Finding Middle Path “All Things DBT” A Workbook
Constructed By: Rachael Julstrom, LPC, LCPC
Edited by: Bonnie Monahan, LPC, PLPC
“Lord, you give me everything I need.” – Lauren Daigle
Welcome! I am so glad you have decided to REACH OUT and talk to someone about what is going on in your life. If it is one session or we get to work on things more long-term, I am honored that you have taken the first step.
This project was started to combine all of the tools used from Marsha Linehan and other wonderful DBT providers. It was born during COVID-19.
Rachael Julstrom, DBT-C, LPC, LCPC
STARTING DBT General Handouts
The following pages are GENERAL HANDOUTS. This is basic information that is good to know about DBT and how it works best. Please pay attention to the Commitment Strategies, Stages of Treatment, and Therapy Interfering Behaviors.
GENERAL HANDOUT
DBT (Dialectical Behavioral Therapy) has some basic commitment strategies. While this may feel rigid, it is indented to quickly decrease any problematic behaviors and emotions so you can continue to reach your goals.
DBT Commitment Strategies:
DBT is MOST effective when used as a FULL Model:
Individual Sessions
Group Skills Training
Coaching Calls/Crisis Intervention
Therapist Consultation Group
Full Model Requires a larger commitment of 6-12 Months of:
Weekly Individual Sessions
Weekly Group Skills Training
Homework (Practicing Skills)
Diary Card
Prior to engaging client in treatment, client must be: Ready and WILLING to make changes
Agree to year-long commitment
Willing to engage in partnership with therapist
Able to define problems and behavior
Willing to do things differently than before
STAGES OF TREATMENT
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
GENERAL HANDOUT
Therapy Interfering Behaviors
The following is a list of behaviors that the client or therapist can have that interrupts the therapeutic process. This list is important to keep handy to revert to when you feel something is “off” or you are “plateauing” in therapy.
§ Advice-Giving
§ Storytelling
§ Leaving session early
§ Being in continuous, disruptive crises
§ Arguing with the therapist
§ Using humor to deflect from the topic
§ Canceling or not showing up; being late
§ Not completing homework and diary cards
§ Pushing therapist’s limits
§ Interacting with the therapist in an overly personal/friendly way, including sexual, provocative, or seductive behavior
§ Threatening the therapist, therapist’s family, and/or other clients in a harmful manner
§ Lack of gratitude/appreciation for the therapist’s efforts
§ Infringing on the therapist’s personal space
§ Monopolizing
§ Being the Therapist’s Assistant
§ Being too tired to stay awake
§ Withdrawing emotionally, in session
§ Intellectualizing
§ Justifying and rationalizing behaviors
§ Refusing to comply with recommendations
§ Making hostile, critical, and judgmental remarks to other clients
§ Demanding solutions to problems that the therapist can’t solve
§ Excessively requesting coaching calls for things that could wait until the next session
§ Criticism of the therapist’s values and/or personality
§ Minimizing challenges
§ Not being honest about unhealthy behaviors.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
GENERAL HANDOUT
Guidelines for Skills & Group Training
(If and when you attend DBT Group, the following guidelines exist)
1. Clients who drop out of therapy are out of therapy.
2. Each client has to be in ongoing, individual therapy.
3. Clients are not to come to sessions under the influence of drugs or alcohol.
4. Clients are not to discuss past (even if immediate) parasuicidal behaviors with others clients, outside of sessions.
5. Clients who call one another for help when feeling suicidal must be willing to accept help from the persons called.
6. Information obtained during sessions, as well as the names of clients, must remain confidential.
7. Clients who are going to be late or miss session should call/text ahead of time.
8. Clients may not form private relationships outside of skills training sessions.
9. Sexual partners may not be in skills training together.
Other
Rules for this Group:
GENERAL HANDOUT
Goals of Skills Training
To learn and refine skills in changing behavioral, emotional, and thinking patterns associated with problems with living, that is causing misery and distress.
SPECIFIC GOALS
Behaviors to Decrease:
§ Interpersonal chaos, loneliness, being in unhealthy relationships
§ Unstable moods, emotions, and willfulness
§ Impulsive behavior, difficulty accepting reality
§ Mindlessness, emptiness, judgmental attitudes
Behaviors to Increase:
§ Interpersonal effectiveness
§ Emotional Regulation
§ Distress Tolerance
§ Mindfulness
BIOSOCIAL THEORY
Why do I have so much trouble controlling my emotions and actions?
Emotional vulnerability in BIOLOGICAL: It’s simply how some people are born.
§ They are more sensitive to emotional stimuli; they can detect subtle emotional information in the environment that others don’t even notice.
o They experience emotions much more often than others.
o Their emotions seem to hit for no reason, from out of the blue .
§ They have more intense emotions.
o Their emotions hit like a ton of bricks .
o And their emotions are long - lasting .
Impulsivity also has a BIOLOGICAL basis: Regulating action is harder for some than others.
§ They find it very hard to restrain impulsive behaviors.
o Often, without thinking, they do things that get them into trouble
o Sometimes their behavior seems to come out of nowhere .
§ They find it very hard to be effective .
o Their moods get in the way of organizing to achieve their goals.
o They cannot control behaviors linked to their moods.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
An invalidating SOCIAL environment can make it very difficult to regulate emotions.
An invalidating environment doesn’t seem to understand your emotions. It tells you your emotions are invalid, weird, wrong , or bad. It often ignores your emotional reactions and does nothing to help you.
It may say things like “Don’t be such a baby!,” “Quit your blubbering,”” Quit being such a chicken and just solve the problem,” or “Normal people don’t get this frustrated.”
People who invalidate are OFTEN DOING THE BEST THEY CAN . They may not kno w how to validate or how important it is to validate, or they might be afraid that if they validate your emotions, you will get more emotional, not less. They may be under high stress or under time pressure, or they may have too many free resources themselves. There may be just a poor fit between you and your social environment: You may be a tulip in a rose garden.
An ineffective SOCIAL environment is a big problem when you want to learn to regulate emotions and actions.
Your environment may reinforce out - of - control emotions and actions
If people give in when you get out of control, it will be hard for you to get in control.
If others command you to change, but don’t coach you on how to do this, it will be hard to continue trying to change.
It’s the TRANSACTIONS that count between the person and the social environment.
Biology and the social environment influence the person. The person reciprocates and influences his or her social environment. The social environment reciprocates and influences the person. …and so on and so on.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
RECOGNIZING DIALECTICAL DILEMMAS IN TREATMENT
EMOTIONAL VULNERABILITY: There's a profound sense of being misunderstood, treated unfairly, isolated, empty, helpless, and defeated. Everything feels unbearable, like having "emotional third-degree burns" where even the smallest emotional trigger causes intense pain. There's a heightened sensitivity to one's surroundings, leading to feelings of paranoia and hyper-personalization of events.
UNRELENTING CRISIS
Overcome by intense, uncontrollable emotions, such as tearfulness, anger, and despair. The ability to maintain a social facade disintegrates, and as coping mechanisms fall apart, more tangible and practical crises begin to emerge.
BIOLOGICAL LEARNING ENVIROMENT
APPARENT COMPETENCE
Projecting confidence and capability, with an attitude of “I’ve got this,” or “I don’t need help,” while avoiding vulnerability. A significant amount of energy is spent trying to meet others' expectations at any cost, downplaying the challenges faced. This leads to feelings of overwhelm and contributes to ongoing self-invalidation.
ACTIVE PASSIVITY
Experiencing feelings of defeat and helpless despair while actively seeking external solutions to problems or relief from pain. This can manifest in impulsive behaviors such as suicidal ideation, self-harm, ending relationships, quitting jobs, running away, violence, substance abuse, or seeking hospitalization.
INHIBITED GRIEVING
Denies feelings This pattern of emotional suppression and ineffective communication can create a cycle of distress and isolation, making it challenging for individuals to receive the support they need or to develop healthier emotional coping strategies.
SELF- INVALIDATION: Through repeated negative experiences, individuals learn that their internal feelings and needs are not reliable or trustworthy. This leads to associating natural emotions and desires with anxiety, often due to a history of punishment or criticism. As a result, they start depending on others to tell them what they need or how they should feel, losing connection with their own internal cues. This creates an overdeveloped sensitivity to social feedback, along with a deep fear of abandonment and a diminished sense of self-identity
DIALECTICAL DILEMMAS
Dialectical dilemmas are a key concept in Dialectical Behavior Therapy (DBT) that represent seemingly contradictory patterns of behavior that individuals with emotional dysregulation often experience. Understanding and addressing these dilemmas is crucial for effective treatment. Here's an overview of DBT's dialectical dilemmas:
THE THREE MAIN DIALECTICAL DILEMMAS
DBT identifies three primary dialectical dilemmas:
1. Emotional Vulnerability vs. Self-Invalidation
2. Active Passivity vs. Apparent Competence
3. Unrelenting Crisis vs. Inhibited Grieving
Each dilemma represents a pair of opposing behavioral patterns that clients often fluctuate between.
EMOTIONAL VULNERABILITY VS. SELF - INVALIDATION
- Emotional Vulnerability : Extreme sensitivity to emotional stimuli, with strong and persistent reactions to even minor events.
- Self - Invalidation : Discounting one's own emotional experiences and looking to others for validation.
ACTIVE PASSIVITY VS. APPARENT COMPETENCE
- Active Passivity : Approaching life's problems helplessly and demanding that others solve them
- Apparent Competence : Displaying skill in handling everyday problems, but inconsistently.
UNRELENTING CRISIS VS. INHIBITED GRIEVING
- Unrelenting Crisis : Experiencing repetitive stressful events without full recovery, leading to urgent behaviors
- Inhibited Grieving : Avoiding painful emotional reactions and suppressing grief.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
SKILLS TRAINNING
1.MINDFULENSS
2.DISTRESS TOLERANCE
3.EMOTION REGULATION
4.INTERPERSONAL EFFECTIVNESS
5.WALKING THE MIDDLE PATH
1. SOLVE THE PROBLEM
Simple Solutions – If you are hot, turn on a fan. If you need more light, turn on a light. If you need to change the situation, then do so. (Use interpersonal effectiveness skills or problem-solving)
2. FEEL BETTER ABOUT THE PROBLEM
Change (or regulate) your emotions about the problem (Use Emotional Regulation Skills)
3. TOLERATE THE PROBLEM
Accept and tolerate both the problem and your responses to the problem (Use Emotion Regulation Skills)
4.
STAY MISERABLE
Sometimes we need to feel our feels. There is a time and a place to experience our emotions. Yet, knowing the difference between extreme emotions and staying miserable in perpetual/excess emotion is vital (Use Distress Tolerance and Mindfulness Skills)
5. MAKE IT WORSE
Always an option, and I think we know what this feels like. How can you learn to regulate before we get to this point? (This is where we use NO skills)
MINDFULNESS
UNDERSTANDING WHAT IS MINDFULNESS + HOW TO ACHIEVE IT
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
MINDFULNESS: EXERCISE
What do you think of when you hear the word Mindfulness?
Mindfulness Definition:
“Mindfulness means paying attention in a particular way; On purpose, in the present moment, and non-judgmentally.”
- Jon Kabat-Zinn
Benefits of Mindfulness:
1. Helps you slow down.
2. Teaches you to know yourself better.
3. Strengthens your concentration.
4. Teaches you to control ruminating thoughts.
5. Builds resiliently.
6. Helps reset you from traumatic experiences.
7. Repairs the prefrontal cortex and increases impulse control.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
MINDFULNESS HANDOUT
Taking Hold of Your Mind: States of Mind
Wise Mind Reasonable/ Logical Mind Emotion Mind
When in Reasonable / Logical Mind , you are ruled by facts, reason, and logic. Values and feelings are secondary.
Wise Mind / MIDDLE PATH is within each person. They see the value of both reason and emotion. It brings left and right brain together. It is finding the wisdom within and recognizing and respecting feelings.
Emotion Mind is when you are ruled by your moods, feelings, and urges. Facts and reasons are not important. Here, a person wants to act impulsively and not think through actions.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder
MINDFULNESS HANDOUT
Taking Hold of Your Mind:
Think”
Reasonable /Logical Mind
Know”
Wise Mind
Calculated Logical Scientific Fact ual Stoic Conservative Analytical “Numb” Balanced Effective Peaceful Validating No Regrets
Emotion Mind
Reckless Impulsive No filter
Narrow- minded
Narrow- focused Crying
PROS: - Clear - Fact- Oriented - No Distractions - Productive
Wise Mind is more than just a balance between logic and emotion; it also includes your intuition. It's the part of you that understands your deepest desires and needs, even those hidden beneath the surface. It helps guide you to make decisions that are best for your well-being, like a gut feeling or inner voice. Sometimes, the wisest choice is simply not to act at all.
PROS: - Passionate - Loves Hard - Empathic “I Feel”
MINDFULNESS HANDOUT
Mindfulness Activity
In the spaces below, think of the following that would fit in each state of mind:
• Colors
• TV / Movie Characters
• Types of Cars
• Places
Reasonable/ Logical Mind
Wise Mind
Emotion Mind
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
MINDFULNESS HANDOUT
3 STEPS TO ACHIEVE WISE MIND:
WHAT SKILLS
OBSERVE
● Just notice the experience.
● Watch your thoughts and feelings come and go like clouds in the sky.
● Do not push away your thoughts and feelings, just let them happen.
● Notice your bodily sensations – with all senses (sights, smells, touch, tastes, hearing)
● Practice “wordless watching”
Exercise: Take a quick 5-10 second glance at your surroundings. What did you notice that you didn’t before?
DESCRIBE
● Put words on the experience
● Label what you observe. Put a name on your feelings. Label a thought as a thought, a feeling as a feeling, and an action as an action.
● For example: “I feel sad right now,” or “My stomach muscles are tightening.”
● Remember: “If you can’t observe it from your senses, you can’t describe it.”
● Practice the Who, What, Where, When, and Why
● Lean on “Just the Facts”
Exercise : Name 5-10 objects around you.
PARTICIPATE
● Throw yourself completely into what you are doing in the moment (talking, sitting, cleaning, dancing, driving, feeling emotions)
● Become one with your experience. Throw your attention to the moment.
Exercise : What are you doing? – Just the Facts (i.e. – talking, breathing, eating)
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
MINDFULNESS HANDOUT
3 STEPS TO ACHIEVE WISE MIND:
NON-JUDGMENTALLY
HOW SKILLS
● Don’t evaluate - Just the facts.
● Accept the moment
● Let go of your opinions
● Acknowledge the helpful – let go of the Could, Should and Would thoughts
● Don’t judge your judging
Exercise: Give descriptors to 5 objects around you without adding judgment (i.e. ugly, small, big, awful)
ONE-MINDFULLY
● Do one thing at a time
● Let go of distractions
● Think of one thing at a time
Exercise : Pick a simple activity and spend the next 15-30 seconds focusing on just that activity.
EFFECTIVELY
● Focus on what works
● Play by the rules. Act as skillfully as you can, meeting the needs of the moment you are in, not the one you WISH you were in
● Let go of vengeance, useless anger, and righteousness that hurts you and doesn’t work
● Keep your eye on what you want in the long run
● Let go of perfectionism and remember - being effective doesn’t mean being gentle
Exercise : Evaluate what you are not doing right now due to “extremes.” What can get you focused on moving forward? (If you need help try starting with Observe, Describe and Participate.)
MINDFULNESS EXERCISES
Mindful Eating: Have bite-sized pieces of chocolate or mints (individually wrapped). Take the candy and place it in your hand and practice Observe and Describe skills. Then place the candy in your mouth (no chewing) and let it sit on your tongue while you practice Participate and One Thing in the Moment. When you notice your thoughts wandering, acknowledge them and then bring them back to the activity (practicing NonJudgmentally). As the time passes, note what you feel like was Effective about the exercise.
Safety Awareness : Sit in a space that brings on safety. Bring about awareness to your space and start to list all the things that make you feel safe. For example, the walls protect you from outside elements, the roof provides protection, the doors allow you to determine who comes and goes. Begin to relax the body and focus on some mantras such as “I am in the “Serenity of Safety” as I expand into my unknowns.” Remember, safety comes with awareness. If you feel yourself begin to drift or feel unsafe, come back to your breath and allow the thought to pass and come back to a mantra or prayer of your choice.
Mantra/Prayer:
Body Scan Mindfulness : Sit quietly or lie down in a quiet place (eyes shut or open). Start at one end of your body and then focus on each body part. (It might help to name that part while focusing). Notice any tension in that area and take a deep breath and focus on relaxing that part of your body. Continue until you are done with the whole body. You can be as brief or detailed as needed
What have you learned about yourself during these exercises?
Have you had any changes or applied the skills to your life so far?
Have your goals for therapy changed?
What reflections do you have about DBT?
STOP TIPP DISTRACT
SELF-SOOTHE
IMPROVE THE MOMENT PROS AND CONS TURRING THE MIND
DISTRESS TOLERANCE HANDOUT
COPING WITH PAINFUL FEELINGS & URGES
Why Bother?
1. Pain is part of life and can’t always be avoided.
2. If you can’t deal with your pain, you may act impulsively.
3. When you act impulsively, you may end up hurting yourself or not getting what you want.
Crisis Survival Strategies
:
Skills for coping with painful events and emotions when you can’t make things better RIGHT AWAY.
DISTRESS TOLERANCE HANDOUT
STOP Skill
Stop
Take a step back
Observe
Proceed mindfully
Stop! Freeze! Do not react. Do not move a muscle! Your emotions may try to make you act without thinking. Stay in control!
Take a step back from the situation. Take a break. Let go. Take a deep breath. Do not let your feelings make you act impulsively.
Notice what is going on inside and outside of you. What is the situation? What are your thoughts and feelings? What are others saying or doing?
Act with awareness. When deciding what to do, consider your thoughts and feelings, the situation, and other people’s thoughts and feelings. Think about your goals. Ask Your Wise Mind: Which actions will make it better or worse?
Adapted
DISTRESS TOLERANCE HANDOUT
TIPP Skill
Changing Your Body Chemistry
Temperature
Intense Exercise
Paced Breathing
(To calm down fast)
Hold your breath and put your face in a bowl of cold water
Hold ice in your hands (no more than 30 seconds)
Wet a washcloth in cold water and place where desired
Drink ice cold water
(To calm down your body when overwhelmed w/emotion)
Engage in intense exercise for only a short while Expend your body’s stored up energy by running, sprinting, walking fast, doing jumping jacks, doing sit ups, etc.
(Pace your breathing by slowing it down)
Deep belly/abdominal breathing
4-4-8 or 4-7-8 breathing
Wet a washcloth in cold water and place where desired
Drink ice cold water
Paired Muscle
Relaxations
(Calming down using Paired Muscle Relaxation w/ Breathing)
Close your eyes and focus on tensing and relaxing each muscle group for 2 to 3 seconds. Start with your feet and toes, and then move up to your knees, thighs, chest, arms, hands, neck, jaw, and eyes. Maintain deep, slow breaths the entire time.
DISTRESS TOLERANCE HANDOUT
Crisis Survival Strategies
USING COLD WATER, Step by Step
* Caution: Very cold water decreases your heart rate. If you have any heart or medical condition, have a lowered base heart rate due to medications, or are on a beta-blocker, consult your health care provider before using these skills! Avoid ice water if you are allergic to the cold.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
DISTRESS TOLERANCE HANDOUT
Crises Survival Strategies
Distracting with ACCEPTS
Activities
Contributing
Comparisons
Emotions
Push away
Thoughts
Sensations
Engage in hobbies, cleaning, going to events, call or visit a friend, play sports or go for a walk, watch TV or a movie, listen to music, play a game or cards, read.
Contribute to someone, volunteer, surprise someone with something, do something thoughtful, clean out your closet or pantry and give to a charity.
Compare how you are feeling now to a time when you felt different. How did you get through something hard in the past? What is a past memory that makes you feel empowered, happy, or calm.
Watch emotional TV shows or movies (Hallmark Channel or Disney movies), listen to emotional music. Ideas: Find music that matches your mood, and then find music that helps you change your mood.
Push the painful situation out of your mind TEMPORARILY, build an imaginary wall between you and the situation. Box it up and put it on the shelf.
Count to 10, count shapes, colors or like objects around you, work on puzzles, read an educational book, learn a new language, do math worksheets.
Hold ice in your hand or get a washcloth wet and cold and put on forehead, squeeze a stress ball, listen to loud music, eat something spicy or sour
DISTRESS TOLERANCE HANDOUT
Cris i s Survival Strategies
Distracting with ACCEPTS Activity
Taste
Hearing
Smell
Touch
Vision
DISTRESS TOLERANCE HANDOUT
Cris i s Survival Strategies
SELF - SOOTHE with the 5 SENSES
Have a good meal, have a favorite soothing drink (i.e. tea, hot chocolate); have your favorite ice cream, eat mindfully, have a mint or something with a strong flavor
Listen to soothing music, sing your favorite song, pay attention to sounds of nature (birds, rain, waves at the beach and waterfalls), get a white noise machine, play an instrument.
Put on your favorite lotion/perfume/cologne, light a scented candle, bake cookies, cake, or dinner, take a walk outside in a wooded area and take in the smells of nature.
Take a bubble bath, put clean sheets on the bed, pet your dog or cat, put lotion on your whole body, put a cold compress on your forehead, brush your hair for a long time, hug someone.
Watch a sunset, look at a picture or poster that you like, make a wall in your room look nice, look at nature around you, walk in a pleasant part of your neighborhood
BONUS : Put together a kit that you can access quickly at home and a travel kit with some of these things to help when needed.
DISTRESS TOLERANCE ACTIVITY
Cris i s Survival Strategies
SELF - SOOTHE with the 5 SENSES
Go through each sense and write out how you want to try to use this skill for yourself:
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
DISTRESS TOLERANCE HANDOUT
Cris i s Survival Strategies
IMPROVE the Moment
Imagery
Meaning
Prayer
Relaxation
One thing
Vacation
Encouragement
Imagine something relaxing or soothing, think about your favorite place with extreme detail, daydream
EMDR: Calm Safe Place
Find or create meaning or purpose in your situation, think of important things or blessings in your life. Have you been through anything like this before?
Pray, meditate, do a Bible study, read a devotional, listen to an inspirational talk or sermon, tap into your spirituality.
Try muscle relaxation, listen to a guided mediation or soothing music, take a hot bath, do some yoga or just some yoga nidra, try deep breathing and half smile - fake it till you make it.
Focus your attention on doing one thing at a time, try to keep yourself in the moment and when you find your mind wonder, bring it back to your breathing and try again, and focus on sensations.
Give yourself a brief vacation, take a 30min to an hour break from hard work (set a timer), turn your phone off for a day or for a short time.
Cheerleading statements, mantras, encouraging scriptures, funny and/or energizing quotes such as “This won’t last forever,” “I will get through this,” and “I am doing the best I can.”
DISTRESS TOLERANCE HANDOUT
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
DISTRESS TOLERANCE HANDOUT
Cris i s Survival Strategies
Below, write the reasonable responses in each box. (Please do this with Therapist or in Group Setting)
Urges or Impulse:
Resisting Impulse
What is something bad that could come from NOT taking this action?
Acting on Impulse
What is something bad that could come from acting on this impulse?
What is something good that could come from NOT taking this action?
What is something good that would come from acting on this impulse?
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder
Guilford Press, 1993.
DISTRESS TOLERANCE HANDOUT
Cris i s Survival Strategies
Below, write the reasonable responses in each box.
Urges or Impulse:
Resisting Impulse Acting on Impulse
What is something bad that could come from NOT taking this action?
What is something bad that could come from acting on this impulse?
What is something good that could come from NOT taking this action?
What is something good that would come from acting on this impulse?
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder
DISTRESS TOLERANCE HANDOUT
Cris i s Survival Strategies
Pros and Cons - Taking it further.
Still having issues with Pros and Cons? Ask yourself the following questions:
- Am I thinking with Emotion Mind?
- What are some Short-Term Goals that might be impacted if I act on this urge?
- What are some Long-Term Goals that might be impacted if I act on this urge?
ALSO:
Go back through your list and give each one a rating from the following scale:
Once you rank each item, THEN tally up the numbers in each box.
Are you thinking in Wise Mind?
Remember: A Pros and Cons list is best used when not in a high - crisis situation.
DISTRESS TOLERANCE HANDOUT
Turning the Mind
▪ Turning the Mind is like facing a fork in the road. You have to turn your mind toward the acceptance in the road and away from the road of rejecting reality.
▪ Turning the Mind is choosing to accept!
▪ The CHOICE to accept does not itself equal acceptance. It just puts you on the path.
OBSERVE that you are not accepting. (Look for anger, bitterness, annoyance; avoid emotions; saying “Why me?,” “Why is this happening?,” “I can’t stand this,” “It shouldn’t be this way.”)
Go within yourself and MAKE an INNER COMMITMENT to accept reality as it is.
DO IT AGAIN, over and over. Keep turning your mind to acceptance each time you come to the fork in the road where you can reject reality or accept it.
DEVELOP A PLAN for catching yourself in the future when you drift out of acceptance.
If you are here...
DISTRESS TOLERANCE HANDOUT
Crisis Survival Skills Worksheet
Still having a hard time with Crisis Survival Skills? When learning new skills, there can be obstacles that keep us from fully engaging. Reflect on the questions below to better understand what might be getting in your way.
1. Are you having trouble accepting reality?
• Take a moment to notice if you're resisting the situation as it is. What thoughts or feelings are keeping you from accepting reality?
2. Are you being Willful or Willing when trying these skills?
• Willful means you're rigid, refusing to change or try.
• Willing means you're open, flexible, and ready to try new things. Which one are you being right now?
3. Are you trying to use too many skills at once?
• Sometimes we overwhelm ourselves by trying to do too much. Focus on one or two skills at a time. What skills are you currently using? Can you narrow it down?
Reflection
Write down what you learned from answering these questions and how you might approach your Crisis Survival Skills differently going forward.
D ISTRESS TOLERANCE HANDOUT
ALTERNATE REBELLION
When destructive behaviors or high internal chaos starts to stir we use alternate rebellion to help to rebel against authority, conventions and the boredom of life. Alternate rebellion replaces these destructive behaviors and keeps you on a path toward your goals. Be sure to choose things that are semi-permeant and have low long-term consequences.
• Give an honest response instead of a polite one
• Speak out rather than staying quiet
• Change up your style of dress
• Challenge statements when you disagree
• Quit things that are not effective
• Give yourself time to play or rest
• Do Random Acts of Kindness
• Explore your neighborhood, your town, a new area
• Say no to family when they ask for a favor
• Change your color preference of clothing
• Do things out of order
• Seek your own interests
• Don’t cook (Get Takeout or Have an Untraditional Meal)
• Run instead of walking
• Do crazy or drastically different makeup
• Get a radical hair cut or color your hair
• Turn up the volume
• Roll down all the windows in your car
• Play a different style of music
• Shout or scream alone (maybe into a pillow)
• Vocally advocate for an issue you care deeply about
• Sleep late on Saturday
• Dress up for a casual event or down for a fancy event
• Get your ears pierced or any type of piercing
• Buy something impractical
• Break out of roles expected of you
• Get in a food fight
• (Possibly) Get a tattoo
• Paint your face
What have you learned about yourself during these exercises?
Have you had any changes or applied the skills in your life so far?
Have your goals for therapy changed?
What reflections do you have about DBT?
Changing Emotions
o Changing Actions
o Validating Emotions
o Problem Solving for Justified/Fit the Facts Emotions
o Opposite Action for Unjustified Emotions
3.) REDUCING EMOTIONAL VULNERABILITY
o Accumulate Positive Experiences
o Build Mastery
o Cope Ahead
o PLEASE Skill
EMOTION REGULATION HANDOUT
Overview of Emotions
What
are Emotions Good For?
▪ Emotions communicate to ourselves information that something is happening (e.g., “I feel very nervous standing alone in this dark alley.”
▪ Sometimes they are communicated by our “gut feeling.”
▪ Emotions communicate to and influence others (e.g., facial expressions or body posture say a lot about how you are feeling.
▪ Emotions prepare us for action (e.g., if you step off the sidewalk without looking or hearing a horn, you automatically step back).
▪ Be mindful that our emotions are NOT FACTS.
Here is a short list of Primary Emotions:
EMOTION REGULATION HANDOUT
Overview of Emotions cont.
Emotions are made up of a combination of those primary emotions. We often have a reaction emotion to the primary that is called a secondary emotion. Some examples would be:
Feeling angry that you get sad.
Feeling sad after you feel guilt or shame.
Feeling fearful when you are sad.
These emotions are not hardwired into your body or brain, but are learned from our families, our culture and others.
When you have a secondary emotion, it is important to identify the primary emotion, so you can take action on that emotion.
WHY IS IT IMPORTANT THAT I CONTROL MY EMOTIONS?
Remember the “Beach Ball” example. When a beach ball is fully aired and we try to push it under the water it becomes harder to push down and control. Then it pops up out of the water when we least expect it to (out of our control). Our emotions are just like this. If we don’t learn to express them under our control then our emotions will take over and explode when we do not expect it.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
EMOTION REGULATION HANDOUT
The Interaction of Emotions with Thoughts and Behaviors. (Anatomy of an Emotion)
THOUGHTS:
“This is great” “I’m so happy” “This is the best.”
EVENT/TRIGGER:
Being successful. Getting what you want. Receiving praise. Being accepted.
EMOTIONS ABOUT THE EVENT:
BODILY REACTIONS:
Feeling energetic. Having a bright and glowing face. Smiling. Feeling warm.
ACTION: Hugging people Jumping up and down. Laughing.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
EMOTION REGULATION HANDOUT
The Interaction of Emotions with Thoughts and Behaviors.
THOUGHTS:
“It’s not fair” “It should be different” “I’m right.” “I’m going to explode.”
EVENT/TRIGGER:
Losing power. Losing respect. Being threatened. Being insulted.
EMOTIONS ABOUT THE EVENT:
ANGER
ACTION: Throwing things. Cursing. Yelling. Stomping. Withdrawing.
BODILY REACTIONS: Tightness or rigidity. Tense all over or in certain areas. Crying. Flushed. Teeth and mouth clenched.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder
Guilford Press, 1993.
EMOTION REGULATION HANDOUT
The Interaction of Emotions with Thoughts and Behaviors.
THOUGHTS:
“I’m going to fail”
“I’m losing control”
“I might get hurt.”
“I might get rejected.”
EVENT/TRIGGER:
Being alone.
Being in a new place. Being in a threating situation.
Looming illness.
EMOTIONS ABOUT THE EVENT:
FEAR
ACTION: Avoid people. Run away. Freeze up. Attack verbally or physically.
BODILY REACTIONS:
Jittery. Shaking and trembling. Hair on end. Lump in throat. Tense muscles. Quickened breathing. Feeling cold.
EMOTION REGULATION HANDOUT
The Interaction of Emotions with Thoughts and Behaviors.
THOUGHTS:
“I’m a bad person.”
“I’m stupid.”
“I didn’t live up to expectations.”
EVENT/TRIGGER:
Getting caught doing something you shouldn’t.
Hurting someone. Being made fun of.
EMOTIONS ABOUT THE EVENT: SHAME
BODILY REACTIONS: “Punch in the gut” Sense of dread. Crying. Blushing, hot, red face. Jitteriness. Nervousness.
ACTION: Hiding from people. Asking for forgiveness. Repairing the harm.
EMOTION REGULATION HANDOUT
The Interaction of Emotions with Thoughts and Behaviors.
EVENT/TRIGGER:
Being rejected. Experiencing loss.
Things are not the way you hoped or expected.
THOUGHTS:
“It will never end.”
“Why did this happen?” “I’m worthless.”
“This is hopeless.”
“I won’t ever get what I need.”
EMOTIONS ABOUT THE EVENT:
SADNESS
BODILY REACTIONS: Frowning. Crying. Red and burning eyes. Drooping posture. Feeling lethargic. Feeling heavy.
ACTION: Isolating. Being inactive. Over sleeping.
EMOTION REGULATION HANDOUT
The Interaction of Emotions with Thoughts and Behaviors.
Practice Exercise: Practice watching how your thoughts, behaviors, and actions are connected.
THOUGHTS:
EMOTIONS ABOUT THE EVENT:
EVENT/TRIGGER: ACTION:
BODILY REACTIONS:
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
EMOTION REGULATION HANDOUT
Changing
emotions
you want to change.
If there was an emotion that you want to change:
First, determine whether the emotion is justified or fits the facts of the situation. Emotion Is Justified/Fits the Facts
Anxiety/Fear
Sadness
Anger
Envy
Jealousy
Shame
Guilt
Love
There is a threat to life, health, or well-being.
You have lost something or someone, OR things are not the way you expected, wanted or hoped for.
An important goal is being blocked, OR you or someone you care about has been attacked, hurt, insulted, or threatened.
Another person or group has things you don’t have and you want or need them AND there are as many reasons for you to have these things as the other person.
A relationship that is important to you is threatened or in danger of being lost.
You will be rejected from a very important group if characteristics of yourself or your behavior are made public.
Your own behavior violates your own values or moral code.
Loving a person, animal, or object enhances your quality of life AND increases your chances of attaining your own personal goals.
Deciding whether the emotion is justified helps tell us which skill will be most effective to use:
Is the emotion not justified? Is the emotion justified?
Problem Solving Skills Opposite Action Skill
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
EMOTION REGULATION HANDOUT
Changing emotions you want to change.
If the emotion is JUSTIFIED , then we use Problem Solving to find and effective solution.
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 Acceptance Skills (Distress Tolerance).
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? Yay! Reward yourself. OR
STEP 6: It DIDN’T WORK? Reward yourself for trying. TRY a new solution.
EMOTION REGULATION HANDOUT
Changing emotions you want to change.
When an emotion is justified by the situation, you may still want to change that emotion or the intensity of the emotion. Try to find a solution. Here are some solutions that tend to go along with certain emotions. Remember, each situation is different, so this is just a place to start.
Emotion
Anxiety/Fear
Sadness
Anger
Envy
Jealousy
Shame
Guilt
Problem Solving
1. Remove the threat.
2. Avoid the threat.
3. Freeze/run if danger is near.
4. Do what gives you a sense of mastery and control of the event.
1. Retrieve what was lost.
2. Accumulate positives
3. Increase contact with rewarding people.
4. Avoid thinking about what you have lost.
5. Radically accept
1. Overcome the obstacle.
2. Stop further attacks OR take a time out
3. Avoid threating people.
4. Be Kind.
1. Improve yourself and your life.
2. Count your blessings.
1. Protect what you have
2. Leave the relationship
1. Find a new group that fits your values or that like your personal characteristics
2. Change your behavior
3. Appease those who are offended.
1. REPAIR the relationship.
2. Accept the consequences, gracefully.
3. Commit to avoiding behaviors that violate your moral values, in the future.
EMOTION REGULATION HANDOUT
If an emotion we want to change is NOT JUSTIFIED, then we use the skill of Opposite Action.
Emotion Action Urge Opposite Action
Anxiety/Fear Avoid Approach
Sadness Withdrawal Get active
Anger Attack
Envy
Gently avoid, but be decent
Sabotaging, criticizing Count your blessings
Jealousy Accusing, spying
Shame
Guilt
Hide
Let go of controlling others, share.
Be open – tell the secret to the people who will accept it.
Hide Be open
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
EMOTION REGULATION HANDOUT
Changing emotions you want to change by acting on Opposite to the Current Emotion
How to do Opposite Action, Step by Step
STEP 1: IDENTIFY AND NAME THE EMOTION you want to change (if you can name it, you can tame it).
STEP 2: CHECK THE FACTS to see if your emotion is justified by the facts.
STEP 3: IDENTIFY AND DESCRIBE YOUR ACTION URGES.
STEP 4: ASK WISE MIND: Is expression or acting on this emotion effective in this situation?
If your emotion does not fit the facts or if acting on your emotions is not effective:
STEP 5: IDENTIFY OPPOSITE ACTIONS to your action urges.
STEP 6: ACT OPPOSITE ALL THE WAY to your action urges.
STEP 7: REPEAT ACTING OPPOSITE to your action urges until your emotions change.
EMOTION REGULATION HANDOUT
How to Reduce Vulnerability to Emotion Mind “ABC PLEASE” A B C
ACCUMULATE POSITIVE EMOTIONS
Short Term: Do pleasant things that are possible now. Long Term: Make changes in your life so that positive events will happen more often in the future. Build a “Life Worth Living.”
BUILD MASTERY
Do things that make you feel competent and effective to combat helplessness and hopelessness.
COPE AHEAD OF TIME WITH EMOTIONAL SITUATIONS
Rehearse a plan ahead of time so that you are prepared to cope skillfully with emotional situations.
E xercise (movement of any kind) P L E A S E
TAKE CARE OF YOUR MIND BY TAKING CARE OF YOUR BODY
Rehearse a plan ahead of time so that you are prepared to cope skillfully with emotional situations.
P hysical illness (treat it)
L ather, rinse, repeat (physical hygiene)
E at balanced
A void mood/mind-A ltering substances
S leep
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
AEMOTION REGULATION HANDOUT
How to Reduce Vulnerability to Emotion Mind “ABC PLEASE”
A CCUMULATE POSITIVE EMOTIONS
Short Term: Do pleasant things that are possible right now. Increase pleasant activities that lead to positive emotions. Do one thing each day from the Pleasant Activities List.
Long Term: Make changes in your life so that positive events will happen more often in the future. Build a “Life Worth Living.”
Work toward goals: Make list of positive events you want to do. List small steps toward goals. Take first steps.
Pay attention to relationships: Repair old relationships. (nontoxic) Reach out for new relationships
Work on current relationships. (with boundaries)
B
B UILD MASTERY
Schedule one or more activities each day to build a sense of accomplishment. Plan for success, not failure. Gradually increase the difficulty overtime. Look for a challenge.
CC OPE 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. Roleplay a few scenarios so you can practice your emotional response. Practice Relaxation after rehearsing.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
EMOTION REGULATION HANDOUT
Pleasant Activities List
1. Rearrange a room
2. Dance
3. Help groups you respect
4. Go to a park
5. Buy a used musical instrument and learn to play
6. Go to a play, concert, or ballet...
7. Buy something frivolous, like a toy or accessory
8. Do artwork or crafts
9. Read sacred works (Bible, Torah...)
10. Wear clothes you like or that you feel good in
11. Read a book or magazine
12. Hear a lecture, sermon, or podcast
13. Listen to a relaxation tape
14. Go out in a canoe or row boat
15. Work on machines (car, bike...)
16. Play a board game
17. Solve a puzzle or crossword
18. Take a long bath or shower
19. Write a story, poem, or music...
20. Ride in an airplane
21. Sing or play an instrument
22. Go to a church or temple function
23. Learn to say 30 words in another language
24. Bake a cake
25. Hygiene (floss teeth, fix hair...)
26. Visit someone who is ill
27. Do outdoor work
28. Sit in the sun
29. Plan an event
30. Play with animals (dog, cat, horse...)
31. Listen to music (radio, CD’s.)
32. Give someone a gift
33. Take pictures
34. Talk about sports
35. Watch or participate in sports
36. Help or protect someone
37. Hear jokes (i.e. comedy club, funny movies)
38. See beautiful scenery
39. Eat a good meal
40. Improve health (change diet, workout...)
41. Go downtown
42. Go to a museum or exhibit
43. Enjoy a sauna or Jacuzzi
44. Buy some watercolors and paint a picture
45. Be with friends or relatives
46. Join a protest (political, environmental)
47. Talk on the phone
48. Daydream
49. Go to a movie
50. Kiss
51. Cook a meal
52. Go to a restaurant
53. Volunteer at the local animal shelter
54. Write in a diary
55. Say prayers
56. Meditate
57. Read the newspaper
58. Go for a walk or run
59. Play Frisbee or catch
60. 10 minutes of deep breathing
61. Sew or do needlework
62. Go to a barber or beautician
63. Be with someone you love
64. Rent a movie
65. Start a new project
66. Go to the library
67. Watch people
68. Sit in front of a fire/fireplace
69. Sell or trade something
70. Volunteer at a homeless shelter
71. Buy some flowers
72. Write a letter
73. Surf the internet
74. Care for houseplants
75. Plant or tend to a garden
76. Work on or start a collection
77. Spend time with children
78. Stay up late
79. Go to a garage sale or auction
80. Meet someone new
81. Go swimming at the local gym
82. Read cartoons or comic books
83. Ride a bike
84. Go for a drive
EMOTION REGULATION HANDOUT
Pleasant Activities Activity
Make a list of Pleasant Activities you would like to try or experience more of.
. What are some potential barriers that would get in the way of you doing any of these things this week?
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder
Guilford Press, 1993.
EMOTION REGULATION HANDOUT
How to Reduce Vulnerability to Emotion Mind “ABC PLEASE”
P hysical illness (treat it)
L ather, rinse, repeat (physical hygiene)
E at balanced
A void mood/mind-Altering substances
S leep
E xercise
Treat P hysical Illness
L ather, rinse, repeat (physical hygiene)
E at Balanced
A void mood/mind
A ltering substances
Balanced S leep
Get E xercise
Take care of your body. See a doctor when necessary. Take medication as prescribed.
Shower, clean your room/house, and get organized. Your environment highly affects your mood.
Pay attention to what food you put in your body.
Stay away from depressants like alcohol and nonprescription drugs (i.e. pot) . Also beware of caffeine and sugar intake.
Try to get a healthy amount of sleep and get on a sleep schedule. Getting between 7-9 hours is average.
Get active. Be sure to keep your activity balanced. Being stagnate can depress your mood and being too active can tire you out.
What other things can you think of that cause your emotions to be more Vulnerable?
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
EMOTION REGULATION HANDOUT
What have you learned about yourself during these exercises?
Have you had any changes or applied the skills in your life so far?
Have your goals for therapy changed?
What reflections do you have about DBT?
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
INTERPERSONAL EFFECTIVENESS HANDOUT
What
is
stopping you
from
having Healthy Relationships?
▪ Lack of skills
▪ Worried thoughts
▪ High or uncontrollable emotions
▪ Others get in your way
▪ You simply forget your long-term goals for short-term goals
▪ Beliefs that you don’t deserve it
▪ Your environment
Goals for Interpersonal Effectiveness
▪ Learn how to be skillful in getting your needs met from others and how to ask for what you need or want.
▪ Learn how to build healthy relationships, how to end destructive ones, and how to handle difficult people in your life.
▪ Learning how to walk Middle Path – how to maintain the balance of acceptance and change.
INTERPERSONAL EFFECTIVENESS HANDOUT
Statements that get in the way for Interpersonal Effectiveness
1. I don’t deserve to get what I want or need.
2. Saying no to someone is selfish.
3. I must be inadequate if I can’t take care of this myself.
4. If I ask for something, I must be weak.
5. They should just know what I need.
6. Others don’t deserve for me to be skillful.
7. Revenge will feel so good; I don’t care about any consequences.
8. I shouldn’t have to negotiate to get what I want.
9. If they say no, it will feel terrible.
10. I don’t need to be nice to get what I need.
Cheerleading Statements for Interpersonal Effectiveness
1. I will survive if I get told no.
2. I am under no obligation to say “yes” to anyone.
3. I deserve to get what I need.
4. My long-term goals and values make me feel better about short-term decisions.
5. Asking for something and being assertive means it is important to me.
INTERPERSONAL EFFECTIVENESS HANDOUT
How to ask for something effectively.
Describe
Express
Assert
Reinforce
Mindful
Appear confident
Negotiate
Describe
Describe the situation. Stick to the Facts
Express
Assert
Reinforce
Mindful
Appear confident
Negotiate
Express your feelings about the situation. “I feel... “
Assert yourself by asking for what you want or saying “no” clearly. Remember the other person cannot read your mind. “I would like...”
Reinforce by telling the other person why it is important that you get what you need and why they will benefit as well.
(stay) Mindful – focus on your goals and don’t get distracted. Also be mindful of the other person and the timing of when and how you ask.
Appear confident by using a confident tone and body language.
Negotiate. Be willing to give to get. Offer potential solutions and suggest that you take a temporary break and schedule a time to come back to the topic.
INTERPERSONAL EFFECTIVENESS HANDOUT
DEAR MAN Activity
Describe the situation. Stick to the Facts
Describe
Express
Assert
Express your feelings about the situation. “I feel... “
Reinforce
Assert yourself by asking for what you want or saying “no” clearly. Remember the other person cannot read your mind. “I would like...”
Mindful
Reinforce by telling the other person why it is important that you get what you need and why they will benefit as well.
(stay) Mindful – focus on your goals and don’t get distracted. Also be mindful of the other person and the timing of when and how you ask.
Appear confident
Negotiate
Appear confident by using a confident tone and body language.
Adapted
Negotiate. Be willing to give to get. Offer potential solutions and suggest that you take a temporary break and schedule a time to come back to the topic.
Gentle
INTERPERSONAL EFFECTIVENESS HANDOUT
How to keep a good relationship.
G entle
I nterested
V alidate
E asy Manner
Be Gentle: Be Nice and Respectful
No attacks
No threats
No judging
Notice your tone of voice
Interested
Act Interested: Listen to the other person
Don’t interrupt
Be patient
Make good eye contact
Don’t make faces (roll eyes)
Validate: Show that you understand the other person’s feelings and the situation.
“That sucks”
“I am listening...”
See full sheet for *Levels of Validation
Easy Manner
Use an Easy Manner:
Smile
Soft tone
Open stance
Positive body language
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
I INTERPERSONAL EFFECTIVENESS HANDOUT
GIVE Activity
How to keep a good relationship. Gentle
Be Gentle: Be nice and respectful
Interested
Act Interested: Listen to the other person
Validate
Validate: Show that you understand the other person’s feelings and the situation.
asy Manner
Use an Easy Manner:
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
NTERPERSONAL EFFECTIVENESS HANDOUT
*Levels of Validation
1. Pay Attention: Look interested in the other person (no multitasking) Get off your phone. Stop doing other things and just sit with the person who wants to talk.
2. Reflect Back : Repeat back what you heard the other person say or do, to be sure you understand exactly what the person is saying. No judgmental language or tone of voice.
3. “Read Minds” : Be sensitive to what is not being said by the other person. Pay attention to facial expressions, body language, what is happening, and what you know already about the other person. Show you understand by your words and actions. Double check you are hearing them correctly.
4. Understand: Look for context and draw from past experiences of what the person is telling you.
5. Acknowledge the Valid : Acknowledge that the person’s feelings are valid. Look for the facts and support their position (you do not have to agree with it).
6. Show Equality : This is not the time to “one-up” or tell a story of worse pain and struggle. Even telling a story that might equal the person’s emotions might take away from the moment and feel like you’re telling them to “just get over it.”
Fair
INTERPERSONAL EFFECTIVENESS HANDOUT
How to keep respect for yourself
F air A pologies
S tick to Values T ruthful
Be Fair: Be fair to YOURSELF and to the other person. You are allowed to ask for what you need. They are allowed to tell you no.
Apologies
No Apologies: Stop saying you’re sorry for asking for what you need. Observe how often you say “I’m sorry” throughout the day.
Stick to Values
Truthful
Stick to your Values: What are your values? Are you compromising to people please? *Values Assessment
Be Truthful: When asking for what you need, be sure to tell the truth and don’t try to exaggerate to get your needs met.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
Fair
INTERPERSONAL EFFECTIVENESS HANDOUT
FAIR Activity
Be Fair: Be fair to YOURSELF and to the other person. You are allowed to ask for what you need. They are allowed to tell you no
Apologies
No Apologies: Stop saying you’re sorry for asking for what you need. Observe how often you say “I’m sorry” throughout the day.
Stick to Values
Stick to your Values: What are your values? Are you compromising to people please? *Values Assessment
Truthful
Be Truthful: When asking for what you need, be sure to tell the truth and don’t try to exaggerate to get your needs met.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
INTERPERSONAL EFFECTIVENESS HANDOUT
How GIVE, FAST and DEAR MAN all work together.
Gentle
Interested
Validate
Easy Manner
Describe Express
Assert Reinforce
Mindful
Appear confident
Negotiate
Fair
Apologies
Stick to Values
Truthful
All 3 Skills work together at the same time – remember to balance the 3 skills while asking.
Remember that when asking for something, you need to stick to one topic at a time. It is too much change to have to add in multiple topics.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
INTERPERSONAL EFFECTIVENESS HANDOUT
Factors to consider when deciding to ask for something or how to say no.
1. CAPABILITY
2. PRIORTIES
3. SELF-RESPECT
• Is the person able to give you what you’re asking for? If YES, raise the intensity of ASKING.
• Do you have what the person wants? If NO, raise the intensity of NO.
• Are your GOALS important? Increase intensity
• Is your RELATIONSHIP shaky? Consider reducing intensity.
• Is your SEL-RESPECT on the line? Intensity should fit your values.
• Do you usually do things yourself? Are you careful to avoid acting helpless when you are not? If YES, raise the intensity of ASKING.
• Will saying no make you feel bad about yourself, even when thinking in Wise Mind? If NO, raise the intensity of NO.
4. RIGHTS
5. AUTHORITY
• Is the person required by law or moral code to give you what you want? If YES, raise the intensity of ASKING.
• Are you required by law or moral code to give the person what he or she is asking for? If NO, raise the intensity of NO.
• Are you responsible for directing the person or telling the person what to do? If YES, raise the intensity of ASKING.
• Does the person have the authority over you? And is what the person is asking within his or her authority? If NO, raise the intensity of NO.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
6. RELATIONSHIP
7. LONG-TERM VERSES SHORT-TERM GOALS
• Is what you want appropriate to the current relationship? If YES, raise the intensity of ASKING.
• Is what the person is asking for appropriate to your current relationship? If NO, raise the intensity of NO.
• Will not asking for what you want keep the peace but create problems in the long run? If YES, raise the intensity of ASKING.
• Is giving in to keep the peace right now more important that the long-term welfare of the relationship? If NO, raise the intensity of NO.
8. GIVE AND TAKE
9. HOMEWORK
10. TIMING
• What have you done for the other person? Are you giving at least as much as you ask for? Are you willing to give if the person says yes? If YES, raise the intensity of ASKING.
• Do you owe the other person a favor? Does he or she do a lot for you? If NO, raise the intensity of NO.
• Have you done your homework? Do you know all the facts you need to know to support your request? If YES, raise the intensity of ASKING.
• Is the other person’s request clear? Do you know what you are agreeing to? If NO, raise the intensity of NO.
• Is this a good time to ask? Is the person “in the mood” for listening and paying attention to you? Are you catching the person when he or she is likely to say yes to your request? If YES, raise the intensity of ASKING.
• Is this a bad time to say no? Should you hold off answering for a while? If NO, raise the intensity of NO.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
INTERPERSONAL EFFECTIVENESS HANDOUT
BOUNDARIES in RELATIONSHIPS
Healthy Relationships require many factors to not only establish them but to keep them going strong.
Boundaries are important to not only have with others, but as Dr. Cloud and Dr. Townsend (Authors of “Boundaries”) say, it is just as important to keep them with yourself.
Here are the Ten Laws of Boundaries according to Dr. Henry Cloud & Dr. John Townsend in their “Boundaries” Workbook:
1. The Law of Sowing and Reaping (this law of cause and effect is a basic law of life)
2. The Law of Responsibility (people react in various ways to a talk on boundaries and taking responsibility for their own lives)
3. The Law of Power (am I powerless over my behavior; how can I become responsible; what do I have the power to do?)
4. The Law of Respect (if we condemn others boundaries, we can expect them to condemn ours.)
5. The Law of Motivation (what is the true motivation behind your boundaries?)
6. The Law of Evaluation (knowing the difference between hurting and harming someone)
7. The Law of Proactivity (setting boundaries before interactions)
8. The Law of Envy (a destructive sin that guarantees we will not get what we want and keeps us perpetually dissatisfied)
9. The Law of Activity (many times we have boundary problems because we lack initiative)
10. The Law of Exposure (your boundaries need to be made visible to others and communicated to them in relationships).
A real relationship means that I am in the light with my boundaries and other aspects of myself that are difficult to communicate. The path to real love is communicating boundaries openly.
It is important to look at who we let into our boundaries as well. The following Diagram will show you how to view people (anyone ) in our life and where they might fit.
INTERPERSONAL EFFECTIVENESS HANDOUT
BOUNDARIES in RELATIONSHIPS
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
INTERPERSONAL EFFECTIVENESS HANDOUT
BOUNDARIES in RELATIONSHIPS
In ner Circle : In this circle there will be about 2-3 people who are your “Go To” people. These people know the most about your life and what is going on and your daily life. (Mom, Dad, Sibling, Best friend, Husband, Wife etc.)
Your Inner Circle:
2 nd Circle: In this circle, these people are your close friends. You see them and check in on them often. You have a working relationship with them. (Co-Worker, Classmates, Teammates etc.)
3 rd C ircle: In this circle, these are the people that you see regularly and you may not know much about them but the settings they are in. Such as, seeing them at church, bank, coffee shop etc.
4 th /Outer Circle: In this circle, these are your acquaintances. You know them, you might be friends on Facebook/Social Media or know them through other friends.
5 th Circle: These are just people in your life that you have not introduced any sort of relationship with. These might be neighbors in your area or people who work for the same company as you. You see them and you do not know much about them at all.
INTERPERSONAL EFFECTIVENESS HANDOUT
BOUNDARIES in RELATIONSHIPS
Ex iled People: In this space, it is deemed for people who have proven they are not safe in your life. You have removed them. For various reasons, they do not get access to your life.
GATES:
The gates are important. People are free to come and go as you and they please. Remember, this helps us to understand that people do not Abandon us nor do we abandon them. We might have times in our lives when people are closer than they are now. Thinking of relationships like this, helps us to stay more in MIDDLE PATH thinking.
What have you learned about yourself during these exercises?
Have you had any changes or applied the skills in your life so far?
Have your goals for therapy changed?
What reflections do you have about DBT?
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
WALKING MIDDLE PATH OVERVIEW
Why is walking MIDDLE PATH the ultimate goal? It is using your new found skills to handle any situation in the most effective way.
How will you know when you are being effective?
- When you have conflict, you will know how to handle it and be able to find a win-win outcome
- You will stick to your goals without jeopardizing relationships
- When you make hard decisions, you will not ruminate over your choices
- You feel in-control of your emotions – no matter how high or low they are.
- You know when to ask for help and when to provide it
- And over all, a sense of happiness and contentment is your “baseline.”
To begin to walk Middle Path, we start with Validation. Validation is not just for you to receive and give others, but also to give to yourself.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
MIDDLE PATH: Validation
(Emotion Regulation + Mindfulness)
Validation: One Way to Find the Middle Path
What is Validation?
Validation communicates to one another that his or her feelings, thoughts, or actions make sense and are understandable to you in a particular situation.
§ I can see that you are really upset right now.
§ I know that you are upset.
§ I am upset. (That’s if… you don’t need to say anything else.)
Steps in Validation
Active Observation
Listens and observes what the other person is thinking, feeling and doing.
Reflection
Helps the person identify, describe, and label their own responses. Direct Validation
Look for the wisdom and validity of the person’s response and communicate it as understandable.
Why should I validate? Why Bother?
§ It shows you are listening
§ It shows you understand
§ It communicates understanding
§ It is good for relationships
§ It can decrease the intensity of conflicts
Who + What should I validate?
YOURSELF, Others, Relationships + Emotions, Situations, Skillful Behaviors.
MIDDLE PATH:
Validation (Emotion Regulation + Mindfulness)
Validation is NOT Agreeing or Approval.
Validation does not mean that you like what the other person is doing, saying or feeling.
How can I validate another person?
1.) Actively listen and pay attention to the other person. (e.g. make eye contact with them, nod your head when they talk, be mindful of your reactions)
2.) Describe their feelings without passing judgement. (e.g. “It looks like you’re upset,” or “You have a sad look on your face.”
3.) Respond in a way that takes the other person seriously. (e.g. If the other person says they want to be alone for a while, say “Okay,” walk away, and let them calm down before re-approaching them. If the other person is crying, give them a tissue.)
4.) Show tolerance: Acknowledge that the other person’s behavior or emotion make sense even if you do not approve of the behavior or emotion itself.
5.) Do not judge the other person’s emotion.
How can I validate myself?
1.) Actively listen and pay attention to yourself. (e.g., be mindful of your thoughts, feelings and behaviors)
2.) Describe your feelings without passing judgment. (e.g., “Wow, I’m really angry right now.” Or “Yeah, I guess I am a little nervous.”)
3.) Respond in a way that takes yourself seriously. (e.g., Accept that it is okay to have emotions.)
4.) Show tolerance: Acknowledge that your behavior or emotion make sense in your life.
5.) Do not judge your own emotions.
6.) Use interpersonal effectiveness skills (GIVE Skills). 6.) Use interpersonal effectiveness skills (FAST Skills).
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
MIDDLE PATH: Willingness
(Emotion Regulation + Mindfulness + Distress Tolerance)
Another Way to Find the Middle Path
Willingness:
• Willingness is doing what is needed in each situation. It focuses on effectiveness.
• Willingness is listening very carefully to your WISE MIND.
• Willingness is being open to the moment as it is.
• Willingness is being open to new thoughts, feelings, and experiences.
Why would you want to be more Willing?
• Willingness can help you find the Middle Path.
• Willingness can reduce intensity of conflict.
How can you be more willing during family conflicts?
• Be mindful of your stance on the particular issue.
• Be mindful of your emotions and your reactions to the other person/people.
• Put yourself in the other person’s shoes.
• Make the conscious choice to turn your mind: Be willing to be willing.
• Release yourself from the position that gets you stuck. Practice doing this OVER and OVER and OVER again.
Step by Step to WILLINGNESS
1. OBSERVE the willfulness. Label it. Experience it.
2. RADICALLY ACCPET that at this moment you feel (and may be acting) willful. You cannot fight willfulness with willfulness.
3. TURN YOUR MIND toward acceptance and willingness.
4. TRY HALF - SMILE and a WILLING POSTURE .
5. When willfulness is immovable, ASK, “WHAT’S THE THREAT?”
What is causing your Willfulness?
MIDDLE PATH: Dialectics
Understanding Dialectics
(Emotion Regulation + Mindfulness + Distress Tolerance)
Dialectics are a helpful way to view the world.
a.) Dialectics teach us that there is more than one way to see a situation and more than one way to solve any problem.
b.) Dialectics consider all people to have unique qualities and different points of view.
c.) Dialectics stress the importance of looking at the world with an open mind, without absolutes, avoiding black and white, all or nothing thinking.
d.) Dialectics point out that only change is constant.
Acceptance + Change = MIDDLE PATH
If we accept that two things that seem like opposites can both be TRUE, then we can pave the way toward a MIDDLE PATH.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
MIDDLE PATH: Dialectics
(Emotion Regulation + Mindfulness + Distress Tolerance)
FINDING MIDDLE PATH EXAMPLES
MIDDLE PATH
ACCEPTANCE CHANGE
You are doing the best you can at this moment.
AND AND AND
You can do better, try harder, and be more motivated to change
I can do it myself. I can ask for help.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
MIDDLE PATH: Dialectics
(Emotion Regulation + Mindfulness + Distress Tolerance)
Hints for finding the Middle Path
Ways to think and act dialectically:
1.) Move away from “either-or” thinking to “both-and” thinking. Avoid words like “always” and “never.” Be descriptive and honest.
2.) Practice looking at other points of view. There are always at least two sides of the story. Find the kernel of truth in each one.
3.) Remember that no one has the absolute truth.
4.) Use the “I feel _______” statement.
5.) Accept that different opinions can be legitimate (although you do not have to agree with them).
6.) Do not assume that you know what another person is thinking and feeling. Check out your assumptions.
7.) Do not expect that other people can read your mind!!
MIDDLE PATH: Dialectics
(Emotion Regulation + Mindfulness + Distress Tolerance)
Finding the Middle Path
For many families, there are often “power struggles.” This happens when individuals go to “extremes”. This is where neither party involved will budge and are not willing to negotiate. It puts both parties in a defensive stance and often leaves people hurt or unheard. Many times, it also leads to resentment.
Instead, when you use your DBT skills you are able to see the “extremes” and find a way to regain control of yourself and your emotions and act effectively.
Use the following chart to see where you are with dialectics during conflict:
My Opinions are Valid Your Opinions are Valid
In order to find Middle Path, it is important to know how to evaluate yourself and others in order to stop the imbalance.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
Taking quick Body Scans to know what your body is feeling is a good skill to use to know how intense of an emotion you are feeling. Refer back to Emotion Regulation.
MIDDLE PATH: Dialectics
SKILL: Be on the lookout for the following absolute language that demonstrates a person is not in the mindset to think logically:
- None
- Never
- All
- Nothing - Always
- Only
- Must
- Every - No one
- Everyone - Nobody - Everybody
When absolute language is happening, it is important for each party to take a 15-30-minute time out and cool down. It is vital that both parties come back to the conversation and it not just get pushed to the side.
* If someone ask for a break, respect it!
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
If the conversation is also using “name calling” or “violent language” it is important that all parties make smart decisions. Discuss with a counselor about creating a specific safety plan appropriate for your family.
MIDDLE PATH: Dialectics
(Emotion Regulation + Mindfulness + Distress Tolerance)
Finding the Middle Path EXAMPLE
Practice below with a current or recent example where you and someone else had a hard time coming to an agreement.
My Opinions are Valid
What was the issue?
Did you try to find Middle Path?
What was the outcome?
How did you feel afterwords?
Your Opinions are Valid
What would you like to see differently next time (either from yourself or the situation)
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
What have you learned about yourself during these exercises?
Have you had any changes or applied the skills in your life so far?
Have your goals for therapy changed?
What reflections do you have about DBT?
TOOLS for DBT: COGNITIVE DISTORTIONS
1. Filtering
A person engaging in filter (or “mental filtering") takes the negative details and magnifies those details while filtering out all positive aspects of a situation. For instance, a person may pick out a single, unpleasant detail and dwell on it, exclusively, so that their vision of reality becomes darkened or distorted. When a cognitive filter is applied, the person sees only the negative and ignores anything positive.
2. Polarized Thinking (or “Black and White” Thinking)
In polarized thinking, things are either “black-or-white” all or nothing. We have to be perfect or we’re a complete and absolute failure there is no middle ground. A person with polarized thinking places people or situations in “either/or” categories, with no shades of gray or allowing for the complexity of most people and most situations. A person with black-and-white thinking sees things only in extremes.
3. Overgeneralization
In this cognitive distortion, a person comes to a general conclusion based on a single incident or a single piece of evidence. If something bad happens just once, they expect it to happen over and over again. A person may see a single, unpleasant event as part of a never-ending pattern of defeat.
For instance, if a student gets a poor grade on one paper in one semester, they conclude they are a horrible student and should quit school.
4. Jumping to Conclusions
Without individuals saying so, a person who jumps to conclusions knows what another person is feeling and thinking and exactly why they act the way they do. In particular, a person is able to determine how others are feeling toward the person, as though they could read their mind. Jumping to conclusions can also manifest itself as fortune-telling, where a person believes their entire future is pre-ordained (whether it be in school, work, or romantic relationships).
For example, a person may conclude that someone is holding a grudge against them, but doesn’t actually bother to find out if they are correct. Another example involving fortunetelling is when a person may anticipate that things will turn out badly in their next relationship, and will feel convinced that their prediction is already an established fact, so why bother dating.
5. Catastrophizing
When a person engages in catastrophizing, they expect disaster to strike, no matter what. This is also referred to as magnifying, and can also come out in its opposite behavior, minimizing. In this distortion, a person hears about a problem and uses what if questions (e.g., “What if tragedy strikes?” “What if it happens to me?”) to imagine the absolute worst occurring.
For example, a person might exaggerate the importance of insignificant events (such as their mistake, or someone else’s achievement). Or they may inappropriately shrink the magnitude of significant events until they appear tiny (for example, a person’s own desirable qualities or someone else’s imperfections).
6. Personalization
Personalization is a distortion where a person believes that everything others do or say is some kind of direct, personal reaction to them. They take virtually everything personally, even when something is not meant in that way. A person who experiences this kind of thinking will also compare themselves to others, trying to determine who is smarter, betterlooking, etc.
A person engaging in personalization may also see themselves as the cause of some unhealthy, external event that they were not responsible for. For example, “We were late to the dinner party and caused everyone to have a terrible time. If I had only pushed my husband to leave on time, this wouldn’t have happened.”
7. Control Fallacies
This distortion involves two different but related beliefs about being in complete control of every situation in a person’s life. In the first, if we feel externally controlled, we see ourselves as helpless - a victim of fate. For example, “I can’t help it if the quality of the work is poor, my boss demanded I work overtime on it.”
The fallacy of internal control has us assuming responsibility for the pain and happiness of everyone around us. For example, “Why aren’t you happy? Is it because of something I did?”
8. Fallacy of Fairness
In the fallacy of fairness, a person feels resentful because they think that they know what is fair, but other people won’t agree with them. As our parents tell us when we’re growing up and something doesn’t go our way, “Life isn’t always fair.” People who go through life applying a measuring ruler against every situation judging its “fairness” will often feel
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993. 100
resentful, angry, and even hopeless because of it. Because life isn’t fair things will not always work out in a person’s favor, even when they should.
9. Blaming
When a person engages in blaming, they hold other people responsible for their emotional pain. They may also take the opposite track and instead blame themselves for every problem even those clearly outside their own control.
For example, “Stop making me feel bad about myself!” Nobody can “make” us feel any particular way only we have control over our own emotions and emotional reactions.
10. Shoulds
Should statements (“I should pick up after myself more…”) appear as a list of ironclad rules about how every person should behave. People who break the rules make a person following these should statements angry. They also feel guilty when they violate their own rules. A person may often believe they are trying to motivate themselves with shoulds and shouldn’ts, as if they have to be punished before they can do anything.
For example, “I really should exercise. I shouldn’t be so lazy.” Musts and oughts are also offenders. The emotional consequence is guilt. When a person directs should statements toward others, they often feel anger, frustration and resentment.
11. Emotional Reasoning
The distortion of emotional reasoning can be summed up by the statement, “If I feel that way, it must be true.” Whatever a person is feeling is believed to be true automatically and unconditionally. If a person feels stupid and boring, then they must be stupid and boring.
Emotions are extremely strong in people, and can overrule our rational thoughts and reasoning. Emotional reasoning is when a person’s emotions take over our thinking entirely, blotting out all rationality and logic. The person who engages in emotional reasoning assumes that their unhealthy emotions reflect the way things really are “I feel it, therefore it must be true.”
12. Fallacy of Change
In the fallacy of change, a person expects that other people will change to suit them if they just pressure or cajole them enough. A person needs to change people because their hopes for success and happiness seem to depend entirely on them.
This distortion is often found in thinking around relationships. For example, a girlfriend who tries to get her boyfriend to improve his appearance and manners, in the belief that this
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
boyfriend is perfect in every other way and will make them happy if they only changed these few minor things.
13. Global Labeling
In global labeling (also referred to as mislabeling), a person generalizes one or two qualities into a negative global judgment about themselves or another person. This is an extreme form of overgeneralizing. Instead of describing an error in context of a specific situation, a person will attach an unhealthy universal label to themselves or others.
For example, they may say, “I’m a loser” in a situation where they failed at a specific task. When someone else’s behavior rubs a person the wrong way without bothering to understand any context around why they may attach an unhealthy label to him, such as “He’s a real jerk.”
Mislabeling involves describing an event with language that is highly colored and emotionally loaded. For example, instead of saying someone drops her children off at daycare every day, a person who is mislabeling might say that “She abandons her children to strangers.”
14. Always Being Right
When a person engages in this distortion, they are continually putting other people on trial to prove that their own opinions and actions are the absolute correct ones. To a person engaging in “always being right,” being wrong is unthinkable they will go to any length to demonstrate their rightness.
For example, “I don’t care how badly arguing with me makes you feel, I’m going to win this argument no matter what because I’m right.” Being right often is more important than the feelings of others around a person who engages in this cognitive distortion, even loved ones.
15. Heaven’s Reward Fallacy
The final cognitive distortion is the false belief that a person’s sacrifice and self-denial will eventually pay off, as if some global force is keeping score. This is a riff on the fallacy of fairness, because in a fair world, the people who work the hardest will get the largest reward. A person who sacrifices and works hard but doesn’t experience the expected pay off will usually feel bitter when the reward doesn’t come.
Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press, 1993.
