Master DBT Skills for Managing Distress | LPC & LCSW CEUs

Welcome everybody to today's presentation on dialectical behavior therapy skills. This presentation is based in part on Doing Dialectical Behavior A Practical Guide by Kelly Koerner. This is one of those books that if you want to do dialectical therapy as a practice, not just look at some of its tools, it's definitely a must read. Then it's also based in part on dialectical behavior therapy skills, workbook, DBT Made simple and DBT for Substance Abusers, which is an article that was published by Marsha Linehan. So the links to those are in your class, but just give you an idea about sort of the breadth of what we're going to be looking at today. In the short time that we have together, what we're going to do is take a look at why DBT was created. We'll look at understanding emotional regulation, dysregulation and regulation. We'll identify DBT assumptions about both clients and therapists and we'll explore skills to help clients learn distress tolerance, emotional regulation and interpersonal effectiveness. As an aside, we're taking or I've taken the information from this course and combined it with a bunch of other information to make a six hour online course that will be available by the end of the week. But for now we're just going to hit the highlights in the one hour introduction. So why do we care? Why do we want to learn about DBT skills and DBT tools? Many of our clients experience emotional dysregulation or the inability to change or regulate their emotional cues, experiences and responses. Think for a minute about any of your clients. If they're depressed, if they're anxious, if they've got anger management issues, something is going on with their emotional state. They're not able to either get unstuck or control their behavioral responses. So they may be engaging in self injurious behavior, risky behavior, or addictive behaviors they've tried to change and failed, leaving them helpless and hopeless. A lot of our clients, we try to fit them in. Not that we should, but we do try to fit them into this box. If you're depressed, then we're going to look at these things. And one thing I hope you get from these webinars is the fact that every single client is different and there is no box that we can put them in. And you're like, well then how can you do group therapy? Group therapy is really awesome because you can tailor. And that's part of the challenge to doing psychoeducational group therapy. Tailoring the tools and helping people tailor the tools to meet their individualized needs. But they can get feedback and they can see how different tools can be modified just a little bit to fit different individual needs and untenable emotional experiences that lead to self preservation behaviors such as addiction, you know, to kind of numb the pain, to give them a distraction. Non suicidal self injury with talking about cutting, we're talking about those sorts of things. And then even those suicidal behaviors, at a certain point the pain has got to stop. So some people may end up going as far as trying to stop the pain by stopping their existence instead of hurting anyone else. People with emotional dysregulation have high sensitivity. So these people tend to be highly hyper vigilant. They're aware of a lot of things that go on. Now. This was originally created, and I want you to really kind of think about it was originally created as a tool or a protocol to use with people with borderline personality disorder. What do we know about people with bpd? They grew up in really ineffectual environments, so they had to be hyper vigilant to everything that was going on for their own safety and security. So you have someone who either by nature or by nurture, is hypervigilant. These situations have been overgeneralized. The dangerous situations have been overgeneralized. So the world tends to seem more negative and dangerous and out of control. People with emotional dysregulation are easily thrown off kilter because they often have a lot of vulnerabilities. They're not eating well, they're depressed, which is contributing to them not being able to sleep well. They can't focus, yada yada. We've talked about vulnerability abilities. One thing that Dr. Koerner talks about is no emotional skin. And she likens it to someone who has third degree burns. And every single thing, even the air, when it touches it, is just excruciating. There's no middle ground. There's no, oh, that's kind of uncomfortable. It's either not hurting or it's excruciating. People with emotional dysregulation are also highly reactive. So they're hypervigilant. They're aware of everything that's going on. And then every time something happens that sort of triggers their awareness, they jump into this immediate fight or flight reaction. Then they're slow to de escalate. So we're talking about situations in which someone is hyper vigilant. They're on edge maybe because of situations in the past or not. They have this sort of persistent fight or flight or frequent Fight or flight reaction. And again, I'll refer back to our adrenal fatigue class that talked about how the body can only stand to be all hands on deck for so long before it's just like, dude, I give up. And then the sense of depression and helplessness and apathy starts to set in. People who are, who have emotional dysregulation, really, they're either like flat and non existent in their emotions. They just can't even deal with it when they should, or they're overly reactive and then the person is in an invalidating environment. What would be a 2 to some of us on a scale of 1 to 10 as far as how distressing something is probably like an 8 to somebody with emotional dysregulation. Think about a time when you were really stressed out or you had a lot of vulnerabilities going on. Maybe you had a new baby at home so you weren't sleeping and your other kids were acting out. There was just all kinds of stuff going on and you reacted to something with an 8 that everybody else was like, that doesn't deserve that much of a reaction. That's a two. What's wrong with you? People with emotional dysregulation, that's their environment all the time. Everybody's looking at them and going, what's wrong with you? This is not that upsetting. So we need to help people understand that their experience is their experience. And it's not for me to say whether it's a two or an eight. For me it's a two. But let's look at why it's an eighth for you. So the emotional reaction, and this is obviously I didn't get red eye reduction on when I took this picture of Brui, but bless his heart, when I got him, he was a rescue. And he had such terrible, terrible abandonment issues and is so hyper vigilant even to this day. I've only had him like four months, but he's hyper aware of stimuli and people can be hyper aware of stimuli. So anytime somebody moves, he's up, he's looking, he's like, are you going to leave me alone again? When he perceives that something is changing when there's a threat, he goes into all hands on deck and turns into a survival sort of thing. He starts acting out. He goes and finds toys and brings them to me. Heaven forbid we should have to put him out in the garage because we have visitors or something. And it's, you know, climate controlled. It's not like it's horrible. But he Will sit out there and howl until I let him in or go out and tell him it's going to be okay. Now see, as a person, I'm going, that is not a valid reaction. He's like totally overreacting to having to spend 10 minutes in the garage. Whereas from his perspective, he's not overreacting because in the past, when he's been put in the garage, he's been left out there for days, weeks, months, who knows? I don't really know his story too well. Now I use that to kind of highlight the fact that people with emotional dysregulation, we don't know what their past experience was. What they're doing is trying to survive. Now they may be trying to survive a situation in their past, you know, when they were six. And we're going back to the abandonment discussion that we had the other day. But it's important to understand that all these things play in together. Something happens and the body's response system takes in these stimuli and it says, it's dangerous. It's not dangerous. What do we do with it? The brain decides fight or flight. And then they go into the survival response with treatment. What we want to do is help people be able to feel that feeling and not have to act on it right away until they can de escalate some and use a combination of assessing their cognitions and and deciding whether their perceptions are based on the present, the present moment, or the past moment. So primary invalidation. Caregivers dismiss emotional reactions as invalid. We just talked about that. The child or person could be mocked or shamed for their emotional response. We have all probably met parents or worked with parents who have children that are highly emotionally reactive, who tend to get frustrated and overwhelmed by the constant drama that seems to be presented by this child all the time. So the child is often not taught how to self soothe or de escalate. The parents just like really just let it go and go away, which is not helpful because the child doesn't learn how to deal with it. The child is not taught mindfulness to figure out, okay, what's causing this. And the child is not taught effective cognitive processing in most situations. In validating environments, if the child gets upset, even if it seems to be disproportional to whatever the event was, the caregiver will take the child in and say, okay, I hear you're upset right now, let's talk about it. And will walk the child through, maybe not thinking about it, but just being a good parent walks the child through this de escalation process and the cognitive processing secondary trauma or invalidation. And I'm putting this in here. Coping skills can be overwhelmed by trauma or intense stress leading to this high alert, raw status. Think about the people who were survivors of Hurricane Katrina or Hurricane Andrew. I come from Florida, so I think hurricanes, any big event that is ongoing, enduring and distressful, at a certain point you're on your last nerve. So anything could precipitate sort of a crisis. Many people don't receive necessary support during these times and may be shamed for being weak or needy. Sometimes nobody has the ability to cope and everybody's kind of decompensating at once, which is a lot of what we saw with Katrina. But other times there may be people that are functioning just fine and they don't understand why some other people aren't coping just fine and they see that as abnormal and want to distance themselves from it. It's important for us to communicate to people, because we already know this, that crisis is a normal response to an abnormal event. What was abnormal though? Is it this particular incident, maybe? Or is it the fact that this particular incident kind of was the straw that broke the camel's back on a whole chain of incidents leading up to it that were abnormal, that caused this person excessive stress? I was talking to a woman the other day who in the past six years has had a half a dozen significant losses, and I'm just like, wow, you know that that's pretty intense to have all those. And she's also starting her own private practice and everything else right now. And I'm just like, oh my gosh, I can't imagine the amount of stress this woman is going through. Most humans aren't inherently prepared to deal with crisis alone. We're kind of group sort of people, we rely on other people. So if we have this reaction and it's judged to be disproportionate and people kind of distance themselves from us because they see us as abnormal or dysfunctional, then we lose any social support that might have been able to serve as a buffer, which just kind of in turn feeds back and exacerbates this sense of hopelessness, helplessness and isolation. What precipitates a crisis may vary between people based on pre existing stress or mental health issues. And it also may vary with the same person longitudinally across time. What may be overwhelming today may not be overwhelming six months from now, because all of those prior stressors that I'm dealing with right now may have had time to kind of work themselves out so it's important that we help people understand that their reaction is their reaction. And let's just go from there. Let's not say it's bad or it's disproportionate or it's whatever. It just is. So the result of this sort of unpredictable reactivity results in frantic efforts to numb, withdraw, or protect. I need to numb the feelings out because I can't take this kind of pain. If you've ever had a burn that's had to be cleaned or even an open wound that's had to be cleaned out, you know, that's pretty excruciating. So thinking in terms of that, you can see why people would want to kind of get a little Novocaine withdraw. If this support system is invalidating, that adds extra pain and that's excruciating to be rejected on top of everything else. So a lot of times people withdraw, which eliminates any opportunity for social support. And it also exacerbates this sense of rejection. And they do this in an effort to protect themselves. People learn that who they are in invalidating environments, they learn that who they are and how they are results in rejection. So they avoid threats, they avoid putting themselves out there, they avoid making relationships because they're afraid of rejection. And they avoid thoughts and feelings and sensations that may lead to invalidation. I don't want to feel these things because then if I do and I communicate them, you may tell me I'm wrong. Okay, we've laid the groundwork. Now we see where this is a problem. So what do we do about it? Well, the first thing we want to do is look at some of the DBT assumptions about clients. Clients are doing the best they can given the tools they have at this present point in time. And I truly believe that clients want to improve. They wouldn't be in your office if they didn't want to improve for one reason or another. It may be an involuntary referral and they want there's a means to an end. They are in your office because they have hope that something can change and it will benefit them. They cannot fail at dbt. If they go through dialectical behavior therapy, the protocol, and it fails, then the protocol failed them or we as clinicians failed to implement it correctly. Now, today, again, we're talking today just about tools that are present in dbt, not how to do dialectical behavior therapy, the evidence based practice. I want to make that very clear. Clients are existing in what is for them an unbearable state. This pain has got to stop. They need to learn new behaviors in all contexts, not just at work, not just in their relationships. But they need to learn how to function and deal with life on life's terms in all contexts. So they can go to the grocery store, they can get in a traffic jam, they can be in a crowded airport, not feel like the walls are closing in on them. Clients are not responsible for all of their own problems. We know this. Some things they had no control over, but is causing problems for them. But they are responsible for all of their own solutions. And we're going to talk about the four options to problem solving in a few minutes. But they are responsible. They too choose to do something. And clients need to be motivated for change. Motivation. Choosing the more rewarding option out of the available options. Well, yeah, whatever they're doing right now is the most rewarding option they have available in their toolbox. So we're going to give them new tools, but then we need to teach them how to make those tools effective. If you just hand me jigsaw and say, okay, go about woodworking and whatever, I'm not a woodworker, but I'm not going to know what to do with that. So I may go back to using my circular saw or whatever the case may be, which may be very clunky. We need to help clients learn how to use these new tools. So it's more rewarding to use those than those old behaviors that just numbed out the pain or distracted them. Assumptions about therapists, clarity, precision, and compassion are of the utmost importance. We need to be clear with our clients about what's going on. Let's not speak in generalities. We want to try to avoid some of the Socratic questioning that we would normally do. We want to be clear about what we're getting at, what we want them to look at. We need to be precise. We need to not say, well, what is it last week that caused all the problems in your relationships? Well, if they had four different fights, that's four different things we need to look at. We need to be precise in order to identify all of the things that triggered. And we're going to talk about behavior change in a few minutes. So we need to be precise. We also need to be compassionate, even if we don't agree or we think that the reaction was disproportionate, putting ourselves in their mind, in their place, in their raw state. We need to be compassionate and go, okay, you survived it. You did the best you could. Let's take a look at what might have caused that. Why you made the choices you did and what you might choose better next time. The therapeutic relationship is between equals. DBT or therapists can fail to achieve the desired outcome, but the client can't fail. And therapists who treat patients with pervasive emotional dysregulation need support. It's important for us to remember that patients who are always in crisis are by their very nature, it's exhausting because they're always in crisis, which means we are responding in a crisis manner. Not that we need to get all upset and worked up, because that's just modeling the wrong thing. But there is a lot of energy that it takes for us to use the DBT tools, for us to model the DBT tools, and for us to help work the client out of their emotional state into one where they can use their wise mind. So the first step is core mindfulness. Until they figure out what's going on, they can't fix it. So we want to help them integrate their rational mind, their cognitive. This is what happened factual mind with their emotional mind. This is what it felt like into the wise mind. So you can take the facts, you can take your feelings, and you can say with what I know and what I felt, what would be the best interpretation of this or the correct, for me interpretation of this event at this point in time and what can I do about it? One of the things DBT talks about is the fact that truth is sort of subjective. What is a truth for one person may not be the truth for the other person, because we've all had different experiences. But we need to help people not underreact and stay in that cognitive mind. If you're a Star Trek fan, think Data. He was the AI that was kind of human, robot sort of thing, or. And we also don't want people to act in their emotional mind, acting solely on the basis of feelings and trying to make feelings facts, because feelings aren't facts, they're feelings. So we want to help them integrate these two things. And that is more difficult than it really sounds. So it takes time. Mindfulness, using effective non judgmental observation and description of experiences, those thoughts and feelings, and identifying what's the objective evidence for and against what's going on right here, how I'm feeling, what is all the evidence? Let's look at the big picture, not just one little aspect of it. And what are my feelings about this event? Getting in touch with what's going on inside their mind and inside their body is going to be one of the first steps. So I talked about Those four options. When there's a problem, you have four options. You can tolerate it, grit your teeth and bear it there. Sometimes you just can't do anything about it. Traffic jams probably can't do much of anything about it. Change your beliefs about the event. Instead of seeing a traffic jam as a waste of time and just a complete pain in your butt, you can see it as a time to check voicemail and maybe return some phone calls. Be productive. Make it billable. You can solve the problem or change the situation while you're in the traffic jam and stopped. Of course, looking at Google Maps to figure out where the next exit is that you can get off so you can change that situation, or you can choose to just stay miserable. And choosing to stay miserable is a valid choice. When clients make these decisions, we need to look at why was that? Whatever their option was, why was that option more rewarding than all the others? Why is it more rewarding sometimes to stay miserable? For some people, that's what they know. And they're afraid if they feel happy, then they may get disappointed and end up feeling sadder than they already do. Now, some people tolerate the problem because it's what they know. And change is hard and they would rather just tolerate it and deal with it and suck it up than have to muster up the energy to try to change whatever's going on. So again, we want to look and ask them or ask ourselves maybe because they may not know right away. The choice that you made, why was it more rewarding? Why did you choose that over the other three options? So distress tolerance. And we're going to talk about a lot of acronyms here. Acronyms are really important in DBT because it helps clients have sort of a drop back and punt. There are some worksheets. There are lots of worksheets online for dbt, but the acronyms we're going to hit here are going to be some of the highlights that it's going to be important for you to remember. Tip temperature. So you're tipping your physiological balance now. Temperature. I'm not necessarily advocating for this. You don't want to do it. If you've got a heart condition, you obviously don't want to suggest it to clients that have a history of child abuse, especially anything that involved drowning. So this one's a little tricky. One of the things I suggest to some of my clients instead of this is holding on to ice cubes. But the suggestion in the book, hold your breath, dunk your face in for as long as you can. Hold Your breath into a sink full of ice water. Then come up, exhale, inhale, and dunk again. Repeat as many times as you need until you feel calmer. Well, guess what? We've talked about combat breathing. If you are slowing your breathing, which you do if you're holding your breath, your heart rate is naturally going to slow. When your heart rate slows down, your brain says, oh, the threat's going away. Yippee. Yay. I can call off the dogs. There are other ways to slow down your breathing besides necessarily dunking your head. Holding ice cubes. One of the reasons that that can be helpful. Instead of cutting, the person focuses. It's a distracting technique. The person focuses on the PA because it is painful to hold onto ice cubes for a really long time instead of actually cutting themselves. But it also gives their body something to focus on. To go, oh, my heart rate is up because there's pain. When the pain goes away, I can make my heart rate go down. So we're redirecting the brain to go, oh, this is why the heart rate's up. It's not because there's emotional distress. It's because of extreme physical pain. Intense exercise increases body temperature, but it also increases the heart rate. When you're sitting still and your heart rate is 120 beats a minute because you are in a panic attack or in a state of panic, it's very, very uncomfortable, and your mind is going, I don't understand. You're not moving. Why is the heart racing? When you start exercising, which is why walking and getting those big muscles moving often helps, then the body gets less confused. It's like, oh, heart rate's beating fast because body is moving. Score. Got it. So when the person stops moving, the heart rate starts to go down. And this is true even if you're walking around. If you take a client out to walk when they're upset and you are talking about whatever the distressing thing is, I have found, without exception, when they come back inside, they can start to calm down a little bit more, and their heart rate naturally starts to go down. When they stop their physical exercise and then progressive relaxation, you're going to move from head to toe or toe to head, whatever you prefer. But head to toe is usually how we do it. Focusing on muscles, focusing on breathing, slowing breathing, relaxing muscles, forcing the body to relax. So this addresses physiological arousals. So temperature, intense exercise, and progressive relaxation, all of these serve as an ability serve the function of distracting the person from whatever cognitively or intrapsychically or Whatever you want to say is going on. And all of these either explain to the brain why the heart rate is going so fast and or help reduce the heart rate so you know there's something to be said for them. The important thing is for you to brainstorm with your clients when you get physiologically aroused, when you get upset and you are just, your hands are shaking, your palms are sweating, you're breathing fast, your heart rate's going fast. How do you calm yourself down? What works for you? And we're back to BRUI again. Another acronym is accepts in order to distract when there's emotional turmoil. So you can kind of let that adrenaline surge go because you have that initial fight or flight reaction. Then the body kind of goes, alright, let's reassess and see if there's still a threat. Get involved in activities that will help you distract yourself from whatever's going on. When kids get upset, you know, if they're getting stressed out because they're sitting in the lobby in the doctor's office and they know they're gonna get an shot, we give them something to do, we read a book, we talk, we play. Because then they're not focusing on the fact that they're going to get a shot. Contributing, contributing to the welfare of others. Do something nice for someone. Volunteer. Do something productive that gets you focused on someone else. Compare. Compare yourself to others who are doing less. Well, that doesn't work for everybody. You can also compare yourself in the present to your old self and focus on how much better you're doing now that compared to what you were doing six months ago. This doesn't always work, you know, these are options. Not everyone is going to work for every person. Emotions do the opposite. If you're feeling really sad, get a comedian. Get a go to YouTube and Google a comedian and watch a skit or two or 10. So you're doing something that makes you laugh, that makes you happy. Sing silly songs, do silly dances, go out. And there's very little I find more amusing than just listening to a baby laugh. If I'm having a really bad day, I will find those stupid videos of babies laughing at paper tearing and you can't help but laugh with them. Pushing away. Build an imaginary wall between yourself and the situation. Imagine yourself pushing it away, the situation with all your might. Or block the situation in your mind and each time it comes up, tell yourself, tell it to go away. So if you start thinking about something that is particularly hurtful, as soon as it comes into your mind and it comes into your awareness. Go. No, I am not going to think about that right now. Thoughts counting. Some people count to 10, 100. Whatever it takes to get through that initial rush. Some people sing. For me, I think I've shared before. I have this irrational fear of bridges. So whenever I drive over a bridge, I sing. And usually it's not songs on the radio. Usually it's songs I used to sing to my kids. I'll sing the ABCs. Something that doesn't require a whole lot of cognitive interaction because I'm doing pretty good just to get over the bridge. And yes, I know I should be over it, but I'm not. And that's just the way it is. The 10 game I like this one. Think of 10 things that you like the smell of. Think of 10 things that are green. Think of 10 things you see where we're going with this? And you can incorporate all the different senses with it if you go through multiple iterations of it. 10 things that you smelled yesterday. 10 things that you see right now. 10 things that you hear when you're on your way to work. This helps people focus on something other than what's going on in here. The 5, 4, 3, 2, 1 game is sort of similar to the 10 things game. Identify five things you see, four things you smell, three things that you can touch. Follow it all the way down. Sensations. Like I talked about on the last slide, sensations can help distract you from what's going on until you have a chance to kind of get through that initial adrenaline rush. Cold holding ice cubes, rubber band. And I don't like this one, but some people do. They put a rubber band on their arm and every time they start to perseverate on a negative thought, they snap it. Smells. Find some good smells, some smells that bring back good memories. Smells that you like. Maybe it's roses, maybe it's a specific perfume. Maybe you just go to Walmart and start smelling all the air fresheners. Whatever makes you happy. I do suggest avoiding taste because if you start using taste as distress tolerance, then you start moving toward emotional eating. I've seen it happen, so I would avoid that for most people. But if they just desperately want to go there, then you know we're going to go there. Because they are choosing how to distract from their cognitive or intrapsychic sensations. Improve the moment imagery. Go to your happy place, whatever your happy place is. Meaning. Find alternate meaning for what's going on. Now, this can be. Linehan refers to it as making lemonade. We all know how to do that. We don't, we're not necessarily the best at it, but try to make lemonade. Try to look for the optimistic meaning in whatever it is. Prayer. Now, even if someone is not religious, they can be using radical acceptance, accepting it is what it is and not trying to change it, just putting it out there for the universe. Relaxation. Always good to relax one thing at a time. And this isn't focusing on one problem at a time. This is focusing on something. We're talking about distress tolerance and improving the moment. So focus on one thing, like your breathing. Get your breathing calmed down. Once your breathing's calmed down, if you need to focus on something else, then move to maybe the tension in your neck, maybe you need to lower your shoulders and release the tension in your neck. Focusing on physiological things, focusing on other senses besides that abstract stuff that's in your head and in your emotions can help people tolerate the distress until they can think more clearly. Vacation. Take a time out. Sometimes you just need to get away from it for a few minutes. We've had times at work, I'm sure we all have, where you've just been like, you know what, I'm done. And you lock your computer screen, you get up, you walk out of the building. And obviously not if a client's in there, but you walk out of the building and do a couple laps around the campus. Then you're like, okay, I can deal with this again, just clear your head before you try to tackle whatever it is and encouragement providing yourself because you can't necessarily rely on anyone else. Positive and calming self talk. Now back to those stupid memes and videos that I love to death. There's one that has a kitten on a laundry wire and it says, hang in there. I love having those things on screensavers. It's juvenile maybe, but whatever. It makes me happy and it reminds me, you know, even when I'm not in a state of emotional distress, it reminds me, alright, keep on hanging in there. You got it. And it's got an awe factor too. So I always like anything with an awe factor. The goals of emotional regulation. So once you've tolerated this distress, you've gotten through that initial surge, that initial, I cannot take this pain or upset. Then we need to move into emotional regulation. Help people identify, label and understand their emotions and the functions of those emotions decrease unwanted emotional responses and decrease emotional vulnerabilities. So what they're going to do is identify and label emotions, their functions. I'm scared. Okay, you're scared. Tell me why. What's the function of you being scared. What do you want to do and what do you think is causing this scaredness? Improve self awareness through questioning like that, through talking it out, people will start to understand where their emotional reactions are coming from and they can choose whether or not to follow up with it. A behavior. I guess I didn't put it in there. A behavior chain analysis is the way you can go about helping people work through that. And that's a couple more slides. Cop we want to police our thoughts. Check the facts. Look at doing opposite actions. If you want to hurt yourself, look at being kind to yourself. If you want to run, maybe you need to look at staying and then look at problem solving. Reduce vulnerability through the abcp. Accumulate the positives Remember, vulnerabilities are those situations that happen leading up to whatever the distress is. Those are the things that make you more likely to be irritable, overwhelmed, angry, depressed, to get sad over anything instead of not. So we want to eliminate those vulnerabilities or reduce them as much as possible. So we're going to accumulate positives. Gratitude Journals Pictures. If, well, everybody has things in their life that they care about. Have those on your phone in little picture galleries. Have them as your screensavers. Have reminders around about why you get up in the morning. Build mastery so you have mastery of the skills you need to deal with the emotional distress and upset. Cope ahead of time. Plan for distressing situations if you're getting ready to go in for an annual evaluation and those things stress you out to no end. Rehearse it ahead of time. Plan on coping ahead of time. Figure out how you're going to react if it goes bad. Figure out how you're going to react if it goes good. Figure out how you're going to cope and Physical vulnerability Prevention Maintain your health. Chronic pain, Chemical imbalances, hormonal imbalances, those can all cause vulnerabilities or set you up. Make you predispose to feeling like something's an 8 when it's only a 2. Get plenty of sleep. When we're sleep deprived, it's a whole lot harder to deal with life on life's terms. And exercise. Exercise is a great way of releasing or using up some of that stress energy that you release during the day. Behavior chain analysis the first thing you do and a strict behaviorist will have slightly different explanations for how to do this. But just bear with me here. Name the behavioral reaction. What happened now? If you're thinking back to the ABCs, this is going to be Your c. Your consequence, what happened? Identifying the prompting event. ABCs. That would be the a. What was the activating event? Now this is where it differs a little bit. Then we want to look at the behavioral links. So you had the activating event and then there was this reaction. And in between there were automatic beliefs and we have that there, we have thoughts, but there were also sensations, events and feelings. Between what happened and your reaction, what sensations did you feel? Did you get flushed? Did you feel nervous? Did you feel scared? Did you feel sad? Did you have a twinge of something? What feelings were there and what events happened? Did you act out in a certain way? Did you scream? Did you yell what happened? Because these are all things that are going to go into what ultimately ended up being the behavioral reaction. Then we want to look at short term positive and negative effects of what you did, the behavior of the reaction. If you started screaming and throwing things, okay, you did. What was the short term positive effect to that? What was the benefit to that? Because that was what you chose, which means it was likely the most beneficial response you could come up with in your highly emotionally charged mind at that point in time. So what were the benefits and what were the immediate and the short term negatives? And then look at the positive and negative long term effects. In the long term, if you react to this upset by screaming and throwing things, what's the impact going to be? Are there any positive impacts? Are there any potential positive effects of this? And a lot of times it's no. But we want to ask the question just in case there are, because some people will have a positive and we need to address that. This is sort of, if you go back to motivational interviewing, what we think about when we're talking about decisional balance exercises address the problematic links with skills. If there were sensations or actions that exacerbated the distress, then we need to look at distress tolerance. If all of a sudden you had this immediate panic reaction and you couldn't breathe. We need to work on distress tolerance skills so you don't go to that point where you are just, for lack of a better phrase, in a tizzy, thoughts and feelings. If your thoughts get negative and start racing and your feelings are negative and anxious and worried and all those negative words. We want to look at emotional regulation. You know, if you can get through it, where you get through that initial rush and you're still having these getting stuck in the negativity, then we want to look at emotional regulation. Most of the time we're going to look at Both of them. And then the third component, once we've learned how to get through the initial flood, the initial all hands on deck call, and then people have learned to regulate their emotions and identify helpful responses. And instead of talking about good and bad, we want to talk about helpful and less helpful responses. Then we need to look at interpersonal effectiveness and how to interact with other people to make that validating environment exist. So we want to start with interpersonal and intrapersonal, if you will, effectiveness with oneself and then move to others. Describe what's going on, assess how you're feeling, what your reactions are, what the best next step is, assert your choice, reinforce the good things, be mindful, appear confident and be willing to negotiate. And yes, sometimes we have to negotiate with ourselves because there's something that we really, really, really want to do right now. And this is very true with people with addictions. A lot of times they really want to use. They know the long term consequences of use are not where they want to be. So they have to negotiate with themselves to say, alright, I really want to do this right now, but going to choose a different option. In their relationship with others, we want to encourage them to give, be gentle instead of being critical, harsh, which a lot of times is what they've gotten all of their life. Being gentle with other people, accepting them where they are, modeling how they want to be treated, be interested in, in what other people have to offer, what other people have to say and what's going on with them. A lot of people with emotional dysregulation can't handle their own life on life's terms. They can't even begin to handle anybody else's stuff. So a lot of times they appear disinterested, validate other people and their experiences and have an easy manner. You know, sometimes we get too intense. And if everything in your world is either a 0 or a 10, it's easy to be intense about everything. As they develop emotional regulation, things will be different. You know, they'll have fours and fives in there, but practicing that, not being intense and over the top about everything. And then in their relationship with the self, be fast, be fair with themselves. Not judgmental, just fair. Avoid apologies, stick to values and be truthful. 12 Step recovery. Step one starts with honesty, being honest with yourself. Step two, we start talking about hope and faith, which is sticking with values and being fair to oneself. Being compassionate comes couple more steps down. That's not hard or not harmful for any of our clients to teach them to be fair, to be kind, to Themselves and to be honest with themselves and others. So how does treatment progress when we're talking about dialectical behavior therapy as a evidence based practice? Stage one is basically safety. We want people to move from behavioral discontrol to behavioral control. We don't want people getting a phone call, maybe a significant other has to back out on a weekend trip, which with someone with behavioral discontrol could send them into a state where they are self injuring. So we want to make sure that they have the skills to not self harm. And you know, you can't just say, well, you can't cut. And the person's like, okay, so finish. What am I going to do instead if I can't cut? If I knew how to do something else, I'd be doing it right now. We need to help them increase their self care behaviors. Instead of cutting, what can you do? And I've talked before about some of the interventions I've used with some of my clients that have self harm. It's not ideal, it's not where you want to end up. But moving from self harm to, like I said, holding ice cubes or using a ballpoint pen to draw on themselves is definitely preferable to cutting themselves. So we want to look at small steps, not going from, you know, five or six self harm episodes week to nothing. You're setting your client up for failure. We want to reduce the intensity of the self harm so they're not actually breaking skin, so they're not actually damaging themselves. Decreased therapy interfering behaviors, what we typically call resistance. And that can be showing up late, that can be always coming in and trying to derail therapy sessions. It can be being bossy, it can be being reserved, whatever it is that's interfering with the therapeutic process. It's important to understand that therapy interfering behaviors can be exhibited on the part of the counselor too. If the client is experiencing a lot of emotional discontrol, sometimes counselors will start being late to sessions. We'll start forgetting to review the chart before they go in and remember what homework was assigned. We'll start forgetting to do things. So we need to make sure that both the counselor and the client are engaging in motivating therapy participatory behaviors. We want to increase the quality of life behaviors and decrease quality of life interfering behaviors. So if they're engaging in addictions, if they're not sleeping, if they're chain smoking, if they are. And again, these are things. When we look at the priority list, my main focus at first is going to be on self harm. I don't want them to be engaging in those behaviors. And then we're going to start looking at the other things that create vulnerabilities that make them more likely to be unhappy or to be reactive in situations that would make them unhappy. We're going to increase behavioral skills, core mindfulness and accurate awareness. Encouraging clients not just when they're upset, but to engage in mindfulness scans, body scans four or five times a day so they know where they are and they know if they are starting to feel vulnerable, if they're feeling exhausted all of a sudden, if they're feeling foggy, then they know to be kind to themselves. Distress tolerance. We talked about those skills, interpersonal effectiveness. Talked about those skills, emotional regulation and active problem solving. So these are all going to be introduced in stage one, but they're introduced. The client has been using their old behaviors for a lot longer than stage one is ever going to last. So we need to remember that we have to help clients strengthen these behaviors, remember to use them. If they use them at first, one out of every five times, that's one more time than they were using them last week. Let's focus on the positive forward movement and not on what we think they should have done. We don't want to set goals that are going to set them up for failure in stage two. We want to help clients moderate emotions from excruciating and uncontrollable to modulated and emotional. We want to feel feelings. Well, I mean, theoretically we do. So we don't want people to completely numb out and become robots. But we also don't want every single emotional experience to be like debriding a third degree wound. We want something in between. We need to help them decrease intrusive symptoms like flashbacks, memories and hecklers, the things that created the situation where they feel unlovable and unacceptable for who they are. We want to decrease avoidance of emotions. And I know that sounds kind of counterintuitive through increasing emotional awareness. Again, we don't want them to be numb. We want them to feel. Because if they feel, then they can choose how to act and how to react. Decrease withdrawal, increase exposure to life. A lot of times clients with emotional dysregulation have withdrawn because they don't want to be rejected. So they don't go out with friends. They don't experience life on life's terms. They just sit in front of the television and watch Netflix. We want to decrease self invalidation, help them understand that their experiences are their experiences and they're not right or wrong, their choices may be helpful or less helpful, but at any point in time that is their best as well as they can see their best options for survival. So let's not be critical. I'm just happy you're still here. And we want to reduce mood dependency of behaviors. Part of this process we're going to teach people how to create smart goals that are specific, measurable, achievable, realistic and time limited smart goals and make sure they're successful by validating and teaching them to self validate. Encourage them to imagine the possibilities when you're successful, when you accomplish this goal, what's going to be different? How awesome will it be? Encourage them to take small steps, not all or nothing. You know, we want to get get rid of the dichotomies, small steps towards recovery and applaud themselves for even trying. Encourage them to lighten their load. Get rid of stuff that they don't need to be stressing over right now. You know, maybe now's not the time to start remodeling the house and then sweeten the pot. Encourage clients to provide themselves with rewards for successful completion of a goal. Maybe getting through an entire week or for some clients even an entire day without self injury. I encourage you to practice these skills yourself because you'll see how much we actually don't do and how helpful these skills can be. But it also gives you more insight on into ways to help explain things to clients and help them apply these tools to themselves. Think about which skills you've used that were helpful or skills you could have used that would have been helpful in the past week for you because you're going to ask the clients to do this. So let's do it for ourselves so we can put ourselves in their position and think about which skills might have been helpful for a client that you've worked with in the past week. Many disorders involve some amount of emotional dysregulation. That dysregulation can be caused by high sensitivity and reactivity due to innate characteristics and poor environmental fit or external traumas and lack of support or both. DBT seeks first to help the person replace self defeating behaviors with self care behaviors and then moves toward emotional regulation and interpersonal effectiveness to help people develop the support system and learn how to feel feelings, including the good ones. A variety of tools are imparted to clients to help them set smart goals, identify and understand emotions and their functions, decrease unwanted emotional and behavioral responses, and develop a more effective, compassionate and supportive relationship with themselves and others. Finally, remember that not every tool is going to work for every person. It takes some experimentation. Prepare your clients for that. Otherwise, if they try something and it doesn't work, they're going to feel rejected and validated and like failures again. It's a process to work together to help them figure out how they can start interfacing with life and integrating the two dichotomies of thought and emotion to make wise choices in order to help them live happier and healthier.