dbt – Effects of Anxiety

Dialectical Behavior Therapy (DBT) Skills | Mental Health CEUs for LPC and LCSW

Unlimited CEUs for 59 at AllCEUs com welcome everybody. Today,’s, presentation is on dialectical, behavior therapy skills. This presentation is based in part on dialectical, behavior therapy a practical guide by Kelly Koerner. This is one of those books that, if you want to do dialectical therapy as a practice, not just look at some of its tools is a must-read. Then it’s also based in part on dialectical, behavior therapy skills, workbook DBT made simple and DBT for substance abusers, which is an article that was published by Marsha Linehan. So the links to those are in your class, but just give you an idea about sort of the breadth of what we’re going to be looking at today. In the short time that we have together, what we’re going to do is take a look at why DDT was created, we’ll look at understanding emotional regulation, dis-regulation and regulation will identify DBT assumptions about both clients and therapists, and we’ll Explore skills to help clients learn to stress tolerance, emotional regulation, and interpersonal effectiveness. As an aside, we’re taking – or I’ve taken the information from this course and combined it with a bunch of other information to make a six-hour on-demand course. That will be available by the end of the week, but for now, we’re just going to hit the highlights in the 1-hour introduction. So why do we care? Why do we want to learn about DBT skills and DBT tools? Many of our clients, experience emotional dysregulation, or the inability to change or regulate their emotional cues experiences, and responses. Think for a minute about any of your clients, if they’re depressed, if they’re anxious, they’ve got anger management issues, something is going on with their emotional states, or they’re not able to either get unstuck or control their behavioral responses. So they may be engaging in self-injurious, behavior risky, behavior, or addictive behaviors. They’ve tried to change and failed, leaving them helpless and hopeless. In a lot of our clients. We try to fit them in not that we should, but we do try to fit them into this box. If you’re depressed, then we’re going to look at these things, and one thing I hope you get from these webinars is the fact that every single client is different and there is no box that we can put them in and you’re, Like well, then, how can you do group therapy? Group therapy is awesome because you can tailor and that’s, part of the challenge of doing psycho. Educational group therapy is tailoring the tools and helping people tailor the tools to meet their individualized needs, but they can get feedback and they can see how different tools can be modified just a little bit to fit different individual needs and untenable emotional experiences that lead to Self-preservation behaviors such as addiction, you know to kind of numb the pain to give them a distraction, nonsuicidal self-injury. We’re talking about cutting, we’re talking about those sorts of things, and then even those suicidal behaviors. At a certain point, the pain has got to stop, so some people may end up going as far as trying to stop the pain by stopping their existence instead of hurting anyone else. People with emotional dysregulation have high sensitivity, so these people tend to be highly hyper-vigilant. They’re aware of a lot of things that go on now. This was created and I want you to really kind of think about it. It was created as a tool or a protocol to use with people with borderline personality disorder. What do we know about people with BPD? They grew up in really ineffectual environments, so they had to be hyper-vigilant about everything that was going on for their safety and security. So you have someone who, either by nature or by nurture, is hyper-vigilant. These situations have been over-generalized. The dangerous situations have been over-generalized, so the world tends to seem more and dangerous, and out of control, people with emotional dysregulation are easily thrown off kilter because they often have a lot of vulnerabilities. They’re not eating. Well, they’re depressed which is contributing to them not being able to sleep. Well, they can’t focus yadda, we’ve talked about vulnerabilities. One thing that dr Turner talks about is no emotional skin and she likens it to someone who has third-degree burns and every single thing, even the air when it touches it, is just excruciating there’s no middle ground. There’s. No, oh! That’s kind of uncomfortable it’s either not hurting or it’s. Excruciating. People with emotional dysregulation are also highly reactive, so they’re hyper-vigilant. They’re aware of everything that’s going on and then every time something happens that sort of triggers their awareness they jump into this immediate fight or flight reaction. Then they’re slow to de-escalate. So we’re talking about situations in which someone is hyper-vigilant. They’re on edge, maybe because of situations in the past or not. They have this sort of persistent fight or flight or frequent fight or flight reaction. And again, I’ll refer back to our dream fatigue class that talked about how the body can only stand to be all hands on deck for so long before it’s just like dude I give up, and then the sense of depression and helplessness and Apathy starts to set in people who are who have emotional dysregulation, really they’re either like flat and none nonexistent in their emotions. They just can’t even deal with it when they should, or they’re, overly reactive and then the person isn’t in a validating environment. What would be a to some of us on a scale of 1 to 10? As far as how distressing something is it’s, probably like an 8 to somebody with emotional dysregulation, think about a time when you were stressed out or you had a lot of vulnerabilities going on. Maybe you had a new baby at home, so you were, ‘t sleeping and your other kids were acting out. There were just all kinds of stuff going on and you reacted to something with an 8 that everybody else was like that. Doesn’t deserve that. Much of a reaction is that’s it what’s wrong with you, people with emotional dysregulation that’s their environment, all the time, everybody’s looking at them and going what’s wrong with you there? This is not that upsetting. So we need to help people understand that their experience is their experience and it’s not for me to say whether it’s a 2 or an 8. For me, it’s a 2, but let’s look at why it’s an 8 for you. So the emotional reaction – and this is I didn’t – get red eye reduction when I took this picture of bruit but bless his heart. When I got him, he was a rescue and he had such terrible terrible abandonment issues and is so hyper-vigilant. Even to this day, I’ve only had him like four months, but he’s hyper-aware of stimuli and people can be hyper. Aware of stimuli so anytime somebody moves, he’s up, he’s. Looking he’s like. Are you going to leave me alone again when he perceived that something is changing when there was a threat, he goes into all hands on deck and turned into a survival sort of thing and starts acting out? He goes and finds toys and brings them to me. Heaven forbid. We should have to put him out in the garage because we have visitors or something and it’s. You know climate controlled, it’s not like it’s horrible, but he will sit out there and how, until I let him in or go out and tell him it’s going to be okay, now see as a person I’m going. That is not a valid reaction. He’s like totally overreacting to having to spend ten minutes in the garage, whereas from his perspective he’s not overreacting, because in the past when he’s been put in the garage he left out there for days weeks months. Who knows I don’t know his story too. Well, now I use that to kind of highlight the fact that people with emotional dysregulation don’t know what their experience was. What they’re doing is trying to survive. Now they may be trying to survive a situation in their past. You know when there were six and we’re going back to the abandonment discussion that we had the other day, but it’s important to understand that all these things play in together. Something happens and the body’s response system takes in these stimuli and it says it’s dangerous it’s, not dangerous. What do we do with it? The brain decides to fight or flee, and then they go into the survival response with treatment. What we want to do is help people be able to feel that feeling and not have to act on it right away until they can de-escalate some and use a combination of assessing their cognitions and deciding whether their perceptions are based. On the present. The present moment or the past moment so primary invalidation caregivers dismiss emotional reactions as invalid. We just talked about that. The child or person could be mocked or shamed for their emotional response. We have all probably met parents or worked with parents who have children that are highly emotionally reactive, and who tend to get frustrated and overwhelmed by the constant drama that seems to be presented by this child all the time. So the child is often not taught how to self-soothe or de-escalate the parents just like really let it go and go away, which is not helpful because the child doesn’t learn how to deal with it. The child is not taught mindfulness to figure out okay, what’s causing this, and the child is not taught effective cognitive processing in most situations in validating environments, if the child gets upset, even if it seems to be disproportional to whatever the event was, the caregiver Will take the child in and say? Okay, I hear you’re upset right now, let’s talk about it and we’ll walk the child through, maybe not thinking about it, but just being a good parent walks. The child, through this de-escalation process and the cognitive processing of secondary trauma or invalidation, is, and I’m putting this in here. Coping skills can be overwhelmed by trauma or intense stress, leading to this high alert raw status. Think about the people who were survivors of Hurricane Katrina or Hurricane Andrew. I come from Florida, so I think hurricanes, but any big event that is ongoing enduring, and distressful at a certain point. You’re on your last nerve, so anything could precipitate sort of a crisis. Many people don’t receive the necessary support during these times and may be shamed for being weak or needy. Sometimes nobody can cope and everybody’s kind of decompensating. At once, which is a lot of what we saw with Katrina but other times there may be people that are functioning just fine and they don’t understand why some other people are 39, t coping just fine, and they see that as abnormal and want to distance themselves from it, it’s important for us to communicate to people because we already noticed that crisis is a normal response to an abnormal event. What was abnormal, though, is it this particular incident? Maybe, or is it the fact that this particular incident kind of was the straw that broke the camel’s back on a whole chain of incidents leading up to it that was abnormal? What caused this person? Excessive stress I was talking to a woman the other day who, in the past six years, has had half a dozen significant losses and I’m just like wow. You know that that’s pretty intense to have all those and she’s, also starting her practice and everything else. Right now – and I’m – just like oh my gosh – I can’t imagine the amount of stress this woman is – going through most humans, aren’t inherently prepared to deal with the crisis alone. We’re kind of group sort of people. We rely on other people, so if we have this reaction and it’s judged to be disproportionate and people kind of distance themselves from us, because they see us as abnormal or dysfunctional, then we lose any social support that might have been able to serve as A buffer which just kind of in turn, feeds back and exacerbates the sense of hopelessness, helplessness, and isolation. What precipitates a crisis may vary between people based on pre, existing stress or mental health issues, and it also may vary with the same person longitudinally across time. What may be overwhelming today – maybe not may not be overwhelming six months from now, because all of those prior stressors that I’m dealing with right now may have had time to kind of work themselves out. So we must help people understand that their reaction is their reaction and let’s just go from there. Let’s not say it’s bad or is disproportionate or it’s whatever it just is so the result of this sort of unpredictable reactivity results in frantic efforts to numb withdraw or protect. I need to numb the feelings because I can’t take this kind of pain. If you’ve ever had a burn that’s had to be cleaned or even an open wound that’s had to be cleaned out. You know that’s pretty excruciating so thinking in terms of that, you can see why people would want to kind of get a little novocaine withdrawal if this support system is invalidating, that has extra pain and that’s excruciating to be rejected. On top of everything else, so a lot of times, people withdraw which eliminates any opportunity for social support, and it also exacerbates this sense of rejection, and they do this to protect themselves. People learn who they are in invalidating environments. They learn who they are and how they are resulting in rejection, so they avoid threats. They avoid putting themselves out there. They avoid making relationships because they’re afraid of rejection and they avoid thoughts and feelings and sensations that may lead to invalidation. I don’t want to feel these things because then if I do and I communicate them, you may tell me I’m wrong. Okay, we’ve laid the groundwork. Now we see where this is a problem. So what do we do about it? Well, the first thing we want to do is look at some of the DBT assumptions about clients. Clients are doing the best they can given the tools they have at this present point in time, and I truly believe that clients want to improve themselves. Wouldn’t be in your office if they didn’t want to improve for one reason or another. It may be an involuntary referral and they want there’s a means to end there. They are in your office because they have hope that something can change and it will benefit them. They cannot fail at DBT if they go through dialectical behavior therapy, the protocol and it fails, then the protocol failed them or we as clinicians, fail to implement it correctly. Now, today, again, we’re talking just about tools that are present in DBT, not how to do dialectical, behavioral therapy. The evidence-based practice wants to make that very clear clients are existing in what is for them an unbearable state. This pain has got to stop. They need to learn new behaviors in all contexts, not just at work, not just in their relationships, but they need to learn how to function and deal with life on life’s terms in all contexts, so they can go to the grocery store they can get In a traffic jam, they can be in a crowded Airport and not feel like the walls are closing in on them. Clients are not responsible for all of their problems. We know this some things they had no control over are causing problems for them, but they are responsible for all of their solutions, and we’re going to talk about the four options for problem-solving in a few minutes, but they are responsible. They choose to do something and clients need to be motivated to change motivation, choosing the more rewarding option out of the available options. Well, yeah that whatever they’re doing right now is the most rewarding option they have available in their toolbox. So we’re going to give them new tools, but then we need to teach them how to make those tools effective. If you just hand me a jigsaw and say, okay go about woodworking and whatever I’m, not a woodworker, but I’m not going to know what to do with that. So I may go back to using my circular saw or whatever the case may be, which may be very clunky. We need to help clients learn how to use these new tools, so it’s more rewarding to use those than those old behaviors. They just numbed out the pain or distracted them assumptions about therapists, clarity, precision, and compassion are of the utmost importance. We need to be clear with our clients about what’s going on. Let’s not speak in generalities. We want to try to avoid some of the Socratic questions that we would normally do. We want to be clear about what we’re getting at and what we want them to look at. We need to be precise. Do we need to not say well what is it last week that caused all the problems in your relationships? Well, if they had four different fights that’s four different things we need to look at, we need to be precise to identify all of the things that trigger and we’re going to talk about behavior chains in a few minutes. So we need to be precise. We also need to be compassionate, even if we don’t agree, or we think that the reaction was disproportionate, putting ourselves in their mind in their place in their raw state. We need to be compassionate and go okay, you survived it, you did the best, you could let’s take a look at what might have caused that. Why you made the choices you did and what you might choose better next time. The therapeutic relationship is between equals, DBT or therapists can fail to achieve the desired outcome, but the client can’t fail and therapists who treat patients with pervasive emotional dysregulation needs support we need to remember that patients who are always in crisis by their very nature, it’s, exhausting because they’re always in crisis, which means we are responding in a crisis manner, not that we need to get all upset and worked up because that’s just modeling the wrong thing. But there is a lot of energy that it takes for us to use the DBT tools for us to model the DBT tools and for us to help work. The client is out of their emotional state into one where they can use their wise mind. So the first step is core mindfulness. Until they figure out what’s going on, they can’t fix it, so we want to help them integrate their rational mind they’re cognitive. This is what happened factual mind with their emotional mind. This is what it felt like in the wise mind, so you can take the facts. You can take your feelings and you can say with what I know and what I felt. What would be the best interpretation of this or the correct one for me? Interpretation of this event at this point, and what can I do about it? One of the things DBT talks about is the fact that truth is sort of subjective. What is true for one person may not be the truth for the other person, because we’ve all had different experiences, but we need to help people not underreact and stay. In that cognitive mind, if you’re a star, trek fan, think data um. He was the AI that was kind of human-robot sort of thing or, and we also don’t – want people to act in their emotional mind, acting solely based on feelings and trying to make feelings facts because feelings aren’t facts. They’re feelings, so we want to help them integrate these two things, and that is more difficult and it sounds like it takes time. Mindfulness is using effective, nonjudgmental observation and description of experiences, those thoughts, and feelings, and identifying what’s the objective evidence for and against what’s going on right here, how I’m feeling what is all the evidence. Let’s look at the big picture, not just one little aspect of it, and what are my feelings about this event? Getting in touch with what’s going on inside their mind and inside their body is going to be one of the first steps. So I talked about those four options: when there’s a problem, you have four options. You can tolerate it, grit your teeth, and Barratt there. Sometimes you just can’t do anything about it. Traffic jams probably can’t do much of anything about it. Change your beliefs about the event. Instead of seeing a traffic jam as a waste of time and just a complete pain in your butt, you can see it is a time to check voicemail and maybe return. Some phone calls are productive, make it billable, and you can solve the problem or change the situation, while you’re in a traffic jam and stopped, of course, looking at Google Maps to figure out where the next exit is so that you can get off. So you can change that situation or you can choose to just stay miserable and choosing to stay miserable is a valid choice. When clients make these decisions, we need to look at them. Why was that? Whatever their option was? Why was that option more rewarding than all the others? Why is it more rewarding sometimes to stay miserable for some people that’s what they know and they’re afraid if they feel happy, then they may get disappointed and end up feeling sadder than they already do now? Some people tolerate the problem because it’s what they know and change is hard and they would rather just tolerate it and deal with it and suck it up than have to muster up the energy to try to change whatever’s going on. So again we want to look and ask them or ask ourselves, maybe because they may not know right away the choice that you made. Why was it more rewarding? Why did you choose that over the other three options, distress, and tolerance we’re going to talk about a lot of acronyms here acronyms are really important in DBT because it helps clients have sort of a drop back and punt. There are some worksheets. There are lots of worksheets online for DBT but the acronyms we’re going to hit here are going to be some of the highlights that are going to be important for you to remember tip temperature. So you’re tipping your physiological balance now temperature. I’m not necessarily advocating for this. You don’t want to do it. If you’ve got a heart condition. You don’t want to suggest it to clients that have a history of child abuse, especially anything that involved drowning. So this one’s a little tricky one of the things I suggest to some of my clients instead of this is holding on to ice cubes. But the suggestion in the book holds your breath. Dunk your face in for as long as you can hold your breath into a sink full of ice water, then come up. Exhale, inhale and dunk, again repeat as many times as you need until you feel calmer. Well, guess what we’ve talked about combat breathing. If you are slowing your breathing, which you do, if you’re holding your breath, your heart rate is naturally going to slow. When your heart rate slows down your brain says: oh the threats going away, yippee yay, I can call off the dogs. There are other ways to slow down your breathing. Besides necessarily dunking your dunking, your head holding ice cubes is one of the reasons that that can be helpful. Instead of cutting the person’s focus, it’s a distracting technique. The person focuses on the pain because it is painful to hold on to ice cubes for a long time, instead of cutting themselves, but it also gives their body something to focus on to go. Oh, my heart rate is up because there’s a pain when the pain goes away. I can make my heart rate go down, so we’re redirecting the brain to go. Oh, this is why the heart rates are up it’s, not because there’s emotional distress, it’s because of extreme physical pain. Intense exercise increases body temperature, but it also increases the heart rate when you’re sitting still and your heart rate is 120 beats a minute because you are in a panic attack or a state of panic. It’s very, very uncomfortable and your mind is going. I don’t understand you, ‘re not moving. Why is the heart racing when you start exercising, which is why walking and getting those big muscles moving often helps? Then the body gets less confused. It’s, like Oh heart rates, beating fast, because the body is moving score, got it so when the person stops moving, the heart rate starts to go down, and this is true, even if you’re walking around. If you take a client out to walk when they’re upset – and you are talking about whatever the distressing thing is – I have found without exception.

When they come back inside, they can start to calm down a little bit more and their heart rate naturally starts to go down when they stop their physical exercise and then progressive relaxation. You’re going to move from head to toe or toe to head. Whatever you prefer but head to toes, usually how we do it focusing on muscles focusing on breathing slowing, breathing relaxing muscles forcing the body to relax. So this addresses physiological arousal, so the temperature, intense exercise, and progressive relaxation. All of these serve as an ability serve the function of distracting the person from whatever cognitively or inter psychically wants to say, is going on, and all of these either explain to the brain why the heart rate is going so fast or Help reduce the heart rate, so you know there’s something to be said for them. The important thing is for you to brainstorm with your clients when you get physiologically aroused when you get upset, and you are just your hands – are shaking your palms are sweating. You’re breathing fast, and your heart rate going fast. How do you calm yourself down what works for you and we’re back to bruit again? Another acronym is accepted to distract when there’s emotional turmoil, so you can kind of let that adrenaline surge go because you have that initial fight or flight reaction and then the body kind of goes. Alright, let’s reassess and see if there’s still a threat, get involved in activities that will help you distract yourself from whatever’s going on when kids get upset. You know if they’re getting stressed out because they’re sitting in the lobby and the doctor’s office, and they know they’re going to get a chhoti. We give them something to do. We read a book, we talk we play because then they’re not focusing on the fact that they’re going to get a shot, contributing to the welfare of others. Do something nice for someone to volunteer. Do something productive that gets. If you are focused on someone else, compare yourself to others who are doing less well, that doesn’t work for everybody. You can also compare yourself in the present to your old self and focus on how much better you’re doing now compared to what you were doing six months ago, this doesn’t always work. You know these are options. Not everyone is going to work for every person, emotions do the opposite. If you’re feeling really sad get a comedian, get it to go to YouTube, and Google a comedian and watch a skit or two or ten, so you’re doing something that makes you laugh. That makes you happy to sing. Silly songs, dude silly dances go out and there’s very little. I find it more amusing than just listening to a baby laugh. If I’m having a really bad day, I will find those stupid videos of babies laughing at paper tearing if you can’t help, but laugh with them pushing away build an imaginary wall between yourself in the situation. Imagine yourself pushing away the situation with all your might or blocking the situation in your mind, and each time it comes up, tell yourself to tell it to go away. So if you start thinking about something that is particularly hurtful as soon as it comes into your mind and it comes into your awareness go no, I am NOT going to think about that right now. Thoughts counting some people count to ten, a hundred whatever it takes to get through that initial rush. Some people sing for me. I think I’ve shared before I have this irrational fear of bridges, but so, whenever I Drive over a bridge I sing, and usually, it’s, not songs on the radio. Usually, it’s songs. I used to sing to my kids. I’ll sing the ABCs something that doesn’t require a whole lot of cognitive interaction because I’m doing pretty good just to get over the bridge. And yes, I know I should be over it, but I’m not and that’s just the way it is the 10 game. I like this one think of 10 things that you like the smell of think of 10 green things. Think of 10 things you see where we’re going with this, and you can incorporate all the different senses with it. If you go through multiple iterations of it 10 things that you smelled yesterday, 10 things that you see right now, 10 things that you hear when you’re on your way to work. This helps people focus on something other than what’s going on. Here the 5 4 3 2 1 game is sort of similar to the 10 things game, identify 5 things. You see, 4 things you smell, 3, things that you can touch and follow down. Sensations like I talked about on the last slide. Sensations can help distract you from what’s going on until you have a chance to kind of get through that initial adrenaline rush, cold, holding ice, cubes, rubber band – and I don’t like this one. But some people do they put a rubber band on their arm and every time they start to perseverate on a negative thought. They snap its smells and find some good smells. Some smells bring back good memories, smells that you like. Maybe it’s roses: maybe it’s a purse-specific perfume. Maybe you just go to Walmart and start smelling all the air fresheners. Whatever makes you happy, I do suggest avoiding taste, because if you start using taste as distress tolerance, then you start moving toward emotional eating. I’ve seen it happen, so I would avoid that for most people, but if they just desperately want to go there, then you know we’re going to go there because they are choosing how to distract from their cognitive or intrapsychic. Sensations improve at the moment. Imagery goes to your happy place. Whatever your happy place is meaning find an alternate, meaning for what’s going on now. This can be Linehan refers to it as making lemonade. We all know how to do that. We don’t we’re, not necessarily the best at it, but try to make lemons. I try to look for the optimistic meaning in whatever it is prayer. Now, even if someone is not religious, they can be using radical acceptance. Accepting it is what it is and not trying to change it, just putting it out there for the universe, relaxation is always good to relax one thing at a time and this isn’t focusing on one problem at a time. This is focusing on something we’re talking about distress, tolerance, and improving the moment so focus on one thing, like your breathing: get your breath and calm down once your breathing calmed down. If you need to focus on something else, then move to. Maybe the tension in your neck. Maybe you need to lower your shoulders and release the tension in your neck, focusing on physiological things and focusing on other senses. Besides, that abstract stuff that’s in your head and your emotions can help people tolerate the distress until they can think more clearly vacation takes a timeout. Sometimes you just need to get away from it. For a few minutes, we’ve had time at work. I’m sure we all have where you’ve just been like. You know what I’m done and you lock your computer screen. You get up, you walk out of the building, and none of its clients are in there, but you walk out of the building and do a couple of laps around the campus and then you’re like okay. I can deal with this again just clear your head before you try to tackle whatever it is, an encouragement providing yourself, because you can’t necessarily rely on anyone else. Positive and calming self-talk now back to those stupid, memes and videos that I love to death there’s, one has a kitten on a laundry wire and it says: hang in there, I love having those things on screensavers. It’s, juvenile, maybe but whatever it makes me happy, and it reminds me you know even when I’m, not in a state of emotional distress. It reminds me all right keep on hanging in there. You got it and it’s got an all-factor too. So I always like anything with an all factor: the goals of emotional regulation. So once you’ve tolerated this distress, you’ve gotten through that initial surge. That initial, I cannot take this pain or upset. Then we need to move into emotional regulation, help people identify labels, understand their emotions and the functions of those emotions, decrease unwanted emotional responses and decrease emotional vulnerabilities. So what they’re going to do is identify and label emotions and their functions. I’m scared. Okay, you 39. Re scared. Tell me why what’s the function of you being scared? What do you want to do, and what do you think is causing this scared? 39. No self-awareness through questioning, like that through talking it out, people will start to understand where their emotional reactions are coming from and they can choose whether or not to follow up with it a behavior. What I guess I didn’t put in a behavior train analysis is the way you can go about helping people work through that and that’s a couple more slides cop. We want to police our thoughts and check the facts. Look at doing opposite actions. If you want to hurt yourself, look at being kind to yourself, if you want to run, maybe you need to look at staying and then look at the problem. Solving reduced vulnerability through the ABC p accumulate. The positives, remember, vulnerabilities, are those situations that happen leading up to whatever the distress is. Those are the things that make you more likely to be irritable, overwhelmed angrily depressed get sad about anything. Instead of not so, we want to eliminate those vulnerabilities or reduce them. As much as possible, so we’re going to accumulate positive gratitude, journals pictures if well, everybody has things in their life that they care about. Have those on your phone in you know little picture galleries that have them as your screen. Savers have reminders around about it. Why you get up in the morning builds mastery, so you have mastery of the skills you need to deal with emotional distress and upset cope ahead of time plan for distressing situations. If you’re getting ready to go in for an annual evaluation and those things stress you out to no end rehearse, it ahead of time plan on coping ahead of time, and figure out how you’re going to react. If it goes bad figure out how you’re going to react, if it goes good figure out how you’re going to cope and physical vulnerability prevention, maintain your health, chronic pain, chemical, chemical imbalances, hormonal imbalances, those can all cause vulnerabilities or set you up. Make you predisposed to feeling like something’s at eight when it’s only two get plenty of sleep when we’re sleep deprived, is a whole lot harder to deal with life on life 39. S terms and exercise. Exercise is a great way of releasing or using up some of that stress energy that you release during the day. Behavior chain analysis. The first thing you do and a strict behaviorist will have slightly different explanations for how to do this, but just bear with me here: name the behavior reaction. What happened now, if you’re thinking back to the ABCs, this is going to be your C. Your consequence, what happened identifying the prompting event ABC is, that would be the what was the activating event now. This is where it differs a little bit. Then we want to look at the behavioral links, so you had the activating event, and then there was this reaction and in between, there were um automatic beliefs, and we have that there. We have thoughts, but there were also sensations events, and feelings between what happened and your reaction. What sensations did you feel? Did you get flushed? Did you feel nervous? Did you feel scared? Did you feel sad? Did you have a twinge of something? What feelings were there and what events happened? Did you act out in a certain way? Did you scream? Did you yell about what happened? Because these are all things that are going to go into what ultimately ended up being the behavioral reaction, then I want to look at the short-term positive and negative effects of what you did. The behavior of the reaction. If you started screaming and throwing things okay, you did what was the short-term positive effect of that? What was the benefit of that? Because that was what you chose, which means it was likely the most beneficial response you could come up with in your highly emotionally charged mind then. So what were the benefits and what? With immediate short-term negatives and then looking at the positive and negative long-term effects in the long term, if you react to this upset by screaming and throwing things what’s the impact going to be, are there any positive impacts? Are there any potential positive effects of this and a lot of times it’s? No, but we want to ask the question just in case there are because some people will have a positive and we need to address that this is sort of. If you go back to motivational interviewing what we think about when we’re talking about decisional balance, exercises address the problematic links with skills. If some sensations or actions exacerbated the distress, then we need to look at distress and tolerance. If all of a sudden you had this immediate panic reaction and you couldn’t breathe, we need to work on distress, and tolerance skills, so you don’t go to that point where you are just for lack of a better phrase in a tizzy thoughts and Feelings if your thoughts get negative and start racing and your feelings are negative and anxious and worried and all those negative words we want to look at emotional regulation. You know if you can get through it, where you get through that initial rush and you’re still having these getting stuck in the negativity. Then we want to look at emotional regulation most of the time we’re going to look at both of them and then the third component, once we’ve learned how to get through the initial flood, the initial all-hands-on-deck call, and then people Have learned to regulate their emotions and identify helpful responses, and instead of talking about good and bad, we want to talk about helpful and less helpful responses. Then we need to look at interpersonal effectiveness and how to interact with other people to make that validating environment exist. So we want to start with interpersonal and intrapersonal if you will be effective with yourself and then move to others describe what’s going on assess how you’re feeling what your reactions are, and what the best next step is asserting. Your choice reinforces the good things. Be mindful appear confident and willing to negotiate, and yes sometimes we have to negotiate with ourselves because there’s something that we want to do right now – and this is very true – with people with addictions a lot of times – they want to use. They know the long-term consequences of use are not where they want to be, so they have to negotiate with themselves to say alright. I want to do this right now, but I’m going to choose a different option in their relationship with others. We want to encourage them to give me gently instead of critically, and harshly, which a lot of times is what they’ve gotten all of their life, being gentle with other people, accepting them where they are modeling how they want to be treated, be interested in What other people have to offer, what other people have to say and what’s going on with them? A lot of people with emotional dysregulation can’t handle their own life on life’s terms. They can’t even begin to handle anybody else.’s stuff, so a lot of times they appear disinterested, validate other people and their experiences, and have an easy manner. You know sometimes we get too intense and if everything in your world is either a zero or a ten, it’s easy to be intense. About everything, as they develop emotional regulation, things will be different. You know they’ll have fours and fives in there, but practicing that not being intense and over the top about everything, and then in their relationship with the self, be fast, be fair with themselves, not judgmental just fair, avoid apologies, stick to values and be truthful. 12-step recovery step, one starts with honesty, being honest with yourself step two. We start talking about hope and faith, which is sticking with values and being fair to oneself. Being compassionate comes couple more steps down that’s not hard or not harmful. For any of our clients to teach them to be fair, to be kind to themselves, and to be honest with themselves and others. So how does treatment progress when we’re talking about dialectical, behavior therapy as an evidence-based practice stage? One is safety. We want people to move from behavioral disk control to behavioral control. We don’t want people getting a phone call, maybe a significant other has to back out on a weekend trip which was someone with behavioral disk control could send them into a state where they are self-injuring. So we want to make sure that they have the skills to not self-harm, and you know you can’t just say. Well, you can’t cut the person’s like okay, so finish, what am I going to do? Instead? If I can’t cut, if I knew how to do something else, I’d be doing it right now. We need to help them increase their self-care behaviors instead of cutting. What can you do, I’ve talked before about some of the interventions I’ve used with some of my clients that have self-harmed. It’s not ideal. It’s not where you want to end up, but moving from self-harm, too, like I said, holding ice cubes or using a ballpoint pen to draw on yourself is preferable to cutting yourself. So we want to look at small steps, not going from. You know five or six self-harm episodes a week to nothing. You’re setting yourself and your client up for failure. We want to reduce the intensity of the self-harm, so they’re not breaking the skin, so they’re not damaging themselves decrease therapy interfering behaviors what we typically call resistance and that can be showing up late that can be always coming in and trying to derail therapy sessions, it can be being bossy, it can be being reserved whatever it is that’s interfering with the therapeutic process. It’s important to understand that therapy-interfering behaviors can be exhibited on the part of the counselor too. If the client is experiencing a lot of emotional discount role, sometimes counselors will start being late to sessions and will start forgetting to review the chart before they go in and remember what homework was assigned will start forgetting to do things. So we need to make sure that both the counselor and the client are engaging in motivating therapy participatory behaviors. We want to increase the quality of life, and behaviors and decrease the quality of life-interfering behaviors. So if they’re engaging in addictions, if they’re, not sleeping if they’re, changed smoking if they are and again these are things when we look at the priority list, my main focus at first is going to be on self-harm. You know I don’t want them to be engaging in those behaviors, and then we’re going to start looking at the other things that create vulnerabilities that make them more likely to be unhappy or to be reactive in situations that would make them unhappy. We’re going to increase behavioral skills, core mindfulness, and accurate awareness, encouraging clients, not just when they’re upset, but to engage in mindfulness scans body scans, four or five times a day. So they know where they are and they know if they are starting to feel vulnerable. If they’re, it feeling exhausted all of a sudden. If they’re feeling foggy, then they know to be kind to themselves: distress, and tolerance. We talked about those skills, interpersonal effectiveness talked about those skills, emotional regulation, and active problem-solving. So these are all going to be introduced in stage one, but they’re introduced. The client has been using their old behaviors for a lot longer than stage 1 is ever going to last. So we need to remember that we have to help clients strengthen these behaviors, remember to use them if they use them at first, one out of every five times as one more time than they were using them. Last week let’s focus on the positive forward movement and not on what we think they should have done. We don’t want to set goals that are going to set them up for failure in stage two. We want to help clients, moderate emotions from excruciating and uncontrollable to modulated and emotional um. We want to feel feelings. Well, I mean, theoretically, we do so. We don’t want people to completely numb out and become robots, but we also don’t want every single emotional experience to be like debriding. For a third-degree wound, we want something in between. We need to help them decrease intrusive symptoms, like flashbacks memories, and hecklers, the things that created the situation where they feel unlovable and unacceptable for who they are. We want to decrease avoidance of emotions, and I know that sounds kind of counterintuitive to increasing emotional awareness. Again, we don’t want them to be numb. We want them to feel because if they feel, then they can choose how to act and how to react. Decreased withdrawal increases exposure to live a lot of times, clients with emotional dysregulation have withdrawn because they don’t want to be rejected so they don’t go out with friends. They don’t experience life on life’s terms. They just sit in front of the television watching Netflix. We want to decrease self-invalidation and help them understand that their experiences are their experiences and they’re not right or wrong. Their choices may be helpful or less helpful, but at any point in time that is their best as well as they can see their best options for survival. So let’s not be critical. I’m just happy you’re still here and we want to reduce mood dependency of behaviors part of this process. We’re going to teach people how to create SMART goals that are specific, measurable, achievable, realistic, and time-limited SMART goals and make sure they’re successful by validating and teaching them to self-validate, encouraging them to imagine the possibilities when you’re successful When you accomplish this goal, what’s going to be different? How awesome will it be to encourage them to take small steps, not all or nothing? You know we want to get get rid of the dichotomy’s small steps towards recovery and applaud themselves for even trying to encourage them to lighten their load and get rid of stuff that they don’t need to be stressing over right now. You know maybe now’s not the time to start remodeling the house and then sweeten the pot and encourage clients to provide themselves with rewards for the successful completion of a goal, maybe getting through an entire week or for some clients even an entire day without self-injury. I encourage you to practice these skills yourself because you’ll see how much we don’t do and how helpful these skills can be, but it also gives you more insight into two ways to help explain thanks to clients and help them apply. These tools to themselves think about which skills you’ve used that were helpful or skills you could have used. That would have been helpful in the past week for you because you’re going to ask the clients to do this. So let’s do it for ourselves, so we can put ourselves in their position and think about which skills might have been helpful for a client that you’ve worked with in the past week. Many disorders involve some amount of emotional dysregulation. That dysregulation can be caused by high sensitivity and reactivity due to innate characteristics and poor environmental fit or external traumas and lack of support, or both DBT seeks, first to help the person replace self-defeating behaviors with self-care behaviors, and then moves toward emotional regulation and Interpersonal effectiveness to help people develop the support system and learn how to feel feelings, including the good ones. A variety of tools are imparted to clients to help them set SMART goals, identify and understand, emotions and their functions, decrease, unwanted, emotional and behavioral responses, and develop a more effective, compassionate, and supportive relationship with themselves and others. Finally, remember that not every tool is going to work for every person it takes some experimentation, so prepare your clients for that. Otherwise, if they try something and it doesn’t work, they’re going to feel rejected and validated and like failures. Again, it’s a process to work together to help them figure out how they can start interfacing with life and integrate the two dichotomies of thought and emotion to make wise choices to help them live happier and healthier. .As found on YouTube Hi, My name is James Gordon 👻🗯 I’m going to share with you the system I used to permanently cure the depression that I struggled with for over 20 years. My approach is going to teach you how to get to the root of your struggle with depression, with NO drugs and NO expensive and endless therapy sessions. If you’re ready to get on the path to finally overcome your depression, I invite you to keep reading…

DBT Skills Emotion Regulation | Counselor Toolbox Podcast with Dr. Dawn-Elise Snipes

CEUs are available at AllCEUs.com this episode was pre-recorded as part of a live continuing education webinar on-demand, CEUs are still available for this presentation at AllCEUs.com/counselortoolbox I’d like to welcome everybody to today’s presentation of dialectical behavior therapy techniques emotion regulation we are going to start by reviewing the basic premises of DBT and the reason we’re doing that we’re only going to do it in this one because emotion regulation we’re starting kind of at the beginning but we want to go over what is the theory underlying a lot of what we’re going to talk about we’ll learn about the HPA axis and this isn’t something that Linehan talks about in DBT but it is important for understanding our physiological stress reactions will define emotion regulation identify why emotion regulation is important and how it can help clients ourselves staff yay and we will finally explore some emotion regulation techniques there are things besides just preventing vulnerabilities that we can provide to clients to help them regulate their emotions before moving into that distress tolerance realm of skills and activities so basic DBT premises everything is interconnected when you get up in the morning if you’re having a bad the day you know you didn’t sleep well your back hurts you’re cranky you got a lot of stuff to do it’s raining outside you know yay you’re noticing all the negatives your thoughts maybe more negative you may be more likely to notice the negative you may be more likely to have what we call commonly call a bad attitude if you start to have a better attitude what happens to what you observe and we’ll talk about that in a little while the reality is not static what is true right now in the present may not be true which is you know was the future from what the present was half a second ago so reality changes when we look at a situation when we look at an event, we’re looking at how am i reacting and what is my feeling about the situation right now you know we can learn to change where we’re at but with the information, I have right now what’s going on and a constantly evolving truth can be found by synthesizing different points of view because most of the time as humans it’s just kind of part and parcel of being humans we don’t have the whole picture and I did the best I could with these little graphics here think back if you will to some of PJ’s experiments when he was trying to demonstrate egocentrism when we’re looking at this yin and yang sort of model the girl’s stick figure what does she see if you ask her what color is this orb she would probably say black because we’re assuming she sees the black side if we ask this little thick figure model over here what color is the orb she’s seeing the white side so he’d say white now if we asked a little confused guy who is standing kind of on the third side or the south side he sees both of them so he hears the stick figure girl say it’s black he sees a stick figure boy say it’s white and he’s going well it’s kind of both you can synthesize both perspectives and figure out that this is an orb that has multiple colors even though she can’t necessarily see those colors and he can’t necessarily see those colors so BBT says let’s try to take a look and see if there are blind spots see if there are things we’re not seeing or things we didn’t observe the basic assumptions of DBT and well people do their best if we didn’t think that we probably wouldn’t be in this profession so people are doing their best with the tools they have and the knowledge they have at any given time and I added that extra part people want to get better and be happy most people don’t want to be miserable if it seems like they don’t want to get better then we need to ask ourselves what is the benefit to staying miserable why is it is scarier more threatening more awful to look at getting better or being happy and that’s one of those motivational things we’re not going to go there today but in general people are going to choose the most rewarding option when prevents presented with multiple options okay now this one area in that I kind of diverge from the official statement is clients need to work harder and be more motivated to make changes in their lives I’ve had a lot of clients who have been working their butt off but they may not have the right tools it’s like trying to unscrew something that is Phillips head with a butter knife they’re working hard but it’s not going anywhere because they can’t get any traction so I crossed out the work harder and I tend to replace it with work smarter clients need to work smarter they need to have more tools they need to have more effective tools and some of the tools they have may be awesome if we just tuned them up a little bit sharpen their oil and grease them whatever you need to do and be more motivated to make changes in their life and you’re saying well they’re in therapy they’re coming here for whatever reason there why aren’t they motivated to make changes well again let’s look back at motivation and what’s the most rewarding choice is if they tried to make changes before and it hasn’t worked out and they’ve been told that it was their fault they were being resistant or you know they were blamed in some way or they just felt disempowered what’s going to make them motivated to try to do that again please let me run the gauntlet most people don’t want to do that so we need to help clients work smarter and understand that they are working hard and they need to continue to do so and we’re going to help them get more effective tools and we need to help them get more motivated we need to help them see that this time it’s going to be different maybe a little bit different but this time we’re trying something new it may be different even if people didn’t create their problems they still must solve yep you know if you grew up in a dysfunctional household you didn’t create that problem but it is negatively impacting you today so you’re going to have to fix it if you want to be happy which is the whole goal of the lives of suicidal or addicted people are unbearable and when we’re talking about DBT we’re generally talking about people who are highly emotionally reactive and suicidal self-harm those behaviors are away at this point that they’re trying to figure out how to tolerate what seems like an unbearable situation in their head addiction is much the same way it provides some relief from something they feel they have no control over people need to learn how to skillful live skillfully in all areas of their life well yeah because every area is interconnected if you’re stressed out at work do you just leave work go home and you have not stressed out anymore no that’s not the way it works it would be great if it did but it’s just not even if you don’t take all your stresses of work home with you it has taken a toll on your energy level so when you get home you’re more vulnerable to emotional upset or just fallen asleep on the couch at 6:00 p.m. Whatever it is so we need to help people learn how to live skillfully in each area so the exhaustion or negativity or whatever it is from one area doesn’t bleed over into the other area so we need to learn how to juggle stresses in all of our areas to prevent vulnerabilities and people cannot fail in treatment when someone relapses when someone you know backslides whatever word you want to use I look at it as a learning the opportunity I say okay you made a different choice than we wanted you to make a different choice than you were hoping you would make so let’s learn from and figure out why that was the most rewarding choice than what was on your treatment plan the goal that you’re working toward why what happened what were you more vulnerable so you didn’t choose the newer behaviors because they weren’t as readily available let’s use this as a learning opportunity to figure out what’s going on it’s not a failure it’s a learning moment or a teachable moment so what is emotion regulation emotional dysregulation will start there results from a combination of high emotional vulnerability so you’ve got somebody who is kind of reactive and extended time needed to return to baseline so that when they get upset it takes them longer to de-escalate and get back to baseline and an inability to regulate or modulate one’s own emotions so I want you to think about some the time that you’ve been driving on the interstate and you’re just driving along cruising along and heaven forbid if this has happened I hope not but if it did you’re probably just late a semi comes along and runs you off the road onto the shoulder and oh my gosh you get onto the shoulder your legs just to go in like this you can’t even press the gas pedal because you are so stressed out you’re gripping your knuckles are white from gripping the steering wheel so tight your heart racing you’re breathing fast you’re in full-out fight-or-flight mode so you went from a1 on the stress meter you know kind of cruising along aware of the fact that you need to be cognizant of dangers to a5 of oh crap that could have been bad alright so you take a couple of deep breaths you your breathing goes down a little bit you get to the point where you can press the gas pedal and you pull back out onto the highway now are you returning to baseline and just like la-dee-da cutting around like you were before most likely not you’re a little bit more on edge and you’re checking your bat rearview mirror more often you’re looking back making sure nothing’s in your blood spot more awesome so you’re not returning to that same level of less stress Tunis if you will you stay a little bit elevated because your brain is gone you know I thought it was kind of a safe situation but I’m realizing now that not so much so I’m going to keep you on higher alert and it’s going to take longer for you to return to baseline because you’re looking for those threats now you’re much more aware that it could happen to people who come from invalidating environment people who are regularly chronically stressed they’re constantly looking around for anything else that is going to threaten them anything else that’s going to stress them out so they’re not going from a 1 to a 5 back down to a 1 again they’re going from a 1 to a 5 back down to a 2 and then back up to a 5 and then now we’re only going down to a 3 it’s that stress is ramping up so we need to figure out how to help people deescalate get back down to that one and realize okay I got this that was an unpleasant situation but I got this now emotional vulnerability refers to the situation in which an individual is more emotionally sensitive or reactive than others or then they normally would be you know some people this is kind of and when we’re talking about personality disorders this is pervasive when we’re talking about someone who has been under a bunch of stress for six months this may be a situational sort of thing that we need to help them figure out how to get out of but it may not be something that is completely and utterly pervasive in any event when you are stressed you know you’re already kind of on edge and something happens do you react the normal way that you normally would if you were just like sitting there and going off oh well okay let’s figure out how to handle this or does it throw you up sort of into the stratosphere and for a lot of people with emotional dysregulation when they’re their relaxation is on the brink of chaos so they’re standing there teetering and they’re going okay I cannot take one more wind or it’s going to push me over and then they call them damp they get upset and they’re kind of on freefall for a while they get their balance again but then they’re still right there on that precipice they never come down so what we want to look at is what’s going on with these people that’s making them more reactive that’s making them more alert and more hyper-vigilant to stresses and stressors some of these may be because of differences in the HPA axis which play a role in making people more vulnerable or reactive and we’re going to talk about the HPA axis in a minute environment of people who are more emotionally reactive or often invalidating and what does that mean well pick Jane Jane has had a heck of two years you know there’s just been death after death a job loss she lost her home she’s living in an apartment right now but she’s not happy and you know yeah you can just pile stuff on okay so James struggling right now she’s holding on and really trying to do the next right thing she’s trying to make ends meet trying to do what’s right by our kids just feeling stressed out and then something happens something that most of us would react with it to you know it’s annoying but it wouldn’t throw us into utter chaos well James on that precipice Jane’s already at a four maybe a four and a half depending on the day so when this happened just that too puts her on a scale of one to five puts her at a six-and-a-half which is in freefall but people may not understand that they may not understand what’s going on in Jane’s life and they’re like this is not that big of a deal why are you just overreacting which makes Jane feel guilty Phil is self-conscious and feels misunderstood so then she feels isolated and rejected and we’ve talked about basic fears being rejection isolation failure loss of control and the unknown well James kind of experiencing all of those right now and the people around her instead of being validating and going okay you were already stressed out I can see how this was just the straw that broke the camel’s back they’re going what is your the problem so she doesn’t feel like she’s got social support she’s out there on an island unto herself so we want to help Jane with emotional regulation because we know she’s up here and we know she doesn’t like going into that freefall but how do we help her emotional regulation is the ability to control or influence which emotions you have when you have them and how you experience or express them and that’s a quote straight out of Linda hands book so emotion regulation prevents unwanted emotions by reducing vulnerabilities so you can go through life you can go through the day you can experience stress but instead of feeling overwhelmed or enraged you might feel mildly irritated for a second and then choose to move on emotion regulation helps people learn how to change painful emotions once they start so you don’t get stuck nurturing that emotion or feeding into it and being angry with yourself because you got angry about something you have no control over it teaches that emotions in and of themselves are not good or bad they just are it’s your brains hardwired way of responding based on waiting for it the information that it has at this particular point in time spiders if you’re afraid of spiders that is your brain’s way you see a spider and you feel fear it’s your brain’s way of going threat spiders can be a poisonous big threat so you want to get away from it that’s your body’s way your brain’s way of going let’s survive we want to do this now you can figure out you can learn more about spiders so in the future when you encounter then you realize that they’re not you know 99% of them are not threatening to humans but right now at this moment your brain is saying warning getaway you probably want to do that so it teaches that emotions internet themselves are just prompting us to do something they are survival responses and suppressing them makes things worse telling yourself I shouldn’t feel afraid does that do any good if your kid comes to you and tells you that you know I’m having a crappy day or I hate this does it usually do any good to tell them well you shouldn’t feel that way feel better you know just be happy does that work I’ve never had an experience where that worked now it may work for some people but so we want to help people identify their emotions and not get consumed by the emotions are effective when acting on the emotion is in your best interest so sometimes it’s in your best interest expressing your emotion gets you closer to your ultimate goals sometimes expressing your emotion gets you closer to your short-term goals like making the pain stop and true pain is unpleasant however in the big scheme of things 15 minutes from now 3 hours from now is that getting you closer to the goals that you want to achieve or was it just a stopgap expressing your emotions will influence others in ways that will help you so if you want to influence others in ways that are positive and will help you then emotions can be very kinder that can be very helpful emotions are sending you an important message and we already talked about that so I’m thinking the devil’s advocate amigos well I can think of a client that goes you rage is a great emotion to express is it in my best interest yeah gets people to leave me the heck alone does it get me closer to my ultimate goals yeah it reduces my stress by getting people to leave me the heck alone will it influence others in ways that will help you, yeah it make them go away and are these emotions sending you an important message yet rage is telling me that these people like everybody are a threat to me so in the short term when you look at it that way it can be tricky to see but we want to help people get outside of this immediate threat and say where you want to be what happiness looks like to you or however you want to define that ultimate goal and then once you get into distress tolerance was your Thursday talk about how do you endure unpleasant emotions so you don’t take the stopgap route now on to our favorite HPA axis the hypothalamic-pituitary-adrenal axis is our central stress response system and doesn’t get too caught up and all the psychobiology of this I think it’s good to be cognizant of but we’re not prescribing hypothalamus place in the brain release is a compound called corticotropin-releasing factor or CRF which triggers the release of adrenocorticotropic hormone from the pituitary gland which triggers the adrenal glands to release stress hormones particularly cortisol and adrenaline now your adrenal glands are actually on your kidneys and why is that important what I want you to see or understand is there are a lot of systems involved there are a lot of hormones involved there’s a lot of stuff involved it’s not just box you know you’re releasing a bunch of chemicals in your body that are altering the neurochemicals and the other hormones to prepare you for spiders the adrenals control chemical reactions over large parts of your body including the fight-or-flight response and produce even more hormones than the pituitary gland so you’ve got these adrenals this is kind of your stress area if you will it produces steroid hormones like cortisol which is a gluteal corticoid which means it makes your body release glucose what we know is that glucose is blood sugar energy all right so it increases the availability of glucose and fats for the long-term fight-or-flight reaction it also produces sex hormones like DHEA and estrogen okay why is that important because we know that when estrogen goes up serotonin availability goes up so if there are the adrenals are busy doing something else it may cause other hormonal imbalances and it also produces stress hormones like adrenaline that is going to ramp you up they’re going to increase your respiration increase your heart rate all that kind of stuff so once you have that whole reaction we talked about and the perceived threat passes cortisol levels return to normal great this is what happens in the ideal situation but what if the threat never passes what if we’re working with a client who is constantly fearing rejection and isolation they need external validation because they don’t feel good enough as they are they don’t have social support because their emotional reactivity kind of pushes everybody away so they’re constantly feeling this threat of rejection isolation failures loss of control and the unknown they’re holding on just like you were holding on to the steering wheel after you ran off the road and you got back on you know you kept chugging because you wanted to get to your destination but you were scared witless okay so you’re chugging along what’s going on what’s going on in that body the amygdala and the hippocampus are intertwined with the stress response the amygdala modulates anger fear or fighter flight and the hippocampus helps to develop and store memories when you’re under stress and think about a time when you are under a lot of stress were you effective at learning and paying attention to the good things and the bad things or were you just trying to make the pain stop and make the threat go away from the brain of the child or adolescent is particularly vulnerable because of its high state of plasticity which is why do we see people who tend to have personality disorders much of their trauma and stuff really started early in their development and which is why it’s pervasive in every area or many areas of their life, bad things are learned emotional upset prevent learning new positive things to counterbalance it if you’re in a bad mood if you’re scared if you’re threatened you know if you’re hungry homeless put whatever stuff is there are you paying attention to the bluebirds that are flying around and singing pretty songs or are you paying attention to the fact that you got an a on a test maybe not so, we need to understand this person who lives in a chronically stressful environment may also have an overactive HPA axis so they’re already they’ve already got some adrenaline and cortisol going on they live kind of in this state of hyper-vigilance and then something happens and they’re just like through the roof kind of like when you scare a cat what happens to the brain one is a chronic threat to its safety and a constant the underlay of anxiety is constant undercurrent as it learns your brain forces synaptic connections from experience and pruned away connections that aren’t utilized by people who feel a lack of control over their environment are particularly vulnerable to excessive stimulation of the stress response now it’s not just children abuse and neglected children pop right up there but abuse and neglected adults think about a client you’ve worked with who’s been in an abusive relationship for years does she have all the happy connections or is she pretty much terrified exhausted and stressed out most of the time adults with anxiety or depressive disorders it doesn’t even have to be an abusive or neglectful situation if you have someone that forever whatever reason has clinical anxiety or depressive symptoms they are in this state of constant threat and constant of people if you will so they’re not seeing they’re not able to learn and take in as much of the good stuff so there’s more bad stuff coming in they’re paying attention to more of the bad stuff or unpleasant stuff the synaptic connections that form the foundation of people’s schema of themselves in the world become skewed towards the traumatic event at the expense of a synaptic Network-based on positive experiences and healthy relationships so we had this client here and these are her negative experiences she has a lot of them and she’s got these going through her head a lot and it’s not they don’t just go away whenever she meets somebody and she’s like well they’re going to leave me whenever something happened she feels isolated and alone she may fear so she’s got really strong connections to those memories and past experiences and when you’re in the midst of all this, there’s not a lot of happy stuff and even when she appears happy a lot of times she’s faking it she’s not seeing and remembering all the happy stuff she just wants to avoid the pain another example I could give you is thinking about a city planner now a city planner only has a the certain budget just like we only have a certain amount of energy the city planner looks and says what roads and what connections between cities get the most traffic and let’s devote our resources and strengthen those connections because we know we’ve got all kinds of traffic going over there and those roads that don’t travel those back roads we don’t need to pay much attention to them right now because we need to make sure that those roads that are used the most are strong but that’s the best analogy I can give without putting out strings and everything else but so the hyper-vigilant state active IDEs activated by the stress response that disrupts our ability to focus and learn you know we’re just trying to not die we’re trying to not be consumed by pain it impairs the ability to form new memories and recall information due to the physiologic changes in the hippocampus, it’s not time to learn and process and do all that kind of stuff have you ever tried to study for a test when you had 16 other things going on that you are stressed about how well did you remember this stuff over here sometimes people relate things to prior experience well most of the time so maybe they’ve had a lot of dysfunctional relationships and they start to get in a relationship which side is going to be triggered the negative memories are the positive memories and then you have somebody who may be attached to some positive relationships they start to get into a relationship and they remember some of the positives because there have been some really good relationships but you know they may remember the negative too but most likely they’re going to remember more strongly the positive so what’s their reaction going to be if we’re trying to help our clients develop a healthy support system we need to help them address some of those highways that are going towards the negative memories emotion regulation is transdiagnostic or useful with many disorders it helps people increase their present focused emotion awareness it says right now right here right now what are your feelings what are your physical sensations what are your thoughts and what are your urges it helps people increase cognitive flexibility because it helps the kind of step back and take a look and say okay what are my options let me step back from being intertwined with this feeling and go okay I feel angry got it what are my options here what do I usually do what I want to do when I’m on autopilot what are some other options I could do that might help me move toward where I want to go identifying and preventing patterns of emotion avoidance and emotion-driven behaviors we don’t want to get into the situation of constantly trying to avoid unpleasant emotions by lashing out by hurting ourselves or by doing things reactively when I feel this way I must smoke a cigarette I must cut myself I must fill in the blank we want to help people find alternate ways and be able to step back and say that is an option is it the option I want to choose today increasing awareness and tolerance of emotion-related physical sensations sometimes these physical sensations are just so powerful and so overwhelming and sometimes the rush of adrenaline and that foggy wibbly-wobbly feeling you get in your head when you have just adrenaline coursing through your veins is so overwhelming that people don’t know what to do with it and are afraid it won’t stop so let’s help them increase their awareness and tolerance of this helped them understand that it passes and use emotion-focused exposure procedures when they get upset help them think about things in the group sessions that get them a little bit revved up you know we don’t want to precipitate a full-scale crisis or talk about something that happened last week that got them upset and let’s apply these procedures emotional behavior is functional to change the behavior it’s necessary to identify the functions and reinforcers of the behavior so when they did it you know let’s talk about cutting because you know that is one of those behaviors that we see are self-injury it’s what is the function of that behavior cutting or self-injury is a way of inflicting physical pain where the person has control and they focus on that and they feel a sense of mastery when the stuff going on in their head feels completely uncontrollable and intolerable it diverts their attention and it also is something that they they can control how much pain they’re in so that’s how it’s functioning now is the best the response we want no but we can see why somebody might engage in that behavior and what reinforces that behavior well when they do that not only do they get a reprieve from this emotional turmoil that they don’t feel like they can touch or control or do anything with but their body also releases endorphins release natural painkillers to kill that physical pain which makes them feel a little a bit better so they’ve got kind of a double whammy on reinforcers there so we understand that now we need to find something else that they can do and help them figure out how to tolerate the turmoil emotions function to communicate to others and influence and control their behaviors and serve as an alert or an alarm to motivate one’s behaviors so let’s talk about the first one communicate to others so I’m communicating to a rat around me the people around me through my emotions what’s going on if I’m angry I’m lashing out I’m going to influence people’s behavior and they’re probably going to back off if I am sad or crying or scared that might bring them closer and in a more supportive sort of thing you know again you’ve got to look at some of the behavior self-injury can elicit a caretaking response but these emotions before somebody start acting out the behaviors the emotions serve as a cue that okay Sally is getting ready to go in free fall so they can start reacting sooner and it serves as an alert or an alarm to the person to motivate their behaviors if they know you’re on the precipice if you know you’re right on the edge of being vulnerable cranky being irritable that day can motivate your own behaviors to figure out how to reduce some of your vulnerabilities and identify obstacles to changing emotions now we can’t just say be happy and all of a sudden somebody’s like oh I don’t know why I didn’t think of that I’m just going to go ahead and be happy that’s just not how it works we want to look at organic factors do they have an organic long-standing chemical imbalance of some sort and it may not be neurochemical it may be hormonal they may have too much estrogen too much testosterone too little estrogen too little testosterone whatever let’s figure out you know have them go see their doctor and figure out if there is something fibroids or moans whatever that might be affecting their mood okay once we identify anything that we can tweak there we can’t measure neurotransmitters we’re out of luck there because they’re found in so many places in the body that there’s no way to isolate how much serotonin is actually in the brain can’t do it yes we want to look at other factors that are biological imbalances neurochemical imbalances that are caused by chronic stress that cause addiction to sleep deprivation and nutritional problems so what sort of chemical imbalances are we precipitating by keeping the stress going and keeping the adrenaline going keeping your body revved up all the time we want to look at obstacles well let me stay with biological factors here real quick the organic things if we can refer to the physician and we can figure out ways to address those that give the person one step forward so they’re not feeling as depressed or they’re not feeling as reactive people with hyperthyroid you know when their thyroid is overactive may have some anxiety issues or some other mood issues that can be addressed with medication then we Looking at situationally caused things is the ways we can help them reduce their chronic stress sometimes there are some easy right-now sort of solutions other times but chronic stress comes from issues that are so long-standing it’s going to take a while it’s not that we can’t do it but it’s going to be a process so we move on and we say okay addiction we know that when people use stimulants rev them up and then they crash and it makes them more than emotional yo-yo caused by the substances or the addictive behaviors also makes them more vulnerable to emotional reactivity sleep deprivation is all kinds of hormones out of whack and tends to make people more irritable that’s one almost everybody can look at addressing right now and nutritional problems if they’re not eating well not eating at all encourage them to see a nutritionist to make sure they’re getting something balanced that they will adhere to not something that they look at and go yeah that looks great but no way I’m eating nuts skill factors what can we help they with we can identify cognitive responses that are obstacles which as I can’t do that I won’t do that resistance in some way my response to that obstacle is set to look at it and weigh the positives and the negatives do a decisional balance exercise to address the cognitive responses and figure out why is the dysfunctional or unhelpful reaction more rewarding why is it more rewarding to be angry or scared than to look at doing things and thinking of things that will help you feel happier what’s the disconnect generally, it comes back to prior failures and fear of failure because they’ve been down that road before and it’s such a letdown when they’re feeling good for like three weeks and then they crash behavioral responses that are obstacles to changing emotions if somebody lashes out when they get upset they lash out and throw things and then they feel guilty so this behavioral response may lead to having more difficulty changing emotions because we’ve got to help them figure out how to pause before the behavioral the response so they don’t compound the situation with more negative emotions and environmental factors people places and things being in environments where you’re surrounded by people who either agon negativity or who bring out you know they’re there with you they’re talking about conspiracy theories they’re just negative about everything or they’re critical of you or remind you of situations where you’ve been criticized before so first, we want to help people identify and label emotions a lot of our clients are relatively Alex Simon you know they have a small repertoire if any of noting their emotions they just generally go from situation to reaction and label what they felt is kind of a mystery so we want to help them and doing it retrospectively is fine at first because that’s probably all you’re going to be able to get the event profiting the emotion what were your thoughts your physical sensations and your urges help me describe this in enough detail that if we were going to give it to an actor or an actress they could recreate the situation what expressive behaviors were associated with that emotion you know did you cry did you throw things did you hit the wall what were your interpretations of that event at the moment not retrospectively but at the moment what were your interpretations of what was going on what history before the event increases your vulnerability to emotional dysregulation lots of big words what happened before that that already stressed you out or had you on edge and you know we go through a whole bunch of different things and this is you know behavior chaining we’re looking at kind of what led up to the event what made you more vulnerable and what were you feeling at that time and then what were the after-effects of the emotion or the reaction on your other types of functioning so after this event and you went into freefall and you got angry and you lashed out and you screamed and you threw things how did that affect your work how did that affect your relationships with your family how did that affect your mood and just generally your sense of being in yourself for the rest of the day changing unwanted emotions okay so we started labeling them we figure out what we’re feeling we figure out that yeah when we feel that way we act in ways that you know make us feel worse afterward what do we do about it let’s change All alright we already talked about the obstacles and we’re trying to address those but in a moment check for facts ask yourself what are the facts for and against your belief if you believe that someone did something to be antagonistic towards you okay what was their motivation what is the facts for and against that also ask yourself is this emotional or factual reasoning am I making a decision based on how I felt I felt attacked therefore I must have been being attacked or facts you know I felt attacked yes but that was because this person said ABCDE and all of those were very attacking and I felt like I needed to defend myself so those are to check the facts sort of steps or you can go with problem-solving so let’s change the situation that’s called cause any unpleasant emotion like I said with spiders at the moment you may not have enough information to not feel scared but maybe your spouse loves hiking and camping and you want to go but you’re afraid of those aren’t spiders so how can you change the situation so spiders don’t trigger that same reaction increase knowledge increase exposure there are a lot of different ways but problem-solving says ok what can I do so my reaction my correct reaction is not one of threat or anger but it is one of at least mild acceptance prevent vulnerabilities which helps reduce reactivity if you are a hundred percent you know you get up and you’re like this is going to be a good day to day things that come your way are probably going to roll more like water off a duck’s back then smack you upside the face like a mud pie so we want to prevent vulnerabilities from the turn down the stress response because when you’re not when you’re not up here already then you know you can fluctuate a little bit more and they help the person be aware of and able to learn and remember positive experiences so if you turn down that vulnerability and somebody’s in a good place or a better place than they were at least they’re going to be able to notice and we’re going to want to encourage them to notice the positive experiences you know instead of thinking that all people are threatening all people are going to hurt me all people are going to leave they might notice that you know there’s Sally over here who’s worked here for 15 years with me and you know she’s there she sometimes calls in sick but then she comes back she’s generally in a good mood you know she’s not such a bad person and you start noticing some of the things that are not self-fulfilling processes building mastery through activities that build self-efficacy self-control and competence smuggle we don’t want to say you don’t want to set a goal where somebody needs to go an entire week without having an emotionally reactive response let’s say go for hours or maybe even a whole day that would be wonderful but first, we’ve got to talk about how to reduce those vulnerabilities so we set the person up for success what things can you do and well and we’re going to get down here in a minute what can you do if you wake up and you’re feeling vulnerable you know the creepy crowds are going around they cancel school for the entire week for school the county school system kids are off for an entire week because of illness right now but you wake up in the morning and you’ve got a fever and a sore the throat you’re like I don’t want to go to work and get out of bed today what can you do to prevent being grumpy and overly reactive throughout the day’s mental rehearsal and this can go for if you’re getting ready to do something scary or threatening seeing yourself do that and do it successfully and this can even be during the day just envisioning yourself getting up and eating your breakfast driving to work going through your day seeing that one person at the office that always has some sort of snarky comment to say or whatever irritates you laughing at it or dealing with it just fine going through everything in your day as you would like to see it happen envision it see see what you can do rehearse it rehearse how to handle negativity you know if you know you’re going to have to go in for your annual evaluation with your boss okay so mentally rehearse how it’s going to go how are you going to react what’s going to happen so you’re prepared for it you have your responses and it takes some of the unknown out of the situation physical body mind care pain and illness treatment and the acronym for this is please I changed one of them to laughter it used to be physical illness and that was both PNL but I like laughter anyway we’ll get there when you’re in pain or when you’re sick you’re vulnerable to being a little bit cranky you know that’s just because your body is already saying you are weak you know back in the day when you had to defend yourself against predators the sick ones and the ones that were in pain were the ones that usually got taken out first as a part of our brain that still remembers that for whatever the reason so when we’re in pain or when we’re sick our body keeps that cortisol keeps our cortisol levels higher and the stress response a little bit higher so we want to deal with those things but know if we wake up and we’re in that situation moment that was a little bit more vulnerable so we need to handle it with care and laughter you can’t be miserable and happy at the same time laughter releases endorphins laughter helps people feel a little bit better and find something to laugh at and have on my phone I keep comedy skits every once in a while I’ll just pop one in even if I’m not having a bad day pop it in because I like to laugh eat two-sport mental and physical health avoid addictive or mood-altering drugs or behaviors that are going to put you on that the up-and-down roller coaster that goes up and it goes even further down than you were when you started to get adequate quality sleep and exercise also helps increase serotonin and release endorphins which help people be in a better mood mindfulness is a judgemental observation and description of the current emotions we’re not going to go deep into this right now another class on mindfulness and you can also google it remembering that primary emotions are often adaptive and appropriate I know I said that like six times much emotional distress is a result of your secondary responses shame over having it I shouldn’t feel this way anxiety about being wrong you know maybe this is the wrong way to respond or you know what if I’m wrong about this or rage doing due to feeling judged for feeling that way I feel this way and you’re telling me I shouldn’t how dare you so mindfulness is kind of an exposure technique because it helps people identify that yes I feel that way but it helps them learn to step back and figure out how to not judge that and just go okay I feel that way better or worse whatever that’s how I feel exposure to intense emotions without negative consequences that non-judgmental acceptance just going all right is what extinguishes the secondary emotional responses of feeling guilty about it or feeling ashamed or angry at yourself for being angry so think of it this way if you can’t see this one’s the best Bruce Lee picture I could come up with scenario one is an unpleasant experience the person has an unpleasant emotion and then feels guilt shame or anger for feeling that an emotion so instead of having to deal with one emotion one-on-one now you’re having to fight for different unpleasant emotions and you start acting to try to stop the avalanche of negativity in the absence of adequate skills now Bruce Lee he was able to take out four or five at a time but most of us you know we would be beaten because all of these adversaries would be coming at us and we would be building on them in scenario two and this is where we want people to get they have an unpleasant experience which is part of life they identify unpleasant emotions again part of life is sucky but part but they can deal with one emotion they’re like okay I’m angry what do I do about it instead of I’m angry what do I do about it and I’m guilty and you see how you know she’s got this she can take that one emotion so what we’re helping people do is uncomplicated this regulation is common to many disorders people with dysregulated emotions have a stronger and longer-lasting response to stimuli yes they’re already kind of stressed out they’re already hyper-vigilant if you want to say they’re already wound up a little bit and then something happens and it amps for months now we have a scale of 1 to 5 if they’re already on a 4 and it amps them up 2 points they’ve fallen off the scale they’re in freefall so we need to understand that what we perceive as an excessive emotional reaction they may not have been starting from the same place that we were, we’re starting from a 1 if they’re starting from a 4 you know then their reaction to the same thing you seemed pretty reasonable emotional dysregulation is often punished or invalidated and increases hopelessness and isolation emotional regulation means we help people use mindfulness to be aware of and reduce their vulnerabilities so we help them take it so they’re not at a 4 there may be a 2 you know they’re in therapy for a reason we’re going to help them work on the other stuff and get them down to a 1 but right now let’s help them figure out ways, they can take down their stress response take down their just underlying anxiety, and stuff identify the function and reinforcers for current emotions when they happen was understand where they came from because they’re functional do that chaining worksheet check for facts ok now that I know how I feel I know what my reactions are I know what my thoughts are I know what my urges are let’s check the facts in the situation for and against that forces people to kind of step back which lets the urge sail out some and then problem-solves what can I do right now to improve the situation and what can I do in the future so I don’t necessarily experience this exact the same situation again how can I break that mold okay so emotion regulation doesn’t provide us with a whole lot of distress tolerance skills, emotion regulation is really about preventing vulnerabilities and helping people figure out okay here’s where I’m at how do I pause so then I can choose from my disgust distress tolerance problem-solving or interpersonal effectiveness skills but it’s a big step how awesome would it be if you could eliminate some of your vulnerabilities and think about it just for a minute or two what vulnerabilities you’ve got going on in you right now and how many of those you know could you potentially over the next week or two kinds of address sleeping and eating maybe you have 16 things going on and you could pare it down to eight there are a lot of different things that you might be able to kind of pull out of the rabbit hat if you will and what kind of a difference would it make if you’re talking to your staff and looked around at your organizational environment what vulnerabilities are there environmental vulnerabilities physical vulnerabilities my best friend’s working somewhere right now where pretty much everybody is required to work doubles because they are so short-staffed they’re going to start getting vulnerable pretty soon so look around what can you do to moderate that so they can model effective emotional regulation but they can also not be emotionally dysregulated by a client who has emotional dysregulation issues all right so that concludes our discussion today if you have any questions I would love to hear them if you want to discuss that’s awesome if you want to get on to your next client you know I totally understand that I want to wish everybody a happy Valentine’s Day for me I don’t particularly pay a lot of attention to Valentine’s Day but it is the eve before half-price chocolates and that is my kind of my kind a day you you you you if you enjoyed this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with dr.

Schneider I subscribing at all CEUs comm slash counselor toolbox this episode has been brought to you in part by all CEUs calm providing 24/7 multimedia continuing education and pre-certification training for counselors therapists and nurses since 2006 have used coupon code consular toolbox to get a 20% discount on your order this month.As found on YouTube Hi, My name is James Gordon 👻🗯 I’m going to share with you the system I used to permanently cure the depression that I struggled with for over 20 years. My approach is going to teach you how to get to the root of your struggle with depression, with NO drugs and NO expensive and endless therapy sessions. If you’re ready to get on the path to finally overcome your depression, I invite you to keep reading…

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