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Managing Emotions Foundations Group: Running the Program

Managing Emotions Program

Description: The Managing Emotions Foundations Group is a six-week series of 1h 45min group sessions for up to 15 patients, facilitated by two mental health clinicians (with expertise outlined in the preamble and below).

Objective of Managing Emotions Foundations Group: To improve participants’ capacities to consciously manage their emotional experiences, introducing practical acceptance and change strategies to enable them to respond to triggering events and life situations with thoughtful choices.

To Introduce this Program to your Facility

1) You will require three staff with DBT training and competency skills at the same level as if teaching DBT skills group at a formal DBT program. This includes mastery of DBT skills and content as well as mastery of managing behaviours during and between groups. Two of these staff will be group co-therapists and the third will do intakes. We recommend that the third practitioner be a MH nurse because of the capacity to assess, support, liaise, access the EMR, etc.

2) Co-therapists will need to each have the following texts: • Baer, R. (2014). The practicing happiness workbook: How mindfulness can free

you from the four psychological traps that keep you stressed, anxious, and depressed. New Harbinger Publications.

• Linehan, M.M. (2014). DBT skills training manual, second edition. Guilford Press.

3) Referring practitioners should have knowledge of content and format of the

program. Referring physicians should provide at least one pre-booked supportive appointment during the time the patient is attending the group. The physician should have open dialogue with co-therapists for guidance managing patient distress. See Appendix I, II. To orient family doctors to this program, we did one clinic session having staff watch the introductory lecture (video on website) and then having a discussion about the program. In a second clinic session, we presented the slideshow “Orienting family doctors and nurses to DBT Theory and Skills” and also created a tool, “Top 10 DBT Skills”, for doctors and nurses to use with their patients in their offices.

Overview – Managing Emotions Program 1

The Referral Process (1) With no exceptions, interested patients must first attend an information session presentation (we run this monthly). Managing Emotions staff also attend session and monitor patients’ reactions, screening for group suitability. For example, the student who flees the room or sobs throughout is not program ready. Patients who are interested in attending the group take an intake package (Appendix III) to complete. Before completing the package, the patient should see the family physician for referral.

(2) The interested patient sees family doctor for referral. Referral forms are embedded into the EMR.

• When seeing a patient, the physician needs to consider if the patient may benefit from the Managing Emotions Group, considering the inclusion and exclusion criteria (see Textbox A).

• Referring physicians fill out the Managing Emotions Group Referral Form (paper version or embedded in their EMR, Appendix IV) and send it to Mental Health (MH) Medical Office Assistant (MOA) for tracking purposes.

Inclusion Criteria:

1) Students who are motivated to take an intensive skills-based course to learn to better tolerate and regulate emotions.

2) Students who are able to attend all 6 group sessions. 3) Students who are struggling with emotion regulation (e.g. rollercoaster emotions, can’t

identify emotions, numb) and consequent counter-productive behaviours (self-harm, avoidance, excessive behaviours, interpersonal disputes).

a. DSM-5 diagnoses that may be relevant include borderline personality disorder, eating disorders, mood disorders, anxiety disorders, ADHD, substance use disorders, childhood trauma resulting in PTSD and attachment disorders.

4) Students who are willing to suspend self-injurious behaviours for the duration of the group, in order to create the best possible chances for learning skills.

5) Students who are able to participate in group discussions and collective learning without disruptive behaviours.

Rationale: • Commitment is stressed from the outset, and referral sources are asked to gauge and

increase participant motivation. Students will be prone to sign up when seeing their clinician during a crisis, but may not actually have time/energy/motivation to complete the 6-week series. Attrition has a huge impact on a brief behaviour-change group and these inclusion criteria are designed to prevent attrition as much as possible.

• Since the course focuses on skills and universal habits of mind and behaviour, it is appropriate for patients with many diagnoses. DSM-5 diagnoses are used to guide, rather than shape, inclusion criteria.

• Participants are asked to suspend self-harm behaviours for the 6-week duration of the group. This criterion excludes those patients who have more severe coping difficulties (who should therefore have a more intensive level of care), and also selects for students with higher degrees of willingness and commitment.


Exclusion Criteria:

1) Students with psychosis. 2) Students with cognitive or language difficulties that would make use of group materials

too difficult. 3) Students with a high risk for violent or aggressive behaviour. 4) Conditional exclusion of patients who have active suicidal behaviours. Group leaders are

not able to monitor risk, and have limited capacity to provide support. If the patient has ongoing suicidality, the patient may only participate in group if the student is involved in regular sessions with a clinician

5) Conditional exclusion of patients who are actively using substances – students may only participate if their use of substances will not interfere with their involvement in the group, nor impact on others in the group

Rationale

• Exclusion criteria screen out patients who would be unlikely to handle the materials well because of cognitive or psychiatric impairments

• Participants who have active suicidal behaviour (suicide attempts, gathering and/or retaining means of suicide etc.) are unlikely to have the presence of mind or willingness to engage with this group, which relies on self-direction for practice and generalization of the skills. Additionally, the group is more like a classroom, and there is little opportunity for facilitators to engage in risk assessment or mitigation on an individual level. Referral sources are asked to discuss such candidates with the group facilitators before referring. Generally, they should be in individual treatment if they are going to participate in the group.

• Substance use is not an exclusion – the group is likely to be helpful for many with substance use disorders. However, participants have to be able to regulate their use enough that they do not disengage from or disrupt from group due to substance intoxication.


Intake Appointment An intake appointment with the intake practitioner is mandatory (as above - we use the MH nurse). The patient will require the motivation to contact the MH nurse to set up intake appointment, and complete the intake package prior to this appointment for review at intake. If the patient arrives without having completed the intake package, the appointment does not proceed. Not completing the package suggests insufficient motivation and capacity to benefit from the group. The MH nurse will liaise with the referring physician following intake to inform if the patient will be attending group. (1) The MH nurse meets with each prospective participant in an individual session. The objectives

of this session are to assist the patient in determining whether the group is a good fit for the patient. This is accomplished through: a. Reviewing the brief history to elucidate problematic symptoms or behaviours that are

motivating the patient. b. Reviewing the problem list “What is troubling you?” – including distressing internal states,

behaviours, and problematic external situations. c. Reviewing the treatment goal from the problem list. This orients the patient to the limited

scope of the group and helps the patient create realistic expectations. Having a defined treatment goal will also help the participant tailor the skills to this specific area, increasing the likelihood that the patient will be able to develop some mastery even over the short course of the series.

d. Reinforcing the patient’s strengths and resources on the “What gives you strength?” page”. e. Increasing motivation by completing a decisional analysis for participating in the group

(Pros/Cons grid). This may also help decrease likelihood of attrition by helping the patient consider what the patient will do if/when the patient wants to quit.

f. Answering the patient’s questions, providing an idea of what to expect, and normalizing fears of participating in a group process.

g. Review Group Fees and Attendance Policy and obtain signed agreement (Appendix V).

(2) If no concerns are raised, the patient is emailed to indicate acceptance into the group. The referring physician is notified by the MH nurse and this is documented in the EMR.

(3) Each patient pays $60 by cheque or cash to the MH MOA. This provides a monetary incentive to complete all 6 sessions. If six full sessions are attended the student will be refunded the $60. If, (for any reason), only five full sessions are attended the student will receive $40 back. Students who miss more than one session of Foundations series, for any reason, are not eligible for any refund. Monies not refunded to students is applied toward supplies. See the student handbook for more information on attendance policies. Rationale: Emotion-driven behaviours may lead to missing group sessions. This impairs learning, as each session is intensive and builds on the previous sessions. Attending group sessions even when emotions or circumstances make it unpleasant will also provide a real-time opportunity for applying the skills being taught, with the opportunity for coaching from facilitators. Additionally, absences affect group morale and motivation for change in other participants.


Group Delivery and Evaluation

(1) You may decide (one week before the group begins or on day one) to have patients fill out a symptom scale that has been digitized – the Difficulties in Emotion Regulation Scale (DERS, freely available, Appendix VI).

(2) The group is conducted over 6 weeks (booked in advance and mindful of holidays). (3) Each patient completes a Weekly Attendance/Self-Progress Report (Appendix VII) at the end of

each session and returns it to the facilitators. Facilitators review these reports while they debrief immediately after group session to identify and respond to any concerns. After the 6 week series, these progress reports are scanned into the EMR, and paper copies are shredded.

(4) At the end of the Managing Emotions Group, participants are again emailed the link to complete another DERS scale. An evaluation form is completed in the last group session. (Appendix VIII Managing Emotions Participant Evaluation). • Participants who drop out or do not complete all 6 weeks are also emailed the evaluation,

which allows statistics and feedback from non-completers. (5) Staff notify the referring physicians when the Managing Emotions Group has ended. This

includes the following process: • The group facilitators input a summary note (1-2 sentences) for each patient into each

patient’s chart in the EMR and notify the referring family doctor that it is there. • The MH MOA compiles the statistics (pre and post DERS) and completion of the

foundation group (thus updating the tracking form).

List of Appendices (also on site separately) I Referring Doctor Info Sheet II Patient Information Page III Pre-group Work Sheets IV Referral Form for EMR V Fee and Attendance Agreement VI DERS VII Weekly Attendance/Self-progress Report VIII Feedback Form IX Mariko’s Story


Appendix I: Referring Doctor Info Sheet

FOUNDATIONS OF MANAGING EMOTIONS GROUP (6 sessions) There is room for 12 -15 students in the group. Please refer students who:

6) Are motivated to take an intensive skills-based course to learn to better tolerate and regulate emotions.

7) Are able to attend all 6 group sessions. 8) Are willing to suspend self-injurious behaviours for the duration of the group, in order to create

the best possible chances for learning skills. 9) Are struggling with emotion regulation (e.g. rollercoaster emotions, can’t identify emotions,

numb). 10) Are able to participate in group discussions and collective learning without disruptive

behaviours. Please be cautious with students who:

6) Are actively suicidal – group leaders are not able to monitor risk, and have limited capacity to provide supports. If your patient has ongoing suicidality, the patient may only participate in group if the patient is involved in regular sessions with a clinician.

7) Are actively using substances – students may only participate if their use of substances will not interfere with their involvement in the group, nor impact on others in the group.

Please do not refer:

1) Students with psychosis. 2) Students with cognitive or language difficulties that would make use of group materials too

difficult. 3) Students with a high risk for violent or aggressive behaviour.

To date the program is as follows:

• Managing Emotions Information session- run by facilitators and offered monthly. Attendance at the Information Session is required for all students before intake sessions are done with the MH nurse and before participation in the Managing Emotions Foundation Group.

• Foundations of Managing Emotions Group (6 sessions) run by two facilitators. This 6 week group will be offered each semester and is required before any advanced Groups are taken.

Referral process: 1) Inform the patient of the date for the next information session. 2) Give student information sheet. 3) After the student attends information session, the student will get a referral from the

family doctor and then book an intake appointment. 4) Make the referral and task MOA to record on tracking. 5) MH nurse will contact the referring physician following the intake appointment to

discuss if attending Foundations Managing Emotions Group is appropriate.


Appendix II: Patient Information Page

MANAGING EMOTIONS GROUP DATES of sessions TIME of group

What is it? This is a group loaded with practical skills designed to help you change your relationship to your emotions – by learning about them and practicing different ways of experiencing them, you can get more freedom from negative emotions.

Emotions like anxiety, despair, anger, shame and guilt can make life feel very heavy and at times unbearable. Many people put a lot of effort into trying to get away from such emotions – and find themselves zapped of energy and feeling futile. Sometimes, efforts to control emotions result in unwanted habits that are hard to break – avoidance, self-harm, emotional eating, substance use, indecisiveness, and saying and doing things you don’t mean.

Good news! Modern science is helping us better understand how emotions work – and as we learn and apply this knowledge, we can get emotions to work for, rather than against, us. In this group, we will explore the neurobiology of emotions, discuss how emotions, thoughts and behaviours get wired into habits, and practice ways of altering these habits. We will learn how to regulate emotional intensity so that emotions are not overwhelming us. A focus of the group is also to practice self-compassion- learning to treat ourselves more gently as we work on exploring what goes on inside our minds and bodies.

But I don’t want to do a group!

Many students are apprehensive about joining a ‘therapy group’. Think of this group as more of a class – there will be teaching each week, and skills for you to take home and practice between sessions. It helps to treat the group like a class and bring something to take notes. In the end, we often get feedback that learning from the experience of others in the group was one of the best aspects of the experience.

• There will be 12 to 15 students in the class. • Each class is 1h and 45min. • You will be asked to share each week. The first part of each session is a

debriefing about the knowledge and skills learned last week and how it went trying them out in your life. In-depth sharing about personal problems will be discouraged, and you need only disclose as much as you feel comfortable with. Group participants also frequently report that the stress of speaking decreases as they become more familiar with the process.


• That said, if you are interested but feel that participating in the group check-in would be too stressful or impossible we recommend finding an individual therapist to work with.

Is this program for me? Is it the right time for me to do it?

You are encouraged to take this group if:

• You are motivated to learn more about yourself and your patterns. • You would like to have a more user-friendly relationship with your emotions, and

are ready to change what you’re doing in order to develop that. • You are willing to give up habits that help you escape emotions – such as

selfharm, substance abuse, emotional eating, and withdrawing. • You can participate in a 1h 45min group once a week, every week for 6 weeks. • You are ready to try new ways of behaving and talking to yourself – this will

require 5-10 min of practicing the skills at home every day, plus recording about your experience. This is very important, as skills training, like exercise, is most helpful if you practice it regularly.

What do I have to do?

1. Discuss your interest with your family doctor. 2. Attend the Information Session. 3. Book an appointment with your family doctor for a referral. 4. Call the Mental Health nurse to set up an intake appointment

• At this appointment, you and the MH nurse can further discuss the group to see if it is a good fit for you at this time. You will also start setting a goal to help you focus your efforts in the group

5. Pay $60 registration fee to MOA • Participants are expected to attend all 6 sessions, as they build on one

another. We recognize that it can be hard to bring yourself to a group/class, particularly when your emotions are causing you pain. However, this emotional pain is exactly why you are signing up! As an incentive, you will be refunded this fee if you attend all 6 sessions. $40 will be refunded if you miss one session and no refunds will be given for participation of less than 5 sessions.

This group combines aspects of dialectical behaviour therapy, cognitive behaviour therapy, mindfulness, and acceptance and commitment therapy.

Appendix III: Pre-Group Worksheets


Managing Emotions Group Getting Started

Meet Megan!

Megan is currently living on her own, with her dog Dawson, and working full time as an early childhood educator. In her spare time, she usually likes to play outdoors and also to write – she has a talent for poetry and dreams of writing children’s books. She enjoys her alone time, and also has several good friends and is close to her brother and sister-in-law.

Recently, Mary’s brother and sister-in-law had a baby boy. Mary loves her new nephew, but is also feeling sad that she doesn’t have her own child yet. She always imagined herself as someone with a partner and family of her own, and lately she feels discouraged about being single. She feels a sense of loss, and fear for her future.

In response to her low mood, Mary has begun to spend more time at home. She feels that she would be downer if she were to go out with friends, and avoids their calls. She has also stopped writing and going to her writer’s group, as it is too hard to be creative. She has been avoiding her brother and sister-in-law as well, because seeing them with the baby brings up such painful feelings. She feels very guilty about this. At night, especially, she feels despair – believing that the reason she is single and without a child is because there is something wrong with her. She imagines that people at work are only pretending to like her, because inside she feels like a fraud.

As this state has persisted for several weeks, Mary finally went to her doctor and asked if maybe she should start a medication or something. In addition to talking about that, her doctor told her about the Managing Emotions Group. This appealed to Mary, because she likes thinking about her mind and how it works. She’d also prefer not to take medications if possible – but she needs something to change because she recognizes she is miserable and feels that things are getting worse. Welcome to the Managing Emotions Group! This 6-week program offers the opportunity to cultivate a relationship with yourself and with your mind that may be somewhat different than what you are used to. It is helpful before beginning such an endeavor to spend some time reflecting on how things are right now, and where you would like to focus your efforts. The following pages ask you to take the bird’s-eye-view for a moment, and notice the problems you are currently dealing with. You will also survey your resources and strengths – oftentimes these get forgotten when problems are pulling at us. Then you will focus specifically on the time you will spend in the program, thinking about what problem area might be a good place to invest your initial energies.


Finally, you can examine the benefits of making a change, as well as what it might cost you. Your thoughts are for your use only – no one else will read these. Like Megan, you probably have lots of reasons for wanting to take a Managing Emotions Group. Oftentimes there are things in our lives that cause us pain or suffering, and we would like these things to be different. The first step on this road to wellness is to clearly see the things that are troubling you – causing you distress, or getting in the way of you living life the way you want to. Consider things happening in your life, as well as patterns of thinking or acting, such as worrying about everything, or avoiding people or

places.

WHAT IS TROUBLING YOU?

These could be things from the past, your current life, or your future. It could be to do with you, your family, or your community. For more space, use the back of the page.

• ________________________________________________________

• ________________________________________________________

• ________________________________________________________


Megan’s list looked like this:

1. Avoiding brother, sister-inlaw and nephew – feels

awkward and sad

2. No partner

3. Scared I may not be able to

be a mother 4. Feel disinterested at work 5. Feeling anxious all the

time 6. Friends can’t relate to me

7. Low energy 8. Stopped exercising, feel out

of shape 9. Have insomnia 10. Haven’t made any progress

in publishing my writing

• ________________________________________________________

• ________________________________________________________

• ________________________________________________________

• ________________________________________________________

• ________________________________________________________

• ________________________________________________________

• ________________________________________________________

Now, consider an inventory of what your resources are. Looking at all the things that are troubling us at once can sometime make things feel insurmountable. But in fact, we often have strengths we don’t usually think about.

WHAT GIVES YOU STRENGTH?

These may be things inside you – like intelligence, sense of humour, creativity, loyalty, determination, or spirituality. They may also be things around you like family members, friends, pets, hobbies, traditions, activities, nature, or positive memories. These strengths help us cope with difficulties in our lives.

• ________________________________________________________

• ________________________________________________________

• ________________________________________________________


• ________________________________________________________ •

_________________________________________________

• ________________________________________________________

• ________________________________________________________

• ________________________________________________________

• ________________________________________________________

• ________________________________________________________

• ________________________________________________________

• ________________________________________________________

• ________________________________________________________


Megan’s_______ list looked like this:

1. Good sense of humour – can usually laugh at myself

2. Determined 3. Loyal 4. Creative

5. Great dog 6. Brother and sister -in-

law support me and care about me

7. Nephew is adorable and likes to cuddle me

8. I have skill in my job 9. I like my apartment – it is

comfortable and quiet 10. I live near the ocean and

like going for walks there 11. I am a good friend – my

friends appreciate me

12. My body and mind are

working

Next, think about what might be important to accomplish or get started on during your 6 weeks with the Managing Emotions Group.

During the program, you will be exposed to a lot of different concepts and skills. The program is an introduction – you will be working with many of the skills you learn and patterns you recognize over the next months and years. To start with, it is helpful to have a specific goal to guide your thinking and your energy. Research has also shown that change is much more likely when we set specific, concrete and manageable goals. These can be things you are interested in making happen, such as “going to the grocery store regularly”, or “taking time to take care of myself each day”, or “spending time with friends”.

TREATMENT GOAL SETTING Take a moment to think about what goal is most important for you at the present moment. GOAL: _____________________________________________________________

Megan wants to attend the group, hoping “to not spend so much time avoiding”. The way her life has been these last few weeks is hardly recognizable to her.

Now, let’s take a moment to make this goal more concrete. What would it look like once

you have achieved this goal? What things would you be doing? What behaviors would you be engaging in? Try to be as concrete as possible here. Use the back of the page for more space if needed.

• ______________________________________________________


• __________________________________________

• __________________________________________

• __________________________________________

• __________________________________________

• __________________________________________

Thinking about changing or coming into treatment can be scary. When we think about changing, we often don’t consider all “sides” in a complete way. Instead, we do what we think we “should” do, or we avoid doing things we don’t feel like doing. We might even just feel confused or overwhelmed and give up thinking about it at all.

Thinking through the pros and cons of both changing and staying the same, is one way to help us fully consider a possible change and help the process feel more manageable. This can also help us cope with difficult times that might arise along the way.

PROS AND CONS TO CHANGE: LOOKING AT AMBIVALENCE

Write all the pros and cons you can think of for both changing and staying the same in the boxes below. Consider your own goal – what are the upsides and the downsides of pursuing it?

Example Pros/Benefits Cons/Costs


Megan considered that if she were avoiding less she would be:

• hanging out with girlfriends – going for brunch, shopping etc.

• going for walks or runs at Mt. Doug

• reading novels • getting her hair cut • taking Dawson to the dog park

and talking to people there in the afternoons

• hanging out with her brother and sister-in-law and playing

with her nephew

• going to her writer’s group, if

only to listen and provide feedback

Change

Stay the Same

Megan had heard of pros and cons lists before, but had never thought of listing them systematically,

nor considering that there might be pros to not

changing! Her worksheet looked like this:

Example Pros/Benefits Cons/Costs


Change Going to writer’s group; Responding to friends’ invitations; Seeing brother and family

My friends and family will know I care about them I will probably feel better about myself Maybe some of my friends will be able to relate to my feelings, maybe it will bring us closer Maybe I can write about some of these painful thoughts I could get to know my nephew Dawson will get more exercise I’ll live a fuller life

Going out is difficult when I feel like this, and will be hard work I will feel sad to see people with their young families I am afraid people will think I’m stupid or awkward It is hard for me to feel sad around other people If I try to open up like this and it doesn’t go well, then things will feel really hopeless for me. I will have fears I will feel this way forever

Stay the Same Spending most of my time at home

It is easier to just keep my feelings to myself I won’t have to burden others with my sadness or worries When I don’t see others I can avoid thinking about my problems a bit I won’t have to take risks

I will continue to feel this way My life has already become limited, and may become even more limited I will continue to feel despair and down on myself I may get more depressed My health is suffering from the way I’m living now

After doing the pros and cons sheet, Megan realized that the thing she was

most afraid of was sharing her feelings of sadness with others

– this made her feel vulnerable. She was afraid that, if she was vulnerable, she would come across as weak or inadequate.

She hoped that in the group she could gain some strategies for better understanding and coping with her feelings. She knew to make changes she’d have to take some risks and perhaps be more vulnerable, and she also knew she’d need to take care of herself as she did so.

Thinking in these ways has likely required significant effort on your part – so give yourself some credit! You may find that writing these things down stimulates some thinking in the days to come! You are encouraged to continue to notice your thoughts about why you want to participate in the group, and what your treatment goal could look like. Also consider the pros and cons of this type of change – perhaps coming back to this sheet as you think of things throughout the course. It can be helpful to see that there are some benefits to keeping the status quo – mostly around keeping things familiar and not having to experience strong feelings of anxiety or loneliness. These are important needs and fears to be aware of, so that you can best take care of yourself as you proceed with this venture! We look forward to meeting you at Week 1 of the Managing Emotions Group!


Appendix IV: Referral Form

Referral form for Managing Emotions Group, TIME, DATES

Therapist name

Date:

Student Name:

Referring physician:


If student in individual therapy? Yes/No IF SO – with whom? How often?

Psychiatric diagnoses:

(check all that apply)

• Borderline Personality Disorder • Other Personality Disorder • Emotional dysregulation, but not full BPD • Eating disorder • Substance use disorder ________________________ • GAD • Social Anxiety Disorder • Panic Disorder • PTSD • OCD • ADHD • Depressive disorder (MDD, Dysthymic, Depressive Disorder NOS) o Acutely depressed

at time of referral? • Bipolar disorder o Acutely symptomatic at time of referral?

• Other __________________ Relevant risk factors:

• Active cutting, burning or hitting • Active substance use ______________ • Recent (within last 12mo) suicide attempt • Binging, purging • Dissociative events • Other ___________________ Psychotherapy history

• Has previously participated in a DBT program • Has previously participated in an aspect of DBT (e.g. skills group, DBT-informed

therapist) • Has previously had another short-term therapy (CBT, ACT, counseling group) Has

previously had long term therapy (>1yr)


Appendix V: Fee and Attendance Agreement

Group Fees and Attendance Policies 1) The fee to attend a Managing Emotions Group (total of six sessions) is $60. 2) The $60 fee is refundable up to one week before the start of the Group. 3) Students who attend six full sessions of any Group will receive $60 after the end of that

Group. Students who attend five full sessions of any Group will receive $40 after the end of that Group. Students who attend fewer than five sessions of any Group are not eligible for this refund payment. To claim the $40 or $60 payment, see the admin person in the mental health wing of Petersen Centre, during our working hours.

4) Students who miss more than one session of Foundations Group (for any reason) must repeat the entire Foundations Group before moving on to an advanced Group.

5) To protect the cohesion of the group, students who miss more than two of any advanced Group sessions may not return to that group. They may move on to the next advanced Group offered provided they are confident that they will be able to reliably attend.

Individual Support During Group Managing Emotions group participants do not receive individual therapy while they are in group. However, a need for individual support may arise and we therefore encourage you to see your family doctor for this. If you have not already done so, consider booking ahead with your doctor for two or three appointments over the next six weeks.

___________________________________ ___________________________________ Student Date

___________________________________ ___________________________________ Facilitator Date


Appendix VI: Evaluation Difficulties in Emotion Regulation Scale (DERS) (pre, post)

and Participant Feedback (post) Difficulties in Emotion Regulation

Scale (DERS)

Response categories:

• 1 Almost never (0-10%) • 2 Sometimes (11-35%) • 3 About half the time (36-65%) • 4 Most of the time (66 – 90%) • 5 Almost always (91-100%)

1. I am clear about my feelings. 2. I pay attention to how I feel. 3. I experience my emotions as overwhelming and out of control. 4. I have no idea how I am feeling. 5. I have difficulty making sense out of my feelings. 6. I am attentive to my feelings. 7. I know exactly how I am feeling. 8. I care about what I am feeling. 9. I am confused about how I feel. 10. When I’m upset, I acknowledge my emotions. 11. When I’m upset, I become angry with myself for feeling that way. 12. When I’m upset, I become embarrassed for feeling that way. 13. When I’m upset, I have difficulty getting work done. 14. When I’m upset, I become out of control. 15. When I'm upset, I believe that I will remain that way for a long time. 16. When I'm upset, I believe that I'll end up feeling very depressed. 17. When I'm upset, I believe that my feelings are valid and important. 18. When I'm upset, I have difficulty focusing on other things. 19. When I'm upset, I feel out of control.. 20. When I'm upset, I can still get things done. 21. When I'm upset, I feel ashamed with myself for feeling that way. 22. When I'm upset, I know that I can find a way to eventually feel better. 23. When I'm upset, I feel like I am weak. 24. When I'm upset, I feel like I can remain in control of my behaviors. 25. When I'm upset, I feel guilty for feeling that way. 26. When I'm upset, I have difficulty concentrating. 27. When I'm upset, I have difficulty controlling my behaviors. 28. When I'm upset, I believe there is nothing I can do to make myself feel better. 29. When I'm upset, I become irritated with myself for feeling that way. 30. When I'm upset, I start to feel very bad about myself. 31. When I'm upset, I believe that wallowing in it is all I can do. 32. When I'm upset, I lose control over my behaviors. 33. When I'm upset, I have difficulty thinking about anything else. 34. When I'm upset, I take time to figure out what I'm really feeling. 35. When I'm upset, it takes me a long time to feel better. 36. When I'm upset, my emotions feel overwhelming.


Appendix VII : Weekly Attendance/ Self-Progress Report

Name __________________________________________

Week One Date:_______________ Time:_______________ Facilitators: ___________________________

___________________________

Present

On time Late by ____ mins

Absent

Cancelled Clinic

notified Reason

(if known) _________________

Confidence in managing my emotions: 1 = not at all 10= completely ____

Energy Level

High Medium

Low

Mood-Choose 1 Good Anxious Irritated Sad Other______

Participation Active – Engaged, volunteered ideas Answered questions when asked Distracted Felt not present Other___________

Facilitator signature ___________________ Date _____/_______/_____

Week Two Date:_______________ Time:_______________ Facilitators: ___________________________

___________________________

Present


Absent

Cancelled Clinic

notified Reason

(if known) _________________

Homework: did none did a little did a lot did it all

Energy Level

High Medium

Low

Mood- Choose 1 Good Anxious Irritated Sad Other______




Name __________________________________________

Week Three Date:_______________ Time:_______________ Facilitators: ___________________________

___________________________

Present


Absent

Cancelled Clinic

notified Reason

(if known) _________________


Energy Level

High Medium

Low

Mood –Choose 1 Good Anxious Irritated Sad Other______



Week Four Date:_______________ Time:_______________ Facilitators: ___________________________

___________________________

Present


Absent

Cancelled Clinic

notified Reason

(if known) _________________

Homework: did none did a little did a lot did

it all

Energy Level

High Medium

Low

Mood – Choose 1 Good Anxious Irritated Sad Other______




Name __________________________________________

Week Five Date:_______________ Time:_______________ Facilitators: ___________________________

___________________________

Present


Absent

Cancelled Clinic

notified Reason

(if known) _________________


Energy Level

High Medium

Low




Week Six Date:_______________ Time:_______________ Facilitators: ___________________________

___________________________

Present


Absent

Cancelled Clinic

notified Reason

(if known) _________________

Homework: did none did a little did a lot did it all Confidence in managing my emotions: 1 = not at

all 10= completely ____


Energy Level

High Medium

Low





Appendix VIII : Feedback Form

Managing Emotions Group Participant Evaluation

To what extent are the following statements true for you (please circle a number, where 10 is strong agreement with the statement)?

This program was very useful to me

1 2 3 4 5 6 7 8 9 10

I have been able to work towards my treatment goal

1 2 3 4 5 6 7 8 9 10

I am confident in the ability to manage my emotions

1 2 3 4 5 6 7 8 9 10

I am regularly using new skills I have learned

1 2 3 4 5 6 7 8 9 10

Before starting the group, I had a fairly good idea about what to expect yes no

The pre-group orientation session with Cathy:

helped me decide about

participating helped me know

what to expect increased my

motivation to attend

was not necessary; I would have had a similar experience without it

The amount of information we received was too much appropriate too little/too simple Please comment:


The amount of interaction during group sessions was too much appropriate too little

Please comment:

What aspects of the program were helpful to you? (you may comment on the handbook, the facilitators, co-participants, in-group practices, or any aspect)

What aspects of the Managing Emotions group program would you recommend changing?

Would you be interested in participating in another Group? (e.g. 6-week series in summer or fall semester)?


Appendix IX : Mariko’s Story

Skills from Linehan, M.M. (2014). DBT skills training manual, second edition. Guilford Press. Written by Dawn Olson, 2017

Case Example – Mariko’s Background

Mariko was always a sensitive child – anxious, shy, reactive to change and emotional stimuli. Until the age of 9 she had been pretty close with her dad, but at 9 Mariko’s mom died in an accident. Mariko says her relationship with her dad was never the same as dad was now working two full time jobs, barely managing to make ends meet and rarely available. Mariko’s whole world changed. She felt alone and abandoned. Not wanting to place any extra demands on her dad, she withdrew and seldom shared her struggles. The few times she did share with her dad, who was overtaxed with the care of the family, she coped by minimizing and denying her experience. From this, Mariko learned to question her own internal experience. Feelings became glommed together, confusing, and intense. When the pressure of her unsupported emotions became too much, Mariko would explode in anger. At these times, dad was finally responsive…and a pattern was set. Mariko learned to mostly suppress and deny her emotions, but when things were too much, an explosion of anger was sometimes what it took to get the attention she needed.

Mariko Pre Managing Emotions Mariko is working on a project with two other students. She has felt angry with them because she doesn’t feel listened to and sometimes they have notified her of meetings that the two of them have arranged without consulting her. She runs into one of them, Alex, in the hallway and he tells her that there is a meeting tomorrow at 3 to discuss where the project stands. Mariko feels her blood boil…sarcastically she tells Alex, “Fine, really glad that works for you two, I’ve got a class at three. See you later” and she turns around and leaves. Mariko continues to feel lousy and overheated for hours, having thoughts about whether she should even continue with her studies, or her field, if she’s going to get treated like this. Her day is ruined. The foundation of all her ruminations is that she doesn’t have a place with the group, that that are rejecting her. It’s a familiar feeling that comes up for her in many situation. Worries flicker too about what they’ll think of her; in some moments she regrets her tone with Alex. She’s snippy with her roommates, spends the evening in her room and the ruminations keep her awake until 2 in the morning. She still has the problem of missing the meeting and not feeling well treated by them. Mariko Post Managing Emotions – with Skills Same situation. Same background of biological sensitivity and emotional invalidation (through neglect and dismissiveness). Same situation – but post learning skills at Managing Emotions. Alex tells Mariko, without consulting her, that their meeting is tomorrow afternoon. Mariko isn’t sure what she is feeling but it’s intense and overwhelming. She takes a moment to notice her body sensations …


(MINDFULLY OBSERVING and DESCRIBING) – tightened muscles, hot face and she also notices her physical urge – which is to attack (EMOTIONS HAVE URGES, SENSATIONS, THOUGHTS). Mariko identifies (LABELLING EMOTIONS) that she’s angry. Mariko takes a breath, starting with slowly exhaling (ONE BREATH SKILL). Having mindfully shifted to observing and breathing, Mariko has created a little space for herself (BEING MIND/PAUSE) and her anger has come down.

She is now able to think (WORKABILITY ZONE on the DIAL). Mariko reminds herself that her feeling angry is VALID, all feelings can be accounted for, (MINDFULNESS BIRD – WING OF SELF- ACCEPTANCE) but she wonders if the anger or its intensity level is JUSTIFIED. She decides that the intensity level is not justified - most people in this situation would not feel this intensity of anger - and that striking out will be neither HELPFUL NOR EFFECTIVE to her long term goal of succeeding in the course and thereby becoming a strong candidate for the lab position she wants. She thinks, too, about her goal of developing a good reputation among her peers and also about recovering from her BPD. She knows if she lashes out that she may feel momentarily better but it will be ‘long term pain for short term gain’. Given this, she knows that she needs to ACT OPPOSITE to the angry urge she feels (which is to attack) and to act opposite ALL THE WAY. The opposite of attacking is being at least a little bit kind. In the moment. this felt like a monumental task as her angry feelings were still quite strong and it was hard to resist acting on them.

Mariko decides to practice ACCEPTANCE AND WILLINGNESS. She softens her face (HALF SMILE) and opens her hands turning the palms outward (WILLING HANDS). She throws herself into being kind, and approaches Alex, saying, “Gee, I’m not available tomorrow and I really want to be there. I’m so looking forward to discussing our progress on the project. What other times could work for you and Manjeet?” Mariko was very surprised at the outcome of this new approach (RESPONDING NOT REACTING). Alex was quite amenable to trying to find a mutually workable time. And Mariko was very pleased that, following this interaction, she was not overwrought and regretful as she knew she would have been had she given a knee jerk reaction.

It’s possible Mariko may have been giving ‘don’t approach me’ signals to her team and that they had naturally been pulling away from her. Her feeling of being abandoned in her family led her to protect herself in the present even when the threat of being abandoned wasn’t there.


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