Finding Middle Path Workbook - 2022

Finding Middle Path

“All Things DBT”

A Workbook

Constructed By: Rachael Julstrom, LPC, LCPC

Edited by: Bonnie Monahan, LPC, PLPC

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

“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, LPC

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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 § Monopolizing § Storytelling § Being the Therapist’s Assistant § Leaving session early § Being too tired to stay awake § Being in continuous, disruptive crises § Withdrawing emotionally, in session § Arguing with the therapist § Intellectualizing § Using humor to deflect from the topic § Justifying and rationalizing behaviors § Canceling or not showing up; being late § Refusing to comply with recommendations § Not completing homework and diary cards § Making hostile, critical, and judgmental remarks to other clients

§ Pushing therapist’s limits § Demanding solutions to problems that the therapist can’t solve § Interacting with the therapist in an overly personal/friendly way, including sexual, provocative, or seductive behavior

§ Excessively requesting coaching calls for things that could wait until the next session

§ Threatening the therapist, therapist’s family, and/or other clients in a harmful manner

§ Criticism of the therapist’s values and/or personality

§ Lack of gratitude/appreciation for the therapist’s efforts § Minimizing challenges

§ Infringing on the therapist’s personal space § 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:

Adapted

from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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

Tolerance

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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 know 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: Finally, aware of vulnerability, too immersed in it, drowning. Sense of being misunderstood, treated unfairly, alone, empty, alone, helpless, defeated, incapable, vulnerable, “emotional third degree burns” (slightest emotional nuance is excruciating, highly personalization of environment, “transient paranoid ideation.”

Unrelenting Crisis

Overwhelmed with waves of feeling that are perceived as uncontrollable. Tearful, angry, despairing, etc. Can’t manage social façade. More practical crises occur as coping begins to crumble.

BIOLOGICAL LEARNING ENVIROMENT

Apparent Competence

Looking good, acting capable, “I know it all,” “I don’t need any help,” “I am not going to be vulnerable.” Energy devoted to anticipating and meeting the expectations of others at all cost. Minimizing the difficulty of accomplishing tasks experiencing overwhelm perpetuating self invalidation.

Active Passivity

Approaching defeat and helpless despair with active attempts to get the environment to solve problems or end pain for you. Impulsive behavior is expressed: suicidality, self harm, ending relationships, quitting jobs, running away, violence, substance abuse, hospitalizations, etc.

Inhibited Grieving

Denies feelings to avoid punishment and anticipate environmental expectations. Conditioned fear of feelings. Elicit hopelessness, worthlessness, feedback and helpless. Unable to communicate needs.

Self Invalidation: Learn from the environment that internal experiences cannot be trusted as valid information through repeated punishment experiences. Begin to associate naturally arising needs and feelings with anxiety , due to punishment history. Begin to focus on getting the environment/others to tell them what they need, how they should feel , etc. Lose touch with internal information (facts). Overdeveloped social sensitivity. Fear of abandonment and lost of identity.

The three dialectical dimensions include: emotional vulnerability versus self invalidation, active passivity versus apparent competence, and unrelenting crisis versus inhibited grieving.

Emotional Vulnerability versus Self Invalidation

Emotional vulnerability is an extreme sensitivity to emotional stimuli. This is the person who has strong and persistent emotional reactions to even small events. Emotionally vulnerable people have difficulty with such things as modulating facial expressions, aggressive actions, and obsessive worries. On the other end of the dialectical pole is self invalidation. Self invalidation involves discounting one’s own emotional experiences, looking to others for accurate reflections of reality and over simplifying problems and their solutions. The combination of these two characteristics leads to oversimplifying problems and how to achieve goals as well as extreme shame, self criticism and punishment when goals are not met.

Active Passivity versus Apparent Competence

Active passivity is the tendency to approach life’s problems helplessly. Under extreme stress, an individual will demand that the environment and people in the environment solve his or her problems. Apparent competence, on the other hand, is the ability to handle many everyday life problems with skill. Often, people with BPD are appropriately assertive, able to control emotional responses and successful in coping with problems. These competencies, however, are extremely inconsistent and dependent on circumstances. The dilemma of active passivity and apparent competence leaves the individual feeling helpless and hopeless with unpredictable need for assistance and fear of being left alone to fail.

Unrelenting Crisis versus Inhibited Grieving

With unrelenting crisis, repetitive stressful events and an inability to recover fully from one before another occurs results in urgent behaviors such as suicide attempts, self injury, drinking, and/or spending money and other impulsive behaviors. Inhibited grieving is the tendency to avoid painful, emotional reactions. Constant crisis leads to trauma and painful emotions, which the individual frantically attempts to avoid. These three, dialectical dilemmas are intended to help the therapist understand and relate to the individual’s experience. Although the concept of these dilemmas was originally developed by Linehan in her work with people with BPD, DBT is currently used successfully with people with a wide variety of issues. It is likely that these dilemmas are relevant for a wide variety of people.

Matta, Christy. “Dialectical Behavior Therapy: Dialectical Dilemmas & BPD.” Psych Central.com, 13 July 2018, blogs.psychcentral.com/dbt/2010/04/dialectical behavior therapy dialectical dilemmas bpd/.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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)

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

MINDFULNESS

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 Guilford Press, 1993.

The Wise Mind is not simply the integration of both the Reasonable and Emotional Minds, but also your intuition. It is the part of you that is able to access your purest desires and needs that may be hidden in your subconscious or behind a defense mechanism. It is the part of you that knows what you need to feel whole, healthy, and happy. It is the “gut feeling” or a little voice guiding you to make the best decisions for you at that given time. Sometimes the best decision for you may be to not act at all.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

MINDFULNESS HANDOUT

In the spaces below, think of the following that would fit in each state of mind:

• Colors

• TV / Movie Characters

• Types of Cars

• Places

Wise Mind Reasonable/ Logical 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:

HOW SKILLS

NON JUDGMENTALLY

● 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.)

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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 Non Judgmentally). 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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

What have you learned about yourself during these exercises?

you had any changes or applied the skills to your life so far?

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

DISTRESS TOLERANCE HANDOUT

COPING WITH PAINFUL FEELINGS & URGES

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

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Stop

DISTRESS TOLERANCE HANDOUT

STOP Skill

Take a step back

Observe

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?

Proceed mindfully

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

from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Temperature

DISTRESS TOLERANCE HANDOUT

TIPP Skill

Changing Your Body Chemistry

(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

Intense Exercise

(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.

Paced Breathing

Paired Muscle Relaxations

(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

(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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

DISTRESS TOLERANCE HANDOUT

Crisis Survival Strategies

USING COLD WATER, Step by Step

COLD WATER CAN WORK WONDERS

When you put your full face into cold water or a zip lock bag with cold water on your eyes and upper cheeks while holding your breath, it tells your brain you are diving underwater.

This causes the “dive response” to occur. (It may take 15 30 seconds to start)

Your heart slows down, blood flow to nonessential organs is reduced, and blood flow is redirected to the brain and heart.

This response can actually help regulate your emotions.

This will be useful as a distress tolerance strategy when you are having a very strong, distressing emotion, or when you are having very strong urges to engage in dangerous behaviors.

(This strategy works best when you are sitting quietly activities and distractions make this less effective.)

TRY IT OUT!

* 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.

Activities

DISTRESS TOLERANCE HANDOUT

Crises Survival Strategies

Distracting with ACCEPTS

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.

Contributing

Comparisons

Emotions

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 away

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.

Thoughts

Sensations

Adapted

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

from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Taste

Hearing

Smell

DISTRESS TOLERANCE HANDOUT

Crisis Survival Strategies

SELF SOOTHE with the 5 SENSES

Touch

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.

Vision

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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

DISTRESS TOLERANCE ACTIVITY

Crisis 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: Taste:

What is a situation you can use the skill or when could you have used it in the past?

What barriers might come up when you try to use these skills? (Judgments toward yourself or the environment)

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Imagery

Meaning

DISTRESS TOLERANCE HANDOUT

Crisis Survival Strategies

IMPROVE the Moment

Prayer

Relaxation

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.

One thing

Vacation

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.

Encouragement

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.”

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

DISTRESS TOLERANCE HANDOUT

Crisis Survival Strategies

Below, write the reasonable responses in each box. (Please do this with Therapist or in Group Setting)

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 Guilford Press, 1993.

DISTRESS TOLERANCE HANDOUT

Crisis 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 Guilford Press, 1993.

DISTRESS TOLERANCE HANDOUT

Crisis 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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

▪

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...

Rejection Acceptance

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

DISTRESS TOLERANCE HANDOUT

Crisis Survival Strategies

Still having a hard time with Crisis Survival Skills?

When we are first learning skills, there are a few things keeping us from Fully Engaging in the skills. Consider the following:

Are you having a hard time accepting reality?

Are you being Willful or Willing when trying these skills?

Are you trying to do too many skills at once?

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

DISTRESS 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

• 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

• Leave things out of place

• 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

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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:

JOY

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

BODILY REACTIONS:

Tightness or rigidity. Tense all over or in certain areas. Crying. Flushed.

Teeth and mouth clenched.

ACTION: Throwing things. Cursing. Yelling. Stomping. Withdrawing.

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

BODILY REACTIONS:

Jittery. Shaking and trembling. Hair on end. Lump in throat. Tense muscles. Quickened breathing. Feeling cold.

ACTION: Avoid people. Run away. Freeze up. Attack verbally or physically.

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 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.

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.

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.

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. Practice Exercise: Practice watching how your thoughts, behaviors, and actions are connected.

THOUGHTS:

EMOTIONS ABOUT THE EVENT: EVENT/TRIGGER: ACTION:

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 justified?

Is the emotion not 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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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 Problem Solving

1. Remove the threat.

Anxiety/Fear

Sadness

Anger

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.

Envy

Jealousy

Shame

Guilt

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.

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

Emotion Action Urge

Opposite Action

Anxiety/Fear Avoid Approach Sadness Withdrawal Get active

Anger Attack

Gently avoid, but be decent Envy Sabotaging, criticizing Count your blessings

Jealousy Accusing, spying

Shame Hide

Let go of controlling others, share.

Be open – tell the secret to the people who will accept it. Guilt Hide Be open

Changing emotions you want to change by acting on Opposite to the Current Emotion

If an emotion we want to change is NOT JUSTIFIED, then we use the skill of Opposite Action.

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.

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”

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.

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. Physical illness (treat it) Lather, rinse, repeat (physical hygiene)

at balanced

void mood/mind Altering substances

leep

xercise (movement of any kind)

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”

ACCUMULATE 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)

BUILD 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.

COPE AHEAD OF TIME WITH EMOTIONAL SITUATIONS

Create a plan ahead of time so that you are prepared to cope skillfully with emotional situations. Imagine yourself coping effectively. Role play 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

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Do outdoor work

Sit in the sun

Plan an event

Play with animals (dog, cat, horse...)

Listen to music (radio, CD’s.)

Give someone a gift

Take pictures

Talk about sports

Watch or participate in sports

Help or protect someone

Hear jokes (i.e. comedy club, funny movies)

See beautiful scenery

Eat a good meal

Improve health (change diet, workout...)

Go downtown

Go to a museum or exhibit

Enjoy a sauna or Jacuzzi

Buy some watercolors and paint a picture

Be with friends or relatives

Join a protest (political, environmental)

Talk on the phone

Daydream

Go to a movie

Kiss

Cook a meal

Go to a restaurant

Volunteer at the local animal shelter

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

EMOTION REGULATION HANDOUT

Pleasant Activities Activity

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

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 non prescription 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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

INTERPERSONAL EFFECTIVENESS HANDOUT

How to ask for something effectively.

Describe Express Assert Reinforce Mindful Appear confident Negotiate

Describe

Express

Assert

Describe the situation. Stick to the Facts

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

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.

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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

escribe GROUP 20

M

Describe the situation. Stick to the Facts

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...”

indful (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.

……………………………………………………………. N

egotiate 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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Gentle

INTERPERSONAL EFFECTIVENESS HANDOUT

How to keep a good relationship.

Gentle

Interested Validate Easy 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.

GIVE Activity

How to keep a good relationship.

entle Be Gentle: Be nice and respectful

nterested Act Interested: Listen to the other person

alidate 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.”

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Fair

INTERPERSONAL EFFECTIVENESS HANDOUT

How to keep respect for yourself Fair Apologies Stick to Values Truthful

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.

Fair

INTERPERSONAL EFFECTIVENESS HANDOUT

FAIR Activity

Apologies

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.

Stick to Values

No Apologies: Stop saying you’re sorry for asking for what you need. Observe how often you say “I’m sorry” throughout the day.

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.

INTERPERSONAL EFFECTIVENESS HANDOUT

How GIVE, FAST and DEAR MAN all work together.

D

E

escribe

G

I

entle

nterested

V

E

alidate

asy Manner

A

xpress

ssert

Reinforce M

A

indful

Fair Apologies Stick

to Values

T

ppear confident

N

egotiate

ruthful

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

• 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.

2. PRIORTIES

• 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.

3. SELF RESPECT

• 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

• 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.

5. AUTHORITY

• 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

• 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.

7. LONG TERM VERSES SHORT TERM GOALS

• 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

• 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.

9.

HOMEWORK

• 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.

10. TIMING

• 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.

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?)

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

INTERPERSONAL EFFECTIVENESS HANDOUT

BOUNDARIES in RELATIONSHIPS

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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.

6.) Use interpersonal effectiveness skills (GIVE Skills).

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 (FAST Skills).

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993. 88

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.

RADICALLY ACCPET that at this moment you feel (and may be acting) willful. You cannot fight willfulness with willfulness.

TURN YOUR MIND toward acceptance and willingness.

TRY HALF SMILE and a WILLING POSTURE.

When willfulness is immovable, ASK, “WHAT’S THE THREAT?” What is causing your Willfulness?

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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

You are doing the best you can at this moment.

ACCEPTANCE CHANGE 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!!

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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 AND

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

Your Opinions are Valid AND

What was the issue?

Did you try to find Middle Path?

What was the outcome?

How did you feel afterwords?

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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

TOOLS FOR DBT

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

SAFETY PLAN + COMMITMENT

STEP 1. COMMITMENT TO LIFE_____________________________

I, ____________________________, contract for my safety. This means that I will not act on my plan to commit suicide. I will use the skills listed below to assist with my safety and call the people in my support system as needed. I will call 911 or admit myself to the hospital if unsafe and before acting on urges.

STEP 2. KNOW WHEN TO FIND HELP

What are the warning signs you notice when thinking of suicide or when you are distressed? This can include triggers, thoughts, emotions, and body sensations.

STEP 3: COPING SKILLS

What can you do to distract yourself from the problem? This can be any activity.

STEP 4: SOCIAL SUPPORT (Friends + Family)

Who are some safe people you can reach out to when you are feeling distressed. Name Contact

STEP 5: PROFESSIONALS + AGENCIES

Still need support? You can reach out to your local therapist and ask for help. Remember to reach out PRIOR to any action.

Therapist

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

TOOLS for DBT: BEHAVIOR CHAIN ANALYSIS (Questions)

What exactly is the behavior you want to change and/or analyze?

What prompting event/trigger started this behavior?

What were some of the thought/s you were having before/during/after the event? (Thoughts about yourself, others etc.)

What body sensations did you have before/during/after the event? (numb, quick breath, heart pounding)

What emotions did you have before/during/after the event? (anger, frustration, sadness, fear)

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

What were some of the Short Term Reliefs or Benefits of the Target Behavior? (Mom and dad give me attention, I feel alive, I feel like it solves the problem)

What are some Long Term Consequences from the Target Behavior? (Phone gets taken away, I am hospitalized, it keeps me from having healthy relationships)

What things happened that day that caused you to be Vulnerable to this event? (Didn’t sleep well, got in a fight earlier that day, out of routine, felt terrible, around family that feels triggering)

Looking back, what skills do you think you used and what do you want to use next time?

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Are there any repairs I need to make?

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

TOOLS for DBT: EMOTION WHEEL

“I Feel Emotion Wheel”

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

ADDING ON…

Now that you have your top 3 values, let’s go through and do a checkup. Go through each one and ask the following questions.

How are you honoring this value how is it being shown in your current life?

How would you like to strengthen this value?

What are some small goals you can quickly think of to see this value more often, in your life?

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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 fortune telling 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.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

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, better looking, 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.

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. 108

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. 109

TOOLS for DBT: DIARY CARD EXAMPLE

The Diary Card is based off the concept of the Hawthorne Effect. This concept is that when any behavior is observed and awareness heighted, then that behavior changes. Therefore, tracking the behavior and the secondary events around the behavior helps a person become more in control of what they want to change.

There are various examples of diary cards available, and a simple search online will show different layouts, applications, and online sites to help you track your emotions. We have an example of one filled out and a blank one for you to try on your own.

You will see the basics of the diary card are to track your emotions and the basic needs of mental health. There is also a notes section to help you remember any key details about that day. At the bottom, there is also a quick list of DBT skills and the Cognitive Distortions to help you jog your memory.

The Diary Card is to be used weekly to not only help the client to observe their behaviors; it is also to get a baseline (without judgment) of where they are in said behavior(s). It is simply the data to help the client and counselor reach the client’s intended goals.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

TOOLS for DBT: DIARY CARD EXAMPLE

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Assessments

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

Generalized Anxiety Disorder 7-item (GAD-7) scale

Over the last 2 weeks, how often have you been bothered by the following problems?

Not at all sure Several days Over half the days Nearly every day

1. Feeling nervous, anxious, or on edge 0 1 2 3

2. Not being able to stop or control worrying 0 1 2 3

3. Worrying too much about different things 0 1 2 3

4. Trouble relaxing 0 1 2 3

5. Being so restless that it's hard to sit still 0 1 2 3

6. Becoming easily annoyed or irritable 0 1 2 3

7. Feeling afraid as if something awful might happen 0 1 2 3

Add the score for each column + + +

Total Score (add your column scores) =

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all __________

Somewhat difficult _________ Very difficult _____________ Extremely difficult _________

Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993. 114

LIFE EVENTS CHECKLIST (LEC)

Listed below are a number of difficult or stressful things that sometimes happen to people. For each event check one or more of the boxes to the right to indicate that: (a) it happened to you personally, (b) you witnessed it happen to someone else, (c) you learned about it happening to someone close to you, (d) you’re not sure if it fits, or (e) it doesn’t apply to you.

Be sure to consider your entire life (growing up as well as adulthood) as you go through the list of events.

Event Happened to me Witnessed it Learned about it Not Sure Doesn’t apply 1. Natural disaster (for example, flood, hurricane, tornado, earthquake)

Fire or explosion

Transportation accident (for example, car accident, boat accident, train wreck, plane crash)

Serious accident at work, home, or during recreational activity

Exposure to toxic substance (for example, dangerous chemicals, radiation) 6. Physical assault (for example, being attacked, hit, slapped, kicked, beaten up) 7. Assault with a weapon (for example, being shot, stabbed, threatened with a knife, gun, bomb) 8. Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm)

Other unwanted or uncomfortable sexual experience

Combat or exposure to a war zone (in the military or as a civilian)

Captivity (for example, being kidnapped, abducted, held hostage, prisoner of war)

Life-threatening illness or injury

Severe human suffering

Sudden, violent death (for example, homicide, suicide)

Sudden, unexpected death of someone close to you

Serious injury, harm, or death you caused to someone else

Any other very stressful event or experience

Blake, Weathers, Nagy, Kaloupek, Charney, & Keane, 1995 1

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.

PTSD CheckList – Civilian Version (PCL-C)

Client’s Name: __________________________________________

Instruction to patient: Below is a list of problems and complaints that veterans sometimes have in response to stressful life experiences. Please read each one carefully, put an “X” in the box to indicate how much you have been bothered by that problem in the last month

No. Response

1. Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?

2. Repeated, disturbing dreams of a stressful experience from the past?

3. Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)?

4. Feeling very upset when something reminded you of a stressful experience from the past?

5. Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful experience from the past?

6. Avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it?

7. Avoid activities or situations because they remind you of a stressful experience from the past?

8. Trouble remembering important parts of a stressful experience from the past?

9. Loss of interest in things that you used to enjoy?

10. Feeling distant or cut off from other people?

11. Feeling emotionally numb or being unable to have loving feelings for those close to you?

12. Feeling as if your future will somehow be cut short?

13. Trouble falling or staying asleep?

14. Feeling irritable or having angry outbursts?

15. Having difficulty concentrating?

16. Being “super alert” or watchful on guard?

17. Feeling jumpy or easily startled?

Not at all (1)

A little bit (2) Moderately (3) Quite a bit (4) Extremely (5)

PCL-M for DSM-IV (11/1/94) Weathers, Litz, Huska, & Keane National Center for PTSD - Behavioral Science Division

This is a Government document in the public domain.

Adapted from Linehan, Marsha. Skills Training Manual for Treating Borderline Personality Disorder Guilford Press, 1993.