Dialectical Behavior Therapy (DBT) Skills | Mental Health CEUs for LPC and LCSW

Unlimited CEUs for $59 at AllCEUs.com welcome everybody to today’s presentation
on dialectical behavior therapy skills this presentation is based in
part on doing dialectical behavior therapy a practical guide by Kelly
Koerner is one of those books that if you want to do dialectical therapy as
practice not just look at some of its tools is it a must-read then
it’s also based in part on the dialectical behavior therapy skills workbook DBT
made simple and DBT for substance abusers which is an article that was
published by Marsha Linehan so the links to those are in your class but just give
you an idea about sort of the breadth of what we’re going to be looking at today
in the short time that we have together what we’re going to do is take a look at
why DDT was created we’ll look at understanding emotional regulation dis
regulation and regulation will identify DBT assumptions about both clients and
therapists and we’ll explore skills to help clients learn to stress tolerance
emotional regulation and interpersonal effectiveness as an aside we’re taking
or I’ve taken the information from this course and combined it with a bunch of
other information to make a six-hour on-demand course that will be available
by the end of the week but for now, we’re just going to hit the highlights in the
1-hour introduction so why do we care why do we want to learn about DBT skills
and DBT tools many of our clients experience emotional dysregulation or
the inability to change or regulate their emotional cues experiences and
responses think for a minute about any of your clients if they’re depressed if
they’re anxious if they’ve got anger management issues something is going on
with their emotional states, they’re not able to either get unstuck or control
their behavioral responses so they may be engaging in self-injurious behavior
risky behavior or addictive behaviors they’ve tried to change and failed
leaving them helpless and hopeless in a lot of our clients we try to fit them in
not that we should but we do try to fit them into this box if you’re depressed
then we’re going to look at these things and one thing I hope you get from these
webinars is the fact that every single client is different and there is no box
that we can put them in and you’re like well then how can you do group therapy
group therapy is awesome because you can tailor and that’s part of the
challenge to doing psycho-educational group therapy is tailoring the tools and
helping people tailor the tools to meet their individualized needs but they can
get feedback and they can see how different tools can be modified just a
a little bit to fit different individual needs and untenable emotional
experiences that lead to self-preservation behaviors such as addiction
you know to kind of numb the pain to give them a distraction non-suicidal
self-injury we’re talking about cutting we’re talking about those sorts of
things and then even those suicidal behaviors at a certain point the pain
has got to stop so some people may end up going as far
as trying to stop the pain by stopping their existence instead of hurting
anyone else people with emotional dysregulation has high sensitivity so
these people tend to be highly vigilant they’re aware of a lot of
things that go on now this was created and I want you to
really kind of think about it was created as a tool or a
protocol to use with people with borderline personality disorder what do
we know about people with BPD who grew up in really ineffectual environments so
they had to be hyper-vigilant about everything that was going on in their
own safety and security so you have someone who either by nature or by
nurture is hyper-vigilant these situations have been over-generalized
the dangerous situations have been over-generalized so the world tends to seem
more dangerous and out-of-control people
with emotional dysregulation are easily thrown off kilter because they often
have a lot of vulnerabilities they’re not eating well they’re depressed which
is contributing to them not being able to sleep well they can’t focus yadda
yadda, we’ve talked about vulnerabilities one thing that Dr.

Turner talks about what is
no emotional skin and she likens it to someone who has third-degree burns and
every single thing even the air when it touches it is just excruciating there’s
no middle ground there’s no Oh that’s kind of uncomfortable it’s either not
hurting or it’s excruciating people with emotional dysregulation are also highly
reactive so they’re hyper-vigilant they’re aware of everything that’s going
on and then every time something happens that sort of triggers their awareness
they jump into this immediate fight-or-flight reaction then they’re
slow to deescalate so we’re talking about situations in which someone is
hyper vigilant they’re on edge maybe because of situations in the past or not
they have this sort of persistent fight-or-flight or frequent
fight-or-flight reaction and again I’ll refer back to our dream fatigue class
that talked about how the body can only stand to be all hands on deck for so
Long before it’s just like dude I give up and then the sense of depression and
helplessness and apathy start to set in people who are who have emotional
dysregulation they’re either like flat and none nonexistent in their
emotions they just can’t even deal with when they should or they’re overly
reactive and then the person isn’t in a validating environment what would be
a to some of us on a scale of 1 to 10 as far as how distressing something is
it’s probably like an 8 to somebody with emotional dysregulation think about a
the time when you were stressed out or you had a lot of
vulnerabilities going on maybe you had a new baby at home so you weren’t sleeping
and your other kids were acting out there was just all kinds of stuff going
on and you reacted to something with an 8 that everybody else was like that
doesn’t deserve that much of a reaction that’s it – what’s wrong with you people
with emotional dysregulation that’s their environment all the time
everybody’s looking at them and going what’s wrong with you
there’s this is not that upsetting so we need to help people understand that
their experience is their experience and it’s not for me to say whether it’s a 2
or an 8 for me it’s a 2 but let’s look at why it’s an 8 for you so the
emotional reaction and this is why I didn’t get a red-eye reduction when I
took this picture of Bruit but bless his heart when I got him he
was a rescue and he had such terrible terrible abandonment issues and is so
hypervigilant even to this day I’ve only had him like four months but he’s
hyper-aware of stimuli and people can be hyper-aware of stimuli so anytime
somebody moves he’s up he’s looking he’s like are you going to leave me alone
again when he perceived that something was changing when there was a threat he
goes into all-hands-on-deck and turns into a survival sort of thing he starts
acting out he goes and finds toys and brings them to me heaven forbid we
should have to put him out in the garage because we have visitors or something
and it’s you know climate-controlled it’s not like it’s horrible but he will
sit out there and how until I let him in or go out and tell him it’s going to be
okay now see as a person I’m going that is not a valid reaction he’s like
overreacting to having to spend ten minutes in the garage whereas from
his perspective he’s not overreacting because in the past when he’s been put
in the garage, he left out there for days weeks months who
knows I don’t know his story too well
now I use that to kind of highlight the fact that people with emotional
dysregulation we don’t know what their experience was or what they’re doing
is trying to survive now they may be trying to survive a situation in their
past you know when there were six and we’re going back to the abandonment
discussion that we had the other day but it’s important to understand that all
these things play in together something happens and the the body’s response
the system takes in these stimuli and it says it’s dangerous it’s not dangerous
what do we do with it the brain decides to fight or fight and then they go into
the survival response with treatment what we want to do is help people be
able to feel that feeling and not have to act on it right away until they can
de-escalate some and use a combination of assessing their cognitions and
deciding whether their perceptions are based on the present the present moment
or the past moment so primary invalidation caregivers dismiss
emotional reactions are invalid we just talked about the child or person
could be mocked or shamed for their emotional response we have all probably
met parents or worked with parents who have children who are highly
emotionally reactive who tend to get frustrated and overwhelmed by the
the constant drama that seems to be presented by this child all the time so
the child is often not taught how to self-soothe or deescalate the parents
just like really let it go and go away which is not helpful because the
the child doesn’t learn how to deal with it the child is not taught mindfulness to
figure out okay what’s causing this and the child is not taught effective
cognitive processing in most situations in
validating environments if the child gets upset even if it seems to be
disproportional to whatever the event was the caregiver will take the child in
and say okay I hear you’re upset right now let’s talk about it and we’ll walk
the child through maybe not thinking about it but just being a good parent
walks the child through this de-escalation process and the cognitive
processing secondary trauma or invalidation is and I’m putting this in
here coping skills can be overwhelmed by trauma or intense stress leading to this
high alert raw status think about the people who were survivors of Hurricane
Katrina or Hurricane Andrew I come from Florida so I think hurricanes but any
big event that is ongoing enduring and distressful at a certain point you’re on
your last nerve so anything could precipitate sort of a crisis many people
don’t receive necessary support during these times and may be shamed for being
weak or needy sometimes nobody can cope and everybody’s kind of
decompensating at once which is a lot of what we saw with Katrina but other times
there may be people who are functioning just fine and they don’t understand why
some other people aren’t coping just fine and they see that as abnormal and
want to distance themselves from it we need to communicate to
people because we already noticed that a crisis is a normal response to an
abnormal event what was abnormal though is it this particular incident may be or
is it the fact that this particular incident kind of was the straw that
broke the camel’s back on a whole chain of incidents leading up to it that were
abnormal that caused this person excessive stress I was talking to a
woman the other day who in the past six years has had a half-a-dozen significant
losses and I’m just like wow you know that that’s pretty intense to have all
those and she’s also starting her practice and everything else right now
and I’m just like oh my gosh I can’t imagine the amount of stress this woman
is going through most humans aren’t inherently prepared to deal with the crisis
alone we’re kind of group sort of people we rely on other people so if we have
this reaction and it’s judged to be disproportionate and people kind of
distance themselves from us because they see us as abnormal or dysfunctional then
we lose any social support that might have been able to serve as a buffer
which just kind of in turn feeds back and exacerbates the sense of
hopelessness helplessness and isolation that precipitates a crisis may vary
between people based on pre-existing stress or mental health issues and it
also may vary with the same person longitudinally across time what may be
overwhelming today may not be overwhelming six months from now because
all of those prior stressors that I’m dealing with right now may have had time
to kind of work themselves out so it’s important that we help people understand
that their reaction is their reaction and let’s just go from there let’s not
say it’s bad or is disproportionate or it’s whatever it just is so the result
of this sort of unpredictable reactivity results in frantic efforts to numb
withdraw or protect I need to numb the feelings because I can’t take this
kind of pain if you’ve ever had a burn that’s had to be cleaned or even an open
a wound that’s had to be cleaned out you know that’s pretty excruciating so
thinking in terms of that you can see why people would want to kind of get a
little novocaine withdrawal if this support system is invalidating that has
extra pain and that’s excruciating to be rejected on top of everything else so a
lot of times people withdraw which eliminates any opportunity for social
support and it also exacerbates this sense of
rejection and they do this to protect themselves people learn that
who they are in invalidating environments they learn who they are and
how they are results in rejection so they avoid threats they avoid putting
themselves out there they avoid making relationships because they’re afraid of
rejection and they avoid thoughts feelings and sensations that may lead to
invalidation I don’t want to feel these things because then if I do and I
communicate them you may tell me I’m wrong okay we’ve laid the groundwork now
we see where this is a problem so what do we do about it
well the first thing we want to do is look at some of the DBT assumptions
about clients, clients are doing the best they can given the tools they have at
this present point in time and I truly believe that clients want to improve
they wouldn’t be in your office if they didn’t want to improve for one reason or
another may be an involuntary referral and they want there’s a means
to end there they are in your office because they have hope that something
can change and it will benefit them they cannot fail at DBT if they go through
dialectical behavior therapy the protocol fails then the protocol
failed them or we as clinicians fail to implement it correctly now today again
we’re talking today just about tools that are present in DBT not how to do
dialectical behavior therapy an evidence-based practice wants to make
that very clear clients exist in what is for them
an unbearable state this pain has got to stop they need to learn new behaviors in
all contexts not just at work and not just in their relationships but they need to
learn how to function and deal with life on life’s terms in all contexts so they
can go to the grocery store they can get in a traffic jam can be in a
crowded Airport and not feel like the walls are
closing in on them clients are not responsible for all of their own
problems we know this some things they had no
control over but is causing problems for them but they are responsible for all of
their solutions and we’re going to talk about the four options for the problem
solving in a few minutes but they are responsible they choose to do something
and clients need to be motivated to change motivation choose more
rewarding option out of the available options well yeah that’s whatever they’re
doing right now is the most rewarding option they have available in their
toolbox so we’re going to give them new tools but then we need to teach them how
to make those tools effective if you just hand me a jigsaw and say okay go
about woodworking and whatever I’m not a woodworker but I’m not going to know
what to do with that so I may go back to using my circular saw or whatever the
the case, which may be very clunky we need to help clients learn how to use
these new tools so it’s more rewarding to use those than those old behaviors
they just numbed out the pain or distracted them assumptions about
therapists’ clarity precision and compassion are of the utmost importance
we need to be clear with our clients about what’s going on let’s not speak in
generalities we want to try to avoid some of the Socratic questioning that we
would normally do we want to be clear about what we’re getting at and what we
want them to look at we need to be precise we need to not say well what is
it was last week that caused all the problems
in your relationships well if they had four different fights that’s four
different things we need to look at we need to be precise to identify
all of the things that trigger and we’re going to talk about behavior chains in a
few minutes so we need to be precise we also need to
be compassionate even if we don’t agree or we think that the reaction was
disproportionate putting ourselves in their mind in their place in their raw
the state we need to be compassionate and go okay you survived it you did the best
could let’s take a look at what might have caused why you made
the choices you made and what you might choose better next time the therapeutic
the relationship is between equals DBT or therapists can fail to achieve
the desired outcome but the client can’t fail and therapists who treat patients
with pervasive emotional dysregulation needs support it’s important for us to
remember that patients who are always in crisis are by their very nature it’s
exhausting because they’re always in crisis which means we are responding in
a crisis manner not that we need to get all upset and worked up because that’s
just modeling the wrong thing but there is a lot of energy that it takes for us
to use the DBT tools for us to model the DBT tools and for us to help work the
client out of their emotional state into one where they can use their wise mind so the first step is core mindfulness
until they figure out what’s going on they can’t fix it so we want to help
them integrate their rational mind and their cognitive This is what happens factual
mind with their emotional mind this is what it felt like
into the wise mind so you can take the facts you can take your feelings and you
can say with what I know and what I felt what would be the best interpretation of
this or the correct interpretation of this event at
this point in time and what can I do about it
one of the things DBT talks about is the fact that truth is sort of subjective
what is it truth for one person may not be the truth for the other person
because we’ve all had different experiences but we need to help people
not under-react and stay in that cognitive mind if you’re a Star Trek fan
think data um he was the AI that was kind of human-robot sort of thing or and
we also don’t want people to act in their emotional mind acting solely on
the basis of feelings and trying to make feelings facts because feelings aren’t
facts they’re feelings so we want to help them integrate these two things and
that is more difficult and it sounds like it takes time mindfulness is
using effective non-judgmental observation and description of
experiences those thoughts and feelings and identify what’s the objective
evidence for and against what’s going on right here how I’m feeling what is all
the evidence let’s look at the big picture not just one little aspect of it
and what are my feelings about this event getting in touch with what’s going
on inside their mind and their body is going to be one of the first
steps so I talked about those four options when there’s a problem you have
four options you can tolerate it grit your teeth and Barratt there sometimes
you just can’t do anything about it traffic jams probably can’t do much of
anything about it change your beliefs about the event instead of seeing a
traffic jam as a waste of time and just a complete pain in your butt you can see
it is a time to check voicemail and maybe return some phone calls to be
productive make it billable you can solve the problem or change the
situation while you’re in a traffic jam and stopped of course looking at
Google Maps to figure out where the next exit is that you can get off so you can
change that situation or you can choose to just stay
miserable and choosing to stay miserable is a valid choice when clients make
these decisions we need to look at why whatever their option was why
was that option more rewarding than all the others why is it more rewarding
sometimes to stay miserable for some people that’s what they know and they’re
afraid if they feel happy then they may get disappointed and end up feeling
sadder than they already do now some people tolerate the problem because it’s
what they know and change is hard and they would rather just tolerate it and
deal with it and suck it up then have to muster up the energy to try to change
whatever’s going on so again we want to look and ask them or ask ourselves maybe
because they may not know right away the choice that you made why was it more
rewarding Why did you choose that over the other three options so distress
tolerance and we’re going to talk about a lot of acronyms here acronyms are
important in DBT because it helps clients have sort of a drop back and
punt there are some worksheets there are lots of worksheets online for DBT but is
the acronyms we’re going to hit here are going to be some of the highlights
that’s going to be important for you to remember the tip temperature so you are tipping
your physiological balance now temperature I’m not necessarily
advocating for this you don’t want to do it if you’ve got a heart condition you
don’t want to suggest it to clients that have a history of child
abuse especially anything that involved drowning so this one’s a little tricky
one of the things I suggest to some of my clients instead of this is holding on
to ice cubes but the
the suggestion in the book hold your breath and dunk your face in for as long as you can
hold your breath in a sink full of ice water then come up exhale inhale and
dunk again repeat as many times as you need until you feel calmer well guess
what we’ve talked about is combat breathing if you are slowing your breathing which
you do if you’re holding your breath your heart rate is naturally going to
slow when your heart rate slows down your brain says oh the threats going
away yippee yay I can call off the dogs there
are other ways to slow down your breathing
besides necessarily dunking your head holding ice cubes one of the
reasons that can be helpful instead of cutting the person’s focus it’s a
distracting technique the person focuses on the pain because it is painful to
hold on to ice cubes for a long time instead of cutting themselves
but it also gives their body something to focus on to go oh my heart rate is up
because there’s pain when the pain goes away I can make my heart rate go down so
we’re redirecting the brain to go oh this is why the heart rates are up it’s not
because there’s emotional distress it’s because of extreme physical pain intense
exercise increases body temperature but it also increases the heart rate when
you’re sitting still and your heart rate is 120 beats a minute because you are in
a panic attack or in a state of panic it’s very very uncomfortable and your
mind is going I don’t understand why you’re not moving why is the heart racing when
you start exercising which is why walking and getting those big muscles
moving often helps then the body gets less confused it’s like Oh heart rates
beating fast because the body is moving score got it so when the person stops
moving the heart rate starts to go down and this is true even if you’re walking
around if you take a client out to walk when they’re upset and you are talking
about whatever the distressing thing is I have found without exception when they
come back inside they can start to calm down a little bit more and their heart
rate naturally starts to go down when they stop their physical exercise and
then progressive relaxation you’re going to move from head to toe or toe to head
whatever you prefer but head-to-toe is usually how we do it focusing on muscles
focusing on breathing slowing breathing relaxing muscles forcing the body to
relax so this addresses physiological arousal so temperature intense exercise
and progressive relaxation all of these serve as an ability serve the function
of distracting the person from whatever cognitively psychically or
whatever you want to say is going on and all of these either explain to the brain
why the heart rate is going so fast and or help reduce the heart rate so you
know there’s something to be said for them the important thing is for you to
brainstorm with your clients when you get physiologically aroused when you get
upset and you are just your hands shaking your palms sweating you’re
breathing fast your heart rates going fast how do you calm yourself down what
works for you and we’re back to bruit again another acronym is accepted in order
to distract when there’s emotional turmoil so you can kind of let that
adrenaline surge go because you have that initial fight-or-flight reaction
and then the body kind of goes right let’s reassess and see if there’s still
a threat to get involved in activities that will
help you distract yourself from whatever’s going on when kids get upset
you know if they’re getting stressed out because they’re sitting in the lobby and
the doctor’s office and they know they’re going to
get a sa chhoti we give them something to do we read a book we talk we play
because then they’re not focusing on the fact that they’re going to get a shot
contributing to the welfare of others by doing something nice for someone
Volunteers do something productive that gets them focused on someone else and compare
compare yourself to others who are doing less well that doesn’t work for
everybody you can also compare your self in the present to your old self and
focus on how much better you’re doing now compared to what you were doing
six months ago this doesn’t always work you know these are options not everyone
is going to work for every person emotions do the opposite if you’re
feeling sad get a comedian get it go to YouTube and Google a comedian and
watch a skit or two or ten so you’re doing something that makes you laugh
that makes you happy sing silly songs dude silly dances go out and there’s
very little I find more amusing than just listening to a baby laugh if I’m
having a really bad day I will find those stupid videos of babies laughing
at paper tearing if you can’t help but laugh with them pushing away build an
imaginary wall between yourself in the situation imagine yourself pushing it
away the situation with all your might or block the situation in your mind and
each time it comes up tell yourself tell it to go away
so if you start thinking about something that is particularly hurtful as soon as
it comes into your mind and it comes into your awareness no I am NOT going
to think about that right now thoughts counting some people count to
ten a hundred whatever it takes to get through that initial rush some people
sing for me I think I’ve shared before I have this irrational fear of bridges but
so whenever I Drive over a bridge I sing and usually it’s not songs on the
radio usually it’s songs I used to sing to my kids I’ll sing the ABCs something
that doesn’t require a whole lot of cognitive interaction because I’m doing
pretty good just to get over the bridge and yes I know I should be over it but
I’m not and that’s just the way it is the 10-game I like this one think of 10
things that you like the smell of think of 10 things that are green think of 10
things you see where we’re going with this and you can incorporate all the
different senses with it if you go through multiple iterations of it 10
things that you smelled yesterday 10 things that you see right now 10 things
that you hear when you’re on your way to work this helps people focus on
something other than what’s going on in here the 5 4 3 2 1 game is sort of
similar to the 10 Things game identify 5 things you see 4 things you smell 3
things that you can touch and follow down sensations like I
talked about on the last slide sensations can help distract you from
what’s going on until you have a chance to kind of get through that initial
adrenaline rush cold holding ice cubes rubber band and I don’t like this one
but some people put a rubber band on their arm and every time they
start to perseverate on a negative thought they snap it smells find some
good smells some smells that bring back good memories smells that you like maybe
it’s roses maybe it’s a purse-specific perfume you just go to Walmart and
start smelling all the air fresheners whatever makes you happy I do suggest
avoiding taste because if you start using taste as distress tolerance then
you start moving toward emotional eating I’ve seen it happen so I would avoid
that for most people but if they just desperately want to go there then you
no, we’re going to go there because they are choosing how to distract from
their cognitive or intrapsychic sensations
improve the moment imagery go to your happy place
whatever your happy place is find alternate meanings for what’s going
on how this can be Linehan refers to it as making lemonade we all know how to do
that we don’t we’re not necessarily the best at it but try to make lemon I try
to look for the optimistic meaning in whatever it is prayer now even if
someone is not religious they can be using radical acceptance accepting it is
what it is and not trying to change it just putting it out there for the
universe relaxation is always good to relax one thing at a time
and this isn’t focusing on one problem at a time
this focuses on something we’re talking about distress tolerance and
improving the moment so focus on one thing like your breathing
get your breathe and calm down once your breathing’s calmed down if you need to
focus on something else then move to maybe the tension in your neck maybe you
need to lower your shoulders and release the tension in your neck focusing on
physiological things focusing on other senses
besides that abstract stuff that’s in your head your emotions can help
people tolerate the distress until they can think more clearly vacation takes a
timeout sometimes you just need to get away from it for a few minutes we’ve had
times at work I’m sure we all have where you’ve just been like you know what I’m
done and you lock your computer screen you get up walk out of the building
and none of its clients are in there but you walk out of the building
and do a couple of laps around the campus and then you’re like okay I can deal
with this again just clear your head before you try to tackle whatever it is
an encouragement providing yourself because you can’t necessarily rely on
anyone else positive and calming self-talk
now back to those stupid memes and videos that I love to death there’s one
has a kitten on a laundry wire and it says hang in there
I love having those things on screensavers it’s juvenile maybe but
whatever makes me happy and it reminds me you know even when I’m not in
a state of emotional distress it reminds me all right keep on hanging in there
you got it and it’s got an all-factor too so I always like anything with an
all factors the goals of emotional regulation
so once you’ve tolerated this distress you’ve gotten through that initial surge
that initially I cannot take this pain or upset then we need to move into
emotional regulation helps people identify labels and understand their
emotions and the functions of those emotions decrease unwanted emotional
responses and decrease emotional vulnerabilities so what they’re going to
do is identify and label emotions and their functions I’m scared okay you’re scared
tell me why what the function of you being scared of what you want to do and
what do you think is causing this scared ‘no self-awareness through questioning
like that, through talking it out people will start to understand where their
emotional reactions are coming from and they can choose whether or not to follow
up with it a behavior that I guess I didn’t put in a behavior train
analysis is the way you can go about helping people work through that and
that’s a couple more slides cop we want to police our thoughts and check the facts
look at doing opposite actions if you want to hurt yourself look at being kind
to yourself, if you want to run maybe you need to look at staying and then look at
problem-solving reduces vulnerability through the ABC p accumulates the
positives remember vulnerabilities are those
situations that happen leading up to whatever the distress is those are the
things that make you more likely to be irritable overwhelmed angry depressed to
get sad over anything instead of not so we want to eliminate those
vulnerabilities or reduce them as much as possible so we’re going to accumulate
positives gratitude journals pictures if well everybody has things in their life
that they care about have those on your phone in you know little picture
galleries have them as your screen savers have reminders around about why
you get up in the morning to build mastery so you have mastery of the skills you
need to deal with emotional distress and upset cope ahead of time plan for
distressing situations if you’re getting ready to go in for an annual evaluation
and those things stress you out to no end rehearse it ahead of time and plan on
coping ahead of time figuring out how you’re going to react if it goes bad
figure out how you’re going to react if it goes well figure out how you’re going
to cope and physical vulnerability prevention maintain your health chronic
pain chemical imbalances hormonal imbalances can all cause
vulnerabilities or set you up to make you predisposed to
feeling like something’s at eight when it’s only two get plenty of sleep when
we’re sleep-deprived is a whole lot harder to deal with life on life’s terms
and exercise exercise is a great way of releasing or using up some of that
stress energy that you release during the day behavior chain analysis of the
first thing you do and a strict behaviorist will have slightly different
explanations for how to do this but just bear with me here
name the behavior reaction that happened now if you’re thinking back to the ABCs
this is going to be your C your consequence for what happened identifying
the prompting event ABC that would be the what was the activating event now
this is where it differs a little bit then we want to look at the behavioral
links so you had the activating event and then there was this reaction and in
between there were um automatic beliefs and we have that there we have thoughts
but there were also sensations events and feelings between what happened and
your reaction what sensations did you feel did you get flushed did you feel
Nervous Did you feel scared did you feel sad did you have a twinge of something
what feelings were there and what events happened did you act out in a certain
why did you scream did you yell what happened because these are all things
that are going to go into what ultimately ended up being the behavioral
reaction then I want to look at short-term positive and negative effects
of what you did the behavior of the reaction if you started screaming and
throwing things okay you did what was the short-term positive effect to that
what was the benefit to that because that was what you chose which means it
was likely the most beneficial response you could come up with in your highly
emotionally charged mind then so what were the benefits and
what with it immediate in the short-term negatives and then look at the positive
and negative long-term effects in the long-term if you react to this upset by
screaming and throwing things what’s the impact going to be are there any
positive impacts Are there any potential positive effects of this and a lot of
times it’s no but we want to ask the question just in case there are because
some people will have a positive and we need to address that this is sort of if
you go back to motivational interviewing what we think about when we’re talking
about decisional balance, exercises address the problematic links with
skills if some sensations or actions exacerbated the distress
then we need to look at distress tolerance if all of a sudden you had
this immediate panic reaction and you couldn’t breathe we need to work on
distress tolerance skills so you don’t go to that point where you are just for
lack of a better phrase in a tizzy thoughts and feelings if your thoughts
get negative and start racing and your feelings are negative and anxious and
worried and all those negative words we want to look at emotional regulation you
know if you can get through it where you get through that initial rush
and you’re still having these getting stuck in the negativity then we want to
look at emotional regulation most of the time we’re going to look at both of them
and then the third component once we’ve learned how to get through the initial
flood the initial all-hands-on-deck call and then people learned to regulate
their emotions and identify helpful responses instead of talking about
good and bad we want to talk about helpful and less helpful responses then
we need to look at interpersonal effectiveness and how to interact with
other people to make that validating environment exist so we want to start
with interpersonal and intrapersonal if you are effective with yourself and
then move to others describe what’s going on assess how you’re feeling what
your reactions are what the best next step is to assert your choice and reinforce the
good things be mindful appear confident
willing to negotiate and yes sometimes we have to negotiate with ourselves
because there’s something that we want to do right now and
this is very true with people with addictions a lot of times they really
want to use they know the long-term consequences of use are not where they
want to be so they have to negotiate with themselves to say alright I really
want to do this right now but I’m going to choose a different option in their
relationship with others we want to encourage them to be gentle
instead of being critical and harsh which a lot of times is what they’ve gotten all
of their life being gentle with other people accepting them where they are
modeling how they want to be treated being interested in what other people have to
offer what other people have to say and what’s going on with them a lot of
people with emotional dysregulation can’t handle their own life on life’s
terms they can’t even begin to handle anybody else’s stuff so a lot of times
they appear disinterested validate other people and their experiences and have an
easy manner you know sometimes we get too intense
and if everything in your world is either a zero or a ten it’s easy to be
intense about everything as they develop emotional regulation things will be
different you know they’ll have fours and fives in there but practicing that
not being intense and over-the-top about everything and then in their
relationship with the self be fast be fair with themselves not judgmental just
fair avoid apologies stick to values and be truthful 12-step recovery step one
starts with honesty being honest with yourself step two we start talking about
hope and faith which is sticking with values and being fair to oneself being
compassionate comes a couple more steps down that’s not
hard or not harmful for any of our clients to teach them to be fair to be
kind to themselves and to be honest with themselves and others so how does
treatment progress when we’re talking about dialectical behavior therapy as a
evidence-based practice stage one is basic safety we want people to move
from behavioral disk control to behavioral control we don’t want people
getting a phone call maybe a significant other has to back out on a weekend trip
which was someone with behavioral disk control could send them into a state
where they are self-injuring so we want to make sure that they have the skills
to not self-harm and you know you can’t just say well you can’t cut the person’s
like okay so finish what am I going to do instead if I can’t cut if I knew how
to do something else I’d be doing it right now we need to help them increase
their self-care behaviors instead of cutting what can you do I’ve talked
before about some of the interventions I’ve used with some of my clients that
have self-harm it’s not ideal it’s not where you want to end up but moving from
self-harm to like I said holding ice cubes or using a ballpoint pen to draw
on themselves is preferable to cutting themselves so we want to look
at small steps not going from you know five or six self-harm episodes a week to
nothing you’re setting yourself and your client up for failure
we want to reduce the intensity of the self-harm so they’re not actually
breaking skin so they’re not damaging themselves decreasing therapy
interfering behaviors what we typically call resistance and that can be showing
up late that can be always coming in and trying to derail
therapy sessions it can be being bossy it can be being reserved whatever it is
that’s interfering with the therapeutic process it’s important to understand
that therapy-interfering behaviors can be exhibited on the part of the
counselor too if the client is experiencing a lot of emotional discount
role sometimes counselors will start being late to sessions and will start
forgetting to review the chart before they go in and remember what homework
was assigned will start forgetting to do things so we need to make sure that both
the counselor and the client are engaging in motivating therapy
participatory behaviors we want to increase the quality of life behaviors
and decrease quality of life interfering behaviors so if they’re engaging in
addictions if they’re not sleeping if they’re changed smoking if they are and
again these are things when we look at the priority list
my main focus at first is going to be on self-harm you know I don’t want them to
be engaging in those behaviors and then we’re going to start looking at the
other things that create vulnerabilities that make them more likely to be unhappy
or to be reactive in situations that would make them unhappy we’re going to
increase behavioral skills core mindfulness and accurate awareness
encouraging clients not just when they’re upset but to engage in
mindfulness scans body scans four or five times a day so they know where they
are and they know if they are starting to feel vulnerable if they’re feeling
exhausted all of a sudden if they’re feeling foggy then they know to be kind
to themselves distress tolerance we talked about those skills interpersonal
effectiveness talked about those skills emotional regulation and active
problem-solving so these are all going to be introduced in stage one but
they’re introduced to the client who has been using their old
behaviors for a lot longer than stage 1 is ever going to last so we need to
remember that we have to help clients strengthen these behaviors remember to
use them if they use them at first one out of every five times as one more time
than they were using them last week let’s focus on the positive forward
movement and not on what we think they should have done we don’t want to set
goals that are going to set them up for failure in stage two we want to help
clients moderate emotions from excruciating and uncontrollable to
modulated and emotional um we want to feel feelings well I mean theoretically
we do so because we don’t want people to completely numb out and become robots
but we also don’t want every single emotional experience to be like
debriding a third-degree wound we want something in between we need to help
they decrease intrusive symptoms like flashbacks memories and hecklers the
things that created a situation where they feel unlovable and unacceptable for
who they are we want to decrease avoidance of emotions and I know that
That sounds kind of counterintuitive through increasing emotional awareness again we
don’t want them to be numb we want them to feel because if they feel then they
can choose how to act and how to react to decrease withdrawal and increase exposure to
life a lot of times clients with emotional dysregulation have withdrawn
because they don’t want to be rejected so they don’t go out with friends they
don’t experience life on life’s terms they just sit in front of the television
watch Netflix we want to decrease self-invalidation and help them understand that
their experiences are their experiences and they’re not right or wrong their
choices may be helpful or less helpful but at any point in time that is their
best as well as they can see their best options for survival so let’s not be
critical I’m just happy you’re still here and we want to reduce mood
dependency of behaviors part of this process we’re going to teach people how
to create SMART goals that are specific measurable achievable realistic and time
limited SMART goals and make sure they’re successful by validating and
teaching them to self-validate encourages them to imagine the possibilities when
you’re successful when you accomplish this goal what’s going to be different
how awesome will it be to encourage them to take small steps, not all or nothing you
now we want to get rid of the dichotomies and small steps toward recovery
and applaud themselves for even trying to encourage them to lighten their load and get
rid of stuff that they don’t need to be stressing over right now you know maybe
now’s not the time to start remodeling the house and then sweeten the pot
encourage clients to provide themselves with rewards for successful completion
of a goal may be getting through an entire week or for some clients even an
entire day without self-injury I encourage you to practice these skills
yourself because you’ll see how much we don’t do and how helpful these
skills can be but it also gives you more insight into two ways to help explain
thanks to clients and help them apply these tools to themselves think about
which skills you’ve used that were helpful or skills you could have used
that would have been helpful in the past week for you because you’re going to ask
the clients to do this so let’s do it for ourselves so we can put ourselves in
their position and think about which skills might have been helpful for a
client that you’ve worked with in the past week many disorders involve some
amount of emotional dysregulation that dysregulation can be caused by high
sensitivity and reactivity due to innate characteristics and poor
environmental fit or external traumas and lack of support or both
DBT seeks first to help the person replace self-defeating behaviors with
self-care behaviors and then moves toward emotional regulation and
interpersonal effectiveness to help people develop a support system and
learn how to feel feelings including the good ones
a variety of tools are imparted to clients to help them set SMART goals
identify and understand emotions and their functions to decrease unwanted
emotional and behavioral responses and develop a more effective compassionate
and supportive relationship with themselves and others finally remember
that not every tool is going to work for every person it takes some
experimentation prepares your clients for that otherwise if they try something and
it doesn’t work they’re going to feel rejected and validated and like failures
again it’s a process of working together to help them figure out how they can start
interfacing with life and integrating the two dichotomies of thought and
emotion to make wise choices to help them live happier and healthier

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