[PDF] - y RO-DBT via telehealth p o A Radically Open Guide to PDF Document

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25/09/2020

RO-DBT via telehealth

A Radically Open Guide to Webcam-delivered Treatment

Conflicts of interest: We don’t receive any direct commercial support for our training companies Radically Open Ltd or Radically Open Blended Learning. However, Dr. Thomas Lynch, the RO DBT treatment developer and chief RO DBT trainer, receives royalty fees for the RO DBT Textbook and Skills Manual from New Harbinger publishers. He is married to Mrs Erica Smith-Lynch, co-owner and director or Radically Open Ltd.

Today’s Trainer

Virginia O'Hayer, PhD Clinical Associate Professor & Senior RO DBT Clinician @Department of Psychiatry and Human Behavior at Thomas Jefferson University Hospital

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In the Background …. Here to help answer questions

Roelie Hempel, PhD Founder & Co-Director of Radically Open Ltd Erica Smith-Lynch, MA, M.E.C.I., Dip. P.M. Founder & Co-Director of Radically Open Ltd

Webinar Housekeeping

Upvote questions asked by others by using the thumbs up icon – if a lot of people have the same question, the presenter will answer it live Read live captions. Enter questions for the presenters or support team and read their responses. This presentation is being recorded.

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Your questions from the survey

At the end of the webinar we will discuss the questions we received via the
nline survey that are not discussed during this talk and that are related to

today’s topic: TeleHealth

We received several questions that are not related to telehealth but are more

general questions about the principles and practices of the treatment. We will not be addressing these questions today and recommend you consult the text book and/or skills manual, your training binder (if you have attended an intensive training), or the appropriate Blended Learning module.

Alternatively, you can contact one of our supervisors for a consultation session or

supervision https://www.radicallyopen.net/who-we-are/

Or drop a line to the RO DBT list serve: https://groups.google.com/g/ro-dbt-

listserve

Let’s do a Quick Poll

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Overview

Basic orientation to telehealth practices for all
Ethics in telehealth
RO-DBT-specific issues in telehealth
Therapist characteristics
Patient characteristics
Individual RO-DBT sessions
RO-DBT skills class
Self-enquiry

Basic orientation to telehealth practices for all

Set-up, equipment & space

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Invest

Just as you would invest in a therapy office free from distractions
Ensure an optimal connection with minimal freezing/interference
High speed internet
Signal booster
Up-to-date computer
Professional-level Zoom or similar platform (HIPAA-compliant)

Space

As you would with your in-person office, be mindful of how you set up

your virtual space

Consider schedules of others in your home
Consider the professionalism of your virtual space (e.g. kids/pets present? In a

private area?)

More to come re. RO-DBT specific considerations

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Useful Resources for Telehealth Practices

We have compiled a list of resources, including scientific papers and YouTube videos, for you, which can be downloaded from the Chat Function We’d like to highlight this online course to you here:

Telepsychology Best Practice 101 Series: Webinar series approved by the

American Psychological Association https://apa.content.online/catalog/product.xhtml?eid=15132&eid=1921

Through September 30, 2020 this program is available FREE of charge.

Ethics in telehealth

Location, engagement, others, recording

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Location

During the telehealth sessions, is the patient physically located

in a state/region where you are a licensed provider?

If not, you may need to reconsider…
Despite HIPAA being waived at a federal level (investigate this

more…) in the United States, one must still be licensed in the state where the patient is located

Often a temporary license is possible, during the COVID-19
pandemic. Call the State Board of Psychology (or equivalent) in

the state where your patient is located

Informed consent for telehealth

Need to obtain & document this
Need to know emergency contact & emergency services in the area

your patient is located (in case you need to send an ambulance to their home)

Need an agreed-upon plan for what to do if connection is lost?
What if the patient just disappears from session?

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Engagement: approximate an in-person session

Is the patient driving/otherwise engaged in a way that

could be dangerous to be doing while also doing a therapy session?

Is the patient holding their phone/screen in their hand

in a way that creates constant motion, preventing the therapist from fully engaging?

Elicit a commitment from the patient to set aside an

hour (more for skills class) to be present, in a private location, preferably seated and able to take notes

Others present?

Are other people within earshot of the therapy session:
In the patient’s home?
In the therapist’s home?
Are you a therapist living in the fresh-hell of having school-age children

in the home during the day? Are they likely to burst into your “office”?

Plan ahead, as best you can, to ensure that you and your patient have

protected time for a private therapy session

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Recording?

Recording sessions has never been more seamless with telehealth

platforms such as Zoom

Recordings are then converted into a file that you can send to your

supervisor

Be sure to administer a consent form which your patient completes
Be sure to send recordings via HIPAA-compliant platforms, such as

“sendthisfile”

Considerations for your younger patients

Adolescents: issues with space, privacy
Get patient to figure out how to structure your environment
Who is in your family who can help with that?
How to balance with online school, family obligations, etc.
Trying to recreate an office experience
Same goes for people who live in tight quarters, multi-generational

homes.

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RO-DBT-specific issues in telehealth

Therapist set-up characteristics

Your digital identity as an RO-DBT therapist

RO-DBT stands out from many other therapeutic approaches by

providing specific instructions for how to set up the therapeutic space, such that OC patients are able to engage optimally in treatment

Cool room (fan/air conditioning – OCs dislike feeling hot/sweating)
Chairs at a 45 degree angle to each other (allowing for heat on/off)
Beverage (to access social safety)
We can maintain this spirit over telehealth

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Your digital identity as an RO-DBT therapist

Don’t be too close to the screen
Aim to show your face and upper body, so gestures can be seen.

Your digital identity as an RO-DBT therapist

Is your face clearly visible?
Ensure you aren’t backlit

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Your digital identity as an RO-DBT therapist

Consider your background
Where are you located?
What you choose to show on your screen is a social signal
Do you want to have a digital screen background (e.g. office/library/blank)?

Therapist social safety access

RO-DBT places great emphasis on the therapist accessing social safety
We must remain flexible in the face of maladaptive OC social signaling
Recall: the flat face trumps all!
We will end up mirroring our patients’ flat face, rigid posture, lack of

movement, etc. when we don’t mindfully attend to accessing social safety

We need to be able to access social safety when conducting tele-

therapy, just as we would in person

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Therapist social safety access

Sit in a comfy chair that allows you to sit back
Big 3+1
Drink a beverage
Ensure that small children/pets/others who may need your attention

aren’t likely to barge into your session (the fear of this can activate threat)

Self-disclosure…intentional/unintentional

In RO-DBT therapist self-disclosure is used as a therapeutic tool,

deployed with intention, with the purpose of helping our patients

Conducting sessions from our homes could pull for more self-

disclosure, which may be less deliberate/mindful

Tension between self-disclosure & professionalism
Keep in mind, we aren’t inviting pts into our home, but into our

virtual office…

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Hiding self-view

Hide self-view: viewing one’s own face can prompt self-conscious

evaluations, shame, and distraction, all of which can take us out of Safety and into Threat

We want to mimic real-life transactions as much as possible – no

mirror normally available in-person for us to see how we are performing

If self-view is needed, to record a session for supervision, stick a large

post-it note over the part of the screen that shows your face

Be mindful of your facial expressions

They are likely to go flat if/when you’re in threat!
Technological snafus, glitches, etc. may push you into threat
Use of eyebrow wags in digital space – more important than ever!!
You may need to signal bigger – face & body gestures to convey

desired effect via telehealth.

Sit far enough away that arm gestures can be seen
Do a videotaped review of your facial expressions
Is there a difference? Do you need to exaggerate?
Adjust as needed.

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Digital Botox

Over telehealth, your normal transmitting channels (facial, body, voice,

touch) & receiving channels (ability to hear clearly, see clearly, etc.) are hampered/frozen to some extent.

So, you may need to (at least occasionally) signal bigger/more

expressively than in-person

Recall, we are biased to see anything but a really clear and

conspicuous signal of prosocial friendliness as potentially disapproving

r critical.
So signal interactions bigger and/or with more channels to make sure

your friendly intentions are received

E.g. When teasing, raise eyebrows, use body/hand gestures to ensure

the tease is taken as intended

RO-DBT Therapist set-up characteristics

How to use heat on/heat off strategies in a digital space – consider

using whole body more than just looking away.

Look away in order to drink tea/beverage as a heat off strategy

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RO-DBT-specific issues in telehealth

Patient set-up characteristics

Orient the patient to telehealth to set them up for success in telehealth

Setting up the digital treatment space
Encourage privacy
Instruct re. how to hide self-view
Encourage beverage
Fan/air conditioning
Comfortable space/chair

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RO-DBT-specific issues in telehealth

Individual RO-DBT

Enhancing engagement via telehealth tools

Share screen to look at diary card together.
Use whiteboard for chain analysis
Use a fillable chain analysis worksheet
Share videos during session (e.g. “talking eyebrows”

https://www.youtube.com/watch?v=ZaO-llc_E64 )

Do fillable assessments (e.g. styles of coping word pairs): Share your

screen then click “annotate” in Zoom

Orient patients to this & allow time for practice (this can give your

patient tools to help with their kids’ virtual homework too)

How to download worksheets – where to save on computer?

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Enhancing engagement via telehealth tools

Can we use telehealth to our advantage, moving beyond data available

in-person?

If a patient’s family comes into the session briefly, note how they

interact – is there a target there??

Opportunities to observe lack of warm greeting, presence of critical

tone, and many other targets that would never be observable during an in-person session

RO-DBT-specific issues in telehealth

RO-DBT Skills Class

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Set-up logistics: approximating in-person class

Show patients how they can change their on-screen name (and add

their pronouns if your tribe so chooses – mine does )

Some classes may need to mute when not speaking, in order to

conserve bandwidth & maintain a good connection (mine does)

Prior to a Pw/oP exercise, instruct participants to unmute
Our class requires all participants to have their video on
We also limit our class size to about 10-12 (similar to in-person)

Demonstrations of each of the following:

Use of whiteboard to write acronyms & fill in with each skill taught.
Share screen to show handouts (e.g. inkblot)
Consider emailing handouts to participants ahead of time, so they can

access them

Consider pasting handouts in the chat (in Zoom) for easy download.
Move back from screen for P w/o P exercises, so your whole body is

visible.

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Participating without Planning exercises Demonstrations of each of the following:

How to handle patients who turn off their camera during skills class at

times?

How to handle non-participation during P w/o P exercises?
Use of breakout rooms (in Zoom) for paired practice exercises
And for “Chitty chats”

https://www.youtube.com/watch?time_continue=3&v=jbPpdyn16sY&f eature=emb_logo

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Attend to patient engagement & support re-engagement

Easier to zone out when class is virtual
How to manage distractions
Bring attention back to the task at hand
Ok to wander off, as long as you come back 

RO-DBT-specific issues in telehealth

Self-enquiry

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Self-enquiry

For therapists and patients alike: Do you have an edge re. telehealth?
What do I need to learn about myself being in the virtual world?
Any edges re. being clumsy & making mistakes re. videoconferencing

software

To what extent do I feel I am engaged in doing RO therapy online -

what might that mean, what can I learn?

Straight from the horse’s mouth

“How will I know when my patient is at their edge, during self-

enquiry??”

Actual concern I had during my individual RO-DBT sessions
Feedback from Tom:
You’re not required to be able to tell whether someone is at their edge or not
If you can tell that’s great, but it’s not the goal
Ask the client “Are you at your edge?”
Believe their answer
AND dialectic: if after multiple times something seems like they are not at their
edge. Ask them about it - with humility!

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QUESTIONS?

1. Managing risk
2. With the crisis management protocol, how do we take a break if we're

not able to get coffee or go for a walk virtually?

3. Alliance ruptures occurring via Telehealth
4. How to cope with a loss of in-person opportunities to engage in small

talk before/after class and during break

5. When is class too large to hold virtually given how small participants

faces are on the screen?

6. Can you start an RO skills class with only one practitioner?

THANK YOU More information on RO DBT: https://www.radicallyopen.net/

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