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 DIALECTICAL BEHAVIOR THERAPY
The Skills and Treatment of DBT AND Facilities Offering DBT and BPD Treatment

"DBT is a life enhancement program, not a suicide prevention program."  ~ Marsha Linehan, PhD.
Topics on this Page

DBT Day Treatment    
11-21-13
N.A.M.I.'s Mobile Community Education     
2-18-12
More about DBT and Dr. Linehan   
7-16-11
DBT Treatment Overview  
3-18-11
In-Depth Discussion of DBT Skills:  
     (Radical Acceptance is discussed here, under Emotion Regulation)
     Mindfulness, Interpersonal Effectiveness, Distress Tolerance, Emotion Regulation
       
Dual-Disorders Treatment Centers    (Addictions & BPD)  
Treatment Centers in Indiana   8
-13-12
Treatment Centers in other States (not Indiana)  
 8-30-12
DBT-Trained Therapists  there still is a deficit in this area
Is DBT Enough?
 


NAMI Mobile offers free courses
; more Mobile news from Greta Sharp
Published: Friday, February 17, 2012, 2:53 PM
By Press-Register Correspondent Press-Register

MOBILE, Alabama — NAMI Mobile's February Community Education Program is "Borderline Personality Disorder" with Debbie Kingrea, National Education Alliance for Borderline Personality Disorder. The presentation is Feb. 20 at 7 p.m. at Springhill Baptist Church Activity Center, 11 S. McGregor Ave. It is free and open to the public. Light refreshments will be served. For details, visit www.nami mobile.org.

NAMI Mobile also offers two free support groups. The Family Support Group meeting is designed to offer support and education to those living and coping with a mentally ill family member. Contact Diane Kent at 251-591-8021 or krusader@juno.com for more details.
NAMI Connections is a recovery support group for adults with mental illness, regardless of diagnosis. The 90-minute weekly meetings are led by trained individuals who are also in recovery. Meetings are Wednesday afternoons from 4 to 5:30 p.m. at Dauphin Way United Methodist Church, 1501 Dauphin St., and Friday mornings from 10 to 11:30 a.m. at the Drug Education Council Building at 3000 Television Ave. For details on classes and support groups, call the NAMI office at 251-461-3450. Volunteers are available Monday to Friday from 10 a.m. to 4 p.m.

Email Greta Sharp at gretasharp@bellsouth.net. For more Mobile events, including club meetings, view the BayWatch calendar at www.al.com.


An In-Depth Discussion of the Dialectical Behavior Therapy Skills  

DBT looks at emotions as a full-system response, that is made of biological action tendencies and urges, hormones, changes in brain chemistry. From there we look at emotion as making people ready for action, they motivate us to do things.   Emotion is seen as having several important functions such as giving you information and communicating with others. Emotions are problematic for persons who have a biological thermostat that is at a higher set point, so they experience their emotions much more strongly and quickly than others.  Without certain skills emotions can take over, rather than serve the person that feels them.   
    by S. Spradlin

DBT Skills -

1. Mindfulness

2. Interpersonal Effectiveness
3. Emotion Regulation
4. Distress Tolerance


  The above are the skills as devised by Marsha Linehan in 1993 at the University of Washington, Seattle, for the treatment of Borderline Personality Disorder. These 4 points look very small in comparison to some of the other listed presented on this site.  However, each of these skills is a tall order, and is only mastered after hours of practice.  This is a small price to pay for something that will improve the quality of your relationships, and possibly save a Borderline's life.   The challenge of each skill is that they all require the individual to put in place and master brand-new behaviors, never successfully attempted by the Borderline patient earlier in their lives. 

    The discussion under each is detailed, but conclusively delineates what each of the skills entails.  DBT cannot be learned from a book, or online. Being taught and adopting the skills can only be accomplished in a classroom setting to achieve maximum effectiveness.  This is why it is of utmost importance to locate a DBT-certified therapist with whom the Borderline needs to enter into treatment.  I cannot emphasize this enough.  I know.  I have been there.  Learning these skills can be difficult, and sometimes seem even boring or repetitive, but they can and will save a Borderline's life.  If you decide they will not work for you (if you are Borderline), or you are not willing to put forth the effort,  your misery will be eventually refunded to you.

 

DBT Treatment Overview
Learning Center - DBT Therapy Training   from TrueRecovery.org

Dialectic Behavior Therapy Overview
If you want to stop a compulsive behavior you've come to the right place. I believe there is a tragic flaw in most recovery programs today, which is why the vast majority (92% by some studies) can not stay "sober" for a full year. Why do the vast majority fail in their attempts to recover? We believe the answer is simple: they're trying to fix the wrong thing. It's very true that the behavior is problematic, even dangerous. It affects us and the people around us deeply. But, in our view, they are a symptom of something else. Focusing on the thing that's most tempting to us is not only a diversion from the underlying issues, but can also keep that temptation alive in our mind. Find out the skills to better manage your emotional states, and you won't feel compelled to do whatever it is you want to stop doing.

Today's more modern approaches including Cognitive Behavior Therapy (CBT) and Dialectical Behavior Therapy (DBT) have been used, quite successfully, to treat personality disorders previously believed to be incurable. Recently, many in the psychology field have been applying this treatment to a wide range of psychological issues with great success. Those include depression, anxiety, substance abuse and various compulsive disorders. While I'm not a professional in the field, I have studied CBT and DBT to resolve several issues in my life including a devastating compulsive gambling habit. I don't consider myself "cured" yet, but do know it's in my future. This site is dedicated to educating others, like me, who are truly dedicated to ridding ourselves of these damaging behaviors.

There are a number of reasons why we do these self-destructive things over and over again, even knowing how bad it is. Why do we do it to ourselves? Because there are things in our lives we simply can't, or don't yet understand how to deal with. We may have even resigned ourselves to the fact that we'll never be able to resolve them. For each of us it's something different. It may be an abusive childhood or relationship, it may have been a traumatic event like war or rape, or quite possibly it's just dissatisfaction with the life we are living, such as an unhappy marriage, unachieved dreams or a chronic depression.

How did we get hooked? Many of the behaviors began as something social... a feel-good thing. For example we begin to do things like gambling, shopping, eating, taking drugs or drinking alcohol often for fun and enjoyment. We associate great times and good feelings with the behavior. When we're feeling down and can't cope, we desperately want to feel good again so we reach out and cope with the nearest feel-good behavior. They are an escape and our problems don't exist while we're doing them. We make an unconscious choice: face the painful reality of life, or do this fun thing.

At some point, our lives and the stressors become a burden to us. The more we avoid the issues, the bigger they grow. They don't go away, they just get worse and eventually snowball out of control. The worse they get, the more we need to feel good, so we reach more and more for those things. It's not enough to gamble a hundred or so, we need to gamble with thousands. A couple of beers with friends isn't enough, we drink all night even alone. Eventually, these behaviors become so ingrained, we just go on autopilot, we just do it.

We might hit rock-bottom or just see it ahead of us and want to fix it. We simply just don't know how to go about it. Studies show that, in any given year, roughly 5% of us are able to stop on our own, with no therapy, no programs, nothing but a personal decision and commitment. My father was one of those people. He not only kicked a chronic drinking problem but also kicked a three pack a day smoking habit cold turkey. Most of us, however, try to stop on our own but fall flat on our faces. The vast majority of us find a church group or twelve-step program. There, we find others in the same boat. People we can share our experiences with and support. It's nice to know we're not alone and that there's help. In my opinion, the issue with those types of organizations is that they focus on the behavior and managing urges, rather than learning how to get rid of the urges once and for all. As I stated above, talking about our addiction or our compulsion can keep those thoughts alive in our mind and at times even act as a temptation.

I've heard people talk about gambling, alcoholism, drug addiction, eating disorders and many others as if they were incurable diseases which we must constantly work to suppress. In my view, and the view of many, this can serve as a justification for "falling off the wagon". Hey, I can't help the fact that I have this disease, I wish it wasn't there but it is. It's not a disease, it is quite curable, but only if we learn how to effectively manage our own emotions and distress.

Think of your specific behavior as a leak in your ceiling. Water is dripping down on the floor and your belongings. Everyone who gets close enough, can see the drip and knows the water is going to cause damage to your floor, furniture and other belongings. So what do we do? Clearly, we need to stop the water from messing up our stuff. We put a pot under the drip to catch the water. That works for a while, but soon the pot fills up and begins to overflow. So, we change the pot. That's what most recovery methods, do.

Some recovery methods go a little further. Some try and help us patch the ceiling and paint over the water stain. The water does stop for a while, but eventually the leak seeps through the patch and begins to drip again. We learn new, better and quicker methods of changing the pot, without spilling. We learn how to patch the celling quicker and better, stopping the drip for a little longer. The water builds up and sooner or later, it is once again dripping on our floor and belongings.

So, what's the solution? The real solution is to learn how to find the source of the water. Is it a hole in the roof, a broken pipe in the ceiling, or something else? Then, we must learn the skills and get the tools needed to fix the leak. It's not really that important to know what caused the damage...only that the damage exists, how to find it and how to fix it. There are no magic pills or quick fixes to remedy issues that have taken us many years to develop. There are, however, very effective methods of learning those skills to fix whatever leaks might spring in your life. Once we've learned this, and are able to ingrain them in our minds, we can truly consider ourselves cured.

•Protect us -- Before we can really get on top of things, we need to be safe. That means, we need to do whatever is necessary to stop the dangerous behavior. If we're gambling, we have to find whatever means we can to stop gambling.... at least long enough to start rebuilding.

•Learn new skills -- In today's world there are tons of tools, methods and approaches to handle life better, more effectively. This site focuses on a Dialectical Behavior Therapy. DBT provides four key skill sets, with the tools necessary to use them. Those are: Mindfulness, the ability to see things as they are without being clouded by our assumptions and snap judgments. Distress Tolerance, the skills necessary to handle stress or triggers without resorting to self-destructive behavior. Emotion Regulation, the ability to keep your emotional state steady and manageable, this can often reduce or even eliminate hitting those distressing times. Finally, Interpersonal Effectiveness, which provides us the skills and tools necessary to build strong, positive relationships and improve the ones we have now.

•Practice until it's ingrained -- We know, from our own behavior, how ingrained habits can become. How many times have you heard substance abusers say they hate the drugs they use? We may hate our own habits, and know deep down that they're bad for us, but we've been doing them so long that they're ingrained. Once we learn the new life skills, we need to get past that awkward, unnatural phase, until we use them without thinking. We did it with the behavior we're trying to fix, we can do it with productive, positive behavior as well.

 

The following facilities in Indiana have DBT-trained therapists and DBT treatments offered.  Should there be more, they were not listed on the Behavioral Tech website.   Below the Indiana listings are listings for other states.      (8-7-09)


East Chicago Tri-City CMHC
3903 Indianapolis Blvd., East Chicago, IN 46312   
Ph: (219) 392-3307   Fax: (219) 392-6998

Elkart  Oaklawn CMHC 2600 Oakland Ave. Elkhart, IN 46517
Ph : (219) 533-1234 ext. 260

Ft. Wayne  MHC Park Center, Inc.
909 E. State Blvd. Ft. Wayne, IN 46805
Ph: (260) 481-2700    Fax: (260) 481-2731

Ft. Wayne  Park Center, Inc.
909 E. State St,. Fort Wayne, IN 46805
Ph: (219) 481-2700

Indianapolis 
Gallahue
5470 E. 16th St., Indianapolis, IN 46218
Ph: (317) 355-5009

Indianapolis / Carmel / Noblesville   Aspire of Indiana
(13 locations in all;  3 of them listed below.  Go to website above)
697 Pro-Med Lane, Carmel, In  46032
317-574-0055 

2506 Willowbrook Pkwy # 300
Indianapolis, IN 46205
317-257-3903   Jo Ann Ash

17840 Cumberland Rd.
Noblesville, IN  46060
317-587-0546  Trusa Grosso


Indianapolis   Christian Theological Seminary, Pat Scott, DBT-trained

Indianapolis Psych Adult & Child Mental Health
8320 Madison Ave. Indianapolis, IN 46227-6090
Ph: (317) 822-5122     Fax: (317) 888-8642

Kendallville  Northeastern Center, Inc.
PO Box 817 Kendallville, IN 46755
Ph: (219) 925-5133

Kokomo  INDIANA Behavioral Health Howard Commun. Hospital
3500 S. Lafountain St. Kokomo, IN 46904
Ph: (765) 453-8592     Fax: (765) 453-8020

Kouts    Midwest Center for Youth and Families
1012 W. Indiana Street

Kouts, IN  46347  Main  (219) 766-2999  Intake: 219-766-0007

Lawrenceburg CMHC Inc., CSS Division
285 Bielby Rd. Lawrenceburg, IN 47025  
Ph: (813) 532-3453     Fax: (812) 537-5532
Email: rachel.roszell@cmhcinc.org  www.cmhcinc.org
Program(s):Inpatient/Residential,Partial Hospitalization
Population(s):Adult, Substance Use Disorders


Lawrenceburg 
Community Mental Health Center Inc.,
Drug Court
427 Eads Parkway Lawrenceburg, IN 47025
Ph: (812) 537-7375   Fax: (812) 537-5271
Email: njanszen@cmhcinc.org      www.cmhcinc.org
Program(s): Outpatient Population(s):Adult, Substance Use Disorders

Marion  Grant Blackford Mental Health 206 W. 8th St. Marion, IN 46953

Valparaiso, IN   South Shore Academy
2301 Cumberland Drive
Valparaiso, IN  46383   888-629-3471

Warsaw   Otis R. Bowen Center 850 N. Harrison Warsaw, IN 46580  Ph: 574-267-7169

More Indiana Mental Health Providers  (Indiana FSSA-Family & Social Services Admin)



TREATMENT CENTERS  in states other than Indiana      8-30-12

                   CA    "Bridges to Recovery"   

Bridges to Recovery Now Offers Inpatient Treatment for Bipolar Disorder
Bridges to Recovery has been treating mental health disorders since 2003 and now in 2012 it offers several treatment centers for those who are looking.

Bridges To Recovery
An effective alternative to a hospital environment for patients suffering from many types of mental health disorders including bipolar disorder, depression, anxiety obsessive compulsive disorders, grief support and other issues. Pacific Palisades, CA (PRWEB) May 19, 2012

Bridges to Recovery is a residential treatment center in Los Angeles, Santa Monica, Pacific Palisades and Bel Air, California. The treatment center offers an effective alternative to a hospital environment for patients suffering from many types of mental health disorders including bipolar disorder, depression, anxiety obsessive compulsive disorders, grief support and other issues.  Please inquire as to development of Borderline Personality Disorder Treatment Programs.

Bridges to Recovery has been treating mental health disorders since 2003 and now in 2012 it offers several treatment centers for those who are looking for bipolar residential treatment in Los Angeles, or for treatment for a host of other mental illnesses. These centers offer licensed adult residential treatment programs, with one-on-one in-depth psychotherapy sessions to help people recover from their illnesses. The first-class treatment centers are like a home away from home with a helpful, friendly environment. Bridges to Recovery offers treatments that help their clients through a difficult time. They aid with the establishment of healthy life routines, all the while building the clients' self esteem. These both aid the client to not only get well, but to stay well long-term. Anyone that is looking for depression treatment centers in California should check out one of the many locations that Bridges to Recovery has. These residential treatment centers can help get you or your loved one the treatment they deserve. If you're looking for an OCD residential treatment center in LA, look no further than Bridges to Recovery. Their licensed, trained staff is kind, professional and understanding. They have an excellent success rate and have been successful treating clients who have not recovered by using other treatment methods. Clients with a dual diagnosis – both mental health and substance abuse – will be treated for the underlying mental health problems that are causing the chemical dependency.

For treatment for bipolar disorder treatment, panic attacks, OCD, mood regulation, Borderline Personality Disorder and other psychiatric disorders visit Bridges to Recovery.com to find a location nearby. Contact them through the website or call 1-877-386-3398. You can either speak with the staff to ask more questions, have them send you more information, or make an appointment to take a tour of one of the first-class facilities. This is an open-door facility that is open 24/7. The doors are never locked to keep patients in. This provides patients with peace of mind. Bridges to Recovery is a private-pay program, meaning they do not accept insurance payments. They will help clients bill their insurance companies by providing invoices and records.


                  
NY    Borderline Personality Disorder Resource Center

1st Fl. Macy Villa, New York-Presbyterian Hospital-Westchester Div.
21 Bloomingdale Rd., White Plains, NY 10605      Ph: 888-694-2273
Website:
www.bpdresourcecenter.org 
Email: info@bpdresourcecenter.org

 

The Borderline Personality Disorder Resource Center (BPDRC) at New York-Presbyterian Hospital-Weill Cornell Medical College has been set up specifically to help those impacted by the disorder find the most current and accurate information on the nature of BPD and on sources of available treatment.  They offer a toll-free referral phone line (no referral via email).  Their Resource Center and reading library are open for visitors from 9-5 Monday through Friday.
 


NY   Treatment And Research Advancements Association for Personality Disorders (TARA APD)

23 Green St.

New York, NY 10013

1-888-4-TARA APD or 212-966-6514

Website:  www.tara4bpd.org 

 

TARA is a non-profit organization whose mission is to foster education and research in the field of personality disorder. TARA offers family workshops and has a database of therapists who treat BPD.
 


 

WA    BehavioralTech

4556 University Way NE, Suite 200 Seattle, WA 98105

206-675-8588  Website: www.behavioraltech.com  
Email:
information@behavioraltech.org

 

B-Tech is DBT founder Marsha Linehan’s training and resource organization.  The website has a DBT database searchable by region and state. Requests for local therapist referrals can also be made by email and phone.  Individuals and organizations interested in being trained and implementing DBT should contact BehavioralTech.  Trainings and online courses are available.

 


 

M New England Personality Disorder Assoc.(NEPDA)

McLean Hospital, 115 Mill St. Belmont, MA 02478
617- 855-2680 Website: www.nepda.org   Email: info@nepda.org

 

NEPDA is a non-profit organization based out of McLean Hospital.  Their mission is to support local persons with BPD and their loved ones through providing education and support.  NEPDA offers monthly educational workshops as well as an annual conferences and special events. Their board is composed on family members, consumers and professionals.


 

VA     National Alliance on Mental Illness

2107 Wilson Blvd. suite 300

Arlington, VA 22201-3042

Helpline: 800-950-NAMI

TTD: 703-516-7227

Website: www.nami.org   Email: info@nami.org

 

NAMI is the largest  grassroots organization devoted to advocacy and education for mental illness.   Recently they have expanded their priority populations to include borderline Personality Disorder and their website now has a BPD resource section.  NAMI offers family education programs, though they are not specific to BPD (whereas NEA BPD's are) NAMI's consumer support groups are available in many locations but again, they are for all diagnoses, not specifically BPD.
 


TX   The Meehl House
Brazoria, TX
979-798-7972
Website: 
http://www.meehlfoundation.org
 



FL   Life Skills South Florida
 

 

                    WI   Treatments Centers in Wisconsin
 



 

                                For MORE in other states, click here
                                Another directory of therapists is here

 


Dual-Disorders Treatment Centers  Another type of treatment center addressed BOTH the Addictions and the Borderline Personality Disorder. One is discussed in depth in a website.  Another is offered here.

 

WHY IS IT IMPORTANT TO SEE A TRAINED DBT THERAPIST? 
      (Meaning "DBT-Certified")  
 
- from the TARA website www.tara4bpd.org

DBT may be the most hopeful and helpful of any new therapy available for people with BPD. Many people with BPD have problems trusting others, have “failed in treatment” or have been dropped by former therapists. When DBT is not done as designed, the results may not be the same, causing the person with BPD to lose hope and trust and then be reluctant to ever try DBT again. If DBT is not practiced according to the research model that produces effective change but is practiced “my way” by a therapist without adequate training, it probably won’t produce the same kind of results as the research programs. Outcomes from this kind of DBT will not justify additional DBT training or new DBT programs in the community. Currently. Dr. Linehan is working on a way to certify therapists who practice DBT so that people can determine if a therapist is truly qualified to practice DBT.

 

HOW TO KNOW IF A THERAPIST PRACTICES DBT?
These are the questions you should ask:

• Have you completed a 10 day intensive DBT training ?
• Are you a member of a DBT consultation team ?
• Have you been supervised by an expert DBT therapist?
• Are you familiar with the main sets of DBT strategies (cognitive behavioral therapy,
  validation, dialectics)
• Do you teach skills, practice behavior analysis, review diary cards?
• Do you do phone coaching?
• How many clients have you treated using DBT?

The answer to these questions should be yes. You have a right to check on the therapist’s credentials; to know if the therapist is licensed in his/her state; to know the extent and nature of the therapist’s education and training; the extent of the therapist’s experience in treating clients with similar problems; the therapist’s arrangements for coverage or emergency contacts.

DBT TREATMENT TARGETS

Pre-treatment Targets
• Orienting and Agreement on Goal

1st Stage Targets
• Decreasing or eliminating life-threatening behaviors
   (suicide attempts, suicidal  thinking, self-injury, homicidal and aggressive 
   behaviors)
• Decreasing or eliminating therapy-interfering behaviors (missing sessions, not
  doing homework, behaving so that others burn out”. using hospitalization as a way 
  handling crisis).
• Reducing or eliminating hospitalization as a way handling crisis.
• Decreasing Quality of life interfering behaviors (eating disorders, not going to work
   or school, addiction, periodic unemployment).
• Increasing behaviors that will enable the person to have a life worth living.
• Increasing behavioral skills that help to build relationships, manage emotions and
  deal effectively with various life problems. These skills are: Mindfulness,
  Interpersonal Relationships, Emotion Regulation, Distress Tolerance, and Self-
  Management.

2nd Stage Targets
• Decreasing Post Traumatic Stress Disorder

3rd Stage Targets
• Increasing respect for self
• Setting individual goals
• Solving ordinary life problems

4th Stage Targets
• Capacity for Freedom and Joy

Although these priorities are presented in order of Importance however DBT practitioners believe they are all interconnected. If a person does not stay alive, they will not have the chance to receive help. If they don’t stay in therapy, they won’t get the help they need to change their quality of life. DBT aims to convince people to stay alive, stay in therapy and build a life worth living. As the person makes a commitment to life and to stopping self-destructive behaviors, DBT provides them with support in learning how to create and keep a life that is sustaining.


Some assumptions about DBT:     (from the TARA website www.tara4bpd.org)
People with BPD are doing the best they can.
• People with BPD want to improve.
• People with BPD need to do better, to work harder, and be motivated to change.
• The lives of suicidal BPD individuals are unbearable.
• People with BPD must learn new Behaviors. for all aspects of their lives.
• People cannot fail in DBT.
• Therapists treating people with BPD need support
• Families coping with people with BPD need support.
• Stress related dissociative symptoms such as paranoia; feeling as though
  they are losing touch with reality; feeling victimized; unable to accept responsibility.
• BPD is extremely painful to the patients, to those who live with them and to
  society. People with BPD experience emotions intensely and are very vulnerable.
  They are among the most intensive and extensive utilizers of mental health services.


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(12-24-09)

Dialectical Behavioral Therapy (DBT): Is it Enough?
by Tami Green

We recently featured an article which provided an extensive list of DBT inpatient facilities. Our reporter, Kara Kelly, spent considerable time researching these places and the result is a valuable resource for you. Readers since then have also suggested a few other DBT centers and hospitals, and we’ve added them to the bottom of Kara's article for you.

I also received a lot of feedback on that article from folks who have benefited by non-DBT treatment options and it occurred to me that I’ve given most of my airtime to only one recovery alternative.

Up front, to set the record straight, DBT is not the best treatment option for Borderline Personality Disorder. It is one of many, and arguably not the best for some. However, it is possibly the most widely-available option in the United States at this time, one I used, and I have also seen it transform many lives in my on-line classes.

With DBT alone, I would not have a life worth living, because, while the skills reduced my symptoms enough to be able to move on to the next stage, it did not assist me in developing a strong sense of self nor a game plan for getting my relationships, body and career on track. I used life coaching to help me get in touch with who I was and what I wanted in life. The result of coaching, and also some non-DBT therapy, is that people and circumstances now don’t knock me off course—I know me, and that remains constant.

So what exactly is DBT and where might it fall short?

DBT is a compilation of practical, yet brilliant, skills to be practiced each week, with one building upon the other. The most important of the skills is mindfulness, which is the ability to focus entirely on the present, while pushing all distractions more

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Dialectical Behavior Therapy Skills Part 1:       Mindfulness

by Michael D. Anestis, M.S.

    Without question, DBT is the most fulfilling approach to therapy in which I have been trained - I cherish the experiences I've had co-leading skills groups - but it is also the most complex, so I will make an effort to explain this from multiple angles and invite comments and questions regarding points of these articles that require further explanation.

    DBT, which has empirical support as a treatment for borderline personality disorder, bulimia nervosa, and binge eating disorder requires that clients partake in individual therapy as well as group therapy, in which skills are taught and practiced with other clients.  The skills training is comprised of four modules: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.  In today's article, I will focus on mindfulness, which is a pivotal facet of all phases of DBT.

    Defining mindfulness is fairly difficult, but at its core it involves learning to control your attention and keep your focus entirely on the present moment.  Every now and then, everybody finds themselves ruminating or worrying in response to stress.  We even do these things in the absence of stress at times.  Our focus shifts from what is in front of us to what happened earlier or what might happen when we leave the current situation.  Mindfulness skills in DBT are discussed as a way to take a step back when upset so as to allow intense emotional experiences to run their course naturally, enabling clients to make better behavioral decisions and remain calmer while responding only to what is directly in front of them.

     Marsha Linehan, in her Skills Training Manual for Treating Borderline Personality Disorderexplains the role of mindfulness in treatment as a way to find balance between reason and emotion in a state of mind she refers to as "wise mind."  In wise mind, she explains, individuals are not controlled by their emotions or reason, but instead they acknowledge the presence of both and synthesize them into a single, composed state of mind.  In wise mind, an individual does not try to reason away her emotions (e.g., "you shouldn't feel sad - other people aren't sad about this") or use emotions to blunt her reason (e.g., "I don't care what the consequences are right now, I'm sad and that's all that matters).  Balance requires that both sides be considered, allowing for a better resolution (e.g., "I feel sad right now, but I need to find a way to feel better that won't cause me bigger problems").  Linehan teaches clients that they can attain the balance of wise mind through the "what" skills and "how" skills. 

    The "what" skills include three distinct approaches: observing, describing, and participating.  Observing, although seemingly simplistic, is extremely difficult, as it involves simply observing your environment without using words to describe what you perceive.  The rationale for this is to teach clients to slow down their automatic thoughts and reduce their vulnerability to subsequent negative emotions.  Describing is the reaction to observing and involves applying words to your perceptions.  Linehan is careful to point out, however, that these words should describe only facts, not interpretations.  In other words, an effective description of the next lecture I will give in my Abnormal Psychology class would be: "the teacher is describing the symptoms and treatments of various personality disorders.  He is detailing the DSM criteria and explaining what he refers to as the strengths and weaknesses of each diagnosis."  If that description had read: "this lecture is shockingly boring and the teacher lacks the basic social skills required to speak to a room full of students," this would be less consistent with the goals of the describing skill, which aims to teach clients to see thoughts as thoughts rather than facts and to separate interpretations from actualities.  The participation skill teaches clients to fully engage in their current activity rather than allowing their mind to wander elsewhere.  Whereas observing and describing can, at least at first, seem somewhat bizarre to clients, this skills is one with which most readily identify, as we can all think of times during which we have been doing something, but our mind has been elsewhere. 

    Have you ever talked on your cell phone while driving and suddenly realized that you do not remember the last ten minutes of your drive?  Have you ever been in a conversation with somebody and realized that you had spent the previous minute replaying another conversation in your head and now have no idea what the person is talking about?  Has a movie ever reminded you of something, taken your mind back to a memory, and left you clueless as to what happened in the last scene?  In these examples and countless others, participation is lacking.  The individual is so focused on a scenario unfolding his head that he simply is not attending to the stimuli in front of him.  What's frustrating about this is that, as we ignore our environment and focus on the scenario in our mind, we often become increasingly upset.  Given that nothing in our environment is causing us to become upset and we are responding only to our own thoughts, this is obviously an unfortunate and unhealthy situation.  As such, the participation skill teaches clients to focus their attention only on what is in front of them.  When other thoughts enter their heads, the clients are taught not to judge themselves for losing focus, but rather to simply acknowledge that their mind had wandered and to bring their thoughts back to the current environment.

 The "how" skills, which are methods by which Meditationclients can accomplish the goals of the "what" skills, consist of three components: the nonjudgmental skill, focusing on one thing in the moment, and being effective.  The nonjudgmental skill teaches us to dampen our natural tendency to apply evaluative labels to our experiences.  The rationale for this is that, quite often, our labels are based on distorted automatic thoughts, are vague, and leave us without any guidance as to how to resolve the situation.  In this sense, the skill is quite similar to cognitive restructuring, which we described in detail in a prior article.  Instead of thinking "I'm stupid," a student is trained to think "I received a failing grade on this test, and I am frustrated by that, so I need to meet with my teacher and change my approach in order to reach the final grade that I need."  In teaching clients to focus on one thing in the moment, the second "how" skill, DBT again emphasizes the importance of breaking ruminative cycles that are certain to increase the longevity and severity of our negative emotions.  In the third "how" skill, being effective, clients are taught to shift their focus away from how they wish things were, instead choosing to engage in behaviors that are the most likely to help them accomplish their goals.  The rationale behind this skill, much like several of the others, is to help the client prioritize proactive solutions to problems and to diminish the tendency to lose control of their thoughts and spiral into rumination.

    Okay, having explained the mindfulness skills as described in the Skills Training Manual for Treating Borderline Personality Disorder, I suspect that this topic still remains a bit more theoretical than most readers anticipated given the topics we have covered thus far on PBB.  That being said, let's try and consider what I described above in the context of every day life.  All of us can relate to times when we have been upset and become lost in our own thoughts.  Invariably, even when such thought spirals feel productive at the time, we eventually realize that we were exerting very little control over what we were thinking about at the moment.  Mindfulness teaches how to attain that control.  The best way for anyone to fully understand the meaning of mindfulness is through practice.  As such, I want to conclude this article by explaining a few quick mindfulness exercises.  Ideally, I would love for this to result in at least two types of responses.  First, responses from readers regarding their varying levels of success with the exercises - what went well, what did not.  Second, responses from readers regarding other mindfulness exercises worth trying.  Not everyone responds to each exercise the same way.  The key is finding something that works for you that you can apply in just about any situation when you start feeling upset.  Learning to do so will help you prevent overly powerful emotional spirals before they reach their peak.

  1. Focus on breath:  In this exercise, often the first one taught in a group, your aim is to focus only on your breath. Feel the air as it passes down to your lungs.  Notice everything about the physical sensations associated with the passage of air with each breath.  Each time you complete a cycle of inhale/exhale, count it.  Start with one, count up to ten, and then reverse back down to one.  Here's the trick though, any time you have a thought other than a description of your breath and the number of breaths you have taken, start over again.  That includes thoughts like "this is hard," "I'm focusing on my breath right now," and "mindfulness is crazy."  Remember, we're being nonjudgmental here, so do not be critical of yourself.  Simply notice that a thought crept in and move your attention back to your breath.  It is extremely difficult if not impossible to accomplish a one to ten and back to one progression of counting, so the goal isn't really to finish, but rather to give you a neutral stimulus to focus on rather than your own emotionally charged thoughts.  After a few minutes of doing this (maybe even less), you'll likely feel less emotional and be in a better position to address whatever was making you upset.  There is nothing magical about your breath, but focusing on your breath instead of ruminating is a sure fire way to attain wise mind and thus put yourself in a position to make healthy behavioral choices.

  2. Focus amidst distractions:  We often need to use mindfulness skills when the world around us is chaotic.  As such, this skill teaches you to chose a thought amidst stimuli competing for your attention.  Choose a song to play.  Before you start the song, decide on where you will focus your attention, but choose something other than the song.  In other words, I might choose to focus on an image in my head of the beach on Sanibel or on a box of tissues on the table in front of me.  As the song plays, maintain your focus on the thought you chose.  Observe and describe it, using only facts and withholding judgment.  Each time your thoughts wander, pull them back to your original thought rather than allowing the song to dictate your focus.

  3. Mindfully attend to a pet:  If you have a pet, they will love this one.  Spend the next five minutes petting your animal.  Notice what its fur feels like, the pace at which it is breathing, the color of its eyes, or anything else about the pet that you notice.  Do not allow your mind to wander back to memories with your pet.  Keep your focus entirely on the sensations present in that moment.

    In all likelihood, as you attempt these skills, you'll find that it is exceptionally difficult to maintain complete control over your attention.  You'll notice things that you previously did not attend to, like the clicking of a clock, the sound of a fan, or the temperature of the surface on which your hand is resting. Now imagine how hard it would be to do this if you were upset. Taking it one step further, imagine how difficult it is for somebody who has difficulties regulating their emotions in general.  These skills require patience and practice, so do not expect to notice changes overnight, but trust that mindfulness can offer impressive reductions in stress and an increased tendency to fully enjoy your surroundings.

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    Dialectical Behavior Therapy Skills Part 2:       Interpersonal Effectiveness

     by Michael D. Anestis, M.S.

        Yesterday, I began a discussion of DBT by providing an introduction to mindfulness, the core skills and first module of the treatment.  Today, I will shift my focus to the second module, interpersonal effectiveness.  Before doing so, however, a brief description of what goes on in a skills training group seems worthwhile.  Group sessions last two hours and typically include two co-leaders.  During the first hour, the group members take turns briefly explaining a time when they successfully implemented a DBT skill in the prior week as well as a time when they were less successful in utilizing a DBT skill.  Importantly, this is not treated as brief individual therapy sessions for each group member - that type of interaction is meant for the individual therapy component of DBT.  Instead, this is a teaching tool, an opportunity for clients to practice speaking about emotional events in an objective, fact-based manner and for group members to problem solve better ways for implementing certain skills into their lives.  Group members organize their information during the week on "diary cards," which list all of the DBT skills and provide space for the group member to indicate how often the skill was used and to list important notes.  The second hour of the group session is devoted to teaching new skills. 

     

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    Dialectical Behavior Therapy Skills Part 4:    Distress Tolerance

     by Michael D. Anestis, M.S.

        In my final article on the modules of DBT, I will cover a topic we have discussed earlier on PBB: distress tolerance.  Distress tolerance is a measure of the degree to which an individual evaluates the experience of negative emotions as unbearable  and is also defined by some as the ability to persist in goal-directed behavior when distressed   In other words, if I have low distress tolerance, it will take less stress for me to reach a point at which I am overwhelmed by what I am feeling.  Individuals with borderline personality disorder (BPD), the disorder for which DBT was originally designed, are characterized by low levels of distress tolerance, which is believed to contribute to maladaptive behavioral outcomes such as non-suicidal self-injury, and binge eating and purging.  Because of its potentially vital role in facilitating many of the problematic outcomes in BPD, distress tolerance is the focus of a substantial amount of attention in DBT skills training.

        Presented as the final module, distress tolerance training is often met with a certain degree of reservation by clients, as it is the least validating of all the skill sets.  The distress tolerance module, at its core, tells clients that there are times when they simply will not be able to stop feeling bad and that they are going to have to learn to weather the storm.  This is a frustrating idea for anyone, but that is especially true for individuals who experience chronically shifting, powerful emotions and who struggle to regulate those feelings without resorting to problematic behaviors.  Nonetheless, the overall message of the distress tolerance module is a positive one: this too shall pass.  Underlying this message is a simple fact, that emotions are temporary experiences powerless to actually cause us real harm, no matter how powerful they seem.

        Distress tolerance skills are thus centered on methods for individuals to manage difficult emotional states without using dangerous behaviors.  There are four general categories of distress tolerance skills: distraction, self-soothing, improving the moment, and focusing on the pros and cons.  The first several of these categories are addressed through an acronym, ACCEPTS:

    Activities

    • Distract with simple, healthy, pleasurable activities like taking a walk, watching a movie, gardening, or playing a sport

    Contributions

    • Help others when feeling distressed

    Comparisons

    • Compare your situation to that of those less fortunate and attempt to feel thankful not to be worse off

    • Compare yourself to how you were doing prior to treatment and focus on progress

    • Dangerous when overwhelmed by negative emotions, as cognitive distortions (e.g., dichotomous thinking, discounting positives) may skew perceptions of progress

    Opposite Emotions

    • Engage in activities that are opposite to current negative emotion (e.g., listening to happy music when sad)

    Pushing away

    • Take a "planned vacation" by focusing your mind on something pleasant that is unrelated to the current distressing situation

    • This is different than problematic dissociation.  In this instance, the individual is exerting control over his thoughts as he disengages from the immediate environment and focusing only on positive imagery and memories

    Thoughts

    • Distract with neutral thoughts like counting the number of tiles in the room, reading the titles of all the books on your bookshelf, etc...

    Sensations

    • Distract with physical sensations

    • Some individuals hold ice cubes or take warm showers and focus on the resulting physical sensations

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        The ACCEPTS skills, thus, help clients to focus their attention away from aversive thoughts and feelings and to engage in either pleasurable or neutral activities until their emotional state returns to a calmer, baseline level.  Some of the skills are more proactive than others and different clients will respond differently to different skills, so practicing between sessions and experimenting with different methods for implementing the skills is pivotal. 

        Additional skills for improving the moment are provided after the co-leaders discuss the ACCEPTS skills and the group members spend time practicing them between sessions.  These additional skills include using positive mental imagery (e.g., imagine your favorite place and focus your energy on observing and describing every detail you can as precisely as possible), creating meaning (e.g., "make lemonade out of lemons"), praying, relaxing (e.g., progressive muscle relaxation), and doing one thing in the moment (e.g., mindfully engage in one distracting activity, allowing all other thoughts and sensations to pass through your mind as though they are on a conveyor belt).  Some of these skills overlap with other distress tolerance skills, but providing multiple angles for explaining similar concepts can increase the likelihood that all group members find a way to relate to the topic.
    Storm Focusing on the pros and cons of a situation, another general category of distress tolerance skills, is also fairly straight forward, although it asks clients to go a step further than standard pro/con lists.  If an individual is considering self-injury, for instance, she would be asked to make a list of the pros and cons of engaging in this behavior, as well as the pros and cons of not engaging in the behavior.  Four columns are created, and the client is encouraged to be thorough and fair in all four columns.  There will obviously be overlap between several of the columns, but the point of the exercise is simply to slow down the behavioral response of the client and encourage her to consider all the possible repercussions of her decisions.  I have found that clients readily engage in this activity and find it incredibly helpful.  Remember, while some individuals naturally engage in this type of thoughtful analysis before making decisions, for others, a lifetime of impulsive, emotionally driven responses has made such approaches seem foreign and difficult.

        The final distress tolerance skill is the one that I believe may be the most important of all: radical acceptance.  Radical acceptance asks individuals to accept what they cannot change and let go of fighting what is true.  At first, clients often think this means lowering their standards, endorsing things against their beliefs, or declaring a bad outcome a good one.  This could not be further from the truth, however.  Radical acceptance simply states that screaming about your current situation is more likely to exhaust you than it is to effect the desired change.  Rather than engaging in fruitless exercises likely to only increase and prolong negative moods, acknowledge that what is happening is, in fact, happening, and begin to consider the best possible outcome given your current set of circumstances.  For instance, if a client in an inpatient ward fixates on how badly he does not want to be there, how miserable his situation is, and how nothing is the way it should be, he will likely increase his depressive symptoms while doing little to change his unfortunate set of circumstances.  If, however, he accepts that he is there and will be for the foreseeable future and looks to find ways to make that situation livable as he works toward changing it, his experience is likely to improve.  He'll still be in a place he does not want to be, but he'll be more likely to enjoy what positives are there and to find a workable solution to his problem than he would be if he simply focused on his negative emotions and his desire to be elsewhere.  In this scenario, the client does not lie to himself or candy coat what is an objectively aversive experience but rather acknowledges his reality and works within the confines of that situation to find the best possible outcome.

        Distress tolerance skills are imperative, not only for individuals with mental illnesses addressed by DBT (i.e., BPD, bulimia, binge eating disorder), but for anyone.  Individuals with these particular disorders simply tend to need more training in these skills.  By teaching individuals how to keep their balance amidst emotions and situations they are powerless to change at that moment, DBT skills trainers can reduce the sense of panic and helplessness that such individuals have grown accustomed to feeling when upset and replace it with an understanding that even the most powerful storm passes and, though it may leave damage in its wake, there is utility in avoiding strategies that would only make it worse.

    More on Distress Tolerance     (6-23-10)
    by Christy Matta, MA from "Dialectical Behavior Therapy: Radical Acceptance"
     

    For many, reality is hard to accept. Unexpected and overwhelming events like lost jobs, physical illness and financial problems can make us want to give up or refuse to acknowledge the realities of our circumstances.

    In Dialectical Behavior Therapy, the ability to accept life, the reality of circumstances in which we find ourselves and the painful events that each of us must endure is taught as a skill.

    These skills can be difficult to teach and learn because the ability to respond to the world as it is, is an underlying attitude towards life. These skills, taught in the Distress Tolerance Module of the skills training group, include strategies to get both our bodies and our minds into more accepting attitudes.  Below are a few exercises on acceptance:

    Body Awareness

    To cultivate a more accepting state of mind, increase awareness of your body. Start by simply bringing your awareness to the position of your body. This can be done any time and any place. Whether you are walking, standing or sitting, notice your position. Become aware of the purpose of your position. For example, are you folding your arms across your chest in a defensive stance or are you tapping your foot in anxiety. If you notice that your mind has drifted, bring your attention back to your breath. It can be helpful to practice breathing exercises, such as counting each breath or saying “in” with each inhale and “out” with each exhale.

    Turn Your Mind

    Acceptance requires a choice. You have to turn your mind towards accepting reality, rather than rejecting and judging reality. You must commit to accepting the current situation and reality over and over. Each time your mind tells you it’s unfair or shouldn’t be as it is, you must turn your mind towards acceptance.

    Be Willing

    When the world seems unfair and you’re feeling stuck, depressed or frantic, it’s natural to want to give up, try to fix what can’t be fixed, or simply refuse to tolerate the situation. Instead of trying to impose your will on reality, focus on doing what works. Do just what is needed in each situation. Your job is to simply do your best, whatever the world throws at you.

    Accepting reality can become a habit. If done regularly, it can reduce stress and anxiety and improve your ability to identify and solve the problems in your life.   What helps you accept life as it is?

    References

    Linehan, M.M. Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press, 1993.

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