The ABC’s of DBT
in RTC’s
The Basics of Dialectical Behavioral Therapy Coping Skills
in Residential Treatment Centers
Dori Walden, MA
Adolescent Therapist
Mingus Mountain Academy
• In the early 1990’s Marsha Linehan identified patients
were cyclically returning to psychiatric hospitals for the
treatment of suicidal behaviors. There was no treatment
modality that effectively treated borderline personality
disorder and other severe and complex mental disorders
involving serious emotion dysregulation
• She incorporated the philosophies of Mindfulness from
Zen Philosophies with Cognitive Behavioral Therapy
(CBT).
• Dialectical Behavioral Therapy (DBT) has been clinically
proven to help treat clients with Borderline Personality
Disorders: often women with histories of chronic suicide
attempts, suicidal ideation, and non-suicidal injury.
In today’s presentation, we will be discussing using DBT in RTC’s and how universal DBT Coping Skills are. We will be reviewing the key concepts of DBT:
Mindfulness
Emotion Regulation
Distress Tolerance
Interpersonal Effectiveness
Today’s focus will be the introduction and focus of how DBT Skills can be applied in all areas of RTC’s with both students and staff. What are Dialectics?
Dialectical means the art of holding 2 or more things in balance, that my seem to be the opposite, and are both true at the same time. It’s about finding the kernel of truth in each person’s perspective. It’s about balancing competing needs: Love and Anger
Wants and Needs
Feelings and Thoughts
Recreation and Responsibilities
Self‐interest and Interest in Others
Skill Enhancement and Self‐Acceptance
What are Dialectics
in RTC’s?
Structure and Autonomy
Self‐reliance and Interdependence Pending Completion and Desire to Stay
Activity Schedule and Current Needs/Issue
Discharge Planning and Clinical Necessity
Distrust all adults and Knowing others care
Identifying other’s faults and Having the same faults
Working my program and Showing care and concern
DBT BELIEFS/
BASICS/GUIDELINES
DBT is Based on Positive Strengths and Optimism
Group Members are DOING THE BEST THEY CAN and WANT TO IMPROVE THEIR LIVES.
Group Members NEED TO DO BETTER, TRY HARDER, and BE MORE MOTIVATED TO CHANGE.
Group Members MAY NOT HAVE CAUSED ALL THEIR OWN PROBLEMS, but THEY HAVE TO SOLVE THEM ANYWAY.
Group Members MUST LEARN NEW SKILLS in ALL IMPORTANT SITUATIONS of THEIR LIVES.
There are MULTIPLE WAYS OF LOOKING AT ISSUES, as well as MULTIPLE SOLUTIONS.
Group Members CANNOT FAIL in DBT. Using DBT Skills takes practice and there is NO PERFECTION. (A Dialectic) DBT Premises…
Current Problems and Skills to Learn
PROBLEMS
(BEHAVIORS TO STOP)
SKILLS
(BEHAVIORS TO LEARN)
I. CONFUSION ABOUT SELF I. MINDFULNESS
II. IMPULSIVITY
II. DISTRESS TOLERANCE
III. EMOTIONAL CHANGES
III. EMOTIONAL REGULATION
DBT Premises…
Current Problems and Skills to Learn
PROBLEMS
(BEHAVIORS TO STOP)
SKILLS
(BEHAVIORS TO LEARN)
IV. PROBLEMS WITH OTHERS IV.INTERPERSONAL EFFECTIVENESS
V. TEEN AND FAMILY PROBLEMS V. WALKING THE MIDDLE PATH
Challenges of Teaching DBT in RTC’s
• The adolescent mind is still developing
• DBT contains Abstract concepts and
adolescents are still operating from
Concrete thinking.
STATES OF MIND
EMOTIONAL
MIND
REASONABLE
MIND
WISE
MIND
Ways to Practice DBT Everyday
Our lives are stressful, working in RTCs is stressful. We learn and practice the skills discussed on a regular basis and at times we still feel overwhelmed.
Lets consider…
What would have happened if we HADN’T used our skills earlier in the day, or at that moment? How badly/chaotic/emotional or ___________ would the day have been?
MINDFULNESS
Mindfulness is about keeping your awareness in the current moment most of the time. It is about being present and aware in your life today. Mindfulness would say, “The past is the past and the future isn’t here yet”. Being in the past and future mindfully or intentionally is optimal. If you live your life mindlessly in the past or future, you can miss out on really important things going on right now. (This provides Staff an opportunity to use teachable moments and make an emotional connection with the Student in the present)
If you are going to focus on the past and the future, do it intentionally and with full awareness. Students who attend RTC’s often have histories rooted in poverty, abuse and neglect. PTSD symptoms including flashbacks and nightmares. Using Mindfulness with the student in order to help teach them how to be grounded and in the present, can give them tools to be purposely in the present, even when they are feeling pulled into the past. When Mindfulness DOESN’T Happen
Intrusive or negative thoughts creep into
one’s awareness
At times Students are overwhelmed by their
emotions, for example, PTSD flashbacks.
Perhaps at a given time, (meeting with their
therapist) they can direct all of their focus on
the memory, or contain it until a later time.
“WHAT” TO DO TO BE IN WISE MIND”
OBSERVE
• Just notice the experience/ situation in the present moment.
• Wordless watching: watch your thoughts and feelings come and go (like a conveyor belt or a cloud in the sky)
• Don’t push away your thoughts and feelings. Just let them happen, even when they are painful.
• Observe both inside and outside of yourself.
DESCRIBE
• Wordful watching: label what you observed with words. • Put words on the experience
• For example: “I just noticed that I’m feeling sad,” or “my fists are clenched, and I know that happens when I get mad.”
• Describe only what you observe (no interpretations).
PARTICIPATE
• Try not to worry about tomorrow or focus on yesterday. Throw •
•
•
•
yourself into the present moment fully. (ie. dancing, cleaning, taking a test, feeling sad in the moment).
Fully experience your feelings without being self‐conscious. Accept your feelings without judging them.
Listen to your Wise Mind to help you choose to participate (a) in your discomfort; (b) in an alternate activity to escape/avoid distress; or (c) in order to experience life fully.
Act on what you have observed and described
“HOW” TO BE IN WISE MIND
•
Let go of judgements
• Stay focused
• Do what works/be effective
Mindfulness Exercises to Stay in the Present
Grounding Exercises
• Putting your feet flat on the floor as you secure them to the ground as if you are planting deep roots into the ground.
•
Do deep breathing exercises in order to clear out your mind of other distracting thoughts
Mindfulness Exercises to Stay in the Present
• Nature Walks in order to be fully aware of what
they are experiencing
• Relaxation Activities
• Moments of Quiet on the Dorms, during Transitions
• Use the 5 Senses: 5,4,3,2,1
• 5 things they can SEE
• 4 things they can TOUCH
• 3 things they can HEAR
• 2 things they can SMELL
• 1 thing they can TASTE
Mindfulness Exercises to Stay in the Present
Look around the room as if you have never been there before and count all the …
• Items that are RED
• Items that are in the shape of a Square / Rectangle
•
Mindful eating. Slowly eat a piece of hard candy or a Hersey’s Kiss and identify all 5 senses experienced
Mindfulness Skills
WATCH WORDS
INSTEAD OF…
USE…
BUT
AND
TRY
DO; PRACTICE; WORK ON
FAULT
RESPONSIBILITY
HAVE TO
CHOOSE TO; PREFER; WANT; WILL
ALWAYS / NEVER
OFTEN; USUALLY; SELDOM; RARELY
CAN’T
WON’T; DON’T KNOW HOW
SHOULD
CAN; WILL; WANT TO CHOOSE; AM WILLING TO
RTC’s Concepts that can help
with Mindfulness:
• Teaching organizational skills
• “The Five P’s” – “Proper Planning Prevents Poor •
•
•
•
•
Performance”
Discharge Group “Being Aware of Our Surroundings”
24‐7 Calendar – Makes students’ world more predictable
If we are mindful about getting ready for the next day, or upcoming activity it is a skill to prepare for the future. Once prepared we can experience less anxiety about what would or could happen. _____________________