Hello and welcome. I'm Shareen Khan, Vice President of Operations and Strategy at Thresholds, Illinois' oldest and largest provider of community mental health services, and also I'm social work expert for SMI Advisor. I am pleased that you're joining us today for SMI Advisor's webinar, Dialectical Behavioral Therapy for Serious and Persistent Mental Illness, a Skills-Based Approach. Please go to our next slide, Anita. 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. Next slide. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one continuing education credit for psychologists, one continuing education credit for social workers. Credit for participating in today's webinar will be available until August 22, 2022. Next slide. Slides from the presentation 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. Next slide. Also in your control panel, you'll find the questions area. Please feel free to submit your questions throughout the presentation by typing them here. It is found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for your questions. Next slide. Now, I'd like to introduce you to the faculty for today's webinar, Anita Mandley. Anita is an integrative psychotherapist specializing in complex and developmental PTSD, intergenerational and cultural trauma, relationship wounds, ancestral wounds, and interpersonal violence. Her work focuses on clients who struggle with developing internal safety and safety and relationships and in the world. Her goal is to help those who have 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 heal any grief that burdens them. Anita, thank you so much for coming back. This is her second webinar. The first one is also on dialectical behavioral therapy, more of an overview of the concept itself, which you can find in our catalog. So now I'll turn it over to you, Anita. Thank you so much for leading today's webinar. Thank you, Shereen. And thank you for inviting me back. And thank you to everyone who has come to the call and is participating today. So I look forward to spending the next hour or so with you. So I'm going to start here. There may be a few people who have not seen the first webinar, so I'm just going to do a very brief overview. And I'll just start with the concepts of dialectics. And dialectics, I used to explain dialectics as the place where there's two opposing forces, right, that are both true at the same time. Now that's still true, but I've expanded the definition a little bit and looked at it a little more. And so in the expanded definition of dialectics, it's about everything being transient and finite, right? Everything is made out of opposing forces. And gradual changes lead to turning points where one force overcomes the other. The fourth change moves in spirals, not lines, oops, or circles, sorry for the typo, not lines or circles, right? So these are the basic premises of dialectics and dialectical thinking. And then standard DBT, we focus on increasing certain capacities for coping by decreasing tissue damaging behaviors, decreasing therapy interfering behaviors, decreasing quality of life interfering behaviors, while increasing behavioral skills. Stage two in DBT is transforming post-traumatic stress disorder. Now a few people might be a little surprised about this, because I think people sometimes get the impression that DBT is just about gaining skills, but Marsha Linehan, the developer of DBT says there's no empirical evidence that skills training alone creates change. So what she does say is that it's the fusion of the way of doing and the way of being, and that DBT encompasses both, right? Now the third stage of DBT is increasing self-respect and mastery while achieving individual and personal goals. And then there's three stages to skills training. Skills acquisition, which is where people are learning the skills through lectures, for example, skill strengthening, where people deepen their understanding of the skills by practicing them, that's the behaviorism. And skills generalization, where the skills are applied in a broader range of contexts. So I just want to say, I've been teaching, doing DBT, teaching DBT skills since the mid 1990s. And initially when I started, and when I first heard about DBT, I was actually working in a partial program for the chronically mentally ill. And DBT was brought to our program in our department. I was working at a hospital, and it was brought to our hospital by the medical director, the psychiatrist who was the medical director of the department, and very excited about this DBT. But she was really, in the department, was really thinking about DBT in the context of access to diagnosis of personality disorders. And initially DBT was talked about in terms of borderline personality disorder as an effective treatment for borderline personality disorder. Now the interesting thing to me was, because I worked in partial, in a fairly large partial program, the way the department got reorganized, I could have, my groups were not homogeneous. In other words, there were many different diagnosis and diagnostic categories in my groups. So I got a little curious about this, because I was thinking, well, it sounds like it's for borderline personality disorder, but it seems like everybody in the group, regardless of diagnosis, begins to change somehow, or gain benefits somehow from these DBT skills. So I began to ponder, what exactly are the common denominators? Like, where do all these diagnostic categories intersect? And I came to realize, because I have a profound interest in trauma, as you kind of heard in the introduction, that that was the intersection, that if you define trauma, not as about a specific event, but about the experience of feeling powerless, disconnected, devalued, and out of control. Every single person in the program, regardless of diagnosis, had had those experiences and been shaped and changed by those types of experience. I actually really began to understand why stage two of DBT is about PTSD. Because when you think of it, what could be more traumatic than losing control of your own mind? The thing you need to count on to navigate the world. And so I realized that the reason why DBT was helpful, even with the chronically mentally ill, which initially people didn't think about using DBT for chronic mental illness, was because the foundation or the root of their experiences and distress with that illness was trauma. So practical issues to consider when you teach in a group, are you going to have a co-leader? Are you going to do individual or group when you teach skills? Is it going to be an open group where people are allowed to come and go? Or a closed group where whoever starts in the group at the beginning of the DBT group ends with the group after 24, 26 weeks? How are you going to organize the treatment modules? Are you going to have mixed groups or groups that are the same in terms of diagnosis, gender or age, things like that? And how to integrate the individual therapy and the therapist who's doing the skills training. So what I'd like to do today is really talk a lot more about, yes, the skills training and standard DBT, but also the skills connected to radically open DBT. And the reason why I think it's so important for us to consider radically open DBT, not just standard DBT, is because the radically open DBT is what's most likely to be able to target and shift what we used to call the negative symptoms of chronic mental illness. So negative, not in terms of bad, but in terms of what's missing. Positive symptoms, not in terms of good, but in terms of what's present. So standard DBT, I think, really is about managing, controlling symptoms that are out of control, impulsivity, things like that. Radically open DBT is really about, rather than managing, controlling, being the focus and avoidance of certain behaviors being the focus, it's really about those negative symptoms of isolation, lack of context-specific affect, lack of emotional expression, things like that. And the reason why this is so important is because, especially with traumatic experiences, one of the main tenants of a healing process is social engagement. And yet social engagement is one of the things that a lot of people with a chronic mental illness avoid, either because there's a negative feedback loop in terms of how the people see them, how they relate to them, even how they talk to them, things like that, either that or because they've had such problematic relationships, and especially if there's been interpersonal violence or trauma, that they become avoided because they're afraid, which makes a lot of sense. They see threat with social engagement, and not support and resilience. So the standard DBT, the three legs of the stool of standard DBT, of course, starts with dialectics, validation, and then the behaviorism of the practicing the skills. The three legs of the stool of radically open DBT, still dialectics, but radical openness and self-inquiry, yeah? The hierarchy of treatment priorities and standard DBT, life-threatening behaviors, because if you're no longer alive, the rest of the skills really aren't that helpful. Treatment-interfering behaviors, because if they interfere with the treatment enough, again, you don't get help. And quality of life interference behavior, because it just keeps those cycles of suffering going. And radically open DBT, we start with life-threatening behaviors for the same reason. But then we go to the therapeutic alliance ruptures, the disruption, right? Because that's in the context of social engagement, these ruptures happen, right? And the maladaptive over-control that shows up in problems of social signaling, like being able to interact with the environment in such a way that you have a much better chance of being seen, heard, understood, believed, connected, valued, all of that. And the reason that can be such a problem is because of the tendency to move into a place of over-control, because of the threats of emerging in a social context, in a relational context. So in standard DBT, we're increasing mindfulness, emotion regulation skills, and distress tolerance skills, while at the same time trying to decrease the identity confusion, the sense of emptiness and cognitive dysregulation, the labile affect, the excessive anger, impulsive behavior, suicidality, and parasuicide, yep, that's what we're trying to get down while increasing skills. But in radically open DBT, with the focus in the skills training is teaching the context-specific emotional expression, teaching nonverbal social signaling strategies that foster social connectedness, even something as simple as how to tolerate eye contact, or maybe when to use a little bit of a smile, or shift the tone of your voice, or the facial expression, I'm sorry. Teaching skills that activate the brain activity associated with the social safety system, and how to use these skills to facilitate social engagement, and this increases the possibility of that positive social feedback loop, right? So you are gaining validation through a positive social feedback loop, instead of an invalidating experience through a negative social feedback loop. And then it also teaches therapists how to engage with clients in ways that activates the client's own social safety system. So these same skills that we're teaching the clients in terms of a radically open DBT process, we have to learn and use ourselves, and that has to be the foundation of how we engage with clients who experience these issues of over-control. So radically open DBT, therapists need to have their own practice of radical openness and radically open skills. So how does this look? Standard DBT, we're focusing on mindfulness, distress tolerance, interpersonal effectiveness, and regulation as the core skills. Radically open, we're focusing on social signaling, openness, and social connectedness. And standard, we're trying to focus on under-controlled clients trying harder, doing better to contain and control their dangerous and impulsive behaviors. But in radically open DBT, we're looking at clients who over-control and their need to let go of always focusing on performance, performing better, trying harder. Standard, we're trying to stop dangerous and impulsive behaviors, containment, avoidance of these things is our focus. And radically open, we're less directive in that way, but we're encouraging this independent thought and action based on self-inquiry and self-exploration. Like actually teaching clients how to go in a bit to see what's really going on, and then come back out into the world, into relationships, and into community, and into the world. Standard encourages the therapist to help the client gain control, and we provide reinforcement through validation when they're able to control problematic impulses, but they're radically open. We're modeling the social signaling in order to increase the client's engagement in the process, to model what it's like to show up with vulnerability and still engage, and enhance the connection in the therapeutic relationship, right? Because if we can co-create with our clients that space and our relationship with them, then that gives them like a model of how to do it in their lives. We may encourage conflict avoidance or disengagement in standard DBT, but in radically open, we're going out into engagement and openness to conflict, right? Not in a problematic, impulsive way, but in a thoughtful way in order to resolve when we can, when our clients can resolve conflict rather than avoidance, then they gain a sense of mastery. And like it might not be that bad, it might be uncomfortable, but that repair, right? Kind of strengthens our capacity to engage. So yes, there could be a conflict or a rupture in relationship, but the healing happens in the repair. The therapist and standard rewards and validates containment of thoughts and emotions. Radically open encourages honest and open communication. Standard based on Zen Buddhism mindfulness practices, fostering the presence of wise mind. Radically open focuses on self-inquiry to foster a flexible mind, right? To move out of that place of rigidity, but not going to that place of chaos. In order to increase emotional expression and expand social engagement, radical acceptance decreases suffering, but radical openness moves us into places that we initially may want to avoid. And radically open is different than standard because it takes temperament into account, right? In standard DBT, we're kind of grounded in mindfulness, being aware and involved in what is happening in the present moment in order to expand capacity for safety, connection, reinforcing connections between body, mind, spirit, and emotions, improving the capacity to be in the present, decreasing reactivity to our inner experiences, increasing capacity to stay present, even with painful emotions and sensations, increasing capacity to react with awareness and intention and not sort of just reactivity based on just old habits or our mood, you know, where it's incoherent with the present situation. And then we want to increase the capacity to describe and label with words and to be nonjudgmental of our experiences. So there's this what to do in mindfulness, observe, describe, and participate. And the how to do mindfulness in DBT, nonjudgmentally, effectively, and one mindfully, focusing on one thing at a time. If you're going to eat mindfully, just eat, paying attention to all that that involves. If you're going to drive mindfully, just drive, paying attention that of everything that's involved in driving, for example. With radical openness, this core skill in radically open DBT, it's the core principle core skill and sees the main three components of emotional wellness as openness, flexibility, and social connectedness. It's developed for clients with defensive accommodations and management patterns of over control. These can include intractable depression, anorexia, obsessive compulsive disorders, autism, complex PTSD, schizoid personality disorder, and schizophrenia. Often their emotions go unacknowledged, unexpressed, not communicated or explained. And the primary therapeutic in radically open DBT is not containment and control as it is in standard DBT, but it is social signaling and social connectedness skills. And it emphasizes how our biology, what's happening in our bodies physiologically and in our nervous systems influences our perceptions of other people and how that impacts our social behaviors. So in standard DBT, after we teach mindfulness, we teach distress tolerance skills, right? How to tolerate distress without doing anything worse or anything to make the situation worse. It involves the crisis survivor skills, which involve how do you tolerate short term pain? Again, without making the situation worse. And it also includes guidelines for accepting reality in order to tolerate the long term pain. So what we do, what to do in distress tolerance. There's this skill set of wise mind accepts, an acronym accepts stands for activities, doing activities, contributing in some way, using comparison. Sometimes comparisons can be tricky. That's the dialectic. Like all of these skills in some way just are composed of opposing forces. So in that sense, you have to be careful with clients and help them understand are these things going to be positive for them, helpful for them and which ones are helpful, which ones are more complex and maybe not as helpful. Emotions like substituting one emotion for another, pushing away thoughts or emotions, using sensations to decrease the distress in the moment. Self-soothing is another thing. Using the five senses of vision, hearing, smell, taste, touch, in order to soothe and move into a more regulated state, less distress. Sometimes the improve the moment skills are helpful. An acronym of improve stands for imagery, using imagery, meaning making, prayer can be helpful for a lot of people, relaxation, using one thing at a time, taking like a vacation, even if it's just an imaginary vacation in your own mind and encouragement. One of the skills involves in terms of encouragement, having the client write themselves a letter of encouragement that they can pull out and read to themselves at a moment of heightened distress. And then also this can kind of help people, is the, this dialectical model of using pros and cons. So for example, someone gets very, say someone sees someone who's been very mean to them or abusive to them, right? And makes them feel like they want to go home and have a drink, even though they're focusing on their goals is to remain sober. So we would look at what's the pro, what's the positive consequence of not drinking and using a DBT skill, distress tolerance skill instead. What's the con of using, what's the con of tolerating the distress and using a DBT skill instead. Then you go to the other side. What's the positive of not tolerating that distress with a DBT skill and going home and get that drink. And what's the negative consequence or the cons of going home and getting that drink. And so you might think that like the pros and cons in a way, like the pros of tolerating distress is the same as the cons of not tolerating, but it's really quite interesting. And that what I find when I do this type of pros and cons list is I can point out to the client, right? With the pros of tolerating distress and the cons of not tolerating the distress really is about the long-term consequences while the other two are about in the moment, getting some relief, but making things worse in the long term. And so a lot of times when people see that kind of written down, when they have that visual and they come up with it themselves, they really like stop and say, oh, okay. This helps me make my choice, right? So the how to do distress tolerance skills is really fundamentally about accepting reality and starting with radical acceptance. So I'm going to actually go in reverse order or a little change the order of this a little bit. I think for me, over time, I figured out that in a way has to start with willingness, willingness to go to start in this process of accepting reality. And I almost think of it as like a physical motion to look away from non-acceptance of reality and willfulness towards pondering the possibility of acceptance with some degree of willingness, right? So turning the mind is like looking towards instead of avoiding and willingness and sort of with some intention and willingness is about, I'm going to stop fighting this. I'm going to open myself to being willing to do something different or willing to just to tolerate some distress in the short term. Now this radical acceptance, I have to say over the years of teaching DVT skills, I personally don't use this term, which you might find shocking, but it's true because a lot of, because I, when I recognize how many people, no matter what the diagnosis, have these experiences of trauma, right? This is a, it's pretty hard. Either they think it means making it okay, that it was okay, that whatever happened happened to them or that it's never going to change and they have to learn how to just be okay with how things are. And it can cause a lot of people to lose hope actually of a better vision of the future. And I used to get a lot of complaints from my clients and in my own mind, I'm sort of sorry to say it took me a little while to make a shift when I started thinking I was able to make the shift and I was thinking, how could they not have a reaction? So I started to use this term instead of radical acceptance, radical acknowledgement. And as it turns out, I started using this years ago and as it turns out, that's the shift that happens in the radically open DVT. There's not this radical acceptance as a goal. It's radical acknowledgement as a skill, simply the acknowledgement of what is. And that is actually quite powerful. So on radical openness, we're acknowledging the presence of a disconfirming or unexpected event that can be a trigger, an activation of a feeling of tension, resistance, dislike, and then brings out this impulse or urge to attack, to control, or to avoid, right? So we're just acknowledging that it's there. And then after we make that acknowledgement, we practice that self-inquiry by temporarily, not too long, to just look inside and instead of judging the activation and the discomfort as bad or wrong, like being curious, substituting the judgment with curiosity. What is it that I might need to learn? What is this teaching me? It reminds me of when my daughter was young and she'd have a very distressing experience and I'd say, what's the lesson? It was actually pretty effective with her. So rather than automatically regulating and moving out of discomfort by regulating, distracting, explaining, reappraising, or simply accepting, to really be curious and ask yourself some questions. And then when we get those answers back or when we're actually kind of pondering and sitting with these, figuring out what's going on through self-inquiry, to be willing to respond flexibly, not always go to our go-to, our rigid responses, to respond with humility, with the humility of saying, there's something here for me to learn in order to do what's needed in the moment, to effectively manage the situation and or adapt to the changing circumstances in a manner that also accounts for the needs of other people, not just ourself. And then the steps for radically open living is this flexible mind with the acronym of DEF, Reflexible Mind Definitely, where we acknowledge our distress, what happens to us when we feel invalidated, criticized, or people don't believe us, when people don't see us as the best storyteller of our own, best narrator, rather, of our own story, which is invalidation. And then we use the self-inquiry to learn from the distress rather than automatically attempting to regulate, distract, change, deny, or accept, but we say, what is it that I need to learn? Time-limited, we don't linger there too long, but we're not just focusing on finding a solution, we're focusing on understanding what is showing up for us, right? And how this could actually be an opening into another way of doing things. Yeah. And then to be slightly suspicious of quick answers or urges to justify our actions, we're just using curiosity. And then we can flexibly respond with that humility to do what's needed in the moment, account for the needs of others by taking responsibility for our actions without shame, checking facts, asking questions instead of making assumptions, and remembering that what could be going on could actually be connected to our own physiological responses, not just in terms of what's happening now, but previous experiences that have created certain patterns in our brain and in our neurobiology, and not to overdo the problem-solving, not overthinking it. And then the self-inquiry skill of willingness to challenge our beliefs, and knowing that we're being impacted by personal bias and subjective experiences based on the past, and thinking and then going to that, knowing that we are responsible for our perceptions, beliefs, and actions, but doing that in a way where we're not blaming ourselves, where we're not going to that trauma-mind self-view that these things are happening because we're bad or incompetent, right? That they're caused by things, but not caused by us being bad or incompetent. And then affording that same kind of lens in our connections to others and to the world. And then developing the willingness to question ourselves when we feel threatened or challenged, rather than automatically defending ourselves or avoiding or disconnecting. Recognizing that in order to learn anything new, we need to acknowledge our lack of knowledge. Because once we acknowledge our lack of knowledge, we can stay curious and ask questions of ourselves and others. And always thinking, what is it that I need to learn from this experience? And then also rather than seeing our arousal or activation always as the enemy or always as a threat, perhaps it's helpful. What's the message here? Yeah? What's the message in my activation that's connected to what is it that I need to learn? But in terms of what's the message, then maybe I can turn my mind more towards change and growth. And in a personal effectiveness skills and standard DBT, what we're doing, attending to relationships, balancing our own personal priorities versus the demands from others or from the environment, balancing what we want to do with what we should be doing. Because when either of these, any of these are out of balance, it's problematic in the long term. And what can we do in relationship that builds a sense of mastery and self-respect? Yeah? In standard DBT, the building relationships is mostly connected to finding and getting people to like you, like engaging with them, finding what we have in common, the conversation skills, expressing likeness and joining groups, being mindful of others, building closeness through mindfulness, and ending and containing and avoiding any behavior or any relationships that are destructive or interfering, right? And we have that skill in a personal effectiveness that's really about ending hopeless relationships and how to be engaged while staying in wise mind, using skills and focusing on and staying safe. In flexible mind, which is radically open DBT, first we go in and assess our own commitment to improve the relationship. This is something we actually wanna do, the self-inquiry. Look for concrete evidence that mistrust is justified. Is it really justified that I don't trust this person or is this based on some other experience, some previous experience or just some assumption that I'm making that I don't even know is true? And then in order to, if it's about something in the past, are we willing to let go of some of those past hurts and fears? Not necessarily for me, particularly me and Anita Manley about forgiveness. And I know this is gonna be shocking. It's shocked a lot of people. I'm not really into forgiveness in the broadest sense of the word. But one time I had this pastor, a chaplain tell me that he wasn't either. He said, but what he would think of at those moments is how could it be any other way? Given what's happened, the causes, the conditions, how could it be any other way? And that for me allows me to loosen my grip on judgment, on past hurt and past fears. And then quote unquote out ourselves by expressing and revealing our inner feelings like actually sharing. So actually kind of moving beyond our vulnerability and our fears in the moment to like express what's happening. What are we feeling? And being open to the feedback and to continuing the conversation, engaging in the dialogue. So this flexible mind focuses on kindness, effectiveness, connectiveness by resisting the urge to control other people. Not always my strongest suit, but I really work with it. Identifying my interpersonal effectiveness goals and the degree of openness I am to really engage. Clarifying what the interpersonal effectiveness goal is that is my priority in the moment. And practicing kindness, like saying thankful for you. Grateful, I appreciate. I end all my sessions actually. Grateful for you. It's a very powerful form of validation. And the clients really feel valued. Often something they have not heard very often. And then we take into account the other person's needs. In standard DDT, we're working on accumulating positive emotions and emotion regulation, building mastery, coping ahead of time. And then this please skill of treating physical illness, balance eating, avoiding mood altering substances, balance sleep and getting exercise. Increasing positive emotions through activities. Again, some of these are dialectical because for example, they say shopping. For me, that's a dialectic. I love to shop and sometimes that's a problem. Just saying. Over control of emotions and radically open. DDT is about thinking about emotions and therefore reasons. What reason, what is there to learn? How the labeling, simply observing, describing emotions is beneficial to be able to name what's going on, what your experience is. And then the self-inquiry about what did I do? What was I signaling in my eye contact, my posture and the way I expressed myself, my rate of speech, my facial expression? What was I signaling to the other person? And then noticing my antinergists and desires, right? And just kind of, is this helpful or not? So one tool, important tool in DDT stand, this is a standard DDT diary card. Like the concept of logging, which is basic tenant, right? Logging and tracking in CBT, which is when you do the day, the trigger situation, what's the feeling and intensity? What's the urge? Did I use a skill? And then you can name the skill or you can use this rating skill, which actually starts with zero. Didn't think about it or use it, right? And even if they don't, there is benefit to tracking it and just noticing that pattern. And then say exactly what you did. And then in the far right column, what's your distress level short-term and an hour later, immediately an hour later. And they're just tracking that and noticing those sorts of patterns. These can be very helpful, these diary cards. On the back of our diary cards, we also had every single DDT skill that we taught. So it was almost like a flash card on the other side. Well, because when you're really activated, you can't think, right? You can't think of what to do, but if you have it right there, then you could just say, oh, I can do this, I can do that. So that's what we did. Now the diary card in a radically open DBT is very similar, but you're tracking what radically open DBT skills you're gonna use with the activation. And then I know I have to stop for questions and answers. So I'm just gonna, just this one more slide, which is a behavior analysis. And this is how I do behavior analysis in DBT. I did it after they already knew skills for the most part, somewhat as they're learning, but I would start with vulnerabilities, what they had a low tolerance for, what they had a history of, and what beliefs, all these things that make it more likely that they have a particular distress. I would have them name their target behaviors. What did they do that they like, were their target behaviors that they were trying, that they really wanna avoid? Then I'd have them name the event and the dialectical dilemma, which is right underneath. Then I'd have the goal, and you'll have this slide so you can look at it in more detail after. And the conditioned emotional responses, what showed up, what would be a reinforcement of the distress of the trauma? What's the self view that came up? What's the worldview that shows up? And then what would be the place of counter conditioning in the healing? All right, so as I said, I have to stop for some questions, a few at least, but you'll have this slide to look at it in more detail. So I'm gonna stop here. Don't panic, you can do it. Thank you. Thank you, Anita, for such an interesting presentation. And before we shift into the Q&A, I do wanna take a moment to 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 scales, and even submit questions directly to our team of SMI experts. So please download the app now at smiadvisor.org slash app. Okay, so we have time for just a couple questions. I wanna ask something first about radical openness. Do you believe that the therapist or practitioner has to practice living radically open themselves in order to effectively teach it to clients? Absolutely, absolutely. Because if we're not practicing it, we're not gonna be engaged with the client in a radically open way. And clients, especially those who've experienced trauma, they sense what's going on. They will sense that you're not matching. How are they gonna trust us if we're not doing it ourselves, right? Even with DBT and Lenahan's training group and with her certification process, she asked, do you use mindfulness skills? What skills are you using, right? Because we have to practice what we preach in order to be effective. To follow that up, somebody just asked, do you know any resources for practitioners to either to become more familiar and also to practice themselves being radically open? Yes, I would start with the text. Okay. Lynch, it's in the bibliography. Thomas Lynch, the skills training manual. I would start there. It's a pretty big book, but it's worth it. It does all of this. And I think in the back of the book, they have resources for engagement. I know like in Lenahan's group, she has the consultation groups all over, but you can also start your own like a study group. Like everybody in the group has their own book and you come together maybe once a week or once a month, depending on your availability and go through chapter by chapter. And that's actually how I originally really learned DBT after my initial training by behavioral tech was we had a weekly consultation and study group and everybody who did DBT had to be in that group. And we went through the book and then we also consulted with each other on how to remain DBT focused. So you could do the same thing with the radically open. Great. I'm gonna ask one more about radically open DBT and then try to get a skills question in there too. How does the therapeutic stance differ from standard DBT and regular or regular radically open DBT or does it? It seemed as if standard DBT might be more directive than radically open DBT. Absolutely. More directive and the energy is about containment, right? Management and containment. Radically open, the energy is more invitational to join you in the room, share space with you. Yeah. And that's the energetic difference. We're not focusing on containment. We're sort of saying all your parts are welcome here. Great. I'll ask a skills question. So a lot of people aren't able to do DBT skills groups, just because of however their practice is set up. So are there major or what are the benefits to doing DBT skills groups over individual skills training? And if you're not able to do it as a group, how do you recommend supplementing individual skills training in order to kind of get at that social engagement piece or whatever the benefits are to group? Yeah, so I've done individual DBT and sometimes I have had to because of scheduling or even the cost of it to do individual and group was kind of prohibitive for a couple of people. And I would say, then what you have to find in sort of a radically open way is willingness inside yourself to be the group, to really be a peer in certain ways and show up with your own vulnerability and share in an appropriate way your vulnerability, right? And your experiences to teach from your own experience because one of the benefits of the group is people share experiences and the client, oh, I'm not the only one, right? It's developing, it's co-creating that refuge and space for the group to the members to engage with one another in such a way that they are peers equals and talk about shared experiences. So how we have to do that when we're doing individual is we have to figure out plan ahead. What are my experiences that I can share in such a way that it provides that missing resource, right? And so I'm not engaging in this hierarchical fashion that I might, if I were facilitating the group and I'm the lead, but I'm more facilitating in a more egalitarian, more of a flat hierarchical process. If that makes sense, did that make sense? It did, yes, it did make sense. And unfortunately that's all the time we have for questions today. But if we didn't get to your question, you are able to submit a consult. So if there's any topics covered in this webinar that you'd like to discuss further, you can post a question or comment on SMI Advisor's webinar, ROM Table Topics Discussion Board. So this is an easy way to network and share ideas with other clinicians who participate in this webinar. It might be a way you can even start your own radically open clinician group through that. And if you do have questions about this webinar or if we didn't get to yours today or any other topic related to evidence-based care for people who have serious mental illness, you can get an answer within one business day from one of our SMI Advisor national experts on SMI. So this service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI. And it's completely free and confidential service. So SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. 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 could take up to five minutes. You'll then be able to select Next to advance and complete the program evaluation before claiming your credit. And lastly, please join us next week on July 1st as Dr. Shoyinga, Dr. Pat Deegan, Dr. Charles Browning, and Lisa St. George present Learning from Each Other, Reimagining the Role of Medication in Crisis Care. Again, this free webinar will be July 1st from 12 to 1 p.m. Eastern time. That's Friday, July 1st. Thank you for joining us. And until next time, take care. And thank you so much to Anita for your presentation today. Thank you. Grateful for you all. Thank you.

Dialectical Behavioral Therapy

Serious and Persistent Mental Illness

Skills-Based Approach

Anita Mandley

Integrative Psychotherapist

DBT Stages

Radically Open DBT

Emotional Regulation

Behavior Analysis

SMI Advisor