Dialectical Behavior Therapy The Woodward Resource Center Model

Dialectical Behavior Therapy The Woodward Resource Center Model Unleashing The Power 1

Name _______ “Wise Mind” Homework How do I get to wise mind? ___________________________________ Wise mind is the middle between __________mind and _________mind. How does wise mind help me? _________________________________ HOMEWORK: Tell one staff member about Wise Mind and how it helps you. Have them initial here: _____ 2

Mindfulness: Describe “putting words on your thoughts” Position the person so that they cannot see the item that is being put in their hand, yet the rest of the group members can see it. Challenge the person to be “mindful” of the item and first describe it – even if they immediately know what it is. Ask questions such as, is it soft or hard? Dead or alive? Smooth or rough? After the person has described at least 3 or 4 aspects of the item, allow them to “guess” what it is. Take home message: Being mindful of an item means really concentrating on what it is like, even if we know what it is. Also, sometimes “mindful” before we “speak” can be quite helpful, as being mindful allows one to really consider several aspects that may have otherwise been overlooked. 3

Mindfulness: Participating “ 1. 2. 3. entering your whole body into an activity” Have clients stand in a circle. The leader makes eye contact with another client for at least 2 seconds. This is crucial, be sure that the leader does it. After 2 seconds of eye contact, the leader says her own name. Then the two trade places and the new leader takes a turn. Unless she is very mindful, the leader is tempted to say the other person’s name. This takes practice. Ben Joe Tom Ben Andrew Anna 4

Mindfulness: Judgmental/Nonjudgmental “focusing on just the facts” Connect the “Judgmental” statement to the alternative “Nonjudgmental” way of saying the same thing: Judgmental (opinion) Non. Judgmental (fact) My group leader is mean. Exercise takes a lot of effort. Chores are stupid. Once you calm down, you can ……. Bobby is a jerk. I forgot to do my homework last night. Exercise is dumb. I am an idiot! You need to calm down. My group leader follows the rules. Bobby doesn’t want to be my boyfriend. Chores take up my free time 5

Mindfulness: Nonjudgmental “focusing on only the facts, rather than opinions” Strengthen the concept through a fun activity: After reviewing that judgmental statements are opinions and that nonjudgmental ones are facts, divide the group into 2 teams. Each team picks a family name. Read a statement from the attached page. Players hands are behind their back until the group facilitator has completely finished reading the statement. Team members take turns deciding whether or not to ring a bell. If the team who range the bell first can correctly identify the statement as either “judgmental” or “nonjudgmental” the team gets a point. If they are wrong, and the other team can correctly identify the statement, the second team gets 2 points. After each point has been awarded, reread the statement, emphasizing the word / aspect that makes it either judgmental or nonjudgmental. Keep score on the board. Encourage teamwork. First team to 20 points wins. Praise efforts.

My group leader is cool. My group is polite to me. Harry eats like a pig. Harry drips food out of his mouth when he eats. My boss at work is stupid. My boss at work wants me to work hard while I am there. Smoking cigarettes is dumb. Smoking cigarettes costs a lot of money. Brett Favre is a super quarterback. Brett Favre throws a lot of successful passes that turn into touchdowns. La. Bron James was voted MVP for the Cleveland Cavaliers. La. Bron James is a “sweet” rebounder. Watermelons are green on the outside. Watermelons are the best fruit of all. Fish are wonderful pets. Having a fish for a pet does not require a lot of work. Winter is the worst season. Winter is cold, and I don’t like cold weather. The American flag is attractive. The American flag is red, white, and blue. War Head candy is gross. War Head candy is sour. Pizza rocks! Pizza has cheese on it.

Judgmental / Nonjudgmental Homework ________ Write a Nonjudgmental statement for each Judgmental one listed below. Name Judgmental (opinion) Non. Judgmental (fact) Candy is yummy. Candy is sweet. Chores are stupid. ____________________ Sandy is crabby. ____________________ John is dumb. ____________________ I am an idiot! ____________________ DBT group is wonderful. ____________________ 8

Mindfulness: One Mindfully Mindfulness: One-mindfully “Hand Over Hand” “focusing on one activity” 1. Have all participants sit at a table with their arms extended as shown. Cross arms between the wrist and the elbow; right arms are on top of left arms. 2. Hand #1 starts by tapping the table once, then the tapping behavior goes around the table (to the right) with everyone tapping the table in order. #1, #2, #3, #4, etc. Practice this a few rounds, until everyone is fairly successful. 1 2 3 8 7 6 4 5 3. Then add an additional rule: When someone taps the table twice in a row, it reverses the order. Go as slow as necessary, and vocally prompt as needed, to ensure everyone’s success. Take home message: Even when we know what to do (in a crisis), it can be difficult. Practice helps! 9

Mindfulness: Effectively “focusing on what works” But the rule at this house is: we get ice cream for our snack on Friday nights! I’m sorry, but the calendar doesn’t say that I should give you ice cream. You can have an apple instead. Hmmm. I could get angry and argue, but I’d just get in trouble. Think I’ll use my Mindfulness: Effectively skills by accepting the apple tonight, then tomorrow talking with regular staff about getting it on the calendar for next time. Client Relief Staff 10

Mindfulness: Effectively “focusing on what works” If I stay home from work, I lose my chance to earn a bonus “soda” this afternoon. I can’t stay home! You seem really upset. Perhaps you should stay home from work today. Client Staff True, the rule is that “only people who go to work can earn the afternoon bonus soda. ” However, trying to go to work and staying on schedule when your emotions are out of control can result in something a lot worse than losing a soda. Use your Mindfulness: Effectively skills to decide what is going to get you closer to your long-term goals. 11

States-of-Mind Game Reasonable Mind • Calm and Cool • Focusing on Facts • Planful Behavior • Focused attention Mindfulness “What” Skills • Observe • Describe • Participate Wise Mind • Combines emotion and reason Emotional Mind • Hot • Without thinking things through • Decisions that one is happy with for A long time • Using Mindfulness Skills • Facts are Distorted • Decisions feel good at the moment but are often ones we regret later on Mindfulness “How” Skills • Non Judgmentally • One-Mindfully 12 • Effectively

Scenario #2 Scenario #5 Scenario #3 Scenario #4 All my housemates’ moms came to the open house party, but mine. My peer is making fun of the clothes that I am wearing. A friend told me she borrowed my radio without asking. I tried to get my group leader to talk to me, but he would not do it. #1 I called him back and screamed “You are a jerk. I hate you!” #2 I decided that I must be a bad person since my mom doesn’t want to come. Then I ran away from my staff. #3 I am sad and start thinking of myself as a loser. #4 I hit my friend. #5 I started crying. #1 I realized that my brother disappoints me at least 2 times per year. #2 I calmly focus my attention on how many times my mother has disappointed me in the past few months. #3 I plan to tell her that there is nothing wrong with what I am wearing. #4 I calmly count about how many times she has done it, and decide to hide the radio from now on. #5 I look again and see that my staff is busy doing paperwork that is part of her job. #1 I used my Mindfulness Effectively skill, by telling my brother that I am really disappointed when he lets me down. #2 I use my Mindfulness Non Judgmental Skill: I recognize that I am NOT a bad person because of what my mom does, I am just disappointed she did not come. #3 I use my Mindfulness: One Mindfully Skills: I ignore her and instead am mindful of he music I am playing. #4 I use my Mindfulness: Describe Skill to put words on my feelings: I tell her how “disappointed” I am that she took the radio and request that she does not do it again. #5 I decide to use my Mindfulness Participate skill: I focus on engaging my whole body in the Hokey Pokey to help me pass the time until my 13 staff has time to talk with me. Scenario #1 My brother said he would come and get me for a visit, but he didn’t show up.

States-of-Mind Homework Emotional Mind Rational Mind • Calm and Cool Wise Mind • Combines emotion • Focusing on Facts • Planful Behavior • Focused attention • Without thinking things through and reason • Decisions that one is happy with for A long time Using Mindfulness Skills • Facts are distorted • Decisions feel good at the moment but are often ones we regret later on Describe something that happened this week that resulted in you having an “Emotional Mind” response: _________________________________________________________________________________ _________________________________________ What was your “Emotional Mind” response? _________________________________________________________________________________ 14

RELATIONSHIPS: Validating & Giving Compliments Validation: 1. 2. 3. 4. 5. Telling the other person how you think they feel You are yawning, are you tired? You look frustrated. You are smiling, are you happy? You are crying, are you sad? Are you disappointed? 6. ______________ Compliment: Saying something nice about the other person 1. 7. 2. 3. 4. 5. I like your sweater. ______________ That is a pretty necklace you have. You are doing a “good job. ” You are nice. You sing so well! 15

Snip these into cards. Have clients get into groups to play. Or, individually, draw a card, then identify whether it is an example of “validation” or “giving a compliment. ” Make it a game. Prompt, as necessary, to ensure success, but fade prompts as possible. You look thirsty! You’re crying. Are you sad? You look scared. You have thrown the paper down. Are you frustrated? That is a real pretty shirt you have. Wow! You have That is a really nice lost 22 pounds. picnic lunch that you You must be proud fixed for us! of yourself! Good job cleaning your plate. You must be proud of your new shirt. You wanted to go on a picnic today, but it is raining. Are you disappointed? Your friend got a box in the mail and you did not. Are you jealous? You cleaned your plate. You must have been hungry! You must have You did your chore cleaned your room, it really well tonight. looks really nice! You look so nice since you have lost weight! 16 You are a really good friend!

Validation Homework Name _____________________ I saw (name)_______ (action)______________. I III by saying: I validated him/her “You are ____________, you must be (emotion)______. ” I saw (name)_______ (action)______________. I validated him/her by saying: I saw (name)_____ “You are ____________, you must be (emotion)______. ” I saw (name)_______ (action) ______________. I saw (name)_______ (action)______________. I validated him/her by saying: “You are ____________, you must be (emotion) ______. ” “You are ____________, you must be (emotion)______. ” 17

Priorities vs. Demands in relationships Priorities are what are important to you-what YOU WANT TO DO! -for example- “I want to eat that cake!!” Demands are what OTHER people WANT YOU TO DO. -for example- “My doctor wants me to watch my diet. ” Most problems occur when what YOU want is different from what OTHER PEOPLE want. Having good relationship skills will help you learn to balance priorities and demands. 18

Application: Priority/Demand Wednesday Demand Priority Clean Fridge Swimming at YMCA Friday Priority Demand Halloween GYN Dance Appoint. • On paper, assist the person in identifying the demands and priorities for that day. Emphasize the benefit of creating a “balance” of the two: feeling happier, less overwhelmed. • Prompt, as necessary, to create the balance. That doesn’t mean you necessarily need to “provide a circus” for every demand. Rather, strategically scheduling activities/events. 19

RELATIONSHIPS: Repairing Damaged Ones 1. Ask the person to write a friend’s name on paper – think of the paper as a relationship. 2. Ask the person to tear the paper – think of the tear as an argument or mishap. 3. Ask the person to “repair” the tear with tape – – Think of this as “repairing” the relationship Notice that the relationship may be stronger or weaker, depending on the quality of the repair. Also, the relationship may look different. 20

“Relationship Repair” Homework Name __________ 1. Write down something that went “wrong” in one of your relationships during the past week: ___________________________________________ 2. Write what you did to “repair” that relationship: ___________________________________________ 21 ______________________

Repair Goals • Freedom to Radically accept the past pain and move forward. • Invite others in focus on how to Effectively build better relationships • X-ray the problem Non-Judgmentally so as not to repeat the same mistake Fill your toolbox with the right tools to FIX the relationship

Fixing it with self Fixing it with the person Fixing it with Others in house Do a chain analysis to see what I could do differently Let the person choose the Television show Ask to bake something special for others Radically accept what I did— accept responsibility for my actions Write an apology Do an extra chore for no points Write a list of skills –practice one Write a poem Independently as possible follow my program Have a good cry Draw a picture Give people time to work through the feelings Take One Day at a Time. Do the other person’s chore Write an apology and share in group Practice different situations using Wise Mind Let the other person go first in line Group outing let the others choose where to eat/do Other:

FIXing the relationship Homework What DBT Tools can I use to Fix the problem with others What DBT Tools can I use to Fix the problem with Myself • • • ____________________ _____________________ _____________________

Effectively requesting what one wants: “Dear Man” Describe the situation. No judgments, stick to the facts. I’ve done the kitchen chores 3 nights this week. Express feelings or opinions about the situation clearly. I’m frustrated. Assert wishes- ask for what you want. I’d like someone else to take a turn. Reinforce others for their help in you getting what you want. Thank you for checking into this for me. Stay: Mindful- keep your focus. Maintain your position, no distractions. Appear confidence- voice tone/physical manner. Negotiate- ask for or offer alternative solutions. 25

Self Respect “feeling good about yourself and the things you do” Sometimes people say things to us that make us feel bad. I am better than you. You are not important. You have to do what I tell you to do. Your family does not care about you. One way to build self respect, is to stand up for ourselves. We can do that by letting the other person know that what they are saying, or how they are saying it, makes us feel bad. We want to do it appropriately because doing it inappropriately could hurt the other person and get us into trouble. That is not something we would be proud of. I feel frustrated when you talk to me like that, please change your voice. ” “I feel sad when you say things like that. ” 26

Building Self Respect Homework Write something that someone says to you this week that made you feel bad in box #1. Write your appropriate response in box #2. Bring this back to next DBT Skills Group. ____________________ _____________________ ___________ #1 • • #2 I feel sad when you say things like that. I feel frustrated when you talk to me like that, please change your voice. 27

Clients learn how to reduce emotional vulnerability “Things that help me have GOOD days” – a group activity Get exercise every day Treadmill – Bicycle – Walk to work – Exercise Video -Sports Exercise 8 hours each night Limit day naps Sleep Feeling Good! Eat Smart Limit junk food Use smart portions Medication Take each dose, per doctor’s orders 28

Then, snip these into cards. Divide clients into 2 groups. One group at a time, have them take a card, huddle together, read the card, then decided “yes” or no” whether or not it would help someone have a good day. Eating Exercise Medication Sleep At the party, I wanted to eat 2 pieces of cake, but only ate 1 I watched TV today, instead of walking on the treadmill. I was mad at staff and refused to take my medication. I sleep all afternoon, so now I am not tired. Last night I ate the whole bag of potato chips. I walked home from work today instead of taking the bus. I took my meds as soon as I was called to the med cart. I stayed up late watching movies, so I only got 6 hours of sleep. I rode the bicycle I chose an apple for today, but only did it my snack today. for 1 minute. I took my medication 2 hours later than normal. I got 8 hours of sleep last night! I bought a diet pop today, instead of one with sugar. I only took one of my pills today, but the doctor said I should take 2. I slept for 13 hours last night. I wanted something to do, so I did an exercise video. 29

A Group Activity: Associating Bodily States with Emotions involve body changes, such as tensing or relaxing of muscles, changes in blood vessels, fluctuations in heart rate, skin temperature, etc. It is very important for us to listen to our bodies for us to understand what is happening, and what our emotions are. Below are some examples of what might happen to some people’s bodies while they are experiencing different emotions: -SCARED- shoulder muscles get tense, heart starts to pound quickly. -HAPPY- feeling warm, muscles are relaxed. Below are some emotions that we experience often. Try to go back in your mind and think about the last time you felt these emotions. For each one, circle the word that you think describes your body best during that time. These will be different for different people! Disappointed My muscles are relaxed/tense. My heart is beating slowly/quickly. My body temperature feels cool/warm. Excited My muscles are relaxed/tense. My heart is beating slowly/quickly. My body temperature feels cool/warm. Jealous My muscles are relaxed/tense. My heart is beating slowly/quickly. My body temperature feels cool/warm. Hurt My muscles are relaxed/tense. My heart is beating slowly/quickly. My body temperature feels cool/warm. Scared My muscles are relaxed/tense. My heart is beating slowly/quickly. My body temperature feels cool/warm. Sad My muscles are relaxed/tense. My heart is beating slowly/quickly. My body temperature feels cool/warm. 30

“Emotion-Intensity Charades” develops the ability to identify and label social cues of others, which is an important aspect of empathy skills. Idea by Julie Brown 1. One client chooses both an emotion card an intensity card: Happy Scared Sad 1 2. With coaching, the client acts out that emotion / intensity while peers work together to interpret the social cues given. Happy? 3 5 3. Using the 0 -5 scale can also help a client report their internal experiences with greater detail. 3? Happiness Sadness 012345 31

Clients learn: primary and secondary emotions and are encouraged to focus on the primary one Event Primary Emotion Secondary Emotion Behavior: “What I did” My roommate took my radio without asking. I felt frustrated. I got angry. I yelled at her. My family didn’t call this week. I felt sad. I got angry. I didn’t do my chore. Everyone else was going on a trip, except me. I felt jealous. I got angry. I threw a book. 32

Clients learn to: differentiate between emotional reactions that are “useful” from those that are “destructive” Some clients will learn best by seeing “side-by-side” examples: Useful Destructive Feeling stressed makes me want to spend more time relaxing. Feeling stressed makes me feel like throwing things in my room. Feeling sad about losing a friend makes me want to work harder at my relationships Feeling sad about losing a friend makes me feel like I never want to meet new people again. Feeling disappointed about losing makes me feel like practicing harder. Feeling disappointed about losing makes me want to quit the team. Feeling guilty about hurting someone’s feelings help me feel like I should be kinder to others. Feeling guilty about hurting someone’s feelings makes me want to stay in bed all day. Feeling proud makes me feel and look confident. Feeling proud makes me want to brag to my friends. Feeling embarrassed about my zipper down makes me double check before I leave the restroom from now on. Feeling embarrassed about my zipper down makes me want to never, ever wear pants with zippers again! Which emotion is the most useful to you? Feeling __________________________________________ Which emotion gives you the most trouble? Describe: Feeling __________________________________________ 33

Other clients will be successful with stand-alone scenarios. Introduce a variety of emotions; review their meaning, if necessary. I felt shy when I met the new staff, so I listened quietly while she talked with other people until I felt I knew her a little better. I was tired, so I relaxed after work I felt overwhelmed and went to bed 15 with my new job, minutes earlier so I quit. than usual. . I was jealous because my housemate was going on a home visit, so I went in and took one of her CD’s. I was surprised that I got to go on the trip that was planned. I started talking about all the other places I wanted to go. I was sad, so I started watching a funny move. I felt better after I laughed at the story. I was irritable, so when my friend asked me to help with a project, I told her I didn’t have time to do that stupid thing. I felt guilty about calling my friend a name, so I apologized. I was proud that I won at bowling, so I bragged to all my friends for the rest of the day. I was ashamed that I broke the lamp. When staff asked me about it, I lied and said it was my housemate. I was embarrassed I had spinach in my teeth, so I made a joke about it and went to the bathroom to get it out. I was calm, so when staff asked me what was wrong earlier, I talked about how I felt. I was pleased that I got to go with staff to get the pizza for dinner, and really enjoyed the trip. I felt guilty about stealing my friends pop, so when she asked me about it, I got mad and called her names. I was bored on the trip yesterday, so I kept complaining until they decided to come back 34 home.

Distress Tolerance Most approaches to mental health treatment focus on changing distressing events and circumstances, rather than accepting, finding meaning for, and tolerating distress. For 10 sec’s, think about something that really upsets you. . . 10 secs later. . . You were able to accept it, even though you don’t agree with it or like it. Radical Acceptance 35

For someone who is particulalry sensitive to distress, the ability to tolerate it may be accomplished through a shaping process, starting with this approximation of the desired behavior: Group Activity: Person A starts reciting the alphabet, while peer B starts asking them questions. If Person A stops, ask her to start over, reminding her to recite the alphabet “one-mindfully. ” Close eyes and cover ears if necessary What is your name? Who is your boyfriend? What day is it? When is your birthday? What color are your eyes? B A “A-B-C-D-E -F-G-H-I-JK-L-M-N-O -P-Q-R-S-TU-V-W-X-Y -Z” 36

Shaping Distress Tolerance Behavior Where Who Comment Sensitivity Prompts 1 Skills Group Peer Zero Name, etc. If necessary, then fade 2 Skills Group Peer(s) Zero Birthday, etc. none 3 Individual Therapy Therapist Mild, Moderate, High If necessary, then fade 4 Where trouble has occurred e. g. : home Neutral Person e. g. Direct-Care Staff Mild, Moderate, High If necessary, then fade 5 Where trouble has occurred e. g. : home Sensitive Person Mild, Moderate, High If necessary, then fade 37

Self-Soothe 5 Senses: • List and describe at least one thing you find pleasurable, comforting and/or enjoyable through each of your five senses. • When you are trying to tolerate painful events and emotions and you cannot make things better right away, choose one or more of these self-soothing activities and do it. Sight Sound Touch Smell Taste ____________________________ ______________

Distract with “Wise Mind Accepts” Add a favorite of your own. Choose one to do when you are tolerating painful events or emotions that you cannot make better right away. A ctivities: exercise, hobbies, cleaning, going out, calling or visiting friends, playing cards, board or computer games, going for a walk, working, playing sports, getting something to drink. ___________ C ontributing: do volunteer work, make something or do something for someone else, do a surprising, thoughtful thing. _______________________________ C omparisons: Compare yourself with others. Do some of them cope better than you? Some worse? Compare your situation to others who are less fortunate than you. Watch soap operas or dramas, read about things that have happened to other people. _____________________________ E motions (opposite ones): Read emotional books or stories, watch emotional movies, listen to emotional music. Be sure things you are doing create emotions that are different than the ones you are experiencing. Examples: Read joke books when you are sad, watch a comedy when you are mad. _________ P ushing Away: Push the situation away by leaving it for a little while. Think about something else, focus on something mentally that takes your concentration. Block it in your mind. Pretend to put it in a box, and put it on a shelf for awhile. _________________________________ T houghts: Count to 10, count colors in a painting, windows, people wearing blue, etc. Watch TV, read, do puzzles. Think of something you are looking forward to doing. _________________ S ensations: Hold ice in your hand; squeeze a rubber ball very hard, take a hot shower. _________

Improve the Moment Choose one to do when you are tolerating painful events or emotions that you cannot make better right away. I magery: Go to an imaginary safe place. Practice this before a crisis. M eaning: Finding the meaning of a situation helps us tolerate it. Kind of like “making lemonade out of lemons”. P rayer: For those who find comfort in this type of activity. R elaxing: Your body communicates with your mind. If you can relax your body, it will help your mind relax also. O ne thing in the moment: Focus on “just the moment” and not painful memories of the past. V acation: Get someone to cover for you, then take a planned vacation from your responsibilities. Go to a quiet, private spot and “regroup” yourself. E ncourage: Cheerlead yourself like you would to someone you care about who is in crisis.

Improve the Moment Homework Name __________ List 3 places you like to go during Imagery. I magery: Go to an imaginary safe place. Practice this before a crisis. 1. ___________________________ 2. ___________________________ 3. ___________________________ List 3 things you could say to cheerlead yourself in a crisis: E ncourage: Cheerlead yourself like you would to someone you care about who is in crisis. 1. ___________________________ 2. ___________________________ 3. ___________________________

“Vacations” – A vacation from adulthood It means NOT coping with the problem at hand, and allowing oneself to be taken care of for the moment. Vacations can be helpful or harmful, depending on the situation HELPFUL HARMFUL VACATIONS are. . . 1. 2. 3. 4. 5. 6. -brief -planned -at appropriate times -not going to cause further damage -not frequent -A time to “regroup” and problem solve when the vacation is over VACATIONS are… 1. 2. 3. 4. used to “escape” the problem permanently Taken at times that may make problems worse (during important assignments, appointments) Taken repeatedly Ignoring the problem and not returning to problem solve when the vacation is over

”Vacations” Group Activity • Provide clients with two papers: One is a photo symbolizing a “helpful” vacation: One is a photo symbolizing an “harmful” vacation: • Read the scenarios listed on the next page to the clients and have them raise one of the pictures to identify whether is was a helpful or harmful vacation. • Initiate discussion between the participants as to why they chose the answer. • If they are able to come up with examples of a time in their life that they have done something similar to the scenario, encourage discussion about what the LONG-TERM CONSEQUENCES of that vacation were (“I lost my job!!”, “I didn’t get a paycheck!”, etc. ) Variation- have one client draw the scenario from an envelope and have them read it to the group.

“Vacations” Group Activity Scenarios -”My vacation lasted a week!” -”I just didn’t feel like getting out of bed, and didn’t tell anyone”. -”I had a candy bar for lunch”. -”I left the dishes sitting in the sink after dinner and cleaned them up the next morning. ” -”I had 3 candy bars today. ” -”I skipped work for 3 days and didn’t tell my boss what was going on. ” -”I left the dishes sitting in the sink for 3 days. ” -”I skipped my workout today-I’m just not feeling up to it. ” -”I didn’t take my meds this morning- I was just too tired. ” -”I needed a day off of work, so called my boss and explained it to him. I’ll be back tomorrow!” -”I stayed in bed for 2 days. ” -”I decided I didn’t want to pay the bills- I bought a new MP 3 Player instead. ” -”I don’t think I’m going to exercise ever again-I just can’t stand that treadmill!” -”I can’t stand it here! I’m going to leave out the front door. ” -”I’m unhappy with how things are going. If I tell people I’m feeling suicidal, I can stay in the hospital for a few days. ”

Thinking of Pros and Consider the positive and negative aspects of tolerating distress and the positive and negative aspects of NOT tolerating distress. ******************************* Accepting and Tolerating NOT Accepting and Tolerating Accepting reality and tolerating distress lead to better outcomes than do rejecting reality and refusing to tolerate stress.

Visual Aids and Metaphors “Relationships are like flowers. If you don’t tend to them, they will wilt and eventually fade away. ” “Relationships are like muscles. You have to keep working on them if you want to keep them. ” 46

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BCA Vulnerability Following a crisis, the client and therapist work together to identify the chain of events that took place. This may include client behavior, thoughts, feelings, other’s behavior, environmental events, etc. Over time, patterns are identified. Prompting Events Problem Behavior Short-term Consequence: escape emotional misery Long-term Punishing Consequences 48

First the problem behavior is identified. Then we work backwards to figure out “what happened before that…, etc. ? ” My Behavior I fell asleep at the breakfast table. I was tired, as I’d stayed up late the night before watching movies. Other’s Staff said, “Wake up, you need to be ready for work. ” Behavior My Feeling I was feeling humiliated. My Thought I wanted to show staff that I can do what I want. Problem Behavior I tried to ingest a battery. 49

Next, we work to identify the consequences that followed the problem behavior. Often, the short-term consequence is “feeling better. ” However, the long-term consequences are often not enjoyable, and sometimes even deadly. Problem Behavior I tried to ingest a battery. Short Term I felt better right away. My privileges are now limited, so that staff can keep me safe. Long Term When my boyfriend found out, he wanted to break up. 50

Reduce vulnerability factors Reduce prompting events Replace problem behavior with adaptive behavior Short-term consequence: escape emotional misery Long-term reinforcing consequences Adaptive Behavior The client and therapist then work together to identify and learn adaptive strategies that will allow the client to experience positive short-term and longterm consequences. Problem Behavior 51

Bio-Social Theory Biological Factor: Emotion Dysregulation High sensitivity to emotions • Individual reacts more easily; has a low threshold Emotional intensity • Reactions, both negative and positive, are extreme Slow return to baseline • Unable to refocus attention to “here and now” 52

Social Factor: Invalidating Environments Quit crying or I will give you something to cry about. Just try harder! Get over it. A Vicious Cycle: You are such a difficult child! You could calm down if you tried! The child effects the environment, and the environment effects the child. People think I’m a loser when I show my feelings. You make life difficult for me, too! I feel rejected. 53

The damage caused by an invalidating environment stays with the individual long after he/she leaves that environment. I don’t know what to call the feelings I have. Things will never get better for me. I cannot take it any longer. I must escape this emotional misery somehow. I want to hurt myself. I hate myself. 54

Staff learn about a Dialectical Worldview What “Dialectical” Means: For every position (argument), there is an opposite position. One can hold both opposing positions at the same time. Both positions are “true. ” 55

Dialectical Examples are Provided IIwanttotobuy hit my something AND peer I want AND to save money. I want to stay out of trouble. I want to quit smoking AND I want to have a cigarette. I want to lose weight AND I want to eat cake and pie. I want to buy something AND I want to save money. 56

Visual cues/metaphors help explain “dialectical thinking” from the client’s perspective Find another way to escape emotional misery, such as learning new DBT skills. Synthesis Dialectic On one hand, I am so miserable I can’t stand it. I want to die. On the other hand, I want to live. 57

Visual cues/metaphors help explain “dialectical thinking” from therapist’s perspective ( Change Acceptance and change are both useful, if balanced! Synthesis Dialectic On one hand, I I accept you and yourbehavior at atthisminute. On the other hand, I am going to encourage you to change your behavior 58

Remember this skills group activity? To facilitate staffs’ understanding and appreciation of the concepts being taught, during staff trainings, the material is sometimes modified in ways to which staff can relate to it. 59

To facilitate staffs’ understanding and appreciation of the concepts being taught, during staff trainings, the material is sometimes modified in ways to which staff can relate to it. #1 -Scenario A client grabs the kitchen cabinet door and tears it off. #2 -Scenario I had a lot of things I had to do at home last night. I’m tired and didn’t want to come to work this morning. #3 -Scenario A client injured a staff member and the staff had to go to the state doctor. #4 -Scenario I just received the word that I’ve been mandated AGAIN! #5 -Scenario A client is returning to this house, and she has some colorful history and reputation. #1 I tell the client how “destructive” she was and how “disappointed” I am with her behavior. #2 I tell my coworker that I am tired of her complaining about little things. I have real problems and nobody cares about that! #3 I told the client: Now it is your fault we won’t have any regular staff today, which means we cannot go on the trip. #4 “I get really sick of them calling me for this. I hate it!!! #5 She will destroy everything in the house and make our lives miserable! #1 I tell myself that it is not my house and ignore the behavior as it could be worse, it could be me that is “broken. ” #2 I recognize that I need my job. People are depending on me and I’ve promised to do something for a client. She will be disappointed if I don’t give in and get it done. #3 I think to myself: This happened 3 times this week and there is a trip planned for tomorrow. #4 I decide to just “suck it up” and make plans to do the mandated shift. #5 She is “doing better” and hasn’t destroyed things lately. And, our staff is now more skilled than when she lived her before. #2 I decide to go into work. I need my job and they need me at the house. Maybe tonight I can take some time and do something I really enjoy. #3 This is a dangerous / stressful situation that keeps occurring. I use my Mindfulness: effective skills to problem solve a solution that will be effective. #4 I make arrangements to work the extra shift and also make arrangements to mindfully sooth myself with some intense sensory stimulation when the shift is over. #5 The client did destroy things in the past. She is not doing that now. We should build her skills so 60 to revert to she won’t need that old behavior. #1 I validate the client’s feelings and help them identify what they could do in the future with those types of emotions.

Staff learn what validation is: Communicating to the person that his/her feelings and behaviors are understandable within his or her situation. 61

And, what Validation is NOT Validation is not the same as “reinforcement”. It is not saying “good job” or “thank you. ” It is not the same as problem solving. It is putting yourself in the person’s shoes to think about how he or she must be feeling, and then letting him or her know it. E. g. : tired, proud, scared, frustrated, disappointed, worried, exhausted, hungry… 62

Staff are provided the Steps in “Validating” someone #1 Gather information #3 Validate • Listen to what the client is saying “You must be awfully disappointed right now. ” • Consider non verbal behavior and environmental events #2 Reflect back to the person for confirmation “You’re saying that you are not going home this weekend? ” 63

Staff are provided the Characteristics of “Effective Validation” Non judgmental Whether or not you agree “Mary, I think I hear you saying you are sad because you did not get to ride a camel tonight, is that right? ” Sincerely/Genuine Regardless of how ridiculous it may sound From client’s perspective 64

Long-Term Goals are explained Initially, our goal is to create a validating environment, so that the damage from biology and invalidating environments can be “repaired. ” However, our long-term goal is NOT to convince everyone in the world to validate the client. Rather, over time, as damage is repaired, and the client learns new skills, DBT prepares the client to survive in the same invalidating world that we all do. 65

Agreements Client Expectations IDT Expectations • Stay in group and individual therapy for as long as my team and I decide upon. • Attend scheduled therapy sessions. • Work toward reducing suicidal and other dangers behaviors as a goal of therapy. • Work on behaviors that arise that interfere with the progress of therapy. • Accept responsibility to make changes for a life worth living. ______ Client ______ Therapist • Learn and abide by DBT philosophy (including receiving initial training and continued education from the consultation team, etc. ) • Support client’s commitment to attend therapy sessions (individual and group). This will necessitate not scheduling other activities during their scheduled therapy times. • Maintain communication with the DBT Consultation Team (regarding staff and client issues, important events in the client’s life, etc. ) • Support the client receiving treatment in any way possible. This includes, but is not limited to: 1. Providing a validating, accepting environment. 2. Transportation and/or supervision for groups and individual sessions. 3. Assisting clients with any homework, dairy cards, and application of skills. 4. If appropriate, developing and monitoring DBT related IIP’s. _______ IDT Member ________ Consultation Team Therapist Expectations • Make every reasonable effort to conduct competent and effective therapy within the DBT Consultation Team. • Obey standard ethical and professional guidelines. • Be available to the client for therapy sessions and provide needed therapy back-up (such as telephone consultation, etc. ) • Maintain confidentiality. ________ Client _______ Therapist 66