Suffering Motivation-Scarcity? Here's How to Effectively Use Your DBT Team and Commitment Strategies

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 role-play with the therapist playing their own client to get an experience of what is happening and what is needed. The group member role-playing 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)
a.      Skills deficit?
b.      Contingencies?
c.      Conditioned emotional responses?
d.      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? 
 
By John Mader, LMFT. Additional blogs can be viewed at www.dbtfamilyskills.com. 
Adapted and excerpted from Kelly Koerner's Advanced DBT Training of practiceground.org, with much appreciation!

Why Deliberate Practice? Getting Off the Amateur Plateau by Kelly Koerner

Kelly Koerner has generously contributed the inaugural TADBiT blog for the new triangleareadbt.com website. You may know of Kelly from her immensely helpful book, Doing Dialectical Behavior Therapy: A Practical Guide. We are pleased to share with you some her current thinking on the role of deliberate practice for therapists to become more effective in their application of DBT.

Why Deliberate Practice? Getting Off the Amateur Plateau

 

 I love this graphic by Kathy Sierra

I love this graphic by Kathy Sierra

Often performance improves but then levels off, stranding us on the amateur plateau. Our performance plateaus because we become "good enough" at what we do to solve our immediate problem. For example, early on through effort, trial and error, and supervisor feedback we develop enough skill to deal with many situational demands (e.g., early on we learned a way to do an intake session or suggest sleep hygiene ideas or assess suicide risk that seemed good enough to get the job done). Then these ways of doing things became increasingly automatic-it's easy and efficient to do an intake or respond to a clinical problem the way we have always done it. From the point when we reach automaticity of a skill, experience alone does not produce performance improvements. 

Instead, part of what's needed to get off the amateur plateau and move toward true expertise is a process called deliberate practice. Deliberate practice is when you choose to practice what you are not good at with "sustained, mindful efforts to develop the full range of abilities that success requires."  (Gawande, A. Personal Best. The New Yorker, 2011). Like the way a musician might rehearse a difficult passage of music phrase by phrase or an athlete might drill to improve a small but key move. 

Deliberate practice with feedback is the way to build real skill as a therapist. It’s about breaking a complicated skill into pieces, practicing, getting feedback, and trying again.

Try a Deliberate Practice Exercise. Here’s one (modify to suit you). 

The demands and pressures of a normal day often make us begin interactions off center, tight and task focused, irritable or hassled. 

This week, practice beginning interactions from a centered, open, friendly stance. 

  • Think for a moment: for you, what would an A+ look like (the stance you most hope for that is centered, open, friendly)? 

  • Pick one person, one day, or all week with everyone that you will practice, trying for your A+ version of centered, open, friendly as you start an interaction. 

  • Set a reminder (e.g., a note to yourself to help you remember to practice).

  • Then practice. 

  • After each practice, give yourself a quick letter grade to mark how successful you were at starting the interaction from a centered, open, and friendly stance. (This can be just a mental note, "OK that was a C. To be an A next time, I would...")

For example, I will practice with my 13 y.o. daughter. All weekend, each time I begin an interaction with her, I’m going to say her name (in my mind) while I smile and take a deep breath. That would be an ‘A’ for me. A C-, for example, would be me saying a friendly ‘hey’ while I keep typing on my computer. Got the idea? Don’t fret about getting a perfect practice. Any step, however small, to play with this idea will be great. 

Design Your Own Deliberate Practice Exercise. This simple sequence can be used to improve any skill you have as a therapist. Choose an area to improve. What would an “A” look like? Identify and then use a repeating practice situation, trying to hit your target. Then each time reflect: how’d I do? What’s one thing to improve next time? 

Taking the expertise research literature seriously leads to a different approach to teaching and learning as therapists. This motivates our intent at PracticeGround to be shoulder-to-shoulder with colleagues for the long haul, to work where things are hard, to build expertise that improves client outcomes. 

What might it look like for you to move off the plateau and into a mindful effort to develop your full range of abilities as a therapist?

* * *

Kelly Koerner, Ph.D., is Creative Director and CEO of the Evidence-Based Practice Institute, where she explores how technology can scale learning and collaboration so practitioners get better clinical outcomes. More information at www.practiceground.org

She is a clinical psychologist and an expert clinician, clinical supervisor and trainer in Dialectical Behavior Therapy (DBT). She received her Ph.D. from the University of Washington and has specialized training in a number of evidence based treatments. She has served as: Director of Training for Marsha Linehan’s research investigating the efficacy of DBT for suicidal and drug abusing individuals with borderline personality disorder; Creative Director at Behavioral Tech Research where she developed e-learning and other technology based methods to disseminate evidence-based practices; and co-founder and first CEO of Behavioral Tech, a company that provides training in DBT.

Her most recent publications include Doing Dialectical Behavior Therapy: A Practical Guide (Guides to Individualized Evidence-Based Treatment) and Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings.

Source: Kelly Koerner