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DBT Skills

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Miyoung Son

on 15 June 2016

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Transcript of DBT Skills

Reasonable Mind
Wise
Mind

Emotion
Mind

Thought Record
Automatic thoughts
Hot thoughts
Underlying assumptions
Core beliefs
Cognitive Restructuring
What is the evidence for my negative thinking?
What alternative explanations could there be?
What Mind Trap am I using?
What effect does this thinking have on me? on others? on my behaviour?
Mindfulness
Distress tolerance skills
Progressive relaxation
Exposure
Thought Record Questions
What was going through your mind before, during, after the situation? What did it mean to you?
If this is true, what does it say about you? about other people? about the world? about the future?
If someone you care about (friend, family, other) had this thought, what would you tell them?
If someone you care about knew you were thinking this way, what would they say?
what is the worst thing that could happen if it is true? the best thing?
what do you/did you think when you weren't feeling so upset?
Automatic thoughts
Cognitive Distortions
Lymbic System
Amygdala activated(Emotion part)
Five Factor Model

Consequences
Wise Mind Therapist
Socratic Questioning with Teens
Many teens have "borderline qualities"
under-developed pre-frontal cortex
increased emotional arousal due to challenges of adolescence.
well developed avoidance strategies
Be in constant look out for Therapist interfering behavior in sessions (see Wise Mind)
Resolving Dialectical Tension
Challenging just enough to expose manageable emotions, thereby providing "exposure" therapy
Addressing therapy interfering behaviors like “I don’t know” and “I don’t care”
always collaborative
"Can we try to figure this out?"
stress "emotional Intelligence" as key relationship building skill
teaches problem solving skills
3 - being able to "read" what the client is thinking, feeling and/or experiencing (avoid assumptions and check for accuracy)
Validation Strategies
critical to maintain cooperation while completing thought record (constantly alternating validation with periods of inquisition/curiosity/the tough questions)
4 - validating the client's behavior in terms of past experiences and current beliefs
5- stressing that the client's behavior is reasonable, meaningful, effective given the situation
target thoughts with thought records
the search for cognitive distortions that impact negatively on the client’s goal attainment, and then to continue with the purpose of cognitive restructuring.
we can get through this together
Emotional Vulnerability
high emotional response
slow to calm down
low "emotional intelligence"
(lack of self-awareness)
vulnerable to impulsive decisions based on strong emotions
when Lymbic System highly aroused (>8), prefrontal cortex shuts down for problem solving and decision making
prepares for "act now, think later" (decision making process would be disrupted so regulation of behavior can be hard)

scale 1-10
reduce vulnerability to emotion mind
constantly check in re: rapport
practice calm and model calm, but keep focus on problem behavior/thought/emotions
target emotions
thoughts
images
memories
Cognitive Distortions
Emotional Reasoning
"I feel .... therefore I am ...."
Personalization
assuming things are about you/directed at you/in reference to you

Filtering
Discounting the Positives
(focused on only negative aspects of situation)
Mind Reading
Assuming
"it's not all about you"
Should's
Judging the past
Unwritten Rules for Behavior
(You should or shouldn't have...)
polarized thinking
black and white
all or nothing
Control Fallacies
blaming oneself/someone for things out of ones control
the Blame Game
"it's my fault that my parents divorced"
includes "victim thinking"
"I did it because he made me"
Convey lots of confidence
"cheer leading"
spirit of collaboration
Apologizes when necessary
Reason Mind
seeks information to "prove" own theories
about factors maintaining behaviors
makes assumptions about behaviors without asking for clarification or probing deeply enough
Emotion Mind
allows client to avoid difficult questions by changing subjects, going on tangents, etc.
backs off when client starts to become upset/angry/hostile
Maladaptive behavior is the solution to the problem (the problem precedes the behavior)
When did the “problem” begin? (subjectively)
Look for precipitating factors (include predisposing vulnerabilities)
Be very thorough – look for co-occurring events that may seem unrelated at first
Link explicit to implicit thoughts
Choose one incident to analyze
)
“you did that just to get attention”
“you do those things to push people away”
“I’d be better off dead”
“they’d be better off if I was dead”
“I wouldn't be suffering if I was dead”
Self-Instructional Training
(Self Talk)
teach client that "self soothing" is taught/learned and that exposure to the emotions during therapy sessions will help to "desensitize" them to the emotions
radical acceptance - sometimes the solution to the problem is acceptance of the problem
Opposite Action
Changes the problem emotion by doing the opposite
Half Smile
Wise Mind avoids invalidating
Contract with the client on
how to terminate the discussion
This avoids reinforcing otherwise effective strategies (client becoming hostile, walking out, shutting down)
Provides opportunity to look at resistance (what do they think might happen if it is talked about?)
Core Mindfulness Skill
Just notice what you think, feel, or experience without describing or labeling - Focused attention
Use your senses (sight, sound, touch, smell, taste)
Don't try to change anything or control your thoughts
Keep coming back - practice observing
What to do?
Observe
Describe
Participate
Using words and labels to identify what you observe
recognize a thought as a thought, not a fact
recognize a feeling as a feeling, not right or wrong
use words that are understood by others
pay full attention to what you are doing
practice makes perfect (or at least better)
be effective, not distracted
How to be mindful
Non-judgementally
do not evaluate (good, bad, right, wrong)
no opinions, just the facts (be objective)
if you judge, just notice it, don't judge it
accept things as they are in the moment
separate act from consequences (eg. behaviors have consequences)
One Mindfully (focused)
focus on one thing in the moment
no multitasking
bring your awareness to the task at hand
Effectively
doing what works, rather than what we think should work
know what your goals and objectives are
often means playing by the rules
let go of behaviors, thoughts and feelings that are self-destructive or undermining
Benefits of DBT
Strengthens a person's ability to handle distress without losing control or acting destructively.
Helps you keep your balance when some emotions overwhelm you.
Boosts your emotional regulation because the more you try to suppress or put a lid on your emotions, the more overwhelming they can get.
Goals of Skills Training
to learn and refine skills to change problem behavioral, emotional, and thinking patterns
INTERPERSONAL
EFFECTIVENESS
SKILLS
EMOTION
REGULATION
SKILLS
Learning to be in control of your own mind
instead of letting it control you
drawn from thousands of years of meditative practice
allows you to balance reasonable mind and
emotion mind in order to achieve wise mind
requires regular practice, even if only a few
minutes daily
MINDFULNESS
SKILLS
express your beliefs and needs to others
set limits effectively(boundaries)
be more assertive
get more of what you want out of life
negotiate solutions to problems
maintain good relationships by saying NO
treat others with respect by finding out what other person needs
maintain your own self-respect by asking for what you want
learn to better understand what you feel and think
resolve confusion about yourself
choose to focus on positive experiences in the moment
avoid spending time thinking about the past or worrying about the future
overcome negative judgments about yourself and others
live a more honest and truthful life
identify emotions and understand their impact on you
gain greater control over emotional ups and downs
recognize anger before it overwhelms you
reduce power of emotion mind
decrease painful experiences - let go of painful emotions
increase pleasure and positive self-esteem
improve quality of life
change painful emotions through opposite action
* My thoughts don't control my life;
I do."
*I can't change what's already happened."
*It is no use fighting the past."
*The present is the only moment I have control over.
* This too shall pass.
* Mistakes happen; nobody is perfect.
# What is yours?
emotional sensitivity
challenging situations
difficulty making sense of things
"what's wrong with me?"
"why do I keep screwing up?"
"I should be doing....."
"I shouldn't be feeling this way"
Understand emotions you experience
observe and describe emotions
understand what they do for you

Reduce emotional vulnerability
decrease vulnerability to emotion mind
increase positive emotions
Decrease Emotional Suffering
let go of painful emotions through mindfulness
change painful emotions through opposite action
Myths about emotions
there is a right way to feel in a situation
letting people know I feel bad is a sign of weakness
negative feelings are bad and destructive
being emotional means being out of control
emotions can just happen for no reason
some emotions are just plain stupid
painful emotions are the result of a bad attitude
painful emotions should be ignored
Emotion Regulation Skills - What for?
Emotions: What are they?
signals within the body that tell you what's happening
emotional experience (thoughts, feelings, sensations)
evolutionary function - rewards pleasure seeking and avoids pain - fight or flight response (survival)
can be useful or destructive
prompted by events (input from the senses)
external events (eg. angry when insulted)
internal events (eg. guilty about forgetting birthday)
primary emotions (anger, sorrow, joy, surprise, fear, disgust, guilt/shame, interest)
often adaptive and appropriate
tend to be transient - come and go with the situation
a "wave" of feelings
secondary emotions - "feelings about feelings"
tend to be emotions like guilt, shame, anger
tend to overshadow primary emotions - often maintained by thoughts/patterns
can be self-perpetuating when unresolved - become "moods"
Model for Describing Emotions
Function of emotions
communicate to others and influence others
expression requires attending to emotions, describing and naming
types of expression
body language (para-verbal)
words
actions
many emotions trigger urges/physical responses (eg. facial expressions) - this is universal
Practice Exercise
one member - describe a situation or event (just facts)

another member - give an interpretation (meaning)

another member - describe the emotion

another member - give another interpretation

another member - describe the emotion
communicate to ourselves (likes, dislikes, etc.)
gives us information about what is happening for us
sometimes emotions are triggered by unconscious thoughts - these are "automatic" (eg. spiders)
can have a "sense" that something is wrong but can't put words to it.
self-validation (trusting one's responses or "tru)

Self-Expression
Self-Awareness
Organize and Prepare for Action
motivate us to take action
action urge connected to some emotions is hard wired (fight/flight)
saves time (not having to think through a situation) eg. guilt

Thought Defusion
Through Imagination
Build Positive Experiences
do things that trigger positive emotions - hobbies, interests
strong emotions distort thinking - develop self-awareness
make a list of positive goals - do things that help you achieve them, step-by-step
don't put all your eggs in one basket
avoid avoiding - don't give up (learned helplessness)
use distress tolerance skills to minimize negative outcomes (cycles)
attend to relationships - make new relationships (use interpersonal skills)
be mindful of positive experiences (glass half full) -
avoid being mindful of worries
develop "Opposite to Emotion" skill
enhance the overall quality of your life -
Pleasant events
- evoke positive imagery
- go for a walk
- listen to music
- do something with a friend
- have a hobby
- watch a favorite show
- plan something to look forward to
- think of positive memories
- play a game
- learn to play an instrument
- practice relaxation skills (body scan)
- call a friend and ask about their day
- do a task that you have been avoiding (clean your
room; organize desk; finish assignment)
Let Go of Negative Emotions
"riding out the wave"
practice the WHAT skill
just observe the emotion
don't try to block or control it
don't try to suppress it
don't hold onto it
don't amplify it
learn to label the primary and
secondary emotions
Be Mindful of the Emotion
Always remind yourself
you are NOT your emotion
get distance between you and the emotion
you don't have to act on your emotions
an urge is just an urge
remember times you felt differently
remember times things turned out better
don't judge your emotion
radically accept your emotion
compare yourself to others who are worse off
(exposure)
Opposite Action
change emotions by acting opposite to the current emotion
Fear
Guilt / Shame
Sadness / Depression
Anger
assess the realities
do what you are afraid of doing
approach things you are avoiding
take small steps to avoid feeling overwhelmed
do things that help you feel in control
Pain does not equal suffering
painful emotions will always come and go while suffering is sustained by an unwillingness to accept things as they are, rather than how we think they should be.
assess if guilt or shame is justified
repair the relationship
apologize, make it up to the person
try not to make the same mistake again
accept the consequences
let it go - don't beat yourself up
get active
approach rather than avoid
call someone
do something
flight
run
withdraw
hide
avoid
defend
avoid
sleep
isolate
fight
attack
lash out
urge =
urge =
urge =
urge =
assess if in emotion mind
do something nice rather than mean
be friendly rather than cold
avoid rather than confront
think of sympathy rather than blame
try to see things from their point of view rather than yours
Emotion Regulation Skills
Interpersonal Effectiveness Skills
building and maintaining positive relationships
Why use skills
Attend to Relationships
don't let hurts and problems build up
use skills to head of problems
resolve conflicts before they overwhelm
end hopeless or destructive relationships
interact in ways that make you feel good instead of helpless and/or overly dependent
stand up for your beliefs and opinions
Balance Priorities
between what's important to you
and what's important to others
ask others for help when needed
say no when necessary
get others to take your opinions seriously
balance what you "want" to do (things that make you happy)
with what you "should" do (things that need to get done)
What for?
Achieve your objectives (asking for or saying no)
Maintain healthy relationships
Maintain your self-respect
be effective
get people to do what you want
get people to take your point of view seriously
resolve conflict
refuse to be controlled by others
act in ways that keep people liking and respecting you
balance current goals with maintaining long term relationships
respect your own values an beliefs
feel good about yourself
act in ways that make you feel capable
Things that get in the way of being effective
Lack of skills - not knowing what to say or how to act
Worry thoughts that get in the way
worrying about negative consequences (eg. "they'll think I'm greedy")
worrying about whether you deserve to get your way (eg. "I haven't done anything to deserve this")
worrying about not being effective (eg. "I won't be able to get them to understand")
Emotions controlling what you say or do - being in emotion mind rather than in wise mind
Indecision - not being sure of what you want or what you should do
- not being able to identify your needs
Things in the environment
other people are too powerful
other people will have some reason for not liking you if you get what you want
other people won't give you what you want or let you say no without punishing you
Myths about Interpersonal Effectiveness
if I ask for something, it will mean I'm helpless
I should be willing to sacrifice my own needs for others
Saying no to someone else means I'm selfish, or don't care
the problem is just in my head, so I should solve it myself
telling yourself that you don't care - denial
if they reject me, I will fall apart
if someone else is upset with me I'll feel bad
it takes a strong person to admit they need help
my needs are just as important as the needs of others
I can care about someone and still say no
the problem is between me and them
being aware of my wants and needs is important
I can handle rejection and move on
I can still feel good about myself even though someone
is upset with me
Wise mind statements
Obstacles
raised in punitive way
invalidating
family lacks role models
too many "should's" leads to resentment, depression, anger
too many "wants" leads to irresponsible lifestyle (eg. not keeping comittments)
Obstacles
Problems
can ask strangers but not friends
can use skills in some situations but not others (eg. alone vs. in front of others)
good at asking but not at saying no, or vice versa
and....
instead of ....
active passivity
apparent competance
getting other people to do things by acting helpless
manipulating situations negatively - "victim" -"I can't" thinking
"acting out" - eg. self harm to get compassionate attention
coming accross as okay when you are not
saying you don't need help when in reality to you
failing rather than asking
Cheerleading
positive self-talk
things we say to encourage ourselves
using imagery to practice
use encouraging statements of friends
give us the courage to act
prepare for the situation
counteract unrealistic assumptions
Skills for achieving your objective
D
escribe
E
xpress
A
ssert
R
einforce
briefly describe the situation you are reacting to. "I think"
be objective and stick to he facts, avoiding judgments.
express feelings about the situation clearly - "I feel"
don't expect the other person to know how you feel
clearly ask for what you want. "I want"
don't tell them what they should do

reward people who respond positively to you
suggest possible effects of getting what you want beforehand
M
indfully
A
ppear
confident
N
egotiate
keep your focus on your objective - keep making your point
don't be distracted - ignore attempts to divert you
use a confident tone of voice - don't come accross as unsure
maintain eye contact
be willing to give something to get something
turn the table - ask them to come up with a solution
Relationship Effectiveness
be
G
entle
avoid raised voice or aggressive manner
don't make manipulative statements or hidden "if..then" threats
no judging (avoid "shoulds" or guilt trips
act
I
nterested
listen to the other person's point of view
don't interupt or talk over them
be patient
(GIVE) skill
in pairs, practice validating responding and invaldating responding
Practice Validation
V
alidate
acknowledge the other persons feelings and opinions
be non-judgemental
may involved mind-reading
E
asy manner
be friendly - smile
use humour
positive manipulation - make it easy for them to give in
be mindful of prioritizing Long Term effectiveness over Short Term
(allow the person to be angry with you today when you "stand up for yourself')
Self-Respect Effectiveness
be
F
air
don't
A
pologize
S
tick to Values
be
T
ruthful
be fair to yourself and the other person as you try to solve the problem
don't do things that damage your self-respect (cheating; taking advantage)
for asking, disagreeing, or having an opinion
apologies imply that you are wrong; excessive apologies often irritate
balance "relationship effectiveness" apologies with "self-respect" skills
be mindful of your values, morals, beliefs, integrity
don't "sell out" to make friends or get your way
don't lie, exaggerate - may work in short term but causes damge over the long term
don't act helpless when you are not - active passivity damages relationships
if you decide to die ("white lie"), do it mindfully (effectively)
(FAST) skills
Objectives Effectiveness
(dear man) skills
Old habits of the aggressive kind
often learned in the home; school; playground
Discounting - invalidating the other persons needs or feelings
Withdrawing or Abandoning - threaten to leave or end the friendship
Threatening emotional or physical pain - often implied "you just wait and see"
Blaming - making the problem the other person's fault
Belittling - making the other person feel foolish for their wants/needs
Guilt-tripping - making the other person feel their needs/wants are morally wrong
Derailing - changing the subject, getting off focus
Taking away - withdrawing something positive (eg. "I don't feel like going to the movie" because you are upset with the other person)
Old habits of the passive kind
avoiding
Distress Tolerance
A
ctivities - keeping busy
C
ontributing - get your mind off yourself
C
omparisons - "it could be worse"
E
motions - change the moment - "half smile"
Push Away - block out thoughts/feelings
Thoughts - distracting thoughts; SITS
Senses - do something that activates the senses

Wise Mind "Accepts"
Self-Soothe
Vision - draw, watch TV, be creative
Hearing - listen to music, go for a walk and listen
Smell - have a scented bath
Taste - make a snack - treat yourself
Touch - sink down in a couch
Improve the Moment
Imagine - think of better times, better things
Meaning - look for one positive in the situation
Prayer -
Relaxation - quite your body - breathing mindfully
One thing in the moment - try to focus your attention
Vacation - take a time out; daydream
Encouragement - SITS - tell yourself things will be okay
Deep Breathing (focus attention on the movement of your stomach as it rises and falls. Breath into your stomach, then your lungs. Breath in longer than you exhale to slow it down.
Mindful Walking (co-oridnate your breathing with your steps)
Counting Breath (like counting sheep, but with breath)
Scan Your Body (sit or lie down, paying attention to your body in sequence. Start with right foot, then ankle, then calves, etc.)
Quiet Your Muscles (like the scan, but as you focus, tense the muscle for a few seconds, then relax it - go through the body)
Breath Exercises
Pros and Cons
make a list of pros and cons of TOLERATING the distress using skills and NOT TOLERATING the distress and act on impulse
focus on long term goals - the light at the end of the tunnel
think of the positive outcomes of avoiding the impulse, and spend time imaging it
think of the negative outcomes of acting on the impulse - remind yourself of past outcomes
Getting Through Painful Emotions Without Making Things Worse
Fear Mindfulness
Close eyes - imagine fear situation with people in the room - imagine that everyone feels the same fear -
Dialectical Behavior Therapy
(DBT)
living the good life through
wisdom and balance



4 Skills of DBT
1. Distress Tolerance
Helps you focus on one thing at a time in the present moment. By doing this, your overwhelming emotions do not get the better of you.

Helps you learn to identify and separate judgemental thoughts from your experiences. These judgemental thoughts often fuel your overwhelming emotions.

3. Emotion Regulation Skills
2. Mindfulness
4. Interpersonal Effectiveness
DBT and Parenting

Seated process when all members are home and reasonably calm
the third party to a conflict must seek a dialectical conclusion (both/and)
If you are "coaching" someone with "intrapsychic" conflict, seek dialectical synthesis (see wise mind)
Address cognitive distortions and bring them to the surface (see list of thought distortions)
Validate the presence of strong emotions (see validation levels)
Coach both sides using DEAR MAN GIVE FAST skills (see skill details)
Take notes - a record of what is being said
Create Family Consultation Team
Be in control of your mind
by controlling your
attention !
Distract Yourself from Self-Destructive Behaviors
(Taking Hold of your Mind)
Pick a Practice
attend to sensations
notice your thoughts
mind eyes (imagine)
notice distraction and refocus attention
Observing
Describing
label what you observe
list descriptive words
thoughts vs. facts
notice types of thoughts
about self
about others
judgements vs observations
Participating
the act of doing
ultimate goal of observing and describing - "to be good at doing...."
sports
acting
working
After what I told you not to think of RED,
did you actually think or picture The RED
or not?




Mindfulness
Focus on a single object
Imagine
body scan
sensing
(inner/outer)
thought diffusion
emotion conjuring
mindful breathing
judgements/labels
mindful "I"
Obstacles
(willful desire, aversion, sleepiness, restlessness, self-doubt)
Presented by Miyoung Son

* Radical Acceptance
-Getting angry or upset over a situation stops you from seeing what is really happening ("Being blind by rage")-

1) Acknowledge your present situation, whatever it is,
without judging
the events or criticizing yourself.

2) Looking at yourself and the situation and seeing it as it really is.

3) Refocus your attention on what you can do now.

<Keep in mind that radical acceptance does not mean that you condone or agree with bad behavior in others. However, it means you stop trying to change what's happened by getting angry and blaming the situation>
Radical Acceptance Coping Statements
* Instead of hurting yourself, hold an ice cube in one hand and squeeze it.
*Draw faces of people you hate on balloons and then pop them.
*Write letters to people you hate or to people who have hurt you.
*Throw foam balls, rolled-up socks, or pillow against the wall as hard as you can
*Cry


# Any ideas?
Do not think about or picture the color of RED!!
Is that so?
" You can't always control what you feel, but you can control how you react to those feelings."
1. Imagine sitting in a field watching your thoughts float away on clouds.
2. Picture yourself sitting near a stream watching your thoughts float past on leaves.
3. See your thoughts written in the sand and then watch the waves wash them away.
4. Envision yourself driving a car and see your thoughts pass by on billboards.
5. Imagine sitting beside a tree and watch your thoughts float down on leaves.
6.Picture yourself standing in a room with two doors; then watch your thoughts enter through one door and leave through the other.
Thinking function
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