Dialectical Behavior Therapy (DBT) Skills | Mental Health CEUs for LPC and LCSW

welcome everybody today's presentation on dialectical behavior therapy skills this presentation is based in part on doing dialectical behavior therapy a practical guide by Kelly koerner this is one of those books that if you want to do dialectical therapy as a practice not just look at some of its tools is it definitely a must read then it's also based in part on dialectical behavior therapy skills workbook DBT made simple and DBT for substance abusers which is an article that was published by Marsha Linehan so the links to those are in your class but just give you an idea about sort of the breadth of what we're going to be looking at today in the short time that we have together what we're going to do is take a look at why DDT was created we'll look at understanding emotional regulation dis regulation and regulation will identify DBT assumptions about both clients and therapists and we'll explore skills to help clients learn to stress tolerance emotional regulation and interpersonal effectiveness as an aside we're taking or I've taken the information from this course and combined it with a bunch of other information to make a six hour on-demand course that will be available by the end of the week but for now we're just going to hit the highlights in the 1-hour introduction so why do we care why do we want to learn about DBT skills and DBT tools many of our clients experience emotional dysregulation or the inability to change or regulate their emotional cues experiences and responses think for a minute about any of your clients if they're depressed if they're anxious if they've got anger management issues something is going on with their emotional states they're not able to either get unstuck or control their behavioral responses so they may be engaging in self injurious behavior risky behavior or addictive behaviors they've tried to change and failed leaving them helpless and hopeless in a lot of our clients we try to fit them in not that we should but we do try to fit them into this box if you're depressed then we're going to look at these things and one thing I hope you get from these webinars is the fact that every single client is different and there is no box that we can put them in and you're like well then how can you do group therapy group therapy is really awesome because you can tailor and that's part of the challenge to doing psycho-educational group therapy is tailoring the tools and helping people tailor the tools to meet their individualized needs but they can get feedback and they can see how different tools can be modified just a little bit to fit different individual needs and untenable emotional experiences that lead to self preservation behaviors such as addiction you know to kind of numb the pain to give them a distraction non-suicidal self-injury we're talking about cutting we're talking about those sorts of things and then even those suicidal behaviors at a certain point the pain has got to stop so some people may end up going as far as trying to stop the pain by stopping their existence instead of hurting anyone else people with emotional dysregulation have high sensitivity so these people tend to be highly hyper vigilant they're aware of a lot of things that go on now this was originally created and I want you to really kind of think about it was originally created as a tool or a protocol to use with people with borderline personality disorder what do we know about people with BPD they grew up in really ineffectual environments so they had to be hyper vigilant to everything that was going on for their own safety and security so you have someone who either by nature or by nurture is hyper vigilant these situations have been over generalized the dangerous situations have been over generalized so the world tends to seem more and dangerous and out-of-control people with emotional dysregulation are easily thrown off kilter because they often have a lot of vulnerabilities they're not eating well they're depressed which is contributing to them not being able to sleep well they can't focus yadda yadda we've talked about vulnerabilities one thing that dr. Turner talks about is no emotional skin and she likens it to someone who has third-degree burns and every single thing even the air when it touches it is just excruciating there's no middle ground there's no oh that's kind of uncomfortable it's either not hurting or it's excruciating people with emotional dysregulation are also highly reactive so they're hyper vigilant they're aware of everything that's going on and then every time something happens that sort of triggers their awareness they jump into this immediate fight-or-flight reaction then they're slow to deescalate so we're talking about situations in which someone is hyper vigilant they're on edge maybe because of situations in the past or not they have this sort of persistent fight-or-flight or frequent fight-or-flight reaction and again I'll refer back to our dream fatigue class that talked about how the body can only stand to be all hands on deck for so long before it's just like dude I give up and then the sense of depression and helplessness and apathy starts to set in people who are who have emotional dysregulation really they're either like flat and none non-existent in their emotions they just can't even deal with it when they should or they're overly reactive and then the person isn't in an in validating environment what would be a to to some of us on a scale of 1 to 10 as far as how distressing something is it's probably like an 8 to somebody with emotional dysregulation think about a time when you were really stressed out or you had a lot of vulnerabilities going on maybe you had a new baby at home so you weren't sleeping and your other kids were acting out there was just all kinds of stuff going on and you reacted to something with an 8 that everybody else was like that doesn't deserve that much of a reaction that's it - what's wrong with you people with emotional dysregulation that's their environment all the time everybody's looking at them and going what's wrong with you there's this is not that upsetting so we need to help people understand that their experience is their experience and it's not for me to say whether it's a 2 or an 8 for me it's a 2 but let's look at why it's an 8 for you so the emotional reaction and this is obviously I didn't get red eye reduction on when I took this picture of bruit but bless his heart when I got him he was a rescue and he had such terrible terrible abandonment issues and is so hyper vigilant even to this day I've only had him like four months but he's hyper aware of stimuli and people can be hyper aware of stimuli so anytime somebody moves he's up he's looking he's like are you going to leave me alone again when he perceived that something is changing when there's a threat he goes into all-hands-on-deck and turned into a survival sort of thing he starts acting out he goes and finds toys and brings them to me heaven forbid we should have to put him out in the garage because we have visitors or something and it's you know climate-controlled it's not like it's horrible but he will sit out there and how until I let him in or go out and tell him it's going to be okay now see as a person I'm going that is not a valid reaction he's like totally overreacting to having to spend ten minutes in the garage whereas from his perspective he's not overreacting because in the past when he's been put in the garage he left out there for days weeks months who knows I don't really know his story too well now I use that to kind of highlight the fact that people with emotional dysregulation we don't know what their past experience was what they're doing is trying to survive now they may be trying to survive a situation in their past you know when there were six and we're going back to the abandonment discussion that we had the other day but it's important to understand that all these things play in together something happens and the the body's response system takes in these stimuli and it says it's dangerous it's not dangerous what do we do with it the brain decides fight or flight and then they go into the survival response with treatment what we want to do is help people be able to feel that feeling and not have to act on it right away until they can de-escalate some and use a combination of assessing their cognitions and deciding whether their perceptions are based on the present the present moment or the past moment so primary invalidation caregivers dismiss emotional reactions is invalid we just talked about that the child or person could be mocked or shamed for their emotional response we have all probably met parents or worked with parents who have children that are highly emotionally reactive who tend to get frustrated and overwhelmed by the constant drama that seems to be presented by this child all the time so the child is often not taught how to self-soothe or deescalate the parents just like really just let it go and go away which is not helpful because the child doesn't learn how to deal with it the child is not taught mindfulness to figure out okay what's causing this and the child is not taught effective cognitive processing in most situations in validating environments if the child gets upset even if it seems to be disproportional to whatever the event was the caregiver will take the child in and say okay I hear you're upset right now let's talk about it and we'll walk the child through maybe not thinking about it but just being a good parent walks the child through this de-escalation process and the cognitive processing secondary trauma or invalidation is and I'm putting this in here coping skills can be overwhelmed by trauma or intense stress leading to this high alert raw status think about the people who were survivors of Hurricane Katrina or Hurricane Andrew I come from Florida so I think hurricanes but any big event that is ongoing enduring and distressful at a certain point you're on your last nerve so anything could precipitate sort of a crisis many people don't receive necessary support during these times and may be shamed for being weak or needy sometimes nobody has the ability to cope and everybody's kind of decompensating at once which is a lot of what we saw with Katrina but other times there may be people that are functioning just fine and they don't understand why some other people aren't coping just fine and they see that as abnormal and want to distance themselves from it it's important for us to communicate to people because we already noticed that crisis is a normal response to an abnormal event what was abnormal though is it this particular incident maybe or is it the fact that this particular incident kind of was the straw that broke the camel's back on a whole chain of incidents leading up to it that were abnormal that caused this person excessive stress I was talking to a woman the other day who in the past six years has had a half-a-dozen significant losses and I'm just like wow you know that that's pretty intense to have all those and she's also starting her own practice and everything else right now and I'm just like oh my gosh I can't imagine the amount of stress this woman is is going through most humans aren't inherently prepared to deal with crisis alone we're kind of group sort of people we rely on other people so if we have this reaction and it's judged to be disproportionate and people kind of distance themselves from us because they see us as abnormal or dysfunctional then we lose any social support that might have been able to serve as a buffer which just kind of in turn feeds back and exacerbates the sense of hopelessness helplessness and isolation what precipitates a crisis may vary between people based on pre-existing stress or mental health issues and it also may vary with the same person longitudinally across time what may be overwhelming today maybe not may not be overwhelming six months from now because all of those prior stressors that I'm dealing with right now may have had time to kind of work themselves out so it's important that we help people understand that their reaction is their reaction and let's just go from there let's not say it's bad or is disproportionate or it's whatever it just is so the result of this sort of unpredictable reactivity results in frantic efforts to numb withdraw or protect I need to numb the feelings out because I can't take this kind of pain if you've ever had a burn that's had to be cleaned or even an open wound that's had to be cleaned out you know that's pretty excruciating so thinking in terms of that you can see why people would want to kind of get a little novocaine withdrawal if this support system is invalidating that has extra pain and that's excruciating to be rejected on top of everything else so a lot of times people withdraw which eliminates any opportunity for social support and it also exacerbates this sense of rejection and they do this in an effort to protect themselves people learn that who they are in invalidating environments they learn who they are and how they are results in rejection so they avoid threats they avoid putting themselves out there they avoid making relationships because they're afraid of rejection and they avoid thoughts and feelings and sensations that may lead to invalidation I don't want to feel these things because then if I do and I communicate them you may tell me I'm wrong okay we've laid the groundwork now we see where this is a problem so what do we do about it well the first thing we want to do is look at some of the DBT assumptions about clients clients are doing the best they can given the tools they have at this present point in time and I truly believe that clients want to improve they wouldn't be in your office if they didn't want to improve for one reason or another it may be an involuntary referral and they want there's a means to end there they are in your office because they have hope that something can change and it will benefit them they cannot fail at DBT if they go through dialectical behavior therapy the protocol and it fails then the protocol failed them or we as clinicians fail to implement it correctly now today again we're talking today just about tools that are present in DBT not how to do dialectical behavior therapy the evidence-based practice want to make that very clear clients are existing in what is for them an unbearable state this pain has got to stop they need to learn new behaviors in all contexts not just at work not just in their relationships but they need to learn how to function and deal with life on life's terms in all contexts so they can go to the grocery store they can get in a traffic jam they can be in a crowded Airport and not feel like the walls are closing in on them clients are not responsible for all of their own problems we know this some things they had no control over but is causing problems for them but they are responsible for all of their own solutions and we're going to talk about the four options to problem solving in a few minutes but they are responsible they choose to do something and clients need to be motivated for change motivation choosing the more rewarding option out of the available options well yeah that whatever they're doing right now is the most rewarding option they have available in their toolbox so we're going to give them new tools but then we need to teach them how to make those tools effective if you just hand me a jigsaw and say okay go about woodworking and whatever I'm not a woodworker but I'm not going to know what to do with that so I may go back to using my circular saw or whatever the case may be which may be very clunky we need to help clients learn how to use these new tools so it's more rewarding to use those than those old behaviors they just numbed out the pain or distracted them assumptions about therapists clarity precision and compassion are of the utmost importance we need to be clear with our clients about what's going on let's not speak in generalities we want to try to avoid some of the Socratic questioning that we would normally do we want to be clear about what we're getting at and what we want them to look at we need to be precise we need to not say well what is it last week that caused all the problems in your relationships well if they had four different fights that's four different things we need to look at we need to be precise in order to identify all of the things that trigger and we're going to talk about behavior chains in a few minutes so we need to be precise we also need to be compassionate even if we don't agree or we think that the reaction was disproportionate putting ourselves in their mind in their place in their raw state we need to be compassionate and go okay you survived it you did the best you could let's take a look at what might have caused that why you made made the choices you did and what you might choose better next time the therapeutic relationship is between equals DBT or therapists can fail to achieve the desired outcome but the client can't fail and therapists who treat patients with pervasive emotional dysregulation needs support it's important for us to remember that patients who are always in crisis are by their very nature it's exhausting because they're always in crisis which means we are responding in a crisis manner not that we need to get all upset and worked up because that's just modeling the wrong thing but there is a lot of energy that it takes for us to use the DBT tools for us to model the DBT tools and for us to help work the client out of their emotional state into one where they can use their wise mind so the first step is core mindfulness until they figure out what's going on they can't fix it so we want to help them integrate their rational mind their cognitive this is what happened factual mind with their emotional mind this is what it felt like into the wise mind so you can take the facts you can take your feelings and you can say with what I know and what I felt what would be the best interpretation of this or the correct for me interpretation of this event at this point in time and what can I do about it one of the things DBT talks about is the fact that truth is sort of subjective what is it truth for one person may not be the truth for the other person because we've all had different experiences but we need to help people not under react and stay in that cognitive mind if you're star trek fan think data um he was the AI that was kind of human robot sort of thing or and we also don't want people to act in their emotional mind acting solely on the basis of feelings and trying to make feelings facts because feelings aren't facts they're feelings so we want to help them integrate these two things and that is more difficult and it really sounds so it takes time mindfulness is using effective non-judgmental observation and description of experiences those thoughts and feelings and identify what's the objective evidence for and against what's going on right here how I'm feeling what is all the evidence let's look at the big picture not just one little aspect of it and what are my feelings about this event getting in touch with what's going on inside their mind and inside their body is going to be one of the first steps so I talked about those four options when there's a problem you have four options you can tolerate it grit your teeth and Barratt there sometimes you just can't do anything about it traffic jams probably can't do much of anything about it change your beliefs about the event instead of seeing a traffic jam as a waste of time and just a complete pain in your butt you can see it is a time to check voicemail and maybe return some phone calls be productive make it billable you can solve the problem or change the situation while you're in the traffic jam and stopped of course looking at Google Maps to figure out where the next exit is that you can get off so you can change that situation or you can choose to just stay miserable and choosing to stay miserable is a valid choice when clients make these decisions we need to look at why was that whatever their option was why was that option more rewarding than all the others why is it more rewarding sometimes to stay miserable for some people that's what they know and they're afraid if they feel happy then they may get disappointed and end up feeling sadder than they already do now some people tolerate the problem because it's what they know and change is hard and they would rather just tolerate it and deal with it and suck it up then have to muster up the energy to try to change whatever's going on so again we want to look and ask them or ask ourselves maybe because they may not know right away the choice that you made why was it more rewarding why did you choose that over the other three options so distress tolerance and we're going to talk about a lot of acronyms here acronyms are really important in DBT because it helps clients have sort of a drop back and punt there are some worksheets there are lots of worksheets online for DBT but is the acronyms we're going to hit here are going to be some of the highlights that's going to be important for you to remember tip temperature so your tipping your physiological balance now temperature I'm not necessarily advocating for this you don't want to do it if you've got a heart condition you obviously don't want to suggest it to clients that have a history of child abuse especially anything that involved drowning so this one's a little tricky one of the things I suggest to some of my clients instead of this is holding on to ice cubes but the suggestion in the book hold your breath dunk your face in for as long as you can hold your breath into a sink full of ice water then come up exhale inhale and dunk again repeat as many times as you need until you feel calmer well guess what we've talked about combat breathing if you are slowing your breathing which you do if you're holding your breath your heart rate is naturally going to slow when your heart rate slows down your brain says oh the threats going away yippee yay I can call off the dogs there are other ways to slow down your breathing besides necessarily dunking your dunking your head holding ice cubes one of the reasons that that can be helpful instead of cutting the person focuses it's a distracting technique the person focuses on the pain because it is painful to hold on ice cubes for a really long time instead of actually cutting themselves but it also gives their body something to focus on to go oh my heart rate is up because there's pain when the pain goes away I can make my heart rate go down so we're redirecting the brain to go oh this is why the heart rates up it's not because there's emotional distress it's because of extreme physical pain intense exercise increases body temperature but it also increases the heart rate when you're sitting still and your heart rate is 120 beats a minute because you are in a panic attack or in a state of panic it's very very uncomfortable and your mind is going I don't understand you're not moving why is the heart racing when you start exercising which is why walking and getting those big muscles moving often helps then the body gets less confused it's like Oh heart rates beating fast because body is moving score got it so when the person stops moving the heart rate starts to go down and this is true even if you're walking around if you take a client out to walk when they're upset and you are talking about whatever the distressing thing is I have found without exception when they come back inside they can start to calm down a little bit more and their heart rate naturally starts to go down when they stop their physical exercise and then progressive relaxation you're going to move from head to toe or toe to head whatever you prefer but head to toes usually how we do it focusing on muscles focusing on breathing slowing breathing relaxing muscles forcing the body to relax so this addresses physiological arousal so temperature intense exercise and progressive relaxation all of these serve as an ability serve the function of distracting the person from whatever cognitively or inter psychically or whatever you want to say is going on and all of these either explain to the brain why the heart rate is going so fast or and or help reduce the heart rate so you know there's something to be said for them the important thing is for you to brainstorm with your clients when you get physiologically aroused when you get upset and you are just your hands are shaking your palms are sweating you're breathing fast your heart rates going fast how do you calm yourself down what works for you and we're back to bruit again another acronym is accept in order to distract when there's emotional turmoil so you can kind of let that adrenaline surge go because you have that initial fight-or-flight reaction and then the body kind of goes alright let's reassess and see if there's still a threat get involved in activities that will help you distract yourself from whatever's going on when kids get upset you know if they're getting stressed out because they're sitting in the lobby and the doctor office and they know they're going to get an sa chhoti we give them something to do we read a book we talk we play because then they're not focusing on the fact that they're going to get a shot contributing contributing to the welfare of others do something nice for someone volunteer do something productive that gets you focused on someone else compare compare yourself to others who are doing less well that doesn't work for everybody you can also compare your self in the present to your old self and focus on how much better you're doing now that compared to what you were doing six months ago this doesn't always work you know these are options not everyone is going to work for every person emotions do the opposite if you're feeling really sad get a comedian get it go to YouTube and Google a comedian and watch a skit or two or ten so you're doing something that makes you laugh that makes you happy sing silly songs dude silly dances go out and there's very little I find more amusing than just listening to a baby laugh if I'm having a really bad day I will find those stupid videos of babies laughing at paper tearing if you can't help but laugh with them pushing away build an imaginary wall between yourself in the situation imagine yourself pushing it away the situation with all your might or block the situation in your mind and each time it comes up tell yourself tell it to go away so if you start thinking about something that is particularly hurtful as soon as it comes into your mind and it comes into your awareness go no I am NOT going to think about that right now thoughts counting some people count to ten a hundred whatever it takes to get through that initial rush some people sing for me I think I've shared before I have this irrational fear of bridges but so whenever I Drive over a bridge I sing and usually it's not songs on the radio usually it's songs I used to sing to my kids I'll sing the ABCs something that doesn't require a whole lot of cognitive interaction because I'm doing pretty good just to get over the bridge and yes I know I should be over it but I'm not and that's just the way it is the 10-game I like this one think of 10 things that you like the smell of think of 10 things that are green think of 10 things you see where we're going with this and you can incorporate all the different senses with it if you go through multiple iterations of it 10 things that you smelled yesterday 10 things that you see right now 10 things that you hear when you're on your way to work this helps people focus on something other than what's going on in here the 5 4 3 2 1 game is sort of similar to the 10 things game identify 5 things you see 4 things you smell 3 things that you can touch and follow it all the way down sensations like I talked about on the last slide sensations can help distract you from what's going on until you have a chance to kind of get through that initial adrenaline rush cold holding ice cubes rubber band and I don't like this one but some people do they put a rubber band on their arm and every time they start to perseverate on a negative thought they snap it smells find some good smells some smells that bring back good memories smells that you like maybe it's roses maybe it's a purse specific perfume maybe you just go to Walmart and start smelling all the air fresheners whatever makes you happy I do suggest avoiding taste because if you start using taste as distress tolerance then you start moving toward emotional eating I've seen it happen so I would avoid that for most people but if they just desperately want to go there then you know we're going to go there because they are choosing how to distract from their cognitive or intrapsychic sensations improve the moment imagery go to your happy place whatever your happy place is meaning find alternate meaning for what's going on now this can be Linehan refers to it as making lemonade we all know how to do that we don't we're not necessarily the best at it but try to make lemon I try to look for the optimistic meaning in whatever it is prayer now even if someone is not religious they can be using radical acceptance accepting it is what it is and not trying to change it just putting it out there for the universe relaxation always good to relax one thing at a time and this isn't focusing on one problem at a time this is focusing on something we're talking about distress tolerance and improving the moment so focus on one thing like your breathing get your breathe and calm down once your breathing's calm down if you need to focus on something else then move to maybe the tension in your neck maybe you need to lower your shoulders and release the tension in your neck focusing on physiological things focusing on other senses besides that abstract stuff that's in your head and in your emotions can help people tolerate the distress until they can think more clearly vacation take a timeout sometimes you just need to get away from it for a few minutes we've had times at work I'm sure we all have where you've just been like you know what I'm done and you lock your computer screen you get up you walk out of the building and obviously none of it clients in there but you walk out of the building and do a couple laps around the campus and then you're like okay I can deal with this again just clear your head before you try to tackle whatever it is an encouragement providing yourself because you can't necessarily rely on anyone else positive and calming self-talk now back to those stupid memes and videos that I love to death there's one has a kitten on a laundry wire and it says hang in there I love having those things on screensavers it's juvenile maybe but whatever it makes me happy and it reminds me you know even when I'm not in a state of emotional distress it reminds me all right keep on hanging in there you got it and it's got an all factor too so I always like anything with an all factor the goals of emotional regulation so once you've tolerated this distress you've gotten through that initial surge that initial I cannot take this pain or upset then we need to move into emotional regulation help people identify label and understand their emotions and the functions of those emotions decrease unwanted emotional responses and decrease emotional vulnerabilities so what they're going to do is identify and label emotions their functions I'm scared okay you're scared tell me why what's the function of you being scared what do you want to do and what do you think is causing this scared 'no self-awareness through questioning like that through talking it out people will start to understand where their emotional reactions are coming from and they can choose whether or not to follow up with it a behaviour what i guess i didn't put it in a behavior train analysis is the way you can go about helping people work through that and that's a couple more slides cop we want to police our thoughts check the facts look at doing opposite actions if you want to hurt yourself look at being kind to yourself if you want to run maybe you need to look at staying and then look at problem solving reduce vulnerability through the ABC p accumulate the positives remember vulnerabilities are those situations that happen leading up to whatever the distress is those are the things that make you more likely to be irritable overwhelmed angry depressed to get sad over anything instead of not so we want to eliminate those vulnerabilities or reduce them as much as possible so we're going to accumulate positives gratitude journals pictures if well everybody has things in their life that they care about have those on your phone in you know little picture galleries have them as your screen savers have reminders around about why you get up in the morning build mastery so you have mastery of the skills you need to deal with the emotional distress and upset cope ahead of time plan for distressing situations if you're getting ready to go in for an annual evaluation and those things stress you out to no end rehearse it ahead of time plan on coping ahead of time figure out how you're going to react if it goes bad figure out how you're going to react if it goes good figure out how you're going to cope and physical vulnerability prevention maintain your health chronic pain chemical chemical imbalances hormonal imbalances those can all cause vulnerabilities or set you up make you predisposed to feeling like something's at eight when it's only a two get plenty of sleep when we're sleep-deprived is a whole lot harder to deal with life on life's terms and exercise exercise is a great way of releasing or using up some of the that stress energy that you release during the day behavior chain analysis the first thing you do and a strict behaviorist will have slightly different explanations for how to do this but just bear with me here name the behavior reaction what happened now if you're thinking back to the ABCs this is going to be your C your consequence what happened identifying the prompting event ABC is that would be the a what was the activating event now this is where it differs a little bit then we want to look at the behavioral links so you had the activating event and then there was this reaction and in between there were um automatic beliefs and we have that there we have thoughts but there were also sensations events and feelings between what happened and your reaction what sensations did you feel did you get flushed did you feel nervous did you feel scared did you feel sad did you have a twinge of something what feelings were there and what events happened did you act out in a certain way did you scream did you yell what happened because these are all things that are going to go into what ultimately ended up being the behavioral reaction then I want to look at short-term positive and negative effects of what you did the behavior of the reaction if you started screaming and throwing things okay you did what was the short-term positive effect to that what was the benefit to that because that was what you chose which means it was likely the most beneficial response you could come up with in your highly emotionally charged mind at that point in time so what were the benefits and what with it immediate in the short-term negatives and then look at the positive and negative long-term effects in the long-term if you react to this upset by screaming and throwing things what's the impact going to be are there any positive impacts are there any potential positive effects of this and a lot of times it's no but we want to ask the question just in case there are because some people will have a positive and we need to address that this is sort of if you go back to motivational interviewing what we think about when we're talking about decisional balance exercises address the problematic links with skills if there were sensations or actions that exacerbated the distress then we need to look at distress tolerance if all of a sudden you had this immediate panic reaction and you couldn't breathe we need to work on distress tolerance skills so you don't go to that point where you are just for lack of a better phrase in a tizzy thoughts and feelings if your thoughts get negative and start racing and your feelings are negative and anxious and worried and all those negative words we want to look at emotional regulation you know if you can get through it where you get through that initial rush and you're still having these getting stuck in the negativity then we want to look at emotional regulation most of the time we're going to look at both of them and then the third component once we've learned how to get through the initial flood the initial all-hands-on-deck call and then people have learned to regulate their emotions and identify helpful responses and instead of talking about good and bad we want to talk about helpful and less helpful responses then we need to look at interpersonal effectiveness and how to interact with other people to make that validating environment exist so we want to start with interpersonal and intrapersonal if you will effectiveness with oneself and then move to others describe what's going on assess how you're feeling what your reactions are what the best next step is assert your choice reinforce the good things be mindful appear confident willing to negotiate and yes sometimes we have to negotiate with ourselves because there's something that we really really really want to do right now and this is very true with people with addictions a lot of times they really want to use they know the long-term consequences of use are not where they want to be so they have to negotiate with themselves to say alright I really want to do this right now but I'm going to choose a different option in their relationship with others we want to encourage them to give be gentle instead of being critical harsh which a lot of times is what they've gotten all of their life being gentle with other people accepting them where they are modeling how they want to be treated be interested in what other people have to offer what other people have to say and what's going on with them a lot of people with emotional dysregulation can't handle their own life on life's terms they can't even begin to handle anybody else's stuff so a lot of times they appear disinterested validate other people and their experiences and have an easy manner you know sometimes we get too intense and if everything in your world is either a zero or a ten it's easy to be intense about everything as they develop emotional regulation things will be different you know they'll have fours and fives in there but practicing that not being intense and over-the-top about everything and then in their relationship with the self be fast be fair with themselves not judgmental just fair avoid apologies stick to values and be truthful 12-step recovery step one starts with honesty being honest with yourself step two we start talking about hope and faith which is sticking with values and being fair to oneself being compassionate comes couple more steps down that's not hard or not harmful for any of our clients to teach them to be fair to be kind to themselves and to be honest with themselves and others so how does treatment progress when we're talking about dialectical behavior therapy as a evidence-based practice stage one is basically safety we want people to move from behavioral disk control to behavioral control we don't want people getting a phone call maybe a significant other has to back out on a weekend trip which was someone with behavioral disk control could send them into a state where they are self injuring so we want to make sure that they have the skills to not self harm and you know you can't just say well you can't cut the person's like okay so finish what am I going to do instead if I can't cut if I knew how to do something else I'd be doing it right now we need to help them increase their self-care behaviors instead of cutting what can you do and I've talked before about some of the interventions I've used with some of my clients that have self harm it's not ideal it's not where you want to end up but moving from self harm to like i said holding ice cubes or using a ballpoint pen to draw on themselves is definitely preferable to cutting themselves so we want to look at small steps not going from you know five or six self-harm episodes a week to nothing you're setting yourself your client up for failure we want to reduce the intensity of the self-harm so they're not actually breaking skin so they're not actually damaging themselves decrease therapy interfering behaviors what we typically call resistance and that can be showing up late that can be always coming in and trying to derail therapy sessions it can be being bossy it can be being reserved whatever it is that's interfering with the therapeutic process it's important to understand that therapy interfering behaviors can be exhibited on the part of the counselor too if the client is experiencing a lot of emotional discont role sometimes counselors will start being late to sessions will will start forgetting to review the chart before they go in and remember what homework was assigned will start forgetting to do things so we need to make sure that both the counselor and the client are engaging in motivating therapy participatory behaviors we want to increase the quality of life behaviors and decrease quality of life interfering behaviors so if they're engaging in addictions if they're not sleeping if they're changed smoking if they are and again these are things when we look at the priority list my main focus at first is going to be on self-harm you know I don't want them to be engaging in those behaviors and then we're going to start looking at the other things that create vulnerabilities that make them more likely to be unhappy or to be reactive in situations that would make them unhappy we're going to increase behavioral skills core mindfulness and accurate awareness encouraging clients not just when they're upset but to engage in mindfulness scans body scans four or five times a day so they know where they are and they know if they are starting to feel vulnerable if they're it feeling exhausted all of a sudden if they're feeling foggy then they know to be kind to themselves distress tolerance we talked about those skills interpersonal effectiveness talked about those skills emotional regulation and active problem-solving so these are all going to be introduced in stage one but they're introduced the client has been using their old behaviors for a lot longer than stage 1 is ever going to last so we need to remember that we have to help clients strengthen these behaviors remember to use them if they use them at first one out of every five times as one more time than they were using them last week let's focus on the positive forward movement and not on what we think they should have done we don't want to set goals that are going to set them up for failure in stage two we want to help clients moderate emotions from excruciating and uncontrollable to modulated and emotional um we want to feel feelings well I mean theoretically we do so we don't want people to completely numb out and become robots but we also don't want every single emotional experience to be like debriding a third degree wound we want something in between we need to help them decrease intrusive symptoms like flashbacks memories and hecklers the things that created the situation where they feel unlovable and unacceptable for who they are we want to decrease avoidance of emotions and I know that sounds kind of counterintuitive through increasing emotional awareness again we don't want them to be numb we want them to feel because if they feel then they can choose how to act and how to react decrease withdrawal increase exposure to life a lot of times clients with emotional dysregulation have withdrawn because they don't want to be rejected so that don't go out with friends they don't experience life on life's terms they just sit in front of the television watch Netflix we want to decrease self invalidation help them understand that their experiences are their experiences and they're not right or wrong their choices may be helpful or less helpful but at any point in time that is their best as well as they can see their best options for survival so let's not be critical I'm just happy you're still here and we want to reduce mood dependency of behaviors part of this process we're going to teach people how to create SMART goals that are specific measurable achievable realistic and time limited SMART goals and make sure they're successful by validating and teaching them to self validate encourage them to imagine the possibilities when you're successful when you accomplish this goal what's going to be different how awesome will it be encourage them to take small steps not all or nothing you know we want to get get rid of the dichotomies small steps towards recovery and applaud themselves for even trying encourage them to lighten their load get rid of stuff that they don't need to be stressing over right now you know maybe now's not the time to start remodeling the house and then sweeten the pot encourage clients to provide themselves with rewards for successful completion of a goal maybe getting through an entire week or for some clients even an entire day without self-injury I encourage you to practice these skills yourself because you'll see how much we actually don't do and how helpful these skills can be but it also gives you more insight on in two ways to help explain thanks to clients and help them apply these tools to themselves think about which skills you've used that we're helpful or skills you could have used that would have been helpful in the past week for you because you're going to ask the clients to do this so let's do it for ourselves so we can put ourselves in their position and think about which skills might have been helpful for a client that you've worked with 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 or external traumas and lack of support or both DBT seeks first to help the person replace self-defeating behaviors with self-care behaviors and then moves toward emotional regulation and interpersonal effectiveness to help people develop the support system and learn how to feel feelings including the good ones 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 and develop a more effective compassionate and supportive relationship with themselves and others finally remember that not every tool is going to work for every person it takes some experimentation prepare your clients for that otherwise if they try something and it doesn't work they're going to feel rejected and validated and like failures again it's a process to work together to help them figure out how they can start interfacing with life and integrating the two dichotomies of thought and emotion to make wise choices in order to help them live happier and healthier

Channel: Doc Snipes

Views: 107,108

Keywords: Lpc ceus, lmhc ceus, counseling, ceus, mental health ceus, live webinars, NBCC CEUs, NAADAC CEUs, CCAPP ceus, recovery coach, addiction counselor, addiction ceus, addiction training, certification training, online education, LADC, LCDC, CAP, CCDP, CADC, CCJP, etherapy, counselor education, cheap ceus, unlimited CEUs, fast CEUs, ce4less, online ceus, homestudy ceus, dbt, lcdc, continuing education, online training, dialectics, dialectical behavior, linehan, yt:cc=on, donnelly snipes

Id: TL9TTC4FagI

Length: 59min 13sec (3553 seconds)

Published: Thu Jul 28 2016