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Self Soothing and Distress Tolerance: DBT Skills for Stressful Times

Dialectical behavioral therapy (DBT) can be effective for certain mental health disorders. This presentation explains how DBT can be used in clinical settings.

Estimated watch time: 59 mins 

Available credits: none

Presentation Materials:

Presenter, Ritu Anand, LCSW has over 15 years of experience working in a variety of nonprofit environments with different populations including immigrant families and adults, children with disabilities, college students, families experiencing domestic violence, and adults with severe and persistent mental illness. Ritu also has a background as a clinician, trainer, and supervisor in the fields of community mental health and crisis intervention. Ritu is the founder of Creative Healing Collective, LLC.

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems. 

Ashley:
My name is Ashley. I’m the event director for Advanced Recovery Systems. Just wanted to say, “Happy New Year,” and thank you for coming to our first webinar in 2021. We will keep continuing to have these every Wednesday from 2:00 to 3:00 p.m., Eastern standard time. And if you want to be a speaker or have somebody in mind, please reach out to me, and we would love to start a conversation and have it set up. So, I’m going to go and introduce our speaker today. Ritu has over 15 years of experience working in a variety of nonprofit environments with different populations, including immigrant families and adults, children with disabilities, college students, families experiencing domestic violence and adults with severe and persistent mental illness. Ritu also has a background as a clinician, trainer and supervisor in the fields of community health and crisis intervention. Ritu is the founder of Creative Healing Collective. I’m going to pass it off to her, and if we can wait for questions at the end of the presentation, that would be great. We’re going to save some time at the end. But if you want to put it in the chat just so you don’t forget it, you can do that, and I will monitor that. So, thank you for coming, and I will pass it to her. 

Ritu:
Thank you, Ashley. I appreciate that intro. Thank you to everybody who’s here. I’m looking in the chat. It looks like we have people from all over the country. That’s so amazing. I see somebody is a student, so I look really forward to if you guys have any questions at the end of the presentation. But as Ashley mentioned, we’re going to go through the presentation first. And I’m really grateful that you guys chose to spend your afternoon with me, so we’ll go ahead and get started. And then like I said, at the very end, we can save some time for questions. Let me go ahead and get adjusted to Zoom; it’s been a while. 

Today, our presentation is DBT skills, and I’m specifically focusing on self-soothing and distress tolerance. I want to give everyone the disclaimer that DBT, which I’ll go further into what it is — if you’re not sure what it is, it’s a clinical intervention, and you can get certified as a DBT trainer. I am not certified as a DBT trainer, but I have had training and I have used the intervention. I just want to give you guys a disclaimer that this is not a substitute for getting more intensive training, but it is an opportunity to learn a little bit more about the skills, whether you’re a clinician and you want to implement them in your practice or whether you are just a community member. Whether you’re a community member or a clinician, and also for clinicians, we can use these ourselves. I definitely use them. 

Let’s go ahead and get started. This is just about my background, but I believe Ashley already introduced me, so we’ll go ahead and move on. Again, we actually already kind of gave you guys a background, but I just wanted to give you a little bit more information. I’ve worked in assertive community treatment and community mental health. I’ve also worked in intensive psychosocial rehab, and often, our clients were those that were at high risk of recurrent inpatient hospitalization. We often had clients in our caseload that might’ve had a diagnosis of borderline personality disorder, which is one of the diagnoses that can benefit from this intervention, so this was something we often used as a clinical intervention in these environments. Just to kind of give you guys a background on where I was kind of using the DBT intervention, I was using it very often in these settings.

Today’s objectives: We’re going to go over some history, some core foundational knowledge and then also talk about self-soothing and distress tolerance techniques. The purpose of speaking about these things is I wanted to give tools for you that could help you ease stress, increase relaxation and improve emotional regulation in your day-to-day life but also in times of stress, because I thought that was very relevant for 2020 and 2021 this last week. I think it’s relevant in general, but I think especially when we have increased uncertainty times of stress — where we might be more at risk of being emotionally vulnerable — these can be really valuable. Give me one second, I’m just gonna do something here. Then I also wanted to give you guys some concrete tools on how to implement some of these practices, whether it’s in your clinical practice or whether it’s in your personal life. I wanted you to leave the training with some tools as well.

We’re going to also do that at the very end. In the very beginning of our training, I’m going to kind of give you a little bit more information on DBT as an intervention and the history of it, and then we’ll go more into the skills that we are speaking about. Because I’m focusing more on a little bit of history and some tools, it’s not going to be as comprehensive. Like I said before, in the very end, I can talk to you more about, “Where can I learn more? How can I get more knowledge on some of these contexts that I’m touching on?” Thanks for your patience. There we go.

So, why did I want to present on this topic? As I mentioned a minute ago, I think it’s very relevant always, but especially in our last year — especially in our last week. These skills that I’m going to be speaking to you about were originally developed to treat chronic suicidality and also developed to treat persons diagnosed with borderline personality disorder. But I also think we’re living in, I would say, unprecedented circumstances — maybe not in the history of the globe, but definitely in my lifetime — with the global pandemic and with situations happening within our country at this moment. I would say a lot of the things that we’re facing and a lot of the ways our lives have changed due to that are very unprecedented. 

COVID-19 has been going on for more than a year — or I guess early last year. We started to learn about COVID-19, then a couple months after, a lot of places were shutting down. We all may be being impacted differently based on our own circumstances, but many of us have had changes in our day-to-day life based on the pandemic. The way that our routines used to be, the way that our days used to be structured, the coping skills that we used to use or our support systems that we had access to. Our usual coping skills and our methods of self-soothing — we may not have the same access to them because of the pandemic. Also, we’ve had recent events of civil, racial and political unrest in the United States that were going on over the summer. There was just a recent event in the news about a week ago, and many of us might be wondering what’s going to happen in the next week and just be uncertain about the future, whether it’s about COVID-19, whether it’s about our own personal lives and whatever changes we’ve had to go through due to COVID-19, or maybe it’s about the future of our political situation. I think it’s very timely that we’re speaking about this, and that’s why I wanted to give people concrete tools on how to manage distress and overwhelming feelings because many people are experiencing an increase in mental health symptoms due to all of these things that I just mentioned.

We are going to go a little bit through the history of how DBT was developed. I know I brought it up a couple of times, but we’ll go a little bit more in-depth. Again, the original treatment was developed for women at high risk of death by suicide, but I think that these are skills that can benefit many of us, especially in these times. Of course, they can also be used when we’re not in the midst of a global pandemic. They can be used in our day-to-day lives. They can be used if things get better soon; if we get a vaccine and things become more stable, it doesn’t mean we can’t still use these skills. And I think they can be very valuable in times of uncertainty, stress and crisis because we might be more emotionally vulnerable and we might have more emotional distress. We might have more intense emotions and have trouble managing them, but they’re definitely valuable in times where we’re not having a crisis situation as well. I know in my practice with the clients, I’m seeing there’s a lot of people who are having a lot of changes within the span of a year. And it might be, “I’m at home all the time with my partner and we’re really stressed out. We see each other all the time,” or it might be, “I’m really lonely. I don’t get to see my family as much.” So, there’s a variety of different ways that people are experiencing the pandemic. I think it’s really important right now too, considering that we don’t have our usual routines. Maybe we don’t feel safe to go to the gym like we used to, or maybe we’re trying to work out at home. There are just so many different situations that we might be navigating based on our unique personal circumstances, so I think that some of these skills can be very useful, especially right now. That’s why I wanted to present on this topic. 

Let’s go ahead and talk a little bit about, “What is DBT?” I don’t know how familiar everybody who’s attending would be with DBT. If you’re not familiar, I want to give you a little bit of background and also talk to you about how it is different than CBT. And if you’ve never heard of any of those things, it’s okay. I’m going to give you a little bit of a background on both things. And I’ll give you a little bit of definition on certain things we speak about, like borderline personality disorder. But again, I cannot comprehensively get into everything because of time constraints and the fact that we’re meeting for an hour. So, DBT is an abbreviation for dialectical behavioral therapy and it was developed by Psychologist Marsha Linehan. Linehan was originally looking for a diagnosis for people with borderline personality disorder and also looking for treatment for people who were at risk of suicide and self-injury. 

She was evaluating the literature on effective psychosocial treatments for other disorders that were already established effective treatments — things like anxiety disorders, depression and other emotion-related difficulties. What she originally did is she basically came up with, like, a package of evidence-based cognitive-behavioral interventions. She was specifically trying to target suicidal behavior. I’m going to give you a little bit more background on Linehan herself in a moment, but what she noticed is when she was focusing solely on things that were changing people’s thoughts and behaviors — we’re going to talk more about cognitive-behavioral therapy, but she was basically focused on how we help people change their thinking and their behaviors — but she noticed that many clients were feeling criticized, misunderstood, invalidated. And some people were dropping out, or many people were dropping out of treatment. As she was coming through the literature — as she was assembling an intervention herself — she was finding that there was something missing with this intervention.

I want to talk to you a little bit about her theory of suicidal behavior. She had a bio-social theory that states that suicidal behavior is a learned method for coping with acute emotional suffering. She looked at suicidal behavior as a skill deficit, and we’ll talk more about this coming up, but basically seeing it as a skill deficit, which means that people are trying to kill themselves as the solution for intense suffering because they don’t have any other options that they can come up with. We’ll talk more about this like I said, but a lot of the DBT intervention is focused on skills and skills training that might help people have other methods of problem-solving or managing really difficult, overwhelming and intense emotions.

So, what populations are treated with this intervention? As I’ve mentioned, the intervention was originally developed for people with the diagnosis of borderline personality disorder, and also for people that were having recurrent self-harm and suicidal behaviors. But it’s also been found to be effective for patients with substance use disorders, people who meet the criteria for binge eating disorder, depressed, elderly patients. For those of you that may not know a lot about borderline personality disorder, I’m just going to give you a brief description. If you have the DSM, the DSM details all the different symptoms and factors that might lead to a diagnosis, but basically, borderline personality disorder is defined as a pervasive pattern of instability in interpersonal relationships, self-image, affects and marked impulsivity. One of the features of borderline personality disorder might be that someone has a marked reactivity of mood or affective instability. That’s originally who Linehan was looking for effective treatments for when she developed dialectical behavioral therapy, but these skills can be helpful to other populations. I think that some of the skills that we’re going to talk about today can also be used in a variety of treatment settings. It may not look the same as a setting where people are certified in DBT and they’re doing therapy based on the model of DBT, which I will detail to you guys in a moment, but I still think that we can use some of these skills with a variety of people. We will talk about them in-depth, but a lot of it is focused on regulating emotions, tolerating distress, improving relationships. I think anybody can really benefit from those.

Let’s talk a little bit about Marsha, the founder of DBT. It was really interesting. I didn’t know a lot about her before doing this presentation, but she actually — herself, at 17 — she was put into seclusion at an inpatient unit because she was burning her wrists with cigarettes. She was slashing her arms and legs and her midsection with anything she could get her hands on. So, as a very young woman, she was self-harming and she was struggling with symptoms. Once they put her in seclusion, things got worse; she started banging her head against the walls, the floors. I believe I mentioned she was 17 when she was first hospitalized, and in her discharge note, during 26 of 26 months of hospitalization, she was one of the most disturbed patients. That’s what they put in her discharge note. So, she was informed by her own lived experiences as she decided to pursue a doctorate in psychology.

As she founded DBT, she had been informed by her own experiences. I got this information from a New York Times article, but if you actually look it up, you’ll find several New York Times articles about her and her history. In one, she’s giving an interview — you can watch her speaking about it — and she’s speaking about a religious experience she had at some point after getting out of the hospital. She had this religious experience where, all of a sudden, she had this moment of love for herself. And I think that informed some of these things we’re going to talk about. Like, we’re going to talk about acceptance, and that’s — we’ll talk further, but I think that informed her. She actually said — in this article that I’ve cited — she said, “I suppose it’s true that I developed a therapy that provides the things I needed for so many years that I forgot.” She was motivated by her own circumstances to build on the CBT interventions and add certain things into it.

Let’s go ahead and talk about the difference between DBT and CBT. If you guys have not heard about CBT — you can see a little graphic here — but what CBT basically says is that we have a set of core beliefs about ourselves that we have internalized based on our past experiences. And these beliefs about ourselves impact how we think about ourselves, how we think about other people, how we may think generally, how our thinking has developed, what we think about the future. And CBT talks about a concept called automatic thoughts. That means automatic thoughts are the thoughts that we just have automatically without even really noticing. It’s like the tape that plays in our head, and often, we have these thoughts based on patterns of thinking, but also our own self-concept and what we have internalized about ourselves.

You can see that in the middle where it says core beliefs — that triangle. But then surrounding the triangle, you’ll see it says, “Feelings, behavior and thoughts,” and you see these arrows. The arrows just mean that our thoughts influence how we feel, which influences how we behave. But also, our feelings influence our behavior and our thoughts; our behaviors influence our thoughts and our feelings. They’re all linked. In cognitive-behavioral therapy, which is an evidence-based treatment, often what the focus is is helping people identify thinking and patterns of thinking. Identify how those thoughts make them feel. Can we reframe those thoughts? Identifying thinking errors, like the ways of thinking that may not be effective or productive or may not make us feel good. Are there other ways of thinking about a situation? So, CBT has a lot of similarities if it’s just that it adds on and builds onto that intervention. 

Some of the things that are unique about DBT would be the four following, which I will break down for you guys. I’m gonna go over it, and then we’re going to break it all down as well. DBT serves five functions of treatment. That’s the first thing that makes it different. It is based on a bio-social theory that emphasizes emotion and treatment, and it’s also based on dialectical philosophy, and it incorporates mindfulness and acceptance-oriented interventions. Let’s talk about what all that means. The five functions of DBT treatment: The first one is enhancing capabilities. In the beginning of the presentation, I’d mentioned to you that Linehan saw suicidal behavior as a skills deficit — not having the skills to deal with those intense emotions that make people feel like life is not worth living. So, the first function in DBT is that the treatment is meant to enhance capabilities. The assumption is that patients need assistance in developing critical life skills, which includes emotional regulation skills, mindfulness skills, navigating interpersonal situations effectively, tolerating distress and surviving crisis without making things worse. 

This is usually achieved with weekly skills training. Usually, it’s a group of four to 10. That’s what they recommend — four to 10 individuals in a group setting. It would be a skills training. It would be like a group that focuses on skills training. And usually, what would happen is you would use the group setting to let people practice these skills that you’re teaching, discuss the skills. And also, give homework assignments so that people can practice in between sessions as well so that they can really develop these skills that we’re trying to teach, which we’re gonna go over what some of these skills are. We’re not going over every single skill that DBT teaches ‘cause the intervention also teaches how to have better interactions with people — like, interpersonal situations — but I’m not focusing on that today. I’m going to focus on some of the other ones, like self-soothing and distress tolerance, but the purpose of the weekly skills training would be so that the people attending the group would be able to develop these skills and practice them in a group setting.

The second one is generalizing capabilities, and what that means is we want to make sure that whatever we are focusing on in treatment is also going to work in the person’s natural environment, where they go after they come to group or after they come to one-to-one therapy or whatever the program might be that they’re attending. The way we would do that is giving homework assignments, and a lot of times, this is also achieved in one-to-one therapy. Often, people are recommended to attend both one-to-one therapy and group skills training. Many DBT therapists are also available to people between sessions in case they’re having a crisis situation.

The third function would be improving motivation and reducing dysfunctional behavior. This would be — again, it’s a lot like what it sounds — helping the patients have the motivation to change and also reduce behavior that’s inconsistent with a life worth living. The goal for people who are at high risk of suicide is to help them have less behaviors that would contribute to suicide and also to have a life worth living. Often, this is also through one-to-one therapy. A lot of DBT therapists will have something called a diary card, which is basically tracking treatment targets. It might be self-harm. It might be suicide attempts. It might be emotional misery. They would track the treatment goals that they’re targeting. It might be reducing suicide attempts, reducing self-harm. In one-to-one sessions, as they’re tracking those behaviors, the clinician would usually focus first, of course, on the life-threatening behaviors. Those would be given priority, but then they would also, depending on what has happened that week, they might also be talking about therapy, interfering behaviors. If a person is absent, late, non-collaborative with the therapist, as well as behaviors that might interfere with the quality of life, then they might talk to them about what led up to the behaviors, what’s reinforcing or maintaining those behaviors. Are there other ways to problem-solve or regulate emotions to reduce those behaviors?

And then the next one would be enhancing and maintaining therapist capabilities and motivation. So, for the therapists that are dealing with people who might be having a lot of suicide attempts — and there might be other things happening with the patients — therapists need to make sure that they have the capacity to treat their patients and also that they have support. So, it’s really important to have a consultation for therapists. It’s recommended that therapists have a team meeting, like, one to two hours a week that provides therapeutic therapist consultation. The purpose would be supporting the therapist, monitoring the therapist for burnout, validating the therapist, but also providing continued training and skill-building and making sure that the therapist keeps up to date on how to best treat the population and have the support, but also continue to build their skills as well.

And then the very last one would be structuring the environment. The point of this would be structuring the treatment environment to reinforce effective behavior and not reinforce maladaptive or problematic behavior but also helping the client structure their environment. For example, if someone is struggling with substance use, it might be talking about how their environment is — are they in social circles or in a home situation where substances are available or people are using substances? Is there any way to be able to limit their access to those people or to substances within their environment? If someone is self-harming, we might talk about access to things that they could harm themselves with, or also who’s around them. Are they supportive or are they — whether it’s their significant others, whether it’s their family members — what is their interaction with their social circle, and are there ways that we can encourage the people around them to also have supportive behaviors?

So, that would be the ways. These are the really kind of specific things that are part of DBT that are not necessarily a part of CBT. That kind of is part of what makes DBT unique. And then there’s a couple of other things; there’s also the biosocial theory. This is basically speaking specifically about borderline personality disorder. You can see in the name bio-social: biological and social. They’re talking about the different contributions. Through this lens, people who developed borderline personality disorder are biologically disposed towards emotional vulnerability, which means a low threshold for responding to an emotional stimulus, intense emotional responses and difficulty returning to a baseline level of emotional arousal. And then the other part of it is the social part of it. Often, the thought is that there was a lack of skillful parenting. 

Children look to their caregivers for a lot of things; they look to their caregivers to be role models for them. They watch their caregivers to see how we behave in certain circumstances. So, if a child is having emotional reactions and they don’t have skillful parenting, they may not learn how to regulate their feelings or even identify their feelings, and that may make it hard, as they get older, to know how to do that. That’s why with DBT, the interventions are focused on behavioral skills that help people learn how to recognize, understand, label and regulate their emotions. So, the first step. We’ll talk more about this, but the first step is, “What am I feeling? Why am I feeling it? What is the feeling? How do I manage the feeling?” And I think a lot of people might say, “I don’t think it’s just people with borderline personality disorder who might have these struggles.” If we didn’t really see people identifying their feelings, expressing their feelings, managing their feelings, I think many of us might not have seen that we might benefit from developing these skills. 

The third factor is dialectical thinking. Basically, what this means is that reality consists of opposing polar forces that are intended. And I think it’ll make more sense — if that doesn’t make sense to you, we’re going to talk more about it. I think it’ll start making more sense. But basically, if we’re applying change-oriented treatment strategies, it can create tension within treatment because the patient also has a desire to be accepted rather than changed. But each force — they’re different things, right? Being accepted and changing — they’re two different things, and they can be in tension and they also can be incomplete on their own. If we only complete, or if we only focus on change — you have to change, right? We have to change ourselves. That can be incomplete because we may not feel accepted. But if we only focus on acceptance, that can also be incomplete and ineffective because, often, the people who are at very high risk of self-injury and suicide may require extensive changes in their lives to reduce their suicidal behaviors and thoughts and the feelings that contribute to them. They’re both kind of incomplete, and if we can kind of put them together, then that might be more of a nuanced and complete way of treating people. 

Dialectical thinking can encourage more open-minded and nuanced thinking because it’s both instead of either/or. I’ll show you guys some examples, but if you think about it, black-and-white thinking is, “Either I’m good or I’m bad. Either I did good or I did bad,” where dialectical thinking might be, “I don’t like how I performed today, but I did my best.” Right? It’s kind of like being able to not just think of things in black and white; there’s more shades of gray. There’s more nuance. We can be more open-minded. We’re not going to be as likely to think of things as, “I always fail, I never succeed.” That kind of thinking can make us feel hopeless. It can make us feel certain types of emotions. That always/never, black-or-white thinking can contribute to negative feelings, and the other type of thinking can kind of hold space for nuance and contradictions. 

I’ll give you guys some examples of that. So, I decided to make some examples of things that might apply to maybe this time right now with coronavirus. I am feeling challenged, and I can see some benefits of what I’m going through. It’s not just, “Oh, this is great.” There’s, like, “Let’s just look at the bright side. Let’s just look at the silver lining.” I’m validating the fact that I am feeling challenged, but I can also see some benefits of what I’m going through. The world is suffering, but a lot of growth is happening through this change as well. I’m feeling frightened, and I’m also feeling brave and resilient. I accept myself and I want to make changes. I think you guys can see how there is a — it’s not just one or the other. I can accept myself and want to make changes, which is, again, a lot about what dialectical behavioral therapy focuses on — acceptance and also learning skills and making changes.

And then one of the last ones is mindfulness and acceptance-oriented interventions. Mindfulness are skills that help us to be in the here and now, and they help us to observe the present moment in a nonjudgmental fashion. That’s one aspect of DBT. The other one is radical acceptance. Radical acceptance means that we accept the experience of the present moment for what it is without struggling to change or resist it. It doesn’t mean we like it or condone it. It’s not that we’re happy that we’re in a global pandemic — it’s that we acknowledge we are in a global pandemic, or we acknowledge that we are under stress. If we can accept the experience of the present moment and we’re not struggling to change or resist it, that can help us in many ways, which we’ll talk about. Because we can kind of accept what’s in our control, what’s not in our control, and we might avoid labeling, like, “This is good or this is bad,” but it’s like, “This is what it is. I don’t like it, but this is what it is.”

We’re going to talk a little bit more about those things. Again, radical acceptance. The ways that it can help us in terms of our mental health is helping us realize that some things are in our control, but not everything is. I’m not happy about this global pandemic, but I also cannot control the fact that it’s here or when it will go away. What I can control is my own ability to manage myself and my safety as we all navigate it. That’s when we kind of think about what’s within our control. It can produce feelings of stress and anxiety. It doesn’t mean we don’t have stress and anxiety, but it can help us focus on what’s in our control. I gave you guys an example of typical thinking versus radical acceptance. Typical thinking might be, “It’s unfair that COVID-19 has been going on for more than a year, and I’m not able to spend time with my family and friends.” Is it unfair? Yes, it’s unfair. I don’t like it. I don’t want to be stuck in the house. I know not everybody is able to stay at home. I know some people are going to work — and frontline workers — so everybody’s having a different experience. But yes, it is unfair. Radical acceptance might say, “I’m unhappy that we’re in a global pandemic that restricts what I’m able to do, but I’m going to take precautions to stay as safe as I can and figure out how to get the vaccine as a way to reduce my risks.” It doesn’t mean, “Oh, I’m so happy that I’m worried about leaving my house, seeing my family members and that this has been going on for a while.” It’s not about that. It’s more about validating that I’m unhappy about it, but also I’m accepting that that’s where we are right now. 

So, I put the serenity prayer in here. You guys may have heard of this before; it’s often used in 12-step groups, and I think it kind of really demonstrates the concept of radical acceptance. It usually says, “God grant me,” but not everybody is religious, so it may not apply to you. So, I just put in some other stuff — God, universe, a higher power — or you just can take that part out. You can just say, “Grant me the serenity to accept the things that I can not change, the courage to change the things that I can and the wisdom to know the difference.” And I think that’s a really good reflection — they’re talking a lot about what’s in our control. Some things are, some things aren’t. Maybe we have to accept sometimes when things are not within our control and then focus on what actually is within our control. And if we spend a lot of time focusing on things we can’t control, like other people or things that are complicated and beyond us, then we can feel helpless and we can feel distressed.

So, distress — what is distress tolerance? ‘Cause I’ve been using the word; you may not have known what I’ve meant. Let’s talk more about that. Distress tolerance is the ability to tolerate and manage painful, overwhelming or intense emotions, and the ability to use techniques to manage or reduce the emotional intensity of emotions and enhance coping skills and the ability to regulate your emotions. Part of it is being able to identify our emotions. It’s really important too because we’re talking about managing painful feelings, but if we don’t even know what we’re feeling, that’s going to be hard. A lot of times, we have to work on identifying our feelings as part of the skill. And once we are able to — when we become accustomed to identifying our feelings — it can help us understand how to manage them as well.

I just put a couple of things about identifying feelings. I put “feelings are not good or bad.” Often, when I was running groups in my previous place of employment, we would talk a lot about anger management and that anger is not a bad emotion. It’s an indicator of something. It’s something that’s telling us feelings or information. When we are feeling something, it’s information for us to pay attention to; if we don’t pay attention to it, the feeling will still be there — almost manifest somehow. Anyway, there are not good or bad feelings; feelings are telling us something. It’s telling us to pay attention. And then “feelings are not facts,” which just means that sometimes, we can see things through our feelings. Like, we are interpreting situations based on what we’re feeling but that may not be what’s actually happening, and we’ll talk more about, well, then how do we counteract that? How do we manage our feelings in a way where we can look at our own assumptions and interpretations of what’s happening? 

Identifying feelings — I’m just giving you a little bit of this. There’s a lot more about this, but just to give you an idea. A lot of times, our bodily sensations — our signals — are giving us a clue as to what we’re feeling. If you’re feeling angry, it depends, but you might tense up. Your jaw might clench. Your shoulders might get tense. You might breathe, shout, or if you’re feeling nervous or anxious, your body might react. A lot of times, it’s noticing our body and our signals. In treatment — often, when I was doing groups, we were using feeling charts as another way. Feeling charts are pictures of emotional expression and what feelings are associated, and then they can be used to help people identify their feelings. With kids or also just in general, if you’re doing work with helping people identify their feelings, sometimes you can use feeling charts, but also journaling, exploring your feelings or being in therapy. I didn’t put that on here, but having the support of someone else where you can process feelings, because feelings can be complicated. And then another thing would be just slowing down, ‘cause when you slow down — which isn’t always easy, but we’re going to talk more about it — you’re more likely to pay attention to your bodily signals. And then mindfulness skills can help us slow down again. Mindfulness is being in the moment. Meditation. I know not everybody likes meditation, but there’s a variety of ways that we can practice the mindfulness — the slowing down — without actually having to sit down and meditate for 30 minutes. We’ll talk more about that in just a moment as well.

I’m just looking at the time to make sure we’re not running out of time yet. We’re going to kind of try to get through these last couple slides. These are the last part of the training — what are the things I can take home for myself and for my clients? We’re going to talk about distress tolerance techniques. Acceptance — we’ve already spoken about — which is learning to have the thinking, which is, “I accept what is happening. I don’t like it, but I accept it.” But we’re going to talk a little bit about distraction and how to improve the moment. DBT has a lot of acronyms, and you can find worksheets all over the internet that talk about this acronym and break it down for you. There’s a website called Therapist Aid that has all sorts of worksheets that has the acronyms and examples. I’m going to go over examples for you, but you can also access these. And I’ll talk more about other resources for learning more about DBT in the end, and you’ll be able to learn more, but they use a lot of acronyms in DBT. 

So, distraction. I want to really quickly say that we tend to sometimes think if we distract ourselves, it’s a negative thing. It means we’re avoiding our feelings, and avoidance — avoiding our feelings — is a little different than what this is. Distraction is more about using skills that — I’m going to actually take out my notes because I also need to look at it. So, the way that they refer to a distraction is that our negative feelings will usually pass or lessen with intensity over time. So, it’s not about avoiding your feelings — it’s about doing something that could distract you so that the emotional level or the intensity level can reduce so that maybe they are more manageable, these negative or painful feelings. I just want you to think of it in that context. The acronym is ACCEPTS: activities, contributing, comparisons, emotions, pushing away, thoughts and sensations. That probably makes no sense, but I’m going to go through it with you. 

Activities — again, these are all methods that can help reduce the intensity of our feelings. Activities is anything that requires thought and concentration. Engaging in an activity. If you’re at a very high level of emotion — you’re at eight or a nine of a feeling — it might be helpful to do something like a hobby, a project or even work or school to get your mind off of it. Doing something that requires focus — it might just kind of distract you. Contributing, focusing on someone other than yourself. Volunteering, doing a good deed, contributing to a cause. It doesn’t have to be volunteering. It could be, “I’m going to call my friend and see how they’re doing. I’m going to make dinner for somebody. I’m going to write a card to someone. I’m going to call someone and see how they’re doing, or do a Zoom chat with somebody.” Just getting the focus off of yourself.

There are also comparisons. So, we tend to often think it’s — I know for me, I don’t. When I see this, I think, “Okay, but we shouldn’t compare ourselves to other peoples.” We should validate what we’re going through, but I think this is different. Comparison in this sense could be about having perspective. It’s comparing to something worse than what’s happening, but not in a way to invalidate your feelings, but more of maybe a perspective-taking. So, can you think of a time when you were in more pain than you are now? Where things were worse than they are now? Or can you think of someone else who might be struggling more than you are? It’s, again, not to invalidate what you’re going through, but just to maybe reduce the intensity of your emotion by having a different perspective on it. Often, when I was running groups with this concept, a lot of people were able to say, “Yeah, I’m going through a hard time,” but when they were reflecting, they would think about times where things were a lot more difficult and how they were able to still get through it. Often, that would be helpful for them, 

Then there are emotions; this is competing emotions. So, this is if you’re sad, you can watch a funny movie. If you’re nervous, you can put on soothing music. That’s the opposite of what you’re feeling. Pushing away is pushing away negative thoughts out of your mind. It doesn’t mean you’ll never think about it, but it’s more like putting things on the back burner so I’m not going to think about this right now. Maybe a different day when I’m less stressed out, I’ll come back to this, but right now, this is actually not that important for me to think about. I’m overwhelmed. I’m going to do something else, and then I’ll come back to this later. Thoughts is just doing something like counting to 10, reciting a poem in your head, reading a book — basically, just trying to do something that requires thought as a way to manage overwhelming emotion. And then sensations would be a safe, physical sensation that might distract you. It could be a rubber band on your wrist, pinching your wrist with a rubber band — again, not to cause pain, but just distraction. Having an ice cube in your hand and your mouth, sour lime, something that kind of takes you into your senses. 

Then we’re going to talk about improving the moment. This is helpful to help us ground ourselves in the present moment, which can help us to relax our nervous system and be more in the moment. That just means we’re in the present rather than being in our thoughts or in our anxious thinking. We’re getting into our bodies. Let’s go through that. Often, we can use the five senses to think of ways to improve the immediate moment. Maybe for our sight, it would be, “Maybe I’ll take a nice walk in a scenic area.” Lava lamp. We see the way the lava — I don’t know if people still have those, but my nephew just got one for Christmas. That’s where I thought of that. Or maybe there’s a calming video on YouTube. We watch it. There’s all sorts of things that we can do. I just put a couple of things, but I want you, as I’m going through this — we’re going to come back to this shortly — I want you to think about what would be for you. Something that would help you soothe your senses when it comes to sight. Touch: It could be a warm blanket. Put the blanket in the laundry and wrap yourself around it. Self-care — petting your animals, using your sense of touch. Sound could be music you like, or the sounds of nature, or calming sounds. Whether it’s the sounds of birds chirping outside, or whether it’s the sound of the waves at the beach or it’s nature sounds, whatever it might be. Taste: You can have a small treat or take a piece of chocolate if you like chocolate and savor it and eat it slowly and just really taste the scent or smell.

You can’t see it — I have a scented candle in my old agency, We used to have diffusers running, which would just make it more pleasant. It would smell nice. There’s certain scents that can be calming — like, I think lavender is one of them. You could have perfume or cologne and smell it. You could have one of those things that you roll essential oils on your wrist if you’re getting stressed. I know that not everybody has access to all of these things, but for some people, it might just be taking one of those perfume/cologne things out of a magazine, smelling it up, ‘cause that might be what they have access to. Some people hate the smell of perfume and cologne and that wouldn’t work for them, so I would encourage you to just do whatever works for you.

I’m going to try to run through these because I know we’re kind of running low on time at this point. I’m going to just kind of run through some of these other ones, and some of them are actually related to some of the ones that we’ve already talked about. So, opposite action. We kind of already talked about this, but it’s kind of like doing the opposite of how you’re feeling. I was saying to you guys, “If you’re sad, you could watch a funny movie.” This is where if you feel angry, you might typically shut down or yell at someone, but you do the opposite of what you feel and how you usually behave. If you usually yell when you’re angry — I’m pretty loud — right now, make a point to talk, like, in a low, slow voice tone or talk politely. If you usually withdraw when you’re sad, try to kind of get out of that and do the opposite and call a friend.

And then we were talking about feelings are not facts. So, check the facts. If you’re feeling a certain way, ask yourself what triggered this feeling. Why am I feeling angry? What was the trigger? Am I making assumptions or interpretations of what happened? What are the actual facts of the situation, and what am I interpreting? Kind of look into that, and then does my emotion and the intensity of my emotion match the facts of the situation, or does it match my assumptions or my interpretations? That’s another way to help us regulate our feelings — really thinking about the facts of what happened and what we are interpreting and what triggered us and kind of being able to analyze it.

Another acronym is PLEASE, and this is focusing on physical — our mind-body connection. So, treating physical illness, going to get checkups. I know it’s kind of hard right now with COVID, but making sure we’re taking care of our physical body, treating physical illness, trying our best to be eating healthy. Nutrition, avoid mood-altering drugs, sleep well, exercise. I think we all know that if we’re not sleeping well, we might be irritable. We might be tired. Our physical health impacts our mood, so that’s why these are also part of the emotional regulation. There’s also paying attention to positive events. It’s very much human nature that we could have 10 compliments in a day and one person critiqued us, and we’ll remember the one critique. 

This is basically just — if we had 10 compliments and we find ourselves focusing on the one critique — refocusing our brains. Not just focusing on the negative, but looking at the bigger picture. But also, this could be just adding more positive experiences into your routine into your day-to-day. So, whatever you find to be positive. I like to take walks or I like to play with my dog or whatever is positive for you. If you like to listen to music, maybe you can play music as you’re doing your chores. That’s something my therapist helped me with — I never thought about it before — to make chores seem pleasant. Now, when I wash the dishes, I light a scented candle, I listen to music. It doesn’t radically change your life and it doesn’t make everything — like, if you’re having a hard time, it doesn’t radically change that — but it does build. The more you’re able to add these positive experiences into your routine, whatever you find to be positive, it builds up over time. You’ll find that you’ll just feel more relaxed, more pleasant overall. 

Now that we’re starting to wrap up, I just want to ask you to think about one thing you can do based on what we talked about. Whether it’s health-related — it could be something small. Like, am I getting sunshine or am I in the house a lot? Am I moving around? Is my sleep okay? Is there something small I could do to improve my sleep? Is there something small I could do if I’m not getting hydrated? I’ve put a couple things here. You might have something different, but it doesn’t have to be a radical change. It might just be, “I need 10 minutes of sun because I work from home,” or, “I need to make sure I Zoom with my friends once a week ‘cause I’m not seeing people,” if you work from home — I’m speaking from my own experience. Or, “I need to not look at the news at night because I’m anxious and now I’m staying up all night.” I want you guys to think about if there’s any one health-related thing you can improve upon, and then I also want you to think of the self-soothing. Using the senses, is there one thing that you can kind of add into your daily routine? Again, one thing that I have right now is a scented candle. I’m drinking tea. I’ve got these things right here for if I’m nervous. 

I apologize. I know I went a little bit longer than I meant to, but basically, yeah, I think that would be the end. And now, I would be ready if you guys have any questions. If you have any questions about resources, like how you can learn more, I think we would be ready for that now. Someone put one more resource in the chat, but I will be just sending it now. 

We’re winding down, but we hope you guys can join us at the next presentation. And thank you again, Ritu. Thank you. Have a great afternoon, everyone. 

Thank you for watching this video. We hope you enjoyed the presentation.

Objectives and Summary:

The purpose of this presentation is to provide education and awareness to clinicians and community members on dialectical behavioral therapy (DBT) as an intervention. The presentation is also meant to share concrete principles and tools with clinicians and members of the community that can help them reduce stress, improve emotional regulation and enhance overall mental well-being.

After watching this presentation, the viewer will:

  • Understand the history of DBT, as well as how and why it was developed
  • Be aware of the principles that underlie DBT and how they are effective in treating certain mental health disorders
  • Have a basic understanding of DBT and potentially be able to incorporate its general ideas into clinical treatment

Presentation Materials:

Presenter, Ritu Anand, LCSW has over 15 years of experience working in a variety of nonprofit environments with different populations including immigrant families and adults, children with disabilities, college students, families experiencing domestic violence, and adults with severe and persistent mental illness. Ritu also has a background as a clinician, trainer, and supervisor in the fields of community mental health and crisis intervention. Ritu is the founder of Creative Healing Collective, LLC.

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems. 

Ashley:
My name is Ashley. I’m the event director for Advanced Recovery Systems. Just wanted to say, “Happy New Year,” and thank you for coming to our first webinar in 2021. We will keep continuing to have these every Wednesday from 2:00 to 3:00 p.m., Eastern standard time. And if you want to be a speaker or have somebody in mind, please reach out to me, and we would love to start a conversation and have it set up. So, I’m going to go and introduce our speaker today. Ritu has over 15 years of experience working in a variety of nonprofit environments with different populations, including immigrant families and adults, children with disabilities, college students, families experiencing domestic violence and adults with severe and persistent mental illness. Ritu also has a background as a clinician, trainer and supervisor in the fields of community health and crisis intervention. Ritu is the founder of Creative Healing Collective. I’m going to pass it off to her, and if we can wait for questions at the end of the presentation, that would be great. We’re going to save some time at the end. But if you want to put it in the chat just so you don’t forget it, you can do that, and I will monitor that. So, thank you for coming, and I will pass it to her. 

Ritu:
Thank you, Ashley. I appreciate that intro. Thank you to everybody who’s here. I’m looking in the chat. It looks like we have people from all over the country. That’s so amazing. I see somebody is a student, so I look really forward to if you guys have any questions at the end of the presentation. But as Ashley mentioned, we’re going to go through the presentation first. And I’m really grateful that you guys chose to spend your afternoon with me, so we’ll go ahead and get started. And then like I said, at the very end, we can save some time for questions. Let me go ahead and get adjusted to Zoom; it’s been a while. 

Today, our presentation is DBT skills, and I’m specifically focusing on self-soothing and distress tolerance. I want to give everyone the disclaimer that DBT, which I’ll go further into what it is — if you’re not sure what it is, it’s a clinical intervention, and you can get certified as a DBT trainer. I am not certified as a DBT trainer, but I have had training and I have used the intervention. I just want to give you guys a disclaimer that this is not a substitute for getting more intensive training, but it is an opportunity to learn a little bit more about the skills, whether you’re a clinician and you want to implement them in your practice or whether you are just a community member. Whether you’re a community member or a clinician, and also for clinicians, we can use these ourselves. I definitely use them. 

Let’s go ahead and get started. This is just about my background, but I believe Ashley already introduced me, so we’ll go ahead and move on. Again, we actually already kind of gave you guys a background, but I just wanted to give you a little bit more information. I’ve worked in assertive community treatment and community mental health. I’ve also worked in intensive psychosocial rehab, and often, our clients were those that were at high risk of recurrent inpatient hospitalization. We often had clients in our caseload that might’ve had a diagnosis of borderline personality disorder, which is one of the diagnoses that can benefit from this intervention, so this was something we often used as a clinical intervention in these environments. Just to kind of give you guys a background on where I was kind of using the DBT intervention, I was using it very often in these settings.

Today’s objectives: We’re going to go over some history, some core foundational knowledge and then also talk about self-soothing and distress tolerance techniques. The purpose of speaking about these things is I wanted to give tools for you that could help you ease stress, increase relaxation and improve emotional regulation in your day-to-day life but also in times of stress, because I thought that was very relevant for 2020 and 2021 this last week. I think it’s relevant in general, but I think especially when we have increased uncertainty times of stress — where we might be more at risk of being emotionally vulnerable — these can be really valuable. Give me one second, I’m just gonna do something here. Then I also wanted to give you guys some concrete tools on how to implement some of these practices, whether it’s in your clinical practice or whether it’s in your personal life. I wanted you to leave the training with some tools as well.

We’re going to also do that at the very end. In the very beginning of our training, I’m going to kind of give you a little bit more information on DBT as an intervention and the history of it, and then we’ll go more into the skills that we are speaking about. Because I’m focusing more on a little bit of history and some tools, it’s not going to be as comprehensive. Like I said before, in the very end, I can talk to you more about, “Where can I learn more? How can I get more knowledge on some of these contexts that I’m touching on?” Thanks for your patience. There we go.

So, why did I want to present on this topic? As I mentioned a minute ago, I think it’s very relevant always, but especially in our last year — especially in our last week. These skills that I’m going to be speaking to you about were originally developed to treat chronic suicidality and also developed to treat persons diagnosed with borderline personality disorder. But I also think we’re living in, I would say, unprecedented circumstances — maybe not in the history of the globe, but definitely in my lifetime — with the global pandemic and with situations happening within our country at this moment. I would say a lot of the things that we’re facing and a lot of the ways our lives have changed due to that are very unprecedented. 

COVID-19 has been going on for more than a year — or I guess early last year. We started to learn about COVID-19, then a couple months after, a lot of places were shutting down. We all may be being impacted differently based on our own circumstances, but many of us have had changes in our day-to-day life based on the pandemic. The way that our routines used to be, the way that our days used to be structured, the coping skills that we used to use or our support systems that we had access to. Our usual coping skills and our methods of self-soothing — we may not have the same access to them because of the pandemic. Also, we’ve had recent events of civil, racial and political unrest in the United States that were going on over the summer. There was just a recent event in the news about a week ago, and many of us might be wondering what’s going to happen in the next week and just be uncertain about the future, whether it’s about COVID-19, whether it’s about our own personal lives and whatever changes we’ve had to go through due to COVID-19, or maybe it’s about the future of our political situation. I think it’s very timely that we’re speaking about this, and that’s why I wanted to give people concrete tools on how to manage distress and overwhelming feelings because many people are experiencing an increase in mental health symptoms due to all of these things that I just mentioned.

We are going to go a little bit through the history of how DBT was developed. I know I brought it up a couple of times, but we’ll go a little bit more in-depth. Again, the original treatment was developed for women at high risk of death by suicide, but I think that these are skills that can benefit many of us, especially in these times. Of course, they can also be used when we’re not in the midst of a global pandemic. They can be used in our day-to-day lives. They can be used if things get better soon; if we get a vaccine and things become more stable, it doesn’t mean we can’t still use these skills. And I think they can be very valuable in times of uncertainty, stress and crisis because we might be more emotionally vulnerable and we might have more emotional distress. We might have more intense emotions and have trouble managing them, but they’re definitely valuable in times where we’re not having a crisis situation as well. I know in my practice with the clients, I’m seeing there’s a lot of people who are having a lot of changes within the span of a year. And it might be, “I’m at home all the time with my partner and we’re really stressed out. We see each other all the time,” or it might be, “I’m really lonely. I don’t get to see my family as much.” So, there’s a variety of different ways that people are experiencing the pandemic. I think it’s really important right now too, considering that we don’t have our usual routines. Maybe we don’t feel safe to go to the gym like we used to, or maybe we’re trying to work out at home. There are just so many different situations that we might be navigating based on our unique personal circumstances, so I think that some of these skills can be very useful, especially right now. That’s why I wanted to present on this topic. 

Let’s go ahead and talk a little bit about, “What is DBT?” I don’t know how familiar everybody who’s attending would be with DBT. If you’re not familiar, I want to give you a little bit of background and also talk to you about how it is different than CBT. And if you’ve never heard of any of those things, it’s okay. I’m going to give you a little bit of a background on both things. And I’ll give you a little bit of definition on certain things we speak about, like borderline personality disorder. But again, I cannot comprehensively get into everything because of time constraints and the fact that we’re meeting for an hour. So, DBT is an abbreviation for dialectical behavioral therapy and it was developed by Psychologist Marsha Linehan. Linehan was originally looking for a diagnosis for people with borderline personality disorder and also looking for treatment for people who were at risk of suicide and self-injury. 

She was evaluating the literature on effective psychosocial treatments for other disorders that were already established effective treatments — things like anxiety disorders, depression and other emotion-related difficulties. What she originally did is she basically came up with, like, a package of evidence-based cognitive-behavioral interventions. She was specifically trying to target suicidal behavior. I’m going to give you a little bit more background on Linehan herself in a moment, but what she noticed is when she was focusing solely on things that were changing people’s thoughts and behaviors — we’re going to talk more about cognitive-behavioral therapy, but she was basically focused on how we help people change their thinking and their behaviors — but she noticed that many clients were feeling criticized, misunderstood, invalidated. And some people were dropping out, or many people were dropping out of treatment. As she was coming through the literature — as she was assembling an intervention herself — she was finding that there was something missing with this intervention.

I want to talk to you a little bit about her theory of suicidal behavior. She had a bio-social theory that states that suicidal behavior is a learned method for coping with acute emotional suffering. She looked at suicidal behavior as a skill deficit, and we’ll talk more about this coming up, but basically seeing it as a skill deficit, which means that people are trying to kill themselves as the solution for intense suffering because they don’t have any other options that they can come up with. We’ll talk more about this like I said, but a lot of the DBT intervention is focused on skills and skills training that might help people have other methods of problem-solving or managing really difficult, overwhelming and intense emotions.

So, what populations are treated with this intervention? As I’ve mentioned, the intervention was originally developed for people with the diagnosis of borderline personality disorder, and also for people that were having recurrent self-harm and suicidal behaviors. But it’s also been found to be effective for patients with substance use disorders, people who meet the criteria for binge eating disorder, depressed, elderly patients. For those of you that may not know a lot about borderline personality disorder, I’m just going to give you a brief description. If you have the DSM, the DSM details all the different symptoms and factors that might lead to a diagnosis, but basically, borderline personality disorder is defined as a pervasive pattern of instability in interpersonal relationships, self-image, affects and marked impulsivity. One of the features of borderline personality disorder might be that someone has a marked reactivity of mood or affective instability. That’s originally who Linehan was looking for effective treatments for when she developed dialectical behavioral therapy, but these skills can be helpful to other populations. I think that some of the skills that we’re going to talk about today can also be used in a variety of treatment settings. It may not look the same as a setting where people are certified in DBT and they’re doing therapy based on the model of DBT, which I will detail to you guys in a moment, but I still think that we can use some of these skills with a variety of people. We will talk about them in-depth, but a lot of it is focused on regulating emotions, tolerating distress, improving relationships. I think anybody can really benefit from those.

Let’s talk a little bit about Marsha, the founder of DBT. It was really interesting. I didn’t know a lot about her before doing this presentation, but she actually — herself, at 17 — she was put into seclusion at an inpatient unit because she was burning her wrists with cigarettes. She was slashing her arms and legs and her midsection with anything she could get her hands on. So, as a very young woman, she was self-harming and she was struggling with symptoms. Once they put her in seclusion, things got worse; she started banging her head against the walls, the floors. I believe I mentioned she was 17 when she was first hospitalized, and in her discharge note, during 26 of 26 months of hospitalization, she was one of the most disturbed patients. That’s what they put in her discharge note. So, she was informed by her own lived experiences as she decided to pursue a doctorate in psychology.

As she founded DBT, she had been informed by her own experiences. I got this information from a New York Times article, but if you actually look it up, you’ll find several New York Times articles about her and her history. In one, she’s giving an interview — you can watch her speaking about it — and she’s speaking about a religious experience she had at some point after getting out of the hospital. She had this religious experience where, all of a sudden, she had this moment of love for herself. And I think that informed some of these things we’re going to talk about. Like, we’re going to talk about acceptance, and that’s — we’ll talk further, but I think that informed her. She actually said — in this article that I’ve cited — she said, “I suppose it’s true that I developed a therapy that provides the things I needed for so many years that I forgot.” She was motivated by her own circumstances to build on the CBT interventions and add certain things into it.

Let’s go ahead and talk about the difference between DBT and CBT. If you guys have not heard about CBT — you can see a little graphic here — but what CBT basically says is that we have a set of core beliefs about ourselves that we have internalized based on our past experiences. And these beliefs about ourselves impact how we think about ourselves, how we think about other people, how we may think generally, how our thinking has developed, what we think about the future. And CBT talks about a concept called automatic thoughts. That means automatic thoughts are the thoughts that we just have automatically without even really noticing. It’s like the tape that plays in our head, and often, we have these thoughts based on patterns of thinking, but also our own self-concept and what we have internalized about ourselves.

You can see that in the middle where it says core beliefs — that triangle. But then surrounding the triangle, you’ll see it says, “Feelings, behavior and thoughts,” and you see these arrows. The arrows just mean that our thoughts influence how we feel, which influences how we behave. But also, our feelings influence our behavior and our thoughts; our behaviors influence our thoughts and our feelings. They’re all linked. In cognitive-behavioral therapy, which is an evidence-based treatment, often what the focus is is helping people identify thinking and patterns of thinking. Identify how those thoughts make them feel. Can we reframe those thoughts? Identifying thinking errors, like the ways of thinking that may not be effective or productive or may not make us feel good. Are there other ways of thinking about a situation? So, CBT has a lot of similarities if it’s just that it adds on and builds onto that intervention. 

Some of the things that are unique about DBT would be the four following, which I will break down for you guys. I’m gonna go over it, and then we’re going to break it all down as well. DBT serves five functions of treatment. That’s the first thing that makes it different. It is based on a bio-social theory that emphasizes emotion and treatment, and it’s also based on dialectical philosophy, and it incorporates mindfulness and acceptance-oriented interventions. Let’s talk about what all that means. The five functions of DBT treatment: The first one is enhancing capabilities. In the beginning of the presentation, I’d mentioned to you that Linehan saw suicidal behavior as a skills deficit — not having the skills to deal with those intense emotions that make people feel like life is not worth living. So, the first function in DBT is that the treatment is meant to enhance capabilities. The assumption is that patients need assistance in developing critical life skills, which includes emotional regulation skills, mindfulness skills, navigating interpersonal situations effectively, tolerating distress and surviving crisis without making things worse. 

This is usually achieved with weekly skills training. Usually, it’s a group of four to 10. That’s what they recommend — four to 10 individuals in a group setting. It would be a skills training. It would be like a group that focuses on skills training. And usually, what would happen is you would use the group setting to let people practice these skills that you’re teaching, discuss the skills. And also, give homework assignments so that people can practice in between sessions as well so that they can really develop these skills that we’re trying to teach, which we’re gonna go over what some of these skills are. We’re not going over every single skill that DBT teaches ‘cause the intervention also teaches how to have better interactions with people — like, interpersonal situations — but I’m not focusing on that today. I’m going to focus on some of the other ones, like self-soothing and distress tolerance, but the purpose of the weekly skills training would be so that the people attending the group would be able to develop these skills and practice them in a group setting.

The second one is generalizing capabilities, and what that means is we want to make sure that whatever we are focusing on in treatment is also going to work in the person’s natural environment, where they go after they come to group or after they come to one-to-one therapy or whatever the program might be that they’re attending. The way we would do that is giving homework assignments, and a lot of times, this is also achieved in one-to-one therapy. Often, people are recommended to attend both one-to-one therapy and group skills training. Many DBT therapists are also available to people between sessions in case they’re having a crisis situation.

The third function would be improving motivation and reducing dysfunctional behavior. This would be — again, it’s a lot like what it sounds — helping the patients have the motivation to change and also reduce behavior that’s inconsistent with a life worth living. The goal for people who are at high risk of suicide is to help them have less behaviors that would contribute to suicide and also to have a life worth living. Often, this is also through one-to-one therapy. A lot of DBT therapists will have something called a diary card, which is basically tracking treatment targets. It might be self-harm. It might be suicide attempts. It might be emotional misery. They would track the treatment goals that they’re targeting. It might be reducing suicide attempts, reducing self-harm. In one-to-one sessions, as they’re tracking those behaviors, the clinician would usually focus first, of course, on the life-threatening behaviors. Those would be given priority, but then they would also, depending on what has happened that week, they might also be talking about therapy, interfering behaviors. If a person is absent, late, non-collaborative with the therapist, as well as behaviors that might interfere with the quality of life, then they might talk to them about what led up to the behaviors, what’s reinforcing or maintaining those behaviors. Are there other ways to problem-solve or regulate emotions to reduce those behaviors?

And then the next one would be enhancing and maintaining therapist capabilities and motivation. So, for the therapists that are dealing with people who might be having a lot of suicide attempts — and there might be other things happening with the patients — therapists need to make sure that they have the capacity to treat their patients and also that they have support. So, it’s really important to have a consultation for therapists. It’s recommended that therapists have a team meeting, like, one to two hours a week that provides therapeutic therapist consultation. The purpose would be supporting the therapist, monitoring the therapist for burnout, validating the therapist, but also providing continued training and skill-building and making sure that the therapist keeps up to date on how to best treat the population and have the support, but also continue to build their skills as well.

And then the very last one would be structuring the environment. The point of this would be structuring the treatment environment to reinforce effective behavior and not reinforce maladaptive or problematic behavior but also helping the client structure their environment. For example, if someone is struggling with substance use, it might be talking about how their environment is — are they in social circles or in a home situation where substances are available or people are using substances? Is there any way to be able to limit their access to those people or to substances within their environment? If someone is self-harming, we might talk about access to things that they could harm themselves with, or also who’s around them. Are they supportive or are they — whether it’s their significant others, whether it’s their family members — what is their interaction with their social circle, and are there ways that we can encourage the people around them to also have supportive behaviors?

So, that would be the ways. These are the really kind of specific things that are part of DBT that are not necessarily a part of CBT. That kind of is part of what makes DBT unique. And then there’s a couple of other things; there’s also the biosocial theory. This is basically speaking specifically about borderline personality disorder. You can see in the name bio-social: biological and social. They’re talking about the different contributions. Through this lens, people who developed borderline personality disorder are biologically disposed towards emotional vulnerability, which means a low threshold for responding to an emotional stimulus, intense emotional responses and difficulty returning to a baseline level of emotional arousal. And then the other part of it is the social part of it. Often, the thought is that there was a lack of skillful parenting. 

Children look to their caregivers for a lot of things; they look to their caregivers to be role models for them. They watch their caregivers to see how we behave in certain circumstances. So, if a child is having emotional reactions and they don’t have skillful parenting, they may not learn how to regulate their feelings or even identify their feelings, and that may make it hard, as they get older, to know how to do that. That’s why with DBT, the interventions are focused on behavioral skills that help people learn how to recognize, understand, label and regulate their emotions. So, the first step. We’ll talk more about this, but the first step is, “What am I feeling? Why am I feeling it? What is the feeling? How do I manage the feeling?” And I think a lot of people might say, “I don’t think it’s just people with borderline personality disorder who might have these struggles.” If we didn’t really see people identifying their feelings, expressing their feelings, managing their feelings, I think many of us might not have seen that we might benefit from developing these skills. 

The third factor is dialectical thinking. Basically, what this means is that reality consists of opposing polar forces that are intended. And I think it’ll make more sense — if that doesn’t make sense to you, we’re going to talk more about it. I think it’ll start making more sense. But basically, if we’re applying change-oriented treatment strategies, it can create tension within treatment because the patient also has a desire to be accepted rather than changed. But each force — they’re different things, right? Being accepted and changing — they’re two different things, and they can be in tension and they also can be incomplete on their own. If we only complete, or if we only focus on change — you have to change, right? We have to change ourselves. That can be incomplete because we may not feel accepted. But if we only focus on acceptance, that can also be incomplete and ineffective because, often, the people who are at very high risk of self-injury and suicide may require extensive changes in their lives to reduce their suicidal behaviors and thoughts and the feelings that contribute to them. They’re both kind of incomplete, and if we can kind of put them together, then that might be more of a nuanced and complete way of treating people. 

Dialectical thinking can encourage more open-minded and nuanced thinking because it’s both instead of either/or. I’ll show you guys some examples, but if you think about it, black-and-white thinking is, “Either I’m good or I’m bad. Either I did good or I did bad,” where dialectical thinking might be, “I don’t like how I performed today, but I did my best.” Right? It’s kind of like being able to not just think of things in black and white; there’s more shades of gray. There’s more nuance. We can be more open-minded. We’re not going to be as likely to think of things as, “I always fail, I never succeed.” That kind of thinking can make us feel hopeless. It can make us feel certain types of emotions. That always/never, black-or-white thinking can contribute to negative feelings, and the other type of thinking can kind of hold space for nuance and contradictions. 

I’ll give you guys some examples of that. So, I decided to make some examples of things that might apply to maybe this time right now with coronavirus. I am feeling challenged, and I can see some benefits of what I’m going through. It’s not just, “Oh, this is great.” There’s, like, “Let’s just look at the bright side. Let’s just look at the silver lining.” I’m validating the fact that I am feeling challenged, but I can also see some benefits of what I’m going through. The world is suffering, but a lot of growth is happening through this change as well. I’m feeling frightened, and I’m also feeling brave and resilient. I accept myself and I want to make changes. I think you guys can see how there is a — it’s not just one or the other. I can accept myself and want to make changes, which is, again, a lot about what dialectical behavioral therapy focuses on — acceptance and also learning skills and making changes.

And then one of the last ones is mindfulness and acceptance-oriented interventions. Mindfulness are skills that help us to be in the here and now, and they help us to observe the present moment in a nonjudgmental fashion. That’s one aspect of DBT. The other one is radical acceptance. Radical acceptance means that we accept the experience of the present moment for what it is without struggling to change or resist it. It doesn’t mean we like it or condone it. It’s not that we’re happy that we’re in a global pandemic — it’s that we acknowledge we are in a global pandemic, or we acknowledge that we are under stress. If we can accept the experience of the present moment and we’re not struggling to change or resist it, that can help us in many ways, which we’ll talk about. Because we can kind of accept what’s in our control, what’s not in our control, and we might avoid labeling, like, “This is good or this is bad,” but it’s like, “This is what it is. I don’t like it, but this is what it is.”

We’re going to talk a little bit more about those things. Again, radical acceptance. The ways that it can help us in terms of our mental health is helping us realize that some things are in our control, but not everything is. I’m not happy about this global pandemic, but I also cannot control the fact that it’s here or when it will go away. What I can control is my own ability to manage myself and my safety as we all navigate it. That’s when we kind of think about what’s within our control. It can produce feelings of stress and anxiety. It doesn’t mean we don’t have stress and anxiety, but it can help us focus on what’s in our control. I gave you guys an example of typical thinking versus radical acceptance. Typical thinking might be, “It’s unfair that COVID-19 has been going on for more than a year, and I’m not able to spend time with my family and friends.” Is it unfair? Yes, it’s unfair. I don’t like it. I don’t want to be stuck in the house. I know not everybody is able to stay at home. I know some people are going to work — and frontline workers — so everybody’s having a different experience. But yes, it is unfair. Radical acceptance might say, “I’m unhappy that we’re in a global pandemic that restricts what I’m able to do, but I’m going to take precautions to stay as safe as I can and figure out how to get the vaccine as a way to reduce my risks.” It doesn’t mean, “Oh, I’m so happy that I’m worried about leaving my house, seeing my family members and that this has been going on for a while.” It’s not about that. It’s more about validating that I’m unhappy about it, but also I’m accepting that that’s where we are right now. 

So, I put the serenity prayer in here. You guys may have heard of this before; it’s often used in 12-step groups, and I think it kind of really demonstrates the concept of radical acceptance. It usually says, “God grant me,” but not everybody is religious, so it may not apply to you. So, I just put in some other stuff — God, universe, a higher power — or you just can take that part out. You can just say, “Grant me the serenity to accept the things that I can not change, the courage to change the things that I can and the wisdom to know the difference.” And I think that’s a really good reflection — they’re talking a lot about what’s in our control. Some things are, some things aren’t. Maybe we have to accept sometimes when things are not within our control and then focus on what actually is within our control. And if we spend a lot of time focusing on things we can’t control, like other people or things that are complicated and beyond us, then we can feel helpless and we can feel distressed.

So, distress — what is distress tolerance? ‘Cause I’ve been using the word; you may not have known what I’ve meant. Let’s talk more about that. Distress tolerance is the ability to tolerate and manage painful, overwhelming or intense emotions, and the ability to use techniques to manage or reduce the emotional intensity of emotions and enhance coping skills and the ability to regulate your emotions. Part of it is being able to identify our emotions. It’s really important too because we’re talking about managing painful feelings, but if we don’t even know what we’re feeling, that’s going to be hard. A lot of times, we have to work on identifying our feelings as part of the skill. And once we are able to — when we become accustomed to identifying our feelings — it can help us understand how to manage them as well.

I just put a couple of things about identifying feelings. I put “feelings are not good or bad.” Often, when I was running groups in my previous place of employment, we would talk a lot about anger management and that anger is not a bad emotion. It’s an indicator of something. It’s something that’s telling us feelings or information. When we are feeling something, it’s information for us to pay attention to; if we don’t pay attention to it, the feeling will still be there — almost manifest somehow. Anyway, there are not good or bad feelings; feelings are telling us something. It’s telling us to pay attention. And then “feelings are not facts,” which just means that sometimes, we can see things through our feelings. Like, we are interpreting situations based on what we’re feeling but that may not be what’s actually happening, and we’ll talk more about, well, then how do we counteract that? How do we manage our feelings in a way where we can look at our own assumptions and interpretations of what’s happening? 

Identifying feelings — I’m just giving you a little bit of this. There’s a lot more about this, but just to give you an idea. A lot of times, our bodily sensations — our signals — are giving us a clue as to what we’re feeling. If you’re feeling angry, it depends, but you might tense up. Your jaw might clench. Your shoulders might get tense. You might breathe, shout, or if you’re feeling nervous or anxious, your body might react. A lot of times, it’s noticing our body and our signals. In treatment — often, when I was doing groups, we were using feeling charts as another way. Feeling charts are pictures of emotional expression and what feelings are associated, and then they can be used to help people identify their feelings. With kids or also just in general, if you’re doing work with helping people identify their feelings, sometimes you can use feeling charts, but also journaling, exploring your feelings or being in therapy. I didn’t put that on here, but having the support of someone else where you can process feelings, because feelings can be complicated. And then another thing would be just slowing down, ‘cause when you slow down — which isn’t always easy, but we’re going to talk more about it — you’re more likely to pay attention to your bodily signals. And then mindfulness skills can help us slow down again. Mindfulness is being in the moment. Meditation. I know not everybody likes meditation, but there’s a variety of ways that we can practice the mindfulness — the slowing down — without actually having to sit down and meditate for 30 minutes. We’ll talk more about that in just a moment as well.

I’m just looking at the time to make sure we’re not running out of time yet. We’re going to kind of try to get through these last couple slides. These are the last part of the training — what are the things I can take home for myself and for my clients? We’re going to talk about distress tolerance techniques. Acceptance — we’ve already spoken about — which is learning to have the thinking, which is, “I accept what is happening. I don’t like it, but I accept it.” But we’re going to talk a little bit about distraction and how to improve the moment. DBT has a lot of acronyms, and you can find worksheets all over the internet that talk about this acronym and break it down for you. There’s a website called Therapist Aid that has all sorts of worksheets that has the acronyms and examples. I’m going to go over examples for you, but you can also access these. And I’ll talk more about other resources for learning more about DBT in the end, and you’ll be able to learn more, but they use a lot of acronyms in DBT. 

So, distraction. I want to really quickly say that we tend to sometimes think if we distract ourselves, it’s a negative thing. It means we’re avoiding our feelings, and avoidance — avoiding our feelings — is a little different than what this is. Distraction is more about using skills that — I’m going to actually take out my notes because I also need to look at it. So, the way that they refer to a distraction is that our negative feelings will usually pass or lessen with intensity over time. So, it’s not about avoiding your feelings — it’s about doing something that could distract you so that the emotional level or the intensity level can reduce so that maybe they are more manageable, these negative or painful feelings. I just want you to think of it in that context. The acronym is ACCEPTS: activities, contributing, comparisons, emotions, pushing away, thoughts and sensations. That probably makes no sense, but I’m going to go through it with you. 

Activities — again, these are all methods that can help reduce the intensity of our feelings. Activities is anything that requires thought and concentration. Engaging in an activity. If you’re at a very high level of emotion — you’re at eight or a nine of a feeling — it might be helpful to do something like a hobby, a project or even work or school to get your mind off of it. Doing something that requires focus — it might just kind of distract you. Contributing, focusing on someone other than yourself. Volunteering, doing a good deed, contributing to a cause. It doesn’t have to be volunteering. It could be, “I’m going to call my friend and see how they’re doing. I’m going to make dinner for somebody. I’m going to write a card to someone. I’m going to call someone and see how they’re doing, or do a Zoom chat with somebody.” Just getting the focus off of yourself.

There are also comparisons. So, we tend to often think it’s — I know for me, I don’t. When I see this, I think, “Okay, but we shouldn’t compare ourselves to other peoples.” We should validate what we’re going through, but I think this is different. Comparison in this sense could be about having perspective. It’s comparing to something worse than what’s happening, but not in a way to invalidate your feelings, but more of maybe a perspective-taking. So, can you think of a time when you were in more pain than you are now? Where things were worse than they are now? Or can you think of someone else who might be struggling more than you are? It’s, again, not to invalidate what you’re going through, but just to maybe reduce the intensity of your emotion by having a different perspective on it. Often, when I was running groups with this concept, a lot of people were able to say, “Yeah, I’m going through a hard time,” but when they were reflecting, they would think about times where things were a lot more difficult and how they were able to still get through it. Often, that would be helpful for them, 

Then there are emotions; this is competing emotions. So, this is if you’re sad, you can watch a funny movie. If you’re nervous, you can put on soothing music. That’s the opposite of what you’re feeling. Pushing away is pushing away negative thoughts out of your mind. It doesn’t mean you’ll never think about it, but it’s more like putting things on the back burner so I’m not going to think about this right now. Maybe a different day when I’m less stressed out, I’ll come back to this, but right now, this is actually not that important for me to think about. I’m overwhelmed. I’m going to do something else, and then I’ll come back to this later. Thoughts is just doing something like counting to 10, reciting a poem in your head, reading a book — basically, just trying to do something that requires thought as a way to manage overwhelming emotion. And then sensations would be a safe, physical sensation that might distract you. It could be a rubber band on your wrist, pinching your wrist with a rubber band — again, not to cause pain, but just distraction. Having an ice cube in your hand and your mouth, sour lime, something that kind of takes you into your senses. 

Then we’re going to talk about improving the moment. This is helpful to help us ground ourselves in the present moment, which can help us to relax our nervous system and be more in the moment. That just means we’re in the present rather than being in our thoughts or in our anxious thinking. We’re getting into our bodies. Let’s go through that. Often, we can use the five senses to think of ways to improve the immediate moment. Maybe for our sight, it would be, “Maybe I’ll take a nice walk in a scenic area.” Lava lamp. We see the way the lava — I don’t know if people still have those, but my nephew just got one for Christmas. That’s where I thought of that. Or maybe there’s a calming video on YouTube. We watch it. There’s all sorts of things that we can do. I just put a couple of things, but I want you, as I’m going through this — we’re going to come back to this shortly — I want you to think about what would be for you. Something that would help you soothe your senses when it comes to sight. Touch: It could be a warm blanket. Put the blanket in the laundry and wrap yourself around it. Self-care — petting your animals, using your sense of touch. Sound could be music you like, or the sounds of nature, or calming sounds. Whether it’s the sounds of birds chirping outside, or whether it’s the sound of the waves at the beach or it’s nature sounds, whatever it might be. Taste: You can have a small treat or take a piece of chocolate if you like chocolate and savor it and eat it slowly and just really taste the scent or smell.

You can’t see it — I have a scented candle in my old agency, We used to have diffusers running, which would just make it more pleasant. It would smell nice. There’s certain scents that can be calming — like, I think lavender is one of them. You could have perfume or cologne and smell it. You could have one of those things that you roll essential oils on your wrist if you’re getting stressed. I know that not everybody has access to all of these things, but for some people, it might just be taking one of those perfume/cologne things out of a magazine, smelling it up, ‘cause that might be what they have access to. Some people hate the smell of perfume and cologne and that wouldn’t work for them, so I would encourage you to just do whatever works for you.

I’m going to try to run through these because I know we’re kind of running low on time at this point. I’m going to just kind of run through some of these other ones, and some of them are actually related to some of the ones that we’ve already talked about. So, opposite action. We kind of already talked about this, but it’s kind of like doing the opposite of how you’re feeling. I was saying to you guys, “If you’re sad, you could watch a funny movie.” This is where if you feel angry, you might typically shut down or yell at someone, but you do the opposite of what you feel and how you usually behave. If you usually yell when you’re angry — I’m pretty loud — right now, make a point to talk, like, in a low, slow voice tone or talk politely. If you usually withdraw when you’re sad, try to kind of get out of that and do the opposite and call a friend.

And then we were talking about feelings are not facts. So, check the facts. If you’re feeling a certain way, ask yourself what triggered this feeling. Why am I feeling angry? What was the trigger? Am I making assumptions or interpretations of what happened? What are the actual facts of the situation, and what am I interpreting? Kind of look into that, and then does my emotion and the intensity of my emotion match the facts of the situation, or does it match my assumptions or my interpretations? That’s another way to help us regulate our feelings — really thinking about the facts of what happened and what we are interpreting and what triggered us and kind of being able to analyze it.

Another acronym is PLEASE, and this is focusing on physical — our mind-body connection. So, treating physical illness, going to get checkups. I know it’s kind of hard right now with COVID, but making sure we’re taking care of our physical body, treating physical illness, trying our best to be eating healthy. Nutrition, avoid mood-altering drugs, sleep well, exercise. I think we all know that if we’re not sleeping well, we might be irritable. We might be tired. Our physical health impacts our mood, so that’s why these are also part of the emotional regulation. There’s also paying attention to positive events. It’s very much human nature that we could have 10 compliments in a day and one person critiqued us, and we’ll remember the one critique. 

This is basically just — if we had 10 compliments and we find ourselves focusing on the one critique — refocusing our brains. Not just focusing on the negative, but looking at the bigger picture. But also, this could be just adding more positive experiences into your routine into your day-to-day. So, whatever you find to be positive. I like to take walks or I like to play with my dog or whatever is positive for you. If you like to listen to music, maybe you can play music as you’re doing your chores. That’s something my therapist helped me with — I never thought about it before — to make chores seem pleasant. Now, when I wash the dishes, I light a scented candle, I listen to music. It doesn’t radically change your life and it doesn’t make everything — like, if you’re having a hard time, it doesn’t radically change that — but it does build. The more you’re able to add these positive experiences into your routine, whatever you find to be positive, it builds up over time. You’ll find that you’ll just feel more relaxed, more pleasant overall. 

Now that we’re starting to wrap up, I just want to ask you to think about one thing you can do based on what we talked about. Whether it’s health-related — it could be something small. Like, am I getting sunshine or am I in the house a lot? Am I moving around? Is my sleep okay? Is there something small I could do to improve my sleep? Is there something small I could do if I’m not getting hydrated? I’ve put a couple things here. You might have something different, but it doesn’t have to be a radical change. It might just be, “I need 10 minutes of sun because I work from home,” or, “I need to make sure I Zoom with my friends once a week ‘cause I’m not seeing people,” if you work from home — I’m speaking from my own experience. Or, “I need to not look at the news at night because I’m anxious and now I’m staying up all night.” I want you guys to think about if there’s any one health-related thing you can improve upon, and then I also want you to think of the self-soothing. Using the senses, is there one thing that you can kind of add into your daily routine? Again, one thing that I have right now is a scented candle. I’m drinking tea. I’ve got these things right here for if I’m nervous. 

I apologize. I know I went a little bit longer than I meant to, but basically, yeah, I think that would be the end. And now, I would be ready if you guys have any questions. If you have any questions about resources, like how you can learn more, I think we would be ready for that now. Someone put one more resource in the chat, but I will be just sending it now. 

We’re winding down, but we hope you guys can join us at the next presentation. And thank you again, Ritu. Thank you. Have a great afternoon, everyone. 

Thank you for watching this video. We hope you enjoyed the presentation.

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