The Skills System: An Emotion Regulation Skills Curriculum for all Learning Abilities

Our final final presenter Julie Brown will be joining us next she is program director of Justice Resource Institute integrated clinical services she is a behavioral tech trainers which means that she does training for in DBT for the group that was developed by Marsha Linehan so she still works in that capacity with Marsha Linehan she is the author of the skill system which is a modified DBT emotion Regulation skills curriculum designed for children adolescents adults who have learning challenges we'll be hearing a lot about that skills system she provides consultation on that system in the US

Canada and Europe she is the recipient of the American Association on intellectual and developmental disabilities Leadership Award I would like to highlight that I think one theme of this conference is not getting too attached to our labels our methods and I Think that what we're gonna hear about in in julie brown's work is very exciting because she saw a population where if we hung too closely to what works we wouldn't reach it there was need for flexibility and change and we got to i think we'll see some real creativity of how to reach people who

otherwise would not be served we have to take them where they are and i think that that what she put together really speaks to that so i'm very excited to Have her and in terms of dealing with individuals helping individuals with intellectual challenges this is really a perfect end to our day because it really speak to what are some things you can do when the issue is that there are intellectual attentional thinking difficulties we're gonna see in operation what this can look like so thank you very much for joining us Julie brown well I'm really

honored and really Excited and really cognitively dysregulated so I'm just I'm being it for you so myself together like I said we're gonna talk about some treatment options for folks with intellectual disabilities that expose that experience emotional cognitive and behavioral regulation problems also and I feel like I'm representing the treatment options but it's like batting ninth in this all-star lineup so thanks for hanging in here what an incredible day I'm just an Emotional fantastic day um I was thinking it's really interesting that I'm here representing the intellectual disabilities world is related to treatment because if

you think about it I'm a master's level social worker I'm presenting to you an emerging practice that's got pilot data and to be honest it's about as good as it gets in the disabilities world at this point so I'm just so excited that you guys are all here and just it's like a great big Family bringing everybody on board so they're thinking about this population through sort of mainstream means I just really appreciate that you're all here I've already made one disclosure I'm a social worker I'm out about it now I'm actually just went back

to get my PhD and so I'm almost like a born again social worker I talked about marginalization and all that stuff and I actually believe it now code of ethics term I my real code but the other real Disclosure is about the fact that we are going to talk about the scale system it really is a treatment tool it is not an evidence-based practice at this time it's a set of strategies that's really in its infancy really was developed through practice with my clients collaboratively so I just you know I'm hoping that it improves self-regulation

I mean it's really why I tortured myself at almost age 50 to go back to school so that I can actually get Data and learn how to actually use it so that's something I got to coordinate all this so let's just okay I did it use this Oh forward backward and a laser oh goodness okay more cognitive dysregulation okay so I figured um I talked to Seth about it and originally I was just gonna talk about the skill system but he and I chatted a bit and decided it might be interesting for you folks to

the folks might be interested in learning a little Bit about improving accessibility of DBT for folks with intellectual challenges so I thought we'd start there and then move into learning how to be skills masters ourselves so hopefully you'll actually walk away with a few treatment ideas but I think before we get started I've got this down that's for sure I'll tell you a little bit about my program I've worked for about 20 years now in Rhode Island and I've got treating individuals with intellectual Disabilities and very serious or acutely dysregulated behavioral challenges it is part

of justice Resource Institute it's a very small program and what we do is we provide individual DBT therapy but we combine it with the skill system for the skills training component I'll talk a little bit about how we got there in a couple of minutes but people with intellectual disabilities as well as all the folks that we've already been talking about today are at increased Vulnerability people with intellectual disabilities have much higher rates of victimization over three times as much they're also at higher risk for mental health issues as well as experiencing what they call

in the field is challenging behaviors and I think that's kind of interesting so the rates are very diverse on this from 10 percent up to 85 percent are some numbers around and how many people exhibit challenging behaviors Unfortunately there's not much treatment that's empirically validated out there for this particular population of folks that are really dually diagnosed with mental health and intellectual disabilities ABA is a tool that is used in some populations of disabilities but it's not generally used as much with adults living in community-based settings that are in the mild intellectual disabilities range due

to feasibility issues and consistency Additionally there's some research about CBT that looks pretty good unfortunately the methodologies are not fantastic as well as the measures people are using are more staff reports and and these like looking at hypothetical situating hypothetical situations there's very little with actual behavioral data that looks at generalization of skills which is really the main concerned with this population which is how do we get them to generalize into the context of their Lives so you go farm unfortunately there aren't many silver bullets out there for this group as well things like diagnostic

overshadowing there's a lot of side effects the communication problems with the clients unfortunately there's not really great data either way on that as well now although there's not a lot of actually they were I just was looking up neurofeedback I thought that was so cool there are a few small studies for that I don't know much about Them but they could be worth looking at for sure but there really isn't much data around adapting DBT for this population there are a few small studies but if you think about it DBT is really built to treat

sort of ingrained reinforce patterns of emotional cognitive and behavioral self-regulation problems and this population experiences those and it's a comprehensive multimodal treatment and this population really needs that so at First blush it's a it's a great fit I actually I'll disclose also that I fell in love with DBT in 1997 I was working a residential school half voice half girls that had that were duly diagnosed with intellectual disabilities and mental health issues and it was a fiasco there it was a you know it was a very challenging environment I had no idea what I was

doing straight out grad school and when Stanford you know the trauma expert said to me you want to go Check out this DBT it's for like suicidal women and have something oh that's a great application for me that's just gonna dump tail perfectly but I went there and I kind of as I was desperate so I went oh this is gonna be and Heidi heard started talking about the biosocial theory and and Marcia's you know it framework for emotional dysregulation and it was like everything just came clear to me I was like angels were singing

and I was like here's Talking about the kids that I'm dealing with with intellectual disabilities and so it was really a starting point for me I then harassed my boss for the next two years and was able to get intensively trained and I remember the moment of like getting my certificate at the DBT training I don't know if you guys play several of you that have gone through this but she's like dance at the end and I like actually did a cartwheel and Cindy and Charlie were there was so Psyched and such a loser but

I was pumped no seriously and I'm like I'm going back to Rhode Island and I'm gonna be adherent is I don't want to make margin mad alright no I the marshal looks like my mother but that's a whole nother I'm not going there for this room I'm not going there so anyway so I the good news was that I found that really let's go to the next little slide I found it you know maybe It's a stretch maybe I'm just used to dealing with this population but the fit for individual therapy was not a million

Mouse off I felt like I could definitely make accommodations that were making that work and it was really an important part of what I saw the is what was effective about DBT for this group the skills on the other hand was a little bit of a challenge and we'll get into that a little bit more um so you you are you may not be treating people with Intellectual disabilities and when I say intellectual disabilities the people that I treat have IQs between about 45 and 70 so we're talking folks that have very very limited intellectual

capacities very very but not like they're pretty but everybody is verbal that I deal with but they definitely have very impaired learning capacities so you probably you may not be treating that I know I have bumped into some folks that are treating folks with Disabilities you may not be treating them and you may also not be using DBT but I hope as we talk maybe you can just you know find a few helpful hints in this about dealing with people with serious learning vulnerabilities so the folks that I deal with definitely reading and writing is

a barrier and so instead we use communication sheets in conjunction with the diary cards and the diary cards are really secondary it's very important when we do the behavior Analysis part of DBT with this group especially people that are exhibiting a lot of stage one high end behaviors that we have good information so that we can really do the behavior and solution analysis because folks that have recall problems in memory and executive functioning and sequencing problems it's really hard to get a clear picture within the time that we have for individuals there we use a

lot of written forms which is Sort of ironic but we read them too we sort of you make sure that we read it read things to people and things like informed consent we take a lot of time on that because folks with intellectual disabilities that have you know been in the system for a long time it's you know it's their sense of identity and their sense of their sort of over compliance sometimes in the system is really prevalent and so we take a lot of time to make sure that they really are Interested and doing

engaging in this relationship so that's a little bit more pronounced all the DBT strategies we use by the book with when we'll talk about the the the quickstep assessment helps make the adjustments and that's actually the next thing we're going to talk about but the stages the hierarchies validation contingencies I think what we do a lot more of though is orientation because folks with disabilities have a hard time with transitions and so Helping orient people the shifts in the treatment shifts in the conversation and in the focus and orienting to what what is going on

is a really useful tool like I said behavior analysis is impacted by people's memory and sequencing capacities it's a slower process we definitely use a lot more visuals to sort of chart out finding the doing the chain analysis treatment itself has a longer time frame and like I said we had to change the Accessibility to the skills folks that have been that had these issues and have trauma issues have a hard time with novelty and so and and have a difficulty like I said with transitions and so I think that has to be sort of

in the forefront of our mind developmental issues actually we talked about behavioral treatment planning I think that you know it definitely is a part of the treatment but it really does have to be negotiated with the person carefully Just applying I've talked to certain people feel like you just intensify behavioral treatment planning but that's just you can't use that as a broad brushstroke it really is a process with getting the person integrated into the process so that they so yeah they're not just getting acted upon by the environment that there are actually collaborators in that

and that's an important issue when we're dealing with these folks sometimes There's a lot of polarization between staff and and the consumer and DBT is wonderful because it really creates an egalitarian sort of playing field where it's not sort of I'm smarter than you you're you're you know you're not so there's that there's no fewer power struggles and for this population it's really important to really clearly define this as inegalitarian relationship and that's really that allows that identity that we've been Talking about today just to begin to sort of be mobilized and that's a big

part of what the skill system is about is sort of engaging that sort of identity okay ebrill Trina I talked about that okay we also do integration of services so we do wraparound supports I have to say it's really challenging sometimes to get teams to function as skills coaches and we get into a lot of systems work within the agencies and I think that's sort of One of those things that sounds really easy well we'll just train staff to be skills coaches sometimes it's just really difficult and that's it's really one of the next things

I'd like to master if I possibly could okay all right the quickstep assessment is something that we developed i actually developed as just it's really just a common-sense tool it's based on on the work of sweller with the cognitive load theory and it just I had to transfer the Idea of what it's like to sit with a person with intellectual disabilities and make the adjustments that have that we have to do when we're trying to create an intervention so the first step is to to assess the cognitive load of the intervention and we'll talk about

that in just one minute the second step is to evaluate where the person is at in that moment with their level of cognitive regulation and the third is to make the changes that you need - in the in the intervention we just go over this one quick quote from sweller about this cognitive load theory is a is concerned with the learning of complex cognitive tasks in which learners are often overwhelmed by the number of interactive information elements that need to be processed simultaneously before meaningful learning can commence I just love this next this bit of

information that he gives us so these are the these are the elements that Increase cognitive load and and that impacts people's learning capacities and their ability to process information so when there's simultaneous processing of information or new information or high volume of information or interactivity of information retrieval of divergent information rapid shifts without transition from one topic to another strong emotional responses to information and strong emotion and strong emotional responses to the Intervention so pretty much everything increases cognitive flow so what do we do what we what are we so step two so it's just

paying attention when you're going to be doing something is what I'm doing going to increase cognitive load it's really important for us to be proactive and understanding that what we're doing is going to be part of the transaction with this consumer / this client and so we really have to be mindful of what we're asking them to do And which things on this is it going to be triggering cognitive dysregulation okay so what do so then we start looking for as we're moving through an intervention we want to see how somebody's reacting to it do

we say signs of confusion are they becoming unfocused is there some sort of avoidant looking behavior are they experiencing discomfort or what might look like well willfulness or resistance and some of it that resistant client I'm sure sometimes Has to do with the fact that we haven't designed things properly and that people are just having a really hard time with what we decided to talk about and how we're doing it so here are just some ideas about things you can do in that moment when you start seeing those signs of when people are dysregulated we

can try to simplify the concepts you can do a task analysis sometimes that's a common problem is that we don't see like how Many steps are in something and like they get jammed up on one of the early steps and worse we kind of in our minds are oversimplifying how to get there we don't see that there are some intermediate you know processes that are going on that they're not they're not able to transition through worked examples kind of give people the right answers don't make them have to go and search sometimes so showing them

how to do it Correctly through like modeling is is helpful shaping obviously of interventions validating the person's experience positive reinforcement and then contingency management just sort of letting people know sort of how they're doing okay great all right so I here's the cover of the book and it's called the skill system instructors guide and in this present the skill system and it's got like all the all the curriculum materials you'd Ever need and you can you can get it through Amazon for like 29 bucks it's it's a really inexpensive set of very comprehensive tools for

people and so let's just take a second to look at our data our little pilot data that Milton Brown did with me thank God because he's a fantastic statistician we had an N of 40 of folks with intellectual disabilities that were at ICS for at least one year they all demonstrated challenging behaviors their IQs or the Mean was about a 59 something and then and the I cute like I said that was the I kid in the ages the mean was 36 everybody also had a mix of mental health disesteem I got to put that

in here but notice there is no control group so it's not an experimental design we broke it down into three levels of risk red-flag behavior is like low-risk sort of non-compliant behavior dangerous situations just like threatening Behavior and then laughs behaviors are sort of really sort of violent aggressive or problematic behaviors that break the law we looked at demographic information we took behavioral outcomes over a four year period there's a lot of data in the disability system because people when they have a behavioral a treatment plan you have to you do a lot of tracking

of behaviors so we're really fortunate that way that is one of the strengths of the study and it was long It was longitudinal in it was four years we used the repeated measures design and some hierarchy when a linear modeling for some of the associations we did see if you can see that well the data looks pretty good I mean so um where to pick up four numbers um so the red flag behaviors came down really quickly in the first year with this combo individual DBT and skills training down to a point zero zero one

significance of change and in the dangerous situations Was a point zero zero three level of significance and then in laps behaviors and so you can see that and it's really kind of interesting here they're in dangerous situations that come and goes up although not significantly but it goes up a little bit as the lapses go down that kind of cool that's gonna say to me all right that's threatening and they're not doing so that's just kind of cool but I love this sort of trajectory they're on the laps behavior where it Comes down then it

kind of doesn't significantly go up but Italy goes up and I kind of see that as that sort of adolescent I'm all that and a bag of chips I'm trying to get my you know I'm kind of working with my team like it's and it goes down further eventually and that's at the four year mark and so I think that's sort of it's one of the fewer articles that's impressed right now with the Journal of mental health research and into like in intellectual Disabilities but it really does sorta for the first time talk about the

fact that the treatment needs to be longer for this group so the design of the skill system well talked a little bit about it and this may be relevant for what we've already talked about today a little bit so the skill system is built as a series of skills that are over learned to help span the duration of an emotion Marsha talks about sort of a slow return to Baseline on an emotion and a lot of times if folks are just using like a single a single skill application what we're looking for is really spanning

the entire experience and we talked today also about the ability to be in the present moment you know when someone doesn't have any regulatory capacities and an emotion can be a very hot hot difficult thing and so it we really are working to increase self-awareness in the moment and being able to be in the Present as it is it makes me think of you know I I think about my clients that what it's kind of like you know one of those movies where the guys running through the jungle and he's got the machete and the

bad guys are chasing and he's coming and then and he and the girl are there and they get up to the the chasm like that and they stop and it's like oh my god they almost fall over and they look and they look up and what do they see they see a bridge but that Ain't a good bridge is it it's never a good bridge it's like a vine and a piece of metal and like one piece of wood and they're like holy what are we gonna do so so that's kind of what I noticed

with my clients is that they're they're running and they stop and they just don't have the skill and this sort of is so them stepping through an emotion where they have to stop and say they just don't have the skill to get across it so we stopped and so what I'm hoping In theory the skill system really is about them placing boards in that bridge so that as many as necessary to spin across that entire experience and and be having the capacity to do that to be able to assemble their own skill chains helps them

manage novel experiences more effectively so the the skill system is also as far as cognitive aspects it's designed to to facilitate recognition and recall another silly story i guess i have a lot of those is i Went fishing once of my dad it was a big day and he usually dragged me out fishing like long boat rides we've never caught anything he was he was having a blast it was torture but this one day he took me out and he's like we're gonna go mackerel fishing i don't care alright so but it was cool about

it is on the hook they were you had the line and there were six little hooks and what you did was you put it in and yeah caught six fish at one time so i'm like why do we Do the other stuff why what's wrong with mackerel i didn't eat any of it anyway obviously it's oily anyway but i know is a bowl was fully beautiful fish anyway so what's that got to do to the skill system but it's basically the idea the design of it is the skill system is built like that that line

of hooks that once they start it because it's all connected with the skills that you can start the process and it all comes out because it's as folks learn it as a System and so ok so the other thing is it's structured as well as flexible and that's really critical for managing humanity i think in the disabilities field it's really common for things to get oversimplified and kind of dumbed down I hate that word but it's kind of use and you'll say well we got a board game to fix that you know and we're not

looking and sometimes there's also this misnomer that we're looking at squashing or repressing emotion getting people Just to be compliant and that that's what teams are sometimes seeming to look for that's not what the skills isms built for it's really to help people experience a full range of emotion just like physical therapy getting a full range of motion of like physical motion this is about getting the full capacity to experience joy and strengths and love and intimacy and making money and you know doing all the things that sort of create satisfaction for people it's Important

that people with disabilities have access to that as well and now that turbulence that is life is important to have a system that they can actually navigate that through that wind and you know I think from all the reactions that people have from their you know past experience before therapy you know there's a lot of ingrained sort of maladaptive chains of behavior and ingrained patterns and so what we want to do is create a system where the Chains of the adaptive capacities and adaptive skills get really more reinforced on it actually also by having this

prosthetic and system in place and it really allows people also to to engage in contextual learning because it function it's almost like a prosthetic or a template for them and so when they go into context which are very very complicated when you're a person with intellectual disabilities this the situations that they live in are really Complex they the day programs have a lot of people that have a lot of issues a lot of behavior problems and you're dealing with staffing it's it's not an easy life in a lot of ways and so being able to

learn and utilize something in that when they're at a very high level of cognitive dysregulation it's important that that it's over learned so that they can then recall it in those high-stress situations ok so we're hoping that folks get some Behavioral control by being able to make effective transitions and like I said constructing those chains and it's really helping you know we talked about navigating and difficulty navigating with the earlier talks today this really functions almost like a map for people you know it helps them manage the variables they're internal and external variables in an

organized kind of flexible way so that they can they can sort of navigate both of those internal And external environments more effectively and more consistently the other thing is the developmental piece I think Bessel was talking about it's really cool he said experience itself the way you are and that really is sort of how the skill system is built because the skill system doesn't mobilize a lot of like this is right this is wrong the pros and cons the cognitive exhorted explicit thinking it's really tries to get at wisdom it tries to get to that

Inner voice that inner capacity that all these people have and its really mobilizing their strengths not their weakness and it has a double bang for the buck because not only is it a strength but it's also a really important part of identity development to really get that sort of sense of self you know activated in their life context it also creates you know art in these systems that creates a common language between people in group as well as in Their in their group homes and and that can also expand learning um also gives people environmental

tools to use in their environments we're talking about manipulation before it's like no I want I'm gonna train my guys to be manipulative they are going to be very very manipulative they're gonna be getting what they need from people and that's really what we really work on being effective and trying to to manage these very complicated expansive teams Of people that are supporting them and so the skill system is an important part of that okay now enough talking about that now you have to start remembering stuff all right there are how many skills the skill

system nine very good skills masters I love that all right you guys are good alright um okay so adapting back to that adapting question okay so I came back to her down and after getting trained was really gonna do it Well the first sign was when the bell went flying out the window that I said that's not a great sign and I'm a pretty good teacher and it wasn't working and then I just had this sense that I was actually in fact torturing my client and I had another you know I was I was like

I was better I was it hearing so there's a real dialectic there and so I just kept I had little flashbacks to of like when I was a kid I had my sister 7 years older and she was wicked cool and She didn't like me very much which was kind of made me sad but but every once in a while I was like twice a year she'd say to me she'd go so Julie you want to play cards I'm like what do I think yeah oh my god so inside I'm like oh my god my

sister wants a card she thinks I'm so cool we're gonna be bonding I love this and she's like yeah 52 pickup like every time and I get that look every time like you're like in a movie so it's like I Look down and it's like everywhere and that's kind of what I mean I look I love DBT as much as it can be loved but unfortunately the way that the skills curriculum is put together it's not really user friendly telling people sort of what skills to use when and so I kept I would I sort

of think about 50 to pick up because that's what my clients they just didn't have the capacity to draw things together in these contexts where they're totally dysregulated and they Have a 45 IQ to boot so and sometimes the mnemonics are a little bit challenging alike my favorite is Elle and please what's L for please you know treat physical illness with Elle oh no I'm sure it's very good no it's just not hugely intuitive but it's just it's just me okay now all right let's go no it's it sounds like Marsha bashing but it is

not Marsha bashing okay you can't barely read this and I managed To mess up your handout a little bit so you have a different version sorry sorry sorry about that but everything that's on this you have in your whole little packet so try not to to get too upset about that but let's just go through these so um so these are the nine skills and you'll notice that we try to get the language to reflect the action that we're looking for the person to do so let's think about what's implicitly built in to the concept

of clear picture And it's number one for a reason it's first so what do you think clear picture well we're gonna say it's probably clarity right the sense that the first step is to be aware of your internal and external experience in the moment and it just doesn't end there you know it's it's that's just the the first element so there are six parts of it I'll just read through them quickly this is what you don't have but it is later okay so the first thing is and These are not in any particular order but

we basically learn them in order but the six constant concepts are take a breath notice your surroundings label I mean do a body check label and rate emotion notice your thoughts and notice your urges okay the point is really to get a 360 degree view sort of have outside an inside and we're not talking about this like oh meditation thing we're talking about a quick snapshot that helps you understand where you're At where everybody else is at my clients talked about it taking about between two and three seconds usually to get a clear picture and

they're amazingly good at it the next one is on track thinking let's think about what's implied there I'm very sensitive to the term on track I hear it everywhere which is a great thing that's the point right we want to be mobilizing the common knowledge that people have that that are intuitive and so on track Implies a goal potentially and the idea of thinking and being on track is thinking that's going to be on track to your goal now within that there's a few steps and we'll talk about that but I just want to prime

your memories a little bit get it in there that first time the idea is to sort of reflect and then check remember we had a clear picture the last step was notice the urge up there the transition point to on track thinking is to check the urge and That checking process it's thumbs up for an urge that's going to help you get to your goal and thumbs down for urges that are not going to get you to goal and this is where this wise mind concept or inner wisdom or just what you think is right

in your gut really it should be down here and you're good I suppose but I have it near my heart usually when I do it with my clients and that's sort of you know and these guys are really sensitive to what We want them to do because of some of the issues around supports and so the idea of really getting people to sort of Center down to what it is really that they want isn't it is is a very important process and it's hard because the folks that supporting these people are pretty traumatized too and

so they tend to kind of rush and unfortunately that's not overly useful and then starts power struggle and so really that idea of taking time to really make this self Evaluation of whether this actions going to be helpful or not helpful the next concept of it is turn it and that's sort of turning it to on track thinking sort of you know working with sort of off track not helpful thoughts and turning it to on track thoughts okay so let's look at on track action what's implied they're the same thing we have okay so we

have on track thinking it's thinking about doing what's on track and then the the next key part is on track action Which is taking it not you know talks pretty cheap we've got to be moving it into action when I had James gross the editor of the emotion regulation handbook look at this material he was terrifically helpful but he was really stressing the idea of this this triangle of clear picture on track thinking and on tract action really being the core concepts that are very very important okay well go kind of quickly through These so

just safety plan pretty obvious what that's about right that's looking at how to manage your own sort of situation in the safe way we'll go into more detail about that the next one is Noomi activities that's sort of all the things you do during the day and will break down different types of activities and the different functions that each one can fit I mean and that gets into that cognitive regulation emotion regulation sort of about what you do has A different impact on your body and on your emotions and then the problem-solving that's obvious I'm

expressing myself that's fairly obvious and something called getting it right is actually the equivalent of deer man in and DBT and this is how people get what they want and this is a very important skill for this population because they have so many people to manage and getting things and they have very few resources and so they really have to Leverage their capacities very very well and effectively to get what they need and the last one is relationship Karen will talk about that too okay all right now we've talked a little bit about the skills

and but now okay so you have skills but the whole point was the time all together right so we don't we we've got to talk about the difference so there are three what we'd call system tools little guidelines or rules almost for putting them together and these go Along with the nine skills that they learn and so the first one here is called the feelings rating scale and we'll go to that in a second it's basically a zero to five scale that we use to rate emotion hang on let's just go and the second one

is categories of skills the skills are broken down into two categories one is calm as one is all the time skills and the other one is calm only skills and then the last one is a recipe for skills so let's just go Through those so this is our feelings rating scale and it's really not a feelings rating scale but I couldn't call it emotional cognitive behavioral rating scale because that would have really been like that would have been not not really a good term and so we use the feelings rating scale and basically it's how

folks rate emotions and you remember when we looked at clear picture a few minutes ago when it said label and rate Emotions and getting a clearer picture this is that scale zero to five that folks use now basically a zero up to three is the range where people are basically cognitively regulated obviously three is a stronger emotion than a one but basically in that zone people are able to be effective in relationships they're able to have what we would say a two-way street relationship with they're listening and they're talking and they're still being Able to

be effective once they cross over from the three into the four zone that's when the straw it's a stronger emotion the cognitive dysregulation is kicking in more as well as the behavioral dysregulation as well then the the transition and they're they're really only able to do one-way street relationships where either they're expressing and they're not hearing you know or vice versa and then a5 there's a difference between four and five because Of five is when someone is out of control overwhelmed to the point where they're hurting self other or property okay okay great sorry about

that okay here's here's um now the feelings rating scale is very important because it helps us understand what skills that you can use in the moment and I loved what was it Gabriela that said strike while the iron is cold this morning that was great this is a lot about what this concept is About it's really about doing certain skill see the first five skills clear picture on track thinking on track action safety plans and Noomi activities our skills that are really done independently sort of with the independently the person with themselves and you can

use those from a zero to five emotion and so really if the person is over a three I II really upset these are the skills that they focus on first and and the second set which are called Calm only skills which is problem-solving expressing myself getting it right in relationship care you only use zero two three when you're able to be interactive these skills are obviously more complex they involve other people they involve people saying that word no or maybe which is really difficult it involves people having opinions of their own and it that you

need to be very strategic to be able to use these skills so it's really Important that people are cognitively regulated emotionally and behaviorally regulated as well I would have to say that about ninety nine per no data to support that a lot behavioral problems that my folks have are when they're using their comm only skills when they're over three they're off very often they'll come in will do a behavior analysis and they have given somebody a piece of their mind well that's expressing myself or they've Run away well that's kind of like problem solving and

so is you know they end up sort of trying to get stuff and they're screaming at people and so it's getting it wrong instead of get it or right so those are the kind of things that that so what I like about it is that when you are doing behavior and solution analysis you're really looking at that when people you know have target behaviors during the week it's often a Skill breakdown that it's like that they just chose the wrong skills that weren't as effective in that moment and in that way sort of depersonalized I

said a little bit it's really oh you know and the idea isn't you know because when there's trying to do safe problem-solving areas a commonly skill those skills are really really important for this population because you know they've got to be able to be activated and manage themselves in their Environment so it's not that that we don't want them I don't want them doing problem solving it's just what you wanted to is do the other skills first until your level of escalation comes down a little bit and you're able to step back and then engage

in in the in the skill when you're going to be effective at it and so it really builds in some delay at that point it doesn't it doesn't mean not do it okay and the last one we saw we've got our feelings So we've got that first two tools are your feelings rating scale zero to five we've got our categories of skills and now we've got our recipe for skills now this says that you basically for every level of emotion you add a skill or if every level of emotion including zero you use a skill

so a couple of things so at zero we need to be using one skill I bet you can figure out that it's probably clearer picture that we need to be doing all the time and then and then At a five you need six skills and so we talked about is stringing together two nume activities because you notice that the um categories said there are only five skills in the first category so if you're at a very high level we're saying and need to double up on one of those in the first category okay so this

is kind of what it looks like this is one of those little chains and there's no particular it's just just a visual on it so the dotted line represents a more Dysregulated response of you know a very sharp quick this is like for a level a very high level stressor where it goes up and then you see that slow return to baseline up top on the jiggy jag and then sort of that exacerbation sometimes when they start coming down and go back up with what you might think would be a relatively small stressor and so

the alternative is to become aware of the emotion sort of early in the experience As early as possible in the experience and you can see the pictures here represent clear picture on track thinking on track action in this situation the person used the safety plan and a new me activity and the new me activities they chose were video games and listening to music and the point is really to kind of bend the top of that emotion a little bit you know to help them tolerate the distress without bumping out and then once you sort of

Get regularly then you're doing that when your emotion changes again or when a situation or your your levels change you start back again with clear picture and on track thinking and on track action and so really it's like this for evolving skill use throughout the day when people first start and group it's kind of interesting because I'll say I'll say something like so how is clear picked how many times should use clear picture this week and sort of some People the rookies will say or used it twice and then rinse I'm going to look at

me like Julie how can I count as a clear picture I did it like thousands of times this week and it's been really I can you know it's like re I'm strategy key and so that's really true is that they're using it all the time and it really gets integrated into their experience okay all right so we have okay so let's so that's sort of the overview now let's take a couple of Minutes and start looking at each one of the skills I can't guarantee him and get all through these because I am just horrible

time manager but if you don't get all the way through I'm really sorry okay so here the six clear picture do's and I know it starts with a breath but it's never really the first one because usually it's some other event whether it's something in the environment so you're getting aware of your surroundings first maybe it's a feeling That that sort of triggers the need to use skills it might be a thought that pops in it might be an urge but what I try to help the folks talk about is that it's important to then

follow that with the if possible so so it would be maybe a feeling than going to the breath notice the thoughts so we're looking at is really trying to expand awareness through the sort of structured way of the of the current moment okay one of The things too is the breath is so critical and it's you know we talked about the macro fishing it really is that trigger that cue that starts the whole process physiologically it already it also sort of starts the process of relaxation or at least it's really about focus it's not necessarily

relaxation that's actually focusing attention and emotional deployment on the breath kind of moving into the belly area if possible or wherever you're you're Focusing attention whether it's on the nose of the chest or the belly but it's at attentional deployment to start bringing awareness to their internal experience the other cool thing is that doing the breath it really does trigger that sort of sense of centeredness and that sense of internal sort of wisdom and capacity and that sense of sort of connection that touchy-feely connection to your self-concept and it's really nice that So so it's

really a concrete activity that they can do that starts this important process okay so if somebody says to me oh you know I'm really I'm really mad I'm just want to punch him in the face my comment is gonna be good clear picture it's very good you know I'm happy with that that's really actually a really excellent clear picture I mean I've done it yet you know but they're they're telling me what's going on and so I Think sometimes if somebody were to walk up to somebody and say that it'd be don't do that you

know so that's sort of one of the differences with clear picture it's about observing and describing what's there and expanding that capacity another thing is like the feelings rating scale the clients will say to me I'm gonna I'm at a 10 like alright so that's pretty good seems like you're pretty upset I said are you hurting yourself oh they're property Well no I said well then I'm a okay right there right there's a nice little de-escalation just a really simple intervention they're really kind of mad they're two four all right that's true I mean if

that's what it looks like it's really true it's not to invalidate cuz it feels like a ten it really does feel like a ten and it's kind of this at reframing their well actually I'm enduring this and I'm not beating you up And hurting myself and I am actually sustaining this sort of for and to be honest with you they're probably technically at a three at that point because they're able to have a reciprocal conversation where they're listening and I'm talking and they're probably feeling miserable but at a three okay all right so we talked

a little bit about the feelings rating there and getting a sense of you know part of as they go through I didn't Really talk about it too much but so part of this is to part of clear picture when they do do the breath let's make sure there are three components of clear picture that are really important in your coaching I mean it's all important but if you had to do a quick and dirty on it you'd want to make sure that you we coach the breath and we want to make sure we get the

feelings rating why do you think that's important why do we need to get a feelings rating when we're Coaching this good answer it tells us why what category what category to use remember so it's really important that so if I know that I'm at a level two you can look at your handout and cheat that's really fine it's a worked example so if I'm at a level two what skills can I use all of them very good I can use both categories I can talk about contacts I can talk about people I can talk about

any and do problem solving because I'm the level two why I tells me Something else to I'm at a level two I can use all my skills which is really really important information at the same time it tells me how many I have to use right because of my recipe I need to be using at least three skills okay and that's part of that understanding that it's the idea of sort of a responsibility to multiple steps and that's and just having people understand that it's not like alright I did one skill now I can Put

my feet up and not do anything else today I'm it's started you know the recipe kind of started along obviously only time ago but I remember clients coming to me and say Julie I took a breath alright it's like I didn't want to get into the math but it's like one-sixth of one skill right so it's just not enough okay okay great so here's our transit so we have our transition we notice the urge we're gonna be checking it so here we go we Went over that a little bit with checking it using the thumbs

up thumbs down and turning it and it's really important to like the clients that we're dealing with this sort of sense of turning it it's almost like this gets really rusty and to be on track sometimes because they sort of have a lot of off-track thoughts and a lot of self devaluing thoughts and so these are hard to mobilize sometimes but when they say when they first start what I notice Is that it's mostly about sort of consequences like if I do this bad things will happen I'll get on restriction or I won't be able

to go in a trip or something that and what evolves later is more like well you know if I do that it doesn't help me get to my goals they become a little more conceptual like that's really not who I want to be but when we first start out I have to say the the the turnit kind of thoughts are generally about bad stuff Happening but you notice you know as hard as it is to turn sometimes it's like got a really but it's like like very slippery on the downside and so these old behaves

old thoughts come back really quickly so we have to do a lot of turning just that they have a lot of ingrained sort of thoughts okay the last part of Ontrack thinking is about making a plan that's sort of thinking through the options that they've got and so in that they're going To be thinking about all right what acts what skills can I ask and you know doing how many do I need to use although I think probably that the recipe is a better retrospective tool when you're doing solution and behavior analysis because most of

the skills masters that I choose that we have they understand that that recipe thing is really just a the first step it's really about using a lot of skills you use way more than the recipe they use these long Long chains and not just two or three because that's just not going to be as effective as when you really pile up the skills in a certain situation and so they're out skilling a situation and really slang it so that's they get pretty excited about really cranking on that and then they decide sort of which you

know so in high-risk situations if they've got some danger they know the safety plan new me activity is an important thing you know if they're Having some distress about their plan or something like or rules things like that they're gonna be thinking problem-solving but they're so P owed about the rules that probably what's going to happen is they'll have to do safety plan new many activities till they're in a good space and then get some help and sort through sort of how to do the problem solving you know things like that that's the thinking is

sort of what skill is going to help them Get there get what they want and it's really a dialogue I think that there's a really important dialectical process that goes on in group skills groups are a blast they're easy to run at least the folks with intellectual disabilities on I do a transitional age youth group of non-disabled people and adolescents and that one's a little trickier but I believe or not so a group runs really really well and when people sort of have the dialogue about what skills to use And they're all debating and talking

about what skill and we talk about a context and what skill was that well was that this or was that that was it getting her right I don't know I was expressing myself you sure Julie was that an Ontrack actually like these dialogues are like very interesting sort of dissections of situations and they have a ball doing it and they get very savvy at understanding the concepts in context Okay so then we transition to entre so here we are they're sort of on track an off-track motif that we talked about and it's really important about

staying on track but honestly how much do we stay on track really right we're not on track all that much so just being realistic about the idea that that's slipperiness I mean we're all pretty slippery with our goals and sort of understanding that tenuous relationship that we have that changing relationship And one of the speakers talked about that this morning sort of about being being realistic about sort of our capacity is forced assistant or sustainability on goals is important so really equally important is the idea of getting back on track sort of once you fall

off and so the main concept of an on track action is really that first action that you take in a situation so if I feel like I want to throw the clicker at my house mate because he's Being incredibly annoying my on track action would probably be a safety plan at that point because I'm up at about a level four and my on track action would probably be taking the clicker that's in my hand and putting it down on the coffee table okay so that's our just an example of that first thing you do does

having some off on track thinking isn't isn't the end of it you need to be actually executing that on track action but there are also a few other concepts That are important in this skill so the idea of switching tracks is helpful this folks get kind of problem focused or they get kind of what you might call stuck or off-track and so we talked about is that attentional deployment or actually behavioural change an activation that needs to be shifting in another direction we call switching tracks the other one cool thing is something called an on

track action plan and this is really sort of things that People do proactively during the week and during their day to help manage their biology you know it's things like balanced sleep balance eating you know engaging in work and balanced ways doing yoga or you know all those things that you do to sort of keep yourself sort of on track and so when when disruption does come from inside or out there in a little bit better position to manage it they're less vulnerable physically accepting the Situation is really hard and and important to do sort

of when you've already done everything and that's a tricky balance sometimes just making sure that the helping the person understand that they really can do everything that doing everything they can is really important to solve these problems because it's really easy to get disenchanted living in these systems that are so how to describe it but for folks not in a disabilities world it's They're very challenging environments that tend to be pretty entrenched and in the way that they work and and so except there are times like they have to deal with being quick waiting they

just wait a lot more than we do they're like waiting for vans they get right on vans with people they don't even like they got staff they can't stand I think there's a lot of acceptance that goes on as an intellectually disabled person and so there are times and you just have to Coach on track action and except the last one is letting go let it pass and move on you know this gets into sort of that time where you're saying all right you know you know you've spent you know we spend quite a lot

of time and in the moment with an with an either a thought or a feeling or a situation like that and it's sort of when you say to yourself all right this is actually causing me to increase my emotional arousal versus decrease and I'm kind of Ready to bring that arousal level down and so it's sort of that you know it's that attentional deployment again sort of our situation change to try to sort of move into another direction okay here's the on track action plan I just love on track action plans these are just things

in the curriculum like that it's all like is all this like things are in work all the worksheets and you can and then you can copy a copy right you can copy them and then you can use Them in individual therapy like you know that's kind of a fun activity just like having people set up their on track action plans I like this clip art look at that little guy I know I need to get a life don't I but but that's a cool one don't you think I love that little guy these guys worries

memories painful emotions look at them all all right I just show that just so you can see how cool it is all right so here we go all right so you got The three so we got our little triangle which is our clear picture on track thinking on track action right and then the next sort of on track actions that they can take at that point at any level would be safety plan and Noomi activities which we'll get to and then if they're if they're below if they're above a level three they don't have access

to these but if they're below they can do problem-solving expressing myself getting it right and relationship Care I'm just kind of visually helping you get a little picture of that now we're gonna watch a little video these are my clients all the releases they love this stuff it's on my website so I think I hope you enjoy it now they're yes Todd you're in the stage left is the Savior all right wait I'm gonna try this all on my own all right there we go what it's so close to just do it so we don't

have a lot of time and so What I thought we could do oh very good really quickly and like we have like five minutes okay great skill number four will do we can talk about the video too after if you want I never get tired of watch them because I do all the video editing I just I love it so so safety plan is skill number four just amazed I'm gonna give you the zip through really really quick on these so it's just they learn how to rate their risk unfortunately folks sometimes Over eight their

risk being too high and they get really avoidant or they under rate and get in tough situations so safety plan is really about having a clear sense of what the actual risks are different levels engaging thinking talking and written safety plans understanding that there are different things you can do in low risk situations it's it might be best to stay there and really focus on what you're doing instead of just bumping out of it and Being avoidant and so gauging when you should stay and engage and do exposure really to the situation instead of escaping

immediately is an important thing to know in higher risks and folks you know move proximity they move away or leave the area so that's and here is like one of the safety plans for example that they would do like a written safety plan everyone's favorite skill for the most parts Noomi activities and these are all the things you do during the day That are just the activities day of daily living we break them down into four and I'm sure this more but that focus Noomi activities feel good distracting myself and having fun really important especially

when folks are cognitively and emotionally disregulated to have focus activities to do that help with cognitive regulation I think one of my favorites is just a very simple like if we're not there Somebody's getting dysregulated I'll just do a simple card sort with them and it's basically just shuffling a deck of cards and kind of putting black and red to start with because when they're really ripped off right they're really upset they're kind of slamming and they put him in wrong color and the wrong thing and so the pile is are going everywhere and sort

of slowly as they get through it and I asked them to kind of tidy up a little bit and they focus And pretty soon you're going to have they're able to do the black and the black and the red and the red and it's they're keeping it together and then once they get through that we sort once they're doing that effectively we go into diamonds and hearts and spades and clubs and that's a little bit more differentiation there that they have to do and so that's just kind of like a tangible little trick that I

like but organizing cleaning and counting folding Just having a repertoire of these kind of things whether it's a video game or solitaire or folding clothes from your laundry these guys have no money and so it's you know you have to be pretty creative with Noomi activities that actually are fulfilling and interesting and they also have a hard time engaging in novel activities and what you think might be a really reinforcing activity you're like why are you not doing this you're asking yourself but really that Hesitation and that sort of difficulty with transitions as well as

just you know they're theirs they're just not great sometimes it going out of their comfort zone and so you have to do a lot of work really reinforcing people to take those on track actions to do different Noomi activities to expand those capacities feel good these are sort of you know you know once the your body is triggered trying to sort of improve the sensory experience You know calming yourself self soothing distraction is important it's really important to know when to distract and when not to when you've done everything you can you need to chill

out then distraction is a great thing if there's a lot of things you can be doing at that time and you need to be doing a safety plan or some other activity or responsibilities distractions not the best thing and so really gauging when to distract And when not to so that you can modulate your engagement fun these guys and we people need to have a lot of fun what time a quality of life really want people to experience a fulfilling you know human human experience and so having a lot of different fun activities is good

am i getting them oh I'm at zero okay guys but that's the all the time skills and check it out if you want to know more about it sorry I couldn't get through it All thank you hey stay up there please we're gonna have let's um we have time for questions and and and there may be more things you want to share that can come out in the questions the questions are starting to roll in okay first easy question is can your intervention be modified for use with young children with or without PDD pervasive developmental

disorder people my goal was to make this very accessible And so I tried to put a lot of tools for people like on my website really cheap so that people can practice with it and try it and I think there are a lot of people sort of experimented with different groups I personally the only other group I run which is a transitional age youth group it's basically like taking all the teaching strategies that I put in the book and turning them upside down so I think basically the teaching strategies That are in the book it's

in the curriculum are you need to be tweaked you can't follow the curriculum for everybody it's really for this population and so but if you alter the strategies I think maybe I like collaborating with teams you know they have diverse populations I'd be willing really like collaborating with people that want to take it in a little different direction and that way you can keep kind of like what I did you know You can keep adherence with the model at the same time on that it sounds like there's at least some people that would like to

contact you so you're open to emailing and cell phone 5:08 it's all over the website - no I'm just not three one seven two one one five call me no I want to and if you use it you know call me I like hearing about it because I liked it we would come in network I was like doing a conference a couple weeks ago while ago and this guy Came up he's like I'm from speed and I'm using the skill system I really love it oh sorry I didn't do that accent right but who's this

really cool has the program been used with behaviorally diss controlled such as duly diagnosed young adults yes we're doing it now it makes me feel really old but yes they call me call me on that kind of stuff where we can really just kind of talk about how to tweak it with the with that age group we really we have to increase the Relevant context part of teaching really getting that they have a very high threat you need to make it relevant for that group and so it really does change they're not as sort of

readily wanting to to become regulated so helping motivate them is a key part of it can't be used with children down to what age would you say young has a bit you know does it use with children I don't know I know that it's being used at Swansea would school in Massachusetts they go Down at age 13 actually Arcadia children his home in Rhode Island was using it and those were those kids were like eight nah but we're talking about I don't have any data for that for sure how can others such as caregivers help

use skills that's a great question well it's a little bit challenging to teach folks how to be skills coaches but I would say that the the tools that are available on the website for like 15 bucks you can get a CD that has the Whole summary on it and you could like stick it in your car radio and listen to it I think that's a nice tool the other thing is online on my website there's competency evaluations that are free and so you can you can listen to that and then you can go online and

take your quiz there's also a skills coaches CD and there's also skills coaches exam and so you know for relatively small resources you can get the information this one may Relate to what you're just saying it's about dealing with follow-through between therapy sessions if there's a substantial intellectual disability so that things may get lost when they walk out the door how do you effectively deal with DBT we do phone skills coaching so that's a really important part of what what we do and and that really helps with integration and generalization of the skills and like

I said we do really try to teach teams but it's hard staff Really are the people in these environments are not paid very much and they have a few resources around training opportunities and it's not complicated but it's a little bit common so a lot less complicated than DBT but even this is really hard for a staff member to understand and understand the nuances of coaching because it's not just the skills it's about that relationship it's about its you know being able to respect their autonomy During the whole intervention can the system be used with

nonverbal individuals that's a good question I think I think it helps staff in that when staff kind of understand sort of some basic concepts then it can help them regulate themselves helping them be more effective and not acting dysregulated ways you know basically sort of not getting people you know to do complicated things when they're already aroused that's another thing I've there are teams doing that and and it's one of those things where I'd like to collaborate and just talk about ways that it could be would you highlight any skill system implications limitations with respect

to TBI and then also dissociation yeah it's a good question I know Ivy Street School in Massachusetts is a TBI program and they're using and I haven't been in touch with them since some of the new materials got out so I think this might be some drift of There but I I'm sorry I don't really I mean obviously some of the folks I deal with have TBI and so I think that I think the the structure of it the infrastructure we talk you know Anthony was talking about sort of memory you know aids and I

think that the whole thing functions like a template or a prosthetic for people and so it allows them to be more oriented when they're disoriented and then the contextual learning that goes on in group helps More put more fat on those bones or more muscles on those bones and so the over learning of it and then putting it in context for all the people suddenly the arborizations really going crazy and it really makes it more automated another one with populations has been used with in correctional institutes um a lot of the folks that we deal

with have sexually dangerous behaviors so it really was developed to help people that have ingrained patterns of that are that Are really sexually problematic and so I think it's a great application there it's very heavy on safety planning in some ways and I have a lot of that kind of material if anybody is working in Corrections Kokomo Indiana right now has a Samsa grant for an implementation in a hospital that was just reopen and they're looking at shifting it also from the outpatient and hospital setting into the back into the correction setting because a lot

of people are coming from Corrections to the mental health center and so they're taking it back to help with the transition out so yeah it's definitely and actually I think Robin McCann one of the other trainers is using it in Colorado as well given that individuals with intellectual disabilities are are three to four times more likely to experience abuse how do you help clients learn when resistance rather than acceptance is appropriate yeah I think that's all part of clear Picture understanding you know that's why the system is really important and under in the dialogue in

skills training it's not like a class it's it's like a group really when you're there you're talking to people about the nuances of situations and I'm not you could pick it up from the video but the clients are fairly savvy and have a lot of awareness and I think that those are those conversations where they're able to sort of make that dialectical Synthesis where they're able to sort of bring together the polarization and I know that I don't this is anecdotal but you know people with disabilities have really seen as having black and white thinking

well I find that with skills training and I'm not saying it's a magic thing or anything but with the the training process you can really see people able to see the gray and things but it's just taking the time and having the venue to do it in and people that Are listening in a way that can hear people and so when they're able to be regulated and they have a cohort that are all having this conversation it's amazing how sort of much less polarization there is and more synthesis there is this may be a follow-up

to to that how did you get your clients to the place that they understand and accept acceptance everyone hates acceptance don't we all it's a process you know I don't say Everybody is fantastic at acceptance I think it's I think you know we probably get beat down to acceptance in some ways you know if it's a dialogue I sort of knowing what's going to work and and understanding through trial and error sort of right you know I've done what I can and and then sort of regrouping it's not static no no this is static you

know it's like if it doesn't work today we can reevaluate it we didn't get to problem solving but that's about like Making plan a B and C you really want to really want to get to sort of be a top reach and then sort of the middle and the bottom you don't want to we've got to be really flexible and shoot for things so what I would say is try something else in that vicinity all right and there and then the last ones were compliments on your on your presentation and also again about contacting you

which I'm going to direct people to your website which is in the Materials it's just WWE skill system comm and I'm like the webmaster so be nice about the site it's not very fancy okay I'm the social worker I know and I'm like film editor you know it's like had somebody had some none of it particularly fantastic but it kind of helps bring it to you know when I get clothes from Alaska saying I've got these people I've got no money my program has no money and we've got these disabled people in the boonies of

you Know Ontario Northern Ontario that you know and so it's just you know pulls it those social worker heartstrings and so I just want to get it all so they can get it really cheap and easy and free as much as possible okay thank you very much