creating a life worth living

1. Dialectical Behavioral Therapy:
Creating a Life Worth Living
Presented by Niki Serravalle

2. What to expect….
• The theory
– Quick overview
• The skills
– Few examples
• How it relates to
us and what we
do
Cheese face

3. What is DBT:
Dialectical Behavioral Therapy
• Developed by Dr. Linehan,
Washington University to
treat persons with
Borderline Personality
Disorders. (1991)
• A combination of CBT and
Eastern meditative
practices.

4. Marsha Linehan

5. What is the Dialect in DBT?
• The term Dialectics refers to
opposing forces that create a
whole or a synthesis. DBT
focuses on finding a balance in
opposing forces.

6. More on Dialects
DBT makes three basic assumptions:
– (1) all things are interconnected
– (2) change is constant and inevitable and
– (3) opposites can be integrated to form a closer
approximation of the truth.
In DBT, the patient and therapist are working to resolve the
contradiction between self-acceptance and change
Cha Accep
nge tance

7. The theory
Individuals are born with a biological
predisposition for emotional
dysregulation who are then subjected
to an invalidating environment where
they learn maladaptive behaviors which
are reinforced over time.
Treatment that specifically designed for persons with
BPD and high suicidal behaviors

8. Symptoms of a person with BDP
•Make frantic efforts to avoid real or imagined abandonment.
•Have a pattern of difficult relationships caused by alternating between
extremes of intense admiration and hatred of others.
•Have an unstable self-image or be unsure of his or her own identity.
•Act impulsively in ways that are self-damaging
•Have recurring suicidal thoughts, make repeated suicide attempts, or
cause self-injury through mutilation, such as cutting or burning himself or
herself.
•Have frequent emotional overreactions or intense mood swings, including
feeling depressed, irritable, or anxious.
•Have long-term feelings of emptiness.
•Have inappropriate, fierce anger or problems controlling anger. The
person may often display temper tantrums or get into physical fights.
•Have temporary episodes of feeling suspicious of others without reason
(paranoia) or losing a sense of reality.

9. DBT Goals
• The focus of DBT is on
helping the individual learn
and apply skills that will
decrease the effects of
emotion dysregulation and
unhealthful attempts to
cope with strong emotions.
• Create a life worth living by
improving coping skills,
interpersonal effectiveness
and problem solving.

10. The hierarchy
DBT targets behaviors in a descending hierarchy:
• decreasing high-risk suicidal behaviors
• decreasing responses or behaviors (by either therapist
or patient) that interfere with therapy
• decreasing behaviors that interfere with/reduce
quality of life
• decreasing and dealing with post-traumatic stress
responses
• enhancing respect for self
• acquisition of the behavioral skills taught in group
• additional goals set by patient

11. Diary Cards

13. How DBT Works…
• Individual session that improving the client’s motivation to work
toward obtaining a life worth living
• DBT focuses on group skills training to enhance Mindfulness,
Interpersonal Effectiveness and Distress Tolerance and Emotional
Regulation.
• Telephone consultation is to ensure generalization of skills and
effective problem-solving strategies in daily living
• The commitment to therapy is imperative to success in treatment.
Individual and therapist commit to goals prior to beginning.
• A weekly consultation team meeting is held between DBT therapists
for the purpose of enhancing each therapist’s own motivation and
capability to effectively treat BPD clients

14. The Contract States…
• To accept a dialectical philosophy (at least 1 year
of therapy)
• The individual will participate in therapy and
follow all given directives. Even when they don’t
want to. (Irreverence)
• The therapist believes that the individual is doing
the best they can at all times, that behavior is a
result of their past experiences, and there is a
willingness to change. (Dialect)
– No one can fail at DBT, the treatment fails.

15. Therapy Interfering Behaviors (TIB)
• arrives late
• leaves early
• passive or helpless
• not do diary card (homework)
• excessively talks (hard for therapist to talk)
• complains but does not work in session
• excessively angry
• excessively judgmental/critical of therapist

16. Assumptions….
• Clients are doing the best they can
• Clients want to improve
• Clients needs to do better, try harder and be
motivated to change
• Clients have not caused their problems, but they are
forced to solve them
• Their lives are unbearable (suicidal)
• Clients must learn new behaviors
• Clients can not fail in therapy
• Therapists need support (interdisciplinary: staff
meetings a MUST)

17. Core Concepts (skill models)
• Mindfulness: Paying attention on purpose
• Distress tolerance: Bear pain skillfully
• Emotional regulation: Manage emotions
instead of being managed by them
• Interpersonal effectiveness: All the skills come
together in a synergistic way

18. State of our Mind
• Emotional Mind: thoughts are being
controlled by our emotions. Unable to be
reasonable.
• Reasonable Mind: think logically, be rational
about what is occurring. No emotions.
• Wise Mind: The balance of emotional mind
and reasonable mind. Goal of DBT

19. States of Mind Diagram
Reasonable
Mind
Wise Mind
Emotional Mind

20. Mindfulness Exercise
• Feel
• Smell
• Imagine/experience
• Taste
• Listen
• Hear

21. Mindfulness
• Is paying attention on
purpose
• Being non-judgmental
• In the moment, present,
in the here and now
• Increases awareness of
all senses

22. Research suggests
Mindfulness practice will….
– Reduce stress
• Lowers blood pressure
• Improves circulation
– Elevate mood
• Brain and immune function
improves
• Able to recovery from
negative faster
– Improve Productivity
• Feel better, better work

23. Mindfulness Skills
The “What” Skills The “How” Skills
• Observe: attending to • Non-judgmentally:
emotions/behavior without experiencing the world around
trying to end (increases us without judgments; separate
awareness) our thoughts and feelings from
• Describe: apply verbal labels what's actually going on
to behavioral and • Effectively: Use the skills that
environmental events you are learning; do what works.
(separates emotion from • One-mindfully: sustained
thought) attention on the present
•Participate: action with moment; do one thing at a time
attention, not mindless
participation

24. Emotional Regulation
Emotions can frequently be very intense and labile, which means they change often.
Emotions often drive behavior (problems to be solved). A lot of the behavior
focuses around finding ways to get those emotions validated or to get rid of the pain.
DBT teaches skills to manage these emotions more effectively. In the past they
learned to not feel emotions because they were taught to (smile and be nice even
when you feel angry or upset-invalidating environment). These emotions are a
secondary response to a primary emotion (feels ashamed because I was angry).

25. Emotional Regulation Skills
1. Identifying and labeling emotions
2. Understanding the function of emotions
3. Identifying obstacles to changing emotions
4. Reducing vulnerability to “emotion mind”
5. Increasing positive emotional events
6. Increasing mindfulness to current emotions
7. Taking opposite action

26. Emotional Regulation Skills:
Identifying and Labeling Emotions
1. Prompting event
2. Interpretation
3. Phenomenological experience: physical sensation of
emotion
4. Behavior expressing emotion
5. After effects of the emotion on other areas of life
Event Interpretation Emotion
See bff with bf They are talking about me Anger
See my car with flat tire Someone did this to me Anger
Getting negative points Staff is out to get me Anger
See staff laughing They are making fun of me Sadness

27. Emotional Regulation Skills
Reducing vulnerability to “emotional mind”: PLEASE MASTER
PLEASE MASTER
Treat PhysicaL Illness Take care of your body, see a doctor
when needed
Balance Eating Don’t eat too much or too little, stay
away from foods that make you feel
emotional
Avoid mood Altering Drugs Non-prescribed drugs and ALCOHOL
Balance Sleep Get the amount that makes you feel
good
Get Exercise Build up to 20 minutes a day
Act MASTERy Do one thing at a time to make yourself
feel confident and in control

28. Distress Tolerance
• Acceptance of reality is not equivalent to
approval of reality.
• DBT assumes pain and distress are a part of life;
they cannot be entirely avoided or removed.
Therefore one has to learn to tolerate and
survive. Accept life as it is in the moment.
• DBT teaches how to bear pain skillfully.
• Distress Tolerance skills address impulsivity in
high risk behaviors.

29. Distress Tolerance Skills
• Distracting
• Self-soothing
• Improving the moment
• Thinking of the pros/cons
The most important aspect of these skills is the
radical acceptance of the dialect…

30. Distracting…
• WISE mind accepts:
Activities
Contributing (changes focus from self to others, creates a
sense of meaning in life, giving back)
Comparisons (changes focus from self to others by
examining how others cope)
Emotions (replace with positive ones)
Pushing away (leave situation causing stress, blocking, only
used in ER)
Thoughts (fill head with thoughts that provide powerful,
positive physical reactions)
Sensations (hold ice cubes, snap the bands)

31. Improving the Moment
• IMPROVE:
Imagery: Imagine relaxing scenes, things going well, or other things
that please you
Meaning: Find some purpose or meaning in what you are feeling
Prayer: Either pray to whomever you worship, or, if not religious, chant a
personal mantra, LET GO
Relaxation: practice deep breathing, use self soothing
One thing in the moment: stay present
Vacation: take a brief break, allow yourself to be taken care of
Encouragement: cheerlead yourself

32. Pros/Cons Skill
To get opposite action: Pros/Cons of new behavior:
• Pros/Cons of new •Postpone behavior for a specific
behavior small amount of time (fully commit)
• Mindfulness of current •Distract, relax, or self-soothe
emotion/urge
•Postpone behavior again
• Break overwhelming
tasks into small pieces •Do the behavior in slow motion
and do first step •Do the behavior in a very different
– something always way
better than nothing •Add a negative consequence for
• Problem solve; Build behavior
mastery

33. Interpersonal Effectiveness
The interpersonal effectiveness module focuses on
situations where the objective is to change something
(e.g., requesting that someone do something) or to
resist changes someone else is trying to make (e.g.,
saying no). The skills taught are intended to maximize
the chances that a person’s goals in a specific situation
will be met, while at the same time not damaging
either the relationship or the person’s self-respect.

34. Interpersonal Effectiveness Skills
Focuses on developing skills that address problem solving. They
balance the dialect between maintaining the relationship and
maintaining self respect. Difficult to do with populations that
vacillate between all or nothing (avoidance of conflict and intense
confrontation).
1.Objectives effectiveness- prioritizing achievable objective goals
2.Relationship effectiveness- prioritizing a conflict-free relationship
3.Self-respect effectiveness- prioritizing acting within your own
principles so that you feel comfortable with how you approached
the situation

35. Interpersonal Effectiveness Skills
The Skills
1.Attending to
Relationships
2.Balancing the Wants-
to-Shoulds ratio in Life
and Relationships
3.Building Mastery and
Self Respect

36. Interpersonal Effectiveness Skills
GIVE
Skill for maintaining relationships
Gentle: Use appropriate language, no verbal or physical attacks, no put downs,
avoid sarcasm unless you are sure the person is alright with it, and be courteous
and non-judgmental.
Interested: When the person you are speaking to is talking about something, act
interested in what they are saying. Maintain eye contact, ask questions, etc. Do not use your
cell phone while having a conversation with another person!
Validate: Show that you understand a person’s situation and sympathize with them.
Validation can be shown through words, body language and/or facial expressions.
Easy Manner: Be calm and comfortable during conversation, use humor, smile.

37. Interpersonal Effectiveness
DEARMAN - getting something
This acronym is used to aid one in getting what he or she wants when asking.
Describe your situation.
Express why this is an issue and how you feel about it.
Assert yourself by asking clearly for what you want.
Reinforce your position by offering a positive consequence if you were
to get what you want.
Mindful of the situation by focusing on what you want and ignore
distractions.
Appear Confident even if you don’t feel confident.
Negotiate with a hesitant person and come to a comfortable
compromise on your request.

38. Interpersonal Effectiveness
Balancing priorities with demands:
Priorities are those things you want, are important to you
Demands are those things other people want, important to them
FAST - keeping self-respect
This is a skill to aid one in maintaining his or her self-respect. It is to be used in
combination with the other interpersonal effectiveness skills.
Fair: Be fair to both yourself and the other person.
Apologies: Don’t apologize more than once for what you have done ineffectively,
or apologize for something which was not ineffective.
Stick to Your Values: Stay true to what you believe in and stand by it. Don’t allow
others to get you to do things against your values.
Truthful: Don’t lie. Lying can only pile up and damage relationships and your self-
respect.

39. Skills applied…
Problem solving and change strategies are
again balanced dialectically by the use of
validation. It is important at every stage to
convey to the individual that their behavior,
including thoughts feelings and actions are
understandable, even though they may be
maladaptive or unhelpful.

40. Therapist skills
• Radical Acceptance
• Validation: communicates validation by listening,
reflecting, and highlighting the valid or “kernel of
truth” in the client’s phenomenal experience
• Reciprocal communication: being responsive,
warm, and engaged; using self-disclosure; and
being genuine.
• Irreverent communications aim to get the
patient’s attention, shift the response, and help
the patient see a different point of view.

41. DBT for kids

42. PLEASE MASTER becomes SEEDS Grow
Emotion regulation handout 10
Keeping control of your emotions
SEEDS
GROW
Sickness needs to be treated You need to take care of yourself and
your body. See your doctor and take your medicine
Eat right You need to eat good food. Do not eat too much or too little
Exercise Do some exercise every day. Stay in shape
every day
Drugs are Stay away from drugs and alcohol. They make you out of
bad control
Sleep Get enough sleep at night so you are not tired during the day
GROW Do something you are good at every day and try doing
every day something new every day

43. Diary Card looks like

44. THANK YOU
Questions….