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DBT Fundamentals I:How to Deal with Pain to AvoidSufferingDr. Kimberly Vay, LPC, NCCkvay@hside.org 2016 Vay1

Goals of DBTGoals of DBT DecreaseLife-threatening behaviors Therapy-interferingbehaviors Quality-of-life interferingbehaviors Mindlessness Increase Core Mindfulness Distress Tolerance Interpersonal Effectiveness Emotion RegulationWhat does DBT helpwith? 2016 Vay Emotions: DBT can help youregulate your emotions Relationships: DBT can helpyou get along with people better Behaviors: DBT can help youget through painful/hard thingswithout acting out impulsively Mindfulness: DBT can teachyou to really concentrate onone thing at a time.2

DBT Assumptions People are doing the best they can People and children want to improve People need to do better, try harder, and be moremotivated to change People cannot fail in DBT People may not have caused all of their own problems, butthey have to solve them anyway The lives of group members are painful as they arecurrently being lived There is no absolute truth 2016 Vay3

Main Goal of DBT CreateA LIFE WORTH LIVING https://www.youtube.com/watch?v 5EJwSHOqIHs 2016 Vay4

Structure of DBTDBT is organized with specific: Stages of Treatment Targets of Treatment Modes of Treatment 2016 Vay5

Stages of Treatment 2016 Vay6

Pre-Treatment StagePre-Treatment ‘Stage’of DBT includes: Orientation to the therapyGaining Commitment towork on suicidal and selfharming behaviorsSet agreed upon goals fortherapyPre-Treatment typicallytakes 1-2 sessions 2016 Vay7

Stage I:Stage I: Moving from Being Out of Control of One’s Behavior toBeing in Control (Linehan) Work to develop greater behavioral control with a primaryemphasis on the here and now. The treatment focuses on the severe behavioraldysregulation exhibited by the patient. 2016 Vay8

Stage I Cont Patients in Stage 1 are typically miserable and theirbehavior is out of control When patients first start DBT treatment, they often describetheir experience of their mental illness as "being in hell." Patients in Stage 1 may be trying to kill themselves,self-harming, using drugs and alcohol, and/orengaging in other types of self-destructive behaviors. The main goal of this stage is to decrease lifethreatening and other self injurious behaviors. 2016 Vay9

Core Mindfulness 2016 Vay10

Why Mindfulness? The ability to be fully present in the moment without judgment orresistance Being more aware of the present moment allows a person toexperience: Freedom from suffering Research shows that increased mindfulness can help in the followingareas: Self-awareness Emotional Reactivity Anger/Stress Management Anxiety/Depression Anxiety/Panic Disorders Insomnia 2016 Vay11

Core Mindfulness: Three States of MindEmotion MindReasonable/Rational MindWise Mind 2016 Vay12

Three States of Mind: Emotion Mind Emotion mind is ruled by feelings and urges When a person is in Emotion Mind, their responses arecontrolled by their emotions and they tend to act onimpulsesEmotion Mind is not bad and it can bebeneficial; we must mediate it withawareness and presence.-Strazar, 2009 2016 Vay13

Three States of Mind: Emotion Mind When we are controlled by an emotional state, thenEmotion Mind takes over. When we impulsively act the waywe feel it can lead to out of control and unsafe behavior,which creates chaos, hurt feelings and suffering. When weact on strong emotions, our vision of what is actuallyhappening is blurred and can cause a strong response(stress response: fight/flight/freeze). 2016 Vay14

Three States of Mind: Reasonable Mind Facts and logic is the framework to Reasonable mind Reasonable Mind is important in learning new skills Helps you define a problem and determine a solution Reasonable Mind is much easier when you are healthy,strong, and feeling good When you are tired, vulnerable, weak, Emotion Mindtakes over 2016 Vay15

Three States of Mind: Wise Mind Wise mind is the active integration of emotion mind andreasonable mind Making a decision – thinking it through and LETTING GO Wise mind blends the logic of reasonable mind with theintense emotions of emotion Mind to create a calm state ofmind When you can act skillfully and relate what you know to astressful situation, you are acting in Wise Mind As you learn skills, you begin to act intuitively out of WiseMind 2016 Vay16

Core Mindfulness Skills WHAT SKILLS (what to do to bemindful) Observe Describe Participate HOW SKILLS (how to remainmindful) Non judgmental One mindful Effectiveness 2016 Vay17

Core Mindfulness Skills: What SkillsObserve: Wordless watching: Just notice the experience in the present moment. Observe using all of your sensesDescribe: Put words on the experience: Label what you observe with words, usingonly the facts Describe only what you observe without interpretations. Stick to thefacts!Participate: Throw yourself into the present moment,fully experiencing your feelings 2016 Vay18

Core Mindfulness Skills: How SkillsNonjudgmental:Notice but don’t judge. Stick to the observable facts of thesituation, using only what is observed with your sensesOne-Mindfully:One-mindfully: Focus your attention on only one thing inthis momentEffectively (Do what works):Be effective: Focus on what works toachieve your goal 2016 Vay19

Distress Tolerance Sometimes emotions become so overwhelming that they causepeople to lose control and act impulsively. Dysfunctionalbehaviors are often uncontrollable responses to emotional painor attempts to relieve suffering. Dysfunctional behaviors areshort-term solutions and can undermine long-term goals. Distress tolerance skills are ways of surviving terrible situationswithout resorting to dysfunctional behaviors that will make thesituation worse. These skills help us experience, tolerate, andaccept emotional pain in order to build a life with less sufferingand more acceptance of the world as it is. 2016 Vay20

Why Bother? Why Bother Tolerating Painful Feelings and Urges? Pain is a part of life and can’t always be avoided If you can’t deal with your pain, you may act impulsively When you act impulsively, you may end up hurting yourselfor someone else 2016 Vay21

Distress Tolerance SkillsDistress tolerance contains two sets of skills:1. Crisis survival strategies Focusing on pros and cons Self soothing IMPROVE the moment Distract with ACCEPTS TIPP2. Reality acceptance 2 subsets of skills Basic principles for accepting reality Guidelines for accepting reality 2016 Vay22

Crisis Survival Strategies: Pros & Cons DBT Pros & Cons are different from the “average” Pros & Cons inthat DBT Pros & Cons looks at the Pros & Cons of tolerating distressvs. not tolerating distress. When determining the pros and cons, youare looking at the consequences of potential actions.Key points to keep in mind: Before an overwhelming urge hits, write out your Pros & Cons andcarry them with you When an overwhelming urge hits, Review your PROS and CONSand imagine the positive consequences of resisting the urge.Imagine (and remember past) negative consequences of giving in tocrisis urges 2016 Vay 23

Pros & ConsPros Cons Acting on Crisis UrgesPros of acting on impulsiveurges:Cons of acting on impulsesurges:Resisting Crisis UrgesPros of resisting impulsiveurges:Cons of resisting impulsiveurges: 2016 Vay24

Crisis Survival Strategies: Self-Soothe Most of us recognize self-soothe techniques, but many of ushave never learned how to effectively self-soothe to make usfeel better and to avoid crisis situations from getting worse. These techniques can be used when feeling distressed,when emotions become overwhelming and when you havedifficulty managing situations effectively. 2016 Vay25

So what is self-soothe in the DBT world?Self-soothe has to do with comforting, nurturing and being kind toyourself.Self-soothing deals with all 6 senses:1.Vision: Doing something that soothes the eyes; looking at beautiful flowers2.Hearing: Music soothes t he mind; Listen to a favorite song3.Smell: Finding smells that you find soothing; perfume, flowers, cooking, etc.4.Taste: Peppermint candy, special tea5.Touch: Very important when it comes to soothing; getting close to someone,put lotions on, feeling clean sheets; pet an animal6.Movement: Rock yourself gently; stretch; go for a run; do yoga; dance! 2016 Vay26

Crisis Survival Strategies: IMPROVE the Moment What do you do when everything is going wrong? The world feels like it isliterally crushing down around you? We've all been there and it's an awful place to be. Sometimes you just can'tchange what's going on around you. This skill allows you time when youcan step back, separate emotionally, and separate what's actually going onfrom your thoughts. This is when the tool IMPROVE works great! It canhelp get you centered and allow you to see the situation in a wholedifferent way. IMPROVE the moment Imagery Meaning Prayer Relaxation One thing in the moment Vacation Encouragement 2016 Vay 27

IMPROVE the Moment: ImageryImagery:Creating a situation or ascene that is differentfrom the one that you arecurrently experiencing.Envision in your mind aplace that you would liketo be your ‘happy’ place,a safe place, a relaxingplace and let yourself feelthat you are in this place. 2016 Vay28

IMPROVE the Moment: MeaningMeaning:Finding the meaning in adifficult situation. Makinglemonade out of lemons.Very powerful skill topractice! 2016 Vay29

IMPROVE the Moment: PrayerPrayer:Praying to your higherpower or Wise Mind for theskills to cope with a difficultsituation. NOT to fix it. 2016 Vay30

IMPROVE the Moment: RelaxationRelaxation:Progressive musclerelaxation, take a bath,massage your muscles,breathe deeply 2016 Vay31

IMPROVE the Moment: One thing in the momentOne thing in the moment:Focus on one thing only. Donot give the difficultsituation the power. 2016 Vay32

IMPROVE the Moment: Mini-VacationMini-Vacation:Take a break in your mind.Go to the beach, go to yourhome, anywhere is open toyou. It costs no money andhas no limits. 2016 Vay33

IMPROVE the Moment: EncouragementEncouragement:Listen to motivating music,validate your positivequalities, cheerlead you! Youdeserve it! 2016 Vay34

Crisis Survival Strategies: Distract with ACCEPTSDistract withACCEPTS Activities Contributing Comparison Exercise Push Away Thoughts Sensations 2016 Vay35

Distract with ACCEPTS: ActivitiesActivities:Anything active works here!Go for a walk, play games,talk or visit a friend, exercise,clean, do school work can allhelp you feel better about asituation and take your mindoff of it temporarily. 2016 Vay36

Distract with ACCEPTS: ContributingContributing:Doing kind things for othersthere is something veryhealing in making otherssmile (words or deeds workeasily as well.) Kindnesstowards others createskindness for ourselves. 2016 Vay37

Distract with ACCEPTS: ComparisonComparison:Compare the currentsituation to a worse timeyou've experienced andsurvived. Compare yourcurrent situation to otherswho have/are survivingworse circumstances. 2016 Vay38

Distract with ACCEPTS: Emotion SwitchingEmotion Switching:Anything which changes the emotion your experiencing.Music, Movies, T.V. can be really helpful. Remember to lookfor shows/songs which are different than what you'refeeling. 2016 Vay39

Distract with ACCEPTS: Push AwayPush Away:Push the situation out ofmind temporarily. Build awall between you andsituation. Come back to itwhen your emotions are lessintense 2016 Vay40

Distract with ACCEPTS: Thought SwitchingThought Switching:Activate your reasonablemind! Read, do wordproblems, count, write astory 2016 Vay41

Distract with ACCEPTS: SensationsSensations:The senses are your friendsin this skill. Some scientistlist up to 21 senses. For ourpurposes we will simplifythem into 6. Touch, Taste,Hearing, Smell, Vision, andmotion. Everyone leanstowards one sense overanother. 2016 Vay42

Crisis Survival Strategies: TIPPT-emperature ChangeI-ntense ExerciseP-aced BreathingP-rogressive MuscleRelaxation 2016 Vay43

Crisis Survival Strategies: TIPPTIPPT-emperature Change: Splash ice cold water on your face andneck. Focus around your eyes. Use a rag in the freezer or an icecube. If you are chilly afterwards.you win this exercise Activates the dive reflex and gets the parasympathetic nervous system tokick in and calm you down (Linenhan, 2011)I- ntense exercise: get your heart rate UP! Dance, jog in place, dopush-ups, jump up and down, MOVE! Try 5 minutes of this. 2016 Vay44

Crisis Survival Strategies: TIPPTIPPP-aced breathing: Breathe out longer than you breathe in.Try to see how long you can do each. Oxygen helps yourreasonable mind combat emotion mind.like giving Popeyespinach :)P-rogressive muscle relaxation: tighten and release eachmuscle group. Squeeze your fists. See how many musclegroups you can try this with! 2016 Vay45

Crisis Survival SkillsCreating a Crisis Survival Kit forHome, School or Work 2016 Vay46

Distress Tolerance Reality Acceptance 5 ways of responding when a problem occursSolve the problem2. Change how you feel about the problem3. Accept the problem4. Stay miserable5. Make it worse Radical acceptance Turning the mind Willingness versus Willfulness Half-Smiling and Willing Hands1. 2016 Vay47

Accepting Reality Basic principles for accepting reality include: Radical acceptance Turning the mind Willingness versus WillfulnessThe main difficulties clients have with the skills include: Accepting something without necessarily approving of it Expecting acceptance to make the pain go away Accepting there's a cause for everything even if the causeis not apparent. 2016 Vay48

3 Principles of Radically accepting a situation1) Reality is as it is:Accepting reality in the present moment is an important part of building a life worth living.This is incredibly difficult when life is painful because none of us want pain. Through pain is anunavoidable part of life suffering we attached to it is avoidable.2) Everything has a cause:Another step toward radical acceptance is remembering that everything has a cause. This ideamay be obvious in some situations. Most of us know that a sunburn is caused by staying in thesun too long or that neglecting maintenance leads to major car repairs down the road. Butsometimes things in life are so painful and unwanted that it's difficult to see that, they too, havecauses. Accepting that everything has a cause even if you don't know what it is can help toreduce the suffering.3) Life can be worth living even if there's pain:Pain doesn't make life worthless. Often we try to turn from pain is if it will make life better butin fact it does not. It's easier to see that life can be worth living if we live our lives in the presentmoment. Many of us spend most of our time in the past and future instead of focusing onwhat's going on right now. This adds the pain of the past and future onto our pain in thepresent moment which makes things feel heavier than they would be if we lived only in thepresent. 2016 Vay49

Turning the Mind Turning the mind is the second of the three basic principles of accepting realityChoosing to radically accept isn't a single decision but one that youmust make again and againTo Turn the Mind you must constantly make an active choice to exceptin a very literal wayRemember that Turning the Mind toward acceptance reduces sufferingto ordinary painThink of acceptance like any skill - it gets easier with practice. Topractice turning the mind in life means that when you come to a fork inthe road, you deliberately choose to accept over and over and over,remembering that acceptance reduces suffering and helps build a lifeworth living. 2016 Vay50

3 steps for turning the mind1. Notice you're not accepting The first step is to notice that you're not accepting. Generally the tip off is that you are angry, bitter, or annoyed. You might find yourselfengaging in certain thoughts and behaviors or questioning again and again "why me"?Also notice when you find yourself using words like "should have" or "shouldn't have"if so you're judging the situation.2. Make an inner commitment: Once you notice that you're not excepting reality as it is in the present moment try totell yourself that you are going to eventually accept the situation as it is. It can behelpful to literally tell yourself that you're going to turn your mind toward acceptanceand then feel yourself make the transition, for even just a moment.3. Do it again: The last step is to do it over and over again once you've turned the mind it may bounceright back to unacceptance. You need to walk yourself through the three steps forturning the mind again. 2016 Vay51

Willingness vs. WillfulnessWillingness versus willfulnessis the third of the three basicprinciples of acceptingreality.A critical part of learningreality acceptance is beingable to distinguish betweenwillingness and willfulness. 2016 Vay52

WillingnessWillingness: Willingness is really an attitude toward life. It involves realizing thatyou are connected to and part of life. When you were willing youwere agreeing to be a part of life. You allow the world to be what it isand you make a commitment to active participation in that reality. Willingness is not "approval" or "lying down and letting yourselfget walked on" but it does require doing what is needed in thecurrent situation or moment. 2016 Vay53

WillfulnessWillfulness: Willfulness is the refusal to accept your connection to life. It involvessaying no to life and to reality. When you are willful you impose yourwill on reality by trying to fix everything or rejecting what is neededin the current situation or moment.It's like throwing a fit or sitting onyour hands when action is called for. 2016 Vay54

Hillside DBT Clinic Contactswww.hillsideDBT.orgClinical Therapist: Kimberly Vay, EdD, LPC, NCCkvay@hside.orgReferral Relations Coordinator: Gaan Ackers, LAPCgackers@hside.orgChief Operations Officer: Lori Hogeman, LSCWlhogeman@hside.orgBusiness Development Director: Mark Pulliammpulliam@hside.org 2016 Vay55

Putting it all into practice 2016 Vay56

Interpersonal Effectiveness Emotion Regulation What does DBT help with? Emotions: DBT can help you regulate your emotions Relationships: DBT can help you get along with people better Behaviors: DBT can help you get through painful/hard things without acting out impulsively Mindfulness: DBT ca

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