Rogers Memorial Hospital Presented at the WSCA Annual Conference on February 22, 2017, Madison, Wisconsin Introduction to Dialectical Behavior Therapy: Applying DBT Skills and Philosophy in the School Setting Lisa Herpolsheimer, LCSW, DBTC Rogers Memorial Hospital Nashotah Program Clinical Services Manager Carissa Buchanan, M.S. Rogers Memorial Hospital Kenosha Campus Clinical Services Manager Psychological Assistant

Learning Objectives Learn the definition of “Dialectical Behavior Therapy,” which was created by Marsha Linehan, PhD and her colleagues Develop an increased awareness of how an individual struggling with intense emotions may present, and begin to consider how effective emotional and behavioral strategies can enhance students’ capabilities Learn the key principles of DBT, including dialectics Understand how teaching DBT skills for emotion regulation, mindfulness, distress tolerance, and interpersonal effectiveness can assist students in managing emotionally intense situations in the school setting and beyond

The Emotionally Sensitive Student…. MERGING behaviors with others alternate with cycles of rejection. Primary fear is that of ultimate abandonment, judgement. Intense and longer lasting emotional responses were repeatedly met with an invalidating social environment. Principally this increases SHAME. Shame is “I AM A BAD” to wish to hide and disappear (vs Guilt, I did a bad thing to which I can repair). They feel powerless, vulnerable; may use aggressive behavior to mask this; or “apparent competence” which is looking completely put together and capable but at drop of the next activating event they are suicidal.

DBT Philosophy Dialectical…..To actively and on purpose seek a Synthesis. “Two Seemingly Opposites Can be Equally True and Valid at the Same Time.”

DBT Philosophy Behavioral…..All behavior is caused; therefore it can be modified when: 1) behavior is accurately understood, 2) we effectively structure the environment to respond to behaviors to increase or decrease them, AND 3) we teach to overcome skills deficits so the person may learn and test out new behaviors (Think: “This is a road map for building a life worth living. DBT is LIVED not just passively learned or prescribed to someone).

DBT Philosophy : “EFFECTIVE COMPASSION,” Marsha Linehan, PhD. Non-judgmental stance: To know the objective causes and functions of a behavior helps us to be more effective to change that behavior. Judging, blaming, or assuming another’s “intentions,” is not helpful and reduces the likelihood that our change interventions can be delivered or accepted. Assumptions of DBT At any given time we are all doing our best and can keep doing better All people want to reduce their suffering and improve their lives

Dialectical Philosophy DBT Philosophy Zen / Contemplative Practice Behavioral Science ACCEPTANCE CHANGE Dialectical Philosophy Slide Author: Carissa Buchanan, M.S.

DBT Philosophy : To intervene, use Acceptance Strategies before using any of the Change Strategies. Core Mindfulness Observe, Describe, STOP skill…what is my/our goal in the here and now? At this VERY moment? Radical Acceptance Lots of VALIDATION but don’t validate the invalid. Listen for the EMOTION. This is NOT RESCUING, FRAGILIZING, Reassuring, problem solving or minimizing! “Makes Sense” “Kernel of Truth”

DBT Philosophy CHANGE Skills Training + Environmental Structuring Behavioral Chain Analysis (BCA). Environmental Structuring: how we respond to increase or decrease targeted behaviors for change. Activate change by assigning use of DBT skills by the learner: For example, Opposite Action.

DBT Skills

DBT Skills - Mindfulness Definition Being present in the moment Purposely paying attention Goals Increase emotional stability Learn how to control one’s attention Practice being present in everyday activities Requires daily practice

DBT Skills - Mindfulness What are the benefits of engaging in mindfulness? Helps focus on the present Changes brain activity Increases nonjudgmental perspective Assists with thinking before acting Improves ability to attend to a situation

DBT Skills - Mindfulness Incorporate a brief activity daily Have a bell or sound to cue the start of mindfulness Encourage students to focus on themselves Remind them why it is important to practice mindfulness Discuss how they felt afterwards

DBT Skills - Mindfulness Wise Mind Emotion mind Reasonable mind Wise mind “What” skills Observe the experience Describe with words Participate in mindfulness “How” skills Non-judgmentally One-mindfully Effectively

DBT Skills – Wise Mind Skill Emotion mind Emotions dictate action Little attention to thoughts and reason Reasonable mind Dealing with only facts Focus on solving the problem Wise mind Integration of emotions and logic Remaining mindful and nonjudgmental

DBT Skills – Distress Tolerance Crisis survival strategies Wise mind ACCEPTS IMPROVE the moment Pros and cons STOP TIP Self-Soothing Reality acceptance skills Radical acceptance Turning the mind Willingness Half-smiling and willing hands

DBT Skills – TIP Skill Tip the temperature of your face with cold water Physiologically cool your body Intense exercise Calm your body Paced breathing Slow your breathing Paired muscle relaxation Pairing deep breathing with relaxed muscles

DBT Skills – Emotion Regulation Understanding emotions Why emotions are important Describing emotions Decrease frequency of unwanted emotions Check the facts Use opposite action Reduce emotional vulnerability ABC PLEASE Increase positive emotions Decrease emotional suffering Let go of painful emotions through mindfulness

DBT Skills – Wave Skill Experience your emotions like a wave Don’t try to push away the emotions AND don’t try to hold on to them Be mindful of body sensations You are not your emotions You don’t have to act on your emotions Don’t judge your emotions Radically accept your emotions

DBT Skills – Interpersonal Effectivenes Be skillful in getting what you want and need from others Objective effectiveness: DEAR MAN Relationship effectiveness: GIVE Self-respect effectiveness: FAST Build healthy relationships and end destructive ones Walk the middle path How to solve problems

DBT Skills – DEAR MAN Skill How to assertively obtain what you want: Describe Express Assert Reinforce Mindful Appear confident Negotiate

Rogers Memorial Hospital Six Rogers Memorial Hospital Wisconsin locations: Oconomowoc Inpatient hospital 8 residential centers Partial hospital (PHP) and intensive outpatient (IOP) programs West Allis PHPs and IOPs Brown Deer Madison PHPs and IOPs Kenosha Appleton 

References Christensen, K., Riddoch, G.N., Huber, J.E. (2009). Dialectical behavior therapy skills, 101 mindfulness exercises and other fun activities for children and adolescents: A learning supplement. Bloomington, IN: AuthorHouse Dimeff, L.A. & Koerner, K. (Eds) (2007). Dialectical behavior therapy in clinical practice: Applications across disorders and settings. New York: Guilford Press. Harvey, P. & Rathbone, B.H. (2013). Dialectical behavior therapy for at-risk adolescents: A practitioner’s guide to treating challenging behavior problems. Oakland, CA: New Harbinger Publications, Inc. Koerner, K. (2012). Doing dialectical behavior therapy: A practical guide. New York: Guilford Press. Linehan, M.M. (1993b). Skills training manual for treating borderline personality disorder. New York: Guilford Press. Linehan, M.M. (2015). DBT skills training handouts and worksheets (2nd ed.). New York: Guilford Press. Linehan, M.M. (2015). DBT skills training manual (2nd ed.). New York: Guilford Press. Mazza, J.J., Dexter-Mazza, E.T., Miller, A.L., Rathus, J.H., & Murphy, H.E. (2016). DBT Skills in Schools: Skills Training for Emotional Problem Solving for Adolescents (DBT STEPS-A). New York: Guilford Press. Miller, A.L., Rathus, J.H., Linehan, M.M. (2007). Dialectical behavior therapy with suicidal adolescents. New York: Guilford Press. Rathus, J.H. & Miller, A.L. (2015). DBT skills manual for adolescents. New York: Guilford Press.