DBT Secrets Unveiled | DBT Made Simple

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@Allce.com Counselortoolbox I want to welcome everybody to today's presentation on DBT or Dialectical Behavior Therapy Made Simple. This presentation was actually based off the book by the same name, Dialectical Behavior Therapy Made Simple. Bad graphics there and I really like this book because it presents DBT skills in a very usable format. There are a lot of us who aren't ready to launch into being a formal DBT practitioner, but we are intrigued by how DBT works and some of the skills and all that kind of stuff. This is a great introduction. If you're not if you haven't really studied DBT and you want to figure out how you might be able to use it with your current client base. Great place to start, especially if you're working with clients who aren't at the level that Marsha Linehan was working with when she developed dbt where there's a lot of self injury. I personally like to err on the side of being conservative when I'm starting with new techniques and you know, I use newer things that until I get a good feeling for how they work and what the outcome is going to be, I use those newer things with less acute clients and I use my old tried and true with clients that may be struggling a bit more. And I want to make sure that when I put something out there, it usually hits the mark. Not to say that I do it every time. So we're going to go over the basics of dbt. We'll review the B in dbt. What you need to know about behavior. There is a ton of stuff. I got my minor in behaviorism. I took classes in behaviorism for 16 college credit hours. So there's a ton of stuff we could go over and we're not going to cover anywhere near that right now and most people don't want to cover anywhere near that all so understanding in DBT there's a few things you need to know, but it's not crucial to be a behaviorist. We're going to talk about mindfulness again and it is really important and interesting to me that over the past few years how much mindfulness has been incorporated in most every new sort of mainstream therapy. Now it's not exclusively the therapy, but there is a core element of mindfulness that we're talking and I think prior to the emergence of the term mindfulness we talked about it but we didn't have a label to put on it. And mindfulness with the label gives us the ability to have some skills groups that are specifically tailored around mindfulness, which from a therapeutic perspective is wonderful and from a business perspective can also be wonderful. We'll talk about reducing emotional reactivity, developing distress tolerance skills, what clients need to know about emotions, including regulating the painful ones and increasing the positive. You know, I harp on that concept of you can't just eliminate bad, you have to add positive. Otherwise you're going to have a person who's just kind of sitting there going, well, I can't do what I used to do, but I don't have any other tools. And we want to help clients become more effective in relationships. We find that a lot of the traumas that people experience, especially people with high emotional reactivity, can go way back to where they were knee high to a grasshopper, and they were expressing how they felt, they were expressing their heightened sensitivity and they were being invalidated. They were being told, you need to suck it up. This isn't that bad. So from the get go, they had difficulty expressing how they were feeling, what was going on with them, and they were in an environment that was invalid. So there's a lot of relationship stuff that people need to look at in terms of their anxiety and frustration levels. I mean, when you keep getting told you're wrong, you feel some particular way and you tell someone, this is how I'm feeling, and they tell you, no, you shouldn't feel that way, yeah, it's going to increase anger and frustration and your sense of isolation and helplessness. So with dbt, we help people examine some of these things, provide self validation, but also develop tools for handling this emotionality. So the clients that we're working with are typically clients with a higher amount of emotional vulnerability. They react to things others wouldn't react to and their reaction is more intense than others. So instead of being, you know, a 2 on a scale of a 1 to 10, their reaction is more like a 4 or a 5. Sometimes that's because they have a whole bunch of pent up stuff that they're trying to keep bottled up. And then this is sort of the straw that broke the camel's back. But more often than not, they are just highly sensitive and their recovery time is longer than others, which makes sense. If you get more reactive, if you get more of an adrenaline rush, it's going to take longer to come back to baseline than a person who only had half the adrenaline rush. Totally makes sense. However, if the person is in an environment where other people don't share these same characteristics, they're going, I don't fit in. Everybody else is fine, and I'm still feeling not fine. They have an inability to regulate emotion again, because when they were growing up, they didn't develop that emotional vocabulary, that ability to communicate to others what was going on and the validation that, okay, this is how you feel. Let's figure out how to deal with it. Many times this particular set of clients was told, you need to suck it up, get over it, it's not that bad. So they didn't learn the tools to tolerate distress. They didn't learn the tools to handle their emotions. We want to help them understand why they feel the way they feel. If they get upset about something. Okay, let's look at why. Because there's a lot more to feelings than just that surface level. And these particular clients typically have difficulty expressing the emotion in an effective way. So it comes out as either gushing or passive aggressive or angry. Because when they've tried to express it the only way they know how, they've been shut down. Sometimes they will bottle it up because people keep telling them they're wrong. So they're like, well, I'm in excruciating agony, but nobody understands, so I am just going to go drink myself into a stupor. Not the healthiest way to handle things. These are the clients that we're dealing with. They're highly sensitive, which means that they get really revved up and it takes a while for them to calm down and they need to help figuring out how to navigate in a world where other people may not get as revved up or may be able to calm down more quickly. One of the underpinnings of DBT is dialectical therapy or dialectical theory. Sorry. Everything is interconnected. There's an action and there's a reaction. If I scream at someone, I'm probably pushing them away. They're probably gonna be like, oh, I don't want a piece of that. So if I scream at somebody, I push them away. But what else goes along with that? Then I'm more isolated, I have fewer social supports, which means I may feel more stress because I can't spread it out and get support, which may increase the frequency and, or the intensity with which I scream at people to push them away. So it's a sort of self perpetuating cycle, if you will. Some of the examples of action and reaction addiction. If someone uses drugs, if someone engages in a behavioral addiction, there is an epinephrine rush, there's a dopamine rush. There is a lot of excitatory stuff going on in the brain. And the person goes, that felt good. I want to do that again. But the brain has said we're not equipped to handle that level of stimulus. So we're going to shut down some of the gates, Turning it down to protect itself. The brain does. The person uses again. They don't get quite the same rush when they sober up. Some of those doors, some of those gates are shut. So it takes more for them to feel happy than it did before they started using. So now they've created a situation where when they sober up, they're still feeling pretty crappy, so they use again. So there's an action reaction. Now, likewise, when they stop using, as the brain recovers the action of stopping using and the brain recovering produces the reaction of getting more positive neurotransmitter secretions and actually seeing color in the world, if you will. I already gave you the example of anger. When people are really angry, it pushes everyone away. Most people don't want to hang around with somebody who's just angry all the time. It's exhausting. So being angry all the time pushes people away, People who tend to be angry all the time. Part of what I hear from them is, nobody wants to be my friend. I'm all alone. Nobody gets it. Well, let's look at how you got to be all alone. So you push these people away, and now you're feeling frustration. How can we deal with that? Depression. When someone's depressed, sometimes they'll stay in bed all day. What does that do? That messes up their circadian rhythms. So then they don't know when they're supposed to sleep. They don't know when they're supposed to be awake. When they do sleep, it's not quality sleep. So they get more fatigued, so they want to sleep more, and then they can't seem to wake up, and it intensifies their feelings of helplessness and hopelessness. And then finally, social interactions. For our final example, when you have a positive social interaction with someone, what comes back? You want to hang out with them again. When you give out positive vibes, if you will, positive begets positive. Most of the time, I mean, as clinicians, we see someone hurting, and most of us are more than more than likely to run over and go, how can I help? But after we get past that, when we're talking about just social life, when you put out positive, you get positive in return. When you put out negative, you may be surrounded by other negative people, or you may be all by yourself. So let's look at what the action reaction was. Reality is in a constant process of change. So helping clients remember how they perceive something now may be different than how they perceive it. In an hour, if you get an evaluation, and it is not a good evaluation, and it's just devastating, you know, it hurts. You're dealing with that right now. But in an hour, when the adrenaline has a chance to go away, when you've had a chance to, you know, lick your proverbial wounds in an hour, how do you feel? Is it the end of the world still, or have you kind of adjusted? Most of us have learned how to tolerate distress, ride the wave, whatever you want to call it, and an hour later, we're like, okay, that really sucked. But it's not the end of the world. Some of the things we can ask clients to do is look at what things change their perception between, you know, something happens and they feel one way, and an hour later or a day later or six months later, they're like, that wasn't that big of a deal. What changed their perception? Was it just time? Or how do they change their perception? Another thing we can ask them to do is figure out what when they're in a crisis, when they're upset, what is their emotional mind saying? What is their heart saying? If their heart could talk, what is their reasonable mind or their detective saying? Taking the two of those, and this is the dialect, the heart and the head, and combining them and going, all right, now what can I get out of that? I may not be able to do exactly what my heart wants. I may not be able or I may not want to do exactly what my head says I should do. So how can I find a compromise? Where can I find that middle ground? Finally, the truth is always evolving and can be found by integrating multiple perspectives and tolerating that two opposite things may coexist. Two opposite things may coexist. Let's talk about these perspectives simultaneous. If you go to a crime scene and you ask five people who saw it take place, what happened, you don't get the same response. You're going to get five different reports. Now, there's going to be some overlap, but there's also going to be some interpretation of what happened based on their prior learning experiences. Doesn't mean they're wrong. No, that's their reality. So if you take five different realities and merge them all together, hopefully you get something closer to an objective reality when there's an interpersonal disagreement. And I was watching, Golly, the Daily show the other day, and Trevor Noah was talking about how in this particular election, if you're Hillary supporter and something comes out about Hillary, you can get frustrated that the news is focusing on this and not focusing on all the Donald Trump stuff. If you are a Trump supporter and something bad comes out about Hillary, you can get excited that they're not focusing on the bad stuff about Trump and they are focusing on the bad stuff about Hillary. So it's perspective. Is it a good thing or a bad thing that something's coming out and how are you interpreting it? What is meaningful to you longitudinally means thinking about things from, you know, what was meaningful when I was 6 versus what is meaningful when I'm 26. One example would be if a child says, you know, my mom had no use for us and that's why she left. And a lot of kids feel that way. Or a lot of kids don't understand why mommy or daddy chooses alcohol and drugs over them, because that's their perception. As they grow up and gain more knowledge, learn more about addiction, hopefully sooner rather than later, they start to understand that, yes, the parent left. Yes, the parent chose alcohol and drug addiction. However, does that mean that the parent loves you any less? So we need to talk about what that means. Another example is in abusive situations where a parent is supposed to love the child, but the parent also beats the child. So the child's going, well, if mommy loves me, but Mommy beats me, then I must be bad. It has to be something with me, because Mommy tells me she loves me. But then I don't get it. Helping the child or the adult, the adolescent, kind of rectify those two things that they can, they can coexist. Your parent can love you, but they can also do things that are harmful and hurtful at the same time. Does it mean that you are bad? What other things could it mean? So one of the things that is interesting in DBT is the fact that there are skills training groups and in individual sessions, a lot of clients with high emotional reactivity really want to deal with whatever their present crisis is. They really want to deal with them. So it's not a time to start teaching a whole lot of skills. In skills training groups, clients are able, in a relatively neutral environment to learn some basic skills. And then we can take from those training groups and apply them in individual sessions in a more heated situation where the person's telling you about their current crisis. So your main skills Include core mindfulness, which is increasing self awareness of thoughts, feelings and urges. When you have an emotion, anger, what thoughts are you having? What feelings, physical feelings are you having? You've already labeled the emotion as anger. So what physical feelings are you having? What secondary emotions are you having? We don't ask that a lot. So there's anger, but there's also probably other stuff in there. Guilt, resentment, jealousy, what's going on and what urges are you having when you have these thoughts? When you have these physical feelings and reactions? What is your desire? What is your behavioral urge? This helps people start to understand what's going on with them and go, okay, I see how the dots are connecting. And the cool thing is that you only have to kind of break one of the links in the chain to interrupt this behavior. So if they feel an adrenaline rush coming on, you know, they know they're anxious, they can feel their blood pressure coming up. If they're mindful and aware of that happening, then they can intervene earlier than if they wait until they're in full out thought feeling urge, I've got to make it stop mode. Core mindfulness also helps clients develop an understanding of their emotions as things that don't have to be acted on. And this is a new concept. This is a really new concept for a lot of people. And you know, it's interesting because my daughter is 12, almost 13, and I was typing a response to something on Facebook the other day and I was pretty passionate about it and we were getting ready to go out and put the chickens up or something. I'm like, hang on a second, let me just finish this post that I'm doing. And she looked at me, she's like, you're going off on somebody about something, aren't you? I'm like, well. And she's like, you don't need to let them get you that upset. I'm like, really? My 12 year old is telling me this. So I finished my post. It was polite, but it was to the point. And you know, we went on and did that. But her awareness of the fact that you can get angry, you can get sad, you can get whatever it is, but you don't have to follow through with a particular behavior I thought was pretty good for 12. Interpersonal effectiveness helps people develop assertiveness skills. So they can say, this is how I feel. You don't have to feel that way. And you don't even have to agree that I should feel, should feel this way, but it's how I feel. It is what it is. And we also help people identify the goals of their relationships and skills and activities needed to achieve those goals. So how do you effectively communicate? How do you create a win win situation? How do you negotiate and compromise instead of thinking of things in terms of black and white? Emotion regulation skills is your third group of skills that you're going to deal with. Helps people label and effectively communicate feeling states. If you're telling someone that you're angry and you use. When I was in counseling 101, our first counseling class, we were told we were not allowed to use the words happy, mad, sad, glad, or afraid. We had to find some synonym. But we were not allowed to use those five words in class because she wanted us to develop deeper repertoire of emotion words. So we developed an understanding of irritated and enraged and those sorts of things. You can do a lot of really cool activities with charades. You put 15 or 20 different emotions in a hat on little pieces of paper. People draw them, draw them from the hat. Then they've got to act out that emotion so they get a sense of what it might feel like, what it might look like. And then you can talk about what types of thoughts might go through your head when you're feeling like that. Emotion regulation helps us understand the function of emotions and why we don't want to eliminate them. Is anger a functional emotion? Heck yeah. Anger and fear tell you there's a threat. There is something you either need to defeat or get the heck away from. Now does nurturing it and holding onto it and whatever we do with it, is that functional? That's generally not as helpful. Anger and fear are our body's way, our mind's way of saying you need to do something, and that's it. Then you get up and you do something. You either let it go, you fix it, or you get away from it. Happiness is an emotion. We don't want to get rid of that, that one either, because it says, I want to do it again. And thinking about kids when they're little, some of the things they want to do. We were talking yesterday about peekaboo, and I was sharing with my daughter that small children are so thrilled. I mean, they can be amused for 20 minutes or more if you just cover your eyes. Then you go peekaboo and you do it again and again, and they laugh every time. And you're just sitting there looking at them going, how can you find this amusing? This helps children. Laughter is cathartic. Laughter is helpful. Anything we do that makes us laugh, that makes us happy. It's something we want to do again. Now, whether the child really finds it all that confusing or they just think it's fun to watch us make complete fools of ourselves, which I think is probably more it. It's providing joy to that child. Learning the connection between thoughts, feelings and behaviors and how to break the chain. As people start labeling their feelings, they can say, when I get angry, this is what I first notice when I get angry. My thoughts, my feelings, my behavioral urges are so they can figure out what can they do. A lot of times the first intervention focuses on those behavioral urges. We don't want you to go out and use. We don't want you to go out and cut. We don't want you to do something that's self harming. So when you feel this emotion, what else could you do? And then we start talking about distress tolerance and how to get through those periods of where emotions feel overwhelming. And your distress tolerance skills are really just your survival skills and alternatives to self harm. It's saying, I'm in a lot of distress right now. However, I'm making the choice not to engage in an unhelpful behavior. So some of the assumptions in DBT are that clients are doing the best they can with the tools they have at this point in time. Nobody gets up in the morning and says, I want to be miserable, so I'm going to half ass it today. You know, we really, we get up and we go, I want to have a good day. And if people don't end up having a good day, you know, life happens. So you're doing your best and you're surviving the best way they can. Clients want to get better. If the situation they're in is causing them distress, they generally don't want to keep doing it. Do you want to keep banging your head into the wall? No. You know, the old adage goes, why does Johnny keep banging his head into the wall? Because it feels so good when he stops. So we want to say, all right, you're doing this behavior and it ends up having a bad consequence. Let's take addiction for example. You get under a lot of stress, you get angry, you go out, you drink, you pass out, you wake up the next morning during that short period where you were drinking, you were inebriated and you were unconscious, you didn't hurt. That is the reward that we're looking at. It's not that they didn't want to get better. It's not that they were choosing alcohol. It was that they were choosing to survive. So we need to figure out how to help them work harder and smarter. So what are you going to do instead? Let's give you some more tools to work with. It is hard. Changing from that knee jerk reaction that has worked most of the time to changing to something else, which is a new skill or a new tool, that's exhausting. That's hard. It is hard work. Therapy is hard work. But we're going to provide you some tools so you can do it efficiently. And we'll be there to support you and help you figure out how to, you know, tweak how you're using that tool to make it more efficient for you. This helps them stay motivated. Clients need to remember that even if they didn't create their problems, they got to fix them. Sometimes stuff happens and it is out of that person's control. But they've got to figure out how they're going to live with that. If someone in their family, someone they're close to, passes away, they're going to feel grief, they're going to go through all those stages and it really stinks. They didn't create that. They didn't, you know, cause the person to die. But they have to figure out how they're going to live with it. So it's not their problem anymore. So they don't stay grieving for 5, 10, 15 years. Clients need to learn to act skillfully in every area of their lives. And one thing that is pointed out in the book is the fact that there are a lot of people with high emotional reactivity who are very successful in one or two areas of their life. You know, they may be, you know, very, very successful at work, but their home life is a shambles. Or they may be, you know, really good at home, but interpersonally, you know, in social situations and at work, not so much. So we need to help clients learn how to generalize these skills and use them in every area of their life. And finally, and one of the most important in my opinion is clients cannot fail in therapy. If we give them the tools and they're doing their best and we're working with them, then we need to stop back and look and say, okay, how did the techniques, how did your knowledge or what we've imparted to you not meet the standards that it needed to. How did we fail? How did the therapeutic process fail? Not the client. The client's doing the best they can. The therapeutic process may not have been as effective treatment priorities. Obviously, the first priority, if somebody is suicidal or engaging in self harming behaviors, including addiction, that's our primary thing. Then we look at behaviors that interfere with therapy. Calling in, not showing up to appointments, showing up late. And this includes the clinician. And obviously we're not going to discuss that with the client. But we need to be cognizant of things that we may do that interfere with therapy. And we've all had clients before that have been more challenging than others. And you're like, okay, so and so is coming today and, and you know that they're trying to work, you know, they're trying to do their best. However, you're just really struggling at that point in time because it's exhausting. And this is when DBT therapists or therapists in general need some support. Then we want to identify suicidal or self harm ideation and misery. So we're not talking about the behaviors. We've gotten down to the point where the person just thinks about cutting or thinks about committing suicide, or thinks about using. How do we deal with those obsessions or ideation, if you will? Once we have eliminated the self harming behaviors, they're engaged in therapy. They're not idealizing, they're not thinking constantly about self harming behaviors. They've made a lot of progress and we're going to focus on treatment gains. So let's keep this going. You know, you don't want to hurt yourself. Look how far you've come. And what are some other goals that have been identified by the client? Now in each one of these places we need to interject mindfulness, emotion regulation, interpersonal effectiveness and distress tolerance. So if you're working with someone who is actively suicidal or engaging in self harming behaviors, obviously make sure they're safe. If they need to be in a facility so they are safe, then that's a whole other step. But you get to the point where you're working with the person and you have them start becoming mindful of what triggers their suicidal impulses. You start addressing the emotions that just flare up and feel like a tsunami as opposed to a ripple. Start looking at that emotion regulation, start looking at interpersonal effectiveness. When you start feeling this way, how can you assertively communicate this? And to whom can you assertively communicate this? And finally, when you start feeling, feeling this way, before you engage in self harming behaviors, what distress tolerance techniques might be available? Now remember somebody at this level, at level one, suicidal self harming behaviors, when they have an emotion, when they get overwhelmed, it's not just a little overwhelmed, it's drowning in a tsunami overwhelmed. So they're not going to go, well, what did my therapist say? All of these things need to be written down. They need to have them somewhere accessible that they keep with them at all times so they can look back on it and go, okay, this is what I need to do. And it may be as simple as a phone number of someone they need to call. Now, if you're familiar with the DBT theory and the DBT structure, a lot of doing. True dialectical behavior therapy involves phone consultations with the clinician between appointments and a whole lot of other stuff, not just skills groups and individual therapy. For the purposes of this particular presentation, we're just going to focus on the skills that one would use in the dialectical behavior therapy, skills that one could use in traditional therapy, taking it to that next level, developing a consultation group, all that other stuff is a huge undertaking and a whole other task. It's wonderful, but it's more than we can cover right here. And then we move down once we've got it, to the point where the person is not actively trying to harm themselves. And again, I say suicide, cutting addictive behaviors because all of those have the potential for self harm or maybe even accidental suicide. We address those first. Then we move down to behaviors that interfere with therapy and we go through the list again. When you're engaging in these behaviors, maybe you're coming late to sessions. Let's talk about mindfulness. What is it that's motivating that or why does therapy feel like it's something you don't want to come to? Start talking about what feelings and what thoughts surround therapy. As far as a priority, what's changed? Move down to emotion regulation. Sometimes coming to therapy and talking about emotions all the time is just exhausting. So how can we deal with that draining factor? One mistake I find that a lot of my patients make when they start therapy is thinking that therapy is easy. You know, I'll just go to therapy an hour a week and everything will be fine and I'll get better. And I'm like, no, no, that's not it, I'm sorry. You need to plan for therapy to be a part time job for the next eight to 10 weeks because it's going to take a lot of energy. Even if it doesn't take a lot of time between sessions, it's going to take a lot of energy. You're going to be drained. So you need to figure out how you can prepare for that and prevent it from interfering with your life, which will potentially make you want to drop out of therapy. Suicidal or self Harm ideation and misery. Again, go through the list. Maintaining treatment gains. And then clients generally have their own goals. So sometimes you work on that at the end. Sometimes you can work on a goal concurrently with some of these other priorities. And it's sort of the carrot at the end of the stick. It's something the client wants to work on. That's a positive behavior. We're increasing in addition to addressing, eliminating the negative behaviors, stages of treatment, attaining basic capacities, identify behaviors that pose a direct threat to clients or other people's safety. Monitor the frequency intensity of behaviors using a behavior tracking form. She gives you examples of a lot of these forms and a lot of these protocols in the book. You can also go to dbt self help. I think it's.com and there's a lot of the stuff just on general DBT there. We want to address suicidal behaviors, behaviors that interfere with therapy, general misery, maintaining gains and client initiated goals. In stage one, we want to get the ball rolling. In stage two, the person has kind of gotten control of their emotions. They can label them, they feel when they're coming on. They have some interventions that work. They're feeling stable, they're not feeling great, but they're feeling stable. So in stage two, we want to go on to reducing traumatic stress. And the traumatic stress can come from negative relationship experiences related to emotional dysregulation, those invalidating environments that I talked about earlier and lack of interpersonal skills. So they feel rejected all the time. Their self esteem is low, so they have a hard time validating themselves. They've always kind of been told that they're wrong or they're overreacting or they're this or they're that. So they don't feel good about themselves. And then they have a hard time getting validation from anyone else. So they're pretty lonely, they're pretty isolated. So we want to reduce some of this and help them feel validated and help them feel good about themselves. Which takes us to stage three of increasing self respect and achieving individual goals, teaching them how to set boundaries, teaching them how to be assertive. The B in DBT benefits, we want to look at the positive and negative reinforcement when somebody does something. You know, I gave the example earlier of drinking. If an alcoholic relapses and drinks again, what were the positive benefits of that? It numbed the pain. The negative, well, I kind of mixed up my reinforcements here. But the negative reinforcement was it made the pain go away. The positive reinforcement was it made them feel good. So not only did it make the pain go away, but it had the additional increasing serotonin making them feel good, making them feel generally more sociable. We also want to look at the punishment. What were the consequences of using? You know, if you woke up and you had 500 less dollars, that's. That's punishing. If you woke up and you've realized that you had relapsed and you felt guilty about it, that's. That's also punishing. That's adding a negative feeling on top of it. So we want to look at the consequences of the behavior, and we have to look all along the behavior, not just when the person used or when the person cut, but what was the end goal of that behavior, and what were the rewards? We want to talk about intermittent reinforcement. Think about the kid in the candy store who. Or even in the grocery store. We were in publix one time. My son was about 4, and he was hungry, and he did the thing that all little kids do at some point or another, and he wanted candy. And you know how they have the candy right next to the checkout aisle. And I said, no, it's about time for dinner. And he's please. I was like, no, it's about time for dinner. And he looks at me with no volume control whatsoever, says, well, so much for publix, where shopping is a pleasure. I was mortified, but I didn't give in. When you give in at a certain point, then the child or the animal or whomever learns that, hey, this is where I've got to start. This is where the threshold is. So if I just start acting like this, I will get my own way. And we also need to model effective coping, effective emotion regulation. We don't want to be screaming at our clients or screaming at our staff. That's kind of not what we want them to learn from us. Remember that reinforcers increase the likelihood of a behavior and punishments reduce it. You don't do things if there's. If it's more punishing than reinforcing vulnerabilities increase the likelihood of a fight or flight response. So if you wake up in the morning and you're tired and you're sick, and you've got 6 million things that you've got to get done that day, you're already vulnerable because you've got stress going on, which means you have less energy to deal with whatever is thrown your way when you get to the office. And finally, we want to look. In order to understand some of this for people, we do backward chaining. So client a Has an outburst, we say, okay, that's what happened. It's not what you wanted to have happen. Let's look at how we got there. Coworker said something insensitive. Okay. And that led to the outburst. I think there's more to it than that because co workers have said things that were insensitive before, and you haven't had an outburst. So what else happened? Well, let's go back a little bit farther. When you woke up, you felt drained already. You didn't feel like you slept well, and you knew you had a lot going on, and you were just like, ugh, coffee. Okay, was that enough? Have there been times you felt drained and people were rude that you didn't have an outburst? Yes. Okay, so let's go back a little bit further. You had to put your cat down the day before. That was a traumatic, draining event. So all these things added together, you see where there was a major stressor. You got the message from your brain by waking up the next morning that you're drained. You don't have the happy chemicals, you don't have as much energy. So you need to kind of play it close to the vest. However, that person came in and said something insensitive, and you didn't have the energy reserves to deal with it, which led to the outburst. So what could we do differently? Next time, Remember that triggers or stimuli, whatever you want to call them, cause a reaction. They remind a person of a prior situation in which a behavior was either rewarded. So if they lashed out and they got control, guess what they're probably going to do again in a similar situation? Lash out. Or it was punished. They lashed out, it did no good, and the client felt an increasing sense of helplessness. So in a similar situation, lashing out may or may not be repeated based on whether it was rewarded or punished. So they need to look back at prior instances of that behavior. And when was it rewarded? And what about alternate behaviors? Were they ever rewarded or were they ever even tried? Triggers may communicate to the person that there's a threat. It says, warning, you need to do something. Okay, so if somebody's already a little hyper vigilant, a little hyped up, they may react extremely. But triggers can also prompt feelings of well being. If you've ever opened your phone and there's been a picture of your kid on there, and you're just like, aw, that was a trigger, too. Triggers aren't always bad, and we want to increase positive triggers, decrease negative triggers. Shaping, and I know I'm going a Little bit fast, but I got behind. Shaping means rewarding successive approximations. So, for example, if you're dealing with somebody who has anger issues, level one is not throwing things or being physically aggressive. Maybe they get in fights with their spouse, but they're not throwing things or being physically aggressive. Awesome. Progress, not perfection. Level two, now we want to say not only are you not going to throw things or be physically aggressive, but you're going to try to disengage until that urge subsides, until the adrenaline and the norepinephrine subsides enough and you feel like, okay, we can have a calm discussion. Level three would be taking it the next step and saying, okay, I didn't throw anything. I disengaged, I calmed down. Now I can actually come back and have a calm discussion. These levels progress over time. Level one, it may take a month before the person gets to that point. I hope not, but it may. Level two, it may take a month or more for the person to remember, I need to just walk away, I need to disengage, I need to go to the bathroom. Whatever it takes for that person to let the adrenaline rush go away. Once they've mastered those skills, then they can work on calmly discussing the issues. And if they start to get upset again, disengaging and coming back, addiction or self harm. I have two levels here. Level one is engaging in a secondary coping behavior. I'm not going to be real particular about what that is. If you are not cutting or using drugs, illegal drugs, then, you know, let's go with it. Right now we're talking about harm reduction. So even if it is smoking, which is a drug, I realize walking, eating, which again is not the healthiest reaction, but it's a whole lot better than using crack or cutting yourself. So once the person gets used to not engaging in that primary urge that they had, then we say level two, let's take a mindfulness minute to evaluate the situation and then choose a behavior consistent with your goals. So you take a time out. You've got that secondary coping behavior going on. Now let's take a look at what's happening instead of just trying to shove it down and forget about it. Mindfulness means developing an in the moment awareness of how you are emotionally, mentally and physically, and exploring the interconnection of thoughts, feelings, and physical sensations. Remember that distress in one of those areas leads to distress in others. If you're sad, you may have a foggy head and you may have aches and pains, you may just feel lethargic if you are sick or in pain, you may be grumpier and you may have a harder time focusing because the pain is distracting you. So remember that they're all interconnected and we want people to become aware of the emotional wave so when they get upset they can say, okay, this wave is a tidal wave and I am down here. I'm not even finished rising yet, or I'm at the top and I'm coming down. Reminding them that most emotions will dissipate within five to 15 minutes if we don't stoke the fires. We want to reduce emotional reactivity and one of the acronyms is please. P and L means treat physical illnesses. Be healthy. Remember, not feeling good. Not gonna help your mood. Eat a nutritious diet. Don't use mind or mood altering drugs unless prescribed by a doctor. Get plenty of sleep and exercise. Exercise releases serotonin. Can do a whole lot to help people deal with pent up stress if you will. Build positive experiences. It's not just about eliminating miserable stuff. You want to have fun things each day, even if it's five minutes. What was one positive thing you did for yourself today? And be mindful of your current emotion. If you're angry, you're angry. Don't tell yourself you shouldn't be. Just say I am and then you can move on from there. Distress tolerance. Another acronym accepts activities. So do hobbies. Watch a video, Go for a walk. If you're feeling really upset, try to do something to distract yourself. Contribute. Do volunteer work. Compare yourself to people who are coping either the same as or less well than you and go, okay, other people can do this. I got this too. Emotions. Try to distract with the opposite. If you're feeling really down, try to watch a comedy. Push away a distressing situation by leaving it mentally for a while, which kind of goes back to distracting. You're just pushing that out of your head going, I'm not going to think about that right now. And you can even tell yourself those exact words. Thoughts. Think about something else. So get engaged in puzzles or a book or something to distract you. For me, it's cartoons, you know, I don't know why. And sensations. If you distract with intense sensations, you're focused on that. If you're holding ice cubes, you're going to focus on that after about three or four minutes, trust me. So what do clients need to know about emotions? And there's a whole chapter on that. But basically, like I said earlier, we want to decrease the negative emotions. They're there for a reason. But we want to decrease the intensity and develop an understanding of what causes depression, anxiety, anger, envy, frustration, irritation, whole list, whatever it is for the person in that person, and what are the ones we can eliminate? What are the unnecessary irritants we can just get rid of? Because there are some things that, you know, we should get upset about, but there are some things that we can eliminate we don't have to bother ourselves with. And increasing the positive. What are some positive things that you can do? You can't be happy and depressed at the same time. So how can you increase the positive? Keep a list of positive things, things that make you smile, things that make you happy. Some days it'll feel like you need a crowbar to get you out the door to do them, but getting out and doing them makes you feel that much better. Interpersonal effectiveness. Teaching assertiveness, distress tolerance, emotion identification and communication. So if the person can assertively say, this is how I feel and this is what I really need or want in order for it to be resolved, it'll be a whole lot more effective than throwing a tantrum or acting out or walking away or being passive aggressive. In order to be interpersonally effective, people need to understand their own needs. You know, that's, you know, obvious, but also the needs of others. What is it that another person needs? That whole empathy thing. What do they need in order to support you? What do they need in order to want to support you? And then we want to help people explore situations using dialectical theory. So taking multiple perspectives in an argument or in an interpersonal situation to try to imagine what was the other person thinking or feeling. Dear man, is your acronym here. Describe the situation objectively. Express why this is an issue or a need, how you feel about it. Assert sharing clearly what you're feeling and asking directly for what you want and need. Not passive aggressively not going well. I wish there was something that could be done. Well, if there's something you want done, say what it is. Reinforce what you want done and why it's a good thing by offering a positive outcome or a win win. Be mindful, focusing on what you're requesting and not getting distracted by all this other stuff. Appear confident and be willing to negotiate. You know, my kids want pizza a lot because they're kids, they want pizza and I have to negotiate that. But sometimes they will come to me and they will make a case for why they deserve pizza and create a win win situation. They're like, hey, and by the way, mom, you won't have to clean up or cook dinner. So there you go. And I'm like okay, fine, whatever, you win. Now obviously our clients are dealing with a whole lot more than pizza, but you can apply this in non threatening situations to help people master it before you start applying it to the more emotionally laden stuff. So DBT is a great tool to help clients become more aware of their emotions Identify the thoughts, feelings and urges associated with those emotions Develop a greater sense of self awareness regarding the whys of emotion. Why do I feel this way? Why do I act this way when I feel this way? They develop an awareness of their vulnerabilities which make them more likely to be emotionally reactive or sensitive. Most of the time when you say you know when you don't feel well, you tend to be grumpier. People are like yeah, you know, you're right. But I'd never thought of that. So helping people understand that Mind, body connection and DBT provides an awesome framework for teaching skills groups that benefit an array of clients who have difficulty with emotionality and I can't remember exactly when in the next couple of weeks there's a class that we're going to do on DBT and mindfulness skills for adolescents. And if you work with adolescents or you just remember being an adolescent, adolescence is a time of high emotionality. I don't care who you are. So DBT skills can be really useful for that particular group. Like I said, this book was this presentation was based on a book by Sherry Van Dyke, DBT Made Simple. You can get it at New Harbinger Publications if you want to. I will be putting out a I believe I figured out it was a 10 hour on demand class. If you want to learn more and really get all the tips, tools and tricks that she has in that book, that will be available probably in two weeks. But if you want to just peruse it in the library. I'm pretty sure I've seen it at like Borders and Barnes and Noble too. So you can look at a copy and see if it's something that interests you. You Are there any questions? If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing@Allce.com Counselortoolbox this episode has been brought to you in part by allce.com providing 24.7 multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. Use coupon code counselortoolbox to get a 20% discount off your order this month.