Dialectical Behavior Therapy Skills for Individuals and Groups Disclosures The development of these training materials were supported by grant H79 TI080209 PI R Martin from the Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration United St ID: 1037091
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1. Taylor D’Addario, LMHC, LCDPDialectical Behavior Therapy: Skills for Individualsand Groups
2. DisclosuresThe development of these training materials were supported by grant H79 TI080209 (PI: R. Martin) from the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, United States Department of Health and Human Services. The views and opinions contained within this document do not necessarily reflect those of the US Department of Health and Human Services, and should not be construed as such.
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4. Grounding Exercise 5,4,3,2,1What is mindfulness?
5. WelcomeYour NameYour Job/AgencyWhat You Hope To Learn TodayHow Familiar Are You With DBT ( 1-10 )
6. Goals of Todays TrainingLearn DBT skills for yourselfLearn how to use DBT with clientsLearn how to facilitate a DBT skill building groupLearn about the DBT manualLearn about what behaviors DBT treats
7. Dialectical Behavioral Therapy HistoryDeveloped in the 1980’s by Marsha LinehanOriginally used to treat Borderline Personality DisorderCombines standard CBT with emotional regulation, distress tolerance, acceptance and mindful awareness
8. What Behaviors Does DBT TreatEmotion DysregulationAffective lability, intense angerInterpersonal DysregulationFear of abandonment, idealization, & devaluationBehavior DysregulationSuicidal behaviors, other self-injurious behaviors, & impulsivity Self DysregulationEmptiness, identity disturbanceCognitive DysregulationDissociation & paranoia
9. Typical DBT Outcomes Suicidal attempts, self-injury Substance misuse, binge-eating disorder Hospitalizations, emergency-care Drop-out from treatment Anger & hopelessness Social adjustment & self-esteem Costs of treatment
10. DBT Bio-Social Theory
11. Set Up The GroupEvery client should have a notebook with handouts and assignmentHave extra pen & paper availableSit around a tableUse a white board, black board or flip chartBehavior, and elicit behavior, appropriate for a classroom setting
12. The 4 Modules1234
13. ORIENTATION TO SKILLS TRAINING(General Handout # 1)Mindfulness: the practice of being fully aware and present in this one moment.Distress Tolerance: how to tolerate pain in difficult situations, not change it.Emotion Regulation: how to change emotions that you want to change.Interpersonal Effectiveness: how to ask for what you want and say no while maintaining self-respect and relationships with others.
14. ORIENTATION TO SKILLS TRAINING(General Handout # 1)In the group context, explain the purpose of the first session is to introduce members to one another and to the skills training leaders.Ask each participant to introduce herself with her name and a statement of why the member is here.Leaders: introduce yourself and give information about yourself and why you are leading skills training.Orient members to the structural aspects of the therapy (e.g. format, rules, and meeting times).
15. ORIENTATION TO SKILLS TRAINING(General Handout # 1)Mindfulness skillHomework reviewTeach new skill(s)Lesson summary and assignment of homework
16. ORIENTATION TO SKILLS TRAINING(General Handout # 1)Describe order and length of modulesDescribe use of session time (1/2 for homework practice 1/2 for learning new skills)Make it clear that neither time or format allows for discussion of personal problems unrelated to using behavioral skillsDiscuss use of telephone calls to skills trainer
17. ORIENTATION TO SKILLS TRAINING(General Handout # 1)Goals of skill trainingPractice commitment (practice, practice, practice)
18. GUIDE LINES FOR SKILLS TRAINING(General Handout #3)Group AgreementsSets boundaries
19. SKILLS TRAINING ASSUMPTIONS(General Handout # 4)People are doing the best they canPeople want to improvePeople Need to be better, try harder and be more motivated to changePeople may not have caused all their own problems. But they have to solve them anywayNew behaviors must be learned in all relevant contextsAll behaviors (actions, thought, emotions) are causedFiguring out and changing the causes of behaviors work better than judging and blaming
20. ModulesTeaching NotesClient HandoutsClient Worksheets (for homework)
21. Module Handouts
22. CORE MINDFULNESS SKILLS
23. CORE MINDFULNESS: GOALS(Mindfulness Handout # 1)To get in control of your mindBy enhancing awarenessBy strengthen attentionBy increasing presenceNot by controlling the contents of your mindTo find and activate WISE MIND
24. EMOTION MINDHot MindMood-dependent mindWhen the mind is driven by emotionsEmotion mind is exaggerated by:Imbalances in sleep, eating, exerciseStress, loss, disruptionPoor self care re: medical problemsSome psychotropic medications
25. REASONABLE MINDCool mindLogical MindTask-focused mindUseful for soling a million logical problems:Planning, timing, travel, sequencingPredicting outcomes, weighing probabilitiesFinances, logisticsBy itself, can be too dry, colorless
26. WISE MIND(Mindfulness Handout # 1)Difficult to describe“True self”, “Center”, “Intuitive”, “Spirit”Each client must “discover” wise mind through life examplesA central aim of core mindfulness skills in DBT is to locate and activate wise mindWise Mind is a synthesis of Emotion Mind and Reasonable Mind
27. Getting to Wise MindReasonable MindEmotion MindWiseMind
28. Case Example: Pick 1Tanya was at a party when a friend passed her a bottle of beer. She thought “everyone else is drinking. Will they accept me if I don’t?” Then she remembered that she had an important exam on Monday; she realized she wouldn’t study well the next day if she got drunk that night, so she said, “No thanks.”
29. Case Example: Pick 1Joe needs to take a bus to his dentist appointment next week at 2:30pm. Joe figured that he could stand at his bus stop at 2:00pm and hope that a bus shows up. But instead Joe looked up the bus schedule online to plan his bus ride so he gets to his dentist appointment on time next week.
30. Case Example: Pick 1Makenna was shopping for a specific jacket she saw online at Macys.com. When Makenna got to the store the sales person informed her that they were sold out. Makenna snapped at the sales person, yelling and screaming at them for ruining her life.
31. Case Example: Pick 1Catherine was sitting in class when a classmate tripped and knocked over her waterbottle spilling water all over the floor. Catherine was angry and embarrassed and wanted to punch her classmate for spilling her water. Catherine realized she didn’t want to create problems with her classmate so she went over to the sink to grab paper towels to help clean up.
32. TEACHING CORE MINDFULNESS SKILLSAfter helping each client find “Wise Mind”…Teach that there are six skills to “Wise Mind”.Three “What Skills” (what you do)Observe, Describe, ParticipateThree “How” skills (how you do what you do)Non-judgmentally, One-mindfully, Effectively
33. OBSERVE(Mindfulness Handout #4)Just noticing exactly what isBeing like a guard at the place gateAlert to everything that comes and goesHaving a “Teflon Mind”Just noticing without labeling, interpreting, judging, or finding patternsChildren do it all the time (looking at sky, water, fire, bugs, etc)
34. DESCRIBE(Mindfulness Handout #4)Adding a label to an observed experiencePutting words on experienceNotingJust the factsYou cannot describe something unless you observe it; be aware of assumptionsYou cannot observe another person’s thoughts, emotions, or intentions
35. PARTICIPATE(Mindfulness Handout #4)To enter completely into what you are doing in the present momentResponding spontaneously, without ruminating, without self-consciousnessEngaging completely, with immersionBeing in “the zone”, being one with the activity; no boundary between self and activity
36. NON-JUDGMENTAL(Mindful Handout #5)See reality exactly as it is, without judging it as either good or badNotice judgments as judgments, facts as factsEvaluate, by discriminating and measuring, but without adding on judgmentsJudgments are compact statements condensing valid events, reactions, consequences
37. ONE-MINDFULLY(Mindfulness Handout #5)To do one thing at a time, with awarenessBring your entire attention to this one momentWhen overwhelmed by many things simply do one thing at a time, with total focusWash the dishes, one at a time, to wash the dishes (Thich Nhat Hanh)
38. EFFECTIVELY(Mindfulness Handout #5)To use skillful meansFocus on what worksNot what is right versus wrongPlay by life’s rule, just do what’s neededKeep an eye on your goals and your valuesIt sometimes means letting go of your “ego”
39. Diary Card- Practice Makes Perfect ProgressTo be completed every dayReview skills monitoring only
40. Getting through a painful moment without makingthings worse.DISTRESS TOLERANCE SKILLS
41. DISTRESS TOLERANCE:Overview of ModuleGoals of the ModuleWhen to Use Crisis Survival Strategies vs. Reality Acceptance SkillsCrisis Survival SkillsReality Acceptance Skills
42. GOALS OF THE MODULE(Distress Tolerance Handout #1)Survive Crisis Situation w/o Making Them WorseAccept Reality As It is In The MomentBecome FreeWhen we are free, we can look in the face of distress, cravings, and desiresPain and distress are a part of lifeTry to get rid of them can increase suffering
43. WHEN TO USE CRISIS SURVIVAL SKILLSWhen intense pain or problems that can’t be helped quicklyWhen acting on emotion mind would make things worseWhen emotional distress threatens to be overwhelmingWhen feeling overwhelmed but needing to meet demands
44. CRISIS SURVIVAL STRATEGIES(Distress Tolerance Handout #2)The STOP SkillPros and ConsTIPS Skills, for Changing Body ChemistryDistracting SkillsSelf-Soothing SkillsImproving the Moment Skills
45. CRISIS SURVIVAL SKILLS(Distress Tolerance Handout #4)The STOP SkillStopWhen emotions are about to take control, freeze!Take a Step BackTake a step back physically or in your mind; get unstuckObserveWhat is happening inside and around youProceed MindfullyAsk Wise Mind how to deal with the problem
46. PROS AND CONS(Distress Tolerance Handout #5)Main Goal: To learn that accepting reality & tolerating distress leads to better outcomes than rejecting reality and refusing to tolerateWhen to Use Pros and Cons:Compare pros and cons of different peopleHelps to resist impulsive or destructive urges
47. Pros And Cons: How to Thinking of Pros and ConsWhen in distress, and considering engaging in a problem behavior (cutting, drugs, purging, etc.)List the pros and cons of acting on crisis urges; thenList the pros and cons of resisting crisis urgesWhile doing pros and cons noticePositive long term consequences of toleratingVersus negative consequences of using the problem behavior for short term relief
48. Example: Pros and Cons of Self-CuttingProsConsSelf- CuttingReduce tensionReduce negative emotionsGet supportShow misery externallyScarsAlienate othersSelf hatredSense of failureResisting CuttingScars diminishOthers approveMove towards goalsIncrease positive feeling; prideDistress remainsOther behaviors are not as effective in short runCan’t function as well in the moment
49. Further Teaching Points: Pros and ConsRehearse pros and cons multiple timesReview earlier pros and cons that have been written downIt can be difficult to do it in emotional mindSay “NO” to crisis urges (out loud) when over whelming emotions hitE.g., “NO! There’s no going back!”.
50. TIP SKILLS TO MANAGE EXTREME AROUSAL (Distress Tolerance Handout #6)Rapid ways to reduce arousal when very highWork within seconds to minutes4 SkillsTemperatureUse of cold water on face to elicit “diver response”Intense ExercisePaced BreathingPaired Muscle Relaxation
51. FACIAL TEMPERATURE WITH COLD WATERInduce the “dive reflex” which activates para- sympathetic system, slows heart rate, etc.Induce withBowl of cold water (30-60 seconds)Ice pack over eyes and upper cheeksSplash cold water on eyes and cheeks might workCan try when cannot sleep, or when dissociate
52. INTENSE AEROBIC EXERCISEWhy intense exercise?State anxiety will increase if HR gets to 70% of Max. Decrease in positive emotions if HR is up to 55-70%Can re-regulate the body to a less emotional stateWhen to use intense exerciseAgitated, angry, ruminatingWhen you need to bring mood and willingness up to a higher level
53. PACED BREATHINGSlowing the pace of inhaling and exhaling to an average of 5-6 breath cycles per minuteBreathing deeply from the abdomenBreathing out slower than breathing inThis activates the parasympathetic nervous system and leads to decrease emotional arousalUse a clock, to count seconds inhale, seconds exhale
54. PAIRED MUSCLE RELAXATIONPairing muscles relaxing with breathing outTense muscle groups, notice sensation of tension while breathing in…Then relax them by letting go of tension, notice sensations as tension goes downTeach participants to notice tension and then relax musclesPair exhaling with word “relax”
55. DISTRACTING SKILLS (ACCEPTS)(Distress Tolerance Handout #7)Wise Mind ACCEPTS by focusing the mind on:ActivitiesContributingComparisonsEmotions (opposite action to the aversive emotions)Push awayThoughtsSensations (intense sensations)
56. SELF SOOTHING SKILLS(Distress Tolerance Handout #8)Get through difficult moments/episodes by focusing the mind on soothing stimuli, using each of the FIVE SENSESVisionHearingSmellTasteTouch
57. IMPROVE SKILLS(Distress Tolerance Handout #9)IMPROVE the moment by engaging in:ImageryMeaningPrayerRelaxationOne-mindfulness (one thing in the moment)VacationEncouragement
58. REALITY ACCEPTANCE SKILLS(Distress Tolerance Handout #10)To decrease suffering and increase freedomSkills for Accepting Your Life as it is NowSix SkillsRadical AcceptanceTurning the MindWillingnessHalf Smiling & Willing Hands Allowing the mind: mindfulness of thoughts
59. RADICAL ACCEPTANCE(Distress Tolerance Handout #11)Acknowledge exactly what is, see the truthAllow what is, allow the truthDon’t push away realities, even painful onesNot the same as approving, agreeingNot a passive positionOnce reality has been radically accepted, the door opens to using skillful strategies for tolerating
60. TURNING THE MIND(Distress Tolerance Handout #12)The act of choosing to accept what isAgain and again and againNoticing that you are no long acceptingThen make an inner commitment to acceptThen do it again, over and overMaking a plan to catching yourself when you drift out of acceptanceWhat cues tell you that you are drifting?
61. WILLINGNESS(Distress Tolerance Handout #13)Willingness (over willfulness)Readiness to respond to life's situations wisely, as needed, voluntarily, without grudgeChoosing to “go with” realityRather than to opposing itComplete openness to the momentWillfulnessActing in opposite to the processes and rules of reality, in order to counter them, oppose then, control them, revers them, or overcome them.
62. HALF-SMILE(Distress Tolerance Handout #14)A Way of Accepting Reality with the BodyAdopt a serene facial expressionRelax face, neck, shoulder musclesBy letting go or tensing and letting goThen, lift corner of lips, just slightlyHalf Smile…When you wake up, during free moments, while listening to music, when lying down, in sitting positionWhen irritatedWhen contemplating the person you hate or despise
63. WILLING HANDS(Distress Tolerance Handout #14)Another Way to Accept Reality with the BodyHands unclenched, palms up, fingers relaxedClenched hands go with anger; opening up the hands acts opposite to angerAcceptance rather than controlPracticeWhen you wake up, during free moments, while listening to music, when irritated, etc.
64. MINDFULNESS OF CURRENT THOUGHTS(Distress Tolerance Handout #15)Let thoughts come and go; just notice themNotice them, radically accept themAs thoughts, not factsReducing suffering caused by believing thoughtsObserve thoughts, adopt curious mind about thoughtsRemember: you are not your thoughtsObserving thoughts is the path to freedom
65. Distress Tolerance PracticesEvery day: notice something difficult to acceptTurn the mind to radically accept itUse the Crisis Survival StrategiesObserve your own willing responsesAnd observe your own willful responsesReplace willful ones with willing onesAllow yourself to notice your connectionsTo a chair, to a person, to nature, to the universe
66. Reduce emotional vulnerability and suffering bybetter regulation of emotions.EMOTION REGULATION SKILLS
67. EMOTION REGULATIONOverview of ModuleUnderstanding and Naming EmotionsIdentify (Observe and Describe) emotionsUnderstand the function of emotionsIdentify obstacles to changing emotionsChanging Unwanted EmotionsChecking the factsProblem solvingOpposite action
68. EMOTION REGULATIONReduce Vulnerability to Emotion Mind Accumulate positive emotionsBuild mastery and learn to cope aheadTake care of the body (PLEASE skills)Managing Extreme EmotionsMindfulness of current emotionsIdentifying the skills breakdown point
69. UNDERSTANDING and NAMING EMOTIONS(Emotion Regulation Handout #2)Functions of EmotionsWhat emotions does for usFactors that Make it Hard to Regulate EmotionsA Model for Describing EmptionsWays to Describe Emotions
70. FUNCTION OF EMOTIONS(Emotion Regulation Handout #3)Emotions Have Functions that Help Our Species SurviveEmotions Motivate and Organize US for ActionEmotions Communicate to (and influence) OthersEmotions Communicate to Ourselves
71. FACTORS MAKING IT HARD TO REGULATE(Emotion Regulation Handout #4)BiologyLack of SkillsReinforcement of Emotional BehaviorsMoodinessEmotional OverloadMyths about Emotions
72. A MODEL OF EMOTIONS(Emotion Regulation Handout #5)Characteristics of EmotionsComplex, Automatic, Can’t be Directly ChangedSudden (rise and Fall), self perpetuatingComponents of EmotionsSee Emotion Regulation Handout # 5Observe and Describe EmotionsSee Emotion Regulation Handout 6
73. CHANGING EMOTIONAL RESPONSES(Emotion Regulation Handout #7)Check the Facts (Handout #8)Opposite Action (Handout #9, 10, 11)Problem Solve (Handout # 12)The “Yes, BUT” Barrier to Changing Emotions
74. REDUCE VULNERABILITY TO EMOTION MIND(Emotion Regulation Handout #14)Become Less Vulnerable to Painful EmotionsABC Please SkillsAccumulate Positive EmotionsBuild MasteryTacking Care of the BodyNightmare ProtocolSleeping Hygiene Protocol
75. MANAGE REALLY DIFFICULT EMOTIONS(Emotion Regulation Handout #21)Mindful of Current Emotions (Handout #22)Manage Extreme Emotions (Handout #23)Troubleshooting Emotion Regulation Skills (Handout #24)Reviewing Skills (Handout #25)
76. Getting Relationships in Order Dealing with ConflictAsserting YourselfINTERPERSONAL EFFECTIVENESS SKILLS
77. INTERPERSONAL EFFECTIVENESSOver of Module (Handout #1)Core Interpersonal Effectiveness Skills:Obtaining objectives while maintaining relationships and self-respectSkills for Building Relationships and Ending Destructive OnesFinding potential friendsMindfulness of othersHow to end relationshipsWalking the Middle PathDialecticsValidationStrategies for changing behavior
78. Three Priorities/Goals for Interpersonal Effectiveness (Handout #4)Objectives EffectivenessGetting your objectives or goals in a situationRelationship EffectivenessGetting or keeping a good relationshipSelf-Respect EffectivenessKeeping or improving respect/liking for self
79. Skills for Getting Your Objective: D.E.A.R. M.A.N. (Handout #5)Describe the current situation (stick to the facts)Express your feelings and opinions about itAssert yourself by asking directly or say noReinforce the other person ahead of timeMindful: Stay focused on your objectivesAppearance: Appear effective and competentNegotiation: be willing to negotiate
80. Skills for Keeping A Good Relationship: G.I.V.E. (Handout #6)Gentle: be courteous and temperateNo attacks, threats moralizing, blaming; show genuine interestInterested: really listen to the other person’s feeling, difficulties, wants, opinionsValidateEasy Manner: use humor; use a light touch, a “soft sell”
81. What Is Validation in DBT?To recognize and acknowledge a response (past, present of future)Emotion- Cognition- or ActionTo convey the response makes senseEmpathy is a prerequisite for validation
82. Why Do We Validate?Reduce negative emotional arousalCounter habitual self-invalidationStrengthen the bond with the clientStrengthen clients capacity to problem solveStrengthen clinical progress (reinforcement)
83. 6 levels of ValidationWide awake mindful listeningAccurately reflecting clients communicationsArticulating clients non-verbal thoughts/emotions/behavior patternsMaking sense of clients behavior(past and biology)Normalizing clients behavior in the current contextRadical genuineness
84. Skills for Improving Self-Respect:F.A.S.T. (Handout #7).Fair:Be fair to yourself and the other person(No excessive) Apologies:Don’t overly apologize for making a request; having an opinion, or being aliveStick to Values: Stick to your own values; don’t sell out(Be) Truthful:Don’t lie, act helpless, exaggerate, or make-up excuses
85. Factors Reducing Interpersonal Effectiveness (Handout #2)Lack of Skill: not knowing what to say or doWorry Thoughts: worries about bad consequences, badness, effectivenessEmotions: negative emotions get in the wayIndecision: not being sure really what you want or what matters mostEnvironment (Reality): even if you are very skillful, sometimes reality blocks you
86. Myths About Interpersonal Effectiveness(Handout #4)Review all myths listed in handout #4Consider which myths belong to youMake up challenges fore each myth: reasonable re-frames (look at “Cheerleading Statements”)Come up with other myths of yours about relationships that are not listed and come up with challenges
87. Decide How Intensely to Assert Yourself: (Handout #8)Six point scale from 6 to 06= Ask or say not with the maximum intensity4=Ask or say no firmly; willing to take no for an answer, expressing unwillingness but say yes0=Don’t even ask, don’t hint, and don’t say noConsider factors while deciding
88. Factors to Consider When Deciding Intensity in Asking, Saying No1.Priorities6.Rights2.Capacity7.Relationship3.Timeliness8.Reciprocity4.Homework9.Long vs. Short Term5.Authority10.Respect
89. Interpersonal Effectiveness: Teaching TipsStart out first session discussing relationshipsRole-plays are essentialEach person should be working on one or several relationships “projects” during moduleJudicious and frequent self-disclosure is often very helpfulAssign/watching videos with examples
90. Using Role Plays in GroupRole plays are essential in this module, but clients and therapists often avoid themSuggestions:Co-leaders can role play firstStart with simple ones in the first sessionRound robin roleplaysAt first, leader plays clientTwo clients role play, leader coaches themREINFOCE EVERYONE FOR ROLE PLAYS!
91. Building Relationships and Ending Destructive Ones (Handout #10)Building New Relationships (Handout #11):Find FriendsProximity Favors FriendshipSimilarity Tend to Increase LikingConversation Skills are ImportantExpress Liking SelectivelyJoin Conversation GroupsJoin Organized Groups
92. Building Relationships and Ending Destructive OnesMindfulness of Others, by Observing (Handout #12):Paying attention with interest and curiosityBeing open to new information and othersLetting go of overly focusing on selfStaying in the presentStopping multi-taskingGiving up judgments and being right
93. Building Relationships and Ending Destructive OnesMindful of Others by DescribingDescribe what you observePut aside judgmental thoughts and statementsDon’t make assumptions about othersDon’t question others’ motives and intentGive others the benefit of the doubtAllow others to earn your trustMindfulness of Others, by ParticipatingThrow yourself in, go with the flow
94. How to End Relationships(Handout #13)Think clearly and use finesseDecide to end relationships in wise mindTry problem solving to repair difficult relationshipUse cope ahead skills to plan how to end itBe direct: DEAR MAN, GIVE, FAST
95. Walking the Middle Path Skills(Handout # 14)Being Dialectical (pp. 286-294)Using Validation (pp.294-206)Strategies for Changing Behavior (pp. 306-316)
96. THANK YOU!Contact Information: Taylor D’AddarioTaylor.daddario@salve.edu