SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians, one Continuing Education Credit for Psychologists, and one Continuing Education Credit for Social Workers. Credit for participating in today's webinar will be available until May 10, 2022. Next slide, please. Slides from the presentation today are available in the handouts area, which is found in the lower portion of your control panel. You can select the link to download the PDF. And please feel free to submit your questions throughout the presentation by typing them into the question area, also found in the lower portion of your control panel. Next slide. We will reserve 10 to 15 minutes at the end of the presentation for Q&A. Next slide. Now, to introduce you to the faculty for today's webinar, Anita Mandley. Anita is an integrative psychotherapist specializing in complex and developmental post-traumatic stress disorder, intergenerational and cultural trauma, relationship wounds, ancestral wounds, and interpersonal violence. Her work focuses on clients who struggle with developing internal safety and safety in relationships and in the world. Her goal is to help those who've been marginalized restore and acquire their own capacity to be empowered, feel safely connected, have a sense of personal value, and expand their capacity to help that, to help through any grief that burdens them. Anita, thank you so much for leading today's webinar, and I'll turn it over to you for our talk. Oh, thank you very much, Shereen. Grateful. And so before I get started, I'd just like to say that I have no relationships or conflicts of interest related to DBT or any other subject matter that's in this presentation. Yeah. Yeah. So today, our learning objectives include the participants being able to understand the value of DBT, looking at DBT through the lens of the middle path, looking at ways to not only follow DBT, but adapt DBT skills according to the specific client population, learning how to use DBT for the therapist's own self-care, and to kind of manage compassion fatigue, which is often an obstacle when working with the chronically mentally ill or clients that are considered sometimes difficult to treat. Also, we will learn a little bit about the DBT consultation group, which is actually a prime component, not an ancillary component, but a prime component of DBT. And I just want to say, this is an interesting thing. I actually started learning DBT in the early 1990s, and what happened was the medical director, the psychiatrist who was in charge of the partial hospitalization program that I worked at, came back from an APA conference and had heard DBT presented by Marsha Linehan for the first time at APA. And she came back so, so, so excited. And the reason she was excited is because at that point, the clients that we considered hardest and most difficult to manage and the ones that were considered most difficult and depleting for the therapist were clients that were diagnosed as being on the access to diagnostic category, the personality disorders. And the reason why I think they were considered the most difficult to treat is because medications did not seem to manage their distress or help them not use problematic management strategies. And they were also, because they had such difficulties with attachment and social engagement, that things that could engage certain other clients didn't seem to really make a difference. And the medications were making a difference, and so they were considered difficult to treat. So when she came back really, really excited about DBT, something happened that was just sort of like a miracle, meaning that she got the administration of this hospital to close down the partial program for an entire week, close down the partial program for chemical dependency and parts of outpatient for several days, which meant that there was no billing being done. So that's why I say it was sort of like a miracle. And then hired staff from behavioral tech, Marshall Linehan's training group to come and do an intensive. And so eventually I became, within a year or two, I became the coordinator of this program. But it was really interesting because as it was designed and described as working with clients on the access to spectrum, what I began to notice was that everybody in the DBT groups got benefit. Now I have to say that along with the, this is why I started talking about this, but along with what would happen in the milieu, in the PHP milieu, was that with this particular population, sometimes the whole client milieu would just blow up. Now what was really fascinating was when the client milieu blew up, the staff milieu blew up. It was very fascinating. And it seemed to be because some of the staff was on the side of acceptance, like as a compassionate lens, of course. And then there were other staff that were sort of like needing change, needing for them not to do what they did, not to think what they thought, not to engage the way they engaged. And so it would cause this tension between the staff members separate from what was happening with the clients. So that was an interesting phenomenon. And so this consultation supervision and support in the consultation group is an imperative. It's not a luxury. It's an imperative because not only do the DBT clients need to stay and be engaged within a DBT framework, so do the therapists, so do the therapists. And so that's how I got on that. So that's my little introduction to how I got to DBT. So when I started doing DBT, one of the main goals of DBT, of standard DBT was stated as helping people get to wise mind. And at that point, what was being taught was that there were two mind states. One was rational mind, a state of mind dominated by reason and logic. One was emotion mind, a state of mind dominated by emotional reactivity, and wise mind, which in my words, these are my words, are dominated by intrapersonal coherence and internal attunement of body, brain, mind, and relationship. And in a state of wise mind, people could find safety, coherence, and effectiveness. But because I worked in partial, and because I often had clients who had an Axis I diagnosis, adjustment disorders, Axis II, you know, whatever the diagnosis, I couldn't pick and choose which clients were in the DBT groups, like with diagnostic category. And so what I began to notice in doing the groups was that even though DBT was designed for people on the, clients on the Axis II spectrum, everybody seemed to be getting benefit. Everybody seemed to be getting benefit, which was an interesting thing to me. And they had different needs, of course, but it was interesting to me. The other thing I began to notice is that there seemed to be two other mind states at that time. I think there's probably a broader spectrum now. But at that point, what I noticed was this intuitive mind. Like people had a sense of knowing about each other, or about their families, or their environment. And I was like, what's going on with this? What's going on with this? And how I define intuitive mind is when we're able to perceive things in the absence of perceptible cues. There's a state of nonverbal encoding and decoding that gives people information, right? Now what I also notice that it will even adjunctive, as an adjunct or adjacent rather to emotion mind was something kind of different than emotion mind, meaning that there was a lot of emotional reactivity, but it wasn't really emotion mind. So I said, I named this state trauma mind, which is the state of high global, high intensity distress, right? High emotional reactivity. This vacillation between states of hyper arousal and numbness that was often misdiagnosed as bipolar, but was really a lack of a big enough container for the activation, right? And it was also this really negative self view that bad things happened to them because they were bad or incompetent. And this hyper vigilance that led to not, didn't match the situation, the fight and flight and freeze that was really not situation specific. It was mood dependent, right? And so as I began a familiar side, as I began to think about these things, I also realized that all these mind states happen differently in the brain. That rational mind seems to be predominantly in the prefrontal cortex and the cortical structures of executive functioning. Human mind kind of midbrain to neocortex, sort of a back and forth, like pulling from both often, intuitive mind, totally midbrain where this activity happens. And as I learned more about intuition, I learned that it's actually a process that is heightened through estrogen. So this sense of female intuition, right, is actually a real thing, a real biological thing, this intuitive mind, right? And it's this encoding, decoding, along with the memory of past events. So it's like this encoding and decoding happens, and then the sequential thinking takes place and we come to a conclusion. And that trauma mind was really dominant, right, in the limbic system. And wise mind, really, was not necessarily separate or absent in these other mind states, but also sort of was the moderator or sort of the control panel, so to speak, for all other mind states. And so this paradigm has really, really been helpful for me because then I could fine tune my interventions and the way I engaged relevant to what was happening at the moment with my client. Marsha Linehan calls this mindfulness in threes, where you're able to be aware of what's happening within your own self as the helper, the healer, the therapist, be mindful in the moment at the same time of what's happening in your clients, and at the same time, mindful of the process in the room. Yep, Marsha Linehan calls that mindfulness in threes. So a little bit about mind states. Features that I've figured out about mind states is that they're adaptive. They are management patterns in response to some stimuli. They are functional. They're very helpful. When I'm teaching to clients, I say, if you get a flat tire, you go to the repair shop, you have a little toddler with you, right? And then somehow the toddler gets away from you as the car that's on that little thing that goes up in the air is coming down. I forget what you call it, but anyway, as it's coming down, somehow the baby's pinned underneath the truck or the car. What mind state do you want to be in? Most often I get, why is mine? And I say, wrong answer. If my baby is underneath a car, I want to be in trauma mind, right? Because in trauma mind, all those stress hormones are going to be rushing into my system and my prefrontal cortex is going to be shut down. I'm not going to think or problem solve. I am going to run over to that car. And because I have all those stress hormones rushing through my body, I'm going to lift that car off my baby. If I was in wise mind, I might call the paramedics and by the time they got to the shop, something could be wrong. My baby could be dead. So it's not that any of these mind states are fundamentally better or worse, but in the context, in the specific situation, which is the most adaptive? Which is the one that functions for that specific need in the moment? And it's an evolutionary process. The higher the threat, the more primitive our reaction system is going to be, right? So with that example that I just gave, right? I'm going to go all the way back to trauma mind, very primitive, run over there and lift it up, like almost like the caveman would do, right? I don't want to be intellectually curious about what's happening. Now the other thing is that they're not always, you're not always able to differentiate them clearly. A lot of times people think wise mind is the same as rational mind. A lot of times people think emotion mind is the same as trauma mind, but they're totally different. They're happening in a totally different way in the brain and you have totally different capacities often in each mind state. So we have to maintain a position of curiosity and we have to notice when judgment is creeping in and we have to substitute the curiosity for judgment. And this last piece is a really powerful piece for me personally and as a clinician is that all of them are present in everybody. There's a mutual possession, a potential at any moment for any mind state to be present and at the same time, because they're all present, there's a way in the moment to access the one that's going to be the most beneficial at that moment, right? So what happens with states is that a lot of our clients, it's sort of like how I explained it, do not have a gear shift. When they need to go in reverse, they are stuck in drive or overdrive. When they need to be in maybe neutral, they start backing up in reverse and they can't shift from state to state. So part of the function of learning these skills is to help them develop a gear shift so that there's an internal sense of control over what state of mind they're in and that it's situation and context specific and not mood dependent. So I see trauma, as you can probably guess from this, this trauma mind piece and how I'm speaking about it, that I have evolved into seeing a lot of my work in terms of trauma. And I think what people don't often think about is that fundamentally DDT is a trauma intervention. About a couple of years after I started DDT, Behavioral Tech, which is the training group, research group for DDT, sent out a mass email. And the one thing that stood out to me was that DDT is not skills training. And so people often think that that doesn't make sense. That's what they've heard, that when you do skills training, you do DDT. Marsha Linehan says that's not true, that you do skills training in order to get to DDT. That DDT is not just what you're doing, it's also the way of being with. And that the potential of DDT for helping and healing is a stage oriented model. Skills training is only the first stage that allows you to get to the next stages. So when I look through the lens of trauma, I don't think of trauma as the event, but I think about trauma as these composite features of being powerless, being disconnected, not belonging, being devalued, and feeling out of control. So when I look at it through the lens of trauma, I can see why everybody in my group had benefit because all of them, right, had trauma. Yeah, and you say, how could that be? What could be more traumatic than losing your mind? When not being able to count on your mind to help you navigate the world, to help you manage your emotions, to help you be successful in relationships, right, to have a hopeful vision of the future, what could be any more traumatic than that? So Judith Herman, in her seminal book, Trauma and Recovery, says, psychological trauma is an affliction of the powerless. At the moment of trauma, the victim is rendered helpless by overwhelming force. When the force is that of nature, we speak of disasters. When the force is that of other human beings, we speak of atrocities. Traumatic events overwhelm the ordinary systems of care that give people control, connection, and meaning. So when you look at this slide and you think about the clients and the client population that you work with, does this ring a bell? Does this ring a bell? So I see DBT as such a helpful component for these states of pervasive emotion dysregulation, for complex PTSD and disorders of extreme stress, chronic mental illness. All these things are disorders of pervasive dysregulation across both negative and positive emotions. Positive emotions can cause these states of global high-intensity activation. DBT is a comprehensive treatment for emotion dysregulation across diagnostic lines, and each DBT skill set fundamentally is designed for the purpose of emotion regulation to help our clients and our patients develop a bigger well of tolerance for their own lives, for their own emotions, for whatever is showing up for them. Yep. And so this bio-social theory says in DBT that this dysfunction... She phrased it as dysfunction, but I'd say these global high-intensity activation, the way the dysregulation shows up is the result of transactions between an invalidating environment and the person's own emotion regulation system. And I'll get to that. And that the transactions between the two, the individual environment and the outside invalidating environment produces this pervasive emotion dysregulation. And then when you think about it in terms of dialectics, it says these states and their accompanying emotional dysfunction are the results between a constitutional vulnerability to emotional dysregulation. Some people are just born as sensitives in an environment that is prone to invalidate the expression of private experiences, beliefs, and actions. DBT suggests that the individual and the environment are co-active in providing conditions for the development of dysfunction. Yeah. A lot of times we want to put the blame, quote unquote, or say that the cause lies solely in the patient and in the thoughts the patient is having and the behaviors of the patient. And sometimes we say it's totally the result of some external environment, right? The olden days used to be the mother, I'm just saying. Now sometimes it's like an abusive offender. Sometimes it's the therapeutic milieu. Just saying. I did this training for Loyola once for their adolescent therapists. And I was reading this and then reading what I'll show you later about what invalidation actually is. And when I looked up and I saw there was about 100 people in the room, their complexions had changed, their faces were frozen. People were just breathing from the top of their lungs. And I just paused and I said, this is what I'm noticing. We're showing up for people. And this one therapist or social worker said, a little teary, a little choked up, said, I do some of those things. And I said, yeah. And now you're on the path to change. Awareness and acknowledgement open the door to change. So in this system of the individual and the environment, the individual functioning and environmental conditions are mutually and continuously interactive. They're reciprocal and interdependent. The environment and the individual adapt to and influence each other. In reality, they cannot be distinguished. They are a system. They come together. And if one changes, it changes the other. Yeah, on the one hand, the individual lifts the environment that creates dysfunction. And on the other hand, the environment exacerbates vulnerabilities that in a more benign environment might not have developed. Similar to Milan's biosocial learning theory of personality disorders, where patterns of interactions crystallize in the personality. So this emotional vulnerability on the individual side, it's an enhanced sensitivity and enhanced reactivity to the stimuli and the prolonged activation and a longer time to return to baseline. So what this actually means is that, right, I sort of get the story of the princess and the pea. And I'm sort of the princess that would feel the pea under 20 mattresses, right? So I would be sensitive to that pea. I would feel it under 20 mattresses. Not only would I feel it, but my system would react as though it got hit with a ruler or something, right? I would get a bruise. It would be sore. And then the prolonged activation, that soreness could last for days, yeah? So it's quicker, higher, longer, yeah, reactivity. So what are these characteristics of invalidation? There's a lot of them, and I'm going to go through them really fast. It's where their experiences are being met with exaggerated, inappropriate, or an extreme response. Their experience is not validated. It's often punished or trivialized as being silly or discounted. But the painful emotions and what's causing them are disregarded. People just move on and say, that's not true. Their interpretations of their behaviors and their motivations for behaviors are dismissed. And somebody is telling them that they're wrong in both the description and how they analyze their experience, particularly when it comes from what is causing the emotion, the belief, or the action. Their behaviors and their beliefs are attributed to socially unacceptable characteristics or personality traits. It's an interesting thing. When I was working at the hospital, I worked there for almost 19 years before I moved into the practice. Yeah. I would also do screening. I did the screenings as well as other things at the program. And so I would get calls for the DBT groups. And it was interesting. I would get a call from a therapist, and they'd say, I want to refer my client to your group. She's a borderline. I could get another call, and the therapist would say, my client really needs DBT. She has complex PTSD. Energy, totally different, right? Totally different from the therapist and then to the person receiving me, receiving the referral. With the PTSD, I'm saying, oh my, oh my, yeah, compassion, huh? That's to the trauma. To the personality disorder, my system's saying, uh-oh, how does that show up in the treatment room? Failure to live up to expectations brings disapproval, criticism, sarcasm, or attempts to change the individual's attitude. And then what happens? They don't learn how to label private experiences and emotions in normative manners. They don't learn to modulate their emotional arousal. They can't recognize their problems in the same way, and so they don't learn problem-solving skills. People aren't saying, oh, that's valid, what do we do about that? And then these extreme problems or emotional displays become necessary in order for them to get some sort of response from the people around them. And it results also in inhibition or extreme, either inhibited emotional states and shutdown or extreme emotional shutdowns through hyperarousal and high activation. They don't learn how to tolerate distress or form realistic goals and expectations. They learn not to trust their own emotional response as truth. And then they begin to internalize all of that invalidation and shame. And so Marsha Linehan initially started thinking as a way to help women who at that point were sometimes hospitalized for years because they were suicidal, chronically depressed, or had certain behaviors that were deemed unacceptable or problematic. She actually started a little thing, what do you call it, research project on some inpatient units of CBT. And she did a CBT protocol, trained the staff. They started implementing the CBT with these patients and it blew up. What would happen was either the client would just totally shut down and disconnect or they would become enraged and attack the therapist. And so with both situations, the impact on the therapist with the shutdown was discouragement. And with the attacks was to withdraw the therapy in order to appease and avoid the attacks from the patient. So Marsha Linehan said, well, maybe this is not going to help the CBT for this population. And instead of saying it's not good, she said, maybe there's just something missing. So she goes into Zen, studies with a Zen master, and learns the middle path. And so the middle path is an alternative to the sort of thinking that becomes locked in these extremes of either chaos or rigidity. Rather than offer a compromise between such opposing views, the middle path posits that neither extremes represents reality. When one rejects attachment to the extreme, what remains is the true nature of things. Therefore, the middle way is not a passive state of middle of the road thinking, rather, a recognizing and rejecting limiting or biased views. It is an active state, a moment-to-moment active and interactive, I would add, state of developing the wisdom to perceive the true nature of things and to act accordingly, yeah, to act accordingly. So the skills of the middle path, dialectics, validation, and behaviorism, dialectics. Everything is transient and finite, including and particularly states of mind. Everything is made out of opposing forces, right? And gradual changes lead to turning points where one force will overcome the other. And also that change will move in spirals, not a straight line, not circles. Even if your client is trying to change their drinking patterns and somehow they come back to a point of high activation and they take back some alcohol, they're not at the same point that they were before because they've had experiences between one point of drinking to the other. They're in that spiral, but it's not a circle. They're not in the same place. And validation. We validate as acceptance to balance the change. We do it to teach our patients how to self-validate. Validation strengthens the clinical progress. Validation provides the feedback and strengthens the therapeutic relationship. And this is real important. How do we interfere with our patient's progress? Sometimes we embody an imbalance of change versus acceptance, flexibility versus stability, nurturing versus providing a context of support for change. We are reciprocal versus irreverent communication. Sometimes we show lack of respect for our patients and sometimes we blame them. They're manipulative, they're resistant instead of thinking what's missing like Marcia did. And so the standard DBT goals, standard treatment goals, decreasing what I call tissue for stage one, which is the skills training in order to decrease tissue damaging behavior, therapy interfering behavior, quality of life interfering behavior as we increase the behavioral skills. But that's only stage one. Stage two, according to Marcia Linehan, is to transform the PTSD. And stage three is to increase self-respect and mastery as they achieve their individual life goals. And so we do groups because as much as we have the best intentions to train clients and skills, oftentimes we get sidetracked by managing the crises and we get turned away from the skills training. Sometimes the groups are the best place for them to be able to see in action that movement between acceptance and accommodation of change. And that concept of acceptance of change can now be a part of individual therapy. And therapy is, the individual therapy can be focused on learning to deal with natural fluctuations of events within therapy and in their home environment. And the group skills training can stay focused on teaching and learning skills. So it is composed of individual therapy to address motivation and life, moment-to-moment changes in their lives, skills training to help them learn skills, telephone consultation and coaching, because it's only fair to provide a means for them to touch base as they're living life. And then supervision consultation that is aimed at keeping us as therapists within a therapeutic frame to help us balance those dialectical dilemmas and also balance the way we work with our clients because I have to acknowledge that sometimes I would get activated. It would pull me out of that frame of dialectics. So the consultation group's so important to provide us a place of community, opportunities for us to receive validation and support, to understand that we have limits and that's okay because we're actually human beings, that helps us keep that dialectical stance. We get the cheerleading instead of hoping that it's coming from our patients. That's not their job. Opportunities to manage and resolve that splitting when the staff mill blows up, right? And then it gives other therapists a chance to share their observations because what could be happening in their interactions could be totally different than what's happening in mine. And so getting like more of a whole picture, this one to accept that all of us are fallible and to acknowledge that we're fallible and make mistakes without shame and that we get support in making plans, repairing difficulties and ruptures and giving us opportunities to get empathy and permission to take care of ourselves instead of again, longing for the empathy from the clients to maintain that therapeutic DBT state and that it's necessary for us because DBT is so powerful for the clinician, gives us a stage oriented integrated model, gives us things we can do that increase our sense of mastery that something we can do that will help decreases also our sense of being helpless and powerless which is sort of traumatizing to us and gives us interventions that effectively decrease and manage those extreme behaviors and crises and this refuge of supervision and consultation groups. And the behaviorism is the practice, practice, practice, practice. Now this other, I'm not gonna spend too much time at this. There's a lot of adaptations for DBT. DBT, when you're adapting, it's really important to learn the standard first then move to the adaptation. But because we're sort of thinking about the chronically mentally ill population, I really think that if you learn the standard DBT really move into thinking about the radically open because as standard DBT is about containment fundamentally and internal management or whatever. The radically open is about being effectively, safely engaged with the social environment, right? Having that flexibility, really focusing on changing certain things and developing that gear shift so that someone can be more connected in social environments. And it's really helpful for clients whose really main issue is being shut down and too internally focused. You see this a lot with depression, eating disorders, especially anorexia, OCD, autism spectrum disorders, complex PTSD, schizoid personality and schizophrenia where their emotions go unacknowledged, unexpressed, not communicated or explained because they can't get into that engagement piece to have that happen. So the therapeutic is not containment and control, but social signaling and social connectedness skills. And it emphasizes how biology influences our perceptions of other people and how that impacts our social behaviors. So I'm actually, again, I have over packed my slides. The rest of the slides are basically about the radically open DBT process. Yeah, this last piece I will say about therapists needing to have their own practice. Here we're saying radically open skills, radically openness. In DBT, it's the skills of DBT, the core skills, right? And mindfulness, right? And so I think that's really important. We need to have our own mindfulness practice in order that we can show up as a model, but also as a well-regulated presence. All right, and so this one just shows a little bit of the comparisons between what's being emphasized in the S, which is standard DBT, and the RO, the radically open. And so look at that and the priorities, treatment priorities on both sides. A standard DBT diary card, which is a great tool for tracking and management and learning skills, practicing skills. And I included a radically open DBT diary card in your slides. And a behavioral analysis that shows how it can be actualized and how it shows up. But don't panic. I know this is a lot. You can do it. I did it. You can do it. Thank you very much. Grateful for you. Grateful for your presence. Thank you, Anita, for such an interesting presentation. Before we do shift into the Q&A, I wanted to take a moment and let you know that SMI Advisor is accessible from your mobile device. So you can use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating skills, and even submit questions directly to our team of SMI experts. So download the app now at smiadvisor.org slash app. So we do have a little bit of time for Q&A, and it seems like most people wanna know how they can access a DBT consultation group. I guess both about the DBT consultation group and also where can they obtain more additional training on DBT? Do you have any ideas on how to do either of those or both, Anita? Yeah, you know what? If you go to behavioral tech, I think it's a .com, but if you just Google behavioral tech, one word, they have resources on their website, registered DBT programs all over, might be the world, but especially in the United States, and consultation groups. When we started our consultation group at the hospital, it was just us that worked in a program. If you're solo practitioners, then maybe you can, if you have a online group or you have people that you work with or study with, form your own group. In Marsha Linehan's text, she speaks to how to form your own group and what the necessary components are, what the DBT agreements are for participants in a DBT consultation group. So I will use those primary, get the text. It will give you instructions, detailed, detailed instructions. Look online for behavioral tech and go into their resources. That would be my suggestion. Great, thank you. So we're getting flooded with questions now, so I'm trying my best to figure out. I think a question that would sum up for a few people, what they're asking is, so can you use components of DBT as standalone interventions? Is that effective? Or does somebody need the entire program? Absolutely. I think the entire program is fabulous and not everybody needs it and not everybody can do it. They could be constrained by finances, for example, or availability in terms of whatever their time situation is. I use it. You know, I'll run off a copy of some homework or a informational sheet, say of interpersonal effectiveness and integrate it into my work with someone. Yeah, so definitely you can use it in an integrative fashion and, but it depends on, sometimes it's also dependent on what level of care the person needs and their availability financially, time-wise and their tolerance. There are some people who don't do well in groups, right? They don't have that kind of bandwidth for social engagement or they have so much shame, right? So then we need to be a bit flexible develop a plan. Maybe out of 20 people, two of them are like that. Can we do it a small group process with two people? Yes. Yeah. Could we do individual DBT? Yes. And then could we do it in an integrative treatment format of just pulling out what's needed in the moment according to what you're working on in that session? Absolutely. Great. Thank you. I have one more question. And then for those of you that we didn't get to your questions, I'll tell you after this last question how you can submit them and still get your answers. So this is an intellectual question about kind of one of the core components of DBT. So, you know, that you mentioned that an imbalance of acceptance and change can get in the way of treatment. So how, do you have any just kind of final thoughts on how you can strike an effective balance between acceptance and change or how will you know that you're striking an effective balance? Because change happens. Yeah. Well, that's a pretty simple, right? Straight to the point answer. If it's not effective, they will be in fight, flight or freeze and it won't be their fault. Right. So we have to show up as the well-regulated presence as the refuge, as the witness, as the competent protector as the compassionate comforter. We have to ask permission. We have to give them information about what's gonna happen to them, inform them and get their consent for what's gonna happen. And we have to be collaborative. We cannot do what was done to them and other environments that created the state in the first place. Right. If we make a mistake, it will show up. Yeah. But if we do it right, it also shows up and we're gonna make mistakes. That's the dialectic. We're gonna do the best we can and we will make mistakes. When we make mistakes, we seek supervision and consultation. We acknowledge and we change. Thank you, Anita. And a lot of people are interested in learning more about DBT and more trainings from you. So just stay tuned and we will let you know when we're able to offer additional trainings on DBT. So if you have follow-up questions that were not answered today, or if you think of any later or about any other topics related to evidence-based care, for SMI, our clinical experts are available for online consultations. So any mental health clinicians can submit a question and receive a response from one of our experts and they're free and confidential. So on behalf of SMI Advisor, I'd like to invite you to learn more about the APA's 2022 Annual Meeting. The in-person conference takes place May 21st through 25th in New Orleans. And the virtual meeting takes place June 7th through 10th. During the live conference, clinical experts from SMI Advisor are leading a variety of sessions on how to improve care for individuals who have SMI. Topics include the basics on how to use Clozapine, digital health navigators and how to make technology work and how to improve physical health in patients who have SMI and many more. I encourage you to take a moment and browse the agenda at psychiatry.org slash annual meeting. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes and you'll then be able to select next to advance and complete the program evaluation before claiming your credit. Please join us next week on March 17th as Dr. Swapnil Gupta presents a delicate dance, the principles and practice of deprescribing antipsychotic medications. Again, this free webinar will be on March 17th from three to 4 p.m. Eastern Standard Time. Thank you so much for joining us and thank you to Anita. Until next time. Thank you, grateful for you all. Thank you.

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