Click on the hyperlinks highlighted in the infographic for more information.
Note: If you have a small office, you may want to consider a video camera with a wide angle lens. That was necessary in my office. The Sony Handycam has a wider angle lens than most. Older models can be picked up on ebay quite reasonably. Comments and suggestions welcome. Enjoy!

3/19/2016. Here is the new and improved version.

4/20/2016. Version 3.0 with corrections from our friends at DBT-LBC!

Over the course of a week, we may face many challenging moments with people we care about who are in pain. We may find ourselves at an impasse, feeling stuck, or lacking the motivation to do what is needed. What do we do then?

​We can go to our DBT team!
 
When bringing a case to team for feedback, Kelly Koerner suggests that we can improve our effectiveness (getting what we really need from our team) by addressing 3 Questions to identify our central consultation need. Ideally, this can be followed by doing a short roleplay with the therapist playing their own client to get an experience of what is happening and what is needed. The group member roleplaying the therapist gets to "wing it" knowing the focus is NOT on brilliant interventions, rather the purpose is for the therapist and the team to have an experience of what is needed for both therapist and client to increase motivation and/or effectiveness.
 
Please grab a piece of paper and pen to respond to each of the 3 Questions and the instructions that follow in italics.
 
Here are the 3 Questions to improve our consultation team effectiveness. These aim to help us get the support we need to be as effective as possible with our clients.
 

1. CLEAR. Are both you and your client clear about the problem definition?  Clear on the therapy task (i.e., what to do about the defined problem)? 
2. MOTIVATED. Are you both motivated to do what is needed?
3. If you are both clear on the desired alternative behavior/task and you are both motivated, then WHAT GETS IN THE WAY? (you can use these questions to define what gets in your way and/or what gets in your client’s way)

• Skills deficit?
• Contingencies?
• Conditioned emotional responses?
• Cognitive content or processes? 

Let’s pretend that with your team’s assistance, you have clarified the problem and the task of what to do at this stage.  Yet, the question of motivation persists.
 
The second question of motivation can be further addressed by the seven DBT commitment strategies. Write down as many of the commitment strategies as you can recall. I usually get stumped on at least one.
 
Let's first consider what we mean by commitment. Kelly Koerner suggests that when we use the word "commit" we are referring to three behaviors. Before you read the next paragraph, take a moment to consider and write down what behaviors you are doing when you are acting "committed?"  It may help to bring to mind a work task or project that you are clearly motivated to do.
 
In contrast, what is a task for which you are lacking motivation? Write down this task. 
 
With this challenging task in mind, let's consider the role of commitment as defined by these three specific behaviors. Here they are: wanting it, saying you want it, and acting like you want it. How does this apply to the task you have written down? Which of those three behaviors need more attention to increase your motivation and commitment to do the challenging task you identified above?
 
Next, we are going to use the DBT Commitment Strategies to increase our motivation. Here are the seven strategies DBT uses to enhance commitment, along with some prompting questions:

1. Basic rationale for commitment: Pros and cons - What are the reasons to take action steps? What are the reasons to refrain from action steps?  
2. Devil’s advocate - Can I hold the arguments (mine and others) to not commit... AND still want it?  
3. Foot in the door - What is the smallest action I can take in the direction of my goal I have committed myself to?  
4. Door in the face - Consider giving this commitment 100% of your time and energy. Okay? Likely not, so let’s be reasonable given the demands of your life and identify how much time, at this stage, you will give these commitment behaviors (wanting it, saying you want it and taking action).
5. Connecting present commitments to prior commitments - Remember when you have been able to want it, say you want it and to act like you wanted it…how can you build on that experience in this current situation?  
6. Highlighting freedom to choose and absence of alternatives - Consider that you can choose to not take action toward the goal so you remain where you are and that getting to the goal can only occur when you take action.
7. Using principles of shaping - How can I encourage myself to take progressive steps toward my goal?

Having reviewed each of these commitment strategies, again bringing to mind your challenging task, which of these commitment strategies could you apply to increase your motivation? Describe how that strategy would benefit you?
 
In summary, consider how these exercises have helped to clarify what you need to do to increase your motivation to do what is needed (with your challenging task). Consider how this might apply to your clients who are lacking motivation with key tasks. Once, we have used the commitment strategies to help increase our own and our client's motivation, then we can address the third of the 3 Questions - What gets in the way of our desired behavior or task? What gets in the way of our client’s desired behavior/task? 
 
Adapted and Excerpted from Kelly Koerner's Advanced DBT Training of practiceground.org, with much Appreciation!

The highlight (didactic) of the 2014 ISITDBT (International Society for the Improvement and Teaching of Dialectical Behavior Therapy) gathering for me was Melanie Harned and Kate Korslund's presentation on "Improving Competence in DBT: Avoiding Common Adherence Pitfalls." The bullet points below are from their handout. They outlined a system of coding videos for adherence. Each then shared clips from a less than perfectly adherent session...and bravely invited a group coding, that is 400+ of us in the room at the time, to score them for adherence. How validating to see examples of mistakes and omissions!

Harned and Korslund presented their findings from nearly 1500 sessions that have been coded for adherence over the last 10 years. The strategies and procedures of DBT have been analyzed as 12 subscale scores (*see below). The three subscales most commonly coded as insufficient were: dialectical strategies, exposure, and problem solving. It was suggested that more attention be placed on modeling a dialectical worldview by generating balanced solutions and striving for dialectical synthesis. This could be largely remedied with more "Both-And" language.

• Adopt and model a dialectical worldview
• Infuse session language with dialectical language. Add "Both-And"
• Strive to balance nurturance and acceptance with push for change
• Generate both acceptance-based and change-based skills and solutions

How can we show that we believe and live a dialectical view, including more Both-And and less Either-Or? What is left out? How can we acknowledge and accept the polarities at play? How can we hold both polarities (in our open hands)?

We were encouraged to look for opportunities to use formal and informal exposure and to implement each step (Kelly Koerner's PracticeGround Learning Community provides effective training on this).

• Use it! Look for and create opportunities
• Highlight and block efforts to avoid emotions in session
• Redirect clients back to the cue for a sufficient length of time (while blocking avoidance)
• Obtain ratings of distress before and after

Even if we are not highly trained in formal exposure, how can we look to use informal exposure? Can we be on the lookout for when an emotion is avoided, such as when a joke is cracked that serves to avoid? What helps us to coach our client back to experiencing the emotion? Do we notice avoiding for a sufficient amount of time? Do we continue our conversation with the emotion? Have we checked the SUDs level before and after?

Problem-solving could be improved by emphasizing agreement and commitment to implement new behaviors and to troubleshoot.

• Generate solutions that are reflective of the major problems
• Ensure that solution generation translates to behaviors that will be tried
• Be specific and clear on the new plan
• Seek agreement to implement new behavior
• Troubleshoot

Do we actually have an agreement? Let's troubleshoot this plan-what might get in the way? Do we have sufficient detail? Are we clear on the consequences in the chain? Have we clarified the contingencies relevant to the new plan?

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* The 12 subscales: Reciprocal, Validation, Contingency Management, Structural, Cognitive, Irreverent, Assessment, Protocols, Problem Solving, Dialectical, Exposure