Episode 24 – Dialectical Behaviour Therapy Pt2

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Trigger warning: this podcast discusses self-harm, suicide, drug abuse and destructive behaviours.

If you feel suicidal call 999 immediately.

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Rethink Mental Illness
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Dialectical Behaviour therapy – notes

Background/overview

Dialectical Behavior Therapy (DBT) is a cognitive behavioral treatment developed by Marsha Linehan, PhD, ABPP. It emphasizes individual psychotherapy and group skills training classes to help people learn and use new skills and strategies to develop a life that they experience as worth living. DBT skills include skills for mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.

Developed in the 1980’s by Dr Marsha Linehan as a result of her own practice of treating women with histories of chronic suicide attempts, suicidal ideation, urges to self-harm, and self-mutilation in the 1970’s. After some discussion with colleagues she identified that she was treating women who met the criteria for BPD. She originally started their treatment with CBT and wanted to investigate it’s effectiveness in helping people whose suicidal thoughts were as a result of extreme pain and distress. During this time some three significant issues were found to be particularly troublesome in the treatment of these individuals:

1. The unrelenting focus on change which is a key component of CBT felt invalidating to the individual client and so clients responded by withdrawing from treatment, by becoming angry, or by vacillating between the two. This resulted in a high drop out rate. And, obviously, if clients do not attend treatment, they cannot benefit from treatment.
2. Clients unintentionally positively reinforced their therapists for ineffective treatment while punishing their therapists for effective therapy. In other words, therapists were unwittingly under the control of consequences largely outside their awareness, just as all humans are. For example, the research team noticed through its review of audio taped sessions that therapists would “back off” pushing for change of behavior when the client’s response was one of anger, or emotional withdrawal, or shame, or threatened self-harm. Similarly, clients would reward the therapist with interpersonal warmth or engagement if the therapist allowed them to change the topic of the session from one they didn’t want to discuss to one they did want to discuss.
3. The sheer volume and severity of problems presented by clients made it impossible to use the standard CBT format. Individual therapists simply did not have time to both address the problems presented by clients – suicide attempts, urges to self-harm, urges to quit treatment, noncompliance with homework assignments, untreated depression, anxiety disorders, etc, — AND have session time devoted to helping the client learn and apply more adaptive skills.

So Linehan and her research team added dialectics and validation to the standard CBT model

They added in new types of strategies and reformulated the structure of the treatment.

So, the new strategies, are known as Acceptance-based interventions, or validation strategies.

Adding these communicated to the clients that they were both acceptable as they were and that their behaviors, including those that were self-harming, made real sense in some way.

Further, therapists learned to highlight for clients when their thoughts, feelings, and behaviors were “perfectly normal”, helping clients discover that they had sound judgment and that they were capable of learning how and when to trust themselves.

The new emphasis on acceptance did not occur to the exclusion of the emphasis on change: Clients also must change if they want to build a life worth living. Thus, the focus on acceptance did not occur to the exclusion of change based strategies; rather, the two enhanced the use of one another.

In the course of weaving in acceptance with change, Linehan noticed that a third set of strategies – Dialectics – came into play. DBT therapists and patients aim to adopt a dialectical world view, with its emphasis on holism and synthesis of opposing perspectives.

This worldview enables the therapist to blend acceptance and change in a manner that results in therapeutic movement, speed, and flow in individual sessions and across the entire treatment. This counters the tendency, found in treatment with clients diagnosed with BPD, to become mired in arguments, polarizing positions, and extreme positions. Beyond the dialectical worldview, specific dialectical strategies used in session, such as the devil’s advocate technique, irreverence, and the use of metaphor can help to prevent the therapist and client from becoming stuck in the rigid thoughts, judgments, feelings, and behaviors that can occur when emotions run high, as they often do in the treatment of clients diagnosed with BPD. Thus, these three sets of strategies and the theories on which they are based form the foundations of DBT.

it is now recognized as the gold standard psychological treatment for people with BPD. In addition, research has shown that it is effective in treating a wide range of other disorders such as substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders. 

Goals of DBT

To have a life worth living

Its unique to each individual – it could be music, books, horses, crafts etc

It is not a suicide prevention program and is not a way for people to stop doing behaviours that bother others

DBT helps the individual who needs it

In other words, there is hope if you feel suicidal and DBT is one of those ways to overcome those feelings

Crisis plan

I had a crisis plan that all clients had to agree to. It listed their expectations of me and what I should expect from them.

It also had the agreed goals that I wanted to achieve from therapy:

Short term:

• practise the use of skills in everyday life e.g. at home and with friends
• reduce impulsive behaviour e.g. spending, etoh, meds, eating and destructive expression of anger

Long term:

• the ability to have emotions but not react impulsively e.g. expressing needs to Husband in a way that isn’t destructive
• to experience joy and positive emotions freely without shame

I agreed to a 14 month therapy plan 2 sessions per week one therapy session and a 2.5 hr skills session. The use of the DBT crisis phone, attend all sessions, work at reduce suicidal behaviours, work collaboratively with the therapist, reduce therapy interfering behaviours such as using alcohol, drugs or attending hung over, arriving late and forgetting my homework.

Defining DBT

Dialectical – philosophy known as a dialectic which is 2 things that seem opposite to each other but in fact can both be true at the same time e.g. everyone is doing the best they can, but everyone also needs to try harder

in DBT the main dialectic is balancing acceptance with change you have to try different things to get the life you want you have to be motivated and work harder

DBT therapist is in a kind of dance understanding where you are coming from and also pushing you when they can

B is Behaviour and that is anything that can be reinforced and rewarded

Reinforcer is anything that is likely to get the behaviour to occur again

e.g. study hard get an A on your exam the A is the reinforce and you are more likely to study hard again or giving your dog a treat if he sits the treat is the reinforcer

in DBT therapists work with you to establish target behaviours

things you are working to increase and often in the beginning decrease to make your life better e.g. suicidal thoughts, self-injury, restricting meals, bingeing and purging, using drugs or alcohol, engaging in risky sexual behaviour, reckless driving, physical aggression, and shoplifting

therapy which is different to other types of therapy traditions

main goals:

• stay alive
• stay in therapy until you can meet your goal which is the most important and gives the individual a life worth living

DBT therapists job to know how hard it is to change and simultaneously push you to keep you moving forward

DBT therapists also believe that therapy with someone is really a relationship between equals so asking a question about their lives would mean they would more than likely just respond honestly

Therefore the work in DBT therapy is done by both of you

DBT has been and still is being researched and has been shown to be most effective with people who have difficulty regulating their emotions meaning that your life may feel a bit like an emotional rollercoaster and will help you if:

You are more effected than your friends if plans are cancelled or things don’t go your way

You cry at movies a lot or even commercials

You feel like you were born into the wrong family like you are a lion cub born into a family of house cats

https://behavioraltech.org/resources/faqs/dialectical-behavior-therapy-dbt/ 

Components of DBT (full DBT)

Four modes of treatment

1. Structured individual therapy – focus on behaviours and dialectics the balance between acceptance and change. You will also be asked to do some tracking of your emotions and behaviours between sessions
2. Skills group – 2-2.5 hrs long where you learn a new skill to manage emotions tolerate distress and have effective interpersonal relationships
3. Skills coaching – calling your therapist to help use your skills and not engage with your target behaviours
4. Consultation team – less obvious support each other and do the best treatment possible
   

1. Individual therapy

Individual therapy typically involves weekly one-to-one sessions with a DBT therapist. Each session lasts approximately 45–60 minutes.

The individual sessions have a hierarchy of goals, including:

• To help keep you safe – by reducing suicidal and self-harming behaviours.
• To reduce behaviours that interfere with therapy – by addressing any issues that might come in the way of you getting treatment.
• To help you reach your goals and improve your quality of life – by addressing anything that interferes with this, such as other mental health problems like depression or hearing voices, or problems in your personal life such as employment or relationship problems.
• To help you learn new skills to replace unhelpful behaviours and help you achieve your goals.

Your DBT therapist is likely to ask you to fill out diary cards as homework which you can use to monitor your emotions and actions. You will be asked to bring these cards with you to your therapist each week to help you look for behaviour patterns and triggers that occur in your life. You then use this information to decide together what you will work on in each session.

Behaviour Chain analysis

It looks at your patterns of behaviour in a particular situation – something happened, then what happened next, and then this happened, then this happened, then I though this, then the problem behaviour happened, and then this happened – so you describe the chain of events

So it’s like a series of questions your Doctor might ask or you have a problem with your computer, it is refusing to print a document and you go through a problem solving process e.g. has it worked before, is it plugged in to the power, is it switched on, is the computer talking to the printer, is it out of paper

So, in DBT it’s about identifying the target behaviour (the self-harm or injury, the binge eating, the purging, the drinking alcohol, the reckless driving etc)

Then assess the controlling variables – what is it that’s causing this behaviour

Always asking what’s the function of this behaviour? (what’s keeping it going what’s reinforcing it?) but usually we don’t know even if it seems obvious because if it was obvious someone would have moved in and changed it by now

So you go through the process with an open mind to see the variables that make this behaviour happen again and again

You usually go through the situation chronologically – earlier to later and ideally the problem behaviour is three-quarters of the way through so there is stuff before the behaviour and stuff after it

Both the therapist and client work through the problem as it is the easier to repeat the chain for similar behaviours allowing the clinician and client to identify the variables that keep coming up that explains the behaviour as well as identify if there is something missing

When I was doing this with my therapist she would put it on her white board and we would draw out the events with arrows and thoughts that would pop in – it was more like we were just having a conversation about the event but we were then adding meaning to it and directionality as to what parts impacted other parts and she would validate me and my feelings

So, the chain analysis is split into five sections

• Vulnerabilities
• Prompting event (the thing that made the story turn)
• The links in the chain of events
• The problem behaviour
• The consequences

Sometimes you will find that there are things missing – in the video that I have posted in the show notes Dr Charles Swenson talks about one of his clients that he was talking to and doing a chain analysis. They are talking about an event were the client punched the boss in the head and he asked why, and they say because they were angry. He follows this up with do I need to know this will this happen when you are angry should I get some protective gear and they were like no I am angry most of the time so that shows something in the chain analysis is missing – and the client says well he smirked at me and that’s the important prompting event and then you can look into why they have this pattern of behaviour that if someone smirks at them the deserve to be hit. Showing that sometimes the prompting event isn’t easily recognised the first time around

When with your therapist what will often happen is that the chain doesn’t get discussed directly in the form described above the vulnerability, the prompting event, the links, the problem behaviour but it will often begin with the problem behaviour

Step 1: describe the prompting behaviour

Whilst doing this you need to be:

• Specific and detailed and not using vague terms
• Identify what you did, said, thought, felt and identify what you didn’t do
• Describe the behaviour as if you need someone to act out what you did
• If the behaviour was something you didn’t do ask yourself if a) you did not know you needed to do it b) you forgot it and later it never cane to your mind to do it c) you put it off when you did think about it d) you refused to do it when you thought about it e) you were wilful and rejected doing it or some other behaviour, thoughts or emotions interfered with you doing it
• If a or b was the cause, then move to step 6

Step 2: describe the prompting event

What was it that started the whole chain of behaviour?

• Begin with the environment even if you don’t think it was a result of an environmental prompt possible questions to help the person get there are:
• What exact event precipitated the start of the chain reaction?
• When did the sequence of events that led to the problem behaviour begin? When did the problem start?
• What was going on right before the thought of or impulse for the problem behaviour occurred?
• What were you doing/thinking/feeling/imagining at that time?
• Why did the problem behaviour happen on that day instead of the day before?

Step 3: describe specific vulnerability factors before the prompting event.

• What factors or events made you more vulnerable to reacting to the prompting event with a problematic chain? Areas to examine are:
• Physical illness; unbalanced eating or sleeping; injury
• Use of drugs or alcohol; misuse of prescription drugs
• Stressful events in the environment (positive or negative)
• Intense emotions, such as sadness, anger, fear, loneliness
• Previous behaviours of your own that you found stressful coming into your mind

Step 4: describe in excruciating detail the chain of events that led to the problem behaviour. Imagine that your problem behaviour is chained to the precipitating event in the environment. How long is the chain? Where does it go? What are the links? Write out all links in the chain of events, no matter how small. Be very specific, as if you are writing a script or play. Links in the chain can be:

• Actions or things you do
• Body sensations or feelings
• Cognitions (i.e. beliefs, expectations or thoughts)
• Events in the environment or things others do
• Feelings and emotions that you experience

What exact thought, feeling, or action followed straight after the prompting event? Then what followed that and so on

• Look at each link in the chain after you write it. Ask yourself if there was any other thoughts, feelings or actions that could have occurred. Could someone else have thought, felt acted differently in the situation? If so explain how they could see it differently
• For each link in the chain ask whether there is a smaller link that you could add in and describe further.

Step 5: describe the consequences of the behaviour. Again be specific, how did the other person react immediately or later? How did you feel immediately following the behaviour? Later? What effect did the behaviour have on you and your environment?

Step 6: describe in detail at each point where you could have used a skilful behaviour to head off the problem behaviour. What key links were the most important in leading to the problem behaviour. If you eliminated these behaviours, the problem behaviour probably would not have happened.

• Go back to the chain of behaviours following the prompting event. Circle each link where if you had something different, you would have avoided the problem behaviour.
• What could you have done differently at each link in the chain of events to avoid the problem behaviour? What copy behaviours of skilful behaviours could you have used?

Step 7: describe in detail prevention strategy for how you could have kept the chain from starting by reducing your vulnerability to the chain.

Step 8: describe what you are going to do to repair important or significant of the problem behaviour.

• Analyse: what did you really harm? What was the negative consequences you can repair?
• Look at the harm or distress you actually caused others, and harm or distress you caused yourself. Repair what you damaged, e.g. you broke a window and you bring them flowers – fix the window. Repair a betrayal of trust by being very trustworthy long enough to fit the betrayal, rather than trying to fix it with love letters and constant apologies. Repair failure by succeeding, not by berating yourself.

https://www.youtube.com/watch?v=qvI6qstjdn8

https://www.mind.org.uk/information-support/drugs-and-treatments/dialectical-behaviour-therapy-dbt/dbt-sessions/#.Wnm04JPFLOQ

http://www.dbtselfhelp.com/html/diary_cards1.html

https://www.youtube.com/watch?v=kuhImFdGW_w

https://www.youtube.com/watch?v=1s44Lo-9b-Q

Diary card

In between the sessions I would be asked to keep a diary card which I have added an example in the show notes which would help me, and my therapist see how my week had been. I would record my urges giving it a rating between 1 and 5 (1 being the least and 5 being the highest urge) to self-harm, suicide, and use alcohol/drugs. I would also rate my emotions and my vulnerabilities so if I was in pain, sad, shame, anger and fear. I also identified some problem behaviours for me it was spending, drinking and taking alcohol and rate those on urges again 1 – 5. I then would identify if I followed through on my urges e.g. did I self-harm or did I drink, or did I take alcohol. The last section identified if I felt joy and if I used skills on a 0 – 7 scale.

And what it means by skills is if I was applying the skills I learnt from skills training ro actual life.

0 – did not even think about using skills

1 – thought of using skills but did not (did not want to)

2 – thought of using skills but did not (although wanted to)

3 – tried skills (but could not use them)

4 – tried skills (but it did not help)

5 – tried skills (and it helped)

6 – used skills (but it did not help)

7 – used skills and it helped

It also asked if I wanted to quit therapy – which would be always addressed first in a one on one therapy session

Indicate my confidence of controlling my emotions, behaviours and thoughts

If I used the DBT phone (which they would have a report about)

Did I attend the skills session this week?

On the back of the card it had a list of the skills and then I could indicate I had tried and worked on the different skills

Skills training in groups

In these sessions DBT therapists will teach you skills in a group setting. This is not group therapy, but more like a series of teaching sessions. There are usually two therapists in a group and the sessions typically occur every week. The room is sometimes arranged like a classroom where your skills trainers will be sat at the front. The aim of these sessions is to teach you skills that you apply to your day-to-day life.

There are typically four skills modules:

1. Mindfulness – a set of skills that help you focus your attention and live your life in the present, rather than being distracted by worries about the past or the future. The mindfulness module may be repeated between modules and sessions may often start with a short mindfulness exercise. (See our pages on mindfulness for more information.)
2. Distress tolerance – teaching you how you can deal with crises in a more effective way, without having to resort to harmful behaviours such as self-harm.
3. Interpersonal effectiveness – teaching you how to ask for things and say no to other people, while maintaining your self-respect and important relationships.
4. Emotion regulation – a set of skills you can use to understand, be more aware and have more control over your emotions.

In these group session you may be asked to do group exercises and use role-play. You are also given homework each week to help you practise these skills in your day-to-day life. By completing the homework weekly, you might find that these skills gradually become second nature and you become better at dealing with difficult situations.

When I did each of these modules where 8 weeks and new people would join the group after each block and others would “graduate” from skills training.

Those 8 weeks were split into 2, the first two weeks focused on mindfulness which is a core module and then 6 weeks on one of the additional modules, interpersonal effectiveness, emotion regulation and distress tolerance.

Each of the modules had handouts – each person was given a skills handbook which I still have and have purchased the second edition (link in the show notes)

Mindfulness

https://bemindful.co.uk/

https://www.youtube.com/watch?v=wAy_3Ssyqqg

https://mrsmindfulness.com/an-introduction-to-mindfulness-melli-obrien-interviews-prof-mark-williams/

What is mindfulness?

Simply means awareness – awareness of what’s happening as it’s happening both in the inside world and the outside world. It comes from a very ancient word, but it’s probably easiest to understand if you think of its opposite mindlessness. Mindlessness – where you keep forgetting to do things, you don’t listen properly, you’re not attending properly, the world is going by without you really being there for it or here for it and mindfulness is the awareness that emerges when you make a decision to train your mind, to some extent, to check in more often to how things are.

It’s a way of living awake, with eyes wide open.

It’s a set of skills, mindfulness practice is the intentional process of observing, describing, and participating in reality non-judgmentally, in the moment and with effectiveness

Why does DBT use mindfulness

A characteristic of BPD is people’s inability to regulate their emotions (emotion dysregulation) and things that may seem trivial for some can be extremely triggering for someone with BPD because of judgements we make about situations and what others are thinking.

I found this fantastic example on the cognitive behavioural Los Angeles website: http://cogbtherapy.com/cbt-blog/mindfulness-in-dbt

e.g. you are a shop assistant at a clothing shop and you like the part of the job where you like interacting with customers, you like clothes and you like the working environment. But there is one part of the job that you don’t like is folding jeans (for me I loved folding jeans!) it’s boring but you need to do it for a part of your day but as you are folding the jeans your mind starts to wonder and you start making negative judgments about everything like your job sucks, this is stupid, this is a waste of time etc.

Rather than spending the time focusing on folding the clothes, your mind is busy telling all kinds of disturbing stories about this task, and will likely trigger emotions such as anger, resentment, even despair and as a result it impacts your emotions for the rest of the day. Another aspect of BPD is this issue were certain emotions can linger for a long

What’s worse, these emotions have a way of impacting the rest of your day. Now instead of tolerating 30 minutes of an unpleasant chore, you spend the whole day in a foul mood, judging all aspects of your job negatively, feeling worse every minute. Because being in a bad mood for most of the day, more days than not, is very unpleasant, you start having judgments about your mood, thinking, “I can’t take this anymore.” So, what started out as a relatively insignificant thing has caused a lot of suffering.

A mindful approach to this dilemma would be to approach the unpleasant task in the spirit of acceptance, willing to engage in it without engaging in a lot of judgments about it. The moment you notice a judgment, your turn your mind to folding the clothes, aware of the sensation of the fabric against your fingertips. Noticing the movement of your arms. Describing the smell of the new fabric as it reaches your nose in waves. By fully engaging in the task, repeatedly turning the mind to it, there is little room for negative attributions. You may now even find it to be a calming, soothing activity. This is one-way mindfulness can help avert an emotional downward spiral.

Mindfulness can help us to make the best decisions because we can get into the wise mind which I will talk about shortly. But because people with BPD have often grown up in an invalidating environment with people around you constantly telling you that what you are feeling is wrong you start to question everything. You don’t believe how you are feeling about situations e.g. someone has said that you did a good job and instead of taking that as a positive you think they are lying, they are just saying it because that’s what people do, they don’t really mean it and so you get angry instead of feel pride for a job well done. Or you are upset about someone who told you that it was time to stop dressing like a student even though you had been wearing trousers and blouses to work. You feel offended because you had tried really hard and you tell someone that it upset you and they say it’s something to not get upset and sad about and you believe them. Over time you start to lose who you really are and no longer believe your own emotions and what they are telling you. People who have become really good at being a self-invalidator you start to live lives that are inconsistent with your own values and dreams if at this point you still have them! They don’t find it important when their needs are being sacrificed for those of someone else. All of this results in people who do not do what is best for themselves, which is a hard way to live life. As a result, they are unhappier, and thus more prone to becoming emotionally dysregulated.

Mindfulness can help with that emotional dysregulation by way of helping to relinquish the struggle with painful emotions. One of the reasons people develop emotion dysregulation is because they try to quash or control their emotional responses to things. This just doesn’t work – I know this intimately because I spent years and years just trying to control my anger and then when I failed to control it then I would end up feeling shame and guilt and then more anger, so I was kind of stuck in this cycle.

Mindfully experiencing emotions is the opposite of the control strategy. With mindfulness, you simply observe what comes up with the emotion.

In skills training mindfulness covered seven skills in three sets:

• Wise mind
• What skills of observing, describing and participating
• How skills of non-judgmentally, one-mindfully and effectively

Wise mind

So, wise mind is one of the three states of mind: wise mind, emotion mind and logical mind. Wise mind us the inner wisdom that each of us have, when we access this we can say that we are in wise mind. Wise mind consists of emotion mind and logical mind and the integration of them together. So imagine this all in a venn diagram which are two overlapping circles, emotion mind is in one circle, logical mind in the other circle and that interlocking section in the middle is the wise mind.

For people with BPD we tend to get stuck in emotion mind, and particularly for me the logical mind is no-where to be seen so I had to do a lot of work to try to develop a wise mind approach to different situations.

What skills in mindfulness

These are the skills that you employ whilst doing mindfulness you observe, you describe and participate. You do each of them one at a time.

Observe: pay attention on purpose to the present moment that you are in

Describe: you put the observations into words – example describe what it’s like to record the podcast.

Participate: to fully engage in the activity, become immersed in whatever you are doing

How skills in mindfulness

These skills are related to the what skills, how do you do the what skills of observe, describe and participate, you do that non-judgmentally, one-mindfully and effectively. Unlike the what skills that you practice one at a time (although you could argue that observe and describe have a lot of overlap) you practice the how skills all at the same time.

Non-judgmentally: stick to the facts, don’t evaluate if what you are observing describing or participating in are good or bad, accept each moment, acknowledge the difference between what is helpful and harmful, safe and dangerous but don’t judge those thoughts, acknowledge your values, wishes, emotional reactions but don’t judge and when you find yourself judging yourself, don’t judge your judging

One-mindfully: rivet yourself to now, be completely in the present moment, one thing at a time like right now I am doing this podcast, notice if your mind wants to be only half-present, and the want to be somewhere else physically or mentally, the desire to do something else acknowledge that thought and then come back to one thing at a time. The mind will wonder. Let go of distractions if things are distracting you keep going back to what you are doing again and again. Concentrate your mind if you find yourself doing two things at once go back to one thing at a time.

Effectively: be mindful of your goals in the situation and do what you need to achieve them, focus on what works e.g. don’t let emotion mind get in the way) play by the rules, act as skilfully as you can, do what is needed for each situation and not what you wish it to be, the one that’s fair or the one that’s more comfortable. Let go of wilfulness (the barriers that you put in place to stop you being effective, deciding not to use skills because it is just too difficult to use them) and not choosing to do something that may achieve your goal.

There are several apps that you can download to your phone to practice mindfulness.

Interpersonal effectiveness 

The idea of interpersonal effectiveness skills will help you to maintain current relationships and help you develop new relationships and deal with conflicts that occur in relationships. Interpersonal effectiveness gives you the skills to be able to effectively communicate with others your own needs.

So, the main aims of this module are to:

Be skilful in getting what you want and need from other people

Build relationships and end destructive relationships

Walk the middle path (maintain relationships)

You learn about the things that get in the way of you being interpersonally effective such as not having the skills, not knowing what you want, emotions are getting in the way etc.

As part of this module you learn the skills of DEAR MAN, DEAR GIVE, DEAR FAST and it will help you to identify which situation the skills would be most important and effective

Describe

Express

Assert

Reinforce

(Stay) Mindful

Appear Confident

Negotiate

Describe: the situation that you are in stick to facts and tell the other person exactly what you are reacting to

Express: your feelings or opinions about that situation – the other person doesn’t know what you are feeling

Assert: what it is that you need so ask for what you want or say no clearly. Again, don’t assume others know what it is that you want

Reinforce: or reward the person ahead of time by explaining the positive effects of getting your needs met, at this point you could also identify the negatives if you don’t get what you need.

(Stay) Mindful: stay focused on your goal and employ the broken record if needed e.g. you keep asking or you repeatedly say no

Ignore attacks so if the person tries to attack you change the subject, ignore the threats, comments and attempts they are making to get you to say yes or ignore you needs. Don’t respond to those attacks (which is easier said than done) ignore any distractions and keep making your point.

Appear confident: use a confident voice, confident body language eye contact

Negotiate: be willing to give a little to get what it is that you are asking for, offer other solutions, if the other person thinks they will not met your need then reduce what you are asking (but don’t give everything e.g. there is a certain time I expect to see my husband come through the door and he didn’t and didn’t tell me I asked if he could call and he said no just assume that I am never going to be home by a particular time). You can always ask the other person what they could do to help met your needs.

Example: I went to the fridge to find that you had used all the milk. This really embarrassed me as I had offered our guest a hot drink and couldn’t deliver it. I would really like it if you could tell me when you finish the milk, or the milk is getting low and we need more. That would really be appreciated and would make me less frustrated with you if you did that. Thank you.

DEAR MAN, GIVE skills if you want to maintain the relationship

 (be) Gentle

(act) Interested

Validate

(use an) Easy manner

(be) Gentle: no attacks (no expressing anger), no threats (don’t describe painful consequences), no judging (if you loved me you would x) and no sneering (eye rolling, smirking, etc.)

(act) Interested: listen to the other persons point of view, don’t interrupt, use body language that shows you are listening e.g. leaning forward, eye contact etc.

Validate: using both words and actions show that you understand and empathise with the other person about the situation

(use an) Easy manner: smile! Use humour, soft voice

DEAR MAN, FAST skills to maintain your self-respect

(be) Fair

(no) apologies

Stick to values

(be) truthful

(be) Fair: fair to yourself and the other person, validate your own feelings and wishes as well as the other person

(no) apologies: don’t over apologise about your opinion, about your request, about disagreeing

Stick to values: don’t sell out what you believe

(be) truthful: don’t lie don’t act helpless, don’t exaggerate or make up excuses

Emotion regulation

The goal of this module is to reduce the emotional suffering an individual is suffering from. The key message is that even though emotions can be difficult particularly for people suffering from BPD they are actually important and have a function to play in our daily lives. One thing I wanted was to get rid of my emotions which is not the one of the goals of this module.

What happens is that it gives people the skills to be able to regulate emotions that you want, not regulate emotions that other people tell you that you should and reduce the intensity that those emotions are felt.

In terms of the chain analysis emotion regulation can help you in reducing the vulnerabilities that you may be experiencing, which in turn helps your emotions to not become painful and increase your resilience to emotions. By this DBT skills help you to reduce the peaks of emotions that you feel and then help you to recover from extremes of emotion.

This module requires you to use core mindfulness skills particularly non-judgmental stance and observations and helps you then to be able to describe those emotions.

For me the only emotion I could feel and recognise was anger but not everything is anger sometimes it was sadness coming out as anger. Or shame coming out as anger. This module takes you back really to the beginning of your understanding of emotions because unless you know what the emotion is you cannot effectively regulate it.

So this module takes you through 8 key emotions, anger, disgust, envy, fear, happiness, jealousy, love, sadness, shame and guilt.

DBT skills teaches you a model of how to describe emotions and how to then put a name to that emotion, it talks you through the prompting events, your vulnerabilities because there are things that can impact how you deal with emotions, the biological changes in the body that emotions can cause, e.g. how changes in the brain impact your nervous system with the unconscious increase in heart rate and temperature and the body sensations that accompany the emotion and how that links in with how you then express that emotion in body language, words and actions. At that point you have a better understanding as to what the emotion is and then can name it but there is a possibility that you are expressing a secondary emotion rather than the primary emotion. E.g. when I express anger and in reality, its sadness or fear.

e.g.

You had wanted to go out with friends but they have all cancelled, your start to feel your heart rate increasing, your temperature rising, your muscles tightening, your fist clenching, your teeth clamping together and tension in your jaw. Resulting in your shouting at the people who have let you down = anger but underlying that you are sad, you blame yourself for the friends cancelling, your irritable and grouchy and you are seeing the world in a negative light.

So when you feel the emotions you are taught to be able to change those emotions by checking the facts, does your emotion match the situation are you making assumptions about why everyone has cancelled? Is that really the case?

If you have identified that your emotion is not aligning with the facts – you are to blame but everyone has the flu which has been going around – your anger is not fitting in or isn’t effective, I mean being angry at people who are sick isn’t going to help. So, you decide to use opposite action skills, you do the opposite to what you feel like doing and that will change your emotion.

If the facts are the problem, as in say someone has said that they would be somewhere at a certain time and they turn up three hours later than the issue is that the person turned up three hours late and hasn’t acknowledge the issue. When using problem solving you realise that you would benefit by using your DEAR MAN skills to tell them that you are both sad and angry that the person was late and hasn’t apologised and that you would appreciate that apology. As a result of approaching the problem with this solution then it will help you to reduce negative emotions.

The other part of this module is strategies that will help to reduce your vulnerability in everyday life, particularly when you are in emotion mind by using the acronym ABC PLEASE.

A – accumulate positive emotions which is split into 2 – short term and long-term. Short term do pleasant things that you can do right now and long-term make changes in your lifestyle maximizing the positive events occurring

B – build mastery, do things that make you feel successful and competent as that helps with making you not feel helpless and hopeless and for me completely useless

C – Cope ahead of time with emotional situations rehearse and plan ahead for emotional situations and the best way for you to deal with it. I spent a lot of time practicing certain skills such as DEAR MAN and ways to change my emotions when they were not supported by the facts.

PLEASE

These skills are teaching you to look after your mind by taking care of your body. Most people identify that emotions are more difficult when you are sick, or if you haven’t had enough sleep and this is what the PLEASE skills address, so PL is treat (p)hysica(l) illness, balance (eating), (altering) avoid mood-(a)ltering substances, get (e)xercise

Distress tolerance

In distress tolerance the idea is to help the client gain the skills needed and the ability to survive times of crisis without making things worse e.g. when I would have an overload of emotions I would self-harm, drink, take OTC medication etc.

This module is important because of two things.

1. Pain and distress is part of everyday life unfortunately. There are times that everyone will feel overwhelmed and so dealing with those in a non-destructive way will improve the person’s life. If you don’t accept that fact that this will increase the clients suffering.
2. Developing distress tolerance is important when you are trying to change your behaviour because pain and suffering can hinder your ability to change behaviours

This module comprises of two main strategies, crisis survival skills and reality acceptance or radical acceptance skills.

So, in crisis survival you are taught STOP skills, pros and cons of behaviours, TIP your body chemistry, distract with wise mind ACCEPTS skills, self-soothe with the five senses and improve the moment that you are in.

STOP skills

S: STOP don’t just react stay in control regardless of what your emotions are trying to get you to do on impulse.

T: Take a step back, take a break if you need to, take a deep breath and think about your next step hold back the impulsivity

O: Observe, and notice what is happening inside and outside of your body, observe what is happening in the situation you are in.

P: proceed mindfully, take charge and decide what you plan to do next and act with awareness not just on auto-pilot where you can get carried away with your emotions. What is going to make the situation better or worse?

Pros and cons are used when you have a decision to make about two different options, what are the pros and cons of the situation if you act on your urges that are being governed by your emotions and what will happen if you don’t act on that urge.

TIP skills – changing your body chemistry (new skill I didn’t do this one)

T: Tip the Temperature of your face with cold water helps you calm down fast

I: Intense exercise helps to calm the body when it is revved up by emotion.

P: paced breathing – breath deep in the belly, slowing down the breath, breathing out longer than in

P: paired muscle relaxation – whilst breathing into your belly, tense your body muscles, notice the tension in your body, while breathing out say the word relax in your mind and let go of the tension and feel the difference in your body

Distracting skills

Wise Mind ACCEPTS

Activities: watching tv, doing a jigsaw, listen to music, exercise, play sports, go out, play cards, crosswords or word searches

Contributing: volunteer, help friends or family, surprise someone, give things away, call someone

Comparisons: compare your feelings now to another time when you felt different, think of those coping the same as you or less than you, compare to others less fortunate

Watch reality shows about other’s problems (I found this the most difficult as I would use it as a way to tell myself of and invalidate my own feelings.)

Different Emotions: read emotional books or tv shows, or listen to emotional music

Pushing away: push the situation away for a period of time, mentally leave the situation, notice ruminating and yell no, refuse to think of the painful situation

Other thoughts: count to ten, count colours in a painting or a poster or outside, watch tv or read

Other sensations: squeeze a ball, listen to really loud music, have a hot cold shower

Self sooth using the senses

Taste: eat your favourite food, chocolate, drink coffee, tea hot chocolate, eat your favourite childhood food, add some spice to your food

Touch: have a hot bath, or shower, pet your dogs/cats, have a massage, stroke a fluffy pillow, hug someone, feel your worry stone

Hearing: listen to music, listen to an open fire, nature sounds, hum, sing to your favourite songs

Smell: nice smelling candles, bath bombs, spritz aftershave or perfume, coffee, the smell of a book, fresh air in the countryside

Vision: buy a beautiful flower, go to a scenic spot and observe, watch a sunrise or sunset, watch your dog’s playing

Reality acceptance

Split into radical acceptance, turning the mind, willingness, half-smile and willing hands and allowing the mind: mindfulness of current thoughts.

So, there are certain things in life that we just have to accept because we cannot change it such as things that you have done in the past, and that can cause pain if we keep thinking about it and going back and telling ourselves off.

Radical acceptance: is accepting something all the way, accepting it in your heart, mind and body. When you accept the reality and stop fighting against it because reality is not what you want it to be then it will just continue to cause you pain.

There are several things that need to be radically accepted: reality is as it is the facts of the past and present are what they are regardless of whether you like it or not. There are always limitations on the future not only for yourself but for everyone. There is always a cause to every situation that can cause pain and suffering. Life can be worth living even with painful events in it.

I was diagnosed with MS during the time I was going through DBT and radical acceptance was a key to helping me deal with my discomfort. So, I have RRMS, what does that mean, the uncertainties, the realisation that as a result of the illness I probably wouldn’t be accepted for permanent residency, would I be able to continue work? All these questions in my mind at the same time as hoping that they got it wrong, but usually MS is diagnosed only when everything else has been ruled out. I have spoken in other podcasts about when I arrived back in the UK how each time when I changed NHS trust areas that they would say no its wrong. So, I had to radically accept the situation, this was just the situation I was in, it wasn’t going to change, and my life would be unpredictable.

There are many reasons why accepting reality can prove beneficial to the individual going through DBT.

• Rejecting what is happening wouldn’t change the fact that I had RRMS
• The way for me to deal with the situation I was in would only happen if I accepted it e.g. accept that there are times when I am exhausted and may need extra rest
• Pain can’t be avoided it tells us something important, the reason why I got diagnosed was because I was experience a change in the way my body felt and ignoring wouldn’t have changed the reality that I was sick
• Rejecting the fact that I had MS would have just caused me more suffering – don’t get me wrong that is not easy to do
• Refusing to acknowledge the situation would just keep you stuck, angry, bitter shame, guilt
• Acceptance may lead to sadness, but calmness often follows

As I said this is not always the case there are times when I wish things were different, that I have hope that they got it wrong but then I need to turn the mind, in DBT we are told to imagine a fork in the road or if you are British a t-junction, you have two choices, acceptance or rejection. You have to purposefully turn your mind to acceptance to keep you on the path to radical acceptance.

Willingness

As part of acceptance you have to be willing to participate in your world. So you must have the right attitude when approaching life. So going back to the MS example I had two options I could fight against the diagnosis, and ignore anything was wrong get really distressed when I couldn’t continue and then retire to my bed hide under the duvet and refuse to live my life, or I could choose to acknowledge what was happening, change some of the things I was doing to allow myself to be able to better deal with my condition, take my medication and face the world. If I was being wilful which at times I certainly was I would have just given up and felt out of control.

Half-smile and wiling hands

These are both techniques to accept reality with your body.

Half-smile is where you relax your face, neck and shoulders and slightly raise the corners of your mouth and adapt a relaxed facial expression as a way to accept reality. Our emotions can be partially controlled by our facial expressions and can give people some control over the emotion they are feeling.

Willing hands are similar to half smile but were clenched fists and hands can influence your feelings of anger if you are able to relax your hands, arms and shoulders then you send the message to your brain and is a way of you doing the opposite to what you might be feeling.

Dealing with addiction (new part of skills)

DCBA

D: Dialectical abstinence

C: Clear mind and Community reinforcement

B: Burning bridges and building new ones

A: alternate rebellion and adaptive denial

Dialectical abstinence is the blending together complete abstinence and harm reduction, whilst not doing the harmful behaviour there are going to be times when you slip up and so then the aim would be to minimise the damage you have been doing.

e.g. drinking whisky because I wanted to be numb, but I chose alcohol I didn’t like to try to make me not repeat the behaviour.

Clear mind is similar to wise mind but comprises of addict mind and clean mind combining the memory of addict mind and the fact that you are clean again having the knowledge that relapse is not impossible but that it is not inevitable.

Community reinforcement, being in certain situations will make it more difficult for you to make the best decision, e.g. continuing to be friends with your drug dealer, or going to a bar to socialise if you have an issue with alcohol but to have a compromise and find other ways to ensure that your lifestyle is more rewarding than your past addictive behaviours.

Burning bridges is you accepting that you will not engage with the addictive behaviour ever again. As previously stated you get rid of the things that will enable you to full back into addictive behaviours. E.g. tell your friends that you are quitting.

Building bridges helps you to deal with cravings that you may get by changing the image and smell opposite to the thing you are addicted to.

Alternative rebellion if one of the reasons for your addictive behaviour is to push back against what is expected, or as a way to combat boredom then try other things to use as a rebellion that is not so destructive such as: shaving your head, unmatched shoes, dye hair a wild colour – I went purple, dress up or down, get a tattoo (I got two), so many other things you can do.

Adaptive denial is when you cannot get rid of the urge and craving for the addictive behaviour you can try to change that behaviour for another one e.g. urge to have alcohol, have something sweet or savoury. Or try to put of the behaviour, so at the moment I am struggling once again with binge eating so I am taking it 5 minutes at a time, and I have increased it to 30 minutes at a time if I can keep putting it off it means at that time I can cope at this time and each subsequent time and slowly I will get to the point when I know I don’t want it.   

DBT skills session format

First half review everyone’s homework

Break

Mindfulness practice

Skills session

Telephone crisis coaching

DBT often uses telephone crisis coaching to support you in using new skills in your day-to-day life. This means that you can call your therapist between your therapy sessions when you need help the most, such as in the following situations:

• When you need help to deal with an immediate crisis (such as feeling suicidal or the urge to self-harm).
• When you are trying to use DBT skills but want some advice on how to do it.
• If you need to repair your relationship with your therapist.

However, you can expect your therapist to set some clear boundaries. For example, calls are usually brief and the hours that you can call them will be agreed between you and your therapist. They may also agree some other rules with you where, in particular circumstances, you may be asked to wait 24 hours before contacting your therapist.

https://www.mind.org.uk/information-support/drugs-and-treatments/dialectical-behaviour-therapy-dbt/dbt-sessions/#.Wnm04JPFLOQ

How effective is DBT

There has been a large amount of research on the use of DBT in the treatment of BPD which was at one point identified as a mental health condition that was untreatable. DBT is now the gold standard for the treatment of BPD, with evidence showing a decrease in deliberate self-harm, and an increase in reported quality of life which I can personal vouch for is that without DBT I don’t think I would be here. I was part of a study performed in the Hunter and whilst speaking with my therapist at the time she identified that she thought that I would have responded well to the control therapy because I was so motivated.

A systematic review and meta analysis of a reseach study about the efficacy of DBT showed that there might be some bias in terms of publication bias (results with less favourable outcomes not published) and inflation of results by bias (which is tried to be controlled for on RCT) in the result reported and that when people where followed up that the results were unstable.

https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2605200?redirect=true

https://www.evidence.nhs.uk/search?q=effectiveness+of+DBT+to+treat+borderline+personality+disorder

https://behavioraltech.org/about-us/founded-by-marsha/

https://behavioraltech.org/research/evidence/

https://www.ncbi.nlm.nih.gov/pubmed/20113305