Dialectical Behavior Therapy DBT Made Simple: Counselor Toolbox Episode 73
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This episode was pre-recorded as part of
a live continuing education webinar. On demand CEUs are still available for this
presentation through ALLCEUs. Register at ALLCEUs.com/Counselor Toolbox.
I want to welcome everybody to today’s presentation on DBT or dialectical
behavior therapy made simple. This presentation was actually based off the
book by the same name dialectical behavior therapy made simple move bad
graphics there and I really like this book because it presents
DBT skills in a very usable format there are a lot of us who aren’t ready to
launch into being a formal DBT practitioner but we are intrigued by how
DBT works and some of the skills and all that kind of stuff this is a great
introduction if you’re not if you haven’t really studied DBT and you want
to figure out how you might be able to use it with your current client base
great place to start especially if you’re working with clients who aren’t
at the level that Marsha Linehan was working with when she developed DBT
where there’s a lot of self-injury I personally like to err on the side of
being conservative when I’m starting with new techniques and you know I use
newer things that until I get a good feeling for how they work and what the
outcomes going to be I use those newer things with less acute
clients and I use my old tried-and-true with clients that may be struggling a
bit more and I want to make sure that when I put something out there it
usually hits the mark not to say that I do it every time so we’re going to go
over the basics of DBT will review the B and DBT what you need to know about
behavior there is a ton of stuff I got my minor in behaviorism I took class
is in behaviorism 416 college credit hours so there’s a ton of stuff we could
go over and we’re not going to cover anywhere near that right now and most
people don’t want to cover anywhere near that at all so understanding and DBT
there’s a few things you need to know but it’s not crucial to be a behaviorist
we’re going to talk about mindfulness again and it is really unimportant and
interesting to me that over the past few years how much mindfulness has been
incorporated in most every new sort of mainstream therapy now it’s not
exclusively the therapy but there is a core element of mindfulness that we’re
talking about and I think prior to the emergence of the term mindfulness we
talked about it but we didn’t have a label to put on it and mindfulness with
the label gives us the ability to have some skills groups that are specifically
tailored around mindfulness which from a therapeutic perspective is wonderful and
from a business perspective can also be wonderful we’ll talk about reducing
emotional reactivity developing distress tolerance skills what clients need to
know about emotions including regulating the painful ones and increasing the
positive you know I harp on that concept of you can’t just eliminate bad you have
to add positive otherwise you’re going to have a person who’s just kind of
sitting there going well I can’t do what I what I used to do but I don’t have any
other tools and we want to help clients become more effective in relationships
we find that a lot of the traumas that people experience especially people with
high emotional reactivity can go wet way back and to where they were knee-high to
a grasshopper and they were expressing how they felt they were expressing their
heightened sensitivity and they were being invalidated they were being told
this you need to suck it up this isn’t that bad so from the get-go they had
difficulty expressing how they were feeling what was going on with them and
they were in an environment that was invalidating so there’s a lot of
relation ship stuff that people need to look at
in terms of their anxiety and frustration levels I mean when you keep
getting told you’re wrong you feel some particular way and you tell someone this
is how I’m feeling and they tell you no you shouldn’t feel that way yeah it’s
going to increase anger and frustration and your sense of isolation and
helplessness so with DBT we help people examine some
of these things provide self validation but also develop tools for handling this
emotionality so the clients that we’re working with are typically clients with
a higher amount of emotional vulnerability they react to things
others wouldn’t react to and their reaction is more intense than others so
instead of being you know a 2 on a scale of 1 to 10 their reaction is more like a
4 or 5 sometimes that’s because they have a whole bunch of pent-up stuff that
they’re trying to keep bottled up and then this is sort of the straw that
broke the camel’s back but more often than not they are just highly sensitive
and their recovery time is longer than others which makes sense if you get more
reactive if you get more of an adrenaline rush it’s going to take
longer to come back to baseline than a person who only had half the adrenaline
rush totally makes sense however if the person is in an environment where other
people don’t share these same characteristics they’re going I don’t
fit in everybody else is fine and I’m still feeling not fine they have an
inability to regulate emotion again because when they were growing up they
didn’t develop that emotional vocabulary that ability to communicate to others
what was going on and the validation that okay this is how you feel let’s
figure out how to deal with it many times this particular set of
clients was told you need to suck it up get over it if not that bad so they
didn’t learn the tools to tolerate distress they didn’t learn the tools to
handle their emotions we want to help them understand why they feel the way
they feel if they get upset about something okay
let’s look at why because there’s a lot more to feelings than just that surface
level and these particular clients typically have difficulty expressing
expressing the emotion in an effective way so it comes out as either gushing or
passive-aggressive or angry because when they’ve tried to express it the only way
they know how they’ve been shut down sometimes they will bottle it up because
people keep telling them they’re wrong so they’re like well I’m in excruciating
agony but nobody understands so I am just going to go drink myself into a
stupor not the healthiest way to handle things so this is the clients that we’re
dealing with they’re highly sensitive which means that they get really revved
up and it takes a while for them to calm down and they need to help figuring out
how to navigate in a world where other people may not get as revved up or may
be able to calm down more quickly one of the underpinnings of DP DBT is
dialectical therapy for dialectical theory sorry everything is
interconnected there’s an action and there’s a reaction if I scream at
someone I’m probably pushing them away they’re probably going to be like oh I
don’t want a piece of that so if I scream at somebody I push them away but
what else goes along with that then I’m more isolated I have fewer social
supports which means I may feel more stressed because I can’t spread it out
and get support which may increase the frequency and/or the intensity with
which I scream at people to push them away so it’s a sort of self-perpetuating
cycle if you will some of the examples of action and reaction addiction if
someone uses drugs if someone engages in a behavioral
addiction there is an epinephrine rush there’s a dopamine rush there is a lot
of excitatory stuff going on in the brain and the person goes that felt good
I want to do that again but the brain has said we’re not
equipped to handle that level of stimulus so we’re going to shut down
some of the gates turning it down to protect itself the brain does the person
uses again they don’t get quite the same rush when they sober up some of those
doors some of those gates are shut so it takes more for them to feel happy than
it did before they started using so now they’ve created a situation where when
they sober up they’re still feeling pretty crappy so they use again so
there’s an action reaction now likewise when they stop using as the brain
recovers the action of stopping using in the brain recovering produces the
reaction of getting more positive neurotransmitter secretions and actually
seeing color in the world if you will I already gave you the example of anger
when people are really angry it pushes everyone away most people don’t want to
hang around with somebody who’s just angry all the time it’s exhausting so
being angry all the time pushes people away people who tend to be angry all the
time part of what I hear from from them is nobody wants to be my friend
I’m all alone nobody gets it well let’s look at how you got to be all alone so
you push these people away and now you’re feeling frustration how can we
deal with that depression when someone’s depressed sometimes they’ll stay in bed
all day what does that do that messes up their circadian rhythms so then they
don’t know when they’re supposed to sleep they don’t know when they’re
supposed to be awake when they do sleep with not quality sleep so they get more
fatigued so they want to sleep more and then they can’t seem to wake up and it
intensifies their feelings of helplessness and hopelessness and then
finally social interactions for our final example when you have a positive
social interaction with someone what comes back you want to hang out with
them again when you give out positive vibes if you will positively gets
positive most time I mean as clinicians we see someone
hurting and most of us are more than more than likely to run over and go how
can I help but after we get past that when we’re talking about just social
life when you put out positive you get positive in return when you put out
negative you may be surrounded by other negative people or you may be all by
yourself so let’s look at what the action reaction was reality is in a
constant process of change so helping clients remember how they perceive
something now may be different than how they perceive it in an hour if you get
an evaluation and it is not a good evaluation and it’s just devastating you
know it hurts you’re dealing with that right now
but in an hour when the adrenaline has a chance to go away when you’ve had a
chance to you know lick your proverbial wounds in an hour how do you feel is it
the end of the world still or have you kind of adjusted most of us have learned
how to tolerate de-stress ride the wave whatever you want to call it and an hour
later we’re like okay that really sucked but it’s not the end of the world some
of the things we can ask clients to do is look at what things change their
perception between you know something happens and they feel one way and an
hour later or a day later or six months later they’re like that wasn’t that big
of a deal what changed their perception was it just time or how do they change
their perception another thing we can ask them to do is figure out what when
they’re in a crisis when they’re upset what is their emotional mind saying what
is their heart saying if their heart could talk what is their reasonable mind
or their detectives saying taking the two of those and this is the dialect the
heart in the head and combining them and going alright now what can I get out of
that I may not be able to do exactly what my heart wants I may not be able or
I may not want to do exactly what my head says I should do so how can I find
a compromise where can I find that middle ground finally the truth is always evolving and
can be found by integrating multiple perspectives and tolerating the two
opposite things may coexist two opposite things may coexist let’s talk about
these perspectives simultaneous if you go to a crime scene and you ask five
people who saw it take place what happened you don’t get the same response
you’re going to get five different reports now there’s going to be some
overlap but there’s also going to be some interpretation of what happened
based on their prior learning experiences doesn’t mean they’re wrong
no that’s their reality so if you take five different realities and merge them
all together hopefully you get something closer to an objective reality when
there’s an interpersonal disagreement and I was watching
gaali The Daily Show the other day and Trevor Noah was talking about how in
this particular election if you’re a Hillary supporter and something comes
out about Hillary you can get frustrated that the news is focusing on this and
not focusing on all the Donald Trump stuff if you are a Trump supporter and
something bad comes out about Hillary you can get excited that they’re not
focusing on the bad stuff about Trump and they are focusing on the bad stuff
about Hillary so its perspective is it a good thing or a bad thing that
something’s coming out and how are you interpreting it what is meaningful to
you longitudinally means thinking about
things from you know what was meaningful when I was six versus what is meaningful
when I’m 26 one example would be what if a child says you know my mom had no use
for us and and that’s why she left and a lot of kids feel that way or a lot of
kids don’t understand why mommy or daddy chooses alcohol and drugs over them
because that’s their exception as they grow up and gain more
knowledge learn more about addiction hopefully sooner rather than later they
start to understand that yes the parent left yes the parent chose alcohol and
drug addiction however does that mean that the parent loves you any less so we
need to talk about what that means another example is in abusive situations
where a parent is supposed to love the child but the parent also beats the
child so the child’s going well if mommy loves me but mommy beats me then I must
be bad it has to be something with me because mommy tells me she loves me and
but then I don’t get it helping the child or the adult the adolescent kind
of rectify those two things that they can they can coexist your parent can
love you but they can also do things that are harmful and hurtful at the same
time does it mean that you are bad what other things could it mean so one of the
things that is interesting in DBT is the fact that there are skills training
groups and in individual sessions a lot of clients with high emotional
reactivity really want to deal with whatever their present crisis is they
really want to deal with them so it’s not a time to start teaching a whole lot
of skills in skills training groups clients are able in a relatively neutral
environment to learn some basic skills and then we can take from those training
groups and apply them in individual sessions in a more heated situation
where the person is telling you about their current crisis so your main skills
include core mindfulness which is increasing self-awareness of thoughts
feelings and urges when you have an emotion anger what thoughts are you
having what feelings physical feelings are you
having you’ve already labeled the emotion as anger so what physical
feelings are you having what secondary emotions are you having
oh we don’t ask that a lot so there’s anger but there’s also probably other
stuff in there guilt resentment jealousy what’s going on and what urges are you
having when you have these thoughts when you have these physical feelings and
reactions what is your desire what is your behavioral urge this helps people
start to understand what’s going on with them and go okay I see how the dots are
connecting and the cool thing is that you only have to kind of break one of
the links in the chain to interrupt this behavior so if they feel an adrenaline
rush coming on you know they know they’re anxious they can feel their
blood pressure coming up if they’re mindful and aware of that happening then
they can intervene earlier than if they wait until they’re in full-out thought
feeling urge I’ve got to make it stop mode core mindfulness also helps clients
develop an understanding of their emotions as things that don’t have to be
acted on and this is a new concept this is a really new concept for a lot of
people and you know it’s interesting because my daughter is 12 almost 13 and
I was typing a response to something on Facebook the other day and I was pretty
passionate about it and we were getting ready to go out and put the chickens up
or something I’m like hang on a second let me just finish this post that I’m
doing and she looked at me she’s like you’re going off on somebody about
something aren’t you I’m like well and she’s like you don’t need to let them
get you that upset I’m like really my 12 year old is telling me this so I
finished my post it was polite but it was to the point and you know we went on
and did that but her awareness of the fact that you can get angry
you can get sad you can get whatever it is but you don’t have to follow through
with a particular behavior I thought was pretty good for 12 interpersonal
effectiveness helps people develop assertiveness skills so they can say
this is how I feel you don’t have to feel that way and you don’t have even
have to agree that I should should feel this way but it’s how I feel it is what
it is and we also help people identify the goals of their relationships and
skills and activities needed to achieve those goals so how do you effectively
communicate how do you create a win-win situation how do you negotiate and
compromise instead of thinking of things in terms of black and white emotion
regulation skills is your third group of skills that you’re going to deal with
helps people label and effectively communicate feeling States if you’re
telling someone that you’re angry and you use and when I was in counseling 101
our first counseling class we were told we were not allowed to use the words
happy mad sad glad or afraid we had to find some sin on him but we were not
allowed to use those five words in class because she wanted us to develop a
deeper repertoire of emotion words so we developed an understanding of irritated
and enraged and those sorts of things you can do a lot of really cool
activities with not charades you put 15 or 20 different emotions in a hat on
little pieces of paper people draw them draw them from the hat and then they’ve
got to act out that emotion so they get a sense of what it might feel like what
it might look like and then you can talk about what types of thoughts might go
through your head when you’re feeling like that emotion regulation helps us
understand the function of emotions and why we don’t want to eliminate them is
anger a functional emotion heck yeah anger and fear tell you there’s a threat
there is something you either need to defeat or get the heck
away from now does nurturing it and holding on to it and whatever we do with
it is that functional that’s generally not as helpful anger and fear are our
body’s way our minds way of saying you need to do something and that’s it then
you get up and you do something you either let it go you fix it or you get
away from it happiness is an emotion we don’t want to get rid of that that one
either because it says I want to do it again and thinking about kids when
they’re little some of the things they want to do we were talking yesterday
about peekaboo and I was sharing with my daughter that small children are so
thrilled I mean they can be amused for 20 minutes or more if you just cover
your eyes there you go peekaboo and you do it again and again and they laugh
every time and you’re just sitting there looking at them going how can you find
this amusing this helps children laughter is
cathartic laughter is helpful anything we do that makes us laugh that makes us
happy it’s something we want to do again now whether the child really finds it
all that confusing or they just think it’s fun to watch us make complete fools
of ourselves which i think is probably more it it’s providing joy to that child
learning the connection between thoughts feelings and behaviors and how to break
the chain as people start labeling their feelings they can say when I get angry
this is what I first notice when I get angry my thoughts my feelings my
behavioral urges are so they can figure out what can they do a lot of times the
first intervention focuses on those behavioral urges we don’t want you to go
out and use we don’t want you to go out and cut we don’t want you to do
something that’s self harming so when you feel this emotion what else could
you do and then we start talking about distress tolerance and how to get
through those periods where emotions feel overwhelmed
and your distress tolerance skills are really just your survival skills and
alternatives to self-harm it’s saying I met a lot of distress right now however
I’m making the choice not to engage in an unhelpful behavior so some of the
assumptions in DBT are that clients are doing the best they can with the tools
they have at this point in time nobody gets up in the morning and says I want
to be miserable so I’m going to half-ass it today you know we really we get up
and we go I want to have a good day and if people don’t end up having a good day
you know life happens so you’re doing your best and you’re surviving the best
way they can clients want to get better if the
situation they’re in is causing them distress they generally don’t want to
keep doing it do you want to keep banging your head into the wall no you
know so the old adage goes why does Johnny keep banging his head into the
wall because it feels so good when he stops so we want to say all right you’re
doing this behavior and it ends up having a bad consequence
let’s take addiction for example you get under a lot of stress you get angry you
go out you drink you pass out you wake up the next morning during that short
period where you were drinking you’re inebriated and you are unconscious you
didn’t hurt that is the reward that we’re looking at it’s not that they
didn’t want to get better it’s not that they were choosing alcohol it was that
they were choosing to survive so we need to figure out how to help them work
harder and smarter so what are you going to do instead let’s give you some more
tools to work with it is hard changing from that knee-jerk
reaction that has worked most of the time to changing to something else which
is a new skill or a new tool that’s exhausting that’s hard it is hard work
therapy’s hard work but we’re going to provide you some tools so you can do it
efficiently and we’ll be there to support you and help you figure out how
to you know tweak how your using that tool to make it more
efficient for you this helps them stay motivated clients need to remember that
even if they didn’t create their problems they gotta fix them sometimes
stuff happens and it is out of that person’s control but they’ve got to
figure out how they’re going to live with that if someone in their family
some of their clothes – passes away yet they’re going to feel grief they’re
going to go through all those stages and it really stinks
they didn’t create that they didn’t you know cause the person to die but they
have to figure out how they’re going to live with it
so it’s not their problem anymore so they don’t stay grieving for 5 10 15
years clients need to learn to act skillfully in every area of their lives
and one thing that is pointed out in the book is the fact that there are a lot of
people with high emotional reactivity who are very successful in one or two
areas of their life you know they may be you know very very successful at work
but their home life is a shambles or they may be you know really good at home
but interpersonally you know in social situations and at work not so much so we
need to help clients learn how to generalize these skills and use them in
every area of their life and finally and one of the most
important in my opinion is clients cannot fail in therapy if we give them
the tools and they’re doing their best and we’re working with them then we need
to stop back and look and say okay how did the techniques how did your
knowledge or what we’ve been parted to you not meet the standards that it
needed to how did we fail how did the therapeutic process fail not the client
the client is doing the best they can the therapeutic process may not have
been as effective treatment priorities obviously the first priority if somebody
is suicidal or engaging in self-harming behaviors including addiction that’s our
primary thing then we look at behaviors that interfere with
therapy calling in not showing up to appointment showing up late and this
includes the clinician and obviously we’re not going to discuss that with the
client but we need to be cognizant of things that we may do that interfere
with therapy and we’ve all had clients before that have been more challenging
than others and you’re like okay you know so-and-so is coming today and you
know that they’re trying to work you know they’re trying to do their best
however you’re just really struggling at that point in time because it’s
exhausting and this is when DBT therapists or therapists in general need
some support then we want to identify suicidal or self-harm ideation and
misery so we’re not talking about the behaviors we’ve gotten down to the point
where the person just thinks about cutting or thinks about committing
suicide or thinks about using how do we deal with those obsessions or ideation
if you will once we have eliminated the self-harming behaviors they’re engaged
in therapy they’re not idealizing they’re not thinking constantly about
self-harming behaviors they’ve made a lot of progress and we’re going to focus
on treatment gains so let’s keep this going you know you don’t want to hurt
yourself look how far you’ve come and what are some other goals that have been
identified by the client now in each one of these places
we need to interject mindfulness emotion regulation interpersonal effectiveness
and distress tolerance so if you’re working with someone who is actively
suicidal or engaging in self-harming behaviors obviously make sure they’re
safe if they need to be in a facility so they are safe then that’s a whole nother
step but you get to the point where you’re working with the person and you
have them start becoming mindful of what triggers their suicidal impulses you
start addressing the emotions that just flare up and feel like a
tsunami as opposed to a ripple start looking at that emotion regulation start
looking at interpersonal effectiveness when you start feeling this way
how can you assertively communicate this and to whom can you assertively
communicate this and finally when you start feeling feeling this way before
you engage in self-harming behaviors what distress tolerance techniques might
be available now remember somebody at this level at level one suicidal
self-harming behaviors when they have an emotion when they get overwhelmed it’s
not just a little overwhelmed it’s drowning in a tsunami overwhelmed so
they’re not going to go well waiting my therapists say all of these things need
to be written down they need to have them somewhere accessible that they keep
with them at all times so they can look back on it and go okay this is what I
need to do and it may be as simple as a phone number of someone they need to
call now if you’re familiar with the DBT theory and the DBT structure a lot of
you know doing true dialectical behavior therapy involves phone consultations
with the clinician between appointments and a whole lot of other stuff not just
skills groups and individual therapy for the purposes of this particular
presentation we’re just going to focus on the skills that one would use in the
dialectical behavior therapy skills that one could use in traditional therapy
taking it to that next level developing a consultation group all that
other stuff is a huge undertaking and a whole nother task it’s wonderful but
it’s more than we can cover right here and then we move down once we’ve got got
it to the point where the person is not actively trying to harm themselves and
again I say suicide cutting addictive behaviors because all of those have the
potential for self harm or maybe even accidental suicide
address those first then we move down to behaviors that interfere with therapy
and we go through the list again when you’re engaging in these behaviors maybe
you’re coming late to de sessions you know let’s talk about mindfulness what
is it that’s motivating that or why does therapy feel like it’s something you
don’t want to come to start talking about what feelings and what thoughts
surround therapy as far as a priority what’s changed move down to emotion
regulation sometimes coming to therapy and talking about emotions all the time
is just exhausting so how can we deal with that draining
factor one mistake I find that a lot of my patients make when they start therapy
is thinking that therapy’s easy you know I’ll just go to therapy an hour a week
and everything will be fine and I’ll get better and I’m like no no that’s that’s
not it I’m sorry you need to plan for therapy to be a part time job for the
next eight to ten weeks because it’s going to take a lot of energy even if it
doesn’t take a lot of time between sessions it’s going to take a lot of
energy you’re going to be drained so you need to figure out how you can prepare
for that and prevent it from interfering with your life which will potentially
make you want to drop out of therapy suicidal or self-harm ideation and
misery again go through the list maintaining treatment gains and then
clients generally have their own goals so sometimes you work on that at the end
sometimes you can work on a goal concurrently with some of these other
priorities and it’s sort of the carrot at the end of the stick it’s something
the client wants to work on it’s a positive behavior we’re increasing in
addition to addressing eliminating the negative behaviors stages of treatment
attaining basic capacities identify behaviors that pose a direct threat to
clients or other people safety monitor the frequency intensity of behaviors
using a behavior tracking form she gives you examples of a lot of these forms and
a lot of these protocols in the book you can also go to DBT self-help links
calm and there are a lot there’s a lot of the stuff just on general DBT there
we want to address suicidal behaviors behaviors to interfere with therapy
general misery maintaining playing games and client initiated goals in stage one
we want to get the ball rolling in stage two the person has kind of gotten
control of their emotions they can label them they feel when they’re coming on
they have some interventions that work they’re feeling stable they’re not
feeling great but they’re feeling stable so in stage two we want to go on to
reducing traumatic stress and the traumatic stress can come from negative
relationship experiences related to emotional dysregulation those
invalidating environments that i talked about earlier and lack of interpersonal
skills so they feel rejected all the time their self esteems low so they have
a hard time validating themselves they’ve always kind of been told that
they’re wrong or they’re overreacting or they’re this or they’re that so they
don’t feel good about themselves and then they have a hard time getting
validation from anyone else so they’re pretty lonely
they’re pretty isolated so we want to reduce some of this and help them feel
validated and help them feel good about themselves
which takes us to stage three of increasing self-respect and achieving in
dual individual goals teaching them how to set boundaries teaching them how to
be assertive the B and DBT benefits we want to look at the positive and
negative reinforcement when somebody does something you know I gave the
example earlier of drinking if an alcoholic relapses and drinks again what
were the positive benefits of that it numb the pain the negative well I kind
of mixed up my reinforcements here but the negative reinforcement was it made
the pain go away the positive reinforcement was it made him feel good
so not only did it make the go away but it had the additional
increasing serotonin making them feel good making them feel generally more
sociable we also want to look at the punishment what were the consequences of
using you know if you woke up and you had 500 less dollars that’s that’s
punishing if you woke up and you’ve realized that you had relapsed and you
felt guilty about it that’s that’s also punishing that’s adding a negative
feeling on top of it so we want to look at the consequences of the behavior and
we have to look all along the behavior not just when the person used or when
the person cut but what was the end goal of that behavior and what were the
rewards we want to talk about intermittent reinforcement think about
the kid in the candy store who or even in the grocery store we were in Publix
one time my son was about four and he was hungry and he did the thing that all
little kids do at some point or another and he wanted candy and you don’t have
to have the candy right next to the checkout aisle and I I said no it’s
about time for dinner and he’s pleased I was like no it’s about time for dinner
and he looks at me with no volume control whatsoever and says well so much
for Publix where shopping is a pleasure I was mortified but I didn’t give in
when you give in at a certain point then the child or the animal or whomever
learns that hey this is where I’ve got to start this is where the the threshold
is so if I just start acting like this I will get my own way and we also need to
model effective coping effective emotion regulation we don’t want to be screaming
at our clients or screaming at our staff that’s kind of not what we want them to
learn from us remember that reinforcers increase the likelihood of a behavior
and punishments reduce it you don’t do things if there’s it’s more punishing
than reinforcing vulnerabilities increase the likelihood
of a fight-or-flight response so if you wake up in the morning and you’re tired
and you’re sick and you’ve got six million things that you’ve got to get
done that day you’re already vulnerable because you’ve
got stress going on which means you have less energy to deal
with whatever is thrown your way when you get to the office and finally we
want to look in order to understand some of this for people we do backward
chaining so client a has an outburst we said okay that’s what happened it’s not
what you wanted to have happen let’s look at how we got there
coworker said something and sensitive okay and that led to the outburst I
think there’s more to it than that because co-workers have said things that
were insensitive before and you haven’t had an outburst so what else happened
well let’s go back a little bit farther when you woke up you felt drained
already you didn’t feel like you slept well and you knew you had a lot going on
and you were just like coffee okay was that enough have there been times who
felt drained and people were rude but you didn’t have an outburst yes okay so
let’s go back a little bit further you had to put your cat down the day before
that was a traumatic draining event so all these things added together you see
where there was a major stressor and you got the message from your brain by
waking up the next morning that you’re drained you don’t have the happy
chemicals you don’t have as much energy so you need to kind of play it close to
the best however that person came in and said something insensitive and you
didn’t have the energy reserves to deal with it which led to the outburst so
what could we do differently next time remember that triggers or stimuli
whatever you want to call them caused a reaction they remind a person of a prior
situation in which a behavior was either rewarded so if they lashed out and they
got controlled guess what they’re probably going to do again in a similar
situation lash out or it was punished they lashed out it
did no good and the client felt an increasing sense of helplessness so in a
similar situation lashing out may or may not be repeated based on whether it was
rewarded or punished so they need to look back at prior instances of that
behavior and when was it rewarded and what about alternate behaviors were they
ever rewarded or were they ever even tried triggers may communicate to the
person that there’s a threat it says warning you need to do something ok so
if somebody’s already a little hyper vigilant a little hyped up they may
react extremely but triggers could also prompt feelings of well-being if you’ve
ever opened your phone and there’s been a picture your kid on there and you’re
just like ah that was a trigger to triggers aren’t always bad and we want
to increase positive triggers and decrease negative triggers shaping and I
know I’m going a little bit fast but I got behind shaping means rewarding
successive approximations so for example if you’re dealing with somebody who has
anger issues level one is not throwing things or being physically aggressive
maybe they get in fights with their spouse but they’re not throwing things
or being physically aggressive awesome progress not perfection level two now we
want to say not only are you not going to throw things or be physically
aggressive but you’re going to try to disengage until that urge subsides until
the adrenaline and the norepinephrine subsides enough and you feel like ok we
can have a calm discussion level 3 would be taking it the next step and saying ok
I didn’t throw anything i disengaged I calm down now I can actually come back
and have a calm discussion these levels progress over time level 1 it may take a
month before the person gets to that point but I hope not but it may level 2
it may take a month or more for person to remember I need to just walk
away I need to disengage I need to go to the bathroom whatever it takes for that
person to let the adrenaline rush go away once they’ve mastered those skills
then they can work on calmly discussing the issues and if they start to get
upset again disengaging and coming back addiction or self-harm I have two levels
here level one is engaging in a secondary coping behavior I’m not going
to be real particular about what that is if you are not cutting or using drugs
illegal drugs then you know let’s go with it right now
we’re talking about harm reduction so even if it is smoking which is a drug I
realize walking eating which again is not the healthiest reaction but it’s a
whole lot better than using crack or cutting yourself so once the person gets
used to not engaging in that primary urge to what if that they had then we
say level two let’s take a mindfulness minute to evaluate the situation and
then choose a behavior consistent with your goals so you take a timeout you’ve
got that secondary coping behavior going on now let’s take a look at what’s
happening instead of just trying to shove it down and forget about it mindfulness means developing an
in-the-moment awareness of how you are emotionally mentally and physically and
exploring the interconnection of thoughts feelings and physical
sensations remember that distress in one of those areas leads to distress in
others if you’re sad you may have a foggy head and you may have aches and
pains you may just feel lethargic if you are sick or in pain you may be grumpier
and you may have a harder time focusing because the pain is distracting you so
remember that they’re all interconnected and we want people to become aware of
the emotional wave so when they get upset they can say okay this wave is a
tidal wave and I am you know down here I’m not even finished right
or I’m at the top and I’m coming down reminding them that most emotions will
dissipate within 5 to 15 minutes if we don’t stoke the fires we want to reduce
emotional reactivity and one of the acronyms is please PL means treat
physical illnesses be healthy remember not feeling good not going to help your
mood eat a nutritious diet don’t use mine or mood altering drugs and less
prescribed by a doctor get plenty of sleep and exercise exercise releases
serotonin can do a whole lot to help people deal with pent up stress if you
will build positive experiences it’s not just about eliminating miserable stuff
you want to have fun things each day even if it’s five minutes
what was one positive thing you did for yourself today and be mindful of your
current emotion if you’re angry you’re angry don’t tell yourself you shouldn’t
be just say I am and then you can move on from there distress tolerance another
acronym accepts activities so do hobbies watch a video go for a walk if you’re
feeling really upset try to do something to distract yourself contribute do
volunteer work compare yourself to people who are coping either the same as
or less well than you and go okay other people can do this I got this two
emotions try to distract with the opposite if you’re feeling really down
try to watch a comedy push away a distressing situation by leaving it
mentally for a while which kind of goes back to distracting
you’re just pushing that out of your head going I’m not going to think about
that right now and you can even tell yourself those exact words thoughts
think about something else so get engaged in puzzles or a book or
something to distract you for me it’s cartoons you know I don’t know why and
sensations if you distract with intense sensations you’re focused on that if
you’re holding ice cubes you’re going to focus on
after about three or four minutes trust me so what a clients need to know about
emotions and there’s a whole chapter on that but basically like I said earlier
we want to decrease the negative emotions they’re there for a reason but
we want to decrease the intensity and develop an understanding of what causes
depression anxiety anger envy frustration irritation whole lists
whatever it is for the person in that person and what are the ones we can
eliminate what are the unnecessary irritants we can just get rid of because
there are some things that you know we should get upset about but there are
some things that we can eliminate we don’t have to bother ourselves with and
increasing the positive what are some positive things that you can do you
can’t be happy and depressed at the same time so how can you increase the
positive keep a list of positive things things that make you smile things that
make you happy some days it’ll feel like you need a crowbar to get you out the
door to do them but getting out and doing them makes you feel that much
better interpersonal effectiveness teaching assertiveness distress
tolerance emotion identification and communication so if the person can
assertively say this is how I feel and this is what I really need or want in
order for it to be resolved it’ll be a whole lot more effective than throwing a
tantrum or acting out or walking away or being passive-aggressive in order to be
interpersonally effective people need to understand their own needs you know
that’s you know obvious but also the needs of others what is it then another
person needs the whole empathy thing what do they need in order to support
you what do they need in order to want to support you and then we want to help
people explore situations to using dialectical theory so taking multiple
perspectives in an argument or in a interpersonal situation to try to
imagine what was the other person thinking or feeling dear man is your acronym here describe
the situation objectively express why this is an issue or a need and how you
feel about it assert sharing clearly what your being
what you’re feeling and asking directly for what you want need not
passive-aggressively not going well I wish there was something that could be
done well if there’s something you want done say what it is reinforce what you
want done and why it’s a good thing by offering a positive outcome or a win-win
be mindful focusing on what you’re requesting and not getting distracted by
all this other stuff appear confident and be willing to negotiate you know my
kids want pizza a lot because they’re kids they want pizza and I have to
negotiate that but sometimes they will come to me and they will make a case for
why they deserve pizza and create a win-win situation they’re like hey and
by the way mom you won’t have to clean up or cook dinner so there you go
and I’m like okay find whatever you win now obviously our clients are dealing
with a whole lot more than pizza but you can apply this in non-threatening
situations to help people master it before you start applying it to the more
emotionally Laden stuff so DBT is a great tool to help clients become more
aware of their emotions identify the thoughts feelings and urges associated
with those emotions develop a greater sense of self-awareness regarding the
whys of emotion why do I feel this way why do I act this way when I feel this
way they develop an awareness of their vulnerabilities which make them more
likely to be emotionally reactive or sensitive most of the time when you say
you know when you don’t feel well you tend to be grumpier people are like yeah
you know you’re right but I’d never thought of that so helping
people understand that mind-body connection and DBT provides an awesome
framework for teaching skills groups that benefit an array of clients who
have difficulty with emotionality and I can’t remember exactly when in the
next couple of weeks there’s a class that we’re going to do on DBT and
mindfulness skills for adolescents and if you work with adolescents or you just
remember being an adolescent adolescence is a time of high emotionality I don’t
care who you are so DBT skills can be really useful for
that particular group like I said this book was this presentation was based on
a book by Cheri Van Dyke DBT made simple you can get it at new Harbinger
publications if you want to I will be putting out a I believe I figured out it
was a 10 hour on demand class if you want to learn more and really get all
the tips tools and tricks that she has in that book that will be available
probably in two weeks but if you want to just peruse it in the library I’m pretty
sure I’ve seen it at like borders and Barnes & Noble too so you can look at a
copy and see if that’s something that interests you are there any questions if you enjoy this podcast please like
and subscribe either in your podcast player or on YouTube you can attend and
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