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Dialectical Behavior Therapy Skills
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC,
Executive Director, AllCEUs

CEs are available for this presentation at

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.
~    DBT for Substance Abusers

~    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 sensitivity
~    Hypervigilance
~    Overgeneralization
~    Easily thrown off kilter (vulnerabilities)
~¬†¬† ¬†No ‚Äúemotional skin‚ÄĚ
~    High reactivity
~    Fight 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‚ÄĒFight 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 ‚Äúraw‚ÄĚ 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

~    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‚ÄĒCore Mindfulness
~    Rational (Cognitive) Mind + Emotional (Feelings) Mind + Wise Mind (Intuition and Interpretation)

~¬†¬† ¬†Mindfulness‚ÄĒeffective, 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)
~¬†¬† ¬†‚Äú‚Ķhold 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.‚ÄĚ
~    Intense Exercise
~    Progressive Relaxation
~    All of these
~    Distract
~¬†¬† ¬†‚ÄúExplain‚ÄĚ 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‚ÄĒHappy place
~¬†¬† ¬†Meaning‚Äď Make lemonade
~¬†¬† ¬†Prayer‚Äď Radical Acceptance/It is what it is.
~    Relaxation
~¬†¬† ¬†One thing at a time‚Äď Focus on one thing, like breathing
~¬†¬† ¬†Vacation‚ÄĒTake a time out
~¬†¬† ¬†Encouragement‚ÄĒPositive 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‚ÄĒPolice 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‚ÄĒDistress tolerance
~¬†¬† ¬†Thoughts/feelings‚Äď Emotional regulation

Interpersonal Effectiveness
~    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
~    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
~    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