Dialectical Behavioral Therapy (DBT) for Youth
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DIALECTICAL BEHAVIORAL
THERAPY (DBT) FOR YOUTH
EDGEWOOD CENTER
Mark Purcell, PsyD
Different Types of Emotions
DBT Goals
RADICAL ACCEPTANCE
Grant me the serenity to ACCEPT the things I cannot
change,
Courage to CHANGE the things I can,
And WISDOM to know the difference.
4
DBT Program Overview
Dialectics Finding Balance
Dialectics Involves integrating seemingly opposing
views
Similar to Eastern Concepts of Non-Duality
Use the word “And” instead of “But”
Biosocial Theory
I am
Stupid...
There’s
something
wrong with
me
I don’t
deserve
to live
You’re
so
stupid!
I don’t
understand
why you’re
so upset
I wish you
were never
born
Confusion about self; impulsivity; emotional
instability; interpersonal problems
Emotional Dysregulation
High Sensitivity
Immediate reactions
Reactions with only a little
provocation
High Reactivity
Extreme reactions
High arousal makes thinking
clearly difficult
Slow return to baseline
Long-lasting reactions
Higher sensitivity to next
emotional event
Difficulties with changing
one’s own emotions
Difficulties with paying
attention (e.g., in class)
when emotions are felt
Difficulty in stopping
from acting
right away
when emotions are felt
Biological Vulnerability to Emotions
(Sensitive Wiring)
Low Emotional Modulation
Consequences of invalidating
Environment
By not validating feelings, the environment does not teach the individual to:
Label feelings
Effectively regulate emotions
Trust feelings
By making problem solving seem easier than it is, the environment does not teach the
individual to:
Effectively tolerate stress
Form realistic goals and expectations
When communication of anger or sadness is punished
and/or
when only intense anger
or sadness are responded to, the environment teaches the individual to:
Vary between having
no emotions
and having
extreme emotions
.
Types of Dysregulation
Emotional
Interpersonal
Self
Behavioral
Cognitive
D
IALECTICAL
B
EHAVIOR
T
HERAPY
Validation
V
ALIDATION
COMMUNICATES
TO
ANOTHER
PERSON
THAT
HIS
/
HER
FEELINGS
,
THOUGHTS
,
AND
ACTIONS
MAKE
SENSE
AND
ARE
UNDERSTANDABLE
TO
YOU
IN
A
PARTICULAR
SITUATION
.
V
ALIDATION
≠ A
GREEMENT
WHAT
SHOULD
WE
VALIDATE
?
F
EELINGS
,
THOUGHTS
,
AND
BEHAVIORS
IN
:
O
URSELVES
O
THER
P
EOPLE
WHY
SHOULD
WE
VALIDATE
?
I
T
IMPROVES
RELATIONSHIPS
V
ALIDATION
CAN
SHOW
THAT
:
W
E
ARE
LISTENING
W
E
UNDERSTAND
W
E
ARE
NOT
BEING
JUDGMENTAL
W
E
CARE
ABOUT
THE
RELATIONSHIP
C
ONFLICT
IS
POSSIBLE
WITH
DECREASED
INTENSITY
AND
ANGER
Levels of Validation
Interaction of Emotions,
Thoughts
, &
Behaviors
Matching Skills with
Level of Dysregulation
E
M
O
T
I
O
N
A
L
D
Y
S
R
E
G
U
L
A
T
I
O
N
Commitment Strategies
Selling it, evaluating pros and cons
Devil’s advocate
Foot-in-the-door technique
Freedom to choose in absence of alternatives
Shaping
Orientation Strategies
Therapeutic Alliance
Connect problems to areas of dysregulation and skill development
Define problems as targets
Link long-term goals to targets
Introduce biosocial theory
Introduce tx format/characteristics
Introduce diary cards
Review agreements
Use commitment strategies
Pre-Treatment Goals
Agreement on Goals
Commitment to change
Initial targets of treatment
Agreement to Recommended Tx
.
Client agreements
Therapist agreements
Agreement to Therapist-Client Relationship
Treatment Goals
Level 1: Severe Behavioral Dyscontrol
Level 2: Quiet Desperation
Level 3: Problems in Living
Level 4: Incompleteness
Stage 1 Targets
Decrease
Life-threatening/high-risk behaviors
Therapy-interfering behaviors
Quality of life interfering behaviors
Increase behavioral skills
Mindfullness, distress tolerance, interpersonal effectiveness,
emotional regulation
Therapy-Interfering Behaviors
Client
Non-compliance
Non-collaborative
Non-attending
Behaviors that interfere with other clients
Pushing therapists’ limits
Reduce therapist’s motivation to treat
Therapy-Interfering Behavior
Therapist
Extreme acceptance or change
Extreme flexibility to rigidity
Extreme nurturing or withholding
Extreme vulnerability or irreverence
Disrespectful Behaviors
Quality of Life Interfering Behaviors
Incapacitating DSM Disorder
High risk sexual behavior
Extreme financial difficulties
Criminal behaviors
Severe interpersonal dysfuntion
Unemployment, severe school problems
Physical health, dysfunctional behaviors
Severe housing difficulties
Adol. Secondary Targets
Excessive leniency vs. authoritarian control
Normalizing pathological behaviors vs. pathologizing
normative behaviors
Forcing autonomy vs. fostering dependence
Diary Cards
Track and observe behaviors in real time
Structure Session
Spring board to Chain and Solution Analysis
Integration of Skills
Diary Cards
Chain Analysis
vu
VULNERABILIES
PROMTING EVENTS
PROBLEM BEHAVIOR
CONSEQUENCES
Solution Analysis
Identify goals, needs, desires
Generate solutions
Evaluate solutions
Choose a solution to implement
Troubleshoot solution
Responding to Problems
Solve the problem
Change emotional reaction to problem
Tolerate/accept the problem
Stay miserable
DBT Consultation Agreements
To accept a dialectical philosophy
To consult with patient on how to interact with other
therapists
Consistency of therapists is not expected
Observe own limits, without judgment
Consultation Agreements Con’t
Search for non-pejorative, empathic interpretation of
client’s behavior
All therapists are fallible
DBT Team Responsibilities
Plan and trouble shoot treatment
Monitoring adherence to DBT
Progress towards DBT competence
Consult to the therapist
Support to therapist and team members
DBT SKILLS MODULE I
MINDFULNESS
States of Mind
W
I
S
E
M
I
N
D
States of Mind
“What” Skills
“How” Skills
The Mindful Observer
Dialectics Finding Balance
DBT MODULE II:
DISTRESS TOLERANCE
Presented by Mark Purcell. PsyD
Pain & Tolerance
41
41
Avoidance & Acceptance
42
42
Crisis Survival Skills:
Distract with ACCEPTS
43
43
Crisis Survival Skills:
Self Soothe with the Senses
44
44
IMPROVE the Moment
45
45
Urge Surfing
Every urge has three phases.
Ramp-up period begins at
trigger point or event, when
the idea of doing the
behavior first arises.
The peak is the intense high
point of the urge.
Ramp-down or fall off
period as things gradually
return to baseline
TO Urge Surf:
Breath deep and have
willingness to reduce the
urge and let go of the
behavior as a solution for
pain.
Remove yourself from the
situation if you can.
Relax the body and practice
breathing or calming
techniques while staying
mindful and present-focused.
46
46
Pros & Cons of Change
47
47
Distress Tolerance Review
9/11/2024
48
48
RADICAL ACCEPTANCE
Grant me the serenity to ACCEPT the things I cannot
change,
Courage to CHANGE the things I can,
And WISDOM to know the difference.
49
49
DBT MODULE III:
EMOTIONAL REGULATION
Presented by Mark Purcell, PsyD
Different Types of Emotions
What Are Emotions
Emotions
Communicate
to ourselves information that
something is happening .
E.g. “I feel very nervous standing alone in this dark alley.”
Emotions
communicate
to and
influence
others.
E.g. Your sad facial expression may cause the other person
to come closer to you, ask if you are OK, and give you some
support.
Emotions
prepare us for action
.
E.g. If you step off the sidewalk without looking and hear a
horn, your fear makes you automatically step back.
Goals of Emotional Regulation
Understand Emotions You Experience
Identify (observe & describe) emotion
Understand what emotions do for you
Reduce Emotional Vulnerability
Decrease negative vulnerability (Emotional Mind)
Increase positive emotions
Decrease Emotional Suffering
Let go of painful emotions through mindfulness
Change painful emotions through opposite action
Taking
Charge of Emotions
Taking charge of emotions is important because:
•
People often have intense emotions such as anger,
frustration, depression, or anxiety.
•
Difficulties controlling these emotions often lead to
impulsive, dangerous or ineffective behaviors.
•
Impulsive or ineffective actions are often behavioral
solutions to intensely painful emotions, and yet they may
have long term negative consequences.
Interaction of Emotions,
Thoughts
, &
Behaviors
Deciding What to do with our Feelings
When our Emotions are Justified &
Match Situation
When Our Emotions are NOT
Justified or Do Not match situation
Use Problem Solving
Skills to deal most
effectively with the
situation.
Engage in the Opposite
Action from our initial
urge action.
Justified Emotional Responses
Justified Emotional Responses
Steps for Problem Solving
First, try to move towards
Wise Mind
THEN ASK:
Can the problem be solved?
If YES, Try Problem Solving. If NO, Use Distress Tolerance Skills (Acceptance)
STEP 1:
OBSERVE and DESCRIBE the problem. Describe exactly what makes
this situation a problem.
STEP 2:
BRAINSTORM lots of solutions. Be willing to consider all possibilities
without judgment.
STEP 3:
CHOOSE the potential solutions that are likely to work.
STEP 4:
Put the potential solution into ACTION. Try out the solution.
STEP 5:
OBSERVE the outcomes. Is the problem improved or solved? Did
you meet your goals?
STEP 6
: It WORKED? Yeah, reward yourself.
OR
STEP 6:
It DIDN’T WORK? Reward yourself for trying. TRY a new solution.
Change Emotions with Opposite Action
Change Emotions with Opposite Action
Steps for Opposite Action
1.
Figure out what emotion you are feeling.
2.
What is the action that goes with that emotion?
3.
Ask yourself: Do I want to change the emotion?
4.
Figure out the Opposite Action
5.
Do the Opposite Action…ALL THE WAY!
How to Reduce Vulnerability to
Emotional Mind
A
ACCUMULATE POSITIVE EXPERIENCES
In the short term, increase pleasant activities that lead to positive emotions.
Do one thing each day from the Pleasant Activities List.
In the long term, make changes in your life so positive events will occur more often.
Build a life worth living:
Work towards goals:
Pay attention to relationships:
Avoid avoiding.
Avoid giving up.
B
BUILD MASTERY
Schedule one or more activities each day to build a sense of accomplishment.
C
COPE AHEAD OF TIME WITH EMOTIONAL SITUATIONS
Create a plan ahead of time so that you are prepared to cope skillfully with
emotional situations.
Imagine yourself coping effectively.
Accumulate Positive Experiences
In the short term, increase pleasant activities that lead to
positive emotions.
Do one thing each day from the Pleasant Activities List.
In the long term, make changes in your life so positive events
will occur more often.
Build a life worth living:
Work towards goals:
Pay attention to relationships:
Avoid avoiding.
Avoid giving up.
Build Mastery
Schedule one or more activities each day
to build a sense of accomplishment.
Cope Ahead
COPE AHEAD OF TIME WITH
EMOTIONAL SITUATIONS
Create a plan ahead of time so that you
are prepared to cope skillfully with
emotional situations.
Imagine yourself coping effectively.
DBT MODULE IV:
INTERPERSONAL
EFFECTIVENESS
Presented by Mark Purcell. PsyD
What is Your Goal?
Getting something you want done?
Getting someone else to do something.
Saying no to someone.
Having your opinion taken seriously.
Getting or keeping a good relationship?
Acting in a way that makes another person respect you.
Balancing your current goal with your long term goal.
Maintaining your self respect?
Respecting your own values.
Acting in a way that makes you feel good about yourself.
What Stops You?
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Choices for Responding to Any Problem
Situation
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C
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A
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M
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M
a
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i
t
W
o
r
s
e
Getting Something Done
D - Describe
E - Express
A – Assert Yourself
R – Reward
Self/Other
M – Mindful/Focus
A – Appear
Confident
N - Negotiate
Keep Good Relationships
G – be Gentle
I - Interested
V – Validate
E – Ease Conversation
Maintain Self Respect
F – Fair
A- (no) Apologies
S – Stick to Values
T - Truthful
Matching Skills with
Level of Dysregulation
E
M
O
T
I
O
N
A
L
D
Y
S
R
E
G
U
L
A
T
I
O
N
Explore the comprehensive practice of Dialectical Behavioral Therapy (DBT) aimed at enhancing emotional regulation in youth. Learn about different types of emotions, DBT goals, radical acceptance, program overview, dialectics, biosocial theory, and emotional dysregulation. Discover the tools and skills involved, along with the importance of finding balance and managing biological vulnerability to emotions.
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Presentation Transcript
DIALECTICAL BEHAVIORAL THERAPY (DBT) FOR YOUTH EDGEWOOD CENTER Mark Purcell, PsyD
Different Types of Emotions Calm SAD Anger Anger LOVE LOVE Pain PainConfused Confused Worried GUILT GUILT Worried
DBT Goals Increase Target Behaviors Dysregulation TOOLS: Diary Card Behavior Chain TOOLS: DBT Skills Group
RADICAL ACCEPTANCE 4 Grant me the serenity to ACCEPT the things I cannot change, Courage to CHANGE the things I can, And WISDOM to know the difference.
DBT Program Overview Skills for Coping As Needed Weekly Weekly Skills Coach Behavior Coach Individual Therapist Skills Group Leaders Diary Cards Skills Training Target Behaviors Youth & Coach
Dialectics Finding Balance Dialectics Involves integrating seemingly opposing views Similar to Eastern Concepts of Non-Duality Use the word And instead of But One Set of Needs or Wants Opposing Needs or Wants Acceptance Change Trust Suspicion Dependence Independence Careful, Too Fearful Impulsive, Reckless Surrender Protect/Fight Focus on Self Focus on Others
Biosocial Theory I am Stupid... Invalidating Environment Biological Vulnerability You re so stupid! There s something wrong with me I don t understand why you re so upset I don t deserve to live Behavioral Problems I wish you were never born Confusion about self; impulsivity; emotional instability; interpersonal problems
Emotional Dysregulation Biological Vulnerability to Emotions (Sensitive Wiring) Low Emotional Modulation High Sensitivity Immediate reactions Reactions with only a little provocation High Reactivity Extreme reactions High arousal makes thinking clearly difficult Slow return to baseline Long-lasting reactions Higher sensitivity to next emotional event Difficulties with changing one s own emotions Difficulties with paying attention (e.g., in class) when emotions are felt Difficulty in stopping from acting right away when emotions are felt
Consequences of invalidating Environment By not validating feelings, the environment does not teach the individual to: Label feelings Effectively regulate emotions Trust feelings By making problem solving seem easier than it is, the environment does not teach the individual to: Effectively tolerate stress Form realistic goals and expectations When communication of anger or sadness is punished and/or when only intense anger or sadness are responded to, the environment teaches the individual to: Vary between having no emotions and having extreme emotions.
Types of Dysregulation Emotional Interpersonal Self Behavioral Cognitive
DIALECTICAL BEHAVIOR THERAPY Problems (Behaviors to Decrease) Skills (Behaviors to Increase) Confusion about your self Mindfulness Impulsivity Distress Tolerance Emotional Instability Emotional Regulation Interpersonal Problems Interpersonal Effectiveness Parent-Youth Problems Middle Path
Validation VALIDATIONCOMMUNICATESTOANOTHERPERSONTHATHIS/HERFEELINGS, THOUGHTS, ANDACTIONSMAKESENSE ANDAREUNDERSTANDABLETOYOUINAPARTICULARSITUATION. VALIDATION AGREEMENT WHAT SHOULDWEVALIDATE? FEELINGS, THOUGHTS, ANDBEHAVIORSIN: OURSELVES OTHER PEOPLE WHY SHOULDWEVALIDATE? ITIMPROVESRELATIONSHIPS VALIDATIONCANSHOWTHAT: WEARELISTENING WEUNDERSTAND WEARENOTBEINGJUDGMENTAL WECAREABOUTTHERELATIONSHIP CONFLICTISPOSSIBLEWITHDECREASEDINTENSITYANDANGER
Levels of Validation Validation Level Goal of Interaction One Listen Non-Judgmentally Two Accurate Reflection Three Articulate Unspoken Thoughts and Feelings Four Understanding Historical Background of Behavior Confirming Thoughts, Behaviors and Feelings Based on Current Circumstances Five Six Radical Genuineness & Authenticity
Interaction of Emotions, Thoughts, & Behaviors
Matching Skills with Level of Dysregulation EMOTIONAL DYSREGULATION Distress Tolerance Emotional Regulation Interpersonal Effectiveness Mindfulness
Commitment Strategies Selling it, evaluating pros and cons Devil s advocate Foot-in-the-door technique Freedom to choose in absence of alternatives Shaping
Orientation Strategies Therapeutic Alliance Connect problems to areas of dysregulation and skill development Define problems as targets Link long-term goals to targets Introduce biosocial theory Introduce tx format/characteristics Introduce diary cards Review agreements Use commitment strategies
Pre-Treatment Goals Agreement on Goals Commitment to change Initial targets of treatment Agreement to Recommended Tx. Client agreements Therapist agreements Agreement to Therapist-Client Relationship
Treatment Goals Level 1: Severe Behavioral Dyscontrol Level 2: Quiet Desperation Level 3: Problems in Living Level 4: Incompleteness
Stage 1 Targets Decrease Life-threatening/high-risk behaviors Therapy-interfering behaviors Quality of life interfering behaviors Increase behavioral skills Mindfullness, distress tolerance, interpersonal effectiveness, emotional regulation
Therapy-Interfering Behaviors Client Non-compliance Non-collaborative Non-attending Behaviors that interfere with other clients Pushing therapists limits Reduce therapist s motivation to treat
Therapy-Interfering Behavior Therapist Extreme acceptance or change Extreme flexibility to rigidity Extreme nurturing or withholding Extreme vulnerability or irreverence Disrespectful Behaviors
Quality of Life Interfering Behaviors Incapacitating DSM Disorder High risk sexual behavior Extreme financial difficulties Criminal behaviors Severe interpersonal dysfuntion Unemployment, severe school problems Physical health, dysfunctional behaviors Severe housing difficulties
Adol. Secondary Targets Excessive leniency vs. authoritarian control Normalizing pathological behaviors vs. pathologizing normative behaviors Forcing autonomy vs. fostering dependence
Diary Cards Track and observe behaviors in real time Structure Session Spring board to Chain and Solution Analysis Integration of Skills
Chain Analysis vuVULNERABILIES PROMTING EVENTS PROBLEM BEHAVIOR CONSEQUENCES
Solution Analysis Identify goals, needs, desires Generate solutions Evaluate solutions Choose a solution to implement Troubleshoot solution
Responding to Problems Solve the problem Change emotional reaction to problem Tolerate/accept the problem Stay miserable
DBT Consultation Agreements To accept a dialectical philosophy To consult with patient on how to interact with other therapists Consistency of therapists is not expected Observe own limits, without judgment
Consultation Agreements Cont Search for non-pejorative, empathic interpretation of client s behavior All therapists are fallible
DBT Team Responsibilities Plan and trouble shoot treatment Monitoring adherence to DBT Progress towards DBT competence Consult to the therapist Support to therapist and team members
DBT SKILLS MODULE I MINDFULNESS
States of Mind W I S E M I N D
States of Mind Emotional Mind Feeling - Centered Logical thinking is difficult Facts are distorted to match mood You may be impulsive or Hot Headed Emotions are in control Emotions influence and control your thinking & behavior Operate in Emo Mode Wise Mind Thoughts + Feelings Integrate best of emotional & rational minds Viewing situation with loving detachment Observing & responding Not Intense Reacting Not Cool Distancing Operate in Wise Mode Rational Mind Thought centered Emotions are ignored Focus on Facts & Logic Feelings of self & others not considered Cool and detached Operate in Robot Mode
What Skills Just notice the experience Watch your thoughts and feelings come and go Do not push away your thoughts and feelings, let them happen Notice what comes through your senses Observe Describe Put words on the experience. For example: I feel sad right now or My stomach muscles are tightening. Involve yourself in the experience or activity Fully experience feelings without being self-conscious Completely throw yourself into the current moment Don t worry about tomorrow, or about what happened yesterday Just focus on whatever is actually happening Participate
How Skills Don t evaluate Stick to just the facts Accept the moment Just acknowledge the emotion- don t get pulled into it Don t judge your judging Don t Judge Focus Mindfully Focus on one thing at a time Let go of distractions Focus on what works for you Act as skillfully as you can. Play by the rules Keep your eye on what you want in the long run Do what you need to achieve your goals Let go of vengeance, useless anger, and feelings that hurt you and do not work Do What Works
Dialectics Finding Balance One Set of Needs or Wants Opposing Needs or Wants Acceptance Change Trust Suspicion Dependence Independence Careful, Too Fearful Impulsive, Reckless Follow Rules Do What We Want Focus on Self Focus on Others
DBT MODULE II: DISTRESS TOLERANCE Presented by Mark Purcell. PsyD
Avoidance & Acceptance 42 Pain Pain Avoidance Acceptance Suffering Mindfulness
Crisis Survival Skills: Distract with ACCEPTS 43 Activity Engage in exercise or a favorite hobby Contributing Contribute to something Do something for someone else Comparison Compare yourself now to past times when you may have suffered even more Emotions Listen to music; read books; go to movies Be sure the event creates different emotions Pushing Away Push the situation away by leaving it for a while mentally Do something to engage your mind Count to ten. Read an engaging book Thoughts Engage all your senses Squeeze a ball, or ice; listen to music; dance Sensations
Crisis Survival Skills: Self Soothe with the Senses 44 Vision Look at a picture or poster that you like. Look at the stars. Look at nature around you. Hearing Listen to beautiful or soothing music. Pay attention to the sounds of nature (waves, birds, rainfall). Smell Put on your favorite lotion/perfume/ cologne. Boil cinnamon. Bake. Light a scented candle. Taste Really taste the food you eat. Have a good meal. Have your favorite soothing drink (tea, hot chocolate). Touch Take a bubble bath or hot shower. Have a massage. Hug someone. Brush or braid your hair.
IMPROVE the Moment 45 Imagery Imagine a calming and safe place Imagine stress and anxiety draining out Meaning Find a meaning or value to what you are suffering. Focus on positive, growth from challenges. Prayer Turn things over to a Higher Power Find support, strength, or faith to cope Relaxation Use deep breathing and follow your breath Use muscle relaxation and other ways to relax One thing Focus you attention on one thing in the moment. Keep yourself physically and mentally in present
Urge Surfing 46 Ramp down Every urge has three phases. Peak Ramp-up period begins at trigger point or event, when the idea of doing the behavior first arises. Ramp Up The peak is the intense high point of the urge. Ramp-down or fall off period as things gradually return to baseline TO Urge Surf: Breath deep and have willingness to reduce the urge and let go of the behavior as a solution for pain. Remove yourself from the situation if you can. Relax the body and practice breathing or calming techniques while staying mindful and present-focused.
Pros & Cons of Change 47 PROS CONS Engage in Ineffective Behavior CHANGE Do Something Different
Distress Tolerance Review 48 Distraction When Distressed Doing something else until Wise ACCEPTS Soothing with Senses Self-soothing during difficult times Helping yourself feel better Getting through difficult moments Making meaning out of tough times IMPROVE Getting through urge to engage in impulsive behaviors Urge Surfing 9/11/2024
RADICAL ACCEPTANCE 49 Grant me the serenity to ACCEPT the things I cannot change, Courage to CHANGE the things I can, And WISDOM to know the difference.
DBT MODULE III: EMOTIONAL REGULATION Presented by Mark Purcell, PsyD
