1. Dialectical Behavioral Therapy

2. CONTENTS The program Main concepts: Skills Diary card Neuroplasticity - paths 2

3. DBT STRUCTURE WHAT’S INCLUDED  Weekly individual therapy  Weekly skills training group  Coaching  Homework HEIRARCHY OF PRIMARY TARGETS PRETREATMENT Orientation to treatment Agreement on goals FIRST STAGE TARGETS Decreasing suicidal behaviors Decreasing therapy interfering behaviors Decreasing quality of life interfering behaviors Increasing behavioral skills Core mindfulness Interpersonal effectiveness Emotion regulation Distress tolerance Self management SECOND STAGE Decreasing posttraumatic stress THIRD STAGE Increasing respect for self Achieving individual goals 3

4. DBT TEAM  All members are coaches  All members can facilitate groups  Therapists  Coaching: to assist with and encourage skill use in a moment of dysregulation Groups:  1 st hour – review  2 nd hour – new learning  One facilitator teaches, sets the agenda, keeps members on task  Other facilitator adds to the teaching, observes members and acts when needed to have brief 1:1 with a member who is dysregulated or struggling in some way Therapy:  Review diary card and homework - session topic can be found from this  Mandatory priority: life-threatening therapy-interfering quality of life -interfering 4

5. VALIDATION Ways to be validating:  Show interest - listen with your whole body  State observations, repeat back for clarity, summarize  Find something to agree with, don’t try to talk them out of what they are thinking (at least while validating)  Make connections to past things said or from your knowledge of the person’s life  Point out the biology of illness or the latest findings in literature to back up their statement, how it is true for this society, or their life today  Radical genuineness – present similarities in your own life or others you’ve worked with, remember to not upstage them, make it sound like you are better than them, and it should be brief and relevant; and perhaps add how you cope or moved on Sentence starters:  Of course you do/would/feel, how could you not  That makes sense because  That’s understandable/I get that because  Okay, that’s true for you now, let’s figure out how to change that  I know you feel that way but it is pretty self-invalidating, explain to me how that’s true 5

6. CONCEPTS Dia – what? You may not have caused all your problems but you are the one who has to fix them. Pain vs. suffering (extending the pain) Moving from a life of misery to one worth living There is a reason for everything Mindfulness – in the moment 5 options for responding to problems 6

7. CONCEPTS THREE MINDS REASONABLE MIND Respond to information intellectually Think rationally and logically Plan and evaluate logically Focused attention Upside: Can utilize the skills to build, create, discover, advance EMOTION MIND Thinking and behavior are controlled by the current emotional state Good judgment is difficult Facts are distorted to match emotion Upside: Creates motivation and sacrifice when needed, creates beauty, shows passion and compassion WISE MIND Emotion mind and reasonable mind working together Response to painful emotions does not increase suffering To accept the truth and accept it as valid – there is a reason for everything Upside: Wise mind allows people to use their emotions for drive, passion, generosity, safety and making choices while utilizing rational thinking to be logical and engage in effective decision making. ** No one is in wise mind all the time 7

8. SCIENCE OF MINDFULNESS The Science of Mindfulness - Dr. Daniel J. Siegel Fifth-grade girls who did a ten-week program of yoga and other mindfulness practices were more satisfied with their bodies and less preoccupied with weight. A prison offering Vipassana meditation training for inmates found that those who completed the course showed lower levels of drug use, greater optimism, and better self-control, which could reduce recidivism. Eight weeks of MBSR (Mindfulness-Based Stress Reduction) resulted in an improvement in the immune profiles of people with breast or prostate cancer, which corresponded with decreased depressive symptoms. http://psychcentral.com/news/2007/06/22/the-science-of-mindfulness-meditation increased activity in the amygdala, which serves as an alarm to activate a cascade of biological systems to protect the body in times of danger seeing an angry face and simply calling it an angry face changes our brain response “When you attach the word ‘angry,’ you see a decreased response in the amygdala” increased activity in the right ventrolateral prefrontal cortex which is associated with thinking in words about emotional experiences. 8

9. CONCEPTS Dialectical Dialectics represent the mind’s way of understanding concepts by understanding and appreciating their polar opposites. Dialectics are based in part on the fact that we cannot fully understand any of these abstract concepts without appreciating that they consist of bipolar opposites with a higher level of integration somewhere in between them. Concepts, including self esteem, trust, courage, honesty, rage, passivity, withdrawal, impulsivity, inhibition, blameworthiness, guilt, risk taking. First dialectic: Change vs. Acceptance Thought distortion: All or Nothing OPTIONS FOR RESPONDING TO PROBLEMS 1. SOLVE THE PROBLEM 2. CHANGE YOUR EMOTIONAL REACTION TO THE PROBLEM 3. TOLERATE/ACCEPT THE PROBLEM  4. STAY MISERABLE  5. MAKE THINGS WORSE  9

10. CONCEPTS Primary and Secondary Emotions PRIMARY EMOTIONS  Immediate emotional reaction to something said / thought / that occurred  Emotion felt before much thought occurs, and is sometimes out of habit  Anger is often primary after years of being the only emotion allowed, to protect other feelings SECONDARY EMOTIONS  Emotion that follows the primary emotion and may be a reaction to that emotion  Can come quickly and seem to be primary  Prompted by faulty or real interpretations of an event  Valid reasons that your mind goes to the secondary emotions  Following the event thoughts are generated about factors outside of the event (moment)  This may include:  Unworthiness  Fears of what others think  Predictions about the future  Further proof of the patterns one has found to be true for themselves 10 PROMPTING EVENT______________________________________ Primary EmotionsThoughtsSecondary Emotions SKILLS TO USE _________________________________________

11. SKILLS CORE MINDFULNESS  You’re in wise mind when you feel settled with what you did and it stays the next day  Balances the reasoning of your thoughts with the needs of your emotions What skills: Observe, Describe, Participate Observe - noticing events, emotions and behaviors even if they are distressing, the emotion it produces, sensing without words, to realize that what you are feeling may not be what is happening, to step back and see clearly Describe - the response to observing, to label a behavior or event for better communication and control, (feeling afraid does not mean a situation is threatening) Participate - without self-consciousness, taking part in the current moment How skills: Non-judgmental, One-mindfully, Effectively Non-judgmental - to not judge good or bad, worthwhile or worthless, etc., to have facts before forming impulsive opinions One-mindfully - focus on one thing in the moment and not be distracted by worries about the future, memories of the past, other events that are occurring peripherally Effectively - doing what works rather than what’s deemed right or wrong, worthwhile or worthless, reacting to a situation not what a situation should be 11

12. SKILLS EMOTION REGULATION SKILLS  Identify feelings previously unrealized or accepted  decrease sensitivity by living healthy  questioning interpretations and judgments  gaining better control of emotional responses to prevent situations that are later regretted PLEASE MASTER (Treat) PhysicaL illness (Balance) Eating (Avoid) mood-Altering drugs (Balance) Sleep (Get) Exercise (Build) MASTERy OPPOSITE TO EMOTION ACTION - changing the usual emotional response to one that results in a different outcome, action is opposite or alternative to the usual reaction of a negative emotion BUILD POSITIVE EXPERIENCES – Create balance in life and learn how to allow pleasure **BE MINDFUL OF POSITIVE EXPERIENCES…...BE UNMINDFUL OF WORRIES** 12

13. SKILLS INTERPERSONAL EFFECTIVENESS SKILLS For greater effectivness with interactions by learning ways to communicate that is proportionate to the situation, respectful of yourself and others and more often results in better outcomes. DEAR MAN – Objective Effectiveness  Describe - the current situation  Express - your feelings and opinions about the situation  Assert - ask for what you want or say no clearly  Reinforce - or reward the person ahead of time by explaining outcomes/consequences  (stay) Mindful - keep focus on objectives, using broken record or ignoring distractions  Appear confident - and effective and competent  Negotiate - be willing to give to get, consider alternative solutions FAST - Relationship Effectiveness  (be) Fair  (no) Apologies  Stick to your own values  (be) Truthful GIVE – Self-Respect Effectiveness  (be) Gentle - no attacks, threats, judging  (act) Interested - and listen  Validate the other person  (use an) Easy manner 13

14. SKILLS DISTRESS TOLERANCE  Learning to withstand pain skillfully  Ability to tolerate distress  Accepting oneself and one’s situation for what is true, even if not preferred  To perceive one’s environment without putting demands on it to be different CRISIS SURVIVAL SKILLS SELF SOOTHE - utilizing any of the five senses for comfort  Stare at the stars  Aromatherapy  Petting your chinchilla  Listening to the Bach Minuet in G Major or Thomas Rhett’s “Get Me Some Of That”  Eating watermelon DISTRACT - moving your focus to something unrelated to the current dysregulated thinking  Activities  Contributing  Comparing oneself to people less well off  Using “opposite” emotions  Pushing away painful thoughts  Utilizing intense sensations 14

15. SKILLS DISTRESS TOLERANCE IMPROVE THE MOMENT  Imagery - viewing a beautiful scene, walking through that scene in your mind  Finding meaning in the distress  Relaxation (one-mindfully)  Focusing on one thing in the moment  Taking vacations (without guilt and relatively brief)  Self-encouragement PROS and CONS  Considering the positive and negative aspects of tolerating vs. not tolerating distress  Goal – “face the fact that accepting reality and tolerating distress lead to better outcomes than do rejecting reality and refusing to tolerate distress” PROS CONS TOLERATING NOT TOLERATING OTHER SKILLS: Breathing, Awareness, Half Smile 15

16. CONCEPTS and SKILLS DISTRESS TOLERANCE ACCEPTANCE SKILLS RADICAL ACCEPTANCE – see next slide TURNING THE MIND  Opening yourself to the idea of acceptance  Requires commitment to this openness over and over and over……………. WILLINGNESS  Allowing the world to be what it is and participating in it  Being open to change  Doing just what is needed in a situation, being effective  ALLOWS EVERYTHING TO HAPPEN, WITHOUT IT THERE WILL BE NO CHANGE. WILLFULNESS (not a skill)  Giving up…sitting on your hands…not doing what works…resistance…avoidance  It is protective!  Refusing or unable to tolerate reality with attempts to redirect anything that could induce a difficult feeling  Control or otherwise manipulate existence, saying “no” or “yes, but” 16

17. SKILLS RADICAL ACCEPTANCE  Complete acceptance of what is true from deep within  Requires:  For you to change the direction you allow your mind to go  That you accept that you have the ability to act with the power of choice and that most things are choices  Acceptance of relationships and oneself without distortion or judgment of good or bad  Willingness to enter into a situation filled with pain and refrain from trying to stop the pain  It is not approval or agreement with what is true, just admitting to the fact of it 17

18. DIARY CARD 18

19. DIARY CARD 19