Dialectical Behavior Therapy Skills Introduction

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Dialectical Behavior Therapy Skills

Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC, NCCExecutive Director, AllCEUs


Based in part on Doing Dialectical Behavior Therapy: A

Practical Guide by Kelly Koerner (Guilford Press)

The Dialectical Behavior Therapy Skills Workbook (New Harbinger Publications)

DBT Made Simple (New Harbinger Publications) Use promocode 1168SNIPES at New Harbinger for

25% off your entire order. www.dbtselfhelp.com DBT for Substance Abusers

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797106/


Objectives Why was DBT created Understanding Emotional Dysregulation Identify DBT assumptions about clients and

therapists Explore skills to help clients learn

Distress Tolerance Emotional Regulation Interpersonal Effectiveness


Why I Care/How It Impacts Recovery Many of our clients experience emotional

dysregulation The inability to change or regulate emotional

cues, experiences and responses. They have tried to change and failed,

leaving them feeling hopeless and helpless (depressed/anxious)

Untenable emotional experiences lead to self preservation behaviors such as addiction, non-suicidal self-injury, even suicidality


Why DBT Was Created People with emotional dysregulation have:

High sensitivityHypervigilanceOvergeneralizationEasily thrown off kilter (vulnerabilities)No “emotional skin”

High reactivityFight or Flight

Slow de-escalation (Persistent heightened awareness)

Invalidating environment


The Emotional Reaction Hyperawareness of stimuli (Perceptions) Threat perceived (Cognitions) All hands on deck response (Physiological

response—Fight or flight) Actions (Survival)


Primary Invalidation Caregivers dismiss emotional reactions as

invalid Child is mocked, shamed for emotional

response Child is not taught

Self-soothing/de-escalation Mindfulness Effective cognitive processing


Secondary Trauma/Invalidation Coping skills can be overwhelmed by trauma or

intense stress leading to a high-alert “raw” status Many people do not receive necessary support

during these times and may be shamed for being weak or needy

Crisis is a normal response to an abnormal event Most humans are not inherently prepared to deal

with crisis alone What precipitates a crisis may vary between people

based on pre-existing stress or mental health issues


Result High sensitivity + high reactivity +

invalidation = Frantic efforts to numb/withdraw/protect

People learn that who they are and HOW they are results in rejection Avoidance of threats Avoidance of thoughts, feelings, sensations that

may lead to invalidation


Assumptions About Clients Clients

Are doing the best they can Want to improve Cannot fail at DBT Are existing in an unbearable state Need to learn new behaviors in all contexts Are not responsible for all of their own problems,

but are responsible for all of their own resolutions Need to be motivated for change


Assumptions About Therapists Clarity, precision and compassion are of the

utmost importance The therapeutic relationship is between

equals DBT or therapists can fail to achieve the

desired outcome Therapists who treat patients with pervasive

emotional dysregulation need support


Global—Core Mindfulness Rational (Cognitive) Mind + Emotional

(Feelings) Mind + Wise Mind (Intuition and Interpretation)

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


4 Options Tolerate the problem Change your beliefs Solve the problem/Change the situation Stay miserable


Distress Tolerance TIP: Address physiological arousal

Temperature (ice/hot bath)“…hold your breath and dunk your face and head in

for as long as you can hold your breath. Then come up, exhale, inhale and dunk again. Repeat as many times as you need to until you feel quite a bit calmer.”

Intense Exercise Progressive Relaxation

All of these Distract “Explain” or reduce heart rate


Distress Tolerance Distract ACCEPTS

Activities Contributing to the welfare of others Comparisons to others or old self Emotions (opposite) Pushing Away

Build an imaginary wall between yourself and the situation. Imagine yourself pushing it away with all your strength.Block the situation in your mind. Each time it comes up, tell

it to go away, Thoughts (counting, singing, the 10 game, 54321) Sensations (cold, rubber band, smells---avoid taste)


Distress Tolerance IMPROVE the moment

Imagery—Happy place Meaning– Make lemonade Prayer– Radical Acceptance/It is what it is. Relaxation One thing at a time– Focus on one thing, like

breathing Vacation—Take a time out Encouragement—Positive and calming self-talk


Emotional Regulation Goals

Identify, label and understand emotions Decrease unwanted emotional responses Decrease emotional vulnerabilities

Skills Identify and label emotions and their functions Improve self-awareness Conduct behavior chain analysis


Emotion Regulation COP—Police your thoughts

Check the facts Opposite actions Problem solving

Reduce Vulnerability ABC-P Accumulate positives Build mastery Cope ahead of time Physical vulnerability prevention (health, sleep,

exercise)


Emotional Regulation Behavior Chain Analysis

Name the behavior/reaction Identify the prompting event Identify behavioral links (sensations, thoughts,

events, feelings) Short term positive and negative effects Long term positive and negative effects Address the problematic links with skills

Sensations/Actions—Distress toleranceThoughts/feelings– Emotional regulation


Interpersonal Effectiveness DEARMAN

Describe Assess Assert Reinforce Mindfulness Appear confident Negotiate


Relationship Effectiveness Relationship with Others: GIVE

Gentle Interested Validate Easy Manner

Relationship with Self: FAST Fair Avoid apologies Stick to values Truthful


Stagewise Progression of Treatment Stage 1

Move from behavioral dyscontrol to behavioral control

Decrease self-harm behaviors Increase self-care

Decrease therapy interfering behaviors (resistance) Increase motivation and participation

Decrease quality of life interfering behaviors (vulnerabilities)

Increase quality of life behaviors


Stagewise Progression of Treatment Stage 1

Increase behavioral Skills Core mindfulness / Accurate Awareness Distress tolerance Interpersonal effectiveness Emotion Regulation Self-Management / Active Problem solving


Stage 2 - Moderate emotions from excruciating and

uncontrollable to modulated emotional experiencing Decrease

Intrusive symptoms (flashbacks, memories, hecklers)Avoidance of emotions (increase emotional awareness)Withdrawal (increase exposure to life)Decrease emotional dysregulation (heightened and

inhibited)Self-invalidation (increase self-validation)Mood dependency of behaviors (increase accurate

communication of emotional and physical experience)


Create SMART Goals Specific Measurable Achievable Realistic Time-limited


VITALS to Success Validate Imagine the possibilities Take small steps Applaud yourself Lighten your load Sweeten the pot (rewards)


Apply It Practice these skills yourself Which skills have you used or would have been

helpful for you in the past week? Which skills might have been helpful for a

client in the past week


Summary Many disorders involve some amount of

emotional dysregulation That dysregulation can be caused by high

sensitivity and reactivity due to: Innate characteristics and poor environmental fit External traumas and lack of support

DBT seeks first to help the person replace self-defeating behaviors with self-care behaviors

Emotional regulation and interpersonal effectiveness are addressed in the second phase of treatment


Summary A variety of tools are imparted to clients to

help them Set SMART goals Identify and understand emotions and their

functions Decrease unwanted emotional and behavioral

responses Develop a more effective, compassionate and

supportive relationship with self and others Not every tool will work for every person. It

takes some experimentation

Dialectical Behavior Therapy Skills Introduction

Health & Medicine

Transcript of Dialectical Behavior Therapy Skills Introduction