Dialectical Behaviour Therapy Intensive - PEI

TABLE OF CONTENTS Day One Slides

pg. 2

Day Two Slides

pg. 20

Day Three Slides

pg. 30

Day Four Slides

pg. 49

Day Five Slides

pg. 62

Attachment Styles Case Vignettes

pg. 75

Case Study - AAI

pg. 77

Case Study - BPD

pg. 82

Case Vignette Complex Attachment

pg. 83

Jordan Case Study Breakout

pg. 84

Refined Triad Practice

pg. 85

DIALECTICAL BEHAVIOUR THERAPY INTENSIVE

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DBT, Trauma & Attachment – Day 1: Neurological Foundations & Mindfulness Charlottetown 5-Day Immersion with Dr. Eboni Webb, PsyD

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Agenda 01

Understand the neurological underpinnings of emotional regulation and DBT

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Explore the role of neurotransmitters in connection and stress recovery

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Contrast cortisol and oxytocin as biological markers of threat vs. safety

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Examine how early attachment experiences shape neurodevelopment

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Connect brain science to mindfulness as a foundation for DBT

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Stop and Drop In Open Discussion

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Learning the Impact of Trauma on the Brain and Body 30

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SB

Surviving Brain Definition: The most primal and automatic section of the brain, responsible for activating survival systems and regulating essential life functions like heart rate and breathing.

In Trauma: Takes control to manage immediate survival needs, often overriding other brain functions.

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Amygdala: Fight, Flight, and Freeze • Reactionary • Triggers Sensory System (Smell and Touch are the most direct pathways) • Controls autonomic responses

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Cortisol and the HPAA Axis Excessive Cortisol Effects • Neurotoxic to the Hypothalamus • Neuron Death • Clogging of the corpus callosum connecting the left and right hemispheres • Suppression of the immune system

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What Happens During a Stress Response?

Blood Flow Decreases • Frontal Lobe • Nondominant Hemisphere

Sensory System Activates • Hypervigilance • Heightened 5 senses

Blood Flow Increases • Heart • Extremities • Decreases to Gut • Digestive Issues

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Rewiring the Cortisol Loop: Practical Interventions • Chronic stress keeps the body in a cortisol-dominant state, impairing memory, sleep, digestion, and emotional balance • Healing requires consistent input that restores neurochemical balance and predictability

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Six Trauma-Responsive Cortisol Calmers 1. Rhythmic Movement: walking, swaying, drumming, yoga 2.Breath Practices: diaphragmatic breathing, sighing, 47-8 method 3.Eye Contact & Vocal Prosody: relational safety triggers oxytocin 4.Weighted Items & Deep Pressure Touch: blankets, vests, hugs 5.Relational Rituals: check-ins, affirmations, safe routines 6.Humor & Creativity: laughter and expression shift brain states

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Oxytocin

Hormonal Counter to Cortisol Architect of Regulation

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Oxytocin Hormonal Counter to Cortisol Architect of Regulation

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Cortisol vs. Oxytocin – The Battle for Regulation • Cortisol disrupts memory, emotion regulation, and trust • Oxytocin enhances curiosity, empathy, and relationship repair • DBT builds predictable routines that reduce cortisol and increase oxytocin

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Neurotransmitters and Regulation • Cortisol (threat, vigilance, inflammation) • Oxytocin (bonding, co-regulation, safety) • Dopamine (motivation, reward learning) • Serotonin (mood balance, satisfaction)

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Dysregulation: Learned Behavior

Invalidating Environment

Cortisol Release

Distress Cues Dysregulation

Cortisol=Automatic (Uncomfortable) reaction

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How Problematic Self-Regulation is Learned Oxytocin=Responsive release (calming) Problem Behaviors=reinforced as a method to regulate emotions

Invalidating Environment

Cortisol Release

Problematic Behaviors

Oxytocin Release

Reinforcement of Problem Behaviors

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Treatment Targets to Increase Oxytocin Without Problem Behaviors • Hugs • Breath work • Sing in a choir • Listen without judgment • Give a back rub/foot rub • Positive touch • Hold a baby • Proximity • Stroke a dog or cat • Laugh/Dance • Perform a generous act • Pray • Make positive eye contact

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EB

Emotional Brain Definition: Located in the midbrain, it's crucial for storing memories, accessing emotions, learning, and detecting danger and safety.

In Trauma: Becomes hyperactivated, leading to sensory overload and intense emotional responses.

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Attachment and the Neurobiology of Connection • Secure attachment optimizes brain development and nervous system flexibility • Early caregiving shapes how cortisol and oxytocin systems develop • Attachment repair = rewiring the brain for safety and connection

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Stop and Drop In Observing Mind Practice

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OB

Observing Brain Definition: Part of the prefrontal lobes responsible for higher-order functions like thinking, organizing, dreaming, and planning.

In Trauma: Can become impaired or 'go offline', losing its ability to function optimally.

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Mindfulness as a Neurological Reset • Activates the observing brain and quiets the survival brain • Restores present-moment awareness interrupted by trauma • Reduces automaticity and reactivity

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From Neurobiology to Mindfulness: Engaging the Observing Mind • The prefrontal cortex—our "observing brain"—is often hijacked under chronic stress or trauma • When reactivated, it allows us to step out of survival reactivity and into choice • Mindfulness helps us shift from automatic responses to conscious awareness • This is not about mastering a technique—it’s about reclaiming access to higher-order functioning

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Observing Mind Practice – Dual Awareness • Guided Practice: • Notice a sound in the room • Feel the weight of your body on the chair • Name an emotion as if it's weather (e.g., cloudy, bright, shifting) • Return to the breath as an anchor • Debrief Prompt: • What did you notice?

• What shifted when you observed without judgment?

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Practice: Grounding in the Present (Observing Mind) • The prefrontal cortex—our "observing brain"—is often hijacked under chronic stress or trauma • When reactivated, it allows us to step out of survival reactivity and into choice • Mindfulness helps us shift from automatic responses to conscious awareness • This is not about mastering a technique—it’s about reclaiming access to higher-order functioning Debrief Prompt: • What did you notice without effort?

• What shifted when you stopped naming something as good or bad?

• How might you guide a client through this type of practice?

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Anchoring the Work Understanding Emotional State The adolescent often functions from a survival or em otional brain state, feeling unsafe and dysregulated due to her background.

Importance of Safety and Regulation Establishing a sense of safety and em otional regulation is crucial before deeper therapeutic work can begin.

DBT and Mindfulness Skills Introducing D BT or m indfulness techniques, such as distress tolerance and grounding, fosters self-awareness and em otional control.

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What’s Alive in You Now? 1.

What insight are you taking away?

2. What would you like to explore deeper?

3. What’s one way you might adjust your lens or pacing with clients?

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DBT, Trauma & Attachment –Trauma, Attachment & Interpersonal Effectiveness Charlottetown 5-Day Immersion with Dr. Eboni Webb, PsyD

Day 2 –Relational Repair Through a DBT Lens

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Five Movements Mindfulness

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Rudyard Kipling “Often and often afterwards, the beloved Aunt would ask me why I had never told anyone how I was being treated. Children tell little more than animals, for what comes to them they accept as eternally established.”

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• Differentiate developmental and attachment trauma • Understand the impact of parenting styles on attachment formation • Explore how DBT interpersonal skills support attachment repair • Apply trauma-informed strategies for relational safety and boundaries

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Trauma That Shapes Relationship Blueprints Long-term effects: affect dysregulation, avoidance, clinginess, control Developmental Trauma

Attachment Trauma

• Repeated emotional threats in caregiving

• Inconsistent, frightening, or absent relational safety

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Authoritative: Warm + Boundaried → Secure attachment Authoritarian: Harsh, controlling → Avoidant attachment Permissive: Indulgent → Anxious attachment Uninvolved: Neglectful → Disorganized attachment Parenting Styles & Attachment Outcomes

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DEFINITION: ATTACHMENT

SelfConcept

Affect Regulation

Cognition

Behavioral Regulation

“A N I N - B O R N S Y S T E M I N T H E B R A I N T H AT E VO LV E S I N WA Y S T H AT I N F L U E N C E A N D O R G A N I Z E M O T I VAT I O N A L , E M O T I O N A L A N D M E M O RY P ROC ES S ES WI T H RES P EC T TO SIGNIFICANT CAREGIVING F I G U R E S . ” ( B OW L B Y )

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THE STRANGE SITUATION SECURE ATTACHMENT oReunion behaviors are more insightful than separation behaviors. oImmediate reassurance from the return of their secure base (distress is natural and expected at separation). oReconnection prompts return to independent exploration and play. oChild Behaviors: Flexibility and resilience oSecure Parent = Sensitivity, attunement, acceptance, cooperation and emotional availability

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THE STRANGE SITUATION AVOIDANT ATTACHMENT oReunion behaviors are more insightful than separation behaviors. oApparent lack of distress should not be mistaken for calm. Superficial indifference is a trauma defense. oReconnection displays active rejection of bids for connection by parent resulting in limp physical connection. oParent Behaviors: W ithdraw and Rebuff oAvoidant Parent = Inhibited emotionality, aversion to physical contact, and brusqueness

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THE STRANGE SITUATION AMBIVALENT ATTACHMENT oReunion behaviors are more insightful than separation behaviors. Looking for their absent parent even when the parent is present. oTwo presentations: Angry or Passive oReconnection displays overt bids for connection and expressions of rejection (e.g. full-blown tantrums, leaning away, etc.) to implicit bids for solace displayed in helplessness and misery. Lack of exploration.

Parent Behaviors: Unpredictable and Intermittently available oAmbivalent Parent = Insensitive signaling, neither verbal or physically rejecting while discouraging autonomy

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PARENTING STYLE VIGNETTE 1 BALANCED & BOUNDARIED A 10-year-old describes their mother as 'firm but fair.' She sets clear expectations for homework and bedtime, but always checks in about how the child is feeling. When conflict arises, she listens and then calmly negotiates a solution.

The father plays with the child regularly, holds boundaries when needed, and encourages independence.“

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Authoritative Parenting

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PARENTING STYLE VIGNETTE 2 – HARSH & CONTROLLING "An 8-year-old reports being yelled at frequently and describes both parents as 'always mad.'

They talk about being grounded often without knowing why and say their parents don’t explain rules—just enforce them. There is little emotional warmth, and affection is only given when rules are followed perfectly."

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Authoritarian Parenting

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PARENTING STYLE VIGNETTE 3 – WARM BUT INCONSISTENT "A 7-year-old says their mom is 'really nice' but sometimes forgets to pick them up from school.

They describe their dad as 'fun' but often asleep during the day and too tired to help with schoolwork. They feel special when their parents do things together but often don’t know what to expect."

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Permissive Parenting

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PARENTING STYLE VIGNETTE 4 – DISCONNECTED & DISTRACTED "A 9-year-old describes their caregivers as 'busy' and 'gone a lot.' They spend most of their time alone or on screens. Meals are often skipped or eaten alone. They cannot recall a recent conversation where a parent asked how they were doing emotionally."

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Neglectful Parenting

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Adult Attachment Interview Role-Play and Overview

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Case Vignette – Complex Attachment & Neurobiology Client Overview: 42-year-old woman raised in Memphis with two maternal caregivers (biological mother and JC).

Themes: Emotional neglect, inconsistent caregiving, warmth and rupture, hyper-functioning, grief, and embodied trauma.

DBT Relevance: Illustrates cortisol sensitivity, relational trauma, and the long arc of attachment repair.

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Vignette #1 Client, 42, describes her mother as: loving, strict, warm, anxious, supportive.

Her father: calm, distracted, humorous, fair, emotionally distant. When asked for memories, she shares a story about how her mother often became overwhelmed during homework help and would snap but would later apologize and ask to talk it through. She recalls her father forgetting a school pickup once, but says he explained and reassured her when he got there. Her storytelling is emotionally coherent. She reflects on these moments with warmth, noting, “They weren’t perfect, but I always knew they loved me and wanted to do better.”

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Vignette #2 Client, 29, describes her mother as: busy, cold, tired, efficient, unavailable. Her father: funny, charming, inconsistent, angry, gone. She struggles to recall consistent care, saying, “I think they did their best.” She quickly deflects with humor and often speaks in generalities. She minimizes painful memories and avoids emotion.

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Vignette #3 Client, 36, describes her mother as: loving, mean, unpredictable, confusing, everything. Her father: missing, deadbeat, sorry, sometimes-there, apologetic. She shares contradictory memories and seems distressed while speaking. Her language becomes chaotic, jumping between blame and guilt. She cries and then laughs inappropriately.

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Vignette #4 Client, 31, describes her mother as: affectionate, nervous, talkative, critical, overbearing. Her father: absent, silent, serious, stressed, working. When asked for memories, she gives several detailed examples of calling her mother repeatedly at work to be reassured she wasn’t angry. She reports being punished one moment and smothered the next, and says, “I always felt like I had to prove I was good enough.” Her tone is anxious, her narrative is linear but emotionally intense, and she seeks reassurance from the interviewer.

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Interpersonal Effectiveness and Attachment Repair Validation and Repairing Interpersonal Wounding

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•Validation = emotional visibility •Boundary-setting = self-trust and clarity •Conflict navigation = fear of rupture repair •Assertiveness = reclaiming voice and needs

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Levels of Validation (Linehan, 1997) • Level 1: Being acutely attentive • Level 2: Reflecting verbal communication • Level 3: Describing nonverbal communication • Level 4: Expressing how experience makes sense given history or biology • Level 5: Expressing how experience makes sense in the present moment and context • Level 6: Being in genuine, human contact

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Validation Practice “I went to the store yesterday and I saw these Red Hot candies. I completely lost it and forgot what I went into the store to get. It reminded me of when I was little and my mom wanted to teach me about waiting. I had asked for some of those candies and she said no, but when she tucked me in that night, she forced me to eat a huge bag until my mouth and eyes burned. I thought I was past that, but I am having urges to cut myself again. I get so angry with myself. I keep myself from eating. If I had any pills, I’d take them…you know, just to numb out.”

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Holding Space Without Losing Self • Trauma survivors fear closeness and isolation simultaneously • DBT helps build the ‘middle path’ between enmeshment and avoidance • Interpersonal Effectiveness = boundary work that doesn’t sever connection

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Grounding and Release Practice • Instructions: • Bring awareness to your breath • Notice areas of the body holding tension—offer permission to soften • Recall a moment from today that offered clarity or curiosity • Set an intention for the evening or tomorrow’s learning Closing Prompt: What does your nervous system need right now? Who do you want to be with this new awareness?

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DBT, Trauma & Attachment – Day 3: Trauma's Impact on Brain Development & Emotion Regulation Charlottetown 5-Day Immersion with Dr. Eboni Webb, PsyD

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Brain Development & Emotional Regulation

Linking Developmental Trauma to Emotion Dysregulation in DBT

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Day 3 Learning Objectives Biopsychosocial Model of Trauma Understand how trauma impacts development through biological, psychological, and social factors that shape a person's responses.

Influence on Emotional Systems Learn how trauma affects core systems involved in emotional development and influences emotional responses in daily life.

Biphasic Arousal Model Application Apply the Biphasic Arousal Model to better understand and interpret client behaviors shaped by trauma.

DBT Skills and Trauma Regulation Connect DBT emotion regulation skills to managing trauma-based emotional dysregulation by identifying core organizers of experience.

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The Biosocial Model of Trauma &Emotional Dysregulation

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Overview • Children can suffer from emotional vulnerabilities • Emotional vulnerabilities can come from many sources (e.g., attachment issues, loss, trauma), but is often assumed to be biological • Chronic and consistent invalidation exacerbates emotional vulnerabilities • An ongoing, reciprocal relationship exists between emotional vulnerabilities and environments

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The vagus nerve is the largest nerve in the body and controls our body’s ability to detect danger, sense safety, experience rest/relaxation, and connect socially. It is refined through connection from birth and innervation of touch.

The Polyvagal Theory (Porges, 2011) 7

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Safe

Danger!

Life Threat

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Types of Dysregulation

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• Divorce • Prolonged separation from parents and/or siblings • Frequent moves • School transitions • Bullying (Cyber, physical, etc.)

• In utero assaults • Delivery difficulties • Health of both parents during conception • Mental Illness • Abandonment via adoption • Learning difficulties

• Identity disturbances • Racial issues • Inside threats • Sexual assaults • Accidents (falls, vehicle, etc.)

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Common Types of Invalidation ╺

╺ ╺ ╺ ╺ ╺

Abuse and neglect Being ignored Open rejection of thoughts, feelings, and behaviors Making “normal” responses “abnormal” Failing to communicate how experience “makes sense” Expecting behaviors that one cannot perform (e.g., due to developmental level, emotionality, or behavioral deficits

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Core Emotional Systems (Panksepp) • SEEKING – curiosity, vitality • RAGE – protest, injustice • FEAR – danger, threat • PANIC/GRIEF – abandonment, loss • CARE – nurturance, empathy • PLAY – social joy, creativity • LUST – hormonal development

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Need

Age of Development

Healthy Development

Unhealthy Development

Key Emotions Impacted

Emotions

Threat Response

Fear, Happy, Anger Fear, Jealousy, Love

Survival

0-2

Security

2-3

Pleasure

0-3

Body-Self Development

Body Shame

Shame, Disgust, Envy, Love, Guilt

Affection

4-5

Capacity for love, sense of love and belonging, worthiness

Inhibition from autonomous connection

Love, Anger, Envy, Jealousy

Esteem

5-6

Recognition, Acknowledgement, Self-Acceptance

Lack of trust in self

Sadness, Shame, Guilt

Control

3-7

Choice

Compulsion, Impulsivity

Jealousy, Anger, Fear

Power

7+

Intention

Invulnerability

Envy, Guilt, Fear

Self in Relationship Diffuse Boundaries

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Borderline Personality Disorder Key Characteristics

Attachment Disturbances

Pattern of Impulsivity

Instability in interpersonal relationships

Instability in life

Hypersensitive to abandonment

Unstable self-image and emotions

Pattern of undermining success in relationships

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The Biosocial Model ╺

Emotional vulnerabilities are characterized by: -

Emotional sensitivity

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Emotional reactivity

Slow return to emotional baseline Over time emotions get sensitized, leading to a “kindling” effect This emotionality (and associated invalidation) is associated

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╺

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with many problems (disorders) Emotionality leads to escape and avoidance that leads to chronicity

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Em otional Arousal

Emotional Dysregulation CopingAvoidance Escape Behaviors Heightened Reactivity Innate Sensitivity Tim e

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Social Engagement System Eye-gazing Language Prosody Touch Proximity

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Working Through Biphasic Arousal

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Biphasic Arousal Biphasic arousal typically involves an initial phase of heightened stimulation, excitement, and alertness, followed by a period of decreased arousal and relaxation. Such a response can be seen pertaining to the utilization of certain substances like caffeine or alcohol, when experiencing emotional reactions, or during physiological processes.

This type of arousal often begins with a higher surge of activity that is then followed by a period of calming down and becoming more relaxed.

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HYPERAROUSAL

Window of Tolerance HYPOAROUSAL Sensorim otor Psychotherapy Institute®/Sensorim otor Psychotherapy founder, “Pat Ogden

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Window of Tolerance

Hyperarousal-Fight, Flight, Freeze,

Hypoarousal-Dissociation, Numbing, Depression

Sensorimotor Psychotherapy Institute® Sensorimotor Psychotherapy founder, “Pat Ogden

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Core Organizers of Experience (Ogden) • Arousal • Affect • Behavior • Cognition • Perception • Memory • Identity

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How Do We Create Our Stories?

Thoughts Emotions Sensations Urges Movements ╺

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How the Brain Organizes Our Experiences

Sensations

Thoughts

Emotions

Urges

Movements

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Case Vignette A 15-year-old male named Jordan has been referred for chronic school avoidance, irritability at home, and increasing isolation. His mother reports that he was a "sensitive" child with early separation anxiety. At age 8, he witnessed a violent home invasion in which his father was assaulted. His father left the family shortly after the incident, and Jordan has not seen him since.

Since the event, Jordan has experienced frequent nightmares, a persistent startle response, and episodes of shutting down when overwhelmed. At school, he is often silent or disengaged, and teachers note that he becomes defiant when asked to participate. He spends most of his time in his room playing video games and avoids family activities. His mother describes him as either "exploding or disappearing."

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Case Study Debrief – Jordan • What stood out in your group’s analysis of Jordan’s dominant emotional systems?

• How did your group differentiate between hyper- and hypoarousal in his behaviors?

• What did you notice about the disrupted core organizers (e.g., identity, perception, behavior)?

• What was your group’s first instinct for a DBT intervention or skill introduction?

• If you were to introduce mindfulness to Jordan, what might that look like?

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Daily Trauma Healing

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Resource Domains (Ogden & Fisher, 2015) Somatic

Psychological

Spiritual

Relational

Artistic/Creative

Nature

Emotional

Intellectual

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Somatic Internal

External

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PL.E.A.S.E.D SKILLS • Physical health •

List resources and barriers (each area)

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Eat three healthy, balanced meals

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Avoid mood altering drugs

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Sleep between 7 to 10 hours

• •

Exercise at least 20 minutes Daily

• Address Barriers • Develop a plan/track on diary card

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BODY CENTERED AND GROUNDED

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BREATHE |HISS & HOLD|SHIMMY Heart, Lungs, Belly

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Sensations Calm Cool Relaxed Light Releasing Expanded Expansive Floating Draining Tense Constricted Hot

Sweaty Frozen Disconnected Heavy Block Contracted Numb Hollow Tight Nauseous Shaky Dizzy

Tingling Twitchy Burning Radiating Itchy Suffocated Blocked Spacious Warm Clenched Knotted Full

Jasonholley.net

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Urges Drink Eat Urinate Defecate Reach Grasp Push

Surrender/relax Run Punch Breathe Reproduce Sexual tension Rest/sleep

Adjust temperature Neutralize irritants Avoid discomfort Avoid illness Return to comfort Protect health

thelogician.net

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Movements Balancing Running Jumping Catching Hopping Throwing Galloping Skipping

Leaping Kicking Flexion Extension Protraction Retraction Hyperextension Hyperflexion

Abduction Adduction Circumduction Rotation Supination Pronation Depression Elevation

Etarc.com.au http://library.open.oregonstate.edu /aandp/chapter/9-5-types-of-bodymovements/

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LET’S WAKE UP YOUR BODY 40

EMOTIONALLY REGULATED

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Emotion

Function

Action Urge

Anger

Boundary, Identity, Injustice

Attack, Define a boundary

Disgust Envy Fear Guilt Happy Jealousy Love Sadness Shame

Protect from contamination/influence Obtain something not currently possessed Survival, Life Threat To signal a threat to personal morality Connect with pleasure To signal a threat to an important relationship Connect relationally To signal a loss (relationship or expectation) To signal a threat to social standards/expectations

Reject, Separate Obsess, Aspire Survival Defenses To make amends or apologize Maintain Possess, Posture, Protect Connect, Sustain Isolate, Withdraw Hide, Conform

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“

We cannot selectively numb emotions, when we numb the painful emotions, we also numb the positive emotions.

Brene Brown 43

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Emotion Dysregulation in DBT •Emotional vulnerability (high sensitivity + slow return to baseline) •Invalidating environments (chronic misattunement) •DBT’s biosocial model applied to trauma history

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From Trauma to Skill – Rebuilding Regulation • Naming and mapping emotional responses • Anchoring emotion in somatic language • Teaching emotions as adaptive messengers • Using DBT emotion regulation skills to build choice

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FROM A TRAUMA STATE TO A CLEAR STATE OF MIND…….

Sex

Alcohol

SelfHarm IT DIDN’T REALLY HAPPEN

Work Drugs 46

Eating Disorders

P

G

A I

U I

NEW SELF

HOPE

L T

N

IT REALLY HAPPENED

IT REALLY HAPPENED TO ME

N G

S H A

E R

M E

A

VOICE

HEAL

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RESET SURVIVAL DEFENSES

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RAGE

GROUP CHAOS

TERROR

POSSESIVE JEALOUSY

PANIC

HYPERAROUSAL

FEAR SADNESS SHAME

Window of Tolerance Sensorimotor Psychotherapy Institute®/Sensorimotor Psychotherapy founder, “Pat Ogden

ANGER

HYPOAROUSAL

JEALOUSY

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FEIGNED COMPLIANCE

DISSOCIATION PSYCHOTIC BEHAVIOR

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Opposite-to-Emotion Action • 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 • Examples include activity when depressed, approaching when anxious, and being kind when angry

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Let’s Practice!

Recall

Recall an event that is/was emotionally-charged for you.

Close

Practice

Close your eyes and see yourself in the situation with all the emotions and all the details.

Wrap your arms around yourself, head down and allow whatever emotions you have to flow in until you hear the bell chime.

After you hear the chime, sit up and place your hands palms up on thighs.

Practice holding a half-smile.

Remain

Eyes will remain open.

Lift

Lift eyebrows and breathe fully.

Continue

Continue recalling the emotionally-charged event until you hear the chime again.

Wrap Sit up and place

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Build Positive Experience •

Must be planned/scheduled

•

Must include mindfulness skills

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Address distractions that interfere with BPEs Address judgments that interfere with BPEs (e.g., not deserving, etc.)

• •

Address concerns about expectations

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Build Positive Experience • •

Short term • Do pleasant things that are possible now Long term • Invest in relationships (Attend to Relationships-A2R) • Invest in your goals • Build a satisfying life • Take one step at a time

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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!

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Group Reflection + Integration • What new language or concepts resonated today?

• How might you use this model to explain a client’s symptoms?

• What personal insight did you gain about emotional development?

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Restoring Regulation Before We Re-Enter the World • Guided Prompt: • Take a few breaths into your belly and place a hand on your chest or core • Recall one idea or experience from today that touched you • Ask: "What do I want to carry forward from this session?"

• Ask: "What can I leave behind that does not serve me or my clients?"

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D B T, T R A U M A &ATTACHMENT – DAY 4: DBT SKILLS FOR TRAUMA, ATTACHMENT & RELATIONAL DYNAMICS

CHARLOTTETO W N 5-DAY IM M ERSIO N WITH DR. EBONI W EBB, PSYD

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Day 4: DBT Skill Objectives Coping with Trauma

DBT skills help individuals manage trauma and handle complex relational situations, fostering healing and resilience.

Emotional Regulation and Distress Tolerance

Enhancing emotional regulation and distress tolerance supports individuals in managing overwhelming feelings during trauma recovery.

DBT for Personality Disorders

Targeted DBT interventions address personality disorders and attachment adaptations for more adaptive functioning.

M apping DBT to DSM-V Diagnoses

DBT strategies are mapped to diagnoses like BPD, PTSD, Anxiety, and ADHD, ensuring tailored support for each condition.

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DBT as a Trauma-Responsive System

• Structure builds safety and containment • Skills provide language for inner and outer experience • Validation re-patterns shame, helplessness, and isolation

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Using DBT for Relational Trauma

• Emotional dysregulation + ruptured attachment = high reactivity • Mindfulness + interpersonal effectiveness = emotional safety • Distress tolerance helps prevent re-traumatization

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Walking the Middle Path – Trauma & Dialectics • Trauma often splits our thinking into extremes: safety/danger, good/bad, trust/distrust • Dialectical thinking helps widen the window of tolerance • Introduce the concept of holding two truths at once • Skill Spotlight: "Both-And" language, dialectical dilemmas, wise mind

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Walking the Middle Path – Trauma & Dialectics • Practice Vignette: “My therapist cares about me… but I also feel abandoned when she doesn’t reply right away.”

How could you validate both truths?

• What dialectical phrase might you offer?

• How can you model 'middle path' thinking without minimizing the pain?

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W H AT A R E DIALECTICS? n Opposites, extremes, or polarities (e.g., each thesis has a antithesis) n Neither position is absolute, and in fact, are interconnected n Each position has a wisdom or truth n Movement toward a synthesis is sought n Movement (and conflict) produces change n Change (e.g., working the dialectic) is constant and continual

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“THE CURIOUS PA R A D OX IS T H AT WHEN I ACCEPT MYSELF JUST AS I AM, THEN I CAN C H A N G E .”

--CARL ROGERS

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nMost Fundamental Dialectic in DBT is the fluid movement between Acceptance and Change

Dialectics In Therapy

nUse Validation to move toward acceptance and CBT techniques to move toward change nRemember that context will suggest how to balance these strategies

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Dialectical Dilemmas EMOTIONAL VULNERABILITIES

ACTIVE PASSIVITY

UNRELENTING CRISIS BIOLOGICAL SOCIAL

APPARENT COMPETENCE

INHIBITED EXPERIENCING SELFINVALIDATION

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1. Balance of “old” self with “new” self 2. Balance of “want-to’s” with “have-to’s” 3. Balance of your wants/needs with

W AY S CLIENTS CAN PRACTICE DIALECTICS

others’ wants/needs 4. Activating Wise Mind 5. Considering alternative viewpoints and opinions 6. Weighing pros and cons 7. Choosing “middle path” behaviors 8. Engaging willingness to shift from “stuck”

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Validation and Alignment Interventions • Stay alert to what client says, feels, and does • Validate emotions, thoughts, and behavior • Enter the client’s world: it does it make sense for them, from their context?

• Sit with distress (and manage your own): don’t move in to “fix” it • Move forward together: these strategies are one end of the dialectic You have to start with where the client is at before change happens!

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1. Highlighting the contradictions in client’s behavior, therapy, or in reality

DIALECTIC ST R AT E G IE S : ENTERING THE PA R A D OX

2. Refusing “right and wrong;” different perspectives can both be true and answers can be yes and no 3. Key is not to step in with logic to solve the dilemma or struggle; allow the client to make a shift

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1. Metaphor and Teaching Stories 2. Playing Devil’s Advocate

OTHER DIALECTICAL S T R AT E G I E S

3. Extending (aikido self-defense) (can be used with resistance) 4. Activating Wise Mind 5. Making Lemonade Out of Lemons 6. Allowing Natural Change 7. Dialectical Abstinence 8. Dialectic Assessment: W hat’s Missing?

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DISTRESS TO LERANCE IN THE CONTEXT OF TRAUMA 15

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Distress Tolerance in the Context of Trauma

• Trauma often creates a false urgency to act • TIPP and self-soothing can anchor in the body • Radical Acceptance can disrupt shame spirals

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Goals of Distress Tolerance • Ability to tolerate painful emotions • Distraction without avoiding • Paths to other skills • Action instead of reaction • Managing crisis without making it worse

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Effective Distress Tolerance • Less emotion-based coping (might work shortterm, but often does not long-term) • Fewer impulsive behaviors • Decreased self-injurious urges/behaviors • Decreased suicidal urges/behaviors • Decreased crisis orientation to life AND • Decreased chronic distress avoidance

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Self-Soothe • Mindful engagement of the senses to comfort: • Vision • Hearing • Smell • Taste • Touch • Balance

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Distract: Wise Mind ACCEPTS A

Activities

C

Contributing

C

Comparisons

E

Emotions

P

Pushing away

T

Thoughts

S

Sensations

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IMPROVE the Moment I

Imagery

M

Meaning

P

Prayer

R

Relaxation

O

One thing at a time

V

Vacation (mini)

E

Encouragement

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“Acceptance must come from deep within.”

Marsha Linehan

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Acceptance Mindfulness

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1. “Everything is as it should be.”

MINDFULNESS PRACTICE AC C E P TA N C E

2. Focus on an object in the room.

3. Breathe.

4. As any area of thoughts, emotions, sensations, and/or feelings emerge, silently repeat the phrase above.

5. 3 minutes

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RADICAL A C C E P TA N C E

SELF-CO M PA SSIO N

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CHOICES WHEN LIFE IS PA I N F U L : • Change painful situations when you can • Shift your perspective of the situation • Radically Accept the situation • Continue to suffer

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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

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Stages of Acceptance (from Kubler-Ross)

• Denial: not wanting to believe its 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

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1. Willingness is doing what is needed, not sitting on your hands 2. Willingness means dealing with reality,

WILLINGNESS VS. R E S I S TA N C E

not what you wish it would be 3. The concept contrasts our Western philosophy of “when there’s a will there’s a way” 4. “Where there is willingness, there is a way” is the message 5. What are you willing to do given the situation?

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Case Study: Adult with BPD + Attachment Trauma • Overview: 32-year-old female with a history of abandonment, emotional abuse, and chronic invalidation. Diagnosed with BPD and PTSD. Frequently enters therapy dysregulated, demands reassurance, and panics with perceived therapist distance.

• Discussion Prompts: • What skill sequences might support her in-session?

• How would you use validation without reinforcing dependency?

• Where might DBT offer containment without control?

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DBT Strategies by Diagnosis

BPD: Validation, Wise Mind, DEAR MAN, Radical Acceptance

PTSD: Check the Facts, Mindfulness of Current Emotion, TIPP

Anxiety Disorders: IMPROVE, Mindfulness of Thoughts, Half-Smile

ADHD: PLEASE, Mindful Participation, Structured Routines

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§

M any causes of emotional sensitivity (e.g., attachment problems, loss, trauma, invalidation)

EMOTION DYSREGULATION: THE “CORE” DEFICIT OF PERSONALITY DISORDERS

§

Connected to neurochemistry although mediated by psychological factors

§

High emotional arousal predicts increased susceptibility in the future due to kindling effects

§

Emotion dysregulation leads to escape and avoidance behaviors in BPD and other personality disorders

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WORKING WITH R E L AT I O N A L PAT T E R N S

"INTERPERSONAL SKILLS AREN’ T J U S T A B O U T ‘ G E T T I N G W H AT Y O U WANT’ —THE Y ’ RE ABOUT RESTORI NG DI GNI TY I N DI ALOGUE. "

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Personality Disorders & Trauma Sensitive Emotional Borderline Dependent

Containment

Maintain Proximity

Boundaries

Regulate Intensity

Sensitive Withdrawn Schizoid

Sensory Processing

Paranoid

Spectrum Disorders

Connection Body Awareness

Directed Proximity Autonomy

Self-Reliant Obsessive-Compulsive Paranoid

Avoidant

Collaboration Validation

Softening Boundaries Regulate Intensity

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Personality Disorders & Trauma Dependent Endearing Borderline

Empowerment

Needs Assertion

Dependent

Self-Validation

Delaying of Gratification

Tough Generous Antisocial Borderline

Obsessive-Compulsive

Narcissistic Histrionic

Borderline Dependent

Surrender Authenticity

Boundaries Grounding

Charming Manipulative Mindfulness Self-Validation

Authenticity Making Direct Requests

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Personality Disorders & Trauma Burdened Enduring Borderline Obsessive Compulsive

Avoidant

Antisocial Borderline

Narcissistic Histrionic

Schizotypal Obsessive Compulsive

Narcissistic Histrionic

Borderline Antisocial

Activation

Needs Assessment

Self-Validation

Assertive Communication

Expressive Attention Seeking Mindfulness Containment

Explore the source of attention-seeking

Industrious Overfocused Obsessive Compulsive

Rest Self-Compassion

Collaboration Self-Validation

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1. Prompt: Break into triads.

2. Client A = presents with relational trauma + anxiety

GROUP IN T E G R AT IO N ACTIVITY

3. Therapist B = offers DBT-based intervention 4. Observer C = tracks for validation, skill usage, emotional pacing Debrief Questions:

1. W hat was effective?

2. W here did the therapist get stuck?

3. W hat could deepen the connection?

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Mindful Prompt

“What did I learn today that I want to embody in my clinical presence?”

“Where did I notice my own attachment history show up in this learning?”

“How will I protect my nervous system as I support others?”

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DBT, Trauma & Attachment – Day 5: Critical DBT Interventions for Trauma and Attachment

1

Deepening Attachment Repair through DBT Interventions Proximity, Boundaries & the Therapeutic Base

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Agenda

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What Makes an Attachment Repairing Intervention?

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HEALTHY ATTACHMENT

From Bowlby and Beyond

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S T E P S T O A DA P TAT I O N : L E A R N I N G H OW T O F I T I N YO U R FA M I LY S Y S T E M Intersubjectivity (Trevathen, 1980) Wounding

Intention

Attunement

Communication

Action

Repair

Trauma Mirror Neurons (Gallese, 2007)

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ATTACHMENT GOAL SECURE AND AUTHORI TATI VE PARENTI NG PRODUCES AUTONOMOUS AND I NTERDEPENDENT ADULT S

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ATTACHMENT RULE AT TAC H M E N T I S N OT F I X E D O R A B S O LU T E .

G ROW T H A N D CHANGE ARE D R I V E N BY O N E ’ S SEASON OF LIFE.

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DEFINITION: ATTACHMENT

SelfConcept

Affect Regulation

Cognition

Behavioral Regulation

“A N I N - B O R N S Y S T E M I N T H E B R A I N T H AT E VO LV E S I N WA Y S T H AT I N F L U E N C E A N D O R G A N I Z E M O T I VAT I O N A L , E M O T I O N A L A N D M E M O RY P ROC ES S ES WI T H RES P EC T TO SIGNIFICANT CAREGIVING F I G U R E S . ” ( B OW L B Y )

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How do we live and thrive as humans? (Bowlby to Ainsworth)

Secure Base

Safe Harbor

Proximity Maintenance

Seeking, m onitoring, and attempting to

Fleeing to an attachm ent figure when in

Attunem ent, presence, accountability,

m aintain connection to a protective attachm ent figure.

situations of danger or alarm

direction, protection, correction, and connection.

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How do we embody this as therapists?

Safe Harbor

Proximity Maintenance

Attuned therapists that are skilled

O ffice safety and security, inform ed

Tolerate, M odulate, and C om m unicate

listeners, attuned, present, and activated towards change and challenge

Secure Base

consent, confidentiality, com m unity safety planning and protection

D ifficult Em otions, Feelings, and Sensations as they arise in session.

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Critical Interventions: Building the Therapist’s Resource Toolkit

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Stability Availability

SECURE BASE

Marriage/ Partnerships

Nonviolence

Parents Ancillary Providers

PROXIMITY MAINTENANCE

SAFE HARBOR

HEALING

Fam ily R ituals

Therapists

Home Environment

Psychiatrists

State of the U nion

Body

HOLISTIC THERAPY

Mind

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Boundaries

Authoritative Therapy: Proximity Maintenance

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Containment

Screening

Protection

Envision the Human Cell

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Boundaries (Limits) Core Assumptions (Pederson, 2011) ╺ ╺

╺

╺

╺

╺

Clients often don’t recognize boundaries Ineffective boundaries can create dysfunction in relationships Ineffective boundaries can create ineffective responses in therapists Clients want to learn about and practice effective boundaries for themselves Clients need to learn about and recognize the boundaries of others Therapists need to model effective boundaries

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Boundaries (Pederson, 2011) ╺

╺ ╺

╺

Clients benefit from exercises that help them define their boundaries Clients need education about individual differences Clients often need to radically accept individual differences and to learn not to take differences “personally” (also a boundary) Effective teaching will result in healthier connections with less enmeshment, disengagement, and extremes

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Boundary (Pederson, 2011) Be aware Observe others Understand limits Negotiate sometimes Differences exist Always Remember your values Your safety first

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Prosody Authoritative Therapy: Attuned and Moderate Communication

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B O U N DA R I E S & P ROX I M I T Y I N T H E D B T FRAME

•

Use of session structure to regulate proximity Boundary ruptures as teachable moments

•

Chain analysis around overreach or emotional enmeshment

•

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Prosodic Communication

• Pitch • Intonation • Rhythm • Loudness • Tempo • Stress

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THE SECURE BASE IN DBT Predictability: rituals, routines, visual anchors Repair: validating pain and maintaining limits Permission: inviting autonomy without withdrawal 22

WHAT TO LOOK FOR

SelfInvalidation

• Self-hate/criticism • People-pleasing • Perfectionism

Emotional Vulnerability

• Anger, Bitterness Towards Others • Fragility,Vulnerability

Inhibited Experiencing

• Active avoidance • Passive avoidance, dissociation

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HOW TO HELP

SelfInvalidation

• Modeling failure • Communicating validation

Emotional Vulnerability

• Model self-care • Create a safe home environment

Inhibited Experiencing

• Model Emotions • Display authentic reactions without exaggeration

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WHAT TO LOOK FOR

Unrelenting Crises Active Passivity Apparent Competence

• Uncontrollable Events • Crisis-Generating Behavior

• Willfulness, Demandingness • Helplessness

• Disconnect between verbal and non-verbal behavior • Contextual Competence (mood/situational)

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HOW TO HELP Unrelenting Crises

• Control the Controllable in the Home • Practice/Model Delayed Gratification

Active Passivity

• Cheerlead • Encourage problem-solving • Set Personal Limits

Apparent

• Highlight effective behaviors observed • Lose the assumption of how the loved one “should” behave in all contexts based upon one.

Competence

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The Therapeutic Space Authoritative Therapy: Creating a Safe Haven

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The Therapeutic Space Seating Windows Lighting Smells Fidgets Food Weighted blankets Spacing

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VIDEO CLIP https://youtu.be/wx4hDYEBsIk?si=4HA6U3lYdfl0mFU5

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Validation The Keys to the Kingdom 30

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Levels of Validation (Linehan, 1997) • • • • • •

Level 1: Being acutely attentive Level 2: Reflecting verbal communication Level 3: Describing non-verbal communication Level 4: Expressing how experience makes sense given history or biology Level 5: Expressing how experience makes sense in the present moment and context Level 6: Being in genuine, human contact

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VALIDATION PRACTICE “I went to the store yesterday and I saw these Red Hot candies. I completely lost it and forgot what I went into the store to get. It reminded me of when I was little and my mom wanted to teach me about waiting. I had asked for some of those candies and she said no, but when she tucked me in that night, she forced me to eat a huge bag until my mouth and eyes burned. I thought I was past that, but I am having urges to cut myself again.

I get so angry with myself. I keep myself from eating. If I had any pills, I’d take them…you know, just to numb out.”

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Levels of Validation (Linehan, 1997) • • • • • •

Level 1: Being acutely attentive Level 2: Reflecting verbal communication Level 3: Describing non-verbal communication Level 4: Expressing how experience makes sense given history or biology Level 5: Expressing how experience makes sense in the present moment and context Level 6: Being in genuine, human contact

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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

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Reciprocal Communication: Self-involving disclosure Sharing “benign” and human examples of skill use and practice Using examples of how you have approached and solved a problem Sharing when you would 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) Letting the client know about the current state of the relationship, to manage contingencies or address feared reactions

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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?

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Final Case Reflection

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Closing Integration Practice

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Attachment Styles Case Vignettes – Group Activity Instructions: Read each case vignette carefully. As a group or individually, reflect on the attachment style that each vignette best represents. Be prepared to explain your reasoning based on the descriptors, memories, and emotional tone used by the client.

Can I get my own way?

No

Do you love me?

Yes

Yes

No

Neglectful

Authoritarian

Distant

Rule-bound

Dangerous

low communication

dismissive

Deductive discipline

Permissive

Authoritative

lack of boundaries

develop. appropriate expectations moderate communication Inductive discipline

Vignette 1 –______________________Attachment Client, 42, describes her mother as: loving, strict, warm, anxious, supportive. Her father: calm, distracted, humorous, fair, emotionally distant. When asked for memories, she shares a story about how her mother often became overwhelmed during homework help and would snap, but would later apologize and ask to talk it through. She recalls her father forgetting a school pickup once, but says he explained and reassured her when he got there.

Her storytelling is emotionally coherent. She reflects on these moments with warmth, noting, “They weren’t perfect, but I always knew they loved me and wanted to do better.”

Vignette 2 – ______________________ Attachment Client, 29, describes her mother as: busy, cold, tired, efficient, unavailable. Her father: funny, charming, inconsistent, angry, gone. She struggles to recall consistent care, saying, “I think they did their best.” She quickly deflects with humor and often speaks in generalities. She minimizes painful memories and avoids emotion.

Vignette 3 – ______________________ Attachment Client, 36, describes her mother as: loving, mean, unpredictable, confusing, everything. Her father: missing, deadbeat, sorry, sometimes-there, apologetic. She shares contradictory memories and seems distressed while speaking. Her language becomes chaotic, jumping between blame and guilt. She cries and then laughs inappropriately.

Vignette 4 – _____________________ Attachment Client, 31, describes her mother as: affectionate, nervous, talkative, critical, overbearing.

Her father: absent, silent, serious, stressed, working. When asked for memories, she gives several detailed examples of calling her mother repeatedly at work to be reassured she wasn’t angry. She reports being punished one moment and smothered the next, and says, “I always felt like I had to prove I was good enough.” Her tone is anxious, her narrative is linear but emotionally intense, and she seeks reassurance from the interviewer.

Pa g e |1 Subject's Background Interviewer: Can you tell me a little about your background?

Subject: Sure. I'm originally from Memphis, born in 1981. Back then, it was a smaller town, you know, the kind where you didn't have to lock your doors. There was a sense of safety and a closeknit neighborhood vibe. I was the middle child in our family, living in a poorer neighborhood. I had an older sister and a younger brother. We were raised by two moms. My biological mom was the main breadwinner of the family. The other mother, whom I'll refer to as JC, presented in a more masculine way and was the more nurturing and engaged one of the two. My biological mother, on the other hand, was quite the opposite. She presented herself in a very feminine manner and made it clear that she was the 'prize' or the 'queen' of the house. We were often reminded, almost as if we were born to be her personal slaves. I remember running to put her shoes on for her. In terms of discipline, it was a bit of a mixed bag. My biological mother was quite permissive, and JC was maybe too nurturing. We didn't get punished a lot. I found myself in a parentified role early on, being the one who always did the right things and was considered the smart one. Things changed when my mother left JC. That's when I really stepped into a parental role. A stepfather was brought into the picture, and our family dynamics became somewhat polyamorous. It was a period marked by a lot of chaos, but I managed to navigate through it pretty well. As for my biological father, there was no real connection there. He came around once when I was about five years old. I didn't even know who he was until after he left. I haven't seen him since then.

Subject's Description of Biological Mother Interviewer: Can you give me five adjectives to describe your mother in relation to you as a child between the ages of 5-12 years?

Subject: 1. Absent (Valence:

)

Age: 7

Story Associated: She was always gone. We would get up in the morning and JC would be there, making a beautiful breakfast spread. I didn’t see my mother until around 6-7pm. By the time she came home, we were already back at the house, getting ready for bed.

2. Threatening (Valence:

)

Age: 7-8

Story Associated: I remember watching her get into fights with JC. I would come downstairs to see her throwing plates at JC, yelling, and screaming.

3. Beautiful (Valence:

)

Age: 11-12

Story Associated: JC absolutely adored her. JC would write about her, and I would read these descriptions, always portraying her beautifully. When she came home, her uniform was still neatly pressed, she smelled good, and her makeup and hair were perfectly done.

She had this long, luxurious “Wave Nouveau.” She was larger than life, like a queen or a godlike figure. We would run to her, take o^ her shoes, and ask about her day.

Pa g e |2 4. Firm (Valence:

)

Age: 6

Story Associated: It was usually JC who would inform us that we had done something wrong and that she would let my mother know. My mother didn’t administer the punishment herself; she would instruct JC to do it. This involved switches, belts, and watching them get beaten down. JC would get us in the plank position for this.

5. Nonchalant (Valence:

)

Age: 6

Story Associated: I recall an incident outside where my brother got a green machine, I got a pink big wheel, and my sister got a bike. My sister picked up a piece of plastic with a point on it and hurt me. JC came out when my brother called. When this was told to my mother, she didn’t discipline my sister. It felt like she didn’t defend me. The situation was quite threatening.

Subject's Description of JC Interviewer: Can you describe JC, who you referred to as your father figure, using five adjectives?

Subject: 1. Creative (Valence:

)

Age: 7

Story Associated: We had so much fun together. There are countless memories of good times. We would create songs, making sounds and trying to harmonize. JC taught us all kinds of di^erent songs. It was a really creative environment.

2. Adventurous (Valence:

)

Age: 10

Story Associated: JC definitely sparked the adventurous side of me. She had been in the military and traveled abroad, and I loved hearing about her experiences. She encouraged me to explore, leading me to spend a lot of time in the library, befriending librarians and discovering new things. She really ignited those interests in me.

3. Nurturing (Valence:

)

Age: 7

Story Associated: JC taught me how to cook. She made homemade biscuits and dumplings and was always cooking. I would watch and learn, and she let me try and fail without any fuss. Another thing - my biological mother wasn't into hugs and kisses, she would push me away. But JC was the opposite; she allowed hugs, kisses, and leaning on her. I've made sure to give my child as much a^ection as she needs, thanks to JC. 4. Present (Valence:

)

Age: 12

Story Associated: JC was always there for me. She was involved in everything I did. Even when I was in magnet schools and she didn't understand the material, she would sit with me, trying to help. She also established structured processes for our activities, ensuring our success.

Pa g e |3 5. Weak (Valence:

)

Age: 7-8

Story Associated: I realized this when I would talk to JC about my feelings and question why she let my mother treat her the way she did. Her response was always about love. That made me question the nature of love and what it meant to be strong in a relationship.

Subject's Experiences Interviewer: Which parent would you say you were the closest to, and why?

Subject: I was closest to JC. When she left when I was 15, I wanted to go with her but wasn’t allowed. I really clung to the nurture I got from her. The discipline I got from my mother was more like neglect, whereas JC gave me...

Interviewer: Can you tell me about a time when you were emotionally upset as a child, and what happened?

Subject: [Long pause] I think I was emotionally upset when I was 5. There was an incident with a maintenance man who gave my brother and me lollipops through the window into the room where we were taking naps. The lollipops were taken from me, and I was told that I didn’t take care of my brother. I felt shame and guilt. I felt jealous of my brother but not fear as my mother came home. My mother got huge and big and then turned on JC, and JC got blamed. I felt bad for JC. It was not dealt with, and it’s a story where I dropped the ball in defending my brother, and I became the person to defend others and had to forgo my pleasure for others.

Interviewer: Can you tell me about a time when you were physically hurt as a child, and what you did?

Subject: The only thing I can think of is scraped knees, and JC came to my rescue. [foggy memory] I was playing, running, scraped my knee after falling o^ the wall, fell down, scraped both knees, crying, and JC would come for it.

Interviewer: Can you tell me about a time when you were sick as a child?

Subject: When I would get sick, JC would come with Vicks VapoRub, covering our bodies, and blankets to sweat it out. I remember anytime we got sick, this was the first thing we would do. We would get soup and blankets. I don’t remember even being tucked in.

Interviewer: Were your parents a^ectionate with you?

Subject: JC was very a^ectionate. She wouldn’t initiate hugs or kisses, but...

Interviewer: Did you ever feel rejected as a child?

Subject: Oh yes, my mother rejected me all the time. She was always pushing away aggressively.

Interviewer: Tell me about a time you felt frightened as a child?

Subject: I remember feeling frightened when I thought JC might be hurt by glass being thrown at her, and she got cut. I haven’t been specifically frightened...

Pa g e |4 Interviewer: Tell me about a time you felt threatened as a child?

Subject: Yeah, that’s what I wanted to use before. I think I stepped into this when I was 11-12, and we all would get threatened to be beaten, and I would take ownership...

Interviewer: Were you ever abused as a child?

Subject: Circumstances were neglect, emotional abuse. By whom? My bio mom. E^ects? I'm still working on it even now, not putting myself on the backburner, giving myself rest, not overthinking everyone else, and trying to be a pacemaker for everyone due to a lack of having to figure it all out on my own because I didn’t have guidance. I craved unconditional love with nurture and discipline (nurture, no discipline, only toxicity). I might overdo it with myself and am working on making it healthier.

Interviewer: Did you endure any other type of trauma?

Subject: Ages: 15. Circumstances: JC leaving. E^ects: I knew I would have to do it all, lost support, and I had to be mama. I was called granny in high school. I developed my own inner child that wants to be wild and free.

Subject's Adult Experiences Interviewer: How is your current relationship with your mother?

Subject: My bio mom lives with my stepfather, who moved in with us when I was 15. I’m embarrassed by her and wouldn’t want anyone to know that I’m related to her. I don’t want to be a part of it. I did a 180, and then I realized that I had to see the qualities that I do share with her.

Interviewer: How is your current relationship with your father/JC? Subject: I could have gone with her. My mother took me over to her house to have a conversation, and JC told me how we couldn’t be together. There was no communication after that. I wrote to her, and she wrote back, ending the relationship. She told me she is a reminder of a life she no longer has and that she goes to church now and can’t introduce me as her daughter. This has been since I was 19 or 20 years old.

RELATIONSHIP WITH CHILDREN

Interviewer: Do you have children?

Subject: Yes, a daughter, 9 years old.

Interviewer: Why did you choose to adopt or have a child?

Subject: I’ve always wanted her. I wanted a child at 16, but I used to take care of my cousins. I named her before she came along. I was 29 and had her despite having polycystic ovarian syndrome. I named her Acire, which is my name backwards. I wanted her more than I wanted a husband, as I had a husband before. He was praying for her too. I had a child because I’m a mother.

I also wanted to be a mother that a child would choose.

Pa g e |5

Interviewer: Have you ever been separated from your child/children?

Subject: Yes, and it’s great. She is with her father every other month. He lives in Knoxville, which is 2 hours away. I’m not big on Christmas but I’m big on birthdays. Before her father was signed up, I was parenting her like JC parented me. She turned into a beast like my mother. We went four months with her being with her father, and now we go back and forth, and it’s been great.

Interviewer: What are your wishes for your child/children?

Subject: I wish for her to be exactly who she sets out to be. I already know that. She is a gift from God. I’m supposed to take care of that gift, but she is not mine.

Interviewer: What did you learn from your own childhood?

Subject: I learned [pause] that balance is so important, and I strive for it every day in my life. I felt so involved in my community and with my family. I belonged. I feel like that is what I am seeking—to belong without being too attached. Attached but unattached. There is a faith that it's going to turn out as it's supposed to. So then she can get the overflow.

Case Study Handout – Adult with BPD + Attachment Trauma Client: A 32-year-old female with a history of abandonment, emotional abuse, and chronic invalidation. Diagnosed with BPD and PTSD. Frequently enters therapy dysregulated, demands reassurance, and panics with perceived therapist distance.

Reflection Prompts 1. What DBT skill sequences might support her in-session?

2. How would you use validation without reinforcing dependency?

3. Where might DBT offer containment without control?

Optional Follow-Up Sketch a sample treatment plan for the next three sessions using DBT skills that support emotional containment and relationship safety.

Case Vignette Handout – Complex Attachment & Neurobiology Client: A 42-year-old woman, raised in Memphis, TN, in a family with two caregivers—her biological mother and a paternal figure named JC. From ages 5–12, her experience with her biological mother was marked by emotional inconsistency, neglect, and power imbalances. Descriptions included: "absent," "threatening," "beautiful," "firm," and "nonchalant." While her mother was perceived as physically attractive and commanding, she was emotionally distant and often aggressive.

The client described instances of emotional abuse, including being neglected during illness, invalidated during distress, and blamed for sibling conflicts.

In contrast, JC was described with warmth: "nurturing," "creative," "adventurous," and "present." JC was emotionally available, affectionate, and helped the client build a sense of capability and identity through shared activities like cooking, music, and study. However, the client also perceived JC as "weak" for tolerating mistreatment from her mother, creating internal confusion about love and boundaries.

At age 15, JC left the household, a loss the client described as profoundly traumatic. She internalized responsibility, assumed a caregiving role, and earned the nickname “granny” in high school due to her maturity. As an adult, she describes lingering shame and emotional distancing from her biological mother and unresolved grief toward JC, who cut off contact.

The client now has a 12-year-old son. She is conscious of her parenting patterns and strives to balance nurture with structure, often reflecting on her own childhood to inform her parenting choices. She experiences the effects of early trauma in her nervous system, particularly in over-functioning, chronic guilt, and relational hypervigilance.

Group Reflection Prompts - Which neurotransmitters show up in this client’s story?

- What systems are under- or over-developed?

- What would mindfulness support look like early in this case?

Case Study Breakout – Jordan Jordan is a 15-year-old male referred for chronic school avoidance, irritability at home, and increasing isolation. His mother reports he was a “sensitive” child with early separation anxiety. At age 8, he witnessed a violent home invasion in which his father was assaulted.

His father left the family shortly after the incident, and Jordan has not seen him since.

Since then, Jordan experiences frequent nightmares, a persistent startle response, and episodes of shutting down when overwhelmed. At school, he is often silent or disengaged, becoming defiant when asked to participate. At home, he spends most of his time in his room playing video games and avoids family activities. His mother describes him as either “exploding or disappearing.”

Small Group Discussion Prompts 1. Which emotional systems (Panksepp) appear dominant, suppressed, or dysregulated?

2. What patterns of hyperarousal or hypoarousal do you observe in Jordan?

3. Which core organizers of experience (Ogden) are most impacted?

4. How might you begin to apply DBT emotion regulation skills to support his development?

DBT Triad Practice – Relational Trauma & Skill Integration This practice invites you to explore how DBT skills function in real-time relational dynamics involving trauma and anxiety.

Triad Roles - Client A: Presents with relational trauma and anxiety. Consider themes such as fear of abandonment, emotional volatility, or boundary confusion.

- Therapist B: Offers DBT-based support using validation, interpersonal effectiveness, and mindfulness-based responses.

- Observer C: Notes how the therapist paced the conversation, introduced DBT skills, and responded to dysregulation.

Suggested Flow 1. 5-minute roleplay (therapist and client) 2. 2-minute feedback from observer 3. Rotate roles 4. Debrief as a triad

Integration Prompts • What skill seemed most effective in grounding the interaction?

• How did tone, pacing, and presence affect the therapeutic moment?

• What would you keep, shift, or refine in your next attempt?

Reflection Question What skill do you tend to lean on in high-stakes relational moments—and what new tool do you want to practice more intentionally?