling individual. Emphasize two points: a) People more often believe what they see, not what they hear, and b) If you want to let someone know how you are feeling, make sure that your nonverbal and verbal expression of emotion match. 72

Emotions Communicate to Ourselves 72

For many people, emotions function as signals. For example, anxiety may function like a “stop sign” or a “proceed with caution sign.” Anger, perhaps, may function like a fire alarm as it often increases alertness and prepares a fight or flight response. Most of the time responding to our emotional signals is effective – that is until we start responding to them as if they were facts. One of the core principles of this approach is that thoughts and feelings do not cause behavior; they are responses to our environment and prepare us to act but they do not cause us to act. 72

Emotions Prepare for Action. 72

Emotions are hard-wired with specific action urges. This is beneficial as it saves time and eliminates the need to think through all situations. The benefit is clear in truly dangerous and/or threatening situations, however the benefit is not so clear in many other situations. There are many times when we must inhibit the automatic responses and not respond to the action urges that are evoked by our emotions. Remember, it is not the emotion that is dysfunctional or needs to be changed … it is the actions that would be maladaptive that need to be inhibited. Given the vital functions of emotions, it is no wonder that emotions are so difficult to change. We have all tried to do this and have likely failed at times. 72

Homework: 73

Ask clients to take blank copies of one of the homework sheets home and to fill out when they encounter tough emotional situations. Also be sure that caregivers are aware of this sheet and will prompt clients to complete. It can be completed to illustrate successful handling of events, as well as to process situations that were handled in a less than optimal fashion. Working with this sheet should, over time, increase the client’s awareness of his/her emotions and action urges, as well as the results or consequences for his/her actions. 73

As the group goes on, you should notice an increase in the sophistication with which clients are able to complete this sheet. As they learn more skills, prompt them to use the skills in real life situations in order to make better choices for themselves. 73

Session 10 74

Materials: 74

Emotion Regulation Handout 10: Keeping Control of Your Emotions. 74

Overview: 74

Because emotions are a function of the current environment, an effective way to help moderate one’s emotions is to reduce one’s emotional vulnerability. A helpful way to remember the skills involved in this process is to remember the phrase “SEEDS GROW.” Each of these statements represents a skill that can be utilized to reduce emotional vulnerability. 74

Sickness needs to be treated 74

Eat Right 74

Exercise every day 74

Drugs are bad 74

Sleep well 74

GROW every day 74

Sickness needs to be treated 74

Being sick consumes many resources and reduces one’s resistance to many things, including negative emotions. Taking care of one’s physical body is one way to improve the chances of feeling well. However, sickness applies not only to our physical body, but also to emotional well-being. Talk with your group members about the resources they have available for addressing their needs and how they plan to use those resources. Try to get group members to set specific goals regarding how they will use their resources in specific situations. Use examples that are relevant to the experience of the members in your group. 74

Eat right 74

Balanced eating is another way to improve the way one feels. Discuss the ways that different foods make group members feel (energized, calm, comforted). Emphasize the need to eat all types of food in moderation. Talk about situations that your group members may have experienced in which they way they eat influences the way they feel and possibly even the choices they make. For example, consider how group members might feel after eating a lot of candy or drinking a great deal of a caffeinated beverage. How might those feelings influence thoughts and actions? 74

Exercise every day 74

Consistent exercise is not only a natural antidepressant; it also results in an increase in energy. A healthy lifestyle is an important component in feeling well. Consistent exercise is also a way to build confidence regarding your ability to follow a program and to build mastery of physical skills. Discuss with group members how they feel when they exercise an appropriate amount; how they feel when exercising too little and how they feel when they exercise too much. Talk about how different levels of exercise might influence feelings, thoughts and actions. 74

Drugs are bad 74

Using illicit and other non-prescription mood-altering drugs are excellent ways to increase, not decrease, one’s vulnerability to mood swings and negative emotions. This is a good opportunity to discuss the difficulties clients have had/are having with drugs and alcohol. Clearly explain the differences between temporary/short term solutions to emotional difficulties (like drugs and alcohol) and longer term solutions (like lifestyle changes and therapy). Talk about the influence use of drugs might have on feelings, thoughts and actions. 75

If group members are taking prescribed medications, this section is also a good time to talk about the reasons these medications are prescribed. Leaders should work to differentiate between “drugs” that are bad for us and “medications” that can be very helpful in meeting our goals of better emotional regulation. 75

Sleep well 75

Getting 7-9 hours of sleep is generally recommended for most people. Much less or more sleep may contribute to problems with mood regulation. This is also a good time to present the idea of good “sleep hygiene.” Typical guidelines for good sleep hygiene include limiting activities in the bedroom to sleep and sex, not having a TV in the bedroom, going to bed at the same time every night and getting up at the same time every day, not taking long naps during the day, not drinking caffeine after 12pm, and not drinking alcohol before going to bed. A standard recommendation is that if you are unable to sleep, get up after 20 minutes and read or do a calming activity until feeling sleepy before returning to bed. 75

GROW every day 75

Growing every day takes effort and practice. It is much easier to commit ourselves to making the effort if we are able to identify some success. If someone experiences too many failures s/he is likely to get discouraged and stop trying. On the other hand, if someone is successful without effort s/he will likely have difficulty when greater effort is needed. We all have qualities that we like and things that we are good at, just as we all have areas for growth. Remember, the only way we get good at things is by putting effort into things we don’t do so well. Have group members give examples of things that they have done that have helped them grow. 75

At the end of this handout elicit “action plans” from clients in order to help them actively address those areas that they need to work on. Have them describe their individual goals for growth. Have them list, for example, what foods to eat more of/less of, how they plan to schedule their sleep, what sorts of exercise they are going to do, and what they are going to do in the next week to help themselves grow. Check in with clients occasionally to see if they are following through on these suggestions. 75

75

Homework: 75



Remind clients of the goals for growth that they developed during group. Ask them to report back to the group about their successes and challenges at the next session. 75

Session 11 76

Materials: 76

Emotion Regulation Handout 11: Feel Better More Often 76

Emotion Regulation Handout 12: Ways to Have Fun 76

Emotion Regulation Handout 13: 101 Ways to Have Fun 76

Overview: 76

As mentioned previously, from the DBT perspective emotions are understood as responses to other events. It follows, then, that engaging in pleasurable activities is the most successful way to increase positive emotions. 76

Have Fun 76

Short Term: Do fun things! This is a very simple point, yet highly important. It is very easy to forget to do at least one fun thing every day. Setting aside time to do one fun thing a day is a small step with powerful effects. 76

Long Term: Living a fun, fulfilling, and enjoyable life is what most people want. However, many of our clients are unclear about what it takes to have such a life and often make choices that result in a less enjoyable life style. Group members will likely need encouragement to discuss some of the choices they are making that decrease the amount of fun in their lives. Simple things such as going to time out or breaking rules can prevent them from earning privileges that can increase the amount of positive emotions they experience. For those clients in higher levels of care (such as day-treatment or residential placements) the amount of fun they can have is often highly contingent upon basic choices they make. 76

Depending on the group members, some may need assistance in thinking of small steps they can make in order to increase their positive experiences. With Handout 11 discuss fun things that group members would like to do. Depending on the level of functioning of the group members, leaders might have clients write down a short list of fun things they would like to do or goals that they have; might work as a group to complete these items; or might involve other caregivers in reviewing these items individually with clients at home. However the list is made, it is important to talk about the steps it will take to achieve the goals and to encourage clients to take the first step as soon as possible – in group, after group, and so forth. 76

Be Mindful During Fun Times 76

Another way to increase the amount of positive experiences in life is to actually pay attention when having fun. It can be easy to be overwhelmed when the negative experiences are more numerous and more powerful than the positive ones. Being fully focused and mindful when having positive experiences can increase their power and also protect against destroying fun times with worry. 76

Ways to Have Fun and 101 Ways to Have Fun 76

Leaders may choose to use either or both of these handouts, whichever seems to reflect your groups needs the best. Handout 13 (101 Ways) may be overwhelming for some clients whereas Handout 12 may be too basic. It is probably not necessary to review the whole sheet during group, but it may be helpful to have clients choose 1 or 2 fun activities that they would like to try to get them started. It is also helpful to talk about barriers to getting started. What kinds of things might stop group members from trying new activities that might be fun? Group leaders should try to elicit any fears or embarrassment issues that might be barriers. The group should also talk about how easy it is to continue with old habits that take up all our time and don’t leave the opportunity to try new things. 76

Homework: 77

Be sure that all the group members pick out a couple of fun activities that they will try between now and the next session. Ask them to report back to the group regarding their experiences. Were they successful in having fun? Did some type of unexpected barrier occur or did they try the activity, but find that it wasn’t as enjoyable as they expected? Be prepared to process these experiences in the next session. 77

Session 12 78

Materials: 78

Emotion Regulation Handout 14: Change How You Feel by Acting Differently 78

Overview: 78

Numerous researchers have found that one of the best ways to control how you feel is to act in opposition to emotion-related action urges. For example, if situational anxiety is preventing someone from living the life that s/he desires, intense exposure to the feared situation in the absence of escape and avoidant behaviors is the best way to give the individual freedom to live as s/he desires. Likewise, most effective treatments for depression include an aspect of behavioral activation. The suggestions on the handout are simple, yet very difficult actions to carry out. Leaders should validate group members by talking about how difficult it is to carry out these actions. Take time to explain to group members that their fear/guilt/sadness/anger will not immediately disappear when engaging in opposite actions, but that over time the negative emotions the group members experience will likely decrease in frequency, intensity, and especially duration. Also get examples from clients of times when they have used this skill or when they might have been able to use this skill if they had known about it. Explain that over time, with practice, they will be able to experience strong emotions and control their behavior. 78

In the group, try working with clients to pick out emotions and opposite actions to practice. Role-play can be a very effective way of having group members practice this new skill. Depending on the group, the leader may select one or two members to do the role-play while the rest of the group watches. Then the leader can rotate the role-play and audience roles among the group members. If the group members are functioning on a more independent level, the leader can suggest breaking up into several small teams to do the practice. Once all of the group members have had a chance to do some practice in the group setting, have your clients pick one of their emotions and an opposite action to practice with during the coming week. 78

Homework: 78

Be sure that each client has picked out a strong emotion that tends to be troublesome for them and has identified an opposite action. Encourage the group members to practice the opposite action whenever they experience the strong emotion between now and the next session. Ask the group members to report back regarding their experience. 78

Chapter 9: Relationship Effectiveness Skills 79

Chapter 9: Relationship Effectiveness Skills 79

Overview of the Module 79

Session 1, 2 and 3 80

Just give one simple assignment for each session. Here are some of examples, but any assignment that encourages group members to think about the skills that are being taught will be helpful. Then don’t forget to review client’s success with the assignment at your next session. 81

Between now and the next session, notice your state of mind. How much time to you spend in emotional mind, rational mind and wise mind. 81

Think about what you want in a relationship. Next session be prepared to talk about some of your relationship goals. 81

Think about the methods you generally use to get what you want in a relationship. At the next session be ready to talk about the ways that work well for you and the ways that don’t work as well. 81

Think about how you express respect in your relationships. Next session be prepared to give some examples of how you express respect. 81

Session 4 82

Materials: 82

Session 5 83

Materials: 83

Session 6 84

Session 7 85

Session 8 86

Session 9 and 10 87

Session 11 89

Session 12 90

Session 13 91

Session 14 92

References 93

References 93

Bütz, M. R., Bowling, J. B., & Bliss, C. A. (2000). Psychotherapy with the mentally retarded: A review of the literature and the implications. Professional Psychology: Research and Practice, 31(1), 42-47. 93

Linehan, M. M. (1993a). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: The Guilford Press. 94

Linehan, M. M. (1993b). Skills Training Manual for Treating Borderline Personality Disorder. New York: The Guilford Press. 94

Nezu, C. & Nezu, A. M. (1994). Outpatient psychotherapy for adults with mental retardation and concomitant psychopathology: Research and clinical imperatives. Journal of Consulting and Clinical Psychology, 62, 34-42. 94

Nyanaponika Thera. (1972). The power of mindfulness. San Francisco, CA: Unity Press. 94

Pfadt, A. (1991). Group psychotherapy with mentally retarded adults: Issues related to design, implementation, and evaluation. Research in Developmental Disabilities, 12, 261-285. 94

Sternberg, R. J. (2000). Images of mindfulness. Journal of Social Issues, 56, 11-26. 94

Sue, D. W. & Sue, D. (1999). Counseling the Culturally Different: Theory and Practice (3rd Ed.). New York: John Wiley & Sons. 94

Szymanski, L., King. B., Feinstein, C., Weisblatt, S., Stark, J., & Ryan, R. (1994). American Psychiatric Association Committee Draft Practice Guidelines for Mental Health Care for Persons with Developmental Disabilities. American Psychiatric Association: Washington, D.C. 95

List of Handouts 96

List of Handouts 96

Daily Diary Sheet 1 98

Daily Diary Sheet 2 99

Mindfulness Handout 2 101

Mindfulness Handout 3 102

Distress Tolerance Handout 1 103

Distress Tolerance Handout 2 104

Distress Tolerance Handout 3 105

Distress Tolerance Handout 4 106

Distress Tolerance Handout 5 107

Distress Tolerance Handout 6 108

Distress Tolerance Handout 7 109

Distress Tolerance Handout 8 110

Distress Tolerance Handout 9 111

Distress Tolerance Handout 10 112

Distress Tolerance Homework Sheet 1 113

Distress Tolerance Homework Sheet 2 114

Distress Tolerance Homework Sheet 3 115

Distress Tolerance Homework Sheet 4 116

Emotion Regulation Handout 1 117

Emotion Regulation Handout 2 118

Emotion Regulation Handout 3a 119

Emotion Regulation Handout 4 122

Emotion Regulation Handout 5 123

Emotion Regulation Handout 6 124

Emotion Regulation Handout 7 125

Emotion Regulation Handout 8 125

Emotion Regulation Handout 9 127

Emotion Regulation Handout 10 128

Emotion Regulation Handout 11 129

Emotion Regulation Handout 12 130

Emotion Regulation Handout 13 131

15.Eating a favorite food 131

Emotion Regulation Handout 14 131

Emotion Regulation Homework Sheet 1 133

Emotion Regulation Homework Sheet 2 134

Emotion Regulation Homework Sheet 3 135

Relationship Effectiveness Handout 1 136

Relationship Effectiveness Handout 2 137

Relationship Effectiveness Handout 3 138

Relationship Effectiveness Handout 4 139

Relationship Effectiveness Handout 5 140

Relationship Effectiveness Handout 6 141

Relationship Effectiveness Handout 7 142

Relationship Effectiveness Handout 8 143

Relationship Effectiveness Handout 9 144

Relationship Effectiveness Handout 10 145

Relationship Effectiveness Homework Sheet 1 146

Relationship Effectiveness Homework Sheet 2 147

Relationship Effectiveness Homework Sheet 3 148


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