DBT Group-Based Programs and Contagion

 Contagion is when a person copies the behavior of another

 Happens when a model has social influence, and the behavior has a clear gain... two incentives for
another to copy the behavior
 Contagion is a two-way construct: it can be helpful (e.g., copying skill use) or destructive (e.g.,
copying a self-harm behavior). Effective programs promote helpful contagion.
 Beware the “instigator” and the “imitator” with destructive contagion
 Instigator needs accountability and the imitator needs identity work.
 Destructive contagion is most likely when harmful behaviors are promoted and/or glamorized.
Media is a common culprit.
 Someone who has “social status” in the group.
 Also, that the behavior they are engaging in is getting them something
 Have to shut down anyone who is giving attention to any harmful or negative behavior.
Stomp it out! When you talk about alcohol or drug use and how fun it is/cool it is, i want to
let you know you will not do this here. People come here to deal with their real problems, to
gain skills, and that is not conducive. We do not talk about that here. Am I clear about that?
Be assertive with things like that.
 Contagion is most common in settings in which clients have significant unmonitored time.

Diary Cards

 Self-monitoring of urges, target behaviors, symptoms, skills, emotions, and other important information
(e.g., positive experiences (highlights), treatment objectives, gratefulness)
 Helps to structure and generalize what is learned in therapy to natural environments; builds awareness
and skill use
 Provides a tremendous amount of information to track how the client is doing, determine if there are
target behaviors on the treatment hierarchy to prioritize, and to set the treatment agenda
 Also provides opportunities to positively reinforce success and to inquire about extra-therapeutic factors

Diary Card Guidelines

 Orient clients to why the diary cards are important and how it will help them reach their goals
 Complete each day, preferably at the same time, for the previous 24 hours
o To make a time and place each day where they create a habit for the diary card
o Average distress levels, average urge levels,
o Documenting what skills you are using to actively work on whatever it is (depression, etc.)
 Review diary cards at the beginning of session and use the information to set the agenda with clients
 Address incomplete diary cards as a TIB (treatment-interfering behavior)
Purpose of Behavior and Solution Analysis
 Develop a picture of what comes before a behavior (antecedents)
 Develop a picture of what comes after a behavior (consequences)
 Understand the context that surrounds behaviors
 Use this understanding to actively problem-solve and develop skill use
 Used often during Stage 1 for targets on the treatment hierarchy (SI, SIB, TIB)
 Also, an excellent method for adding structure to sessions
o Also called behavior chain analysis, functional analysis, change analysis. Etc.
o Go through a chain analysis for a number of different situations that led to problem
behavior and try to identify all the functions a problem behavior serves for you
o Allows people to better recognize the factors that contribute e to problem behavior,
identify triggers, and look for solutions to stop the problem at many different points
o Also may be helpful to identify what things might have made you more susceptible to
responding to the situation as you did. Ex: when people don’t sleep or eat enough, they
may be more susceptible to experiencing negative moods or having more reactive
emotional experiences.
How to frame behavior and solution analysis
 Some clients experience change analysis as punishment; if this happens, be sure to validate the
experience. It is often used as a punishment in other settings, so you must orient them to why we do
behavior analysis!
 However, discuss how change analysis is a learning tool to help clients reach their goals
 Discuss expectation that change analysis will be used for target behaviors on the hierarchy (SI, SIB,
TIB), and for both in-sessions and out-of-session behaviors that require problem-solving
 Also consider using change analysis for positive behaviors
During the Behavior and Solution Analysis Process
 Orient clients to procedure and continue to orient as you go through the change analysis (why is this
important to the client?)
 Validate the emotions that arise and that change analysis can be difficult. Attending to emotions also
provides exposure effects.
 Use positive reinforcement for efforts and breakthroughs
 Remember that the end goal is to learn skills and solve problems
 Coordinate what is learned with crisis, safety, and other skills plans
Steps in Behavior and Solution Analysis
 1. clearly define the target behavior
 2. ask about frequency, intensity, and duration of the behavior
 3. go step-by-step until you have a clear picture of the following:
o a. what made the client vulnerable
o b. what was the prompting event (trigger)
o c. what are the links between the prompting event and the target behavior (e.g., emotions,
thoughts, physical sensations, other behaviors, what is happening or not happening in the
environment)
o d. what were the consequences of the target behavior?
 4. go back and have client hypothesize possible skills to use to address vulnerabilities and intervening
links, as well as skills to replace target behaviors (take out safety plan if applicable)
 5. have client problem-solve how to skillfully deal with consequences so they do not develop into
vulnerabilities
 6. have client develop a plan to make amends with others for the target behavior if applicable
 7. get commitment from client that they will actively practice the identified skills
Starting out (pre-treatment stage)

Socializing the Client to Treatment

o Define what DBT is!

o Clarify the clients and your respective roles (as well as the role of other program members and
service providers as needed)
o Define the goals and tasks of each service delivery
o Review important protocols, rules, guidelines, and agreements
o Establish goal(s)
o Be clear that DBT works when you “work” the treatment!

Commitment Strategies

o Evaluate pros and cons of therapy

o Foot in the door techniques
o Door in the face techniques
o Highlight the freedom to choose (especially in the absence of alternatives)
o Play devil’s advocate
o Connect to prior commitments
o Shape stronger commitment (as therapy progresses)
o Coach and cheerlead

Initial Commitment Interventions

o Initial commitment needs to move to agreement on:

 Treatment plan goals and objectives
 Treatment method and means of accomplishing goals and objectives
 Relevant expectations and agreements
o Commitment in therapy is continually revisited for many of the tasks in therapy, big and small,
including revisiting initial commitment
Interventions and orienting

o Orienting is explaining the rationale for why treatment tasks are necessary for the client’s goals:
this means really understanding what the client wants and needs
o Orienting begins during pretreatment and is continuous throughout treatment
o Orienting helps to maintain commitment and to keep therapy client-driven
o Successful orienting keeps clients active and cooperating
Validation: Keys to the kingdom
o Validation is the non-judgmental acknowledgment of the client’s experience
o Validation creates the conditions of acceptance that usually precede change
o As a rule, start with validating the client, and return to validation when the client is “stuck” (remembering
that rules have exceptions)
o Normalizing is communicating to someone “given what you’re going through, you’re kind of in the same
boat as other people going through that. You’re not alone.”
 Vs. Validation: how would the client specifically be experiencing the depression/whatever emotions
they report. Vicki what you’re describing is that there are times when your mood is so low that you
feel like there is a film over you and you can’t do even the most basic tasks. Getting to this
appointment was like moving a boulder. You're in a tough spot with this depression.”
 Affirmations (can be invalidating if you go for that first). Ex: i make so many mistakes, I don’t do
anything right. Im such a disappointment as a person, i don't’ know why anyone would want to like
me as a person.” affirmation would be “you’re a great person and people really respond to your
personality and like you a lot, i know you think you make a lot of mistakes but you do a lot more
things right than make mistakes.” building someone up. BUT THAT IS NOT WHAT SHE NEEDS
IN THIS MOMENT
 VS. VALIDATION: i hear that you’re really down in this moment, you’re so down on yourself. In
this moment, it feels like you can’t do anything right, it feels like “gosh why would anyone want
to know you or be your friend.” you’re really in this place where everything seems down and
going wrong.”
o AND
 Can be affirmation, normalizing, what could be helpful right now? Practice non-
judgmental stances, maybe an activity, reach out to friends, etc.
 Validation must be done slowly! Let it take its time to sink in (like WD-40), let it get
into the rust and work
Levels of Validation (Linehan, 1997)
 Being acutely attentive
 Reflecting verbal communication
 Describing non-verbal communication
 Expressing how experience makes sense given history or biology
o You said you've done therapy before in the past and it didn't work. Its stressful to have
to do something/be apart of something that you feel doesn’t work. You sound frustrated
that dr. Smith is having you come and be apart of this therapy. Its hard to expect that
this can be any different than the past when you don’t know me and don’t want to be
here.
 Expressing how experience makes sense in the present moment and context
 Being in genuine, human contact
Validation as an Exposure Technique
 Regulates emotions by decreasing their intensity
 Provides gentle, informal exposure to emotions with a sense of self-efficacy
 Allows for a more complete expression of emotions, cueing a fuller adaptive response
Balance of Validation and change
 Validation opens clients to change:
o Lets clients know you understand the nature of their issues and pain
o Exposure to painful emotions create a qualitative difference in relating to emotions (decreasing
ineffective escape and avoidance behaviors)
o Exposure to painful emotions can create motivation to invest in change
Validation Exercise
  Form a dyad or triad. Role-playing your client, being to introduce a therapy issue to your therapist.
The therapist (for this exercise) will resist problem-solving and instead stick with validation as the
primary intervention. Aim to validate on the highest level possible.
 After 5 minutes, switch roles

Understanding the Treatment Alliance

Client

Goal

Therapist Method

Behavioral Principles
 Positive reinforcement: behavior is followed by a reward, increasing the behavior’s frequency
 Negative reinforcement (Avoidance learning): behavior is followed by removal of something
aversive, increasing the behavior’s frequency (car seat belt alarm)
 Positive punishment: behavior is followed by something aversive, decreasing the behavior’s
frequency
o Does not teach anyone anything new.
 In the absence of punisher, the person being punished will go right back to the behavior
being punished for in first place
o Causes hostility in relationships. Can create ruptures in alliance
o Activates emotions and goes directly against DBT where we are trying to improve emotion
regulation
 Negative punishment (response cost): behavior is followed by removal of something, decreasing the
behavior’s frequency
o Removing something desirable from someone. Ex: removing the markers from both kids who
are fighting over the markers.
 Extinction: removal of reinforcement for a behavior, leading to a decline in the behavior
 Generalization: performing desired behavior outside of the treatment setting
Behavioral Considerations
  Are effective behaviors reinforced? On what schedule? Be careful to maintain desired behaviors
 How are ineffective behaviors reinforced (maintained)?
 How can i shape effective behaviors while extinguishing ineffective behaviors?
 Consider relevant behavioral principals when analyzing
Behavioral Contingencies
 The consequences of behavior influence what we learn
 A temporally close relationship between behavior and consequence influence what will happen the
next time we are in a similar situation with similar context
 Highlighting contingencies (structure, expectations, safety, immediate feedback, etc.) helps clients
learn and be more effective
Examples of Contingency Management
 Observing boundaries (limits)
 Defined plans with consequences for specific behaviors
 Program rules and expectations with consequences
 Changes to environment to reinforce or extinguish behaviors
 Every observable therapist or team response is an informal contingent procedure
 See handouts on DBT skills group and program expectations and DBT individual therapy
expectations. Also see phone coaching expectations, and consultation group agreement handouts.
Most Effective Behavior Change Methods
 Provide non-contingent reinforcement
o Give people sufficient involvement, attention, caring, reinforcement of different types; and
they don’t need to do anything to earn it. Of course you may withhold it in a specific moment,
but you generally give this all the time.
 Model effective behavior
 Reinforce non-problem behaviors (especially incompatible ones)
 Train skills to reinforce
 Make a high-probability behavior contingent on a low-probability behavior
 Lower vulnerability and meet organismic needs proactively
 Harness high level motivations to leverage change

Dialectical Strategies
 Enter the paradox by highlighting:
o Mismatch between words and behaviors
 It is difficult to create a different life you are unwilling to try anything different
 You are not SOLVING, you are handing it back to the client. Guided discovery.
o Discrepancy between values and behaviors
o Inaction in light of knowledge of what would be helpful
o Tension between preferred reality and actual reality
o When client wants relationship but actively works to destroy it
o Strength and resiliency behaviors that contrast a poor self-concept
 Refusing right and wrong/answers can be yes and no (e.g., a therapist can care and still set limits on
availability)
 Use of metaphors or stories
 Devil’s advocate
 Extending
 Wise mind activation
 Making lemonade out of lemons
 Prescribing the feared behavior
 Using the “exception rule”
  Role reversal
 Allowing natural change
Cognitive Interventions
 Have traditionally been de-emphasized in DBT
 Assume that clients are not fragile, they are able to evaluate thoughts and beliefs
 Clients do benefit from cognitive interventions (non-judgmental stance is a cognitive intervention)
 DBT-style cognitive intervention take a “softer,” more validating approach
 Avoid cognitive interventions with emotionally-activated clients
DBT-style cognitive interventions
 Guided by different theory (emotion dysregulation), so emotions remain the primary target, with thoughts
and beliefs being a secondary target
 Avoids judgmental labels (distortions, errors, maladaptive thoughts, etc.). uses traditional cognitive
“distortions”, but without the labels.(minimizing, black and white thinking, catastrophizing, etc.) and call
them “styles of thinking.” Normalize them. We all think like this from time to time. Sometimes they fit
the facts of the situations, too.
 Validates origin and adaptation that comes from the thought or belief
 Analyzes dialectically rather than categorically
 Emphasizes shifting and expanding rather than a “Cut and paste” style of addressing thoughts and beliefs;
we do not talk clients out of thoughts and beliefs
 Points out effective thinking to develop sense of self-trust

Working with Trauma in DBT

 Develop self-care, build grounding skills, fill the distress tolerance “toolkit”
 Client must be stable before doing exposure-based treatment! Goals of stage one must be met
before stage two
 EMDR is compatible with DBT protocols
 Provide/obtain clear informed consent
When NOT to use Exposure
 When there is active suicidal/homicidal urges
 When there is regular self-injury (or the risk of serious self-injury)
 when there is psychosis
 when there is significant risk of harm from others
 when there is insufficient memory of the trauma
 when there is clinical issue that has more importance (resolve first)
Alternatives to Exposure
 mindful, present-centered approach to life
 re-connection to emotions (especially positive), relationships, and the future (including plans for the
future)
 distress tolerance and emotion regulation skills
 resolution of current life problems
 cognitive interventions around trauma-related thoughts and beliefs
 provide a clear rationale for these alternatives to exposure along with the coherent application of
techniques that accomplish these goals
 Research shows that non-exposure based treatment models have equivalent efficacy when
compared to exposure-based treatment models.

Self disclosure of Personal Information

 Personal information may not relate to client or the therapy. if it is not relevant, do not share it as a rule
 Observe and disclose your limits in regards to personal information when needed (ok to explore what
personal inquiries mean to the client)
 Never share personal problems/issues!
 Does it pass the “public” test? In other words, would you share it in front of an audience of your
colleagues?
 NEEDS to be helpful for the present moment, and client.
 General rule: don’t use self-disclosure to build rapport.
 Less disclosure is more, especially when working with clients with boundary issues. May lead to therapist
over self-disclosing information.

Irreverent Communication
An offbeat style intended to: get the client’s attention through surprise or an unexpected response; to show
another POV or get client to process on a different level; create a shift with emotions, thoughts, & behaviors
Essentials of Irreverent Communication:
 Works best when used by therapists with a naturally irreverent style. Be genuine!
 Assumes client is not fragile
 Needs to be surrounded by validation
 Needs a “solid” therapeutic relationship
 Know your goal, observe the effects, and balance with validation
 Consider if it fits your style or fits your style TOO well!
 Do not use when frustrated or at the expense of the client!!
Examples of Irreverent Communication:
 Responding to or reframing a client’s communication in an unexpected way, usually picking up on a
subtle or unspoken aspect of the communication
 Taking a direct route: going where angels fear to tread
 Being confrontational, like calling “bullshit” on a client
 Calling a “bluff” while providing a (well-timed) way out
 Switch intensity levels (between humor and seriousness)
 Using silence while waiting for a particular response
 Express impotence or omnipotence

Reciprocal Communication
 Engaging and responsive, taking clients wants and needs seriously
 Being authentic and genuine, not staying in a “therapist” role
 Using self-disclosure thoughtfully in the service of therapy
 Sharing “Benign” and human examples of skill use and practice
 Using examples of how you have approached and solved a problem
 Sharing when you have felt, thought, or responded similarly to how client reports in a given situation
 Sharing your reactions to the client in the moment, providing information that manages relationship
contingencies (creating new learning)

DBT additions to CBT Emotion-based guiding theory (CBT= thought-focused, DBT= emotion-focused)
 Dialectical process (synthesis of opposites), balancing acceptance and change
 Emphasis on acceptance strategies; on organized psychoeducational skills training; on consultation
 among treatment team; on treatment stages and hierarchy
Cognitive Interventions (Assume that clients are not fragile, they are able to evaluate thoughts & beliefs)
 Clients do benefit from cognitive interventions (non-judgmental stance is a cognitive intervention)
 DBT-style cognitive interventions take a “softer,” more validating approach
 Avoid cognitive interventions with emotionally-activated clients
DBT-style cognitive interventions
 Guided by different theory (emotion dysregulation), so emotions remain the primary target, with
thoughts and beliefs being a secondary target
 Avoids judgmental labels (distortions, errors, maladaptive thoughts, etc.). uses traditional cognitive
“distortions”, but without the labels.(minimizing, black and white thinking, catastrophizing, etc.) and call
them “styles of thinking.” Normalize them. We all think like this from time to time. Sometimes they fit the
facts of the situation, too. Validates origin and adaptation that comes from the thought or belief
 Analyzes dialectically, not categorically; Points out effective thinking to develop sense of self-trust
 Emphasizes shifting and expanding rather than a “Cut and paste” style of addressing thoughts and beliefs;
we do not talk clients out of thoughts and beliefs
DBT and Cognitive Approaches [Socializing the client to treatment (educate and orient)]
 Client role in therapy, my role, what tasks will be done in therapy
 Educating them about therapy is “a little bit of working hard to make it easy for them”; on the purpose of
therapy (it is not just talking, but processing, understanding, feeling, etc. )
 DBT = active therapy requiring practice of skills outside of sessions. Daily life application is crucial.
 Talk about the major tools and why we do them, why it is useful for the client to do them.
o Self-monitoring techniques (diary card). Tracking skill use around all of that, tracking suicidality; Certain
miracle w/ self-monitoring; what you track changes because you are aware; You have a responsibility to do
something you are aware of/conscious of
 Adapted cognitive modification (validating and dialectical style)
 When we subtract, we must ADD. Give people healthy substitutes for unhealthy behavior and coping skills
DBT and Behavioral approaches (Teaching and reinforcing skills)
 Behavioral analysis (functional analysis, chain analysis) —Usually target or problem bx (everything
leading up to that bx and followed the bx). Bx don’t happen in isolation, there is a reason!
 Different vulnerabilities that may set us up for certain behaviors—Historical vulnerability (trauma hx),
basic hygiene habits, etc.
 Behaviors have their prompts and triggers—trying to meet needs, to gain something. Where did the
reinforcement come from? Did they feel better, get support, avoid withdrawal symptoms?
 How are we going to use those skills to decrease vulnerabilities/manage triggers or prompts/to do
something different than the target/problem behavior?
How will I deal with these consequences so I can lessen the impact on my life?
Contingency management—Establishing the “if, then” relationships that influence behavior for the better
You must believe that the follow-through will actually happen
DBT and Rogerian/Humanistic approaches
 Acceptance-based, non-judgmental orientation; Unconditional positive regard toward clients; Validating
responsiveness (understanding clients’ experience and perspectives; Genuine and authentic approach
DBT and chemical dependency treatments
 DBT overlaps with relapse prevention. Both embrace concepts of acceptance, learning from setbacks, and
developing action plans to prevent future setbacks
o DBT and traditional chemical dependency treatments like 12-step can also be combined
 Supports harm reduction practices while not wavering from promoting abstinence as a treatment goal
Treatment Structure
 Clear treatment framework and service delivery as well as other structure are common factors in
empirically supported treatments for BPD
 More complex client presentations require greater treatment and structure. Structure creates
predictability, safety, and success for clients and therapists
 “Saying what you do & doing what you say” is the foundation of trust, & it speaks to the therapy alliance

Structure of Individual Therapy

 Have a clear framework in mind. The greater the difficulties, the more important the structure.
 Start with 3-5 minutes of mindfulness.
 Review homework and inquiry about other treatment modes if applicable.
 Don't call it homework! Call it skills work, doing a task or experiment, secret mission for adolescents
or kids, etc.
 One way to help get them to complete homework is to initiate it in the session.
 Ask how skills class went, or case manager appt/prescriber appt., etc. And you can put it on the list of
things to do in the day
 Can give clients a binder for homework, diary card, etc.
 Organizer on the door with all documents and stuff available for clients to grab
 Review diary card to determine treatment targets
 Self-monitoring tool
 You can see exactly what happened in the client’s week, what got better/worse/stayed same. What is
priority to address
 Shape the agenda of the session, guide about what is most relevant and prioritized
 Set agenda based on diary card and client input, including client’s description of their current
emotional state
 Do identified work of the session
 Assign homework for the next week
 End with 3-5 minutes of mindfulness
 Leave sufficient time to close the session, especially if difficult material is covered
 End session on time
 Be prepared with handouts and remember to interweave skills throughout treatment
 Use behavioral analysis as needed (nice way of “structuring” a session). Solicit feedback by asking
 (e.g., did you get what you needed today? What was helpful, not helpful, etc.)

Structure of Skills Group

 Determine the skills curriculum; have a syllabus while also being flexible to needs of group
 Common curriculum rotates through the modules, revisiting mindfulness at each stage
 Revisit skills when needed, occasionally mix it up for interest
 Begin with 3-5 minutes of mindfulness
 Review homework assignments
 Cover the scheduled skills lesson
 Assign individualized homework
 End with 3-5 minutes of mindfulness
Structure of DBT Therapy Done in a Group
 Start with 3-5 minutes of mindfulness
 Review homework
 Set agendas for group (e.g., what are the therapy needs of the day and who needs therapy “time”,
all clients with identified target behaviors need to take therapy time)
 Each person gets equal time (there are pros and cons of group-managed time vs. Use of a timer)
 Be sure to generalize what is discussed in time to life outside of therapy
 Keep it validating but largely an application of skills
 Not personal, manage the level of detail.
 I'm having a lot of flashback and intrusive thinking regarding he abuse from my uncle as a kid.
 Vs. Going into the details and getting too deep.
 Assign homework
 End with 3-5 minutes of mindfulness

Treatment Stages
Pretreatment Stage:
 Oriented client & environment to treatment, establish commitment, i.e., agreement on goals & methods
 Rapport, goal, method, agreement
Stage 1: Treatment Targets and Hierarchy of: Stage 2:
 Decrease life-threatening behavior  Decrease PTSD (if applicable) and other major
 Decrease therapy-interfering behaviors stress responses, while
 Decrease quality-of-life threatening behaviors  Increasing more complete emotional
 Increase skill use to address targets experiencing and expression
 If you are multiple sessions in and you are still at
pretreatment stage, you need to move it along!
Stage 3: Stage 4:
 Increase self-respect,  Find fulfillment
 Achieve individual goals, and  Become more actualized, and
 Address ordinary problems of living  Increase personal spirituality

DBT Hierarchy in Detail

 Treatment hierarchy determines “what to treat when” and sets the following priorities (treatment targets)
o Suicidal behaviors and intense suicidal urges
o Self-injurious behaviors (SIB) and Substance use behaviors (SUB)
o Treatment-interfering behaviors (TIB)
o Quality-of-life-interfering behaviors (QIB)
 The hierarchy is a set of guidelines that can be adjusted based on expertise and client needs
 The hierarchy is especially used during the first stage of treatment that is focused on stability
 Hierarchy guidelines exercise
o Has low to moderate suicidal thinking. No history of acting on SI and is currently committed to safety
o Has been drinking to the point of intoxication every evening for the past week
o Has superficial self-injury, scratching arms, leaving marks, but no bleeding
o Has missed the last 3 sessions
o Reports that house is in foreclosure, will be homeless in two months
o Reports high anxiety and depression
o Was cut off by another driver in traffic
o Rank your targets with a rationale
Skills in Individual Settings
 Recommended for low intensity clients (Where some time in individual can be devoted to teaching skills)
 Set aside time in the beginning or end of session for skills training
 Follow a curriculum and/or customize based on client needs and preferences
 Consider a bibliotherapy approach with some clients
 Interweave skills for all types of clients (i.e., “talk” and apply skills throughout session)
 Note: some high-intensity clients require individual skills training for a variety of reasons
Skills in group settings
 Recommended for high-intensity clients (Where there will not be enough time to teach skills in individual
settings)
 Length of group/number of hours of skills training is variable based on level of care, client factors, etc.
 Skills are usually taught “classroom” style
 Be sure to make teaching experiential, Be sure to individualize skills training
Most Common Curriculum
 Mindfulness
 Distress tolerance
o Review mindfulness
 Emotion regulation
o Review mindfulness
 Interpersonal effectiveness
 And then going back to the top
 What you teach can depend on your setting, length of stay, etc.
o Short term setting might not teach all of this stuff. Might do distress tolerance and emotion regulation
DBT skills...
o Provide a common language for effective behaviors
o Help clients label, remember, and use effective behaviors
o Teach new behaviors to reinforce (one of the most benevolent ways of changing behaviors)
o Provide a “safety net” in therapy... therapists and clients can almost always “fall back” on skills
 Bridge burning
o Remove the means of acting on a harmful urge
o Substance abuse example: block dealer’s number, delete dealer’s number, get rid of drug
paraphernalia, tell everyone I no longer use drugs.
Skills Training Checklist
 Follow a clear overall structure
 Begin with mindfulness practice
 Review homework assignments. If HW is not done, that is “therapy-interfering” behaviors (TIF)
 Introduce skills topic
o Define skill, orient clients to the purpose of the skill taught & how it relates to clients’ identified goals
 Show conceptual mastery of skills presented. Clearly show advanced understanding of skill, including
how it relates to other skills, an discuss the skill fluently, and is able to answer questions
 Be prepared with examples and/or experiential exercises for clients (takes skills training beyond
lecture)
 Hold focus of the skills training session
 Encourage and reinforce balanced client participation
 Adapt training appropriately to the treatment population
 Maintain a psychoeducational focus
o Avoid getting into therapy issues and process, and refrains from interventions that are obviously
therapy related. Keeps client examples on a psychoeducation and not therapeutic level
 Assign homework to clients
 End with mindfulness practice
Skills Training Approaches
 Interactive lecture (good for conveying a lot of information quickly)
 Questions/discussion
 Assigning teaching to clients
 Learn/do/teach model
 Experiential exercises
 Using media
Tips to Improve Skills Training
 Be strengths-based (often we think of skills deficits and forget to identify what is working)
 “Catch” and label skill use continuously
 Reinforce anything and everything that is not a problem behavior
 Shape emerging behaviors
 Orient to purpose and goal of skills taught
 Assign individualized homework and get commitment to follow-through with homework
 Use worksheets! Give everyone a binder with the curriculum and all other important documents

MINDFULNESS MODULE (Wise Mind; Core “what” and “how” skills)

Mindfulness (Choosing to pay attention to this moment, on purpose, non-judgmentally.)
 Mindfulness skills teach:
Awareness How to direct your mental processes How to be in the moment How to be responsive with
behavior Increased emotion regulation and decreased (ineffective) mood congruent behavior
Improved connection to experience, enjoyment, peace Increased tolerance of uncomfortability & pain

States of Mind

A person is in Emotion Mind when their emotions are in control. Logical or reasonable thinking is not
present. They seem out of control. They may report feeling overwhelmed, stuck, or confused and simply
cannot find a resolution or a way to move forward.

A person in Logic Mind seems calm, cool, and collected. They approach a situation with knowledge
intellectually. They are thinking logically or rationally. They pay attention to the facts and ignore
emotions. They are practical and cool in developing a plan. Decisions and actions are controlled by logic.

A person using Wise Mind uses input from both Emotion Mind and from Logic Mind; and adds intuitive
knowing. This person focuses on getting things done. Their focus is on the experience.

States of mind are not good or bad, right or wrong, should or shouldn't. They just are.
 There are reasons we have an emotion mind or a reason mind. Start with emotion mind. It is not bad!
Dispel ideas about emotions
 Why do we have an emotion mind?
 Helps with bonding, when we fall in love, how we relate to one another. Compassion for a
stranger, family, etc.
 Emotions make us human, enable us to relate to others, otherwise we would be animals only
thinking in primal ways
 Emotions can be self-protective; they help us to understand the moment
 Motivate our behaviors. Give us messages, help us communicate. Mindfulness helps us regulate!
 Why do we have reason mind?
 Problem-solving; play by the rules
 To inhibit impulses and urges sometimes
 Use logic! Clients may think that reason mind is “good”. Remember, neither are good or bad, right
or wrong. There are liabilities when you go too far into reason mind, too! Often lacks validation
that we inherently want and need sometimes
How to Reach Wise Mind Understand how we got to where we are, logically and emotionally.
 Wise mind is balance; it is a little bit intuitive, centered, and grounded
 We know when we are in a wise mind when our behavior fits with what our goals are, when our
behavior fits with what is important to us, valued to us.
 Wise mind reflects our true selves, who we want to be.
 Maintaining your respectful and interpersonal skills when someone treats you with disrespect
Two Steps to Wise Mind
Step One: Observe and Describe Non-judgmentally and One-mindfully
 Observe (watch and become aware) (“what” skills)
 Feelings, thoughts, urges, physical sensations, behaviors, information from senses, etc.
 Environment... what information is around me?
 Experience integrated (i.e., life here and now)
 You have a window to see into all of these things. You have to choose what you want to observe and
open the window to that. Other windows may blow open (distractions). Go ahead and acknowledge
the open windows and close them. (promotes intention)
 You are simply watching trains pass, watching leaves flow by on a river, etc. You are not rubber
necking, getting distracted. You are just watching things pass by you.
 Describe (“how” skills)
 Put your experience into words (and vice versa)
 Trying to be an objective reporter. Who, what, where, when, why, how much? No opinions, no
analysis, no judgment.
o Don't attach strong opinions, no inflammatory words or labels.
o Be descriptive.
 Words make it clear for you and others
 Non-judgmentally (“how” skills)
 Describing without attaching a label or opinion.
 Not amplifying or pushing away. Noticing it enter and leave. Don't grab your judgment and stick it
to yourself/cling to it.
 Being open to continued evaluation, based on facts
 Focus is on “what is” not good/bad/should/shouldn’t/etc.
 Nothing is good or bad; thinking makes it so.
 Doesn’t mean you’ve figured out a way to turn off all judgments. It's about attending and how you
are attending.
 Judgments are water and you are waterproof. Let them slide off of you
 One-mindfully (“how” skills)
 Choose, direct, and focus your attention and concentration on one thing
 Gently let go of distractions, refocusing over and over
Step Two: Participate Effectively
 Participate (a “what” skill)
 Make a mindful choice about what you are doing
 Practice your skills until they are a part of “you”
 Immerse yourself and be one with your experience
 Bring your full self to whatever it is that you are doing.
 Effectively (a “how” skill)
 Focus on what the situation or moment requires
 Remember your goals and do what “works” to meet them
 Do not “cut off your nose to spite your face”
“What” Skill “How” Skill

Observe Non-judgmental
Pay attention to events, emotions, and thoughts. Taking a non-judgmental stance means: do not judge
Try not to terminate them when they are painful. things as “good or bad,” “right or wrong.”
Try not to prolong them when they are pleasant. It is effective to focus on the consequence of the behavior
Allow yourself to experience with awareness. instead of judging others or ourselves.
It is helpful to fully describe what is observed and collect
Describe just the facts; without judging those involved or the
Describe events, label emotions, identify circumstances.
thoughts.
Try not to take emotions and thoughts as accurate One-mindful
and exact reflections of events. It is the ability to focus the mind (and awareness) in the
List “just the facts.” No need to label or judge. current moment.
Try not to become distracted by thoughts or images of the
Participate past.
Enter completely into the activity of the moment. Try to put your worries about the future away and focus
Try not to be self-conscious. on the task at hand.
Be spontaneous and give attention to the activity. Engage in the activity of the moment with your eyes wide
open.

Effective
Do what works.
Try not to worry about being “right.”
Focus on the outcome you desire.
Mindfulness-Enhancing Qualities
Beginner’s Mind: do not let past experiences cloud the here and now
Compassion: for self and others. Everyone suffers, and empathy and concern heals
 The heart of mindfulness
 Mindfulness activity: kindness or compassion meditation.
 Someone in your life who you don’t like. Instead of ruminating on the things you don't like about
them, you can decide to sit down and meditate on kind/compassionate thoughts for that person.
Tolerance: Learn to experience without judgment or trying to change it.
 Part of mindfulness is learning how to be with this moment as it is, without trying to change it
Trust: Be assured of the benefits of mindfulness
Patience: Reality unfolds in its own time, without regard to preferences
Nonstriving: Be without clinging to a goal or outcome
 Doesn't mean to not have goals. It means to not attach yourself to the goal so that you are there, and not
here in this moment.
 About being in the journey. Yes, you are heading towards a destination; but if you cling to the destination,
you are not present for the journey, the here and now steps you are taking to get to the goal.
 Connect with where people are already having some mindful moments, what they do immerse themselves
into and are interested in.
 Start with everyday things we do automatically. Like driving, grocery shopping, texting, cleaning
or organizing, eating a meal, spending time with a pet or person, etc.
Practice: Benefits come from consistency

Mindfulness: Practice and Application

 Must practice multiple times a day
 Begin and end each session with mindfulness
 Address barriers to mindfulness (e.g., judgments, environmental, etc.)
 Make it relevant, interesting, and enjoyable
 Mindfulness is essential to effective skill use; it’s a “gateway skill” (you always have to bring it with you)
 When skills lack effectiveness, often concurrent mindfulness is what is needed
INTERPERSONAL EFFECTIVENESS MODULE (FAST, DEAR MAN, GIVE, VALIDATE)
Interpersonal effectiveness is complicated. Interpersonal effectiveness teaches:
How to build self-respect Make & maintain relationships Meet wants & needs Set effective boundaries & say NO
Interpersonal skills: (work best when used in combination and guided by values!)
Self-respect effectiveness (FAST); relationship effectiveness (GIVE, VALIDATE); Objective effectiveness (DEAR MAN)
Supplemental Skills
 Many DBT experts have added more skills and/or modules (TIP, ABC’S). Teach what clients need!
 Dialectics; cognitive modification, problem-solving; building structure and routines; social media

Self-respect Effectiveness FAST “How do I want to feel about myself after this interaction?”
 be Fair: be fair to self and to others
o Not be too tough on self or others, Treat people how you want to be treated. Validate your own
feelings and wishes, as well as those of the other person.
o Equality/equity (Even unequal ways of treatment can be fair)
 no Apologies: no unnecessary apologies or apologies for your beliefs, opinions, or for being you
o Of course, apologize if there is a REASON. No apologizing for being alive, making a request at all,
having an opinion, disagreeing. No looking ashamed, with eyes and head down or body slumped. No
invalidating the valid.
o For those who are overly apologetic: stop! The problem is that it erodes your sense of self-respect.
Flooding the market with apologies devalues them.
 Stick to your values: know your values & what is non-negotiable. Resolve value conflicts effectively.
o You need to know what your values actually are, first!
o Stick to your guns. Don’t sell out your values or integrity for reasons that aren’t very important.
 be Truthful: avoid exaggerations, excuses, and lies. Be accountable to yourself and others
o Avoid excuse-orientation to life. Even if it is a “good” excuse. It burns others out, doesn’t matter how
good excuses are if they are constant. Be accountable!
o Don’t lie. Don’t act helpless when you are not. Don’t exaggerate or make up excuses.

Relationship Effectiveness GIVE “How do I want other people to feel about me after this interaction?”
 Genuine/Gentle: be authentic and real, and act from your true self. Be nice and respectful. Avoid
verbal/physical attacks, threats, and manipulation. Avoid harassment of any kind. Express anger directly
with words. Avoid using threatening statements, like “ill kill myself if you…” Describe painful
consequences for not getting what you want, but describe them calmly and without exaggerating. Stay in
the discussion even if it gets painful. Exit gracefully. Avoid judging, moralizing, and blaming. Avoid
smirking, eye rolling, sucking teeth, and interrupting the other person.
 act Interested: make eye contact, show interest to be interested, allow reciprocity in interactions. Listen
to their point of view. Face them, lean towards them rather than away. Don’t interrupt or talk over them.
Be sensitive to their wish to have the discussion at a later time. Be patient.
 Validate: acknowledge what you heard without judging or fixing. Focused on the other person! Show that
you understand the other person’s feelings and thoughts about the situation. See the world from their
POV, and then say or act on what you see. Go to a private place when they are uncomfortable talking in
public.
 Easy manner: use humor, smile, and be easygoing. Ease the person along. Sweet-talk. Use a “soft sell”
over a “hard sell.” Be “political.” Leave your attitude at the door.
VALIDATE
Problem-solving and advice-giving is NOT validation. Over-personalizing is NOT validating (sharing your
experience after someone shares something with you about them), nor is looking on the bright side.
 Value Others: seeking the inherent value in others is essential to validation
 Ask questions: use questions to draw out others’ experience
 Listen and Reflect: Listen to others’ answers to your questions and reflect back the major themes
 Identify with others: work to see the world through the eyes of others
 Discuss emotions: talk about others’ feelings & how they affect them from their perspective (not how it
affects you)
 Attend to nonverbals: notice others’ nonverbal communication to give you information about their
experience
 Turn the Mind: validation does not mean that we agree with others. Turning the mind is especially
important when it is difficult to relate and during conflicts
 Encourage Participation: validation can be a difficult process at times, so we need to encourage
ourselves and others to be engaged with each other.
DEAR MAN Assumptions
 No one know what you want or need
 Don't read minds: ASK!
 Use words, not behaviors
 Be clear on your goals
 Consider timing, intensity, and other factors
 Assertiveness is not a guarantee
Objective Effectiveness DEAR MAN “What do I want or need, what boundary do I need to set to say
no?” “What is it that I want or need about this situation?”
 Describe the details of the situation. Stick to the facts. Tell them exactly what you are reacting to.
 Express your emotions and thoughts about the situation. Don’t assume someone knows how you feel.
 Assert yourself by asking for what you want (or saying no) clearly. Do not assume that others will figure
out what you want. Remember that others cannot read your mind.
 Reinforce by rewarding the other person ahead of time (so to speak) by explaining positive effects of
getting what you want or need. If necessary, also clarify the negative consequences of not getting what
you want or need.
 Mindful: stay focused on the issue. Maintain your position. Don’t get distracted or off topic. Speak “like
a broken record.” Keep asking for what you want. Or say “no” and express your opinion over and over.
o Avoid attacks, distractions, and side tracking. Do not respond to attacks. Ignore distractions.
 Appear confident, effective, and competent. Use a confident voice tone and physical manner; make
good eye contact. No stammering, whispering, staring at the floor, retreating.
 Negotiate. Be willing to offer an alternative. Be willing to ask for an alternative
o Turn the tables; reduce your request; offer and ask for other solutions. Say no but offer to do
something else or to solve the problem another way. Focus on what will work.

Boundary Building Skill

Our emotional health is related to the health of our boundaries. When we grow up in a dysfunctional family
or one that was chaotic, learning to use boundaries is one of the most uncomfortable sets of clothes to try on.
It threatens our former understanding of our self and our survival. Hence, it goes against every grain (or
cell) of our being. With time, the wardrobe changes. We come to see ourselves as clearly separate from
others. Intact and clear boundaries feel good. Healthy boundaries are flexible enough that we can choose
what to let in and what to keep out. We can determine to exclude meanness and hostility and let in affection,
kindness and positive regard.

Learning Boundaries
If you were parented in a way that you learned to stay within certain boundaries and why it mattered, there is
a good chance you learned how to set and enforce boundaries of your own. If the ways in which you were
disciplined as a child weren’t clearly marked with an understanding of where the boundary was or why it was
relevant, it may be more challenging for you to identify and state your boundaries to others as an adult—or to
honor and respect the boundaries of others.

Understanding Boundaries
It’s important to note that sometimes people cross upon your boundaries (and vice versa) unknowingly. If you
haven’t been clear that you have a boundary, then you shouldn’t necessarily expect the other person to honor
it. Of course, there are extreme examples, but this should be understood in common situations you encounter
in your families, friendships, relationships, and in the workplace.

Identifying Your Boundaries

To set boundaries in any area of your life, you must first know what is important to you as well as is a “go” or
“no go.” For many people. Infidelity in their relationship is a “no go.” In your job, being yelled at by your
boss or torpedoed by your peers may be a threshold. For some, family arguments at holiday gatherings might
be a strong boundary.

Communicating and Enforcing your Boundaries

Now that you know what your boundaries and the thresholds are, you’re ready to communicate them. In some
instances, this may be easier said than done, and in some cases, you may find that it’s not difficult at all. The
key is being mindful of how you communicate.

Your Physical Boundaries

Your life is yours. You are the one accountable for your choices. You bear the consequences of your
decisions, and your body bears the consequences of your decisions about it. You choose what to eat, how
much to exercise, how much you will rest. The care of your body is in your hands, and you are the one that
lives with the results. If you decide to floss your teeth, you get to enjoy healthy gums. If you decide to live in
a way that keeps you driven and tense, you are the one who lives with high blood pressure, greater
susceptibility to illness, and strained relationships.

Emotional Boundaries
Emotional boundaries define the self. Assaults to boundaries threaten the self. The following harm emotional
boundaries: ridicule, contempt, insistence of conformity, judgments, any kind of abuse, abandonment, threats,
or insecurity.
EMOTION REGULATION MODULE (Model of Emotions, PLEASED, STOP, BPE, BM, O2E)
Model for Emotions Emotions start with events (external/internal)
 Influence how you feel/what you feel
 How we interpret events has strong
influence on how we feel/what we feel
 Leads to emotions
 Action urge: Behavior Consequences
 Do more events that lead to feeling good
and less events that lead to feeling bad
 Working with your interpretations

Primary Emotions: born with, wired into brain which causes body to act in certain ways and for you to have
certain urges when the emotion arises.
They are direct initial reactions to an event or situation (sadness following a loss, fear when perceiving a
threat):
Anger* Contempt Disgust Fear (anxiety) Sadness Joy/Happiness Surprise
All other emotions are made up by combining these emotions.

Secondary Emotions: emotional responses that follow primary emotions, unless these emotions are
processed effectively in the first instance.
They are defensive or inhibitory emotions (e.g., feeling guilty when angry & then turning the anger inwardly)

Purpose of Emotions Functionality of Emotions

Emotion Action Tendency Message Need Adaptive vs Maladaptive
Sadness Slow down, withdraw Loss, Grief, Sorrow Healing Grieving Hopeless, Despair,
Desperate Clinging
Fear/ Avoidance, Get away Apprehension, Danger, Safety Signals danger Traumatic
Anxiety Dread, Fright, Threat, Panic
Anger Attack or Assert Unfairness, “Someone is Protection, Empowering Destructive
taking advantage of me” Draw
boundaries
Shame Hide, Cover up “There is something wrong Social Belong to group Self-hate, contempt
with me” acceptance,
Approval
Guilt Make Amends, Regret, Remorse “I’ve done Self-respect Apologizing Blaming
Solve Problem something wrong to you”
Disgust/ Aversion, Repulsion Distaste Protection Healthy Outrage Self/other abuse
Contempt
Love/Joy Care, nurture, Protect, The Recipient is Worthy, Connection, Caring, Freeing Addicting,
Kindness, do more of Stay Close, This is Good Relationship Clinging
the Same
PLEASED (original PLEASE, but added D and additional A’s and D’s alternatives)
 Physical Health
 List resources and barriers (each area)
 Eat three healthy, balanced meals
 Avoid mood altering drugs
 Sleep between 7-10 hours
 Exercise at least 20 minutes
 Daily
 Address barriers
 Develop a plan/track on diary card

ABC PLEASE Skill

Accumulate positive emotions by doing things that are pleasant.
Build Mastery by doing things you enjoy (reading, cooking, fixing cars, crossword puzzles, playing musical
instrument, etc.). Practice these things to build mastery and in time you will feel competent.
Cope Ahead by rehearsing a plan ahead of time so that you can be prepared to cope skillfully.
Treat Physical Illness and take medications as prescribed.
Balance Eating in order to avoid mood swings.
Avoid mood-altering substances and have mood control.
Maintain good Sleep so you can enjoy your life.
Exercise regularly to maintain high spirits. No need to make it fancy—get your blood pressure elevated doing
any physical activity outdoors.

STOP Skill: Stop, Take a step back, Observe, Proceed mindfully

Stop: When you feel that your emotions seem to be out of control, stop! Don’t react. Don’t move a muscle.
Just freeze, especially the muscles around the mouth. Freezing for a moment helps prevent you from doing
what your emotions want you to do (to act without thinking). Stay in control. Remember: you are the boss of
your emotions. Name the emotion—put a label on it.

Take a step back: When you are faced with a difficult situation, it may be hard to think about how to feel with
it on the spot. Give yourself some time to calm down and think. Take a step back from the situation. Get
unstuck from what is going on. Take a deep breath and continue breathing deeply as long as you need and
until you are in control. Do not let your emotions control what you do. It is the rare incident, indeed, wherein
we need to make a split-second decision about anything. Hence, it is okay to take our time to decide how to
respond

Observe: Observe what is happening around you and within you, who is involved, and what other people are
doing or saying. Listen to the Automatic Negative Thoughts (ANTs) that occur... remember those are based
on an outdated Belief System that was programmed before you were seven. To make effective choices, it is
important NOT to jump to conclusions. Instead, gather the relevant facts so you can understand what is going
on and what options are available.

Proceed Mindfully: Ask yourself, “What do I want from this situation?” or “What are may goals?” or “What
choice might make this situation better or worse?” or “What act will allow for success?” Stay calm, stay in
control, and when you have some information and how it may impact your goals, you will be better prepared
to deal with the situation effectively. Remember your brain needs time to think all of this through.
Build Mastery
 Engage in activities of daily living
 Accomplish tasks that need to be done
 Take steps toward a challenging goal
 Build a sense of control, confidence, and competence
 Give yourself credit!
Try Something New: Anyone can master a new recipe and with practice, it can become a family favorite.
Finding a recipe for a dish that you and your loved ones can enjoy is the first part of the challenge.
Understanding the components of the recipe and how to follow the steps is next. If you are unsure, ask others
who enjoy cooking or google the questions to find the answer. Collect the ingredients and give the recipe a
try! Expect mistakes, because mistakes help us learn. Seek help when you are not sure about how to proceed.

Practice: Washing the dishes and doing the laundry are thankless jobs, yet when they are complete and done
well, we can feel good that the task is complete. Reading a book to a young child and finding joy in sharing
that time, is also considered building mastery in relationship building. Playing a board game with friends, or
frisbee, or any other sport, can also be a part of building a relationship with involves mastery.

Give Yourself Credit: An important ingredient in this skill building is to remember to give ourselves credit
for building mastery. We often let the day go as if we accomplished nothing at all. Give yourself credit for all
that you accomplished at days end.
Build Positive Experience (BPE)
 Short-term—do pleasant things that are possible now
 Long-term—invest in relationships (attend to relationships (A2R)
o Invest in your goals
o Build a satisfying life
o Take one step at a time
 Must be planned/scheduled
 Must include mindfulness skills
 Address distractions that interfere with BPE’s
 Address judgments that interfere with BPE’s (e.g., not deserving, etc.)
 Address concerns about expectations

Opposite-to-Emotion Action (O2E)

 Break ineffective emotional cycles by acting opposite to behaviors that are mood congruent
 Opposite action may also create a different emotion; Often a “Gateway” skill
Opposite-to-Emotion (O2E) Behaviors
 Activity and social contact when depressed
 Approach fears when anxious
 Gently avoid (not attack) when angry
 Apologizing with justified guilt
Justified guilt is when you actually make a mistake, you know someone is hurt, etc.
o Often, we are tempted to avoid whoever it is we have hurt through our words or actions
o O2E behavior would be to apologize and do the opposite of avoiding!
o Making intention to be more thoughtful in future. Own your mistakes. Accept consequences gracefully
Unjustified guilt is when we feel guilty for having fun/being positive/saying no/setting boundaries/etc.
o When you didn’t do anything, feel regretful, remorseful, or bad about it.
o If you determine that your guilt is unjustified, make a conscious, active effort to let go of it. Avoid
taking on other people’s guilt for them. It enables them to continue repeating their mistakes and
causes you to suffer unnecessarily.
 Keep doing what leads to guilt with unjustified guilt (coach self). Much of life is dealing with “have to’s”
 Opposite Action Skill
All emotions activate us to respond, and the type of activation is biologically wired. The Opposite Action Skill
allows us to choose to respond opposite from what our biological response would activate us to do. They get us
ready to act. Here are some examples:
 Thirst: tells us that we need to hydrate. It activates us to drink water.
 Hunger: tells us that we need to give our body fuel. It activates us to eat.
 Fatigue: tells us that we need rest. It activates us to sleep.
These three emotions are helpful for our survival, but those that follow require thought before we act and
opposite action may be harmful.
Anger gets us ready to attack. It activates us to Opposite: Show kindness/concern or walk away.
attack or defend.
Shame gets us ready to hide. It activates us to Opposite: raise your head up, make eye contact, and put
isolate. your shoulders back.
Fear gets us ready to run or hide. It activates us to Opposite: Go towards, stay involved in it, build courage.
escape danger.
Depression gets us ready to be inactive. It activates Opposite: Get active! Move around. Go outside for 5
us to avoid contact. minutes. Then 10 minutes.
Disgust gets us ready to reject or distance ourselves. Opposite: Push through and get through the situation.
It activates us to avoid.
Guilt gets us ready to repair violations. It activates Opposite: Apologize and mean what you say.
us to seek forgiveness.
Remember:
1. If we want an emotion to stick around or increase, continue to do the action as above. Opposite Action!
2. If we want an emotion to go away or become less uncomfortable, do the opposite action.
3. If we want this skill to work, we must use opposite action all the way and believe that it will work.

Cope Ahead Skill

The Cope Ahead skill is intended to have us consider how we might be prepared in some way to help us reduce
stress ahead of the time. When we are asked to do a task, it’s helpful to think through to the completion it. All
of us at some time have had to give a presentation. Before the presentation, we likely wrote up some notes or
did some research on the subject. We do this in order to increase our chances of communicating a message to
others successfully. Rehearse a plan ahead of time to be prepared to cope skillfully with emotional situations.
1. Describe the situation that is likely to prompt uncomfortable emotions. Check the facts. Be specific in
describing the situation. Name the emotions and actions likely to interfere with using your skills.
2. Decide what coping or problem-solving skills you want to use in the situation. Be specific. Write out in
detail how you will cope with the situation and with your emotions and action urges.
3. Imagine the situation as vividly as possible. Imagine self in the situation now, not watching the situation.
4. Rehearse in your mind coping effectively. Rehearse in your mind exactly what you can do to cope
effectively. Rehearse your actions, your thoughts, what you say, and how to say it. Rehearse coping
effectively with new problems that come up, and with your most feared catastrophe.
5. Practice relaxation after rehearsing.
Examples:
Ken sent his resume and cover letter to a company for a position and was offered an interview. He used the Cope Ahead Skill to
prepare for the interview.
Ken reviewed his resume and the job description and listed the skills he had already mastered. He also researched the company and
prepared a list of questions to ask about the company. He realized he would likely feel anxiety and thought about how he had faced
tougher situations than this in the past. He imagined how he would calm himself so that he would do well in the interview.
DISTRESS TOLERANCE MODULE
(TIP, ACCEPTS, IMPROVE, Self-soothe, Pros and Cons, Radical Acceptance, Willingness)
Distress tolerance teaches:
Ability to tolerate painful emotions Distraction without avoiding Pathways to other skills
Action instead of reaction Managing crisis without making it worse

When to use Distress Tolerance:

 Am I able to solve the problem? (Y/N)
 Is now a good time to solve it? (Y/N)
 Am I in Wise Mind enough to solve it? (Y/N)
 Is this my problem to solve? (Y/N)
 If “yes” to all questions, solve the problem.
 If “no” to any of the questions, distress tolerance may help
 Practice skills when NOT in distress
 Skills tend to be short-term... must have many skills listed; they must be connected to specific bx’s
 Coach clients to change strategies when a skill doesn’t work
Evolve skills plans (written down) consistently... treat like a “living document” and USE PROACTIVELY

Distract: Wise Mind ACCEPTS

Activities—Focus attention on a task that needs to get done.
 Clean a room. Find an event to go to. Play video games. Go on a walk. Exercise. Scroll on your phone.
Respond to some texts. Eat. Call or text a friend to hang out. Listen to music, make a playlist. Build
something. Spend time with your children. Play cards. Read something. Play Sudoku or a crossword.
Contributing—Get your eyes off yourself! Altruism=feeling that one has something to offer/contribute.
 Volunteer, help family/friend, give away things you don’t need, surprise someone with flowers or a card
or a hug, send an encouraging message/ just to say hello. Do something thoughtful, just because.
Comparisons—simply about getting perspective. You’re not the only one going through hard things.
 Compare how you feel now to a time when you felt different. Think about people coping the same or less
well than you. Compare self to those less fortunate. Watch reality shows about others’ troubles; read
about disasters, others’ suffering.
Emotions—Choosing a behavior that is different from the one you are feeling.
 Watch a funny movie when feeling unfunny. Action movies when you feel unproductive. Soothing music
and candles when you feel anxious. Read something inspiring when you feel unmotivated. Be sure the
event creates different emotions. Scary movies, joke books, comedies, funny records, religious music,
soothing music or music that fires you up, going to a store and reading funny greeting cards.
Pushing away—short-term avoidance strategy. Put it out of mind for now.
 Build imaginary wall between self and situation. Block thoughts and images from mind.
 Be available for yourself in the moment by prioritizing your PRESENT self. What can you do for yourself
RIGHT NOW? Notice ruminating: Yell “No!” and refuse to think about painful situations. Put the pain on
a shelf. Box it up and put it away for a while. Deny the problem for the moment.
Thoughts—refocus thoughts on something healthy, engaging, distracting. Put distress on back burner.
 Can't think about more than one thing at a time. So, refocus thoughts on something healthy, engaging,
distracting, to allow the anxious/depressed thoughts to move to the back burner.
 Counting as an intervention (to 100 when angry). Don't ruminate about the anger while counting. Count
colors in a painting/poster/out the window, count anything, repeat words to a song in mind. tv/read.
Sensations— Other healthy sensations.
 Hot or cold shower/bath. Sour candy, peppermint smells, loud music, dancing vigorously, anything to
activate through the senses. Squeeze rubber ball tightly, hold ice in mouth, go out in the rain or snow.
 Nothing harmful (like holding ice in your hand or snapping a rubber band on your wrist). Those are
painful, not conducive to reinforcing healthy behaviors.
IMPROVE the Moment
Imagery
 Guided imagery, scripts online/YouTube/etc. Where you can go when you feel triggered, etc.
 Imagine the “course” you have to do before you do it.
 Visualize using interpersonal skills at home/effectively with someone you need to speak to.
 Imagine a beautiful scene on the beach, mountains, or a safe place in your home.
Meaning
 Finding an important reason “why” it would be important to cope/abstinence/not act on urges/etc.
 If you can figure out a why, you can figure out the how
 Silver lining in suffering (Traumatic growth). Find purpose or meaning in your daily activities.
Prayer
 Help to cope and feel connected to feel better
 Asking for guidance
 Ritual of prayer can be very soothing for those who do it. Prayer and meditation have similar effects on
emotional health and well-being
 How do you connect with your spirituality? Nature, look at the stars, recognizing the interconnectedness
to everything, including all of us.
 Go to your spiritual place in person. Wherever that is. Literally bring yourself there.
Relaxation
 Carve out time to relax
 Initiate a new hobby or get back into an old one.
 Active relaxation. Doing something nice for yourself. Breathe deeply, take a hot bath, massage your neck.
One thing at a time
 One MOMENT at a time. One thing in the moment. Focus your attention on this moment.
 “IDK how I will make it through the weekend; but I can make it through the morning, next 5 minutes, etc.
Vacation
 Taking a BREAK from adulthood. Go to the beach or the woods for a walk.
 Take time away from others for yourself, to clear your head. Set an alarm so you don’t fall asleep and
don't have to think about time.
Encouragement
 Self-talk: we all talk to ourselves; you might as well say something that is HELPFUL.
 Affirmations

MAKE THESE THINGS ACTIVE. Take 2 minutes after each IMPROVE step to have everyone do
that for themselves. PMR, deep breathing, thinking of a happy place, etc.
Have them identify each one in the session so it is easier to do those things outside of the room.
 Self-Soothe
 Mindful engagement of the sense to comfort:
 Vision, Hearing, Smell, Taste, Touch
Remember Mind-sense and Spiritual-sense

Pros and Cons

 List positive and negative consequences
 Weight of short-term vs. Long-term consequences
 Is it worth it?
 Make a decision!
Pros and cons are dialectical and activate Wise Mind
TIP Skill
The TIP Skill is intended to change your body chemistry quickly in order to reduce the effects of an
overwhelmed emotional mind; where your thinking and behaviors are controlled by your overwhelming
emotions.
Tip the temperature. Tip the temperature of your face with ice water (to calm down fast). Hold your breath,
put your face in a bowl of ice water, or hold an ice pack on your eyes and cheeks. Hold for 10-30 seconds.
Intense Exercise. Intense exercise to calm your body down when it is revved up by emotion. Engage in
intense exercise, even if it is only for a short while. Expend your body’s stored up physical energy by
running, walking fast, jumping, playing basketball, lifting weights, etc. The more intense the emotion, the
more intense the exercise.
Paced Breathing. Paced breathing (pace your breathing by slowing it down). Breathe deeply into your belly.
Slow your pace of inhaling and exhaling way down (on average, five to six breaths per minute). Breathe out
more slowly than you breathe in (for example, 5 seconds in and 7 seconds out).

Radical Acceptance
Choices when life is painful:
 Change painful situations when you can
 Shift your perspective of the situation
 Radically accept the situation
 Continue to suffer
Accepting Reality Skills
Radical Acceptance: Freedom from suffering requires acceptance of “what is” from within. Letting go of
fighting reality ends suffering
 Acceptance may still mean tolerating pain.
 Acceptance frees psychological and emotional resources to move forward
 Turning the mind. Continuously recommit to accepting reality... over and over again
Stages of Acceptance (from Kubler-Ross)
 Denial: not wanting to believe it’s real
 Anger: feeling that it is unjust and should not have happened or be happening
 Bargaining: trying to make a deal to escape the reality
 Depression: having reality set in and feeling the impact
 Acceptance: Acknowledging the reality of “what is”
 No matter where you are, you are in the process.
Everyday Acceptance: We meet everyday realities (hassles) with resistance, creating unneeded suffering
and exhausting our psychological and emotional resources: Being stuck in traffic, Having a crabby
significant other, Forgetting something at home, Having to wait for something, Making a mistake, or dealing
with someone else’s mistake. These are all opportunities to practice acceptance.
Acceptance of these realities does not mean being passive, giving in, or giving up; many of these realities
require problem-solving. Acceptance frees up our resources to be responsive and effective
Willingness (vs. Willfulness)
 Doing what is needed, not sitting on your hands; dealing with reality, not what you wish it would be
 The concept contrasts our Western philosophy of “when there’s a will there’s a way”
 “where there is willingness, there is a way” is the message
 What are you willing to do given the situation?
 Ex: when you have two choices and you know the other choice is worse for you and you choose it
anyway. Vs. Choosing the better one
How can I roll with reality the way it is; how can I make it effective for me/do the things needed to get there?

Self-Soothing Skill—doing things that feel pleasant, comforting, and provide stress/pain relief. Helps pass
the time without making things worse.
Vision—look for a beautiful sunrise/sunset, the stars at night, or pictures of these things. Look for beautiful
photos of beaches or mountains or a beautiful flower. Look at nature all around you.
Hearing—Listen to music you enjoy. Listen for the breeze, or the trees in the breeze. Listen for birds or
waves of the water.
Smell—Find a fragrance you enjoy, and smell fragrances around you. Smell a flower, or perfume, freshly cut
grass, or the burning of wood in a fireplace.
Taste—Enjoy some of your favorite foods.
Touch—Apply moisturizer. Take a hot shower, or a long bath. Sit in the sun or shade and feel the warmth of
or cool of the breeze.

DBT
 DBT was one of first western practices to incorporate mindfulness
 Mindfulness research has exploded, because IT WORKS
 The unquiet mind
 Shake up this jar for what is going on with our thinking, metaphor
 Mindfully watch while everything comes to settling spot in jar
 Brings us back to moment
 Allows us to prepare for important work when done at beginning and end of every session
 Hoberman sphere (breathing ball)
 Persuasion and healing by the Frank’s
 How to be effectiveness as a therapist—should seek to learn as many approaches as they can, create
a good therapeutic match educating patient about conceptual scheme and modifying the scheme to
take into account concepts the patient brings to therapy
 Customizing approaches
 DBT is derivative of CBT and other treatments, highly adaptable
 Research on adapted DBT outpaces standard/original DBT framework
 All this information can be used in eclectic/integrative manner
 Adaptations are both mainstream and evidence-based
 Expanded far beyond original focus on a “Standard” model used for BPD clients
 DBT borrows heavily from CBT, added in acceptance-based strategies (third wave CBT treatments have
these strategies too)
 Most notable deviation from CBT comes on the theory level: CBT is thought-focuses whereas DBT is
emotion-focused
 Marsha Linehan is creator of DBT
 Had self-harm and suicidal tendencies as adolescent/growing up
 University of Washington, Seattle
 Created for people who struggled with suicidality

Importance of Treatment Structure

 Clear treatment framework/service delivery and other structure is a common factor in empirically supported
treatments for BPD (weinburg et al., 2011)
 More complex client presentations require greater treatment and structure
 Structure creates predictability, safety, and success for clients and therapists
 “Saying what you do and doing what you say” is the foundation of trust, and it speaks to the therapy alliance

Examples of Treatment Structure

 Treatment framework/service delivery

 Detailed therapy agreements, rules, and expectations (of therapists too)
 Following typical routines of therapy and/or each part of a program
 Use of treatment stages and the treatment hierarchy
 Use of diary cards, behavior analysis, homework, and written safety and skills plans
 Treatment plans with clear goals and objectives, created early in the therapy process
 Detailed protocols for dealing with safety and other issues
 Even starting and ending on time!
 Getting away from skills group training into dealing with someone’s therapy issue. Might ask for
examples to illustrate a point, and someone may provide something that is a good example but
 suddenly we dig into the hole of problem-solving it. Everyone else is just sitting and waiting for us
to get back to the agenda, which for example is skills training. Just be mindful if you find yourself
going down that path. Say thank you to client and say you should bring that up in individual therapy,
etc.
 Always make sure you are coaching, not getting into a social or therapeutic role in group therapy or
skills training.

DBT Group-Based Programs and Contagion

 Contagion is when a person copies the behavior of another

 Happens when a model has social influence, and the behavior has a clear gain... two incentives for
another to copy the behavior
 Contagion is a two-way construct: it can be helpful (e.g., copying skill use) or destructive (e.g.,
copying a self-harm behavior). Effective programs promote helpful contagion.
 Beware the “instigator” and the “imitator” with destructive contagion
 Instigator needs accountability and the imitator needs identity work.
 Destructive contagion is most likely when harmful behaviors are promoted and/or glamorized.
Media is a common culprit.
 Someone who has “social status” in the group.
 Also, that the behavior they are engaging in is getting them something
 Have to shut down anyone who is giving attention to any harmful or negative behavior.
Stomp it out! When you talk about alcohol or drug use and how fun it is/cool it is, i want to
let you know you will not do this here. People come here to deal with their real problems, to
gain skills, and that is not conducive. We do not talk about that here. Am I clear about that?
Be assertive with things like that.
 Contagion is most common in settings in which clients have significant unmonitored time.

Implementing a DBT program: what to consider

 Target population (inclusionary/exclusionary criteria)

 Level of care needed for population
 Program goals (e.g., acute stabilization, symptom reduction, long-term improvements in functioning)
 Available resources (Staffing, space, other)
 Staff “buy in” (allegiance) with the approach
 Sustainability of the approach

Implementing a DBT program: what is needed

 Clear treatment framework

 Clear program expectations
 In-depth DBT and skills training for all staff
 Ongoing consultation
 Ongoing training and program development
 Monitoring outcomes and using them to improve services

Common considerations with DBT programs

 Separate or mixed programs for males and females?

 Open or closed groups?
  Length of stay?
 When to start new clients?
 Program manuals/curriculum?
 How long to teach each skill?
 For adolescents: to include parents in skills training or not?

Four original skills modules (categories of skills)

 Mindfulness
o Wise Mind and Core “what” and “how” skills
 Distress tolerance
o ACCEPTS, IMPROVE, Self-soothe, Pros and Cons, Radical Acceptance, Willingness
 Emotion regulation
o Model of emotions, PLEASED, BPE, BM, O2E
 Interpersonal effectiveness
o FAST, GIVE, DEAR MAN

Diary Cards

 Self-monitoring of urges, target behaviors, symptoms, skills, emotions, and other important information
(e.g., positive experiences (highlights), treatment objectives, gratefulness)
 Helps to structure and generalize what is learned in therapy to natural environments; builds awareness
and skill use
 Provides a tremendous amount of information to track how the client is doing, determine if there are
target behaviors on the treatment hierarchy to prioritize, and to set the treatment agenda
 Also provides opportunities to positively reinforce success and to inquire about extra-therapeutic factors

Diary Card Guidelines

 Orient clients to why the diary cards are important and how it will help them reach their goals
 Complete each day, preferably at the same time, for the previous 24 hours
o To make a time and place each day where they create a habit for the diary card
o Average distress levels, average urge levels,
o Documenting what skills you are using to actively work on whatever it is (depression, etc.)
 Review diary cards at the beginning of session and use the information to set the agenda with clients
 Address incomplete diary cards as a TIB (treatment-interfering behavior)

Purpose of Behavior and Solution Analysis

 Develop a picture of what comes before a behavior (antecedents)

 Develop a picture of what comes after a behavior (consequences)
 Understand the context that surrounds behaviors
 Use this understanding to actively problem-solve and develop skill use
 Used often during Stage 1 for targets on the treatment hierarchy (SI, SIB, TIB)
 Also, an excellent method for adding structure to sessions
o Also called behavior chain analysis, functional analysis, change analysis. Etc.
o Go through a chain analysis for a number of different situations that led to problem
behavior and try to identify all the functions a problem behavior serves for you
 o Allows people to better recognize the factors that contribute e to problem behavior, identify
triggers, and look for solutions to stop the problem at many different points
o Also may be helpful to identify what things might have made you more susceptible to
responding to the situation as you did. Ex: when people don’t sleep or eat enough, they may
be more susceptible to experiencing negative moods or having more reactive emotional
experiences.

How to frame behavior and solution analysis

 Some clients experience change analysis as punishment; if this happens, be sure to validate the
experience. It is often used as a punishment in other settings, so you must orient them to why we do
behavior analysis!
 However, discuss how change analysis is a learning tool to help clients reach their goals
 Discuss expectation that change analysis will be used for target behaviors on the hierarchy (SI, SIB,
TIB), and for both in-sessions and out-of-session behaviors that require problem-solving
 Also consider using change analysis for positive behaviors
During the Behavior and Solution Analysis Process

 Orient clients to procedure and continue to orient as you go through the change analysis (why is this
important to the client?)
 Validate the emotions that arise and that change analysis can be difficult. Attending to emotions also
provides exposure effects.
 Use positive reinforcement for efforts and breakthroughs
 Remember that the end goal is to learn skills and solve problems
 Coordinate what is learned with crisis, safety, and other skills plans

Steps in Behavior and Solution Analysis

 1. clearly define the target behavior

 2. ask about frequency, intensity, and duration of the behavior
 3. go step-by-step until you have a clear picture of the following:
o a. what made the client vulnerable
o b. what was the prompting event (trigger)
o c. what are the links between the prompting event and the target behavior (e.g., emotions,
thoughts, physical sensations, other behaviors, what is happening or not happening in the
environment)
o d. what were the consequences of the target behavior?
 4. go back and have client hypothesize possible skills to use to address vulnerabilities and intervening
links, as well as skills to replace target behaviors (take out safety plan if applicable)
 5. have client problem-solve how to skillfully deal with consequences so they do not develop into
vulnerabilities
 6. have client develop a plan to make amends with others for the target behavior if applicable
 7. get commitment from client that they will actively practice the identified skills

Starting out (pre-treatment stage)

Socializing the Client to Treatment

 o Define what DBT is!
o Clarify the clients and your respective roles (as well as the role of other program members and
service providers as needed)
o Define the goals and tasks of each service delivery
o Review important protocols, rules, guidelines, and agreements
o Establish goal(s)
o Be clear that DBT works when you “work” the treatment!

Commitment Strategies

o Evaluate pros and cons of therapy

o Foot in the door techniques
o Door in the face techniques
o Highlight the freedom to choose (especially in the absence of alternatives)
o Play devil’s advocate
o Connect to prior commitments
o Shape stronger commitment (as therapy progresses)
o Coach and cheerlead

Initial Commitment Interventions

o Initial commitment needs to move to agreement on:

 Treatment plan goals and objectives
 Treatment method and means of accomplishing goals and objectives
 Relevant expectations and agreements
o Commitment in therapy is continually revisited for many of the tasks in therapy, big and small,
including revisiting initial commitment

Interventions and orienting

o Orienting is explaining the rationale for why treatment tasks are necessary for the client’s goals:
this means really understanding what the client wants and needs
o Orienting begins during pretreatment and is continuous throughout treatment
o Orienting helps to maintain commitment and to keep therapy client-driven
o Successful orienting keeps clients active and cooperating

Validation: Keys to the kingdom

o Validation is the non-judgmental acknowledgment of the client’s experience

o Validation creates the conditions of acceptance that usually precede change
o As a rule, start with validating the client, and return to validation when the client is “stuck”
(remembering that rules have exceptions)
o Normalizing is communicating to someone “given what you’re going through, you’re kind of in
the same boat as other people going through that. You’re not alone.”
 Vs. Validation: how would the client specifically be experiencing the
depression/whatever emotions they report. Vicki what you’re describing is that there are
times when your mood is so low that you feel like there is a film over you and you can’t
 do even the most basic tasks. Getting to this appointment was like moving a boulder.
You're in a tough spot with this depression.”
 Affirmations (can be invalidating if you go for that first). Ex: i make so many mistakes, I
don’t do anything right. Im such a disappointment as a person, i don't’ know why anyone
would want to like me as a person.” affirmation would be “you’re a great person and
people really respond to your personality and like you a lot, i know you think you make a
lot of mistakes but you do a lot more things right than make mistakes.” building someone
up. BUT THAT IS NOT WHAT SHE NEEDS IN THIS MOMENT
 VS. VALIDATION: i hear that you’re really down in this moment, you’re so
down on yourself. In this moment, it feels like you can’t do anything right, it feels
like “gosh why would anyone want to know you or be your friend.” you’re really
in this place where everything seems down and going wrong.”
o AND
 Can be affirmation, normalizing, what could be helpful right now?
Practice non-judgmental stances, maybe an activity, reach out to
friends, etc.
 Validation must be done slowly! Let it take its time to sink in (like WD-40), let it get into
the rust and work

Levels of Validation (Linehan, 1997)

 Being acutely attentive

 Reflecting verbal communication
 Describing non-verbal communication
 Expressing how experience makes sense given history or biology
o You said you've done therapy before in the past and it didn't work. Its stressful to have to
do something/be apart of something that you feel doesn’t work. You sound frustrated that
dr. Smith is having you come and be apart of this therapy. Its hard to expect that this can
be any different than the past when you don’t know me and don’t want to be here.
 Expressing how experience makes sense in the present moment and context
 Being in genuine, human contact

Validation as an Exposure Technique

 Regulates emotions by decreasing their intensity

 Provides gentle, informal exposure to emotions with a sense of self-efficacy
 Allows for a more complete expression of emotions, cueing a fuller adaptive response

Balance of Validation and change

 Validation opens clients to change:

o Lets clients know you understand the nature of their issues and pain
o Exposure to painful emotions create a qualitative difference in relating to emotions (decreasing
ineffective escape and avoidance behaviors)
o Exposure to painful emotions can create motivation to invest in change

Validation Exercise
  Form a dyad or triad. Role-playing your client, being to introduce a therapy issue to your therapist. The
therapist (for this exercise) will resist problem-solving and instead stick with validation as the primary
intervention. Aim to validate on the highest level possible.
 After 5 minutes, switch roles

Understanding the Treatment Alliance

Client

Goal

Therapist Method

Behavioral Principles

 Positive reinforcement: behavior is followed by a reward, increasing the behavior’s frequency

 Negative reinforcement (Avoidance learning): behavior is followed by removal of something
aversive, increasing the behavior’s frequency (car seat belt alarm)
 Positive punishment; behavior is followed by something aversive, decreasing the behavior’s frequency
o Does not teach anyone anything new.
 In the absence of punisher, the person being punished will go right back to the behavior
being punished for in first place
o Causes hostility in relationships. Can create ruptures in alliance
o Activates emotions and goes directly against DBT where we are trying to improve emotion
regulation
 Negative punishment (response cost): behavior is followed by removal of something, decreasing the
behavior’s frequency
o Removing something desirable from someone. Ex: removing the markers from both kids who are
fighting over the markers.
 Extinction: removal of reinforcement for a behavior, leading to a decline in the behavior
 Generalization: performing desired behavior outside of the treatment setting

Behavioral Considerations

 Are effective behaviors reinforced? On what schedule? Be careful to maintain desired behaviors
 How are ineffective behaviors reinforced (maintained)?
  How can i shape effective behaviors while extinguishing ineffective behaviors?
 Consider relevant behavioral principals when analyzing

Behavioral Contingencies

 The consequences of behavior influence what we learn

 A temporally close relationship between behavior and consequence influence what will happen the next
time we are in a similar situation with similar context
 Highlighting contingencies (structure, expectations, safety, immediate feedback, etc.) helps clients learn
and be more effective

Examples of Contingency Management

 Observing boundaries (limits)

 Defined plans with consequences for specific behaviors
 Program rules and expectations with consequences
 Changes to environment to reinforce or extinguish behaviors
 Every observable therapist or team response is an informal contingent procedure
 See handouts on DBT skills group and program expectations and DBT individual therapy expectations.
Also see phone coaching expectations, and consultation group agreement handouts.

Most Effective Behavior Change Methods

 Provide non-contingent reinforcement

o Give people sufficient involvement, attention, caring, reinforcement of different types; and they
don’t need to do anything to earn it. Of course you may withhold it in a specific moment, but you
generally give this all the time.
 Model effective behavior
 Reinforce non-problem behaviors (especially incompatible ones)
 Train skills to reinforce
 Make a high-probability behavior contingent on a low-probability behavior
 Lower vulnerability and meet organismic needs proactively
 Harness high level motivations to leverage change

Dialectical Strategies

 Enter the paradox by highlighting:

o Mismatch between words and behaviors
 It is difficult to create a different life you are unwilling to try anything different
 You are not SOLVING, you are handing it back to the client. Guided discovery.
o Discrepancy between values and behaviors
o Inaction in light of knowledge of what would be helpful
o Tension between preferred reality and actual reality
o When client wants relationship but actively works to destroy it
o Strength and resiliency behaviors that contrast a poor self-concept
 Refusing right and wrong/answers can be yes and no (e.g., a therapist can care and still set limits on
availability)
 Use of metaphors or stories
  Devil’s advocate
 Extending
 Wise mind activation
 Making lemonade out of lemons
 Prescribing the feared behavior
 Using the “exception rule”
 Role reversal
 Allowing natural change

Cognitive Interventions

 Have traditionally been de-emphasized in DBT

 Assume that clients are not fragile, they are able to evaluate thoughts and beliefs
 Clients do benefit from cognitive interventions (non-judgmental stance is a cognitive intervention)
 DBT-style cognitive intervention take a “softer,” more validating approach
 Avoid cognitive interventions with emotionally-activated clients
DBT-style cognitive interventions
 Guided by different theory (emotion dysregulation), so emotions remain the primary target, with thoughts
and beliefs being a secondary target
 Avoids judgmental labels (distortions, errors, maladaptive thoughts, etc.). uses traditional cognitive
“distortions”, but without the labels.(minimizing, black and white thinking, catastrophizing, etc.) and call
them “styles of thinking.” Normalize them. We all think like this from time to time. Sometimes they fit the
facts of the situations, too.
 Validates origin and adaptation that comes from the thought or belief
 Analyzes dialectically rather than categorically
 Emphasizes shifting and expanding rather than a “Cut and paste” style of addressing thoughts and beliefs;
we do not talk clients out of thoughts and beliefs
 Points out effective thinking to develop sense of self-trust

Working with Trauma in DBT

 Develop self-care, build grounding skills, fill the distress tolerance “toolkit”
 Client must be stable before doing exposure-based treatment! Goals of stage one must be met
before stage two
 EMDR is compatible with DBT protocols
 Provide/obtain clear informed consent
When NOT to use Exposure
 When there is active suicidal/homicidal urges
 When there is regular self-injury (or the risk of serious self-injury)
 when there is psychosis
 when there is significant risk of harm from others
 when there is insufficient memory of the trauma
 when there is clinical issue that has more importance (resolve first)
Alternatives to Exposure
 mindful, present-centered approach to life
 re-connection to emotions (especially positive), relationships, and the future
(including plans for the future)
 distress tolerance and emotion regulation skills
 resolution of current life problems
 cognitive interventions around trauma-related thoughts and beliefs
 provide a clear rationale for these alternatives to exposure along with the coherent
application of techniques that accomplish these goals
 Research shows that non-exposure based treatment models have equivalent
efficacy when compared to exposure-based treatment models.
Reciprocal communication
 Engaging and responsive, taking clients wants and needs seriously
 Being authentic and genuine, not staying in a “therapist” role
 Using self-disclosure thoughtfully in the service of therapy
 Sharing “Benign” and human examples of skill use and practice
 Using examples of how you have approached and solved a problem
 Sharing when you have felt, thought, or responded similarly to how a client reports
in a given situation
 Sharing your reactions to the client in the moment, providing information that
manages relationship contingencies (creating new learning)
Self disclosure of personal information
 Personal information may not relate to client or the therapy. if it is not relevant, do
not share it as a rule
 Observe and disclose your limits in regard to personal information when needed (ok
to explore what personal inquiries mean to the client)
 • Never share personal problems/issues!
 • Does it pass the “public” test? In other words, would you share it in front of an
audience of your colleagues?
Irreverent communication
 Irreverence is an offbeat style intended to:
 Get the client’s attention through surprise or an unexpected response
 – Show another point of view or get the client to process on a different level
 – Create a shift with emotions, thoughts, or behaviors
 • Irreverence works best when used by therapists with a naturally irreverent style
 • Irreverence is not necessary to be an effective DBT therapist; use it only if it comes
from a genuine place
 Essentials of Irreverent communication:
 Assumes that the client is not fragile
 Needs to be surrounded by validation
 Needs a “solid” therapeutic relationship
 Know your goal, observe the effects, and balance with validation
 Consider if it fits your style, or fits your style too well!
 Do not use when frustrated or at the expense of the client!
 Examples of irreverent communication:
 Responding to or reframing a client’s communication in an unexpected way,
usually picking up on a subtle or unspoken aspect of the communication
 Taking a direct route: going where angels fear to tread
 Being confrontational, like calling “bullshit” on a client
 Calling a “bluff” while providing a (well-timed) way out
 Switch intensity levels (between humor and seriousness)
 Using silence while waiting for a particular response
 Express impotence or omnipotence