Dialectical Behavior Therapy Skills

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Dialectical Behavior Therapy Skills
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs

Based in part on
– Doing Dialectical Behavior Therapy: A Practical Guide by Kelly Koerner (Guilford Press)
– The Dialectical Behavior Therapy Skills Workbook (New Harbinger Publications)
– DBT Made Simple (New Harbinger Publications)
– Use promocode 1168SNIPES at New Harbinger for 25% off your entire order.
– www.dbtselfhelp.com
– DBT for Substance Abusers

Objectives
– Why was DBT created
– Understanding Emotional Dysregulation
– Identify DBT assumptions about clients and therapists
– Explore skills to help clients learn
– Distress Tolerance
– Emotional Regulation
– Interpersonal Effectiveness
Why I Care/How It Impacts Recovery
– Many of our clients experience emotional dysregulation
– The inability to change or regulate emotional cues, experiences and responses.
– They have tried to change and failed, leaving them feeling hopeless and helpless (depressed/anxious)
– Untenable emotional experiences lead to self preservation behaviors such as addiction, non-suicidal self-injury, even suicidality

Why DBT Was Created
– People with emotional dysregulation have:
– High sensitivity
– Hypervigilance
– Overgeneralization
– Easily thrown off kilter (vulnerabilities)
– No “emotional skin”
– High reactivity
– Fight or Flight
– Slow de-escalation (Persistent heightened awareness)
– Invalidating environment

The Emotional Reaction
– Hyperawareness of stimuli (Perceptions)
– Threat perceived (Cognitions)
– All hands on deck response (Physiological response—Fight or flight)
– Actions (Survival)
Primary Invalidation
– Caregivers dismiss emotional reactions as invalid
– Child is mocked, shamed for emotional response
– Child is not taught
– Self-soothing/de-escalation
– Mindfulness
– Effective cognitive processing
Secondary Trauma/Invalidation
– Coping skills can be overwhelmed by trauma or intense stress leading to a high-alert “raw” status
– Many people do not receive necessary support during these times and may be shamed for being weak or needy
– Crisis is a normal response to an abnormal event
– Most humans are not inherently prepared to deal with crisis alone
– What precipitates a crisis may vary between people based on pre-existing stress or mental health issues

Result
– High sensitivity + high reactivity + invalidation = Frantic efforts to numb/withdraw/protect
– People learn that who they are and HOW they are results in rejection
– Avoidance of threats
– Avoidance of thoughts, feelings, sensations that may lead to invalidation
Assumptions About Clients
– Clients
– Are doing the best they can
– Want to improve
– Cannot fail at DBT
– Are existing in an unbearable state
– Need to learn new behaviors in all contexts
– Are not responsible for all of their own problems, but are responsible for all of their own resolutions
– Need to be motivated for change
Assumptions About Therapists
– Clarity, precision and compassion are of the utmost importance
– The therapeutic relationship is between equals
– DBT or therapists can fail to achieve the desired outcome
– Therapists who treat patients with pervasive emotional dysregulation need support

Global—Core Mindfulness
– Rational (Cognitive) Mind + Emotional (Feelings) Mind + Wise Mind (Intuition and Interpretation)

– Mindfulness—effective, nonjudgmental observation and description of experiences (thoughts, feelings)
– What is the objective evidence for an against
– What is all the evidence (the big picture)
– What are my feelings about this event

4 Options
– Tolerate the problem
– Change your beliefs
– Solve the problem/Change the situation
– Stay miserable
Distress Tolerance
– TIP: Address physiological arousal
– Temperature (ice/hot bath)
– “…hold your breath and dunk your face and head in for as long as you can hold your breath.  Then come up, exhale, inhale and dunk again.  Repeat as many times as you need to until you feel quite a bit calmer.”
– Intense Exercise
– Progressive Relaxation
– All of these
– Distract
– “Explain” or reduce heart rate

Distress Tolerance
– Distract ACCEPTS
– Activities
– Contributing to the welfare of others
– Comparisons to others or old self
– Emotions (opposite)
– Pushing Away
– Build an imaginary wall between yourself and the situation.
– Imagine yourself pushing it away with all your strength.
– Block the situation in your mind. Each time it comes up, tell it to go away,
– Thoughts (counting, singing, the 10 game, 54321)
– Sensations (cold, rubber band, smells—avoid taste)
Distress Tolerance
– IMPROVE the moment
– Imagery—Happy place
– Meaning– Make lemonade
– Prayer– Radical Acceptance/It is what it is.
– Relaxation
– One thing at a time– Focus on one thing, like breathing
– Vacation—Take a time out
– Encouragement—Positive and calming self-talk
Emotional Regulation
– Goals
– Identify, label and understand emotions
– Decrease unwanted emotional responses
– Decrease emotional vulnerabilities
– Skills
– Identify and label emotions and their functions
– Improve self-awareness
– Conduct behavior chain analysis

Emotion Regulation
– COP—Police your thoughts
– Check the facts
– Opposite actions
– Problem solving
– Reduce Vulnerability ABC-P
– Accumulate positives
– Build mastery
– Cope ahead of time
– Physical vulnerability prevention (health, sleep, exercise)
Emotional Regulation
– Behavior Chain Analysis
– Name the behavior/reaction
– Identify the prompting event
– Identify behavioral links (sensations, thoughts, events, feelings)
– Short term positive and negative effects
– Long term positive and negative effects
– Address the problematic links with skills
– Sensations/Actions—Distress tolerance
– Thoughts/feelings– Emotional regulation

Interpersonal Effectiveness
– DEARMAN
– Describe
– Assess
– Assert
– Reinforce
– Mindfulness
– Appear confident
– Negotiate
Relationship Effectiveness
– Relationship with Others: GIVE
– Gentle
– Interested
– Validate
– Easy Manner
– Relationship with Self: FAST
– Fair
– Avoid apologies
– Stick to values
– Truthful
Stagewise Progression of Treatment
– Stage 1
– Move from behavioral dyscontrol to behavioral control
– Decrease self-harm behaviors
– Increase self-care
– Decrease therapy interfering behaviors (resistance)
– Increase motivation and participation
– Decrease quality of life interfering behaviors (vulnerabilities)
– Increase quality of life behaviors
Stagewise Progression of Treatment
– Stage 1
– Increase behavioral Skills
– Core mindfulness / Accurate Awareness
– Distress tolerance
– Interpersonal effectiveness
– Emotion Regulation
– Self-Management / Active Problem solving
Stage 2 –
– Moderate emotions from excruciating and uncontrollable to modulated emotional experiencing
– Decrease
– Intrusive symptoms (flashbacks, memories, hecklers)
– Avoidance of emotions (increase emotional awareness)
– Withdrawal (increase exposure to life)
– Decrease emotional dysregulation (heightened and inhibited)
– Self-invalidation (increase self-validation)
– Mood dependency of behaviors (increase accurate communication of emotional and physical experience)

Create SMART Goals
– Specific
– Measurable
– Achievable
– Realistic
– Time-limited
VITALS to Success
– Validate
– Imagine the possibilities
– Take small steps
– Applaud yourself
– Lighten your load
– Sweeten the pot (rewards)
Apply It
– Practice these skills yourself
– Which skills have you used or would have been helpful for you in the past week?
– Which skills might have been helpful for a client in the past week
Summary
– 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
– External traumas and lack of support
– DBT seeks first to help the person replace self-defeating behaviors with self-care behaviors
– Emotional regulation and interpersonal effectiveness are addressed in the second phase of treatment
Summary
– A variety of tools are imparted to clients to help them
– Set SMART goals
– Identify and understand emotions and their functions
– Decrease unwanted emotional and behavioral responses
– Develop a more effective, compassionate and supportive relationship with self and others
– Not every tool will work for every person. It takes some experimentation