managing the storm
TRANSCRIPT
MANAGING THE STORM:EMOTION REGULATION
Part 2 in the 3-Part 2021 DBT Skills Training Workshop
MINDFULNESS: Emotion Identification
PART 2 IN CONTEXT: 3 PART DBT SKILLS TRAINING
WORKSHOPScope: To provide guidance on the the use of DBT Skills to enhance existing clinical practice.
(Already Completed, Available on Video) Part 1
• Options for integrating DBT Skills into your practice appropriately
• Coaching on teaching all of the skills in the standard curriculum for General Skills, Mindfulness, and Distress Tolerance
Part 2
• Continuation of the clinical foundations of DBT
• Increase understanding of how to teach all of the Emotion Regulation skills in the standard curriculum
Part 3
• Review of the Mindfulness skills from the standard curriculum in the context of interacting with others
• Coaching on teaching all of the Interpersonal Effectiveness skills from the standard curriculum, plus the skills for Behavior Change.
TRAINING OBJECTIVES: PART 2
• Enhance understanding of clinical foundations necessary for effective implementation of DBT Skills Training protocols
• Improve comfort with teaching skills for identifying and understanding emotions
• Understand and describe the flow of skills that is necessary for changing unwanted emotions
• Improve effectiveness with helping patients improve self-care skills to decrease vulnerability to negative emotions
• Learn strategies to guide patients to increase positive emotions by making choices and engaging in behaviors that match with their short and long term goals.
• Teach patients to recognize their own Skills Breakdown Point, as well as how to manage it more effectively.
• Gain awareness of opportunities for practical application of Emotion Regulation skills.
SCHEDULE
• 9:00am-Training Begins• 10:10am-Q&A on Clinical Foundations
• 10:15am to 10:25am-10 Minute Morning Break
• 12:00-12:10pm-Q&A on Emotion Regulation
• 12:10pm to 12:50pm-Lunch Break
• 12:50-12:55-Mindfulness
• 1:40-1:50pm-Q&A on Emotion Regulation
• 1:50pm to 2:00pm-10 Minute Afternoon Break
• 2:50-3:00pm-Q&A on Emotion Regulation
• 3pm-Training Concludes, Evaluations
LESSONS FROM PART 1
• New setting to address technological issues
• Challenges around interactivity
• Assigned readings dialectic
• Slide content dialectic
• Timing of training
• Limitations of trainer (Umm…)
AUDIENCE POLL
What are you hoping to get out of today’s training?
• CEU’s—everything else is frosting on the cake
• Get a basic understanding of the Emotion Regulation Skills for my own personal use
• Better understand how I can use some of the skills to supplement my existing practice
• Just looking for a refresher of what I already know about Emotion Regulation
• I want to run a DBT Skills Training group
• I want to develop a Comprehensive DBT Program
Clinical Foundations
ABOUT FORMING THERAPIST CONSULTATION TEAMS
• Consultation Teams function for the purpose of supporting clinicians in learning, troubleshooting, and increasing motivation to provide DBT.
• Time limitations are a barrier for everyone…get creative!
• A Consultation Team is made up of 2 or more clinicians who meet the following criteria:
• Participate VOLUNTARILY (not forced to do so)
• Agree to attend meetings regularly (at least once a week is ideal, but can be more often)
• Have “skin in the game,” in other words are currently practicing DBT with one or more patients
• Are committed to learning and applying DBT, and supporting their colleagues in doing so as well
• Important areas of focus for Consultation Team Meetings:
• Practice of skills
• Identification of barriers to learning and applying DBT
• Encouragement for successful application of DBT
• Therapist support needed to increase motivation for providing DBT
DBT SKILLS TRAINING HANDOUTS AND WORKSHEETS
• Work from the handouts during Skills Training sessions!
• Can run copies of handouts from the book, or print copies from the electronic version. Patients can also be encouraged to purchase their own copies of the book to use and keep for future reference.
• Instructions on accessing electronic version are available in the “How To Use This Book” section of the Skills Training Manual, on page xi.
• Helpful to have extra copies on hand in case patients forget to bring theirs to the session
• Please have Handouts from Emotion Regulation readily available for review so you can follow along with the remainder of today’s training.
ABOUT THE TEACHING NOTES
• Teaching notes are available in the DBT Skills Training Manual, Second Edition, and in electronic form.
• Meant to act as a guide, not a mandate for what must be presented and discussed.
• Tailor your choice of what parts to present based on assessment of needs.
• Can present some different ideas the next time around, or expand in individual sessions.
• Review the teaching notes and handouts before each session, then make your own notes on what parts to use.
• Use Radical Genuineness--add your own “spin” on things, and provide your own examples.
CHOOSING A CURRICULUM
• This training series focuses on skills from the 24 Week Curriculum found on page 110 of the DBT Skills Training Manual, Second Edition, plus a few extra skills I find helpful to add in with most patients.
• Skills Training for adults in DBT typically involves two 24-26 week cycles, for a total of 48-52 weeks (about a year).
• For adolescents, Skills Training in DBT typically involves one 24-26 week cycle conducted in a multi-family group, which includes an additional module on Walking the Middle Path.
• The DBT Skills Training Manual, Second Edition includes a curriculum for adolescent multifamily groups, but the DBT Skills Manual for Adolescents by Rathus and Miller is considered best practice for that age group.
• Pages 110-122 in the DBT Skills Training Manual, Second Edition offer alternate specialized curricula
• All handouts with a star in the upper right corner are considered highly recommended as part of the core curriculum.
• For DBT-Informed treatment, skills can be presented as needed and relevant to current topics in therapy. Just keep in mind that this is not an evidence-based approach, and outcomes may vary significantly from those of Standard DBT or even a Skills Training Only approach!
ORIENT, ORIENT, ORIENT…
• Orienting the patient(s) to goals, expectations, and structure can greatly enhance cooperation, motivation, and outcomes.
• Include information about the purpose of skills training, length and frequency of sessions, and length of overall program.
• Clear orientation about the difference between Skills Training and a support or process-oriented group (or regular individual therapy sessions) is important.
• Make sure to remind them that Skills Training is NOT a time for venting, but for seeking input on how to solve problems using skills.
• For group settings make sure to be clear about how you will manage crises and contact between group members, as well as what’s ok and not ok to share in group (keep in mind the contagion effect of suicidal or self-harm discussion)
• If you are choosing to introduce skills individually without following a curriculum, consider orienting your patient to your rationale, and the pros and cons of doing so.
REVIEW OF STRUCTURING SKILLS TRAINING SESSIONS
Whether Skills Training is conducted in an individual or group setting, the following structure for sessions is helpful and suggested:
• Start with a mindfulness activity-different each week but usually 3-5 minutes in length, plus time to process after
• Review any housekeeping items that are relevant, and agenda for today’s session
• Review homework from previous session
• Introduce new material/handouts
• Assign homework for the following week and answer related questions
SELF DISCLOSURE IN SKILLS TRAINING
• Therapist Self Disclosure is encouraged in the DBT model, with some clear parameters.
• Self Disclosure in the form of stories can help to:
• illustrate examples more understandably (neuroscience supports this!)
• make you as a clinician seem more human and relatable
• increase buy-in when your patients understand that you use the skills too
• Self Disclosure is NEVER used for the purpose of the clinician receiving therapy (that’s what consultation team and your own therapist are for!), or in circumstances where there are clear reasons for not doing so.
• Providing examples where you tried the skills and they didn’t work can help as well, just don’t do it all the time!
• Seeking patient examples for discussion when they are willing can be helpful and appropriate
ASSIGNING HOMEWORK
• Worksheets are available at the end of each skills module in the DBT Skills Training Handouts and Worksheets.
• Worksheets correspond to the handouts in each module.
• Some cover a number of skills in one worksheet, others focus in on just one skill.
• Worksheets provide a number of different options for practice outside of sessions, from the perspective of a number of different learning styles.
• The most important part of homework, whether you use worksheets from the book or not, is that participants practice between sessions, and have the opportunity for feedback and coaching after their effort!
HOMEWORK REVIEW
• A time to reinforce successes, and problem solve for challenges
• Can be helpful to limit time for each review in order to allow time for work on new skills
• Number line check-ins: Confidence with using the skills from homework, and overall effectiveness in applying skills to help with problems encountered over the past week
• Address incomplete homework through Missing Links Analysis (see next slide)
• Keep focus on the intent of the homework: to practice the skills. Not completing a worksheet doesn’t necessarily mean homework wasn’t completed!
• Point out instances when skills were used from patient description—most people aren’t always aware of when they’re using skills
MISSING LINKS ANALYSIS
• Appropriate for addressing incomplete homework in a group setting
• Addressed in General Skills Handout 8: Missing Links Analysis
• Abbreviated form of Chain Analysis (from structured individual sessions) that is used when a skillful behavior (like completing homework) wasn’t performed
• NOT intended as aversive, but can have that effect. Make sure to acknowledge both aversiveness and positive intent out loud!
• Ask each of the 4 questions in progression. If the answer is “NO,” ask what got in the way and problem solve for it; go no further in the remaining questions. If the answer is “YES,” proceed to the next question.
• Did you know what homework was due for today?• Were you willing to do the homework?• Did you think about/remember to do the homework?• What got in the way of doing it when you thought about it?
PRIORITIES IN SKILLS TRAINING SESSIONS
• Apply to both Group and Individual Skills Training
• Allow for focus on the acquisition and practice of skills, where addressing the crisis of the moment instead might mean the skills never get taught
• Priority 1: Stopping Behaviors Likely to Destroy Skills Training—Patients cannot benefit from Skills Training if they are not present in Skills Training!
• Priority 2: Skill Acquisition, Strengthening, and Generalization
• Priority 3: Reducing Therapy Interfering Behaviors—Rarely addressed directly in Skills Training sessions, but can be coached to engage in more effective behavior if disruptive. Acknowledging improvement in these behaviors is important!
MEASURING OUTCOMES
• Can be beneficial in order to track progress and program effectiveness with your population
• DBT Diary Cards track intensity of urge to suicide, instances of self harm, and daily use of skills
• Direct at symptoms the patient is looking to improve as a result of skills training!
• Use a broad range of assessment tools to capture real change.
• Table 3.3 on page 46 of the DBT Skills Training Manual, Second Edition provides a number of suggestions for potential measurement tools, many of which are available free or low cost.
• Relatively small amount of time invested can yield big rewards!
• Assessment tools I’ve found helpful to use as outcomes measures include:
• Difficulties in Emotion Regulation Scale (DERS)
• PHQ-9
• Severity of Posttraumatic Stress Symptoms-Adult.
QUESTIONS?
BREAK
Training will resume at 10:25am with Q&A about homework from the first
training.
Please take a minute during your break to post your
feedback and questions about the homework!
AUDIENCE POLL
How did you do with the Mindfulness practice homework over the past few weeks (practicing Mindfulness for 3-5 minutes daily)?
• I didn’t do it at all
• I didn’t do it intentionally, but now that I think about it there were many ways in which I was mindful
• I tried it, but it was hard and I felt like I was doing it wrong
• I tried it, but it felt too easy
• I tried it, and it seemed helpful
• Other
AUDIENCE POLL
How did you do with homework of practicing some of the Distress Tolerance Skills with your patients?
• I didn’t get a chance to practice
• I tried, but it felt awkward and I wasn’t sure if I was doing it right
• I tried, and I know I was doing what I needed to. I can tell it’s going to take a lot of practice to feel more confident about it though.
• I tried, and it went really well! I felt confident about how it went.
• I already use these skills a lot in practice, so it’s already second nature.
HOMEWORK REVIEW
FROM PREVIOUS TRAINING
Questions/feedback on Mindfulness practice?
Questions/feedback on teaching Distress Tolerance skills?
Questions/feedback about keeping perspective on the importance of practicing skills?
EMOTION REGULATION
Skills for Managing the Storm
ER 1: GOALS OF EMOTION REGULATION
• Straightforward handout, but helpful place to explain the “why” behind the skills• Orient that the ability to identify what emotions you’re feeling is necessary for effectively
changing them
• Inform patients that being able to recognize the purpose of your emotions can help you react more effectively to them
• Orient that not all emotions are possible to prevent, but some can be prevented through awareness of triggers, treatment of vulnerability factors, and avoidance of prompting events
• Emotions tend to be self-perpetuating, but Skills for Changing Unwanted Emotions can be really helpful in interrupting that cycle and introducing new emotions
• Learning the factors that lead to emotional vulnerability, and attending to them as needed, can help decrease emotional intensity
• Intentionally building positive experiences and long term goals into our lives can increase the frequency of positive emotions
CONTEXT OF EMOTION REGULATION
• Emotion Regulation skills are complex! Use of complex skills is not possible when we are beyond our Skills Breakdown Point.
• Emotion Regulation skills for Changing Unwanted Emotions can be used most effectively when we have time and space to use them before or after a critical event…not necessarily in the moment.
• Many people with trauma histories develop a primary coping strategy of avoidance (especially of emotions). This module can be particularly distressing for them, as it can act a form of (emotional) Exposure Therapy!
• Make sure to check in with people who avoid their emotions frequently during this module about their distress level, and coach on Distress Tolerance/Grounding strategies as needed
ER 3: WHAT EMOTIONS DO FOR YOU
• Can be helpful to reference this handout frequently in individual sessions, and encourage patients to identify what purpose(s) their emotions are serving as they come up
• Remind patients that all emotions (even painful ones!) have a purpose
• First box addresses purpose of motivating us for action• Example of running out of the way of a bus• Example of worry about not remembering to pay a bill
• Second box addresses purpose of communicating important information about our experience to others
• Reminder that not everyone has the same emotions about the same situations• The more important it is to communicate our emotions, the harder it is to hide them!• Example of trying (and eventually failing) to be patient through repeated requests when busy
• Third box addresses purpose of alerting ourselves to situations that may be important, where checking the facts to determine whether it’s actually a threat to our safety, our values, or our goals will be critical
• Metaphor of flag worker on a construction site• When this is a primary function, simply checking the facts can help to calm the emotion
ER 4: WHAT MAKES IT HARD TO REGULATE YOUR EMOTIONS
Identifying what’s getting in the way of regulating your emotions is the first step in being able to understand why things are being hard, and how to fix them.
• Biology: Orient patients that some people are hard-wired at birth to feel emotions more intensely, and or for longer periods of time than other people. Some people are also born more sensitive to their environments.
• Lack of Skill: We’re not necessarily taught growing up HOW to regulate our emotions! Not knowing what to do can absolutely get in the way.
• Reinforcement of Emotional Behavior: Overly emotional behavior is rewarded in some environments, and is necessary in others in order to get needs met. Example: kid whining louder in the checkout line to get their parents to buy candy.
• Moodiness: Strong emotions/being stuck in Emotion Mind can interfere with our willingness to take steps to regulate them.
• Emotional Overload: Orient to the Skills Breakdown Point—we all have one, and we can’t behave effectively or skillfully once we’ve reached it!
• Emotion Myths: Having inaccurate beliefs (that we’re sometimes not even aware of until we identify them) can absolutely interfere with our ability to effectively regulate emotion. Examples on next handout 4A.
ER 4A: MYTHS ABOUT EMOTIONS
Our thoughts and beliefs absolutely impact our emotional experience, whether we’re aware of them or not!
• Ask patients to circle the number for each statement that they identify with.
• In a group, asking for a show of hands for how many people identified with each item can help to normalize these thoughts, and identify areas of most benefit.
• Introduce the idea that a challenge to a myth is a way of looking at the same subject matter from a different perspective that
• offers hope
• is grounded in reality
• that you can believe.
• Coach patients through a few, and encourage them to work on others on their own.
• Encourage patients to keep their list of challenge thoughts in an accessible place, where they can reference it when needed.
ER 5: MODEL FOR DESCRIBING EMOTIONS
• Make sure to validate to patients that this is a very confusing diagram to look at, and it’s that way because our emotions are complex!
• Start at the left middle of the page with Prompting Event (describe as an event in our environment, or a thought in our heads).
• Orient that awareness is needed for a prompting event to result in an emotion. Example of natural disaster on the other side of the world that you never hear about, vs. one that you hear about even briefly on the news.
• Orient that the Vulnerability Factors (top left hand side) are what happens, before the prompting event occurs. They can be short term (sleep, nutrition, pain/illness, exercise, use of drugs/alcohol) or long term (prior experiences that “prime the pump”). All vulnerability factors can make us more likely to experience emotions more intensely, and more quickly than we would otherwise.
• We sometimes have awareness of our Interpretation, or thoughts about a prompting event, which can intensify emotional experience.
• Emotions are biological changes that occur in our bodies, not just in our brains but also in our muscles, our nervous system, or respiration. They lead to physical sensations, and the urge to do something (the Action Urge).
• We express our emotions outwardly through body language and facial expression, words/sounds, and actions. Keep in mind that some people are very good at hiding outward expression of their emotions (poker face), and others wear their emotions on their sleeve. What you see is not always congruent with what someone is feeling!
• We SOMETIMES are aware of what emotions we are feeling, and can name them. Other times they impact our experience, but we’re not aware of them.
• Following the long trail at the bottom of the page, all pathways lead to Aftereffects, or the “emotional hangover.” This is not a new emotion!
• We SOMETIMES experience Secondary Emotions, which are what we feel about how we’re feeling (I’m angry that I’m feeling sad…)
• Secondary emotions can act as a prompting event for a new emotion, and the cycle continues…..
• Orient that this model will be referenced in the next handout, where we will talk more in depth about specific categories of emotion and how we experience them.
ER 6: WAYS TO DESCRIBE EMOTIONS
• 10 page handout that breaks full spectrum of emotions down into 10 categories
• Each page identifies a number of specific emotions that fall under that category at the top of the page
• Have patients circle the specific emotions they most frequently identify with, and mark the ones that they don’t identify with
• Orient that each specific emotion can be experienced on a range of intensity
• Remind that this is not an exhaustive list!
• The remaining 5 sections correspond to the main areas identified in Handout 5 Model for Describing Emotions, and can help with normalizing and recognizing emotional experience
• Orient patients that not everyone experiences everything listed, and some people may experience only one or two things in a section. There is no “right” or “wrong.”
• Goal is to build awareness of their own emotional experience and how to recognize it
• Categories identified in this handout are important for use in subsequent skills
• Page 10 identifies Other Important Emotion Words that do not easily fit into one of the 10 categories
SKILLS FOR CHANGING
EMOTIONAL RESPONSES
ER 7: Overview: Changing Emotional
Responses
ER 8: Check the Facts
ER 8A: Examples of Emotions that Fit the
Facts
ER 9: Opposite Action and Problem Solving: Deciding
Which to Use
ER 10: Opposite Action
ER 11: Figuring Out Opposite Actions
ER 7: OVERVIEW: CHANGING EMOTIONAL RESPONSES
• Overview of the three skills that can be effective in making direct change to emotion
• Helpful introduction to connectedness between these skills, which will be reinforced in subsequent handouts
• Requirement of understanding and application of earlier Emotion Identification skills in order to use effectively
ER 8: CHECK THE FACTS
• Can be helpful as a stand-alone skill for changing unwanted emotion, IF the primary function of the emotion is to alert use to something that feels important and get us to check the facts
• In other instances, Check the Facts is a framework skill to build on toward more success in regulating emotion (see Handout 9)
• Top box outlines that there are different pathways from prompting event to emotion—sometimes it happens immediately following the event and then we have thoughts about it, and other times we have thoughts first before the emotion occurs (reference ER Handout 5).
• First identify the CATEGORY of emotion (from Handout 6) that is the biggest priority for change. Check the Facts should be used separately for separate categories of emotion if needed.
• Identify the facts related to that emotion using objective observation. Encourage identification of judgments and replacement with objective observations.
• Encourage patients to seek input from others they trust to help them see things from a different perspective if doing this isdifficult on their own.
• Steps 4 & 5 may not be necessary if the rest of the steps are helpful without them…in that case, jump straight to step 6.
• Steps 4 & 5 are a form of imaginal exposure, and can have the potential to be destabilizing if they are not seen through fully. Use with caution, especially for patients with trauma histories, or obsessive or intrusive thoughts!
• For step 6, reference Handout 8A, Examples of Emotions that Fit the Facts
ER 8A: EXAMPLES OF EMOTIONS THAT FIT THE FACTS
• Orient patients that it is possible for an emotion to be understandable given their past experience, and to not fit the facts of the CURRENT situation.
• Identify the emotion category that you are working on for Check the Facts, and find it on the handout.
• Read the options for times when that emotion would fit the facts, and determine whether current circumstances are similar to or different from those listed
• Remember, there’s an “other” for a reason…not every circumstance is covered here, and it doesn’t mean that it necessarily doesn’t fit the facts!
• Make sure not to miss the box at the bottom of the page—it’s important!
• When addressing how effective an emotion is, weigh the action urge as a result of that emotion against your goals, values, and priorities. Does it help to get you closer to them or further from them?
ER 9: OPPOSITE ACTION AND PROBLEM SOLVING: DECIDING
WHICH TO USE• AWESOME helpful tool for being able to determine which skills may be most
appropriate. Use as a guide, rather than a mandate!
• When teaching skills for the first time, will be helpful to teach Problem Solving, Opposite Action, and Mindfulness of Current Emotions first, or this handout won’t make much sense.
• When other skills have already been taught and there is familiarity with how to use them, use this handout first to determine which skills would be most helpful to focus on.
• “Hidden” skill before asking if acting on this emotion would be effective is What is my action urge as a result of this emotion? What are my values, goals, and priorities in regards to this situation?
ER 10: OPPOSITE ACTION• Make sure to orient patients to times when using Opposite
Action is appropriate (bold areas at the top of the handout)• Review the concept of action urges• Reference that the first box is meant to be an example of how
action urges relate to opposite actions, and not a comprehensive review of opposite action
• Second box references step by step instructions for Opposite Action
• Steps 1-4 are review of the previous Emotion Regulation skills/handouts...each is necessary in succession BEFORE using opposite action
• Describe acting opposite all the way as making sure that body language, facial expression, and tone of voice match with your intended opposite action
• Remind patients that Opposite Action usually needs to be used REPEATEDLY before emotions change...one time is not enough!
• Example: Wanting to buy a horse
ER 11: FIGURING OUT OPPOSITE ACTIONS
• 9 page handout that addresses all of the major categories of emotion, aside from happiness (because we almost never want to change happiness!)
• Meant to act as a guideline, not a mandate• Each page includes a box at the top to remind you when each emotion fits the
facts• Opposite action ideas are guideposts, but will not necessarily fit with every
situation. Make sure to orient patients to use their Wise Minds, and to adapt Opposite Actions to their specific circumstances
• All the way opposite actions are intended to address body posture, voice tone, and other factors that can affect the effectiveness of Opposite Action if not attended to
ER 12: PROBLEM SOLVING
We use Problem Solving for situations where there is a gap between where things are, and what needs to happen in our environments in order for us to feel better.
• We problem solve every day, and may not always need all of these steps.• Problem Solving as a skill can be really helpful if our normal strategies for problem solving
aren’t working, or if we’re feeling stuck• For Step 1, make sure to use objective observations• For Step 2, remember, it’s impossible to problem solve and get to the right answer if you’re
trying to solve the wrong problem! (Example: angry girlfriend who wants to be nicer)• Identifying and clarifying your goal is a critical step--you have a much lower chance of hitting
your target if you don’t know what and where it is!• Coach patients in the brainstorming phase to write down and acknowledge EVERY option, not
just the ones they think will work. This is not a time for judgments! • When choosing a solution, it may be just one, or it may be a combination of solutions that work
together• Make sure to remind patients that failing to try any solution is a surefire way to NOT solve your
problem!• The last step is very important...checking back in to determine whether the solution worked
and was a good fit. If it’s not working, don’t give up...go back to Step 5 and try again!
ER 13: REVIEWING OPPOSITE ACTION AND PROBLEM SOLVING
• Helpful review of both skills, in relation to each of the categories of emotion• Provides some ideas for problem solving specific emotions• “Cheat sheet” for figuring out how to carry out each of the skills, without going into
the level of detail in previous handouts
SKILLS FOR REDUCING VULNERABILITY TO EMOTION MIND
ER 14-OVERVIEW: REDUCING VULNERABILITY TO EMOTION MIND--BUILDING A LIFE WORTH LIVING
ER 15-ACCUMULATING POSITIVE EMOTIONS: SHORT TERM
ER 16-PLEASANT EVENTS LIST
ER 17-ACCUMULATING POSITIVE EMOTIONS: LONG TERM
ER 18-VALUES AND PRIORITIES LIST
ER 19-BUILD MASTERY AND COPE AHEAD
ER 20-TAKING CARE OF YOUR MIND BY TAKING CARE OF YOUR BODY
ER 20A-NIGHTMARE PROTOCOL STEP BY STEP
ER 20B-SLEEP HYGIENE PROTOCOL
ER 14: OVERVIEW: REDUCING VULNERABILITY TO EMOTION MIND—BUILDING A LIFE WORTH LIVING
Outline of the skills to come under this section, and presents another DBT acronym—ABC PLEASE
Meant as an overview/introduction, not intended to spend a lot of time on
Orient patients that the skills for accumulating positive emotions and building mastery are necessary to build a meaningful life you want to be present for
Cope Ahead and the PLEASE skill are necessary in order to address and potentially prevent vulnerability factors for emotion mind
ER 15: BUILDING POSITIVE EMOTIONS: SHORT TERM
• Orient patients that emotions are not things that just “happen,” but are very much related to the behaviors and practices we build into our lives (Example: Joy as a product of gratitude practice)
• Short term enjoyable experiences are necessary in order to increase our emotional reserves and foster the experience of positive emotion on a daily basis
• Only focusing on short term positive experiences can leave our lives feeling void of meaning and purpose
• First box is a fairly straightforward read and discuss. Orient that “avoid avoiding” means “do something!”
• For the last two boxes, orient patients to the practice of integrating mindfulness skills into their experience of short term positive events
• Remember that when asked “not” to do something, that can be all we think about! (Don’t think of the color green)
• Encourage patients to be mindful of doing things they want to stay away from, and gently and kindly redirect their attention back toward focusing on their pleasant experience…again, and again, and again!
ER 16: PLEASANT EVENTS LIST
This is a fantastic list of 225 ideas for things to do in the short term that could be experienced as pleasant
Not all of these ideas are going to be perceived as pleasant by everyone!
Can be really helpful for patients who have a hard time thinking of things they could do that might be pleasant (or those who are frequently willful about making excuses!)
Helpful to review out loud, and to encourage patients to check off or highlight things they already do, and things they’d like to try
Encourage patients to add additional items to the list if they don’t see their favorite activity listed!
Can be helpful to introduce the concept of gratitude practice while reviewing this handout
Now encourage them to pick one thing each day and commit to doing it
ER 17: ACCUMULATING POSITIVE EMOTIONS—LONG TERM
• Introduce patients to the concept that values are beliefs we have about what’s important and how to interact with the world. They are typically conceptual and frequently apply across situations. Different people may (or may not!) have similar values, but their priorities may be entirely different.
• Goals are benchmarks we set for ourselves that can help us to tell whether we’re progressing down the trail of living out our values, or if we’ve gone off the path. Goals are ideally specific and measurable.
• Step 1 identifies that developing meaning in our lives is not something that just happens, it’s something that takes effort and practice.
• Step 2 may or may not take a while. It can be a very important step for people who have not spent a lot of time reflecting on their values and what’s important to them. \
• ER Handout 18 provides a decent list of values to review if they’re having a difficult time coming up with values on their own.
• Orient patients that identifying their values can be helpful not only in developing meaning in their lives, but also in the process of decision making.
• Identifying what they are missing in their lives, or what they would need to be present in order for life to feel more worthwhile can be a helpful reflection to get to values that are currently a priority.
• Encourage patients first to pick something simple to work on as they’re learning this skill, and then to try applying it to more complex situations.
• Encourage picking goals that are realistic, achievable, and measurable.
• Remember that it can be easy to lose motivation for addressing long term goals and living out values if it’s all drudgery and progress is slow. Short term successes (and celebrations) are important!
ER 18: VALUES AND PRIORITIES LIST
Organized in categories, but some people may identify with a value within a category and not the rest of the category
Encourage patients to spend some time reviewing the list, and adding their own values if they’re not listed
Common for patients to identify with a lot of different values, but have difficulty identifying which are the most important/biggest priority now in their lives
Can be helpful to discuss and provide coaching as they work on narrowing down their choices
As an alternate activity, I like to provide patients with the List of Values from page 188 in Brene Brown’s Dare to Lead. It can be a little easier to follow and identify with.
ER 19: BUILD MASTERY AND COPE AHEAD
This handout includes two very important, but separate skills, on the same page
Before teaching Build Mastery, can be helpful to draw the diagram shown here and explain the difference between our comfort zone, the zone of difficult but possible, and the difficult and impossible zone. Using a personal example can be helpful in illustrating the point.
In regards to the Build Mastery skill, orient patients that the goal is to find balance between the challenging but possible zone and the comfort zone, and to make sure you do something every day (but not too many things!) in the difficult but possible zone.
Let patients know that over time, doing more and more things in the difficult but possible zone can actually help to expand your comfort zone.
Remember that it is also important to make sure you’re spending some time every day in the comfort zone, in order to recover from the efforts of doing things that are difficult but possible.
ER 19: COPE AHEAD
• Important skill to learn and use for situations when you can anticipate a difficult or worrisome situation ahead of time
• Cope Ahead is based on the principle of Imaginal Exposure
• Obsessing about worry thoughts tends to increase the intensity of worry, and trying not to think about what we’re worried about only makes the worry bigger if it’s purpose is to get our attention or motivate us for action (Example: Green)
• The idea of Cope Ahead is to not only acknowledge the worry, but to see it through to the other side where you can envision how you would cope with that situation as skillfully and effectively as possible if it were to happen
• Approach and retreat, and limiting the amount of time (or number of situations) you focus on this skill, can be really important in keeping people with obsessive thoughts from going “down the rabbit hole.” Use distraction once alotted time or number of scenarios has been reached.
ER 20: TAKING CARE OF YOUR MIND BY TAKING CARE OF YOUR BODY
Referred to as the “PLEASE” skill
Addresses short term vulnerabilities for negative emotion
Can be a helpful checklist for your patients (and you!) to inventory potential contributing factors when things start going awry
Not all of these things are directly under our control all of the time
Make improvements to the things you can
Acknowledge and create space/compassion for things that can’t be changed
ER 20A: NIGHTMARE PROTOCOL, STEP BY STEP
• Most helpful for recurrent nightmares, but can be helpful with decreasing nightmares that aren’t recurrent as well
• Replaces feelings of helplessness with a sense of agency
• Based on principle of Imaginal Exposure, as well as use of relaxation/grounding strategies
• Step 3 may be too much for some people (especially when the nightmare is trauma-related).
• Helpful to remind patients that nightmares occur in our brains, NOT in the world around us, and that WEIRD stuff happens all the time in dreams.
• The changed outcome to the nightmare can include weird stuff as well, so long as it helps the patient to feel safer and resolves the situation (taking on super powers, changing into something or someone else, etc)
• Make a routine and rehearse, rehearse, rehearse!
ER 20B: SLEEP HYGIENE PROTOCOL
Helpful to at least hand out to patients if you don’t have time to review it in session
First section addresses behavioral factors that can influence quality and onset of sleep. Many patients are resistant to changes in this area…start small and work with what you can get! Get commitment to work on SOMETHING, and shape behaviors from there. Make sure to also inform them of the potential consequences of not making changes.
Second section is pretty straight forward, but make sure to emphasize the importance of getting out of bed if you have been laying there for more than an hour and can’t fall asleep. Situational learning could condition our bodies to learn that bed isn’t for sleeping otherwise!
Cold Water TIP can be an aversive idea if you want to rest—make sure to explain the physiological reasons why it can be helpful.
Make sure not to skip over the importance of emotional experiencing as a means of interrupting rumination.
SKILLS FOR HANDLING REALLY DIFFICULT EMOTIONS
ER 21: OVERVIEW: MANAGING REALLY DIFFICULT EMOTIONS
ER 22: MINDFULNESS OF CURRENT EMOTIONS: LETTING GO OF EMOTIONAL SUFFERING
ER 23: MANAGING EXTREME EMOTIONS
ER 24: TROUBLESHOOTING EMOTION REGULATION SKILLS: WHEN WHAT YOU’RE DOING ISN’T WORKING
ER 25: REVIEW OF SKILLS FOR EMOTION REGULATION
ER 21: OVERVIEW: MANAGING REALLY DIFFICULT EMOTIONS
Outlines the 3 skillsets that are important for managing intense emotions
Helpful to orient patients that the skills for managing emotions once we’re past our Skills Breakdown Point are very different from the complex skills needed when we’re below the Skills Breakdown Point.
ER 22: MINDFULNESS OF CURRENT EMOTIONS: LETTING GO OF EMOTIONAL SUFFERINGImportant reminder of the difference between pain and suffering
Reminder of the wave model of emotions (so long as it isn’t blocked so it becomes a whirlpool)
For skills in the second box, noticing the physical sensations with curiosity, and describing them as objectively as possible can be helpful
For patients who have difficulty tolerating presence with physical sensations, use an approach and retreat strategy. encourage them to “poke” each area of their body where they’re feeling their emotions, and then retreat. Or bring their breath in to that part of the body and take focus away when they breathe out.
Remind them that emotions can be painful and intolerable, and box 3 is not intended to minimize those things. Just to remind you that emotions are NOT behaviors
If loving a painful emotion feels too untenable, try loving what function that emotion is serving (to motivate you for action, to communicate important ideas, or to alert you to something important).
Example: Sadness as an alert of importance
Encourage Radical Self Love in regards to difficult emotions
ER 23: MANAGING EXTREME EMOTIONS
How to recognize the Skills Breakdown Point:
Unable to think of appropriate skills to use
If you can think of skills, you can’t use them or they don’t help
NOT the melt down, shut down, or outburst phase…that’s way PAST the Skills Breakdown Point!
Road/Rumblestrip metaphor
Identify the importance of going to Crisis Survival Strategies (TIP, Distract, Self Soothe, and Improve the Moment) when we are at or past our Skills Breakdown Points
Orient to importance of noticing SUDS (Subjective Units of Distress) once Crisis Survival Strategies have been used to decrease distress, and then making a decision about whether more complex skills are now possible and appropriate
ER 24: TROUBLESHOOTING EMOTION REGULATION SKILLS:
WHEN WHAT YOU ARE DOING ISN’T WORKING
• GREAT step by step guide for how to get back on track
• Always start with short term vulnerability factors—sometimes a sandwich or a nap can reset things really effectively so complex skills become an option
• Step 2 is important because sometimes we think things should just feel better, before we try skills! It’s a good reminder that there’s work to be done if we want to feel better.
• Step 3 addresses ways that our environments may be reinforcing intense emotions, and what we can do about it.
• Step 4 is an important reminder that sometimes a quick sweep with basic skills won’t cut it—we need a deep dive for things to be properly repaired.
• Step 5 can be helpful to address BEFORE step 4 if it feels like the Skills Breakdown Point is being a factor. Try Radical Acceptance when you’re past your Skills Breakdown Point can be a recipe for disaster!
• Step 6 encourages awareness of thoughts that may be interfering.
ER 25: REVIEW OF SKILLS FOR EMOTION REGULATION
• Helpful visual representation of how the skills from Emotion Regulation match up with each component of our Cycle of Emotions
• Don’t have to review in detail unless patients are visual learners, familiar with how the Cycle of Emotions handout works, and find this handout interesting and helpful
• Helps to put together all of the skills that make up Emotion Regulation in a more understandable way
HOMEWORK
Pick one set of Emotion Regulation skills (Identifying Emotions, Changing Unwanted Emotions, Reducing Vulnerability to Emotion Mind, or Handling Difficult Emotions) and practice teaching them to your patients
Finish reading “An Introduction to DBT Skills Training”
Read the teaching notes for Interpersonal Effectiveness in the Skills Training Manual
MINDFULNESS: MODIFIED BODY SCAN
Find a comfortable position and focus on your breath.
Bring your attention to your head, your scalp, your face and mouth. What do you notice there?
Your neck, shoulders, chest?
Your arms and hands?
Torso, lungs, stomach?
Your seat, legs, feet?
Bring your attention back to your breath.
Now bring your awareness back to our conversation.