Created by Marsha Linehan

Ali Gold

*Dialectical Behavioral Therapy(DBT)

*What is DBT?

*Marsha M. Linehan developed DBT in 1993 when CBT and other therapies proved to be unsuccessful with a “specific type” of clients

*These clients were emotionally unstable, sometimes suicidal, and usually engaged in self-destructive behaviors- typically diagnosed with borderline personality disorder

*DBT targets BPD and also other disorders such as depression, bipolar disorder, PTSD, anxiety, eating disorders, alcohol/drug abuse, and in any combination

*The Human Mind

*The human mind is like a radio, it is hard wired differently each time. Some people are wired to experience frequent, stronger emotions than most.

*Trauma can also create stronger specific emotions, as can a chemical imbalance left untreated

*BPD and DBT Clients

*Many factors contribute to BPD and the DBT client but two stand out:

*Emotional vulnerability- quick, intense, difficult to control emotions; like a rollercoaster

*Invalidating environment- the failing to treat a person in a manner conveying respect, attention, or understanding

ex. A shy family member in an outgoing family being teased for his or her shyness

*DBT Therapy

*Individual therapy once or twice a week

*Usually includes patient filling out a daily diary card: rates urges/thoughts/actions/emotions and records skill use

*Group therapy once a week for at least 6 months

*Phone coaching- a client can call/text their therapist in order to receive skills coaching before engaging in a target behavior

*Focuses on 4 modules: mindfulness, emotional regulation, interpersonal effectiveness, and distress tolerance

*Dialectics

You can’t walk in the same river

twice.

*Dialectics

*You can AND can’t walk in the same river twice.

*This is a dialectical statement. A dialectic is an idea in which two

seemingly opposite statements can be true. This component is crucial to DBT

because it helps clients think in a more open and less judgmental way. The

concept of dialectics helps balance the mind and find the middle path between

two extremes. Change is the only constant in life.

With this idea,

we can more easily find acceptance.

*Mindfulness

*Goals:

*Increase awareness of internal and external experiences as they occur

*Learn how to non-judgmentally and effectively observe, describe, and participate in events and experiences

*Increase ability to focus attention on one thing in the moment

*Learn to be in control of your mind rather than your mind being in control of you

*Mindfulness

*Activities: meditating, prayer, yoga, walking, anything as long as you are being mindful and in the moment!

*Mindfulness aims to reduce suffering, increase happiness, and experience reality as it really is

*Helps us find wise mind- both reason and emotion are integrated and find balance- the middle path

Rational Mind

Facts

Reason

Logic

Emotional Mind

Moods

Feelings

Urges to do or say something

*Mindfulness

*Exercise:

*Hold a piece of wrapped gum, be in a quiet environment, focus solely on the gum and nothing else, let thoughts and judgments pass

*Observe it: sight, smell, touch, (taste)

*Unwrap it and let it rest on your tongue without chewing, observe senses

*Take ONE chew, observe senses

*Chew and observe and discuss

* Could you stay focused, one in the moment?

*Emotion Regulation

*Goals

*Understand emotions and how they function

*Increase awareness of emotional experience

*Increase control over difficult emotions

*Increase positive experiences

*Decrease emotional suffering

*Emotion Regulation: ABC

PLEASE

*Accumulate positive experiences- do pleasant things, “build a life worth living”

*Build mastery- do things that make you feel competent and effective

*Cope ahead for emotional situations- rehearse/plan out in order to feel prepared to cope skillfully with stressful situations

*Emotion Regulation: ABC

PLEASE

*(treat) Physical illness

*Lather, rinse and repeat

*Eat (balanced and well)

*Avoid mood altering substances (alcohol, drugs, caffeine too!)

*Sleep (enough and not too much)

*Exercise

*TAKE CARE OF YOUR MIND BY TAKING CARE OF YOUR BODY!

*Emotion Regulation: examples of mind-

body connection

* Your body and mind are connected. Taking care of one is taking care of the other. Example of someone with depression: This person is depressed; they sleep all day and don’t have healthy eating habits. Without the proper nutrients or beneficial amount of sleep, this person will have even more difficulty managing emotions, possibly making them more depressed.

* Another note: let’s say the once depressed person is recovering and doing well. Then, they get sick and as a result are more tired and begin to sleep more. Their body will associate sleeping more with being depressed, so that person will be apt to feeling low. How do we cure the low mood? Trick the body and do the opposite!! Eat well, balance the sleep, and get up and out! Even just smiling WILL lift the mood!

Depressed

Sick

Sleeps more

Emotionally

vulnerable

BREAK THE CYCLE!

Trick the body and

follow PLEASE!

*Interpersonal Effectiveness (IPE)

*Goals

*Build and maintain relationships

*Learn how to set limits and boundaries

*Effectively asking for what you want and/ or need

*Prioritizing and organizing wants/needs

*Building mastery and preserving self-respect

*IPE: DEARMAN- getting what you

want or setting limits

*Describe the current situation

*Express your feelings and opinions about the situation

*Assert yourself by asking for what you want or saying “no” clearly

*Reinforce or reward the person ahead of time by explaining consequences, good or bad

* (stay) Mindful, keep the focus on your objectives

*Appear confident and effective

*Negotiate, be willing to give and get

*IPE: FAST and GIVE

FAST: maintain self-respect and communicate personal limits

* (be) Fair- both to yourself and others

* No over Apologizing- confident body language

*Stick to values- don’t sell out your own values and integrity

* Be Truthful-don’t lie, act helpless, or exaggerate

GIVE: Repair and/or build relationships that you care about

* (be) Gentle- be courteous, no attacks, no threats, no judging

* (act) Interested- actively listen, eye contact too!

*Validate-acknowledge the other person’s feelings, wants and difficulties… “I can understand how you might feel”

* (use an) Easy manner- a little humor never hurts, smile and ease the person along

*IPE: CONCEPT

“Do you want to be right,

OR BE

EFFECTIVE?”~Michael Hollander, DBT Specialist

*Distress Tolerance (DT)

*Goals

*Learn how to effectively tolerate painful experiences

*Increase awareness of how distress is represented in your life

*Learning how to decrease suffering through acceptance of reality

*Increasing willingness over willfulness

*DT: Crisis Survival

Strategies- TIPP

*“TIPP” your body chemistry (great for anxiety and anger)

*Temperature-submerge your body (face especially) in ice cold water, put an ice pack on your chest

* This extreme cold enacts the divers reflex in your body (cheek bones/nose, chest, back of neck) which physiologically slows down your heart rate from 10-25%

*Intense exercise- at least 20 minutes, get the heart rate up!

*Progressive Muscle Relaxation (PMR)- clench and release each muscle one at a time

*Paced Breathing-focus on how long each breath in and out is, goal is to exhale longer than inhale

*DT: Crisis Survival

Strategies- ACCEPTS

*Distract yourself from painful emotions when things cannot get better right away

*Activities- exercise, hobbies, cleaning, friends

*Contributing- volunteer, give gifts, be thoughtful

*Comparisons- find reasons for appreciation

* (opposite) Emotions- emotional books, music, TV

*Pushing away- leave the situation, no ruminating

* (other) Thoughts- count things, puzzles, TV, read

* (other) sensations- hold ice, stress balls, showers

*DT: Crisis Survival Strategies- self-soothe

*Self-soothe with the five senses

*Vision- art museum, observe nature, photos

*Hearing- music, nature, instruments, waves, rain

*Smell- lotions, candles, flowers, cookies,

*Taste- yummy meal, tea, hot cocoa, gum, candy

*Touch- bath, pets, massage, comfy chair, hugs

*DT: Crisis Survival Strategies- IMPROVE

*IMPROVE the moment

*Imagery- imagine relaxing scenes or views, let your mind lay open, beautiful, calming fantasy worlds

*Meaning- create purpose, meaning or value in the pain, focus on positives

*Prayer- God, a higher being, yourself, beliefs

*Relaxation- PMR, hot tub, bath, breathe deeply

*One thing in the moment- focus/stay in the present, be fully aware

* (brief) Vacation- bundle up in a blanket, sit on a park bench for an afternoon, a one-hour breather

*Encouragement- cheerlead yourself, “It won’t last forever,” “I can stand it,” etc

*DT: Reality Acceptance

*Radical Acceptance: Accepting what you cannot change in the moment; turning the mind over to acceptance- it is your choice to accept or not

*Willingness: let go of judgments and do what is effective

*Keep long term goals in mind!

*Make a pros and cons sheet of benefits and negatives of long term and short term actions

*Non-DBT Skills Taught With DBT

*Consulting to the Patient

*CBT

*Problem Solving

*Mentalizing

*Consulting to the Patient

*Goal: To be effective in handling treatment/any medical issue…managing the system

* Interact effectively with psychiatric/medical caregivers to* Get emergency care

* Get meds added/changed/discontinued

* Communicate needs

*Understanding the system

* How/why caregivers make decisions

*Understand professionals are doing the best they can and are fallible

It’s about getting the patient involved and aware about medical specialists’ decisions on what goes

into the patient’s body and why. It’s about honesty- as a patient you know your body best!

*Cognitive Behavioral Therapy (CBT)

*How thoughts affect our mood and behavior:Ex. A student studies hard and works hard to learn math

concepts. He receives a 62% on his first big test. He feels discouraged and depressed and skips the next class, considers dropping the class altogether, and considers changing his career goals.

Usually this creates a pattern. A way to break the cycle is to change one of the steps. In this case, and CBT, we change the thought process. We can’t change what we think but we can change how we think. We can identify cognitive distortions.

Events/situationWorks hard/gets 62%

ThoughtsThat’s a horrible score; I’m stupid; I’m going to fail the class, I can’t do

math

Feelings/BehaviorsDepressed; avoids next

class; drop class? Change career?

*CBT Cognitive Distortions

*Cognitive Distortions are biases in information processing associated with our negative mood states. We do it all the time! It’s the way our mind makes sense of things in the blink of an eye. Remember, thoughts aren’t facts!

*Ex.

*All or nothing thinking- everything is black and white, right and wrong, good and bad; if you fail one test you’re a total failure

* Emotional Reasoning- You assume your negative emotions reflect reality; I feel guilty, I must be a rotten person

* Jumping to conclusions-

* Mind Reading: without fact, you immediately assume someone is negatively reacting to you; you walk by a group of kids talking and “you know” they’re talking about you

* Fortune Telling: You predict things will turn out badly; “you know” you’re going to flunk a test… before you take it! Or, if you’re depressed, “I’ll never get better.”

Ways to Approach a Problem

*Solve the problem

*Change your relationship to the problem

*Radically accept the problem

*Stay Miserable

*Make the problem worse

Steps to Problem Solve

*Observe/describe the problem

*Check the facts (get rid of distortions)

* Identify the goal (what needs to happen to feel ok; keep it realistic)

*Brainstorm solutions (as many as you can!)

*Choose a solution likely to work (pick two, make a pros and cons to compare them, pick the best)

*Put the solution into action!

*Did it work? If not, try a new solution.

*Problem Solving

*Mentalizing

*Mentalizing is a process by which you are able to represent and understand the thoughts, feelings, wishes, beliefs, and desires in yourself and in others. Mentalizing requires that you take a curious and unattached stance about all situations. Imagine there’s a bubble around everyone’s head, and in that bubble lay thoughts, feelings, behaviors, etc. Mentalizing is being curious and open and guessing what’s in your own and others’ bubbles. A further step may be guessing what’s in someone’s bubble and guessing how your own bubble impacts his or hers.

*Failures to Mentalize

* Mentalizing is like a muscle, with practice it gets stronger. Many times,

we as humans fail to mentalize.*“Psychic equivalence”- if I feel it, then it must be

true; “I feel unlikable therefore nobody likes me.”

*“Pretend Mode” or “Pseudo-mentalizing”- It’s like you’re in autopilot. Instead of mentalizing and being present you just agree with others’ explanations about you. Perhaps someone assigns an explanation to one of your behaviors and it sounds kind of right, so you agree. Where’s the curiosity?

*“Teleological Stance”- when one feels that an internal experience is only real if there is evidence in the physical world. “If you loved me you would have given me flowers;” “I am only smart if my teachers call on me a lot in class.”

*DBT

*ABC’s of DBT:*Acceptance

*Balance

*Change

*Thank you for your patience and listening. If ever you find someone (a friend, OR YOURSELF!) who you think could benefit from DBT or worries you because they’ve been engaging in self-destructive behaviors, don’t be afraid to notify a trusted adult. It’s nothing to be embarrassed about, DBT truly changes and saves lives. If you have any questions about DBT or personal matters, don’t be afraid to find me. Thanks again!

*Citations

*A SPECIAL THANKS:

*Marsha Linehan: many books and teachings

*Clip Art

*McLean adolescent DBT programs* http://www.google.com/imgres?

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* (diary card picture)