So, again, I want to welcome everybody, as either Chris or I usually do. I'm Dr. David Stifler, and on behalf of the American Academy of Addiction Psychiatry, welcome to the webinar. This will be our final one of this academic year of our monthly series, so I want to thank all the fellows that have joined us, and if you won't be able to join again, we wish you all the best with graduation and what comes next. So we will be continuing this monthly seminar of evidence-based intensive psychotherapy training for addiction psychiatry fellows and faculty, so we'll be welcoming the new fellows. We're going to skip July, and the next one will be in August with psychedelic-assisted psychotherapy, and then, again, this seminar is hosted in partnership with Oregon Health and Science University and with NYU. So a few housekeeping items that we've gone over before. Feel free to ask questions any time during the presentation. You can click the question button in the lower portion of your control panel and then type in your question, and then we will also have time at the end for questions and answers, and then you can also contribute to the chat box during the talk, which we'll be monitoring, and if appropriate, and if Dr. Harned is open, maybe we can have discussion during the talk in addition to some of your responses to poll questions. As always, after the session, you can claim credit by logging into your AAAP account and accessing the course. You'll need to complete the course evaluation and follow the prompts provided to claim credit, and then, as always, additional courses will be added for next year, so faculty, you're welcome to check to see what we have in the lineup for the next academic year, and any of you fellows that are going to be joining, you're welcome to check them out. I'll turn it over to you, Chris. Hi, everybody. Thanks again. I'm Chris Blazes from OHSU, and we're very excited to have Dr. Melanie Harned, who's a PhD psychologist and coordinator of the DBT program at the VA in Puget Sound. She also is an associate professor in the Department of Psychiatry at the University of Washington. She's previously worked as the research director for Dr. Marshall Linehan's behavioral research therapy clinics at the University of Washington, and as I'm sure pretty much everyone here knows, Marshall Linehan is the person who created DBT, which is what we're talking about today. Dr. Harned's research has focused on the development and evaluation of DBT, prolonged exposure protocol for PTSD, as well as methods of disseminating and implementing this and other evidence-based treatments into clinical practice. Dr. Harned provides trainings and consultation nationally and internationally in DBT and DBT-PE, and is also a licensed psychologist in the state of Washington. We are very grateful that she's coming to talk to us about DBT, and I'll pass it on to Dr. Harned. Thank you so much, and thank you for having me. I didn't realize I was the last one of the year, so pre-congratulations to everyone who's wrapping up their fellowships. I'm going to start with just putting my disclosures up here so people are aware of them, so doing various training and consultation and research grants, royalties, things like that. You can take whatever I say with a grain of salt based on all of that, and talk about what I'm hoping to get through with you today. Trying to basically give you some sense of DBT in an obviously very introductory overview way, hopefully helping you to feel like you understand it well enough to at least make appropriate referrals to that when it's an option, and possibly think about some of the strategies, using them in your own work in some way. I want to describe what the DBT treatment targets are, how we organize treatment according to targets, what the four modes of DBT are. It's a multimodal treatment. We're going to talk through the core strategies that we use in DBT, which is problem solving on the change side and validation on the acceptance side. Then at the end, I will talk about two of the specific skills that have been developed for managing addiction. DBT has a set of addiction skills that we can teach and include when relevant for clients with substance use problems. We'll talk briefly about a few of those just to give you a taste of what those skills are. Okay. Before I jump into the first section, which is to talk a little bit about the story of how DBT was developed and what the overall structure is, we have a poll that we were going to get some sense from folks about your existing knowledge and level of confidence about this particular topic, structure of DBT, and how you might be able to describe it to a patient. Most of you, it looks like, are either not at all confident or somewhat confident. I assume that translates to having very little or potentially no knowledge really of DBT and how it's structured. Then some of you look like you've had a bit more exposure to DBT and would feel pretty confident about doing that. Let's talk it through, and hopefully we will improve your confidence as we go. Okay. DBT originally was developed, obviously, by Marsha Linehan. She spent most of her career at the University of Washington. Her original passion, what she was trying to do, was to develop an evidence-based treatment for people who were highly suicidal, chronically, acutely suicidal, repeated suicide attempts. That was really her interest. She was also particularly interested in highly suicidal patients who were just very complex and difficult to treat patients. She did not start down the road of developing DBT with any particular diagnosis in mind. She was really a suicidologist. That's what she cared about. DBT, over time, has evolved essentially from a trial and error process that Marsha and people who were working with her at the time went through in trying to implement a treatment, figuring out what problems came up, and then trying to make changes to better fit the needs of this patient population. We'll talk through what those main problems were and how DBT has been structured to accommodate and solve some of those issues. Marsha started developing a treatment around 1980. That coincided with when she got her first grant, which was from the National Institute of Mental Health. It was a treatment development grant with, again, a focus on treating suicidal behavior. She was recruiting for people who were at high risk for suicide, which is most often defined in DBT studies as recent unrepeated suicidal or non-suicidal self-harm. She had, as her prior training, well, she was actually a social psychologist and only got clinical training after her PhD. She ended up specializing in behavior therapy, starting in her postdoctoral fellowship. She was a pretty radical behaviorist by training. That's where she started when she began trying to develop this treatment. As you, I'm sure, know, behaviorism is a very change-heavy treatment. It's a lot about figuring out problems, solving problems, asking people to make changes, and figuring out strategies that will change behavior, essentially. When she attempted to apply standard behavior therapy with this population, that kind of blew up pretty quickly because of a couple of things that are typical of this patient population. One is that they're very sensitive to rejection, often feel quick to feel invalidated. This sort of heavy change-only focus, which is essentially you need to change what you're doing, what you're doing is problematic in some way, was not well-received by many patients who then felt like they were being told they were the problem and that there was sort of came across as invalidating, essentially. She switched originally then from this really heavy change focus of behaviorism, started to learn more about Zen, and sort of switched to a really heavy, instead, acceptance-based approach, which was really just sort of understanding, validating their suffering, and sort of being supportive and warm and caring and nonjudgmental. And that also didn't work well because, on the whole, patients would say, essentially, if you really understood my suffering, you would do something to help me change it. And so she kind of tried both extremes with this population, and both of them on their own were not landing well. And this is how she kind of, frankly, by mistake, landed on the idea of dialectics. So she didn't conceptualize it. She wasn't familiar with the philosophy of that at the time, and somebody else described it as dialectical the way she was thinking, and then obviously she became much more knowledgeable about that. But sort of the fundamental dialectic in the treatment is straddling this sort of balance between change and acceptance. And dialectics broadly just mean that two things that are sort of polar opposites can both have truth in them, and that often we're looking for some kind of synthesis of the two to sort of figure out what's going to be most effective. So DBT includes within it a balance of change-focused strategies as well as acceptance-focused strategies, and a lot of the sort of skill of the treatment is in sort of doing the dance of figuring out when change is needed, when we need to do acceptance, and sort of weaving these together to keep patients moving forward towards whatever their goals are. So this is an illustration that sort of captures all of the overall strategies in DBT, all of them balanced between change on the one side and acceptance on the other. The orange boxes are the core strategies, which we'll talk a bit more about problem solving as the change-focused and validation as the acceptance-focused. We also have a set of strategies related more to case management or how we help clients interact with their environment. We have a change-focused one, an acceptance-focused one, as well as strategies that are more about communication styles or stylistic strategies that include irreverence on the change side, the sort of direct confrontation, very matter-of-fact, sort of saying sometimes pretty off-the-wall things, compared with acceptance sort of communication styles on the other side, which is a lot of that warmth and nonjudgmental approach and self-disclosure and being really responsive to the client's needs. And so we have these balances across all these domains. So the dancing people in the middle is that there's often a metaphor used about DBT being like doing a dance or sort of the jazz of DBT is figuring out how to put all these things together and find an effective balance for each client, which is a different ratio, depending on the person, between change and acceptance overall to keep things moving forward. So overall, these are our therapist strategies at a pretty high level. And just to see that that change in acceptance dialectic carries through all of them. So another problem she then encountered was that the patients that she was treating and that we treat in DBT generally have lots and lots and lots of different problems. They, you know, in some of my own research, for example, the patients meet criteria for an average of seven different disorders. They've just got a lot of different complex problems going on, combined with low distress tolerance. Just really hard to stay focused on any one problem, any part of a problem, one disorder, one topic is sort of can be all over the place. This kind of like putting out fires version of therapy with all these crises that often are going on that make it really hard to sort of do some kind of sustained work on any one particular problem area. And so with this, what she realized also is that we needed to be able to teach patients a lot of skills, but that the skills also needed to be change focused and acceptance focused. So, for example, we were going to need to help them accept that we weren't going to be able to solve all their problems at once, tolerate distress of unresolved problems that might be going on, tolerate crises without doing things that were going to make things worse. And at the same time, teaching them skills to be able to actually change problems, change their emotions and improve things while also having to tolerate other things. And so this sort of balance of the skills also falling out between change and acceptance was another part of the development of DBT. So you've probably heard about some of the DBT skills. Many of you, there's four skills modules that are, there's two on the change side, which is emotion regulation and interpersonal effectiveness, two on the acceptance side of mindfulness and distress tolerance. And then with the DBT for adolescents adaptation, they developed a set of skills. That's the middle path skills, which is essentially teaching people how to be dialectical. That has now become a part of standard DBT as well for adults. And so just to say a little bit more about the four core skills modules here, mindfulness is derived directly from Zen and the goals of the skills we teach that are sort of mindfulness skills are really about trying to increase their ability to pay attention into the present moment, experience reality as it is without judgment. And through that, being able to ideally reduce suffering. Distress tolerance is often the first skills we are teaching clients when they come in and they're at acute risk and they've got all sorts of crises going on. And so the distress tolerance skills are really about how to survive crisis situations without making things worse. These are things like distracting yourself and self-soothing and a variety of other strategies that will give you sort of a quick drop in intensity of emotion in a crisis situation. You've maybe heard DBT seems to have gained some notoriety around a common skill is having people put their face in a bowl of ice water as a way to quickly regulate physiology. So that's one of our crisis survival skills, as well as radical acceptance skills are part of our distress tolerance skill set, which is about accepting reality as it is. The things that we cannot change or cannot change right now and being better able to tolerate those things. So those are the acceptance focus skills. The change focus skills are the emotion regulation skills. This is kind of our bread and butter in DBT. We conceptualize emotion regulation as being the sort of core or emotion dysregulation as being the core problem of many of the clients that we're treating. And so I'm teaching them how to more effectively understand and be able to identify their emotions, how to reduce the intensity and the frequency of emotions they would like to not have in skillful ways. And overall, how to reduce their vulnerability to emotions as well, is all part of our emotion regulation module. And then the last set is our interpersonal skills, which are skills related to essentially sort of being skillful and asking for what they want and saying no to things, how to make people like them and maintain relationships. And then also how to behave in relationships in ways that increase their self-respect. So that's sort of a quick and dirty overview of the different types of skills we teach in DBT, again, balanced across acceptance and change. So another issue was that because clients have so many problems and are often in crisis, that from week to week, session to session, it can get quite chaotic. You know, one week you think you're working on treating, you know, panic or something. And the next week they come in and say, I absolutely have to talk to you about my substance use. And then the next week it's that I need to tell you about my relationship breakup, where there's just sort of so many things going on that it can feel really chaotic and confusing for the therapist to know what to do when and not just sort of fall into the putting out fires type of therapy. So the solution here was to balance between a target-based structure of treatment, which I'll define in a minute, which is one that sort of gives us some flexibility, that we choose what we're doing, we prioritize what we're addressing in sessions based on a sort of hierarchy of targets. And then the other side of it is more of a protocol-based agenda. So protocol-based treatments are ones where, you know, in session one, you're supposed to do these five things in this particular order, you know, that approximately this amount of time, you know, where the sessions are very sort of structured and predetermined. Those are protocol-based treatments. And DBT tries to balance the two of those across the modes specifically. So the target-based agenda is what we use in individual therapy. So this means, you know, your client comes in for a session. We have them fill out a diary card every day. And so they bring in their diary card, which is tracking what their main target behaviors are that we're working on, as well as what skills they are using, things like that. There's a variety of things that we get in track on the diary card. We look at that at the beginning of session to see what's been going on since the last time we saw them, and we use that to sort of structure our session agenda based on this target hierarchy. So for clients who are engaging in any type of life-threatening behavior, so we consider that to be suicidal behavior as well as non-suicidal self-injury, both fall in that highest priority category of life-threatening behavior. If that's happened at all or they're at some sort of acute risk or they're engaging in preparatory behaviors, things like that, that is our highest priority. We will make sure that we spend time addressing that in the session. The second tier, second level of priority is what we call therapy-interfering behaviors. These are anything that either the patient does or the therapist does. It's very possible that therapists engage in these behaviors too. Anything that interferes with essentially the patient getting the most effective treatment that they can get engaging effectively in therapy. So on the patient side, these are things like not attending therapy or coming late or leaving early or screaming at you the whole time or being dissociated throughout the session or coming in high or drunk to your sessions, not doing homework. All these kinds of things would fall into therapy-interfering behavior. On the therapist side, it could be things like coming late, being distracted, forgetting important things, not doing things you said you were going to do, being judgmental, whatever it might be on the therapist side. So essentially the priority is we have to keep the person alive first, and then we have to make sure they're actually in therapy and doing therapy in some effective way before we can then do the third tier of behavior, which is everything else essentially. Quality of life-interfering behaviors is what we broadly call it. This is where substance use would fall. This is where any version of psychiatric disorders, psychosocial problems, all sorts of housing relationships, finances, whatever other problems they might be having are in that third tier. And underneath all of it is we're also trying to increase their behavioral skills as a way of addressing these targets overall. So that's how individual therapy is structured, which means that we don't know what we're doing in any given session because we don't know which behaviors have happened or not. And so we always have to keep this target hierarchy in our minds as we sort of set up our agenda and figure out what it is we need to address in the session. That's in contrast to skills training groups. So that was individual therapy. Another mode of treatment is skills training groups. The standard length in clinical trials is usually two and a half hours. It's often less than that in clinical practice. We do two hours in my VA, for example. But the main point here is that skills groups follow a very specific structure. These are more on the protocol-based side of that dialectic where we begin with mindfulness. We spend usually an hour reviewing whatever their skills homework practice was. We might give them a break. And then the second hour we do new teaching of the next skill and possibly some time for wind down. So that follows a much more specific structure. There is also a specific schedule of which skills are taught in what order. This is sort of the cycle of how we teach skills in the group. We get through all of the core skills in DBT in a six-month cycle. And so you see that mindfulness is done in between each of the other skills modules. Mindfulness is a briefer one, two weeks. And it takes six months to get through all these skills. So for adults it's pretty typical that DBT lasts a year. So it means that everybody gets the skills twice, which is often really critical. It's often a lot of information to really take in and understand and begin to sort of feel facile with only one time through. So most time people get two cycles of skills. Adolescents, it tends to be a briefer treatment. And they get six months typically. But there's variation across obviously programs. So the main point here is that there's a clear structure of group and there's a schedule and what you're supposed to teach when, and we know that going in. So that's kind of the protocol-based side of DBT. In the skills training groups, there is a target hierarchy as well. The number one priority is any behavior that's actually going to destroy therapy, which is different than interfere with therapy. So destroying therapy would be things like threatening violence towards other group members or threatening to burn down the clinic or things like that that would be actually going to destroy therapy. If anything like that happens, we have to address that before anything else. But otherwise, the focus of skills training is on teaching skills. We ignore all sorts of things in the service of teaching skills. This is where people learn about all the skills and begin to strengthen them. And then an individual therapy is where we help them tailor them to their specific problems. But it's all about teaching skills. So you'll see that the therapy interfering or treatment interfering behaviors is our third priority. We will ignore all sorts of things if it's not super interfering so that we can get through the skills and make sure people are learning them. So that's the hierarchy and skills group. All right. So another set of problems was that clients at high risk of suicide, it really was hard to only see them for an hour a week given their high risk. And patients very often had trouble applying what they were learning in therapy on their own outside of therapy when in the situations where it was actually needed. And so a third mode of DBT is we have individual therapy. We've got skills group. And then a third mode is phone coaching where we are trying to sort of balance getting clients to be able to be more self-reliant and independent problem solvers with also providing support from the therapist as needed in their lives. So the phone coaching targets the sort of by-the-book version of DBT is that you're available 24-7 to your patients, which I did for 15 years at the University of Washington, which is a lot of time and a lot of settings that's not possible for a variety of reasons, including the VA will not allow us to do that. So our phone coaching is now during business hours only. But principally what's needed here is availability between sessions to help clients specifically with these targets, if you're their individual therapist. So the decreasing suicide crisis behaviors, if there's some kind of crisis going on, really helping them generalize the skills that they're learning in treatment. So ideally these calls are having a really hard time. I'm having urges to use substances or kill myself or whatever it is. I don't know what to do. I've tried some skills. Can you give me some other ideas where we're just on the phone for 10 minutes, you know, or so sort of suggesting some other skills and strategies that they can apply given whatever situation they are in. And then sometimes the phone coaching is used also just for relationship repair. If there has been some kind of significant conflict in the therapy relationship, we want them to be calling their individual therapist for phone coaching, not their skills trainers, but if they do call the skills trainer usually the focus is on getting them to instead call their primary therapist. That's what the target's there. So that is the function of the phone calls or phone coaching. As you might imagine, this population can be pretty stressful to treat for therapists, working with patients at very high risk for suicide, especially can be really scary. For people. And so there were sort of different types of therapists getting emotion dysregulated, getting dysregulated emotionally in a variety of ways. One is getting afraid. Essentially. I've certainly had that happen myself for when I get afraid that I think somebody is actually going to die. My urges are always to try to control them more sort of like move in, try to sort of know what they're doing at all times and make sure they're okay. And then there's sort of the fear or anger side of it. And then sometimes therapists also essentially have just, we call it sort of falling into the pool of despair with clients when clients are really hopeless and miserable and life is nothing but suffering. Where therapists can sort of get excessively empathetic and emotionally dysregulated. And so there's sort of the fear or anger side of it. And then sometimes therapists also essentially have just, we call it sort of falling into the pool of despair with clients when clients are really hopeless and miserable and life is nothing but suffering. And so there's sort of the fear or anger side of it. And sometimes therapists can sort of get excessively empathic in that way and sort of give up on trying to change anything and just be sort of stuck with them in this suffering. And so with that, the fourth mode of dbt is the consultation team for therapists. Where we are really trying to sort of balance the needs of the clients with the needs of the therapists. So the consultation team is a weekly team meeting. And we have our own set of sort of functions for that meeting as well. It's different than most other clinical meetings, a big picture. The consultation team is intended to be therapy for the therapists. It is intended to be a place where, you know, we are addressing our own. Sort of problems with motivation. And so we have our own set of functions for that. We have our own set of functions for, you know, wanting to fire people and not wanting to work with them anymore. Or if we're just really scared or hurt by something that a client has said or done. When we're feeling really stretched. By clients. Demands. As well as some sort of more typical clinical functions, such as, you know, going to the doctor or going to the doctor's office. And things like that. But this, the agenda of consultation team is organized by what therapists need. As opposed to what clients are doing. And so we put ourselves on the agenda for needing support around something or validation around something or problem solving or whatever it might be. And so that's sort of what we're trying to do. And we're trying to keep going with really hard clients and. All of the various reactions that we as therapists can have. In this work. So to summarize, there are four modes of dbt. And we're going to talk a little bit about each of the different modes of dbt. The individual therapy mode. We are targeting any sort of motivational factors. Helping them apply what they're learning to their specific problems. And where we will address other things going on in their environment as well. The phone coaching is about generalizing what they're learning in their environment. And then we'll talk a little bit about. Improving our own as therapists capabilities and motivations. So that is generally the sort of modes and functions of, of dbt. Let's talk a little bit about the sort of core strategies to give you an idea of what we're talking about here. So. As a reminder, this was sort of a schematic that I showed you a minute ago. That the core strategies here are problem-solving and validation. So we're going to start on the problem-solving side and sort of talk that through a little bit. So. The general steps in problem-solving that we do, we start with assessment, which we'll talk about. Our core assessment strategy and dbt is called the chain analysis, which I imagine some of you may have heard of. Sometimes it's called behavioral chain analysis. But this is our assessment strategy. So first we were assessing. Whatever the problem is. Once we have done a thorough assessment, We're going to identify some potential solutions. Possible solutions for it. Then once we identify some potential solutions to try the final piece is to get a commitment to actually do the solutions, implement the solutions. And then troubleshooting. So we'll talk through these different steps in the problem-solving side of things. Okay. So let me tell you a little bit about it. And then we have a poll for you in a minute. So if, in case you're not familiar at all with the general idea here of chain analysis. We use chain analysis. To analyze one specific instance of a behavior, whatever it is. So let's say for example, you're working with somebody. And so if we are trying to understand a problem behavior, that would be the red oval, there's several things that we are looking for in our chain analysis. We start with vulnerability factors, which are kind of the sort of background factors that were going on, leading prior to this behavior happening that sort of made the person more vulnerable to engaging in that behavior at that time on that day. And these are often things like they hadn't slept well, or they'd had a conflict with somebody, or they were hung over, or things like that that just sort of made them more vulnerable that will sort of answer the question like, you know, why did this happen on this day and not another day? When there's some prompting events that doesn't always lead to this behavior, for example. So those are the vulnerability factors, what sort of made them more vulnerable that day. The prompting event is whatever the sort of, it could be often it's an external event, you know, a fight with a partner or, you know, trauma cue that they came across, some sort of external event like that, sometimes it's an internal event, meaning they had a panic attack, or they had a nightmare, or something that happened internally. But one way or another, we're trying to understand sort of what the prompting event was, which is typically the thing that happened right before the thought of engaging in the problem behavior first crossed their mind. Sort of what is that prompting event? And then we're sort of filling in the links between whatever that sort of prompting event was, and the actual behavior, usually no more than a couple of hours in real time that we're trying to sort of make sense of here, of what were their thoughts and emotions, and what situations and what things were going on around them, physiological sensations, sort of what were all the links leading up to the actual behavior that they engaged in. And then after the behavior, we also always want to assess the consequences. So short term, like what happened immediately after they shot up heroin? What was the sort of first thing that they were aware of? Almost always the answer is some sort of emotional relief, some sort of reduction in emotional distress. And then we're also interested in the longer term consequences as well, which are more typically negative things, impacts on relationship or relationships or housing or having to be hospitalized or feeling ashamed and guilty later, things like that. So we're sort of looking at the after effects as well. And so I'm going to put up the poll now with that sort of initial explanation of a chain and sort of see how confident you feel about being able to conduct a chain analysis. Somewhat or whatever the quite confident was, seemed like most of you land in there. That's great. Okay. Well, let's talk it through a little bit more with a specific example and get a little bit more detail for you. So this is going to be an example chain. So starting with vulnerability factors. So in this example, the problem behavior is going to be a suicide attempt. We'll get there in a second, but sort of the vulnerability factors were that this was a woman sort of in her thirties or so. And so on that particular day, she was more vulnerable for a variety of reasons. She was hung over from the night before. She was just generally tired and irritable. She'd had a recent fight with her husband and so was stressed from that. And the house was really messy that day. And so she was just kind of baseline, more vulnerable than she might have been on a different day. So those were the sort of vulnerability factors. The prompting event was that she saw her son watching TV when she had told him that he was not allowed to do that. He was supposed to be doing something else. And she came into the living room and saw that he had turned the TV on and was watching TV. And so with that prompting event, the first link after that that happened was she got really angry, sort of just a real intense spike in anger when she saw that he was not doing what she'd asked him to do. So she yelled at him. And that led her to have the thought that I can't manage. I'm a screw up like my mom. So her mom had been pretty abusive of her, angry, yelling, that kind of stuff. And so she had a pretty negative thought that about herself as being similar to her mom. And so then she had what was a pretty common thought that often is related to suicide, which is that people would be better off without me. I'm a burden, I'm a problem, that kind of thing. So that thought showed up next. And so then she went in the kitchen and did six shots of vodka and took three trazodone that she had with suicidal intent, hoping that she would die. So that was the problem behavior. She immediately felt more relaxed after ingesting all the substances. She then got really tired and fell asleep for six hours. And her son was left unattended during that period of time. He was young enough that he required monitoring. So she passed out and wasn't paying any attention to him, which led her again to feel like a failure and like she was a terrible mother. And ultimately to feel really ashamed about what she had done. And that elicited a desire to avoid therapy, not have to go talk about what she'd done with her therapist. So this is just an example chain, and we're going to use this as we think more about the problem-solving side of things. So we'll come back to that in a second. Oh, there's some more animation there for you of all the different pieces now labeled. Okay, so once we've done our assessment of the problem, the next step is to do a solution analysis. And so essentially what we are trying to do then is to break the links between whatever the prompting events were and the controlling links between that and the problem behavior. Sort of what could we do to make sure that the problem behavior didn't happen in the future and create some new links to some more effective behavior that would prevent this same type of thing from happening again. So that is the overall goal of solution analysis. So in DBT, we have generally four types of solutions that we're thinking about coming. This is just straight cognitive behavioral therapy at this point. Most of our solutions come from CBT. So if the problem was that the person lacked some type of skill that was needed, they just didn't know how to do something like regulate an emotion, regulate anger, for example, in that example, then we're going to pull solutions from skills training. We're going to teach them how to do something more skillful if they just lack that knowledge. Sometimes the problem is that there was just a really intense emotion that they knew what to do that would have been more skillful, but they weren't able to do it because some intense emotion just took over and totally interfered. So if that is the potential problem, then we would use exposure procedures to sort of reduce the intensity of whatever that emotion is that got in the way. Sometimes the problem is faulty beliefs or interpretations, cognitions essentially, got in the way of being skillful. And so we also will use strategies from cognitive therapy, cognitive modification strategies in DBT. And then the last thing is that sometimes the problem is more about what happened after the behavior. So those first three, the skills training exposure and cognitive modification interventions, are usually addressing, we call it the front end of the chain, things that happened before the problem behavior, where we are trying to insert skills or address intense emotions or thoughts that came up that contributed to the problem behavior. Whereas contingency management strategies are sort of fourth category of solutions, are really going after the consequences. The things that happen after the problem behavior that might be maintaining it, either because the behavior is getting reinforced by something or more adaptive or skillful behavior that the person could do is getting punished in some ways, so they're not doing it. So the contingency management solutions are often on sort of what we say the back end of the chain, things that happened after the problem behavior. So if we go back to our example chain analysis that we walked through before, I want to get some people's ideas about what types of solutions, so sort of from this chain, what do you think some of the controlling variables were, like what are the things that really were responsible, sort of contributing to the suicide attempt happening? And what types of solutions might you suggest for this example to prevent the same thing from happening again? So yeah, I'm thinking with the hangover and the lack of sleep, whether like really getting very granular with that and thinking about the evening before in even more detail and how her sleep was during the night and thinking about how she might, you know, get more rest. I like that, I've done some DBT here with the UW training and I like the idea of like doubling down on the PLEASE skills here. All right, you've got the acronyms, yes. So we'll talk about PLEASE skills in a minute, but essentially those skills are about reducing vulnerability to emotion by getting good sleep, you know, avoiding substances, eating healthy, getting exercise, things like that that kind of build resilience essentially for stressors when they show up. So it sounds like that's what you're thinking, Maureen, as things related to trying to improve sleep and reduce substance use so you don't wake up in such a vulnerable state. Yep. Several of you are thinking about how to manage the anger spike. Are there specific solutions that you're thinking of there that you can unmute yourself or be unmuted, either Virginia or Raul? Virginia is ready to answer. Yeah, hi. Yeah, so learning to manage unsettling emotions. I'm more from the mindfulness and acceptance side. That's where most of my skills come from. So my thing with emotions in general is to look at them from a point of view of curiosity. Now, I don't have a lot of experience doing DBT and I can see how, you know, that might not in a really kind of crisis situation, that might not be super effective, you know, for folks like this. So it might be more at a lower level of anger, right? Like if we can catch it before it gets real high, but potential mindfulness strategies of just, you know, we have a skill called mindfulness of current emotion essentially, where the goal is to just sort of ride the wave of the emotion and experience it without trying to do anything, change it or not having to act on it, but just sort of letting it naturally come and go. So that might be something potentially at a lower level of anger. Yeah, great. Any other? Oh, go ahead. No, I was gonna say distraction. You know, at that point, if it's really just about lowering the intensity of the emotion, you know, you were talking about the typical thing of putting your face in a bucket of ice water or doing physical exercise, you know, something that can kind of quickly get your mind off of that. Yeah, some sort of fast acting. Yep. That could reduce intensity quickly and or just distract you. That's right. Anyone else have other thoughts? So far, I didn't know much about DVT, but I know colleagues of mine, just the example of the bucket of ice. Someone told us that the person who is in crisis should choose ice to get off your mind of the emotion that is affecting him. I didn't know too much. I'm very keen to learn about this session. I unfortunately think I didn't catch a fair amount of that. The audio is a little glitchy in there, but I feel like you maybe said something about chewing ice, but I could have misheard that entirely. I hear that some of my colleagues who practice DVT will tell their patients to grab an ice cube to get off this emotion, and all the time I'm hearing the chewing ice cube. So far, I didn't know. I'm very keen to learn about this. Okay, great. I think I got it. Yes, we love ice as a fast acting way to trigger the dive reflex and get all of emotional reactivity down quickly, and sometimes we just use ice cubes if they can't get a bowl of ice water, which is often not possible in a lot of places. Let me just go through, and these are just some examples of you can see how we match up solutions along the chain. As Maureen was saying, the please skills, which I already described, which are about sleeping and eating and avoiding substances and exercising, things like that, that will reduce vulnerability are always good ones for that part of the chain, typically. The anger, probably our go-to strategy would be a skill we call opposite action, which is doing the opposite of whatever your urges are when you're having a specific emotion, specifically as a way to reduce the intensity of that emotion. So when we're angry, our urges are to yell or fight or attack or whatever it is, and so the opposite action would be something like gently avoiding, just turning around and leaving the room, essentially as a way to reduce anger rather than acting on those urges, which are likely to increase anger. Dear man is one of our interpersonal effectiveness skills. It's the one that is about asking, making effective requests. So she could have instead made a more effective request to her son to not watch TV and to do whatever it was he was supposed to be doing instead. But these thoughts are cognitive therapy skill we call check the facts, which is a short version of cognitive therapy, essentially. So could we check the facts and evaluate the logic of the thought she had there that she can't manage and she's a screw-up like her mom? Once we get down to starting to think seriously about suicide, we have a pros and cons skill that often we try to get people to do in advance and put up somewhere in their house so that they can go review it and remember the reasons they do not want to kill themselves, the downsides of suicide. It often goes out of their heads in these moments, so trying to get that information back present in their awareness. And then someone mentioned distraction as well. Often we'll insert those kinds of skills as our sort of last resort right before a problem behavior. This could be all sorts of things. Catch a cat, watch TV, listen to music, dance around, like go for a drive, read a book, you know, whatever kinds of distraction. Just try to get your mind off of it. And on the sort of consequence side, there's a strategy. It's actually a cognitive strategy. We call it contingency clarification, which is making sure that people are clear on, aware of the consequences of their behavior, and ideally so that they see that they have many more downsides than positives, so that they can keep these, again, sort of the negative consequences of attempting suicide or whatever the behavior is, making them much more aware of them so that they will be less likely to do it again in the future. And then all the way down at the end, again, another opportunity for opposite action, in this case to shame, that shame about not wanting to come to therapy because you didn't want to have to talk about it, which would not be effective. So the opposite action to shame would be to come and to share openly and disclose what had happened as a way to get shame to come down by learning that the therapist is not going to reject them, essentially, when they find out what happened. So these are just some examples. These are not, of course, the only solutions, but just to give you sort of a sense of what we're trying to generally do here with these chains and solution analyses. And then the last piece being really about commitment and troubleshooting. So then you pick a couple of those solutions or whichever, you know, ones that the client feels most willing to do, most able to do, seem like will be most effective, and get a clear commitment that they're actually going to implement those solutions. So this week, I want you to practice opposite action for anger. And let's talk about exactly how you're going to do that. Or I want you to figure out your dear man request for whatever thing is relevant this week for your son and practice asking skillfully for something, right? So we sort of come up with what our solutions are. We get a commitment that they're actually going to do them. And then a really critical piece is the troubleshooting part of it, which is what could get in the way of implementing whatever the solutions are, all the barriers. And now we also do a little bit of problem solving around that. That can be things like, I'm not going to remember, or I don't have enough time, or I'm not going to feel like doing it when I get there. Or I might be so angry that I can't stop myself from yelling, or whatever they think the potential problems could be. We troubleshoot those as well to sort of set them up as best as possible for success in actually trying these new solutions and new behaviors. All right, so that is the problem solving side. The acceptance side is validation. So I mean, at its core, DBT is a problem solving therapy. And so validation is a strategy that is used in the service of helping people change, in the service of getting them willing and able to engage in problem solving effectively. And that is a critical part of it, because as I sort of started with, if you push too hard on problem solving, often people become unwilling in one way or another. We've got to also weave in a lot of validation. I have two teenagers myself, and they were having a argument in the car last weekend. And they were just dug in on their sides. And it was about how loud the music was and what kind of music we were going to be listening to in our car. And they just were going back and forth and demanding the other person change in some way. And they understand this lingo enough at some point. I was like, the two of you need to validate each other. Validate. Like you're just pushing for changes isn't going to work. So this is the benefit of having a psychologist as a mother, which they sometimes appreciate. But anyway, validation is critical. So just to be clear, what validation is not. What we do not mean by validation is we don't mean just generally being positive or like, I believe in you, you're a really good person. Like that kind of stuff is not validation. We don't mean just generally being warm or caring. That is not validation. Really importantly, validation does not mean agreeing. I'll come back to that in a minute. But you can validate somebody without agreeing with their position, without agreeing with what they're saying or doing or their reaction. So that can be a barrier to sometimes people being willing to validate because they think that means they have to agree with the other person when they don't. We are also trying not to validate things that are actually invalid. We are only trying to validate valid things. It's not simply sort of saying back to them whatever they just said in some way. Doesn't mean we'd like it, whatever they're doing. Doesn't mean we're happy about it. And it's also not just the opposite of invalidation. So that is what validation is not. I'm going to tell you what we mean by validation in DBT because it's very specific. And it is we have six levels of validation that we can employ in DBT. And they are in general, we try to do the higher levels most often. They're more powerful. In every session we're required to do validation level five and six are mandated to be adherent. So in general, go for the higher levels. But if we start at the level one, which always sounds a little funny, it means staying awake, which literally it means staying awake, like not falling asleep. But mostly what it actually means is like just paying very close attention to the patient, listening very closely, observing what they're saying, observing what they're doing, sort of that sort of mindful attention directed at the patient. That by itself can often be quite validating. But that's kind of the baseline is we are paying close attention. Validation level two is accurate reflection, which is different than parroting. When I think of parroting back what somebody says, it's literally saying their words back to them. The sort of therapist ease, it's one of my pet peeves, is when you start a sentence with, what I hear you saying is, right, that's not what we're trying to do here. But we are taking what they're saying and sort of repackaging it in some way to sort of make it clearer, sort of put our own words on it, and essentially communicate back to them that we understand what they're saying. We have paid close attention and we understood it. We caught it. But it is not just saying the same words right back to them. And then level three is mind reading, which sometimes works and sometimes doesn't because we obviously can't read people's minds accurately all the time. But where we are trying to articulate things that we think are going on but that they haven't said out loud as a way, and why that's validation, is it communicates really getting a person, like really being able to kind of understand how they function and what's happening in there. I had a phone call with a patient the other day who we were getting off the phone and he's like, well, there's a thing I'm having her just to say, but I'm not going to say it because I know you don't want me to. And I said back to him, I was like, I'm pretty sure what you're wanting to say is that you're sorry for being such a burden and taking up my time on the phone. And he was like, yep, but I knew you wouldn't want me to say that, right? And so that's sort of a version of mind read. Like I know him really well. I'm pretty confident that's what he was getting at there. And sort of being understood in that way can be powerfully validating. When you land a mind read like that, that's accurate. Whereas if it's not accurate, then give it up and move on. Don't get stuck on that. Validation level four is about communicating that a person's behavior reactions right now make sense or understandable given their learning history or given their biology. And so for example, somebody who is terrified of shopping malls because they got jumped in a shopping mall when they were an adolescent, right? Like their fear of similar places now actually doesn't make sense in the present moment, but it makes sense given their learning history. It makes total sense to me you're afraid of going there because it reminds you of this past drama that happened, right? And that you would think that this could happen again, given that history. It makes total sense. So that is a validation based on past learning or biology. Things like, you know, having ADHD would contribute to some difficulties in life that you could validate based on biology or based on lack of sleep or based on hormones or based on just being a more emotionally sensitive person in the world. So anything that is kind of a biological origin gets put in this validation level four. What we're really wanting to communicate though is that their behavior makes sense just because it makes sense, just because it's normal for human behavior. That's validation level five. Like this is just normative. And so that's what we're saying a lot of the time. Like I understand why you got angry at your son. You'd asked him not to do that and he was disobeying your order. It makes sense. I think most parents would feel angry in that situation, right? That's a validation level five. The reaction of anger is understandable, reasonable. We can see how it makes sense. That's what we're communicating. Other people would feel the same way. And the highest level is radical genuineness, which we strive for in DBT kind of all the time is just kind of being ourselves. We often talk about this as like behaving with our patients in the way we would behave with friends or family, you know, sort of being a natural, authentic person, not putting on a sort of professional facade, not having a sort of hierarchy, like I'm the expert and I know things better than you do. Really trying to be a natural than you do. I'm really trying to sort of strive for this genuine, real, equal relationship, essentially, which is something that is pretty quite characteristic of DBT therapists. So with those sort of definitions of validation, getting a little more clear, let's put up the poll. We have one last poll here about how confident you feel about your ability to validate patients in these ways. Yes, it makes sense. You'd want immediate relief from such intense emotional suffering. So this is a really good example of validating super problematic behavior, right? Like attempting suicide, but where we can still validate it, which doesn't mean we agree with it. It doesn't mean we like it, but we can say how it's understandable. And what's understandable almost always about these behaviors is they provide relief in some way. And so being able to get relief is of course a thing that most people would want. And so it makes sense that you're going to do something that is going to get you relief. And this is where dialectics are our friend, which as we say, usually we lead with validation. Like, yeah, I mean, it's understandable why you attempted suicide because it has worked to get you relief from a really intense emotion. And this comes to dialectic, it's a total problem. And we're going to have to find other ways to get you emotional relief, right? So that's our sort of balance of change and acceptance, but we often have to lead with that validation for the change to land effectively. Okay. I could also validate that she felt ashamed, that she was worried the therapist might reject her, didn't want to come to therapy. That makes a lot of sense to me as well. So that we can sort of see there's a variety of places in here where things could be validated. When my house is a mess, I am way more stressed out, also makes me be on edge. You know, I think that's me. I'm going to consider that normal. It's normal for me. So we can sort of think of lots of things in here that could be validated. All right. So for the sake of time, I'm going to wrap up here with a little bit about some specifics about DBT for substance use disorders before we have some Q&A time. So DBT has been adapted for substance use disorders. The goal is to be able to provide an integrated treatment that is both targeting substance use and mental health problems in the same treatment. I haven't said borderline personality disorder yet out loud, but that's BPD. And DBT is most often viewed as a treatment for borderline personality disorder. Certainly there's a very strong evidence base for that population. And so that's a quite common disorder of people in DBT, but they do not have to have BPD to benefit from DBT. But nonetheless, DBT for substance use is sort of treating mental health and substance use problems in one treatment. We view emotion dysregulation as the core problem, as I've said before. It's also true for substance use. Often it functions to regulate emotion, gets them that kind of relief. Or in the context of just really out of control emotions, they impulsively use substances. It's sort of the natural consequence of being dysregulated. And so there's been some adaptations to standard DBT. The target hierarchy is a bit different by putting substance use at the top of the quality of life domain as sort of our number one target up there, sort of making it more of a priority. There's a set of DBT addiction skills. I'll tell you a little bit about a few of them in a second. And then there's some special attachment strategies that are often used for people with substance use disorders who are often harder to engage in treatment, and show up less consistently, want to drop out, hard to find, things like that. And those strategies are often more about having more contact between sessions, actively sort of giving them longer sessions or shorter sessions, sort of adapting structure to sort of match what is going to be most effective for them, and actively searching for them when they go missing, trying to get them back into treatment. And so you can see there's been eight randomized controlled trials, 12 uncontrolled trials of DBT in various substance using populations. All right. So dialectical abstinence is kind of the overall goal of DBT for substance use disorder, or sort of, again, trying to find a balance between the sort of typical abstinence approaches and harm reduction approaches. Overall, the sort of goal is abstinence. The idea is that people with really severe disorder are going to be best off being abstinent. And so we're hoping to get people to abstinence. And on the harm reduction side, sort of balancing that with accepting the reality non-judgmentally that people are likely to slip or relapse, and to plan for that and prepare for that and be basically trying to prevent the abstinence violation effect, where if you use, again, when you've been striving for abstinence, that it causes all these intense negative emotions that often make a slip turn into a full-blown relapse and last longer. So we're sort of straddling this with pushing for abstinence while planning for slips and helping people to get back to abstinence as soon as they can, essentially, without judgment. And so that is the sort of overall goal and approach. And then just to give you a sense of a couple of the skills that are the DBT addiction skills. So there's a set here, the burning bridges and building new ones. Burning bridges is essentially making it harder to use substances in whatever way by ending connections with substance using friends and groups. And I have a patient right now who's like, but I really like the guy at the dispensary. He's one of my close friends. He really likes me. And I was like, maybe because you're one of his best customers. And so we have to sort of get them to get rid of contact information for their dealers, for anybody that they usually would use substances with, people who generally promote addiction, get rid of cues and temptations, get rid of paraphernalia, get rid of anything that really is kind of going to be a reminder, and also things like telling all of their friends and family that they have quit to make it harder to use again. So there's sort of a set of strategies there. There's other ones too around burning bridges and sort of making it harder to use again. And at the same time, building new bridges to new behaviors that are not related to substance use. And specifically, sort of pairing those with cravings, for example, some new images or smells that will compete with whatever typically causes cravings. So if you get a craving to sort of do something new or different, like smell a nice candle smell or something, sort of start to try to classically condition a new pairing there in some way. Well, also surfing, we have an urge surfing skill related to sort of riding the wave of an urge to use without acting on it. So cutting off old things that get you to use substances and actively sort of building new connections and new pairings to a non-substance using life. And then I thought I'd put this one in here because it's kind of fun, which is some for people who addicted behaviors function as a way to kind of rebel or stand out or be different or something or sort of shake their fist at the man kind of thing that we might replace some of those behaviors with alternate ways of rebelling. If that's an important thing for them. And so there's a longer list than this, but there's a bunch of ideas on one of the handouts about ways that you can do alternate rebellion. I have a pair of socks. I wear sometimes that people can't see the top of that at the top of the pair. Somebody got this for me. They say like badass with an arrow, like pointing up. And sometimes I'll wear those to like hard meetings or something where, you know, you're doing something, but other people don't know it. So it's sort of that kind of idea of doing something that feels a little bit rebellious that might kind of scratch that itch for people where substance use has at least partly that function for them. So a couple of our DBT addiction skills, there are others. And I want to make sure we have some time for questions. I'll just put this up here as just a reference for folks of what the DBT manuals are. There's the 1993 one as the sort of DBT Bible essentially. And then the other two are related to the skills and skills training groups. So I don't know the best way to do Q and A, but I will open the floor up. Yes. Thank you, Dr. Harned. That was a really awesome explanation of DBT. So we have some questions in the chat and also encourage everyone to continue to add questions and we'll try to get to them. So the first question is it seems that DBT skills are frequently taught in groups in treatment settings without adhering to the comprehensive program. What are your thoughts about the comparative utility of this? Mm-hmm. Yeah. That is incredibly common. I think running a skills group is like the lowest hanging fruit in DBT. To get something going, it's as you can tell, it's a comprehensive, pretty resource intensive treatment to do the full model, comprehensive DBT. And so a lot of places only offer skills groups. And there is certainly research support for that. So there's actually, oh gosh, I'm thinking like 20 something randomized control trials of just DBT skills groups alone as an intervention. And so there's certainly research support for that. Usually it's for less acute populations. So not the super, super high risk for suicide kind of people who usually need more than just a group for support. But skills groups on their own are perfectly reasonable intervention for people broadly who could benefit from all these coping skills, which as far as I know is basically every human, including myself. So, but often skills groups are, so like an RVA, for example, we accept referrals, any type of referral, anybody who is interested and thinks they could benefit from it. So we've got multi-diagnostic populations in our skills groups of veterans. So absolutely, that was a reasonable thing to do. As a quick follow-up to that, do you have a census to like, do you think there's an ideal size of the group? Is it best with one therapist or two therapists? Yeah, that's a good question. So I think 10 patients is where we cap ours. And also, so the VA, for example, is doing a national rollout right now. DBT that I'm involved in, we're capping them at 10 also there. I think that's a good size group. It's kind of unwieldy if all 10 people actually show up, but that is not common. So 10 people. And then in DBT, we always have two leaders. That's actually quite important. So we have the skills leader and co-leader that play somewhat different roles in the group. The leader is the one leading and running the homework review and doing the teaching of the new skills. And the co-leaders, they're almost sort of more managing process, sort of helping people, paying attention to the patients, helping them stay on track, directing them to the right pages and managing the group behavior essentially in various ways. So yeah, two leaders is the standard for skills groups. Another question. Oh, sorry. Another one just came in from Virginia. Can you talk more about the radical genuineness and how it might be different from our quote, regular professional stance? I strive to be genuine in all my interactions with patients, but I'm certainly wearing my professional hat, which is different from the way I interact with friends or family. Yeah. So, you know, there's obviously a line here. We're not going to share things with our patients that we would share with our closest friends. You know, that kind of self-disclosure is kind of its own thing. Self-disclosure is definitely going to be a strategy we use in DBT in the service of the patient, some sort of modeling function or validation function. But by genuineness, really, it's like, what is your genuine reaction to what's happening? I think I had a patient finish with me, a veteran recently. He was like, he's like, I'm just telling you my favorite thing about you is you behave so unprofessionally. And I was just like, I think that is one of the best compliments I could get. Like, if you didn't take that out of context, and he's like, what I mean is like, you're just a person. Like, it's just like interacting with another human who's responding to me like normally, as opposed to some of the, you know, I think things that we can get trained to do the like, what I hear you saying is kind of approach to therapy or the sort of a little bit more standoffish in some way. So I think of it as kind of sharing your actual reactions when it's, you know, strategic and in the service of the client. And, you know, for me, for example, that can include swearing with clients when that's a person who is not going to be offended by that, if that's your normal communication style in life, and just sort of having your normal reactions, like, for the love of God, will you please go to group this week, you know, like whatever it might be. But just striving to kind of be genuine, as opposed to this a little bit more, like wearing a white coat, kind of professionalism, that's a little bit more standoffish or can be. So I don't know if that describes it any better. But one of the things that I think scared a lot of people off when they hear about DBTs, the telephone coaching 24 seven, do you think that that contributes to, you know, kind of burnout? But on the other end, do you think that have you noticed that when that has been relaxed a little bit that there's been a change in ethics? Yeah, it is definitely a thing that scares a lot of people away, understandably. And I did it for most of my career, it rarely burned me out. The problem we most often encounter with 24 seven, with phone coaching period, is that we, our patients would don't call us when we would really want them to. And so they end up doing all sorts of problematic things and not help letting us help and get involved to prevent it. And then we hear about it all later. And often the struggle is around getting them to use the coaching, where they don't want to be a burden and all that kind of stuff gets in the way or they're embarrassed or whatever it might be. So that's the most typical problem is they're not using it, they don't call. The data on phone coaching from several studies is that the average is like one call a month is pretty typical. What everybody's afraid of are the outliers, which can obviously do exist, but it is not normal at all to have a patient who calls all the time, calls multiple times a day or calls in the middle of the night or all the stuff in ways that are actually ineffective, problematic, too much burning you out. Those patients exist for sure. And if you get one of those patients, that becomes a therapy interfering behavior that we are targeting head on to change how they're using phone coaching in some way that will not burn us out as much and will be more effective. So that being said, like I said, there's some systems that won't allow the 24-7 and there's certainly some therapists who have limits that they're just unwilling to do that. If you get in a room of DBT researchers, everybody will say one of the studies that needs to be done is to do DBT with and without that 24-7 phone coaching or phone coaching with more limited availability to see what impact it has on outcome. And I don't think a funding agency is ever likely to fund that particular study. It seems like such a small little tweak, but I can say just anecdotally from my experience of now five years in the VA where it's business hours only, it hasn't in any way felt like a catastrophe to me to not be available 24-7. I was really worried it would having come out of 15 years of being available 24-7. Like what are they going to do in the middle of the night? Or what are they going to do on weekends? Or what are they going to do at six o'clock or whatever if they're in a suicide crisis? And my experience is very rarely has that proven to be a problem. They schedule their crises for business hours, but they call during business hours, but also they can call a crisis line, veterans crisis line, for example, after hours if something else comes up. So it hasn't been a big barrier, but there's no official data on that. That's just my experience. Well, Dr. Hornad, thank you so much. I feel so much wiser for having been here for this lecture. We're very grateful for you and your contribution. And just as a reminder to everybody else, we're off next month, but we'll be back in August. And Dr. Chris Stouffer from Oregon Health and Science University is going to be talking about some interesting work he's doing on using psychedelics for the treatment of addictions. So thank you again, Dr. Hornad, and we'll hopefully see everybody in a couple of months. Thanks for inviting me again. Thank you, everybody. Thank you. Bye, everybody.

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