 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. Welcome everybody to today's presentation on dialectical behavior therapy. Today we're going to talk about dialectical theory. Over the next hour we're going to explore the basics of dialectical behavior therapy. We're going to talk about the B or the behavior in dialectical behavior therapy and what you need to know about addressing behavior. We're going to briefly address mindfulness, talk about reducing emotional reactivity and distress tolerance skills. We'll explore what clients need to know about emotions regulating the painful ones and increasing the positive ones and helping clients become more effective in relationships. We're going to get a high level overview. Obviously there's going to be an entire presentation on mindfulness and entire presentation on distress tolerance. But what I want you to do is get an overview or sort of a envelope with which to start filing the dbt information that you're going to learn over the next few weeks if you're going to be with us. Emotional vulnerability clients who are emotionally vulnerable tend to react to things others wouldn't react to or wouldn't react to as strongly. And that doesn't mean they're wrong for reacting to that it just means they're more sensitive. I tend to be somebody who's really sensitive, especially when it comes to to critters and children. So if I see an animal on the side of the road, or some dog running around, you know, I'm just like, we've got to do something about it. You know, I say a prayer for every dead animal that I see on the side of the road is just that's the way I am. I react to those sorts of things. Other people probably wouldn't even notice. Now, does that mean I'm emotionally dysregulated? No, it just means I tend to be more sensitive and aware of certain things. Now for a lot of our clients, they are more sensitive and aware, but part of that is because they came from environments that were very unpredictable and unsettling. So they had to be aware all the time. Think about living in a household with someone who has an addiction. So you never know which parent you're going to get and you're always kind of walking on eggshells with a person in addiction. And, you know, ironically or maybe intentionally, one of the first mainstream books about living with somebody with borderline personality disorder is called stop walking on eggshells. Because the living in that environment, you have to be attuned to all the little cues that are going on in order to anticipate what's going to happen next. So you become more aware and you may become more sensitive and reactive to it out of fear and with a desire to protect yourself. Another thing we know about people who are emotionally vulnerable is their recovery time is longer than for other people. Well, you know, think about it. If they are emotionally reactive, they're sensitive, they are reacting and getting emotionally stimulated by stuff constantly. That's tiring. So think about it this way, if you went out and you ran half marathon. And then you had to get up the next day and you had to run a 5k would you recover as quickly as someone who would just run a 5k. Probably not, you'd require more recovery time because you expended more energy and used more resources. So we want to understand that people need longer time to recover. And when we're talking about recovery here we're talking about de-escalation. But when somebody is on high alert and they're triggered, they sense there's a threat there. It's going to take them a little longer to calm down and say, okay, things are, things are okay again, they're going to be scanning. Think about a soldier in a foxhole. You know, he's waiting, he's on alert. And if something, you know, bomb goes off really close. That's going to, you know, scare the crap out of him and as it should. So he's going to be on higher alert for quite a while than he was before waiting and paying more attention and being more sensitive and more acutely aware of other things that are going on because that's how he protects himself. So this emotional vulnerability for whatever variety of reasons has evolved as a way of the person's brain trying to protect them. And that's one of the first things I want them to take home is to understand that in a way, and it may not seem like it's helpful right now, but in a way this is your brain trying to protect you. So let's figure out how we can help you tell your brain that it's not as threatening and it's not as scary. So it can turn down the sensitivity and not be as stimulated and as aware and as sensitive to everything all the time as acutely sensitive. People who are emotionally vulnerable have an inability to regulate emotion, partly because they have difficulty identifying and labeling their emotions. They probably grew up or may have grown up in environments that were emotionally invalidating. So they were told suck it up or you shouldn't feel that way, or I don't want to hear about that. So they didn't learn to identify it as an okay feeling, but they may not have even learned to identify what it was they just knew they were feeling out of control or upset. Well upset can mean scared it can mean angry it can mean depressed we need to figure out what it means before we can help the person regulate it. They have difficulty understanding why they feel that way. So they get upset something happens and they all of a sudden are just on full tilt emotional reactivity. And they're like I don't know why I, I get so upset when things like this happen. Okay, helping them understand why giving them the knowledge of why they may react that way is another step in helping them to regulate emotions. And they also may have difficulty expressing the emotion in an effective way. If when they were growing up, and they were scared, and that feeling when they tried to express it that feeling was squished, and their parents said you know suck it up don't worry about it you're making something out of nothing. They still felt scared, you know the child probably didn't feel a whole lot of comfort when they were just told that their feelings were wrong. They just didn't figure out a way to express that feeling in a way to get that need met so they started trying to do different things to get that need met which sometimes is referred to as acting out. But a lot of times when we look to act look at acting out behaviors, we realize that those behaviors are designed to try to get a need met, which wasn't being met before that behavior escalated. People may have developed difficulty expressing expressing themselves before they became out of control they may have developed difficulty asking for help. Everything is interconnected for every action there is a reaction. So let's think about addiction. When somebody uses, they feel really good for a period of time. And then what happens. They feel really bad. Maybe equal and opposite maybe, you know, in balance to the really bad. They sober up or the drug wears off, and they feel really bad. What do they want to do again they want to make the pain stop. So it's this constant yo yo. Anger is another example where something happens and someone gets angry. And generally, when you get angry. You have an effect on everyone around you. I mean most of the time people aren't going to look at you and go, oh, she's angry. Yeah, whatever. And go about their business. They're either going to try to help you feel better. Or, and more likely, they're going to try to stay out of your way. So you've got to understand that whenever you do something, there is is going to have an effect, kind of like butterfly wings. The, the theory that the current created by a butterfly flapping its wings actually has an effect on everything. So the question, think about how you interact differently with people and how people interact differently with you when you're depressed versus when you're happy versus when you're angry. Remembering that it's not just a one way. So I'm angry. I lash out that person bears the brunt of it and feels bad or goes away. Sometimes they're either going to go away and I may feel guilty then or they may lash back and I may feel angry. So it's important to understand exactly how you interact with others, but also how others impact you. So reality isn't a constant process of change. How you perceive something now may be different than how you perceive it in an hour. So what seems like the end of the world right now, or seems really irritating right now, in an hour is it really going to be all that consequential. So understanding that your reality is not something that has to stay constant. You can change it. You can improve the next moment. The reality in this moment may suck, but that doesn't mean it has to stay sucky. It can improve. And we want clients to understand that that we want to accept what is as it is, but also understand that we have the power to improve the next moment. So we want to look at what helps them change their perceptions. We want to look and ask them, what does their emotional mind say about what's going on right now? What does their logical mind say about what's going on right now? And synthesize the two, because reality comes from synthesizing two different points of view to come to what's considered a truth. The truth is always evolving though. So, you know, think about if you've ever started working out the truth when you started working out, maybe you could curl 15 pounds. And if you kept working out for two months, maybe you could curl 30 pounds. So the truth is different now. Reality is different now. What you can lift is different. It's evolved. What you can handle, quote unquote, emotionally right now is what you can handle right now. But by learning new skills and tools, what you can handle emotionally in six months may be very different than what you can handle right now. Likewise, I mean, things may be going along just ducky right now. Everything's coming up roses and you feel happy. But in six months, you may hit some bumps in the road and your reality may be somewhat different. So understanding that truth is always evolving and we want to try to integrate multiple perspectives and tolerate that two things may coexist so things may suck but be good at the same time. It's important to consider when we're talking about dialectical behavior therapy. When I have people consider opposing truths, sometimes I'll ask them to play devil's advocate. So they have all the reasons not to and all the reasons to do something and then synthesize them and figure out of the reasons not to and of the reasons to what is supportive of the best way to solve the current situation. And still help them move forward towards their goals of being happy and healthy and whatever the rest of their goals are. You can also have people step into someone else's shoes if they're having an argument with someone. You know, not just getting their shoes to try to convince them while they're why they're wrong, you want to get into their shoes to understand kind of their perspective and where they're coming from. So then you can synthesize both people's points of view. When there's a crime scene, the person may the cop that may go to the scene may interview multiple witnesses and he will probably get multiple different accounts of what happened. Does that mean somebody's lying? No, that means everybody has a different truth. Everybody noticed different things and everybody interpreted things slightly differently. So it's up to the criminal justice system to synthesize all of those points of view. And another example, like I said would be an interpersonal disagreement where you have two people and the example that I use I have teenagers at home and they have chores they're supposed to do. And I will go home and I will see that their chores have not been done adequately and I'm like, did you guys even do your chores today? And in their reality, they did their chores. So we need to compare our realities. And is it possible that they could have done their chores and still have it look like they didn't do their chores and combining those two. Realizing that two things may coexist as yeah, they did their chores to what they considered completion, not to what I considered completion. So we needed to discuss what the combined reality is of what it needs to look like for their chores to be done in my reality. Longitudinal. It's also important to understand things different to understand that we will understand things differently as knowledge is gained. When children are little, if a parent goes away. One of the things that they may understand or think they know is mommy had no use for us and that's why she left. As they grow. They may start understanding things a little bit differently maybe mommy had a drug addiction and maybe mommy ended up going to treatment and then relapsing and never ended up coming home. Maybe because she had no use for us, or was that because she was sick. So as knowledge changes, truth or your definition of what happened or your perception may change. So in dbt their skills training groups and some of the things that are being taught include core mindfulness. To make sure that people are aware of their thoughts feelings and urges. This is the first thing and not what they felt yesterday, or what they felt five minutes ago. But what are they feeling right now. What are they thinking right now, and what are their urges, because a response to a situation is a combination of all of those we have a feeling. They have thoughts that are kind of supporting those feelings and generally we have some kind of an urge to either do something to make that feeling stop. Core mindfulness helps us develop an understanding of emotions as things that don't have to be acted upon. So as people become more mindful, they start to understand that I can have an emotion. And it can hurt, but I can tolerate it emotions aren't scary, and I can change the next moment I don't have to immediately react to try to make this unpleasantness go away. I can tolerate it, step back, evaluate my options and choose the best course of action. The next type of skills that people will learn our interpersonal effectiveness to help them develop assertiveness skills and identify the goals of relationships and skills activities needed to achieve those goals. So interpersonal effectiveness is huge because our relationships are some of our greatest buffers against stress. If people are not able to communicate their thoughts feelings needs and urges effectively, they can't get support. And worse yet they may alienate their supports by coming off the wrong way or seeming aggressive or angry at other people. So interpersonal effectiveness helps people figure out how to effectively communicate their needs and wants in situations not only when they're just calm in order to prevent emotional upset, but also in situations when they are experiencing emotional distress, and they're trying to get help or they're trying to create a solution. Emotion regulation skills help people label and effectively communicate their feeling states. So, you know, label them, communicate them and nurture those supportive relationships. It helps people understand the function of their emotions and why we don't want to eliminate them. Emotions are there for a reason. Anger and fear tell you to fight or flee because there's a threat. Emotion results when you feel sadness because something important to you is gone for some reason. And happiness tells you that was good. Do that again. But all four categories if you will have emotions are designed to prompt us to do something or to take some sort of an action. We don't want to eliminate that. What we want to eliminate is our dysfunctional way of continuing to deal with feelings and get stuck in feelings. So we want to find helpful ways of improving the next moment and moving addressing whatever's causing that feeling in a way that helps us move towards our ultimate goals. Test tolerance skills are one of the first skills that I teach my clients because it helps them realize that when they feel a feeling, there are things they can do other than choosing behaviors that would be self or self injurious or harmful, which in many cases clients I'm working with are in early recovery from addiction. So the key is or the goal is to help them develop alternate skills so they can stop before they immediately turn to their drug or addiction of choice. Tolerate the distress and then make a more informed choice about what the next step is that they want to take. Dialectical behavior therapy assumes that clients are doing their best. Clients don't generally get up and say, you know what? I want to be happy, but I think I'm going to half-ass it today. They don't. They get up in the morning and they go, they may go, I want to feel happy, but I don't know if I can. That's a whole world different than I'm not going to try. If clients aren't trying, it means they don't feel like what they're doing is effective. They're starting to feel disempowered and helpless. So clients are doing their best. They're trying. They want to get better. Nobody wants to be in pain. They need to work harder and smarter and be more motivated. And, you know, I don't know that I agree with the harder part because some of my clients work really, really hard. But that's part of DBT assumptions. But they do need to work smarter because sometimes they're trying to address things with tools that aren't super effective. It's kind of like trying to take a Phillips head screw out of the wall with a butter knife. It may work eventually, but it's going to take a whole lot longer than if you actually had a Phillips head screwdriver. I've done both. When they are using ineffective or less than effective intervention tools, they're not going to feel empowered. When you don't feel empowered, you don't feel motivated because it's like, well, what's the point when I try to do this? It doesn't get any better. So we want to help them see that when they use these new tools, when they start working smarter, it will be more effective. That will help keep them motivated. It is true, though, that even if clients didn't create their problems, they have to fix them. They may have grown up in a dysfunctional environment. They may have had all kinds of unfortunate things happen to them. And that's true. But it's up to them to figure out where they're going to go from here. If they want to be happy, they need to figure out how they're going to dig themselves out of the trench that they're in right now. So even if they weren't the ones who created the trench, they got to figure out how to escape from it. Clients need to learn to act skillfully in every area of their life. Remembering that vulnerabilities go back to not taking care of mind and body, go back to chronic stress, go back to lack of support. So if clients are stressed in multiple areas of life, they're also probably experiencing emotional dysregulation in multiple areas of their life. So we need to help them learn how to communicate effectively and set boundaries and take care of themselves and work towards their goals in every area of their life, not just maybe their relationship or being happy. Well, living in isolation on an island out in the Pacific, you could probably be happy. But unfortunately, when you're living wherever you're living, which is probably not there, you've also got to deal with work and family and extended family and neighbors and whatever else. So they need to be able to apply all those skills so they can still be happy even if they've got other influences coming in. And it's also important or finally it's important to remember that clients cannot fail in therapy. Failure is a learning opportunity. If a client starts to backslide, and I don't even like the word relapse because that has so many negative connotations with it. If a client starts to backslide or lose motivation, then I want to look at it and I want to say why? What can we learn from this? Why is the motivation waning? Why is the old behavior becoming more rewarding than these new tools? What do we need to change in order to individualize treatment for this particular client? So it's not about failure, it's about learning. Treatment priorities and dialectical behavior therapy start out with suicidal or self harming behaviors, which in there I include uncontrolled substance use, especially well, any uncontrolled substance use. I consider a self harming behavior because it is easy to overdose and it is really hard to move forward in the process if they are constantly imbalancing their neurochemicals. So suicidal behaviors first obviously self harming behaviors come in a close second, if not tied with first. Then we want to move down to behaviors that interfere with therapy. So let's start out with client behaviors that interfere with therapy like not showing up or showing up late or showing up and trying to divert the therapy session every which way instead of staying on task. So we want to address those and figure out what's the motivation behind it. And how can we address that remembering that behaviors are often self protective they're serving a purpose so we need to look at what is the purpose of those behaviors and how can we address them. Now clinicians behaviors that interfere with therapy. We all have experienced it and, you know, ethically we don't we don't want to say we do. We don't want to think we do but we know we do so being aware of it and addressing it is really important to ethical treatment. Sometimes there are those clients that are just really challenging to work with. Clinician behaviors that can interfere with therapy also include being late canceling sessions, not preparing for the session by reading the notes ahead of time or whatever you do to prepare. All of those things can interfere with therapy because it may make the client feel like they're not important. It may make the client feel that they're again being invalidated. So we want to consider what behaviors we have and in session paying attention to a client. Paying attention and being mindful of our own behaviors any judgmental thoughts that come through we want to model dbt as well as teach dbt address suicidal or self harm ideation and misery. Clients may not be engaging in the behavior but they still may think about it. They may have days where they wish they were dead. They may have a lot of days where they really romanticize using again. So we want to talk about these behaviors and start addressing them. Move on to maintaining treatment gains. I mean, once you've come past and you've reduced the ideation, you've got them where they're coming to therapy and participating and actively making progress and the suicidal and self harming behaviors are pretty much non existent anymore. They've made huge gains. So let's work on maintaining those. Let's let them have a plateau and kind of solidify the gains that they've gotten as we start to move towards working on other goals they have identified. So in stage one of treatment, people attain basic capacities. They identify behaviors that pose a direct threat to the client or other safety. We want to know if there's anything we need to do in terms of a safety plan or safety monitoring. Monitor the frequency intensity of an intensity of any self harm behaviors or suicidal behaviors using a behavior tracking form. And you want to start addressing any of these behaviors. Obviously, you're going to take more active and immediate action with suicidal or self harming behaviors than ideation. But making sure that you're tracking how often these happen because you want to see a decrease in the frequency and intensity, not only of the behaviors but of the thoughts about the behaviors. In stage two, you start focusing on reducing traumatic stress. We'll start addressing negative relationship experiences as they relate to emotional dysregulation. When they grew up, they were in invalidating environments. They didn't feel like they got the support they needed from the people who were supposed to be there unconditionally their parents and their caregivers. So you may want to start addressing those experiences and how those relate to the person's inability to regulate their own emotions and the person's emotional sensitivity. Remember how we talked about if they grew up in a situation where there was addiction or domestic violence or uncontrolled mental health issues. This environment may have been very chaotic. So it's important for them to start understanding how all of that has created the situation where they are right now and how their emotional dysregulation is somewhat predictable because they weren't taught the skills. They weren't given the support they needed. And this is also where we start addressing interpersonal skills. Okay, so let's start teaching those skills and start helping you reach out and ask for help from people who can be supportive because it's possible. Those caregivers weren't even able to be supportive at that time. And then at stage three, the clients start working on increasing self-respect and achieving individual goals. So they're no longer having ideation about self-harm. Their life has become at least tolerable where they're not feeling so much emotional distress. They don't know if they can go on. Then you move to addressing traumatic stress, which goes a long way to addressing emotional reactivity. Helping them develop interpersonal skills, helping them develop skills and tools to tolerate distress and change the moment, solve problems. And then in stage three, then they're working on looking back and going, hey, look how far I've come and look at all the good things about me and let's see how far I can go from here. So that B and DBT benefits positive and negative reinforcement. So it's important when we look at the behaviors, whatever behaviors we're looking at, whether they're behaviors we want to eliminate or behaviors we want to add. They're being maintained. So behaviors are being maintained by reinforcement. Positive reinforcement means it brings them something rewarding, such as attention. Negative reinforcement means it takes away something unpleasant, like having to go to school or do chores. So there's something maintaining the behavior and we need to figure out what that is. Punishment is also both positive and negative. So punishment, positive punishment is adding something unpleasant, such as having to write 500 times, I will not hit my sister. And negative punishment is taking away something, such as putting someone in time out or taking away a privilege. In order to increase a behavior, we need to increase the reinforcers. Ideally we do that. Punishment eliminates the behavior, but they've got to have some kind of behavior to put in its place. So if you just punish a behavior, then you're just left with somebody who goes, and that's what happened to the children, leading up to this, which probably created more emotional dysregulation, every time they asked for help, every time they became dysregulated, that was punished. They were told that they were being silly or they shouldn't feel that way. But they weren't told what to do about it. So they were just left with these emotions, not knowing what to do. Consequences of behavior can be negative, harmful, unpleasant, positive, self-explanatory, or neutral. But when I pay my bills, it's not really a positive or a negative experience. I mean, I'm avoiding the punishment of getting my lights turned off, and I have the benefit of keeping my lights turned on. But it's not really, it's not a woohoo moment. It's just, I did what I had to do. So not all behaviors are going to have rewarding consequences. When we apply reinforcement, we want to make sure that we provide intermittent reinforcement. And what that means is you want to make sure the person can't count on the reinforcement always being there. So instead of every single time they do something right, they get lavished with praise, then you're going to back it down. So it's randomly, you know, maybe every third time, maybe every fifth time. And this helps the person keep doing the behavior at a steady state. So intermittent reinforcement produces a longer lasting, more effective behavior change. You can start out with consistent reinforcement, like every time somebody does something, but then you're going to start backing it off a little bit. And then modeling. If you want clients to behave a certain way when they feel a certain way, if you want clients to practice mindfulness, you need to model that. They learn more from what you do than what you tell them to do, just like your kids, unfortunately. So make sure that you're practicing what you preach. You're modeling this. And if you're having a frustrating moment, maybe you had a something happen right before session and you walk into session and you're still kind of flustered. Perfect time to model and walk through dbt with the client to help them see how you're using those skills. I mean, you don't have to get into the nitty gritty, but you can say I, you know, I had a very unpleasant conversation that upset me. So I am, you know, taking a step back. This is this is stress tolerance skill I'm using. And I'm trying to improve the next moment so I can be here and present for you, which is my ultimate goal right now. So remember that reinforcers increase the likelihood of a behavior reinforcers are rewards. Punishments reduce the likelihood of a behavior. So you want to reward as much as possible. If you're rewarding the good behavior or the ideal behavior or whatever you helpful behavior. The unhelpful behavior is probably going to go away because it's not getting rewarded anymore. And every time we have a choice between two behaviors, we choose the one that is most rewarding for the amount of effort. So if the new behaviors more rewarding, then they're just going to ignore the old one. Vulnerabilities increase the likelihood of a fight or flight response, because when you're vulnerable, your body feels like you're vulnerable. So it's constantly in this threat response state. Think about back in, you know, back in the day, when there were lions out there and your brain had to make sure that you were ready and prepared to deal with the hungry lion. Well, the primitive part of your brain still is waiting for that hungry lion. So when you're feeling sick or tired or vulnerable in some way, you're going to be more edgy you're going to be more irritable, which increases the likelihood that when something else comes your way, you're going to be more reactive because you're already spending so much energy trying to wait and protect yourself from that hungry lion that may or may not come. Backward chaining is one tool we use in order to help people identify the reinforcers and vulnerabilities that lead up to some of their dysregulation. So the way I have my clients do it is I have them start out with what happened, you know, had an outburst. Okay, so what caused the outburst co-worker said something insensitive. All right, would that normally get you that upset? No. Okay, so what happened before that? Well, when I woke up this morning, I felt really, really drained and I was just I was ready, already exhausted. I didn't want to go to work. So I was kind of in a funk. Okay, well, what's causing you to feel so drained? What's causing you to feel vulnerable? Well, the day before I had to put my cat down and that took a lot of emotional energy and I was just, I didn't even want to go to work that day. Okay, so now we can see that it wasn't just the co-worker saying something insensitive that led to the outburst. There was a whole cascade of events that wore on this person or built up in this person. So then when the co-worker said something insensitive, that was as they say the straw that broke the camel's back. Helping people see that a lot of times outbursts, relapses, whatever you want to call it, don't come from just out of the blue. If they look back and retrace their steps, they can see how things started to go south, how they started to get exhausted, how they started to feel disempowered, which ultimately led to the unhelpful behavior choice. Remembering that triggers, positive and negative triggers cause a reaction. So remind the person of a prior situation in which a behavior was rewarded. For example, lashing out gave a client control. So in the future, when the client gets upset, they're going to be more likely to lash out. If when the client lashed out, it did no good, then the client will probably be less likely to lash out in the future. But we need to understand what caused the threat. We need to understand that it's important for the person to be able to communicate what is causing their threat. And we want them to put in triggers in their life that prompt feelings of well-being. We always talk about negative triggers, triggers for use, triggers for anger, triggers for anxiety. Why don't we talk about triggers for happiness? What things in your environment look around your office? What things in your environment do you look at and smile? One of the secretaries at one of the places I used to work had a poster of a little kitty cat hanging on a clothesline. And it said, just hang in there. And yes, I'd seen that same poster for 15 years, but it always made me smile. Put in triggers in your environment to prompt feelings of well-being. When somebody gets angry, it's important to help them shape their behaviors. Rewarding successive approximations. So for example, if they get angry, the first step is, you know, we're not going to expect them to never get angry again. Anger is a normal feeling. We're not going to expect them to, you know, not get really angry, but we don't want them to throw things anymore or be physically aggressive. So the first step is not throwing things or being physically aggressive. They can yell. They can, you know, walk around. They can stomp their feet. But if they can get a little bit better and not be physically aggressive, that is a step in the right direction. And we want to reward that. You know, that was that shows progress. So now when you get upset, what can we do to help you disengage or tolerate the distress until the urge to be verbal. Or physically aggressive is gone. So the next step is figuring out how to unhook from that emotional reaction until the person can get in their wise mind. And then level three is being able to calmly discuss the issues or problems without getting overly upset. But each time the person achieves a level of being able to deal with their anger, we want to reward that. And then challenge them to start taking the next step with addiction or self harm. If somebody has gets upset and instead of using they engage in a secondary cope of coping behavior like smoking or eating or drawing. It may not be our ideal solution, but at least they're not using so kudos to them. Once they get the hang of doing that instead of using, then we want to take it to the next level and say, okay. When you get upset, what can you do to remind yourself to take a mindfulness minute to evaluate the situation, then choose a behavior consistent with your goals, instead of just going to another behavior to avoid the feeling. So the first step, not using second step, actually addressing the issue. In mindfulness, we're helping people develop an in the moment awareness of how they're feeling emotionally mentally and physically will help them explore the interconnectedness of their thoughts feelings and physical sensations. So they understand that distressful thoughts are going to lead to distressed emotions which is going to lead to physical distress headaches muscle tension belly aches. But it goes the other way to happy thoughts lead to happy emotions and tend to alleviate a fair amount of pain and somatic stress. Part of doing this we can help them become aware of the emotional wave understanding that feelings come in and feelings will go out. They will peak and then they will start to recede. So helping them identify where they are on the wave. So if they're angry, they can know that they're either almost at the top and they're on the way down, or they can know that yeah, I'm feeling a lot better than I did 30 minutes ago so this feeling will be gone pretty soon. It helps them start tolerating distress and become more mindful of where they are in terms of ability to think in their wise mind versus their emotional mind. So reducing emotional reactivity please is the acronym P and L treat physical illness. Make sure they're eating a nutritious diet. Avoid mood and mind altering drugs. Get adequate quality sleep and try to get some exercise. It doesn't mean going out and running a marathon. It means getting off the couch and moving as much as you are physically capable of doing. We want to help people build positive experiences. Again, you can't be miserable and happy at the same time. So encourage them to actually intentionally engage in positive experiences every day. Encourage them to start becoming mindful of their current emotion so they can intercept it before it becomes a big deal. If they're blue, they can start doing something to feel better before they're clinically depressed. Distress tolerance. The acronym here is accepts. And this is one that I use with my clients a lot. When they have an unpleasant feeling. Sometimes they just need to let that feeling pass for a few minutes while that wave is coming in and out. They can do hobbies, watch a video or go for a walk. They can contribute by doing some kind of volunteer work. They can compare themselves to people that are coping the same or less well than them. They can distract themselves with opposite emotions such as reading a funny book or listening to a comedian. They can actively push away distressing situations by leaving it mentally for a while. They can just check out go I'm not going to pay attention to that for right now. They can think about something else. They can do a puzzle, read a book, start writing a story, whatever it is that can occupy their mind. And they can distract with intense sensations. One of the common things we talk about in dbt is ice holding two pieces of ice in your hand. You're not going to think about much else after two or three minutes except for when can I put this ice down because it is uncomfortable. But you're not thinking about the emotional distress. So sometimes it's helpful just to help people distract from what's going on up here for a few minutes. Clients need to know that it's important to increase positive emotions because when there's positive, the negative is going to go away. In addition to decreasing the negative if you just decrease the negative then again you're left with not much. So what are you going to replace negative emotions with what are you going to replace unpleasant emotions with if you're not angry what are you encourage them to keep a running journal of things that make them happy and positive things that they can do interpersonal effectiveness. We want to help people become assertive be able to state their needs and wants. We want to help them tolerate distress instead of automatically having to act on their urges. Help them identify and communicate their emotions assertively so they can get support from other people. Help them understand their own needs because then they're going to be able to better plan their day and prevent additional vulnerabilities if they're already feeling vulnerable. They don't want to put themselves into a situation that they know is going to cause them emotional turmoil and explore situations with them using dialectical theory. We talked about reality is ever changing and the truth is involved by synthesizing multiple points of view. So helping them walk that middle path. Dear man helps people get what they want and need and this is interpersonal effectiveness skills helps them describe their situation. Express why this is an issue and how they feel about it what what's going on with them helps them assert what they need by sharing clearly what they feel and asking directly for what they want and need instead of just hoping somebody guesses. Reinforce their position by offering a win-win outcome. For example, it would help me to not get nearly as upset when you're late if you would call ahead and let me know that you're running behind that creates a win-win. Mindful focus on what we're requesting not just kind of be all over the place and go well if you knew if you were paying any attention to what was going on you would know what would make me happy. No, be mindful of what is it that you need and communicate it and stay focused on that not go off on six different tangents or a litany of done me wrongs. A peer confident and negotiate because you're not always going to get your way. But if you're confident yourself assured you know what you need and you can be assertive, it will come off a lot better and be more successful. DBT is a great tool to help clients become more aware of their emotions. I identify the thoughts, feelings and urges associated with their emotions in order to figure out the next best step to help them meet their ultimate goal of being happy and healthy. It helps them develop a greater sense of awareness regarding the wise of emotions. Why am I angry? Why am I anxious? Why do I react this way? It helps them develop a self awareness regarding their own vulnerabilities, which are those things that make them more likely to be emotionally reactive or sensitive. I tend to be a lot more emotionally reactive when I'm sleep deprived. Not everybody is, but I know that's a big vulnerability for me. And it provides a framework for teaching skills groups that benefit an array of clients with difficulty with emotionality. So it's not just people with BPD. It's not just people with addictions. It's anybody who has difficulty managing their emotions, depression, anger or anxiety. DBT skills groups can help them become more effective at reducing their reactivity and improving their ability to deal with those feelings. As I said, DBT made simple is one of the go to guides for just getting a general overview of DBT, but there are a lot of other books out there. Marsha Linehan is the one who founded or created DBT. Her books are published through Guilford Press and you can find those on Amazon. Okay, are there any questions? If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. 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