DBT A Christian Overview and Practical Taste of Dialectical Behavioral Therapy for Your Clinical Practice Heidi Vermeer-Quist, Psy.D. Licensed Clinical Psychologist Pine Rest Christian Mental Health Services

Serenity Prayer (for today) Introduction Serenity Prayer (for today) God, grant me the Serenity (tranquility, composure and peace) to ACCEPT (gratefully receive) the things I cannot change (Others, Outcomes and Old stuff), COURAGE to change the things I can (myself in this moment, managing my Feelings, Attitudes, and Behaviors), and WISDOM (understanding) to know the difference… LIVING One Day at a time…ENJOYING One MOMENT at a time (mindfully observing, describing and participating in the precious present) ACCEPTING HARDSHIP as a pathway to PEACE… TAKING, as Jesus did, this sinful (evil, corrupt and broken) world as it IS, not as I would have it… TRUSTING that You are making all things right as I SURRENDER (give in) to YOUR will… So that I am reasonably (sensibly and quite) HAPPY in this life and SUPREMELY HAPPY with You forever in the next. AMEN (So be it!) —Adapted from Reinhold Niebuhr’s original by Heidi Vermeer-Quist You all should have a copy in front of you, for you to easily read Throughout this session take note of the skills – easily integrated in Dr Niebuhr’s prayer Pray together

Resources For You: This PPT @ www.vqconsult.com Introduction Resources For You: This PPT @ www.vqconsult.com Grounding Book Info 2012 AACC Article A Christian Overview and Practical Taste of Dialectical Behavior Therapy (DBT) Heidi Vermeer-Quist, Psy.D. Published in Christian Counseling Connection (2012), Volume 18, Issue 4 (A Publication of the American Association of Christian Counselors)

Overview of DBT Developed by Dr. Marsha Linehan – 1993; Second Edition released in 2014 One of the most effective treatment methods for patients, especially those with Borderline Personality Disorder (Olenchek, 2008) Goal Today: provide an overview of DBT, a Christian integrative approach, and some practical skills you can use with your clients.

Dialectic – the idea that two things can be true at the same time Overview of DBT Cognitive-Behavioral Intervention designed to target maladaptive coping Dialectic – the idea that two things can be true at the same time Central Dialectic: Acceptance versus Change Developed to treat Borderline Personality Disorder (self harm/suicidal behavior), but now expanded to treat many disorders that involve Emotion Dysregulation and Interpersonal Disruption

Four Skills Training Modules Overview of DBT Four Skills Training Modules Core Mindfulness Interpersonal Effectiveness Emotion Regulation Distress Tolerance

First Module Core Mindfulness Mindfulness is the CORE skill reinforced throughout DBT. Take hold of your mind, using your whole mind as fully as possible. Turning your mind to fully participating in the present moment.

Core Mindfulness First Module Engage both our “reasonable mind” and “emotional mind,” increasing the likelihood of better decisions. We come to a place of “wise mind” when we consider both our reasonable and emotional mental processes. Reasonable Mind WISE Mind Emotional Mind

Christian Integration of Core Mindfulness First Module Christian Integration of Core Mindfulness We acknowledge that relying on God’s presence and His Word are enormously helpful: God’s Presence Reasonable Mind WISE Mind Emotional Mind

Christian Integration of Core Mindfulness First Module Christian Integration of Core Mindfulness Wise mind – produced by reasonable mind and emotional minds working together through dependent dialogue with God… God’s Presence Reasonable Mind WISE Mind Emotional Mind

Christian Integration of Core Mindfulness First Module Christian Integration of Core Mindfulness Benefits of Prayer: Feel less alone – aware of being with God Look at a bigger picture Discern meaning and purpose in the midst of suffering A prayerful experience can help clients feel less alone, look at a bigger picture than just their own frame of reference and discern meaning/purpose in the midst of their suffering.

Christian Integration of Core Mindfulness First Module Christian Integration of Core Mindfulness Blessed is the man who trusts in the Lord, whose confidence is in him.  He will be like a tree planted by the water that sends out its roots by the stream.  It does not fear when heat comes, its leaves are always green.  It has no worries in a year of drought and never fails to bear fruit. (Jeremiah 17:7-8, NIV)  God created us to love and depend on Him constantly; therefore, He guides us toward “wise mind”, a grounded place, as we converse mindfully with Him.  I like the imagery by the prophet Jeremiah

Core Mindfulness Skills First Module Core Mindfulness Skills WHAT Skills: Observe – observe the moment you are in. Turn your mind to WHATEVER is in this present moment. External and internal mindfulness… Describe – describe what you are observing. Attach words to what you are experiencing… Participate – participate in the moment. Be involved in whatever you are doing… Linehan trains Mindfulness from a behavioral approach, teaching both the “what to do” and the “how to do it” skills. For example, if someone just tells you to “smile,” you may or may not enjoy it. However, if someone tells you to “smile” and “imagine your favorite place,” you probably will. Similarly with Mindfulness, the “what” skills tell you what to do, while the “how” skills teach you how to approach the “what” skills. Three Steps… Observe - …Focus on what is external (outside of you) or what is internal (inside yourself). Accept it just as it is (not necessarily as you would have it). Do not judge it; rather look at it as objectively as possible. Describe - …Be like a scientist observing and writing down field notes on an object or experience. Participate - …like a musician who is 100% involved in a piece of music. If you are walking—walk. If you are driving—drive. If you are talking—talk. If you are typing—type….

Core Mindfulness Skills First Module Core Mindfulness Skills HOW skills: Non-Judgmentally – Assume non-judgmental stance and accept the moment just as it is. Notice what is helpful and harmful but try not to judge. One-Mindfully – Be mindful of each activity, doing one thing at a time. Let go of distractions – use “Teflon mind” – letting unhelpful thoughts slide off your mental frying pan and then return to the present moment. Effectively – Focus on what works effectively for the moment. Use the principles, morals and values you know and trust. Use effective tools: journaling, prayer and social support. Consider your options – what is most effective (not perfect) for the situation. MINDFULNESS…HOW TO DO IT? First, take a non-judgmental stance and accept the moment just as it is. Acknowledging what is helpful and what is harmful is fine, but try not to judge. Second, each activity is approached as one-mindfully, defined as doing one thing at a time. Let go of distractions that keep you from focusing fully on accomplishing this task. Allow yourself to use what Linehan calls, “Teflon mind,” letting unhelpful thoughts slide off your mental frying pan and then return to the present moment and the task at hand. Let go of “O zone” thoughts… Third, focus on what works effectively for the moment. Use the principles, morals and values you know and trust. Use tools like journaling, prayer and social support to identify your helpful options. Consider your options, and choose what is most effective (not perfect) for the situation. In His Sermon on the Mount, Jesus instructs us to trust God and participate in the present moment, just like the birds of air and the flowers in the fields (Matthew 6:25 -30). He also teaches us to let go of judging, especially judging one another.  We are encouraged to constantly communicate with God, trusting Him to guide us, guide others and allow Him to be the judge (Matthew 7:1-5). I love how Jesus tells us to stop our over-controlling and deal with ourselves...right now...effectively addressing the plank in our own eye and depending on Him to help us remove it.

First Module Mindfulness Exercise External Mindfulness – focus on the breath and guide your clients through observing, describing and participating in their five senses. Internal Mindfulness – focus on breath and guide your clients through observing, describing and letting go of thoughts. Notice, name and move on to the next thought. MINDFULNESS EXERCISE Now let’s apply these skills focusing on our five senses. The fist DBT module shows how to use slow, easy breaths throughout this exercise and give yourself time to focus on each sense for a few minutes. First, pay attention to what you are physically touching. Observe and describe in your mind what you are touching (i.e., the chair or another object). Simply observe what you are touching. Describe or put words on it. Now, participate (feel it and allow yourself to enjoy it) for several seconds. Next, pay attention to what you hear. Simply observe, describe and participate with what you are hearing. Then pay attention to what you smell (observing, describing and participating). Now, turn your mind to what you taste in your mouth. Observe, describe, and participate in that taste. Finally, pay attention to what you see. Gently and slowly observe, describe and participate with one or two objects that you see. With practice, clients will feel more grounded and in tune with themselves and their surroundings.

First Module Mindfulness Exercise Give Thanks as you and your clients practice mindfulness! Pray without ceasing. In every thing give thanks, for this is the will of God in Christ Jesus concerning you. Quench not the Spirit. (1 Thessalonians 5:17-19, KJ21) I also recommend encouraging clients to give thanks as they notice each of their senses and experience the joy of participating in God's presence through his creation...connecting with the sights, sounds, sensations (touch and taste) and smells in the present moment.

Interpersonal Effectiveness Second Module Interpersonal Effectiveness self-respect respect for others respect of their relationships This second DBT module trains clients in interpersonal skills, equipping them to grow and develop self-respect, respect for others and respect of their relationships. My favorite, and a very practical, IE exercise is having clients write out the “DEAR MAN” acronym to prepare for, and become successful at, assertive conversations. Clients are encouraged to focus on responding mindfully, not reactively. DEAR MAN facilitates truthful and loving conversations, a great goal for all of us to pursue in our relationships. "Speaking the truth in love, we will grow to become in every respect the mature body of him who is the head, that is, Christ" (Ephesians 4:15). Clients can benefit from this skill, learn to use their voice and engage more effectively in relationships – speaking the truth in love. Here is the acronym that helps illustrate the technique:

Second Module DEAR MAN A helpful tool to facilitate truthful and loving conversations Speaking the truth in love, we will grow to become in every respect the mature body of him who is the head, that is, Christ (Ephesians 4:15, NIV) My favorite, and a very practical, IE exercise is having clients write out the “DEAR MAN” acronym to prepare for, and become successful at, assertive conversations. Clients are encouraged to focus on responding mindfully, not reactively. DEAR MAN facilitates truthful and loving conversations, a great goal for all of us to pursue in our relationships. "Speaking the truth in love, we will grow to become in every respect the mature body of him who is the head, that is, Christ" (Ephesians 4:15)

Describe the situation. Express what you are feeling/experiencing. Second Module DEAR (WHAT to say) Describe the situation. Express what you are feeling/experiencing. Assert what you want or don’t want. Reinforce how getting what you want will help you and the relationship. Clients can benefit from this skill, learn to use their voice and engage more effectively in relationships – speaking the truth in love. Here is the acronym that helps illustrate the technique:

Second Module MAN (HOW to say it) Mindful: Remain focused and mindful of the objective or subject at hand. Repeat your objective if the other person is going down another track. Appear Confident: You don’t need to feel confident, but maintain good eye contact, remain calm and speak confidently. Negotiate: Respect their “no,” but also explore if you can negotiate a third option to satisfy you both. Also consider his/her perspective. If necessary, take time to think of other options and come back together at a later date. Clients can benefit from this skill, learn to use their voice and engage more effectively in relationships – speaking the truth in love. Here is the acronym that helps illustrate the technique:

Emotion Management… Whoa, Nelly! Third Module Emotion Management… Whoa, Nelly! Linehan uses a horse and rider analogy when training clients about emotions and how to manage them. Imagine that your emotional mind is your internal horse living inside. It gives you lots of signals and reactions that you depend on. Your horse may react in all kinds of ways: excitement, fright, frustration, joy, sadness, caution, anger, nervousness, suffering and more. Here, we are encouraged to identify and value what our emotional mind (“Nelly,” as I like to call her) is signaling. Rather than reacting to automatic feelings, take time to feel them, become more mindfully aware of them, and understand what they are signaling.

Emotion Management… Whoa, Nelly! Third Module Emotion Management… Whoa, Nelly! The horse – emotional mind – needs the rider The rider – reasonable mind – needs the horse (with all of its strength and ability) Designed by God to work together to produce “wise mind” realities, especially as we pay attention to God, our Ultimate Horse Whisperer! The horse needs the rider and the rider needs the horse, with all of its strength and ability.  Similarly, our rational minds (the rider) and our emotional minds (the horse) are designed by God to work together.  As we train our emotional mind with our rational mind, ever drawing from the life source of God, we will produce “wise mind” realities.  God IS, after all, our Horse Whisperer, training us to reign in our emotions and follow Him.

Emotion Management Third Module Observe Your Emotion – just name it. Experience Your Emotion – as a wave coming and going. Remember You Are Not Your Emotion – emotions only last 8-15 seconds. The more we accept what we feel and distract our thoughts to neutral or positive experiences, the less we feed the distress and suffering of our emotions. Practice Loving Your Emotion – don’t judge it… practice accepting it. Linehan encourages letting go of emotional suffering by increasing Mindfulness of the current emotion. She uses the following steps: Observe Your Emotion – just name it. Experience Your Emotion – as a wave coming and going. Remember You Are Not Your Emotion – emotions only last eight to 15 seconds. The more we accept what we feel and distract our thoughts to neutral or positive experiences, the less we feed the distress and suffering of our emotions. Practice Loving Your Emotion – don’t judge it… practice accepting it.

Prayer Journaling through Emotions Emotion Management Prayer Journaling through Emotions Dear God, What am I feeling? What am I reacting to? the current situation: my interpretation (subjective): the truth (objective): How did I (or how am I now) respond(ing) to my interpretation of the situation? What is my typical knee jerk response? What other options do I have? (Really listen to yourself, God, what others have taught you….) What do I choose to do?   While the following journaling exercise is not taken directly from DBT, it effectively helps clients work through their emotions, gain self-awareness, and think through their options… moving toward wise mind decisions.  

PLEASE MASTER Treat PhysicaL illness Balance Eating Emotion Management   PLEASE MASTER Treat PhysicaL illness Balance Eating Avoid mood-Altering drugs Balance Sleep Get Exercise Build MASTERy – do simple activities that make you feel competent and in control   In Emotion Management, Linehan’s “PLEASE MASTER” acronym helps us reduce vulnerability to negative emotions through basic behavioral self-care steps: Treat PhysicaL illness Balance Eating Avoid mood-Altering drugs Balance Sleep Get Exercise Build MASTERy – do simple activities that make you feel competent and in control Can also use HALT – anyone remember that one from AA?

Distress Tolerance Wise Mind ACCEPTS A – Activities C – Contributing Fourth Module Distress Tolerance Wise Mind ACCEPTS A – Activities C – Contributing C – Comparisons E – Opposite Emotion P – Push Away T – Other Thoughts S – Five Senses This fourth skill-training module, Distress Tolerance, provides strategies to assist clients with finding purpose in their suffering. Linehan encourages us to radically accept distressful situations, ground ourselves using our five senses, and improve the moment using mindfulness skills, prayer and positive experiences.

Distress Tolerance PROVE HIM Pray Recreation Opposite Emotion Vacation Fourth Module Distress Tolerance PROVE HIM Pray Recreation Opposite Emotion Vacation Eat Health Imagine Meditate Another DT skill from another famous Linehan Acronymn – IMPROVE Group assisted me in renaming this one: PROVE HIM

Serenity Prayer Radical Acceptance Distress Tolerance Serenity Prayer Radical Acceptance It is what it is. There are just things outside of ourselves we cannot control – “O” zone of Others, Outcomes and Old Stuff. “Accepting what we cannot change” “Taking this sinful world as it as it is, not as I would have it” “Trusting that You are at work…” GYL version – integration of skills with this classic prayer by Reinhold Niebuhr Use GYL Version…

Grounding, Grieving & Growing in the hands of our Master Gardener Gardening Your Life Mental health is a lot like gardening… Grounding, Grieving & Growing in the hands of our Master Gardener John 15 – Abiding in the Vine

Personal Growth Series (for groups or individuals): Gardening Your Life Personal Growth Series (for groups or individuals): Book One: Grounding – Available! AACC Special Today Only: $20 Cash/Check only (regular price $24.95, plus S&H) Book Two: Grieving (pruning) Coming Fall of 2016 Book Three: Growing (new growth in grateful community) Coming Spring of 2017 Close with Serenity Prayer – out loud together

Closing A Christian Overview and Practical Taste of Dialectical Behavioral Therapy for Your Clinical Practice Q & A

Serenity Prayer (for today) Closing Serenity Prayer (for today) God, grant me the Serenity (tranquility, composure and peace) to ACCEPT (gratefully receive) the things I cannot change (Others, Outcomes and Old stuff), COURAGE to change the things I can (myself in this moment, managing my Feelings, Attitudes, and Behaviors), and WISDOM (understanding) to know the difference… LIVING One Day at a time…ENJOYING One MOMENT at a time (mindfully observing, describing and participating in the precious present) ACCEPTING HARDSHIP as a pathway to PEACE… TAKING, as Jesus did, this sinful (evil, corrupt and broken) world as it IS, not as I would have it… TRUSTING that You are making all things right as I SURRENDER (give in) to YOUR will… So that I am reasonably (sensibly and quite) HAPPY in this life and SUPREMELY HAPPY with You forever in the next. AMEN (So be it!) —Adapted from Reinhold Niebuhr’s Original by Heidi Vermeer-Quist You all have a copy in front of you, for you to easily read This time take note of the may DBT skills – easily integrated in Dr Niebuhr’s prayer Let’s pray together