Dialectical Behavior Therapy Skills

the 2021 wellness retreat is an opportunity forclinicians and non-clinicians to enjoy fall in tennessee and maybe even a leaf change while youtake a deep dive into learning about the mind-body connection and strategies for improving youroverall well-being up to 21 ceus will be available for clinicians but again you don’t need to bea clinician to attend the retreat is being held october 20th through 23rd at cumberland mountainstate park and is limited to 60 people to allow me to have plenty of time to interact with everyonego to allceus.com wellness to see the detailed schedule and download the registrationform i look forward to seeing you there i’d like to welcome everybody today’s presentationon dialectical behavior therapy skills i’m your host dr dawn-elise snipes now obviously i callthis dialectical behavior therapy skills because dialectical behavior therapy itselfis a something of a self-contained approach what we’re going to be learning is a lot ofthe skills that are taught within cognitive behavioral therapy and these skills can be veryuseful in clinical practice even if you’re not using the cognitive i’m sorry even if you’renot using the dialectical behavior therapy you know full protocol this presentation isbased in part on doing dialectical behavior therapy a practical guide the dialecticalbehavior therapy skills workbook dbt made simple dbtselfhelp.com and dbt for substanceabusers so there are a lot of different um places that you can find information about how tointegrate dbt skills into your treatment program we’re going to talk about why dbt wascreated understanding emotional dysregulation will identify dbt assumptions about clients andtherapists and explore skills to help clients learn distress tolerance emotion regulationand interpersonal effectiveness so we’ve got a lot to cover dbt was created because therewas a significant portion of the population that was struggling and to get their needs met inthe day-to-day world as well as in a counseling environment these people tend to have uh highsensitivity and become emotionally dysregulated we’ve talked in other classes aboutemotional dysregulation as going from flat to furious going from calm even content oryou know kind of flat and apathetic depending on where they’re at in the spectrum to you know superanxious you know just terrified or enraged um and this is not something that they do intentionallyand it’s not something that they can just you know get over because they’re quote overreactingtheir hpa axis is actually having an exaggerated response and dumping a lot more cortisol andnorepinephrine and adrenaline and all that stuff into their system than a person who is notdysregulating a person who is not highly sensitive high sensitivity can lead to hyper vigilancewhen you’re highly sensitive think about you know getting away from emotions for examplethinking about something more tangible if you are highly sensitive to smells youmay be hyper vigilant when you go into an environment about whether there’s a smell therethat is going to bother you you know i am super sensitive to paint fumes so i tend to notice themmore i tend to be on the lookout for indications that somebody is painting because i know that’syou know bad mojo for me when we’re talking about people with emotional dysregulation we’re talkingabout hyper vigilance to a variety of stimuli whether it’s situations people places things umuh environmental stimuli emotional uh conditions people who are in recovery from addictionsmay also have a fair amount of hyper vigilance partly because their hpa axis is dysregulated butit could be that they had hpa axis dysregulation and this high sensitivity uh prior to thedevelopment of their addiction one of the things we want to help people learn how to copewith is this high sensitivity and when they become dysregulated providing them tools to help themquote re-regulate themselves people who are highly sensitive tend to over generalize they experiencerejection for example in one situation and then they over generalize to you know all othersituations so maybe they experienced rejection in you know class at school one time so then theystart over generalizing and expecting rejection in every classroom in every setting people withhigh sensitivity are easily thrown off kilter they can become vulnerable a lot more easily theymay be more sensitive i’ve shared with you guys before that when i don’t get enough sleep i tendto be much more um sensitive and you know moodier than you know say my my husband who youknow if he gets five hours or if he gets nine hours he’s pretty much the same he’s oneof those people who’s really you know level but people who are high have high sensitivityit’s important for them to identify their physical environmental emotional and cognitivevulnerabilities that can set them up to be more likely to have an exaggerated reaction tosomething and people with high sensitivity often have no emotional skin and and that tosay you know what we tell people they need to be thicker skinned in in order to deal withlife on life’s terms well people with high sensitivity basically have no emotional skin whatis said cuts very very deeply they have difficulty maintaining those emotional boundaries they alsotend to have high reactivity you know guess what when they are hyper vigilant when they’re overgeneralizing when they’re expecting bad things to happen when as when they were growing upor in prior situations when their reactions and feelings have been regularly invalidatedso they always feel like they’ve got to prove themselves or protect themselves because nobodyelse will well of course that is going to put them in a situation where they are on the precipice offight or flight a lot more often they’re going to be more vulnerable because they’re going to feelmore vulnerable environments are going to feel incredibly less safe than to them than toother people who have experienced validation and who don’t feel the same gush of adrenaline andemotions and dysregulation when something happens people with emotional dysregulation and highsensitivity tend to have slow de-escalation they are persistently hyper-activated it takesthem a lot longer to return to baseline after they get upset even when they are you know receivingvalidation and that sort of thing it takes their body physiologically longer to respond and bringthem back down into a rest and digest sort of place and as i mentioned earlier a lot oftimes people with emotional dysregulation are in invalidating environmentsthey may have grown up in them they are probably still in them becausea lot of people don’t understand that in cases where people have high sensitivity incases where they are emotionally disregulating because of prior trauma for whatever reason thatis causing their emotional dysregulation this is not a conscious choice they are not malingeringthey are not quote milking it they are not um intentionally overreacting their hpaaxis actually goes into super overdrive and when they are told that they’reoverreacting or to get over it if they could they would you knownobody wants to feel like that but people instead of providing them tools insteadof providing validation and assistance um you know parents caregivers loved ones whatever they justoften dismiss the person’s reactions and distress the emotional reaction people when they getupset often have a hyper awareness of stimuli in the environment when you grow up in a aninvalidating environment when you grow up in an environment you know you’re hypersensitiveso everything can feel overwhelming or painful guess what that feels pretty daggum unsafe andif you’re never taught the tools to handle that then you may start feeling you know persistentlyunsafe that’s traumatic which creates that hyper vigilance so people start becoming more perceptiveof stimuli they start trying to notice things as quickly as possible because they feel unsafethey perceive a threat when they they feel unsafe then cognitively their brain is telling them heyguess what you’re unsafe so they start having thoughts of being out of control of beingunsafe of being you know threatened in some way and it may not be a physical threat it may bea threat of rejection or failure or loss of control thinking about somebody for examplewho has um borderline personality disorder one of the key factors in bpd is switchingfrom you know love to hate switching between um dichotomies very rapidly well why doesthis happen well the person wants to feel happy they want to feel loved but then they catchthis micro expression or something that tells them that they may experience rejection or failureor loss of control it puts them on the defensive when they get on the defensive their physiologicalreaction is to kick into that fight or flight mode so they have that all hands on deckresponse and they want to fight or flee the actions they take whether it’s yellingwithdrawing drinking whatever that they do is often can be seen and it oftenmakes sense from a survival perspective if they believed that they were unsafe you knowin what way did their behaviors protect them i have a picture it’s kind of a blurry pictureof my dog brewster here and brewster was a rescue and i don’t understand i don’t knowwhat happened to him his first 18 months of life but he is a very hyper vigilant hyper awaredog you know if anybody even has an iota of stress hormones oozing from them he startsto get very anxious and hyperactive um and we may see this in in children in peoplebut with him you know i know his past and is one of those things that we’ve hadto work on with him and you know help him understand as a dog that it is a safeenvironment because you know being 85 pounds you don’t want him getting too stressed outso let’s talk about primary invalidation when people who are highly sensitive and generallyum for a lot of people this is an inborn trait but for some people it may happen as aresult of trauma as a result of developing some level of post-traumatic stress issues youknow i’m going to stop short of saying disorder or or exposure to adverse childhood experienceswhich cause trauma um the person’s hpa axis the person may start to feel that their environmentis unsafe for some reason and their hpa axis may start to become dysregulated okay when thathappens now they are into that place where they are hyper vigilant hypersensitive and mayexperience that exaggerated hpa access response well a lot of times parents caregiversdon’t understand what’s going on when this is happening with their five or sixyear old and or even their 14 or 15 year old and they may um ignore it dismiss it telling themtell them they’re overreacting or react in ways that are unhopeful instead of validating wherethe person is at where the child is at emotionally physically helping them feel safe helping themfigure out how to cope with that dysregulation they may send them to their room until they cancalm down we’ve talked in other classes about the six i think it’s six principles that facilitateeffective attachment and that’s consistency you know a caregiver is there is you know whenone is needed the caregiver is generally always there um consistency responsiveness when thecaregiver is there they are actually tuned in to the child they are responsive to the child’sneeds at you know when that happens the caregiver provides attention they are not just reactive whenthe kid needs something they’ll get up off the sofa they are actually proactively attentive tothe child which helps develop the child’s sense of self-esteem the child says hey you knowcaregiver wants to spend time with me cool v stands for validation what is threateningto us is you know may not be threatening to a child and vice versa children have many many fewerexperiences upon which to judge whether something is threatening or not so a lot of times thingsthat are scary to kids like the monster in the closet that doesn’t exist that we know that butthe four-year-old may not so it’s important that we provide validation recognizing how they feeland what their thoughts are and then helping them figure out how to deal with it you know validatethat hey i i hear that you’re afraid because you think that there’s a monster in the closet whatdo you think we should do about that or how can how can i help you sometimes when you are beingconsistent and responsive attentive validating um and encouraging uh you can also teach copingskills you know those parents are the ones that will get down you know eye to eye withthe kid and you know say okay let’s take a deep breath together or whatever the casemay be in order to model for the child and walk the child through learning new skills thatgenerally doesn’t happen in environments where there is primary invalidation where the caregiversdon’t understand how to be reactive to the child or why the child is reacting so strongly sothey dismiss it as attention getting so in these primary and validating environments charactergivers dismiss emotional reactions as invalid the child is mocked or shamed for their emotionalresponse they’re told they’re overreacting just to stop talking about it whatever the childis not taught self-soothing and de-escalation the caregivers do not recognize the child’sdistress as real therefore they don’t take the steps to teach them how to handle what’sgoing on the child is not taught mindfulness to notice what’s going on and and enableand enable them to articulate ahead of time you know i’m feeling kind of anxiousabout going to the pediatrician today and the child’s not taught effective cognitiveprocessing looking at the facts of the situation secondary trauma and invalidation coping skillscan be overwhelmed by trauma or intense stress leading to a high alert raw status you knowwe talked earlier about when people experience trauma or intense stress they perceive theirenvironment as unsafe and they typically over generalize and it’s just like everywhereall the time life is unsafe so they are hyper vigilant and on that high alert statusmany people don’t receive necessary necessary support during these times and may be shamed forbeing weak or needy it’s important to help our patients who may be emotionally dysregulatingand their family understand that crisis is a normal response to an abnormal event and in thecase of a lot of people who are highly sensitive things that don’t prompt crisis in someone who isnot highly sensitive may prompt a crisis in them you know we talked last week or the week beforeabout people who are have autism spectrum disorders and or schizophrenia for example andthey have different sensory perceptions what is painful to them may not be painful to someonewho doesn’t have disrupted sensory perception most humans are not inherentlyprepared to deal with crisis alone so whether we’re talking about a toddler who youknow falls down and gets hurt at the playground or experiences some other kind of even worse traumaor an adult you know generally crises are a time when we reach out and seek social support we seekvalidation we seek others to help us feel safer what precipitates a crisis may vary between peoplebased on pre-existing stress or mental health issues in adults especially or older childrenyou know if somebody’s already experienced trauma if they’re already hyper vigilant then whatprecipitates a crisis may be a much lower bar than what precipitates a crisis for someone who didn’texperience adverse childhood experiences or trauma likewise for someone who has a cognitive orbehavioral health issue or even a physical health issue that may cause chronic pain for example theymay be in a state of chronic stress or distress which means moving to the state of crisis movingto the overwhelmed doesn’t take as much you know they may more easily experience crisis and i wantyou to think of it kind of like a pressure cooker you know people who are haven’t experienced traumathey’ve had just a storybook life everything’s going well they don’t have chronic stressthey have zero heat on their pressure cooker they have zero pressure building up but every timeyou experience a trauma or an adverse childhood experience that doesn’t get effectively resolvedor whatever it may add pressure to that pressure cooker if it’s not effectively coped with nowthat’s the key if it’s effectively coped with then it takes the pressure down but if it’s noteffectively coped with it just keeps building up that pressure so if someone has trauma and chronicstress and chronic pain then they’ve got a lot of pressure on that pressure cooker and it’s notgoing to take a whole lot more to blow the top off the result is people when people experienceinvalidating environments with um and and they are highly sensitiveand they emotionally dysregulate they may develop frantic efforts to numbwithdraw or protect and numbing can take the form of addictive behaviors withdrawing can takethe effect of sleeping depression self-isolation protection can take the form of you know any ofthose but it can also take the form of aggression or verbal or physical aggressive behaviorso fight or flee people learn that who they are and how they are results in rejection justlet that sink in for a second they learn that not only who they are but how they are howthey react how they act results in rejection this leads them to avoid the threats well nobodylikes to be rejected so at a certain point they may start building up walls emotional walls andor physical walls they may withdraw they may avoid thoughts feelings and sensations that leadto invalidation but since they’re hyper vigilant and over generalizing it starts a snowball effectso eventually it’s like most people most places most things most times may be threateningso they become progressively more withdrawn and or reactive they become progressivelymore sensitive and prone to dysregulation so what are the assumptions about clients wellin dbt linehan asserts that clients are doing the best they can well i hope we all believe thatalready they want to improve if they’re in our office you know chances are they want to improveso we want to believe that they cannot fail at dbt and that is a challenging little statementthere and what i want you to take from that is that dbt is designed to help them understandthemselves and understand what leads up to their reactions and their actions butdbt is not a one-size-fits-all we cannot say that you know you do these sixthings and voila you’ll start feeling better so when a client um experiences a setbackexperiences an episode of dysregulation then we want to explore it with them andlearn from it dbt is a learning experience that helps people understand more about themselvesso while any particular intervention in dbt may fail for the client the client is not failingwhat we want them to do is get curious and try to understand why did that not why didthat not work for me and what might work better another assumption is that clients areexisting in an unbearable state you know think about feeling that frightened feeling thatunsafe feeling that nervous tense all the time and having those episodes ofdysregulation having those gushing you know stress hormone gushing episodesthink about how exhausting that must be people really don’t want to be miserablethey may not know how to change they may be quote and i don’t like this word but i’m goingto use it anyway they may be quote resistant and and much of that is often because they’vetried to change before and they haven’t been successful so they’re terrified to try againthey are terrified that they are going to fail again which is where we go back to they cannotfail at dbt they are not failing the technique may not work for them but we need to look andfigure out what’s working clients need to learn new behaviors in all contexts because generallyby the time they’ve gotten to this point they have done a whole lot of over generalizing they’regoing to learn need to learn the mindfulness and um self-regulation skills at home in understressful situations under sad situations etc clients are not responsible for all of theirown problems we know that growing up in a you know dysfunctional household can create problemsso you know kid didn’t choose that they’re not responsible for all their own problems but theyare responsible for all of their own resolutions and i do like this it seems unfair if theydidn’t create the problem they shouldn’t have to create the resolution well thatmight be however that’s the way it is and this can be seen as empoweringbecause it helps clients see that okay what happened or the problems that are happeningnow some of these i’m not responsible for but let me look at what parts i can change and thendecide how i’m going to best use my energy to address the situation the past my problemsdo not have to continue to control me i have the ability to find resolutions and solutionsto them and clients do need to be motivated for change they need to want to do this because dbt isan active process counseling is an active process in terms of therapists clarity precision andcompassion are of the utmost importance we need to be sensitive to what’s going on with uh with ourpatients and how terrifying the world must be you know there’s a lot of empathy that goes alongwith this the therapeutic relationship is between equals dbt or therapists can fail to achieve thedesired outcome so again the client is not failing what has happened is this approachmay not be working for them or the way we are applying it may not be workingso it’s important to empower the client again to get curious start to understand whysome things work and some things don’t therapists who treat patients withpervasive emotional dysregulation needs support if you’ve worked with clientswho have borderline personality disorder and sometimes clients who are in early recoveryfrom addiction you know that their emotional swings can be significant and they can befrequent and it can be exhausting to um basically walk with them you know you’re you’rewalking with them as they’re swinging back and forth sometimes so it’s important to recognizethat you need to get support another premise of dbt when you’re using the actual modalityis that there are consultation groups and in these consultation groups people who are notworking directly with that client are able to give objective feedback about potential motivationsfor the client’s behavior about what seems to be working and potentially about ways that they maysee the client trying to manipulate the therapist clients don’t do this out of malice clientsdo this out of self-protection if they feel a need to protect themselves if they fearabandonment if they fear rejection for example they may act out in certain ways to manipulate thetherapist so it’s important to examine that and say okay well you know maybe you’re thinking aboutdischarging the client or transferring the client to a lower level of care then all of a suddenthey have a resurgence of symptoms you know let’s look at what does that mean and how could thistransition be undergone in a slightly different way in order to not trigger that that fear ofabandonment that fear of being out of control so core mindfulness uses therational or cognitive mind the emotional or feelings mind and the wisemind which is a combination of the prior to intuition and interpretation you know ultimatelyyou want to take what you know and combine it with what you want to try to find the best possibleoutcome mindfulness itself mindfulness skills help clients learn to have effective non-judgmentalobservation and description of their experiences their thoughts and their feelings so if they’reangry okay they’re angry if they’re stressed out or worried okay they’re stressed out they’reworried not following it up with i shouldn’t be or you know some other dismissal some otherinvalidation just noting their physiological and cognitive and emotional reactions andsaying okay this is how i am right now then taking that state that mindfulstate once they recognize where they are identifying what is the objective evidence forand against my thoughts and my feelings right now you know what is if i’m terrified go back tothat snake that we talk about a lot if i’m out hiking and i see a snake in the in the pathand i’m terrified that it’s gonna kill me okay so i accept in the moment not judgmentally thathey i’m terrified right now i don’t tell myself i i’m overreacting i don’t tell myself ishouldn’t feel that way i say all right this is how i feel so what is the objectiveevidence for and against my belief and ultimate reaction of fear that i am in danger what is allthe evidence the big picture okay even if it does even if the facts support the notion that thisis a dangerous snake maybe it’s a water moccasin what is the big picture well you know in thiscase it’s sunning itself on the path likely if i back away you know it’s not going to chase me ifi don’t poke at it if i don’t get near it you know it’s probably not going to you know just pursueme and you know do horrible things so getting all of the evidence you know maybe it’s poisonousokay if it is you know is it guaranteed to bite me well no you know if i don’t start poking atit chances are it’s not going to mess with me and then what are my feelings about theevent examining how i feel in this situation and noting how their feelings change over time sothere are four options when faced with a problem tolerate the problem change your beliefs about theproblem change the situation i.e solve the problem or just stay miserable so in the case oftolerating the problem sometimes it’s one of those situations you know maybe it’s a unpleasantfamily member that they’re just not gonna change and you decide that okay you know what this is notworth my energy to let this bother me tolerating the problem changing your beliefs with that samefamily member you may say to yourself wow you know and instead of seeing them as being attackingand critical and mean and hateful thinking wow for them to act that way they must feel veryscared or it must be very dark inside their head so you’re changing your beliefs about that personor that situation to make it easier to tolerate the situation you can change the situation maybechoose not to spend time around that person or you know family reunions and stuff have aplan in place so you don’t have to spend a lot of time around that person even if they’rethere or you can just choose to keep doing the same thing and stay miserable and dreadevery family reunion that is a viable option skills that can help people toleratedistress tip is a mnemonic device and it addresses physiological arousal sotemperature when you expose yourself to sensations you know cold uh cold water on your facefor example or an ice bath for your hand that will trigger yeah it’s you know that changein sensation may trigger that hpa axis a little bit but it almost resets itself because then thebody starts paying attention to that sensation instead of the thoughts now obviously if somebodyis in danger you know we want them to get safe we don’t want them to splash cold water on theirface um in the face of danger but you know that always comes up in the youtube commentsyou know obviously get safe but in order to help down regulate sometimes it’s important tosort of trick that hpa axis into refocusing and going oh you know i am excited you know i’m i’mkicked off because of the cold water and then when you know your face starts to warm up or youpull the hand out of your hand out of the ice bath and it starts to warm up your heart ratestarts to go down it’s a really weird thing intense exercise push-ups sit-ups running thatcan you know do the same thing because then your brain says oh i understand why my adrenalineis pumping right now because i’m running hey so then when you stop running guess what itdown regulates some or progressive relaxation and slowing your breathing um slowing you willautomatically trigger that rest and digest and slow the heart rate so there are threeways that can be helpful to not only distract from the immediate problem you know if you’resprinting if you’ve got your hand in ice water or you’re focusing on progressive relaxationyou’re not going to be thinking about that problem or at least not focusing on it and it alsotricks your brain and sort of explains to your brain why your heart rate is active so when thatstimulus goes away it triggers the rest and digest accepts and improve are two other mnemonicdevices that linehan proposed and they stand for different distress tolerance activities orthings that you can do the first one in accepts is activities doing things that can help a persondistract themselves now we’re not saying distract forever the goal of distress tolerance is to helppeople get into their wise mind so they can think clearly to get out of that adrenaline haze so theycan think clearly about what are the facts in the situation what are my options and make a reasonedjudgment 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 wheni get stressed out sometimes i will go outside and do landscaping and my kids know the levelof my stress based on the power of the tools that i’m using so hand shears we’re good but ifi’ve got the chainsaw out they give me some space contributing to the welfare of others can helpyou focus outside of yourself for a few minutes or for a little bit longer than that so whenyou come back to addressing your own situation again that adrenaline has bled offand the hpa axis has down regulated you can compare yourself to others how otherpeople are doing you know recognizing you know some people are doing worse than you or youcan compare yourself to your old self so how you reacted to to similar situations six monthsago well i’m not necessarily hitting the mark yet but i’m not reacting as strongly as i did sixmonths ago so helping people see their progress opposite emotions helps people um triggerobviously the opposite emotions you’re going to be triggering are happiness joy those sorts ofthings and that is going to trigger the release of dopamine serotonin and calming neurochemicals sodoing things that trigger those opposite emotions whether it’s music or funny videos or whateverit is i encourage people to keep a playlist of comedians that they like on theirmobile device or on youtube or both so they always have something they can goto pushing away is another technique and you can encourage people to build an imaginarywall between themselves and the situation or they can imagine themselves pushing awaythe issue or the thoughts with all of their strength i mean sometimes this is one thati use sometimes i will actually find myself you know telling telling the walltelling the air to talk to the hand but pushing away can be helpful because it getsyou out of that frantic loop what you’re trying to do is break that frantic loop so then you can stepback and more effectively analyze the situation you can also just block the situationfrom your mind each time it comes up actually tell it to go away say you knowwhat no i’m not thinking about this right now pushing away only helps for so long becausea lot of times as soon as you stop pushing it tries to come back so a lot of times it’shelpful to combine some of these skills thoughts are something else that you can do and obviouslythoughts can be empowering thoughts about you know your ability to handle the situation they can bepositive thoughts about things that are going well or they can just be erroneous thoughtslike counting from maybe the person just starts counting by fives you know when you’retrying to do that mental math at least for me that takes just enough of your focus that youcan’t focus on you know the other stuff singing sometimes just breaking into your favorite song the 10 game finding 10 things that aregreen finding 10 things that are moving um you know it occupies children well used to back inthe 70s it occupied us when we were in the car it can do the same thing when you’re experiencingdistress because it takes just enough attention that it helps tame that monkey mind andfinally 54321 what are five things that i see four things i hear three things i smell twothings that i can feel and one thing i can taste or as we talked about on the last slideunder a couple slides ago under tip sensations cold is one of my favorite holdingice cubes putting your hand in cold water some people like the rubber band trick where theywear a rubber band and they snap it on their wrist i’ve never found that one to be particularlyeffective for people but whatever smells can also be helpful especially pleasant smells like if yousmell roses or lavender or something and it just momentarily takes you away we know that essentialoils can trigger the release when you smell them through the pituitary it can trigger triggerthe release of dopamine serotonin and gaba so smells can also be helpful forsensations you probably want to avoid taste that just creates a whole other set of problemsimprove stands for improving the moment you can use imagery if you’re dreading i have a doctor’sappointment this afternoon and i’m dreading going to the doctor so a happy place for me would beyou know while i’m sitting in the waiting room i might think about you know going to my gardenand what i’m going to do in the garden when i can actually use my left arm effectively againbut thinking about something like that or going hiking just remembering a happy placeand trying to use as many senses as possible to get there what did it what did i smell when iwas there what did i feel what does it feel like to be hiking in the woods you canalso imagine successful completion if somebody’s stressed about having aconversation with a significant other or job interview encouraging them toenvision successfully completing that task find meaning in the situation and you knowsome people call it making lemonade all right this happened it sucks i don’t like it but whatcan i get out of this you know maybe it’s only i will learn how much more courage or howmuch stronger i am after getting through this prayer or radical acceptance you knownot everybody’s down with praying i understand that um and but radical acceptancecan also be recognizing that it is what it is and some things can’t be changed and you need to givethem over to the universe or to your higher power relaxation skills um slowing down your breathingcan help trigger that rest and digest and help people get into their wise mind taking a mentalvacation the time out and encouragement having them create a script even that they keepwith them of positive and calming self-talk um and and sometimes people are aspatricia points out very attached to that angry story and distress tolerance isdifficult and in those cases you know we look at what is motivating them what is that behaviorsaying why are they afraid you know fear why are they afraid to let go of that angrystory and you know that can help you probe where some of those fears where some of thosethreats are coming from because yeah if if they are feeling unsafe if they are feeling fearfulthen they’re not going to want to tolerate this distress they’re not going to want to go into restand digest because that is a unhypervigilant place that is a potentially threatening and vulnerableplace so always you know when when people have difficulty enacting some of these toolsthen you want to step back and go okay what is that saying what is that behaviorsaying um about what’s going on with you emotion regulation the goals are to identify andlabel and understand their emotions try to figure out where they’re coming from you know why is itthat that made me anxious well it could have to do you know psychodynamic perspective could have todo with something from my past and it reminded me of that so it makes me nervous now when i wasknee-high to a grasshopper i had my tonsils out and the person who took my blood whoever that waswas very rough and not very good at it and ever since then i have been terrified of needles andyou know i’ve had some very good phlebotomists and nurses over the years and it didn’t hurtbut whenever i think about having my blood taken my anxiety at least for a moment goes up andthen i have to use some of those tools and walk it back down and go you know what you’re expectingsomething that you don’t know is going to happen emotional regulation tools candecrease unwanted emotional responses and decrease emotional vulnerabilities sothe skills are identifying and labeling their emotions and their functions what isthe function of guilt you know what is the function of continuing to beat yourself up forsomething what is the function of anger or fear or even happiness we want to help peopleimprove their self-awareness so they notice especially the dysphoric emotions they noticethe early signs of them so they can intervene sooner rather than later and start conductinga behavior chain analysis so they can explore what led up to this what vulnerabilities happenedthat increased the pressure in my pressure cooker that ended up leading to this you knowdysregulation so cop copying is policing your own thoughts check the facts consider opposite actionsso for example if you want to scream at somebody maybe the opposite action in that moment wouldbe to take a breath and then problem solving always make sure you’re safe you knowif something’s going on and you’re in danger get out of the danger first reducevulnerabilities a b c p um accumulate the positives this helps people develop an attitudeof gratitude when we are feeling hyper vigilant when we’re feeling distressed a lot of times wehave difficulty noticing the positive because we’re so worried about staying safe so accumulatethe positives help helps people see the bigger picture build mastery set micro goals to developa sense of self-efficacy make take note of the things that you are good at to develop that senseof mastery and self-control cope ahead of time if you’re going into something and you’re expectingit to be stressful envision it plan for how you’re going to cope it cope with it and maybe even do alittle imagery to see yourself effectively coping and prevent physical vulnerabilities when you’resick when you’re tired when you are have too much nervous energy when you are poorly nourisheduh or even dehydrated it can make you more um emotionally reactive or and it can alsoimpair cognitive abilities especially in the case of dehydration so it’s important to take careof the physical self in order to again reduce that pressure in a behavior chain analysis you’regoing to have the person name the behavior or the reaction that was the problem identifythe prompting event so maybe they screamed at their boss what was the prompting event theirboss wrote them up identify the behavioral links leading up to that what sensations thoughts eventsand feelings happened leading up to that situation what are the short-term positive andnegative effects from screaming at their boss what are the long-term positive and negativeeffects from screaming at their boss and address the problematic links with skills so ifthey recognize that they were you know already had some vulnerabilities it’s important tofigure out how to prevent those in the future it’s also important to look at maybe they theirboss walked into the office they expected bad things and then they started to spiral okay sowhat distress tolerance skills might be helpful for them in those situations over ten thousandpeople come to betterhelp every day looking for a counselor betterhelp makes it easy for youto move your practice online and focus on what you love most helping others betterhelp’s easy touse platform takes care of referrals and billing and provides a secured platform to communicatewith your clients join more than eighteen thousand therapists at better help helpingto improve people’s mental health and lives dear man is another mnemonic fromlinehan um describe the situation assess what’s going on look at the facts assertyourself state how you feel your wants and needs reinforce what you need and reinforce otherpeople when they respond appropriately practice mindfulness to be aware of how you arein the situation how you impact the situation and how the imp situation impacts you appear confidentyou know it’s easier to handle situations when you hold yourself confidently and negotiate be willingto you know not get your own way and these are great skills for interpersonal effectiveness andthey play off in in many ways the seven habits of highly effective people you know synergizingbegin with the end in mind creating win wins relationships with others give when you’reinteracting with others helping people learn how to be gentle interested validating andhave an easy manner in your relationships a lot of times people who experience emotionaldysregulation tend to be perceived and tend to be intense and that intensity can be overwhelmingfor some people so encouraging them to have a an easier manner in in their relationships um notdemanding that they get their own way all the time another mnemonic is their relationship withtheir self and that’s fast be fair with yourself you know recognize what you do and don’thave control over criticize yourself like you would criticize others but don’t holdyourself to unrealistic standards be fair avoid apologies for things that are not yourfault stick to your values and be truthful in terms of treatment for dbt there’s aprogression there’s a stage-wise progression in stage one we’re helping people move frombehavioral disc control to behavioral control now this is behavioral not emotional so what we wantto do is help them decrease self-harming behaviors and that can include addiction by increasingself-care we’re going to help them decrease therapy interfering behaviors or quote resistanceby increasing motivation and participation so we want to understand where that quoteresistance is coming from what is that behavior saying why are they afraid to afraid andunmotivated to move forward and do these things and generally it comes back to some level offear or uncertainty decrease the quality of life interfering behaviors or vulnerabilities sowe want to decrease self-harm increase self-care increase quality of life behaviors like eatingnutritiously and doing things they enjoy we want to increase behavioral skills such ascore mindfulness helping them become accurately aware of how they feel in the moment using theirdistress tolerance skills when they start to feel distress practicing interpersonal effectivenessand emotion regulation and also practicing active problem solving which will help with later onself-management as they start to figure out that hey there are some problems i can solveand recognize their efficacy and agency in situations it greatly increases theirfeeling of safety in the world stage two we want to help people moderate emotions fromexcruciating and uncontrollable to modulate it we want to decrease intrusive symptoms avoidanceof emotion with withdrawal emotional dysregulation self invalidation and their mood dependency ofbehaviors so we really want them to pay attention to what some of those things are like intrusivesymptoms when they hear the hecklers in their head we want to encourage them to note andmake those hecklers address those hecklers in terms of self-invalidation we want themto notice when they are using invalidating language when they’re being mean to themselvesand increase self-validation and compassion we want to help them create smart goalsthey’re specific measurable achievable realistic and time limited people are not goingto start dbt and suddenly not have any more you know episodes whatever their episodesconsist of what we want to do is decrease the frequency and the intensity of those episodesgradually we want to see small measurable progress vitals to success is another tool that people canuse validate validate their feelings their they feel how they feel imagine the possibilities whatcould i do in this situation to make it better or to improve what’s going on take small stepsyou know every day is not going to be a leap you know what’s one small step what’s one smallthing i could do today to improve the situation applaud yourself lighten your load you knowa lot of times people who are emotionally dysregulating also are under chronic stressso encouraging them to address that and not set themselves up with a pressure cookerthat’s already ready to pop the top off and sweeten the sweeten the pot by adding rewardsfor successful even having a successful hour or a successful day encourage them to be kind tothemselves many disorders involve some amount of emotional dysregulation that dysregulation can becaused by high sensitivity and reactivity due to innate characteristics and poor environmentalfit or external traumas and lack of support dbt seeks first to help the person replaceself-defeating behaviors with self-care behaviors emotion regulation and interpersonal effectivenessare addressed in the second phase of treatment a variety of tools are imparted to clientsto help them set smart goals identify and understand emotions and their functions decreaseunwanted emotional and behavioral responses and develop a more effective compassionateand supportive relationship with themselves as well as others remember not everytool is going to work for every person so encourage them to take an eye of curiosityor an attitude of curiosity because it will take some experimentation to figure outwhat works for them are there any questions i know we went through a ton of stuff inthis presentation there is a lot to dbt but there are a lot of skills like distresstolerance skills and vulnerability prevention that can be super helpful for more information ifyou want to go deeper into those tools i do have multiple videos on the youtube channel that go indepth into the stress tolerance emotion regulation interpersonal skills and problem solving sohave a great day and i will see you on thursday

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