We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH learn. My name is Ana Pascual and I'm the ACAMH's DBT lead for East London. My background is as a clinical psychologist, and I'll be talking today about Dialectical Behavioural Therapy, DBT, particularly in adolescence. And you may be wondering what's DBT. You may have heard a little bit about it before. DBT is an evidence-based therapy to reduce emotional dysregulation, and was initially developed by Marsha Linehan to treat individuals with borderline personality disorder. It balances the use of validation strategies and problem-solving strategies, trying to keep that balance between acceptance and change. And what DBT aims for is to help people experience a range of different emotions without necessarily acting on them, because we want, in the end, that young people can have a life that they can call worth living, life that they want. And DBT therapy is frame suicidal behaviour as attempts to solve problems. So we understand young people attempt suicide or self-harm. They are trying to solve a problem, and they need to develop a skills to cope with it in a more effective way. So DBT follows a skills deficit model, and that's why one of the aims is to increase skills. So we in DBT often call young people like clients. They can experience life as what we call life worth living. And this means that making very clear from the beginning in the assessment and pre-treatment stages. What's life worth living. How does it look like for them. It's really important because it would be coming back to it through the treatment to understand and support them. Why do you want all these skills. So DBT is and evidence-based treatment is the treatment that's recommended for adolescents with recurrence of harm, as per NICE guidelines and previous RCTs. And systematic reviews of the previous evidence have suggested that it significantly reduces risk behaviours and emotional dysregulation. I was talking previously about acceptance and change, and what we know is that it's really important that we don't focus only in change, and at the same time that we don't fall into the trap of focusing in acceptance all the time. It's about keeping that balance. There are skills that come from the mindfulness, some practises more related to acceptance. Whereas when we talk about change, it takes principles from the cognitive behavioural therapy or behavioural principles. When we talk about acceptance, we would be thinking about the skills such as mindfulness, validation, radical acceptance. And the final aim is to decrease emotional suffering, learning how to stay in the present. Taking reality as it is when we cannot change it. For us, on the other hand side, we have change using problem-solving skills with the goal of thinking how do we create that change. We'll be thinking about mindfulness and distress tolerance skills to promote that acceptance, and would be looking into other skills, such as emotional regulation or interpersonal effectiveness to generate signs on the other hand side. You may be wondering, what does dialectical mean. How do we do that? The idea of dialectical is that two opposite ideas can be true at the same time. I like using a couple of exercises to introduce that idea. So one option may be writing on a board or on a piece of paper, a 6, and some people would be on one hand side, the other group would be on the other hand side. Some people can see a 6, some people can see a 9. That's a really good way to see that they are both looking at the same thing. And half of the group may be thinking, is this a six? How the group they were thinking, this is a nine. And the reality is that both of them are true. So it's about how when considered together, how we can create that viewing of the situation and how we can help young people and their families to learn to develop that perspective, learn to develop that there is always more than one way to think about that situation, and it's slowly creating that synthesis, how we can support them to learn to use models and less spots. When we think about what are the assumptions about clients, definitely can think about this [INAUDIBLE]. One of the examples is that clients, young people that we are seeing are doing the best they can and they want to improve. They need to do better. They need to try harder and be more motivated to change. And at the same time, they may not have caused all the problems and they need to solve them anyway. The lives of the suicidal young people are unbearable as they are, and that helps so much to develop the necessary empathy to support them. They must learn new behaviours in all the relevant contexts. That's the generalisation. They need to learn how to do things, initially in the therapy session, in the skills groups, and slowly implement this in all the areas they live in. It's really important also to think that they cannot fail in therapy and that therapists themselves need support. That's why the role of the DBT console is so important. So the biosocial model is what informs the treatment as a theoretical model that allows us to see that young people that present with high levels of emotional dysregulation present with high levels of biological vulnerability. They are often very sensitive to the environment. They experience really strong emotions, actually experience that is like an emotional roller coaster that they be living in. And at the same time, this interacts with an environment that doesn't get them. The experience that they got is that they were not understood, they are experienced in the matter or were name exaggerated, dramatic. So is that transaction between their biological temperament, that intensity alongside the responses from the environment who represent together what we call inaccurate responses between the emotions and the need that these young people. And over time this has consequences. It is often the symptoms we can see. So young people may believe that they should avoid intense emotions. So they try to bottle them up until they explode. Or they may feel a lot of shame or fear when they feel those intense emotions. And we often see over time completing the diary cards and the chain analysis, that same fear come up over treatment. They are really important elements to bear in mind. They may also learn to distrust how they are feeling because their emotions were called crazy, inappropriate, dramatic. That may mean they also rely on other people to help them to understand themselves, to understand how they feel. And being alone can feel so, so scary. So they try to cling to others really hard to prevent being abandoned. They may also feel a different emotion that we can call it secondary emotion, such as anger, to block the emotion that feels so scary to feel, such as, for example, shame. Or they may become desperate and try to do anything that's possible to get rid of that emotion. So they may cut themselves. They may try to kill themselves. They may get really, really strong argument because they really, really want to stop that emotion. It feels unbearable. When we think about DBT, we often think about five different areas of dysregulation. So everybody talks about emotional dysregulation. And this is like when we are talking about anger. low mood, anxiety, but are other examples of what we call this regulation. One of them would be behavioural dysregulation is what we call the risk behaviours. We can also harm suicidal attempts impulsive impulsive behaviours such as overspending unprotected sex. We can also talk about interpersonal dysregulation, such as having very intense and unstable relationships, strong efforts to avoid abandonment, difficulty setting boundaries. We can also talk about cognitive dysregulation and family conflict. We are talking about cognitive rigidity and how it's important to develop that dialectical thinking early days on, like conflict resolution, how to change the behaviour. And we can also think about self dysregulation on how to think about the awareness of emotions. Thoughts like difficulties enjoying the moment, feeling very empty, that chronic emptiness and those five areas of dysregulation link with different types of skills. When we think about emotional dysregulation, we think about the most regulation strategies. When we are trying to target behavioural dysregulation, we may be looking into distress tolerance. And it's really important that we don't over rely on distress tolerance. Those skills are to accept reality as it is and to reduce the intensity of the crisis, to avoid making things worse. Interpersonal dysregulation would be associated with skills to improve interpersonal effectiveness. When we think about cognitive dysregulation and family conflict, we'll be looking at the work in the middle path skills. And when we are looking to self dysregulation, we'll be using those mindfulness skills that would be called to other skills as well. And we practise. So those five models of skills. When we work in individual DBT therapy, we would be looking into this DBT treatment hierarchy. And we'll look into decreasing those behaviours starting by. The main priority is to keep young people alive and safe. So we'll be looking into behaviours that threaten life. Life-threatening behaviours. We are talking about self-harm, suicidal behaviours, but also looking into self-harm urges high intensity suicidal thoughts. Then we'd be looking into therapy, interfering behaviours if they are not life-threatening behaviours to target in that session that week, we'd be looking into things that can interfere with therapy or even things that can destroy therapy. It may be coming late to sessions, not completing the DBT diary card, doing homework. It may be not attending a skills group, or actively blocking conversations in therapy that have been agreed as targets. It can also be that life-threatening behaviours are not happening and there are not any present therapy interfering behaviours that week. And then we'd be looking into quality of life interfering behaviours. It can be not going to school, drinking alcohol, not setting boundaries. Concerns about white and would be targeting that. We are talking about behaviours to decrease and we also want to increase other behaviours instead. In the stage one of DBT, that would be the behavioural control stage. We want to increase those skills. We want to achieve some behavioural stabilisation. So for that would be using the five models of skills mindfulness, interpersonal effectiveness, emotional regulation, stress tolerance and walking the middle path. In the stage two, often after like six to eight months when we are looking into a potentially extending treatment, if that was initially from eight months up to a year. If the treatment has been working and it's been effective, life threatening behaviours have reduced or disappear. We would be in a position to work towards experiencing those emotions that felt really, really difficult. How to experience those emotions fully. We'd be using exposure, reducing that avoidance, potentially working into decreasing the intensity of those PTSD symptoms. So in some trauma work and the targets are treating those emotions that were less severe and not treated before, but difficulties in mood, anxiety also examples such as feeling lots of shame that didn't come up before but was underlying, sensitivity to criticism, feeling lonely. We would also be targeting what we call experiential avoidance. So grief that was unresolved and how they can process that feeling empty, feeling bored. There are other stages of activity that are called stage three or five that have more to do with living a fulfilling life that often would not be working towards in the year of treatment would be after that. And often NHS services don't provide that. So what are the treatment components of a DBT programme? So we look into five different treatment components. One of them is that weekly individual therapy that supports with enhancing that client motivation, weekly skills group that often take the form of a multifamily skills group where adolescents and their parents and carers attend and that support enhancing those skills from coaching in the form of the roles of the service has. Often in the NHS can be 9:00 to 5:00. Some services may have availability for longer hours. And the aim of this is to enhance skills generalisation so what we want is that the skills that they learn in group and the individual therapy, alongside the challenges and the chain and the solutions that are implementing the individual therapy and that come out of it, can be practised throughout the week. And we can't expect that they are not going to be challenges throughout the week. So we want to give young people, their families, if needed, the opportunity to call us and have what we may call a TIPS hotline. It's a very specific, practical approach that we can look into at the end of the presentation. To facilitate that, we can deal with the challenges that they are going through at the time. Also really important to practise the weekly consultation team meeting, often called DBT consult, which supports therapists with the skills and motivation and reduces the risk of burnout. And other treatment components that will be the fifth treatment component that's related to a structure in the environment. The case management side of this, which can be supporting parents to implement contingencies in the young person's life. Family sessions. Really important to think about that part of contingency management. That's a really important part of DBT. Some people may be wondering what about when we don't have a full, DBT comprehensive programme with all of these components. And there are lots of services that practise DBT skills training only as a standalone approach, or alongside other types of individual therapy that don't follow a DBT model that works. And the evidence suggests that it works for less complex disorders. When the severity of the most knowledge regulation is lower, when there are problems with emotional regulation that are generally less severe, or if DBT comprehensive treatment is not available. [INAUDIBLE] in the DBT skills for adolescents suggests that thinking about the five areas of dysregulation, those young people that present with at least three of these areas would be considered for DBT comprehensive treatment. Whereas those that may have challenges only with one or two of them may benefit for either DBT skills training or the specific model related to the specific difficulties or other types of intervention that can target those specific difficulties without the cost of the commitment or full comprehensive DBT programme. It's also important that young people and families can be informed about this if they are receiving a DBT, comprehensive treatment, or if they are receiving what we call a DBT informed treatment. After the assessment is being completed, in DBT we do something that we call pre-treatment that often has between four to six sessions. And the goal of this is to orient the young person and the family to DBT and get commitment for them to sign up. When we think about orienting to treatment, we're talking about what's DBT, what does it mean, what are the components, what are the commitments, how the biosocial model feeds into the challenges, how the different areas of dysregulation apply to them and how different DBT skills may support this, Why is DBT something that can be helpful for them. Do they agree with that? Are they on board with that? Are they willing to take the treatment? What are the goals for the treatment? So what can behaviours they want to increase behaviours do they want to decrease? Being very behaviorally specific. What are the patterns in their behaviour? Why are they doing all of this? What are their life worth living goals that keep them going, that help them to, when they are feeling particularly hopeless, to implement those skills? It's important for the clinicians as well, to use this period of time to determine with the young person if they are suitable for DBT, consulting with the client, which is the DBT principle that we need to bear in mind throughout the treatment and treatment. They are willing to be in DBT and obtaining commitment. They don't want to commit to DBT treatment, and if that's the case, they will sign up a contract for that. It's often a challenging period when we often need to make use of different commitment strategies, and this presentation exceeds further explanation of all of them. Yes, as a sample of it, we'll be looking into pros and cons in the short term and the long term. Maybe if this can help to self-commitment and that definitely cons of doing treatment. And the pros in the long term outweighed the cons potentially in the short term. If at least there's minimal commitment, it's often helpful to play devil's advocate. Are you sure you want to do this? Try like to take the other role and see how the young person goes with it. It's really helpful to think about foot in the door, door in the face, asking for something small or something too big, and then slowly building up from there. Freedom of choice. Absence of alternatives. Because this DBT treatment is an option, and they also have the option to not sign up for it and keep on going with the life and the strategies that they are using that don't seem to be working. Cheerleading to generate hope and also using lots of sniping when we notice they're really small. Progress towards commitment. Reinforcing that using lots of positive reinforcement to increase that and doing saving. In individual therapy, at the end of treatment on Wednesday sign up, or DBT would be using what we call DBT diary cards. And this is a template that I need to acknowledge from my colleagues from Islam, from the South London and Maudsley, NHS Foundation Trust for the National specialist services. Support me to implement some of these DBT principles and this template is from them. So it's helpful to bear in mind that the first thing that we'll be looking at is the left hand side of the diary card. Those self-harm and suicidal urges and actions to see if we need to go and change those, and looking into quality of life-interfering behaviours that would be adopting depending on the young person's circuits emotions and if the young person is using skills if they use phone coaching. Really important to also record the urges to quit therapy, and is key that we encourage the young people to do that because often they may avoid that little box. They may feel they don't want to upset you, that you're going to abandon them if they do that. So the people did, or they may be building that and lots of resentment until they suddenly one day tell you or disappear or get really angry. So it's very important we can do that and record the homework task for the week. And this is the other side of the diary card where they can record the DBT skills rehearsal, the skills that they use, the different days and anything else that's helpful for them. In individual therapy, We often start by reviewing the diary card and reviewing the homework. We come back to the target hierarchy and set up the agenda. The chain analysis. Even if it's quite hard sometimes, the goal is to keep it as brief as possible. Maximum 50 minutes trying to do that in this time, because then we need to spend quite a bit of time on the solutions of the target behaviours, particularly thinking about using at least three skills and having the opportunity, if they haven't learned the skill, that can be helpful for the particular target behaviour to teach that, practise it using lots of rehearsal, because that's how behavioural learning happens, and troubleshooting potential difficulties that they may anticipate. We need to move down the hierarchy to discuss potential other skills related to current life situations. If there was time for it. Setting up the homework, summarise the session to make sure that we are clear about what the person is taking out of it and ending. It also exceeds the capacity of this presentation to dig deeper into how chain and solution analysis works. That's something that's really important to bear in mind is start defining the problem behaviour, be very behaviorally specific, and try to make sure that we clarify what was the trigger. What was the prompting event. What were the vulnerability factors. What made them more prone in the hours or days before that. Did they not have a good night sleep. Did they drink a lot the day before. And they were hung over the final exam the day before. And then potentially the prompting event was the parent said something about it. And when we think about the links, we need to think about body sensations that particularly at the beginning of treatment, young people may really struggle to identify. We need to think about thoughts. We need to think about emotions. We need to think about what was going on, the situation and really, really important. But we are also very clear about the consequences, the consequences outside in the environment, but also the consequences in themselves. A very common thing that young people say after, for example, self-harming, is that the first thing they noticed was relief. And it's really important that we get that. Relief from what? Because when it's easier to talk about the emotions that are those links that we want to target. As a brief summary of things that can be helpful for chain analysis is being very specific about the behaviour. We want to know what happened if for example, that they self-harm, did they do in particular, did they cut themselves. Did they use what time of the day, where. So trying to understand the context and define the behaviour. It's important to keep it brief. 15 minutes before moving into the solution analysis. Also trying to identify at least two solutions. So it has to be good enough. There is no way to think about this as being perfect with time limited. So think at least about keeping two solutions would be reasonable. Identify the function of the behaviour. Because looking at those consequences, there is something keeping the problem going. So try to identify what was the function of the-- validate throughout. So it makes sense. Emotions are understandable in the context, something that particularly parents often struggle with when we teach validation is that they feel that if they validate, they agree with the behaviour. And slowly we work through how validation is not agreeing. It's understanding that it makes sense that the young people feel the way they felt in the context. And then we can move into solutions or other strategies. And when we do that same analysis, when we move into solution analysis is really, really important. I can't say how important it is. Practise, practise, practise, rehearsing the solution in the session and troubleshooting what things can get in the way is really important for behaviour generalisation because we want that. Then people are willing to try. And also we want that it can be effective. We want to make it a success. In skills group, it often follows a 24-week instructor. So four weeks for distress tolerance, four weeks for walking the middle path, emotional regulation and interpersonal effectiveness. And in between, we'll be doing orientation and mindfulness. And we looking at the different models of skills. Mindfulness skills involve focusing in the present moment and very, very important when we do mindfulness skills noticing the judgments. And I would emphasise the word not the same because the idea is learning to reduce suffering and increase happiness and increase the control of the minds to experience reality as it is, is what Linehan called live live with eyes wide open. Summarising what mindfulness skills are. We have what skills and how skills. What skills are observing is noticing what's inside and outside, describing what's observed. So putting the experience into words in a descriptive way or judgments, participate. Like for example, enter into the experience, practicing the skills they learn and for how skills is coming back to judgments, being nonjudgmental, doing one thing at a time and being effective. Doing focus on what works. And also looking into how to access the wise mind. How to notice when young people are in the emotional mind or the reasonable mind. Particularly sometimes it can be when interacting with peers, which can be interacting with family. Often we may have young person in emotional mind and a parent in the reasonable mind. They find really difficult to understand each other because it's like they were talking in different languages. So it's how both of them can access that. Why it's mine, how I feel this and I know this and the both are true. When we look into emotional regulation skills, there are different functions that these skills can meet. One of them can be understanding and naming those emotions. We have some young people that really, really struggle to name how they feel. They may have tried so hard to suppress it that they may really struggle to identify it. How to notice, for example, how this body sensations may express for them. What are the functions of the emotions in sending the message [INAUDIBLE]. Emotions are friends. They are trying to tell us something. Changing those emotional responses like for example, like learning to check the facts. Does the emotion fit the facts? And if so, is acting on the emotion effective. Maybe looking into if it's not would be looking into opposite action or problem-solving. If it's something that we really need to solve because emotion fit the facts. It's also helpful to reduce the vulnerability to that emotional mind that we just talked about. So we'll be looking into skill sets as ABC, accumulating positive experiences, building mastery and coping ahead. Also like increases skills to take care of the body but taking care of the mind and looking into decrease emotional suffering. This is a sample of the different emotional regulation skills opposite action, on ABC, please check the facts, problem-solving. The third module, we distress tolerance skills. And these are skills that we need to be very careful that young people don't over rely on at the beginning, maybe the skills that they may be using the most. And it's really important to coach them through using all their skills slowly. Distress tolerance skills are crisis survival skills pros and cons. Example pros and cons of self harm, stop, tip skills, distracting, self-soothing. And what we want with those skills is to avoid making the crisis worse. Often young people say that they tried with these skills in the past that they haven't worked, they still feel miserable. And that's not the function of the distress and the skills. Distress tolerance skills are like a tourniquet. They are going to keep you alive. They are not going to solve your problems. They are not for that. Reality acceptance skills are another type of distress tolerance skills such as using radical acceptance. When we cannot change reality, it can be really frustrating, it can feel unbearable and we need to learn to accept we cannot change it. Those skills can also help young people, families to become free, become free of having to give in to the demands or urges of very intense emotions. Another sample of what these distress tolerance skills are. Those skills we were talking about like stop, pros and cons of self harming behaviours, deep skills thinking, for example, of intense exercise or temperature using the eyes [INAUDIBLE] of young people. Really enjoy that in the groups as they find it's like a very experiential exercise, and they can really see in the moment how it brings the intensity down, pace breathing, progressive muscle relaxation, self-soothing, distractions and improve the moment, accepts and radical acceptance. When we think about interpersonal effectiveness skills, the goals are learning to be skillful so they can get their needs met. So it's basically how to get what you want. It's also learning how to build healthy relationships and relationships that are destructive. And it's also thinking about finding the middle way, using working the middle path. That would be looking into later. What's getting in the way of being interpersonally effective? And this is something that's really important to discuss because that's the barrier that was happening. That's why they are not implementing those skills. If they don't have them, it may be that they have the skills and they have previous experiences when they felt using it didn't work, how to go through, how to troubleshoot that. It may be that they can decide that they don't know what they want or what they need. It may be thoughts or emotions, or it may be the environment, and we may need to look at the different skills for that. We'll be looking into emotional regulation for emotions getting in the way. We may be looking into contingency management. If it's the environment, we're looking into using some of these interpersonal effectiveness skills to deal with other people. The interpersonal effectiveness skills are the amount to get what they want, and sometimes the priority may be to keep the relationship. So we'll be looking to the give skill. Sometimes the priority is keeping self-respect, so we'll be looking to the first skill. And when we look into the walking the middle path skills, there are three core strategies. So one of them is validation, how to help the young person to feel validated, and also how the people, families, can learn to self validate. So the skill is about validating others and also learning how to do self validation, how to validate self looking into dialectical thinking as well. Those initial bids that we were talking about at the beginning about both things can be true, and how to learn to deal with dilemmas, how to learn to deal with apparently opposite views, and also behavioural science. It's really important that we give the message that for behavioural science to occur, it's true opposite contingencies are needed, and it's really important that we can promote as much as possible positive reinforcement, because the evidence suggests that learning is more likely when you use positive reinforcement of the desired and effective behaviour. As a sample of the steps that validation may take, It's important that we explain that the first step for validation is the non-verbal validation. Paying attention. Being present. Eye contact. Listening. Not multitasking. Listening and being nonjudgmental. Acknowledge and reflect the feelings. Replying with descriptions, not judgments. Summarise and ask questions and show tolerance to the emotions because it makes sense that they felt that way in the context. That helps to normalise feelings. And often what we see is that emotions can de-escalate by using validation. They can do so much that the evidence suggests that it helps when young people feel validated and understood by their families. The risk of escalation is so much lower, and often families value it quite a lot because they find that a good strategy to support the young people, and also it helps them to understand them better. It's also important to be genuine when we are using validation and learning to use self-disclosure. When we do comprehensive DBT, one of the key treatment components we were describing it was the phone coaching. And the phone coaching is not a crisis line is what would be a TIPS hotline. It has to be like a maximum of 15 minutes, and it has to be focused in the moment. Everything else would go to the therapy session. Coaching is not a therapy session. It's not a call to chat about how's your day going. It's to be focused. And the key question, which is, do you need every day situations when they are struggling, how to find the solution to a problem? It can be that they are in crisis and they can act on their urges. Yet if they act on their urges, the 24 rule, 24 hour rule would apply, which for adolescents is adapted from the adult model. The young people would not be able to conduct their individual therapies for 24 hours. However, the parent worker can be in contact with the family throughout to support them. It can also be helpful to repair the therapy relationship. It may be that the young person was annoyed and they want to talk about that. Or it may be that as therapists, we are also fallible. Want to have a brief call with a young person, potentially to apologise, because maybe we didn't validate something that should have been validated. And just having reflection, being self-reflective as a therapist and talking about that is really important. Validate throughout and ask for commitment to implement the skills discussed. Are you willing to do that? So as a summary from coaching in DBT involves describing the problem, asking for your needs and very important, what have you tried already? Because I don't want to discuss the same things that you've already tried because they haven't worked, or maybe they haven't worked. Let's have a look at what can be done differently so it works. Generate solutions collaboratively. You do it together. If needed, practise and plan and willingness to practise and willingness. And the need consult. This is another key treatment component in comprehensive DBT involves therapy for the therapist, which, basically, involves that everyone in the console has to be vulnerable and allow themselves to be able to feel that they can talk about it. It's a weakly protected space for DBT a therapist, and it's also a space to promote fidelity to the model. There are different roles that are assigned like the role of the chair, the role of the observer, note taker, time keeper. And at the beginning, an agenda is agreed to help prioritise. It often helps to have questions that help to prioritise these items to discuss. So that would be something that the consultation team would agree with together as a team. And it's important to clarify what's the function of it. So when someone is asking for a consultation, do they want help to assess? Do they want help to generate or implement solutions? Do they want help to empathise with the young person or the family? Do they want validation from the team? And looking at the whole summary of everything we discuss, it's quite difficult to actively summarise everything in a slide. I thought it would be helpful to just include some of the basic principles and things we discussed throughout. So it's really important to keep that balance between acceptance and change. Building a skills to live a life worth living is the ultimate goal of DBT. We don't want young people to be in therapy forever. We want them to have a life that's worth living. And that's what matters. And that's what's the ultimate goal for people to live a life that's the life they want and that they find worth living. It's really important to spend the time to orient, to DBT and to gain commitment. It's quite an intensive treatment, and it's important that young people feel that they know what they are signing up for and that they are willing to do that. That's what the treatment is for before they sign up for treatment. Be aware of the target hierarchy that we were discussing and in individual sessions. Use validation throughout. Validation is a key skill in DBT and all treatment components. And same is true for teaching practise, practise, practise. Rehearsal and practise in multiple contexts. Thank you for using your mindfulness skills during this presentation. Here is my email in case you have any questions. Thank you. [MUSIC PLAYING]