Dialectical Behavior Therapy Skills

Foreign. The 2021 Wellness Retreat is an opportunity for clinicians and non clinicians to enjoy fall in Tennessee and maybe even a leaf change while you take a deep dive into learning about the mind, body connection and strategies for improving your overall well being. Up to 21 CEUs will be available for clinicians, but again, you don't need to be a clinician to attend. The retreat is being held October 20th through 23rd at Cumberland Mountain State park and is limited to 60 people to allow me to have plenty of time to interact with everyone. Go to allce.comwellness to see the detailed schedule and download the registration form. I look forward to seeing you there. I'd like to welcome everybody to today's presentation on dialectical behavior therapy skills. I'm your host, Dr. Donnelly Snipes. Now obviously I called this Dialectical Behavior Therapy skills because dialectical behavior therapy itself is a something of a self contained approach. What we're going to be learning is a lot of the skills that are taught within cognitive behavioral therapy and these skills can be very useful in clinical practice even if you're not using the cognitive behavior. I'm sorry, even if you're not using the dialectical Behavior therapy, you know full protocol. This presentation is based in part on doing Dialectical Behavior Therapy A Practical Guide, the Dialectical Behavior Therapy Skills Workbook DBT made simple, dbtselfhelp.com and DBT for substance abusers. So there are a lot of different places that you can find information about how to integrate DBT skills skills into your treatment program. We're going to talk about why DBT was created. Understanding Emotional Dysregulation will identify DBT assumptions about clients and therapists and explore skills to help clients learn distress tolerance, emotion regulation and interpersonal effectiveness. So we've got a lot to cover. DBT was created because there was a significant portion of the population that was struggling to get their needs met in the day to day world as well as in a counseling environment. These people tend to have high sensitivity and become emotionally dysregulated. We've talked in other classes about emotional dysregulation as going from flat to furious, going from calm, even content, or you know, kind of flat and apathetic depending on where they're at in the spectrum to too, you know, super anxious, you know, just terrified or enraged. And this is not something that they do intentionally and it's not something that they can just, you know, get over because they're quote, overreacting. Their HPA axis is actually having an Exaggerated response and dumping a lot more cortisol and norepinephrine and adrenaline and all that stuff into their system than a person who is not dysregulating, a person who is not highly sensitive. High, high sensitivity can lead to hyper vigilance. When you're highly sensitive, think about, you know, get getting away from emotions, for example, thinking about something more tangible. If you are highly sensitive to smells, you may be hyper vigilant. When you go into an environment about whether there's a smell there that is going to bother you. You know, I am super sensitive to paint fumes, so I tend to notice them more. I tend to be on the lookout for indications that somebody is painting because I know that's, you know, bad mojo for me. When we're talking about people with emotional dysregulation, we're talking about hyper vigilance to a variety of stimuli, Whether it's situations, people, places, things, environmental stimuli, emotional conditions. People who are in recovery from addictions may also have a fair amount of hypervigilance, partly because their HPA axis is dysregulated. But it could be that they had HPA axis dysregulation and this high sensitivity prior to the development of their addiction. One of the things we want to help people learn how to cope with is this high sensitivity. And when they become disregulated, providing them tools to help them quote, re regulate themsel. People who are highly sensitive tend to overgeneralize. They experience rejection, for example, in one situation, and then they overgeneralize to, you know, all other situations. So maybe they experienced rejection in, you know, class at school one time. So then they start over generalizing and expecting rejection. In every classroom, in every setting, people with high sensitivity are easily thrown off kilter. They can become vulnerable a lot more easily. They may be more sensitive. I've. I've shared with you guys before that when I don't get enough sleep, I tend to be much more sensitive and, you know, moodier than, you know, say, my, my husband who, you know, if he gets five hours or if he gets nine hours, he's pretty much the same. He's one of those people who's really, you know, level. But people who are high have high sensitivity. It's important for them to identify their physical, environmental, emotional, and cognitive vulnerabilities that can set them up to be more likely to have an exaggerated reaction to something. And people with high sensitivity often have no emotional skin and, and that to say, you know, we tell people they need to be thicker Skinned in in order to deal with life on life's terms. Well, people with high sensitivity basically have no em emotional skin. What is said cuts very, very deeply. They have difficulty maintaining those emotional boundaries. They also tend to have high reactivity. You know, guess what? When they are hyperv vigilant, when they're over generalizing, when they're expecting bad things to happen, when as when they were growing up or in prior situations when their reactions and feelings have been regularly invalidated. So they always feel like they've got to prove themselves or protect themselves because nobody else will. Well, of course that is going to put them in a situation where they are on the precipice of fight or flight a lot more often. They're going to be more vulnerable because they're going to feel more vulnerable. Environments are going to feel incredibly less safe that to them than to other people who have experienced validation and who don't feel the same gush of adrenaline and emotions and disregulation when something happens. People with emotional disregulation and high sensitivity tend to have slow de escalation. They are persistently hyperactivated. It takes them a lot longer to return to baseline after they get upset. Even when they are, you know, receiving validation and that sort of thing, it takes their body physiologically longer to respond and bring them back down into a rest and digest sort of place. And as I mentioned earlier, a lot of times people with emotional dysregulation are in invalidating environments. They may have grown up in them, they are probably still in them because a lot of people don't understand that in cases where people have high sensitivity, in cases where they are emotionally disregulating because of prior trauma for whatever reason that is causing their emotional disregulation, this is not a conscious choice. They are not malingering. They are not quote milking it. They are not intentionally overreacting. Their HPA axis actually goes into super overdrive. And when they are told that they're overreacting or to get over it, if they could, they would. You know, nobody wants to feel like that. But people, instead of providing them tools, instead of providing validation and assistance, you know, parents, caregivers, loved ones, whatever, they just often dismiss the person's reactions and distress. The emotional reaction people, when they get upset, often have a hyper awareness of stimuli in the environment. When you grow up in a. An invalidating environment. When you grow up in an environment, you know, you're hypersensitive. So everything can feel overwhelming or painful. Guess what? That feels pretty dagum. Unsafe. And if you're never taught the tools to handle that, then you may start feeling, you know, persistently unsafe. That's traumatic, which creates that hypervigilance. So people start becoming more perceptive of stimuli. They start trying to notice things as quickly as possible because they feel unsafe. They perceive a threat when they, they feel unsafe, then cognitively their brain is telling them, hey, guess what, you're unsafe. So they start having thoughts of being out of control, of being unsafe, of being, you know, threatened in some way. And it may not be a physical threat. It may be a threat of rejection or failure or loss of control. Thinking about somebody, for example, who has borderline personality disorder, one of the key factors in BPD is switching from, you know, love to hate. Switching between dichotomies very rapidly. Well, why does this happen? Well, the person wants to feel happy, they want to feel loved. But then they catch this micro expression or something that tells them that they may experience rejection or failure or loss of control. It puts them on the defensive. When they get on the defensive, their physiological reaction is to kick into that fight or flight mode. So they have that all hands on deck response and they want to fight or flee. The actions they take, whether it's yelling, withdrawing, drinking, whatever that they do, is often can be seen and it often makes sense from a survival perspective. If they believed that they were unsafe, you know, in what way did their behaviors protect them? I have a picture, it's kind of a blurry picture of my dog Brewster here. And Brewster was a rescue. And I don't understand, I don't know what happened to him his first 18 months of life, but he is a very hyper vigilant, hyper aware dog. You know, if anybody even has an iota of stress hormones oozing from them, he starts to get very anxious and hyperactive. And we may see this in, in children, in people, but with him, you know, I know his past and is one of those things that we've had to work on with him and you know, help him understand as a dog that it is a safe environment because, you know, being £85, you don't want him getting too stressed out. So let's talk about primary invalidation. When people who are highly sensitive and generally for a lot of people this is an inborn trait, but for some people it may happen as a result of trauma, as a result of developing some level of post traumatic stress issues. You know, I'm going to stop short of saying disorder or, or exposure to adverse childhood experiences which cause trauma. The person's HPA axis. The person may start to feel that their environment is unsafe for some reason and their HPA axis may start to become dysregulated. Okay, when that happens now they are into that place where they are hypervigilant, hypersensitive and may experience that exaggerated HPA axis response. Well, a lot of times parents, caregivers, don't understand what's going on when this is happening with their 5 or 6 year old and or even their 14 or 15 year old. And they may ignore it, dismiss it, telling them, tell them they're overreacting or react in ways that are unhelpful. Instead of validating where the person is at, where the child is at emotionally, physically, helping them feel safe, helping them figure out how to cope with that dysregulation, they may send them to their room until they can calm down. We've talked in other classes about the six, I think it's six principles that facilitate effective attachment and that's consistency. You know, a caregiver is there, is, you know, when, when is needed, the caregiver is generally always there. Consistency, responsiveness. When the caregiver is there, they are actually tuned into the child. They are responsive to the child's needs at, you know, when that happens, the caregiver provides attention. They are not just reactive. When the kid needs something, they'll get up off the sofa. They are actually proactively attentive to the child, which helps develop the child's sense of self esteem. The child says, hey, you know, caregiver wants to spend time with me. Cool. V stands for validation. What is threatening to us is, you know, may not be threatening to a child and vice versa. Children have many, many fewer experiences upon which to judge whether something is threatening or not. So a lot of times things that are scary to kids, like the monster in the closet, that doesn't exist, that we know that, but the four year old may not. So it's important that we provide validation, recognizing how they feel and what their thoughts are and then helping them figure out how to deal with it. You know, validate that. Hey, I, I hear that you're afraid because you think that there's a monster in the closet. What do you think we should do about that? Or how can, how can I help you? Sometimes when you are being consistent and responsive, attentive, validating and encouraging, you can also teach coping skills. You know, those parents are the ones that will get down, you know, eye to eye with the kid and you know, say, okay, let's take a Deep breath together or whatever the case may be in order to model for the child and walk the child through learning new skills. That generally doesn't happen in environments where there is primary invalidation, where the caregivers don't understand how to be reactive to the child or why the child is reacting so strongly, so they dismiss it as attention getting. So in these primary invalidating environments, caregivers dismiss emotional reactions as invalid. The child is mocked or shamed for their emotional response. They're told they're overreacting just to stop talking about it. Whatever. The child is not taught self soothing and de escalation. The caregivers do not recognize the child's distress as real. Therefore they don't take the steps to teach them how to handle what's going on. The child is not taught mindfulness to notice what's going on and, and enable, and enable them to articulate ahead of time. You know, I'm feeling kind of anxious about going to the pediatrician today. And the child's not taught effective cognitive processing. Looking at the facts of the situation. Secondary trauma and invalidation coping skills can be overwhelmed by trauma or intense stress leading to a high alert raw status. You know, we talked earlier about when people experience trauma or intense stress. They perceive their environment as unsafe and they typically overgeneralize and it's just like everywhere, all the time life is unsafe. So they are hypervigilant and on that high alert status. Many people don't receive necessary, necessary support during these times and may be shamed for being weak or needy. It's important to help our patients who may be emotionally dysregulating and their family understand that crisis is a normal response to an abnormal event. And in the case of a lot of people who are highly sensitive, things that don't prompt crisis in someone who is not highly sensitive may prompt a crisis in them. You know, we talked last week or the week before about people who are have autism spectrum disorders and or schizophrenia for example, and they have different sensory perceptions. What is painful to them may not be painful to someone who doesn't have disrupted sensory perception. Most humans are not inherently prepared to deal with crisis alone. So whether we're talking about a toddler who, you know, falls down and gets hurt at the playground or experiences some other kind of even worse trauma, or an adult, you know, generally crises are a time when we reach out and seek social support, we seek validation, we seek others to help us feel safer. What precipitates a crisis may vary between people based on pre existing stress or mental in adults especially, or older children. You know, if somebody's already experienced trauma, if they're already hypervigilant, then what precipitates a crisis may be a much lower bar than what precipitates a crisis for someone who didn't experience adverse childhood experiences or trauma. Likewise for someone who has a cognitive or behavioral health issue, or even a physical health issue that may cause chronic pain. For example, they may be in a state of chronic stress or distress, which means moving to the state of crisis. Moving to the overwhelmed doesn't take as much. You know, they may more easily experience crisis. And I want you to think of it kind of like a pressure cooker. You know, people who are haven't experienced trauma, They've had just a storybook life, everything's going well. They don't have chronic stress. They have zero heat on their pressure cooker. They have zero pressure building up. But every time you experience a trauma or an adverse childhood experience that doesn't get effectively resolved or whatever, it may add pressure to that pressure cooker. If it's not effectively with now, that's the key. If it's effectively coped with, then it takes the pressure down. But if it's not effectively coped with, it just keeps building up that pressure. So if someone has trauma and chronic stress and chronic pain, then they've got a lot of pressure on that pressure cooker and it's not going to take a whole lot more to blow the top off. The result is people. When people experience invalidating environments with and and they are highly sensitive and they emotionally dysregulate, they may develop frantic efforts to numb, withdraw or protect. And numbing can take the form of addictive behaviors. Withdrawing can take the effect of sleeping, depression, self isolation. Protection can take the form of, you know, any of those. But it can also take the form of aggression or verbal or physical aggressive behavior. So fight or flee. People learn that who they are and how they are results in rejection. Just let that sink in for a second. They learn that not only who they are, but how they are, how they react, how they act results in rejection. This leads them to avoid the threats. Well, nobody likes to be rejected. So at a certain point, they may start building up walls, emotional walls and or physical walls. They may withdraw. They may avoid thoughts, feelings and sensations that lead to invalidation. But since they're hypervigilant and overgeneralizing, it starts a snowball effect. So eventually, it's like most people, most places, most things, most times may be threatening. So they become progressively more withdrawn and or reactive. They become progressively more sensitive and prone to dysregulation. So what are the assumptions about clients? Well, in dbt, Linehan asserts that clients are doing the best they can. Well, I hope we all believe that already they want to improve. If they're in our office, you know, chances are they want to improve. So we want to believe that they cannot fail at dbt. And that is a challenging little statement there. And what I want you to take from that is that DBT is designed to help them understand themselves and understand what leads up to their reactions and their actions. But DBT is not a one size fits all. We cannot say that, you know, you do these six things and voila, you'll start feeling better. So when a client experiences a setback, experiences an episode of dysregulation, then we want to explore it with them and learn from it. DBT is a learning experience that helps people understand more about themselves. So while any particular intervention in DBT may fail for the client, the client is not failing. What we want them to do is get curious and try to understand, why did that not work? Why did that not work for me? And what might work better? Another assumption is that clients are existing in an unbearable state. You know, think about feeling that frightened feeling that unsafe feeling that nervous tense all the time, and having those episodes of dysregulation, having those gushing, you know, stress hormone gushing episodes. Think about how exhausting that must be. People really don't want to be miserable. They may not know how to change. They may be quote, and I don't like this word, but I'm going to use it anyway. They may be quote resistant. And, and much of that is often because they've tried to change before and they haven't been successful. So they're terrified to try again. They are terrified that they are going to fail again. Which is where we go back to. They cannot fail at dbt. They are not failing. The technique may not work for them, but we need to look and figure out what's working. Clients need to learn new behaviors in all contexts because generally by the time they've gotten to this point, they have done a whole lot of overgeneralizing. They're going to learn, need to learn the mindfulness and self regulation skills at home in under stressful situations, under sad situations, et cetera. Clients are not responsible for all of their own problems. We know that growing up in a, you know, dysfunctional household can create problems. So, you know, kid didn't choose that they're not responsible for all their own problems, but they are responsible for all of their own resolutions. And I do like this. It seems unfair. If they didn't create the problem, they shouldn't have to create the resolution. Well, that might be. However, that's the way it is. And this can be seen as empowering because it helps clients see that, okay, what happened or the problems that are happening now, Some of these I'm not responsible for. But let me look at what parts I can change and then decide how I'm going to best use my energy to address the situation. The past. My problems do not have to continue to control me. I have the ability to find resolutions and solutions to them. And clients do need to be motivated for change. They need to want to do this. Because DBT is an active process, counseling is an active process. In terms of therapists, clarity, precision and compassion are of the utmost importance. We need to be sensitive to what's going on with, with our patients and how terrifying the world must be. You know, there's a lot of empathy that goes along with this. The therapeutic relationship is between equals. DBT or therapists can fail to achieve the desired outcome. So again, the client is not failing. What has happened is this approach may not be working for them, or the way we are applying it may not be working. So it's important to empower the client again to get curious, start to understand why some things work and some things don't. Therapists who treat patients with pervasive emotional dysregulation need support. If you've worked with clients who have borderline personality disorder, and sometimes clients who are in early recovery from addiction, you know that their emotional swings can be significant and they can be frequent. And it can be exhausting to basically walk with them. You know, you're, you're walking with them as they're swinging back and forth sometimes. So it's important to recognize that you need to get support. Another premise of DBT when you're using the actual modality is that there are consultation groups. And in these consultation groups, people who are not working directly with that client are able to give objective feedback about potential motivations for the client's behavior, about what seems to be working, and potentially about ways that they may see the client trying to manipulate the therapist. Clients don't do this out of malice. Clients do this out of self protection. If they feel a need to protect themselves. If they fear abandonment, if they fear rejection, for example, they may act out in certain ways to manipulate the therapist. So it's important to examine that and say, okay, well, you know, maybe you're thinking about discharging the client or transferring the client to a lower level of care. Then all of a sudden they have a resurgence of symptoms. You know, let's look at what does that mean and how could this transition be undergone in a slightly different way in order to not trigger that, that fear of abandonment, that fear of being out of control. So core mindfulness uses the rational or cognitive mind, the emotional or feelings mind, and the wise mind, which is a combination of the prior two, intuition and interpretation. You know, ultimately you want to take what you know and combine it with what you want to try to find the best possible outcome. Mindfulness itself. Mindfulness skills help clients learn to have effective non judgmental observation and description of their experiences, their thoughts and their feelings. So if they're angry, okay, they're angry. If they're stressed out or worried, okay, they're stressed out, they're worried. Not following it up with I shouldn't be or, you know, some other dismissal, some other invalidation, just noting their physiological and cognitive and emotional reactions and saying, okay, this is how I am right now, Then taking that state, that mindful state, once they recognize where they are, identifying what is the objective evidence for and against my thoughts and my feelings right now, you know, what is. If I'm terrified, we'll go back to that snake that we talk about a lot. If I'm out hiking and I see a snake in the, in the path and I'm terrified that it's going to kill me, okay? So I accept in the moment, not judgmentally, that, hey, I'm terrified right now. I don't tell myself I, I'm overreacting. I don't tell myself I shouldn't feel that way. I say, all right, this is how I feel. So what is the objective evidence for and against my belief and ultimate reaction of fear that I am in danger? What is all the evidence? The big picture, okay, even if it does, even if the facts support the notion that this is a dangerous snake, maybe it's a water moccasin. What is the big picture? Well, you know, in this case, it's sunning itself on the path. Likely, if I back away, you know, it's not going to chase me, if I don't poke at it, if I don't get near it, you know, it's probably not going to, you know, just pursue me and, you know, do horrible things. So getting all of the evidence, you know, maybe it's poisonous, okay? If it Is, you know, is it guaranteed to bite me? Well, no, you know, if I don't start poking at it, chances are it's not going to mess with me. And then what are my feelings about the event? Examining how I feel in this situation and noting how their feelings change over time. So there are four options when faced with a problem. Tolerate the problem, change your beliefs about the problem, change the situation, that is, solve the problem, or just stay miserable. So in the case of tolerating the problem, sometimes it's one of those situations, you know, maybe it's a unpleasant family member that they're just not going to change and you decide that, okay, you know what, this is not worth my energy to let this bother me. Tolerating the problem, changing your beliefs with that same family member, you may say to yourself, wow, you know, instead of seeing them as being attacking and critical and mean and hateful thinking, wow, for them to act that way, they must feel very scared or it must be very dark inside their head. So you're changing your beliefs about that person or that situation to make it easier to tolerate the situation. You can change the situation, maybe choose not to spend time around that person or, you know, at family reunions and stuff, have a plan in place so you don't have to spend a lot of time around that person even if they're there. Or you can just choose to keep doing the same thing and stay miserable and dread every family reunion. That is a viable option. Skills that can help people tolerate distress. TIP is a mnemonic device and it addresses physiological arousal. So temperature. When you expose yourself to sensations, you know, with cold, cold water on your face, for example, or an ice bath for your hand, that will trigger, yeah, it's, you know, that change in sensation may trigger that HPA axis a little bit, but it almost resets itself because then the body starts paying attention to that sensation instead of the thoughts. Now, obviously if somebody is in danger, you know, we want them to get safe. We don't want them to splash cold water on their face in the face of danger. But, you know, that always comes up in the YouTube comments, you know, obviously get safe. But in order to help down regulate, sometimes it's important to sort of trick that HPA axis into refocusing and going, oh, you know, I am excited. You know, I'm, I'm kicked off because of the cold water. And then when, you know, your face starts to warm up or you pull the hand out of your hand out of the ice bath and it starts to warm up, your Heart rate starts to go down. It's a really weird thing, intense exercise, push ups, sit ups, running that can, you know, do the same thing. Because then your brain says, oh I understand why my adrenaline is pumping right now because I'm running. Hey. So then when you stop running, guess what? It downregulates some or progressive relaxation and slowing your breathing, slowing your will automatically trigger that rest and digest and slow the heart rate. So there are three ways that can be helpful to not only distract from the immediate problem. You know, if you're sprinting, if you've got your hand in ice water or, or you're focusing on progressive relaxation, you're not going to be thinking about that problem or at least not focusing on it. And it also tricks your brain and sort of explains to your brain why your heart rate is active. So when that stimulus goes away, it triggers the rest and digest. Accept and improve are two other mnemonic devices that Linehan proposed and they stand for different distress tolerance activities or things that you can do. The first one in accepts is activities doing things that can help a person distract themselves. Now we're not saying distract forever. The goal of distress tolerance is to help people get into their wise mind so they can think clearly to get out of that adrenaline haze so they can think clearly about what are the facts in the situation, what are my options and make a reasoned judgment. So activities generally are ones that are help the person feel happy and or distract them. I've shared with you guys before when I, when I get stressed out sometimes I will go outside and do landscaping. And my kids know the level of my stress based on the power of the tools that I'm using. So hand shears were good, but if I've got the chainsaw out, they give me some space. Contributing to the welfare of others can help you focus outside of yourself for a few minutes or for a little bit longer than that. So when you come back to addressing your own situation, again that adrenaline has bled off and the HPA axis has down regulated. You can compare yourself to others how other people are doing, you know, recognizing, you know, some people are doing worse than you or you can compare yourself to your old self. So how you reacted to to similar situations six months ago. Well, I'm not necessarily hitting the mark yet, but I'm not reacting as strongly as I did six months ago. So helping people see their progress opposite emotions helps people trigger. Obviously the opposite emotions you're going to be triggering are happiness, joy, those sorts of things. And that is going to trigger the Release of dopamine, serotonin and calming neurochemicals. So doing things that trigger those opposite emotions, whether it's music or funny videos or whatever it is. I encourage people to keep a playlist of comedians that they like on their mobile device or on YouTube or both. So they always have something they can go to. Pushing away is another technique. And you can encourage people to build an imaginary wall between themselves and the situation, or they can imagine themselves pushing away the issue or the thoughts with all of their strength. I mean, sometimes this is one that I use. Sometimes I will actually find myself, you know, telling. Telling the wall, telling the air to talk to the hand. But pushing away can be helpful because it gets you out of that frantic loop. What you're trying to do is break that frantic loop so then you can step back and more effectively analyze the situation. You can also just block the situation for your mind. Each time it comes up, actually tell it to go away. Say, you know what? No, I'm not thinking about this right now. Pushing away only helps for so long because a lot of times as soon as you stop pushing, it tries to come back. So a lot of times it's helpful to combine some of these skills. Thoughts are something else that you can do. And obviously thoughts can be empowering thoughts about, you know, your ability to handle the situation. They can be positive thoughts about things that are going well, or they can just be erroneous thoughts, like counting from. Maybe the person just starts counting by fives. You know, when you're trying to do that mental math, at least for me, that takes just enough of your focus that you can't focus on, you know, the other stuff. Singing. Sometimes just breaking into your favorite song. The 10 game. Finding 10 things that are green. Finding 10 things that are moving. You know, it occupies children. Went well used to back in the 70s. It occupied us when we were in the car. It can do the same thing when you're experiencing distress because it takes just enough attention that it helps tame that monkey mind. And finally, five, four, three, two, one. What are five things that I see, Four things I hear, three things I smell, two things that I can feel, and one thing I can taste. Or as we talked about on the last slide under a couple slides ago, under tip Sensations, Cold is one of my favorite. Holding ice cubes, putting your hand in cold water. Some people like the rubber band trick where they wear a rubber band and they snap it on their wrist. I've never found that one to be particularly effective for people, but whatever smells can also Be helpful. Especially pleasant smells, like if you smell roses or lavender or something and it just momentarily takes you away. We know that essential oils can trigger the release when you smell them through the pituitary. It can trigger trigger the release of dopamine, serotonin and gaba. So smells can also be helpful for sensations you probably want to avoid. Taste, that just creates a whole other set of problems. IMPROVE stands for improving the moment. You can use imagery if you're dreading. I have a doctor's appointment this afternoon and I'm dreading going to the doctor. So a happy place for me would be, you know, while I'm sitting in the waiting room, I might think about, you know, going to my garden and what I'm going to do in the garden when I can actually use my left arm effectively again. But thinking about something like that or going hiking, just remembering a happy place and trying to use as many senses as possible to get there. What did it? What did I smell when I was there? What did I feel? What does it feel like to be hiking in the woods? You can also imagine successful completion if somebody's stressed about having a conversation with a significant other or job interview, encouraging them to envision successfully completing that task. Find meaning in the situation and you know, some people call it making lemonade. All right, this happened. It sucks. I don't like it, but what can I get out of this? You know, maybe it's only I will learn how much more courage or how much stronger I am after getting through this prayer or radical acceptance. You know, not everybody's down with praying. I'm understand that. And, but radical acceptance can also be recognizing that it is what it is and some things can't be changed and you need to give them over to the universe or to your higher power. Relaxation skills. Slowing down your breathing can help trigger that rest and digest and help people get into their wise mind, taking a mental vacation, the timeout and encouragement, having them create a script, even that they keep with them, of positive and calming self talk. And, and sometimes people are, as Patricia points out, very attached to that angry story. And distress tolerance is difficult. And in those cases, you know, we look at what is motivating them. What is that behavior saying, why are they afraid? You know, fear, why are they afraid to let go of that angry story? And you know, that can help you probe where some of those fears, where some of those threats are coming from. Because yeah, if, if they are feeling unsafe, if they are feeling fearful, then they're not going to want to tolerate this Distress, they're not going to want to go into rest and digest because that is a unhypervigilant place. That is a potentially threatening and vulnerable place. So always, you know, when, when people have difficulty enacting some of these tools, then you want to step back and go, okay, what is that saying? What is that behavior saying about what's going on with you? Emotion regulation, the goals are to identify and label and understand their emotions, try to figure out where they're coming from. You know, why is it that that made me anxious? Well, it could have to do, you know, psychodynamic perspective could have to do with something from my past and it reminded me of that. So it makes me nervous now. When I was knee high to a grasshopper, I had my tonsils out and the person who took my blood, whoever that was, was very rough and not very good at it. And ever since then I have been terrified of needles. And you know, I've had some very good phlebotomists and nurses over the years and it didn't hurt. But whenever I think about having my blood taken, my anxiety, at least for a moment, goes up and then I have to use some of those tools and walk it back down and go, you know, what you're expecting something that you don't know is going to happen. Emotional regulation tools can decrease unwanted emotional responses and decrease emotional vulnerabilities. So the skills are identifying and labeling their emotions and their functions. What is the function of guilt? You know, what is the function of continuing to beat yourself up for something? What is the function of anger or fear or even happiness? We want to help people improve their self awareness so they notice especially the dysphoric emotions. They notice the early signs of them, so they can intervene sooner rather than later and start conducting a behavior chain analysis so they can explore what led up to this. What vulnerabilities happened that increased the pressure in my pressure cooker that ended up leading to this, you know, dysregulation. So cop copying is policing your own thoughts. Check the facts. Consider opposite actions. So for example, if you want to scream at somebody, maybe the opposite action in that moment would be to take a breath and then problem solving. Always make sure you're safe. You know, if something's going on and you're in danger, get out of the danger first. Reduce vulnerabilities. A, B, C, P. Accumulate the positives. This helps people develop an attitude of gratitude. When we are feeling hyper vigilant, when we're feeling distressed, a lot of times we have difficulty noticing the positive because we're so worried about stuff staying safe. So accumulate the positives. Help helps people see the bigger picture Build mastery Set micro goals to develop a sense of self efficacy make take note of the things that you are good at to develop that sense of mastery and self control. Cope ahead of time if you're going into something and you're expecting it to be stressful, envision it, plan for how you're going to cope it, cope with it, and maybe even do a little imagery to see yourself effectively coping and prevent physical vulnerabilities when you're sick, when you're tired, when you are have too much nervous energy when you are poorly nourished or even dehydrated, it can make you more emotionally reactive or and it can also impair cognitive abilities, especially in the case of dehydration. So it's important to take care of the physical self in order to again reduce that pressure. In a behavior chain analysis, you're going to have the person name the behavior or the reaction that was the problem. Identify the prompting event so maybe they screamed at their boss. What was the prompting event? Their boss wrote them up. Identify the behavioral links leading up to that what sensations, thoughts, events and feelings happened leading up to that situation? What are the short term positive and negative effects from screaming at their boss? What are the long term positive and negative effects from screaming at their boss? And address the problematic links with skills. So if they recognize that they were, you know, already had some vulnerabilities, it's important to figure out how to prevent those in the future. It's also important to look at maybe they their boss walked into the office, they expected bad things and then they started to spiral. Okay, so what distress tolerance skills are might be helpful for them in those situations? Over 10,000 people come to BetterHelp every day looking for a counselor. Better Help makes it easy for you to move your practice online and focus on what you love most. Helping others better helps easy to use platform, takes care of referrals and billing and provides a secured platform to communicate with your clients. Join more than 18,000 therapists at Better Help Helping to improve people's mental health and lives. Dear man is another mnemonic from Linehan. Describe the situation. Assess what's going on. Look at the facts, assert yourself, state how you feel, your wants and needs, reinforce what you need and reinforce other people when they respond appropriately. Practice mindfulness to be aware of how you are in the situation, how you impact the situation, and how the situation impacts you. Appear confident you know, it's easier to handle situations when you hold yourself confidently and negotiate. Be willing to, you know, not get your own way. And these are great skills for interpersonal effectiveness and they play off in in many ways the habits of highly effective people. You know, synergizing begin with the end in mind creating win wins relationships with others. Give when you're interacting with others. Helping people learn how to be gentle, interested, validating and have an easy manner in your relationships. A lot of times people who experience emotional disregulation tend to be perceived and tend to be intense and that intensity can be overwhelming for some people. So encouraging them to have a an easier manner in in their relationships, not demanding that they get their own way all the time. Another mnemonic is their relationship with their self. And that's fast. Be fair with yourself, you know, recognize what you do and don't have control over. Criticize yourself like you would criticize others. But don't hold yourself to unrealistic standards. Be fair. Avoid apologies for things that are not your fault. Stick to your values and be truthful. In terms of treatment for dbt, there's a progression. There's a stage wise progression. In stage one we're helping people move from behavioral discontrol to behavioral control. Now this is behavioral, not emotional. So what we want to do is help them decrease self harming behaviors and that can include addiction. By increasing self care we're going to help them decrease therapy, interfering behaviors or quote resistance by increasing motivation and participation. So we want to understand where that quote resistance is coming from. What is that behavior saying? Why are they afraid to afraid and unmotivated to move forward and do these things and generally it comes back to some level of fear or uncertainty, decrease the quality of life interfering behaviors or vulnerabilities. So we want to decrease self harm, increase self care, increase quality of life behaviors like eating nutritiously and doing things they enjoy. We want to increase behavioral skills such as core mindfulness, helping them become accurately aware of how they feel in the moment, using their distress tolerance skills when they start to feel distress, practicing interpersonal effectiveness and emotion regulation and also practicing active problem solving which will help with later on self management. As they start to figure out that hey there are some problems I can solve and recognize their efficacy and agency in situations it greatly increases their feeling of safety in the world. Stage 2 We want to help people moderate emotions from excruciating and uncontrollable to modulate it. We want to decrease intrusive symptoms, avoidance of emotion with withdrawal, emotional Dysregulation, self invalidation and their mood dependency of behaviors. So we really want them to pay attention to what some of those things are like intrusive symptoms. When they hear the hecklers in their head, we want to encourage them to note and make those hecklers address those hecklers in terms of self invalidation. We want them to notice when they are using invalidating language, when they're being mean to themselves, and increase self validation and compassion. We want to help them create smart goals. They're specific, measurable, achievable, realistic and time limited. People are not going to start DBT and suddenly not have any more, you know, episodes. Whatever their episodes consist of, what we want to do is decrease the frequency and the intensity of those episodes gradually. We want to see small, measurable progress. Vitals to success is another tool that people can use. Validate, validate their feelings, their they feel, how they feel. Imagine the possibilities. What could I do in this situation to make it better or to improve what's going on? Take small steps. You know, every day is not going to be a leap. You know, what's one small step? What's one small thing I could do today to improve the situation? Applaud yourself, lighten your load. You know, a lot of times people who are emotionally dysregulating also are under chronic stress. So encouraging them to address that and not set themselves up with a pressure cooker that's already ready to pop the top off and sweeten the sweeten the pot by adding rewards for successful even having a successful hour or a successful day. Encourage them to be kind to themselves. 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. DBT seeks first to help the person replace self defeating behaviors with self care behaviors. Emotion regulation and interpersonal effectiveness are addressed in the second phase of treatment. 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 and develop a more effective, compassionate and supportive relationship with themselves as well as others. Remember, not every tool is going to work for every person. So encourage them to take an eye of curiosity or an attitude of curiosity because it will take some experimentation to figure out what works for them. Are there any questions? I know we went through a ton of stuff in this presentation. There is a lot to dbt, but there are a lot of skills like distress tolerance skills and vulnerability prevention that can be super helpful. For more information if you want to go deeper into those tools, I do have multiple videos on the YouTube channel that go in depth into distress tolerance, emotion regulation, interpersonal skills, and problem solving. So have a great day and I will see you on Thursday.