Transcript for:
Understanding Dialectical Behavior Therapy (DBT)

hi my name is gloria scott and i'm a nurse at the johns hopkins hospital on the child and adolescent psychiatric unit and i want to talk to you about dialectical behavior therapy i'm hoping that after this presentation that you're able to understand the concepts of dialectical behavior therapy or dbt and be able to use these skills to care for yourself and support your child what is dbt dbt is a treatment that was designed for people who have intense emotions and difficulty managing them but really they're great skills for everyone in life it helps to replace problem behavior so things like running away avoiding things substance abuse cutting with more skillful behaviors we don't want to tell you to just stop cutting we give behaviors to use in its place it helps people experience a range of emotions without necessarily acting on them it helps people navigate relationships and improve their communication with others and the overall goal is to help people create a life worth living what dialectical means is that two opposite ideas can both be true at the same time and we're going to talk about that a little bit later in the presentation the areas the dbt focuses on are mindfulness skills emotion regulation distress tolerance interpersonal effectiveness or communication and walking the middle path there are some basic assumptions with dbt first people are doing the best they can and that really helps you not to judge others and not to judge yourself realizing everybody has different strengths abilities knowledge and you just do the best that you can at that time people want to improve people need to do better try harder and be motivated to change people may not have caused all of their own problems and they have to solve them anyway there's no absolute truth there's no only one answer or one day way to do things and you cannot fail with dbt we're going to give you a lot of skills and a lot of things that can help you and we just hope that something is something meets your needs and can be helpful to you in your life we talk about our three states of mind you have your reasonable mind that's based on facts logic research statistics you have your emotional mind that's all about your feelings and urges and then you have your wise mind and that's where the facts and logic meet your emotions and is a great place to be when you're trying to make important decisions it's also a good place to be when you're trying to make important decisions as a parent if you're talking to your child with just your reasonable mind and you're telling them all about the statistics and why they shouldn't do things it's probably going to go in one ear and out the other but if you can address their emotional needs at the same time they're more likely to hear you also with just parenting in your emotional mind if you are really angry or frustrated you may say or do things that could be hurtful so you want to try to get yourself to your wise mind you may need to take a little time a little space until you can be focused and get there and you may think how do you get to this wise mind and that's when we're going to talk about mindfulness mindfulness is bringing your full attention to one thing in that moment it's being aware of what's going on without judging it or trying to change it and you can do anything mindfully you can eat mindfully walk mindfully breathe mindfully anything you do if you bring your full attention to it you can do it mindfully what i like to do is in the morning i go outside to let the dog out and i just stand on the deck with my eyes closed and i listen to all the birds i listen to all the different bird sounds around and then after a few minutes the dog comes up i open my eyes and go in and start the day and it just has my mind feeling clearer and when you're doing that it also helps to create new pathways in your brain so that you can get to those that clarity when you need to i think about my head as a snow globe and when there's so much going on it's like a snow globe shaken up and all of that snow around it and then with doing some mindfulness activities it helps us know to settle and you can clearly see what's there it really does help you to have a clear head to be able to make important decisions and focus your attention when you need to next we're going to talk about emotions and you may wonder what good are emotions but they give us information they motivate us to act they let you know when things are good or bad or dangerous and then you act accordingly but it's important to know that emotions are feelings they're not facts and sometimes you need to check the facts in a situation i think about it like wires getting crossed and sometimes past experiences can really cause those wires to be crossed an example of this is my daughter she had moved out of state was living there alone and one day she called me terrified and this is a child who's very very um responsible and independent so she called me and she was terrified and a bullet had come through her apartment wall so she was hiding in the shower calling me crying calling the police and it was a very traumatic event for her so it ended up that it was just someone in the next apartment getting their gun to go out to a shooting range and it went off but you know it really affected her so time goes on i didn't think anything more of it and one day she calls me and she says mom you're going to think i'm crazy but i think someone's coming in my apartment when i'm not home and she was coming home from work every day and she was checking in her shower and checking the closets and making sure nobody was in her apartment and that seems to be that event seemed to have caused those wires to get crossed so i helped her to figure out what are the facts and what are the feelings and just did a simple little thing i got her a video camera that was motion activated so if there would be any movement in her apartment when she wasn't there it would send her a video and every day she'd get a little video of her walking in the front door and that was the only movement so that's how i helped her find the facts and separate that from the feelings and sometimes you just have to be creative in supporting your children or other people or even with yourself it's important that we keep our emotions regulated because emotions can often get intense and difficulty controlling these and managing them can lead to problematic behaviors so we're going to talk about some ways to keep them regulated and we use this acronym abc please and the abc are ways to increase your positive emotions and the pleas are ways to decrease your vulnerability to your emotional mind so a is accumulating positive experiences so when you have so many things that are stressful or negative and you don't have any positive things to balance that out life becomes overwhelming to you and thinking about the world right now with covid kids are home they're doing schooling from home sometimes their parents are working from home or maybe out of work and there's just a lot going on and they don't have any outlets for this so if they were at school and they were having a tough day at the end of the school day they may be walking home with their friends talking laughing having a good time and that's bringing balance so you need to do some things to balance out these negative experiences and when you're doing them enjoy them for what they are because if you are trying to go out and you know take a walk with your husband to have some you know a nice break and enjoy yourself but you're talking about all the stressful things at home you're not going to have the benefit of that positive experience so you want to do some fun things you want to enjoy them for what they are and let the worries go during that time one parent compared it to me like a checking account she said you can only take have so many withdrawals before you have to have some deposits so i think that that's a good way to remember these positive experiences that are necessary next is building mastery and building mastery is breaking things down into small steps it's gradually increasing difficulty pushing yourself just outside of your comfort zone so that you can feel successful and confident and then move a little bit further and further an example of this was on our unit um one year that the nurses decided to run a 5k race and they didn't go out and let's everyone say oh we're going to go out and run 5k today and get ready for this race they went out they ran a half a mile they ran a mile they went to spin class and they continued to build and build and build until the day of the race and everyone was able to finish it so you want to build mastery take things in small steps and c is coping ahead of time and that is where you look at a stressful situation or an event that's causing some negative emotions and decide how you're going to manage it put a plan in place on how to deal with it so one day my daughter the other daughter had moved to texas and she moved there because her boyfriend had gotten a job so she was there for a little while they were going to a big family party of his and she was really nervous and extremely nervous and i said to her hey what has you so worried about this party i think you know it'd be nice to meet everyone they're going to be excited for you you guys are getting married this is going to be really fun and she said i haven't found a job yet and i don't know what to say to people when they say to me what do you do do i say i clean the apartment i cook meals i don't know what to say and that had her so stressed that she really couldn't relax and be able to get ready this ready for this party so we talked about it we talked about what she did before she moved what kind of job she was looking for and once she had a response in place she felt much more comfortable and it brought her anxiety down about 70 percent still kind of anxious but um about 70 and she was able to relax and go so we go back to this abc please and now we're going to talk about the please portion and that's where you're reducing your vulnerability to your emotional mind and what that means is you're taking care of your body because you know when you're tired you're hungry you don't feel well your emotions can intensify you can be a little extreme in your responses to things so it is treating physical illness balanced eating avoiding mood altering drugs getting sleep and exercise and as far as balance eating goes you want to have things that give you a steady energy you want to have complex carbohydrates whole grains sweet potatoes proteins dairies fruits and vegetables they'll give you a steady energy through the day you want to avoid things like sodas and sugary snacks that are going to make you feel tired and irritable heavy fatty foods that can make you feel sluggish caffeine that can make you jittery or interfere with your sleep you also want to have balanced sleep and with in order to have balance sleep some things that might be helpful are sticking to a schedule having a bedtime routine avoiding caffeine and nicotine you know keeping your room cool dark quiet avoiding screens at bedtime avoiding naps maybe a hot shower or bath before bed and then the last one that i have here is don't catastrophize and that is the one that's the biggest to me because if i'm having something big going on the next day or i'm going to be working a long day and i'm having trouble falling asleep i start thinking about it and i think oh my gosh how am i going to get through this tomorrow and it just starts running and running through my head and then i feel like i can never get to sleep so i've had to teach myself to start talking myself through it and saying you know what i've done this before i've gotten through it and i'll get through this again tomorrow and that just kind of lets my head clear and settle down a little bit and fall asleep we're going to talk about distress tolerance and if you think about distressing feelings being like waves they come in intensely but they will ease up and go back so we want to talk about some ways to get through that intense period and it's important to remember that pain is part of life and can't always be avoided so you need to learn how to deal with it and get through those periods without acting impulsively and hurting yourself or someone else so first we're going to talk about some ways just to soothe using your senses and these are all things that we tell to teach the basic patients on the unit that they can use when they're having some distress so vision i like to look at the sky the sunrise the sunset the clouds the rain everything about the sky the moon the stars you know that to me is relaxing and soothing hearing i already told you i like the birds in the morning but listening to all the sounds of nature the wind chimes outside listening to music or sound machines smell maybe just a nice scented candle or lotion taste whatever you find relaxing a cup of tea or hot chocolate touch i mean you get a massage but you can also just brush your hair put some lotion on or movement rocking yourself yoga dancing taking a walk a run so these are just some things to relax yourself if you're starting to feel your tension build next we talk about ways to distract yourself using your wise mind accepts we call them and in dbt everything has an acronym so these are your accepts first activity do something just keep yourself busy for a while it might be cooking or yard work or doing a puzzle anything to keep yourself distracted and busy for a while contributing when you do something nice for someone else it always makes you feel better inside so in our unit we adopt a family at christmas time and you know that day we get gifts for all of the kids and we go out and deliver the gifts and it's such a great day and we feel so good inside and you know everybody's in a good mood that day and we're singing christmas songs and we all feel really good so when you're doing something for someone else it feels really good it doesn't have to be anything that big you can just you know pay for the next person's coffee in line at starbucks you know then they get a nice surprise and feel good and you feel good that you've just done something so those little things can make you feel good inside comparison comparison does not mean saying to your child look at all the things that you have you have a good parents and nice clothes and you go to a good school why can't you be happy look at that boy down the street he doesn't even have feet and he still smiles comparison is putting it in perspective for yourself it's thinking about other situations and just putting your life in perspective so when there was one christmas that my daughter wasn't coming home for the first time and it was going to be our first christmas without both kids home in the morning and a few days before christmas i started thinking about it and i started feeling really sad like oh what are we going to do without her who's her sister going to argue with do do we open all her gifts do we do it on zoom or should we just wait for her to come home and it just started making me feel sad and then i thought about my friend and my friend who lost her son and i thought you know what he will never come home and my daughter's coming home the next day i can do this another way to use comparison is just think about another time that it was a difficult time for you and you got through it and realizing if you were able to get through that you can get through this but remember comparison is only about yourself you shouldn't be comparing saying it to other people create a different emotion you can change your emotions by doing something different so if you're feeling kind of sad listening to some upbeat music or watching a funny show if you're feeling irritable do something nice for someone just do the opposite of how you're feeling pushing away sometimes you have to just say you know what i got a lot going on i can't really deal with that i have to put a wall up for a little bit and block that off you know if i was coming in to make this video today and i just argued with one of my children i wouldn't have time to think about that i'd have to just block it off and say you know i'll deal with that later thoughts replace your thoughts do something else that's going to take your full attention i like to do like a word search sudoku putting a puzzle together something that's going to take your full attention or intensifying other sensations maybe a hot shower cold shower holding ice intense exercise those are some things you can do to distract yourself when those intense feelings and emotions are beginning to build some other things that we have are ways to improve the moment and we use imagery imagery i like to think of is seeing myself where i want to be so i'm working to lose weight and instead of seeing all the things that i shouldn't be eating i see myself running around with my grandchild looking and feeling the way i want to feel i remember when i learned to drive the driving instructor saying to me whatever you look at is the direction your car is going to go so if you're looking off to the side your car is going to the side and that's how i think of imagery meaning find meaning in a situation how can you use this situation to help you somewhere in the future what are going to be the benefits you know how can this be useful using prayer if you need to praying for guidance and support to get through this tough time relaxation doing some different relaxation exercises maybe progressive muscle relaxation or listening to a relaxation video one thing in the moment that's kind of like a mindfulness activity like i said on the other one you know word search something like that or just you know watching your breathing and focusing on that vacation doesn't mean you have to go to the beach sometimes it's just taking a walk if it's a busy day i enjoy just walking off the unit and sitting outside for some fresh air you're just kind of taking a little break from things or encouragement cheering yourself on you can do this you can get through it those are things that we can do as we feel those distressing feelings build if you but you need to do them early as soon as you feel a building if it's gotten to a point where it's really gotten extreme we have some tips for that too and t is temperature cold water on your face or ice can start to calm your body down and bring your heart rate down and start to make you feel a little bit calmer and many times i'll just say to the kids at work just go splash some water on your face a few minutes and they do come back a little calmer and then we can talk intense exercise 10 or 15 minutes of hard exercise can get that extra energy and stress out pace breathing just slowing your breathing down for a few minutes i also will do that at work with the kids just say just breathe with me and i slow my breathing down and they'll do that with me or progressive muscle relaxation just starting at your head or your toes and squeezing each muscle group holding it letting it go and then moving on to the next so those are some things that you can do as these emotions become too intense and distressing the next thing i wanted to talk about is accepting reality so i know that we talk about ways to manage these distressing feelings but it's important to realize that some things can't change so when you have a difficult situation or a serious problem there's five ways you can respond you can figure out how to solve the problem you can change how you feel about it you can choose to accept it and it doesn't mean that you like it or you're happy with it but that you don't want it to eat away at you you don't want it to ruin your day you want to be able to just move on you can use no skill and stay miserable or you can make things worse by acting on your impulsive urges so i'll give you an example my daughter was getting married i know i give a lot of examples about my family so they're probably going to love it when they watch this but she was getting married and it was the week of the wedding and she was home and she was talking about the rehearsal dinner that was coming up and she was getting really stressed about it and really anxious because it was getting to be larger and larger and they were going to be a lot of people there and she was saying you know i was thinking in my head something low-key the night before my wedding just very relaxing with a few of the closest people and now it's getting bigger and bigger and it's going to be this big deal and i said i know but it's not going to change it would be nice if you could just let it go and move on things aren't going to change she said i know i'm trying but i'm really struggling with this and i said or you could look at it differently you can realize that all of those people will be there the night before your wedding you'll get a chance to talk to them and then the next day on your wedding day you don't have to again you can just say hi good to see you again and then move on to the dance floor you've already talked to all those people she's like oh my gosh mom you're right and she was able to think about it that way and really it ended up being wonderful but accepting reality it's about accepting things as they are not fighting reality it's the opposite of saying why me and realize things are as they are and life can be worth living even with painful events in it next i want to talk about dialectical thinking dialectics and that's when we say that two opposite things can both be true at the same time and if you look at this picture here how deep is the mud it depends on who you ask we all experience the same things differently both of those dogs would have a completely different response on how deep that mud is and that just shows that everyone's perspective is their truth whatever you're coming to the table with your strengths weaknesses skills knowledge that's how you're going to see a situation and thinking dialectically it helps you to realize there's more than one way to see a situation or solve a problem it helps you look at all points of view or all sides of a problem it helps you to remember that everyone has unique qualities and everyone's opinion can be valid you want to find the truth on both sides of a conflict so i do remember one time when my daughter was a teenager i went to pick her up from her friend's house and it was 11 o'clock like i did every night in the summer and one night i went to pick her up and she said i hate that you have to pick me up at 11 o'clock every night i don't know why i have to have this roll 11 o'clock eleven o'clock nothing is different after eleven than before nothing is happening that's dangerous we're just in someone's house but eleven o'clock i have to have this rule and i believe that she was right nothing bad was happening after eleven nothing different did happen and i said to her well i understand but i have to pick you up and i'm tired i want to go to bed and she said oh i didn't realize that was the reason and i said well it is i do believe you that nothing bad happens but i do need to go to bed so if it was a night i was going to stay up and watch the news or saturday live or she had something really fun she was doing that night she could stay a little longer but when i picked her up she didn't say anything anymore at 11. so we were both able to realize that each of us and each of our points of view were true so by thinking dialectically can help you expand your thoughts and ways of considering situations it helps unstick standoffs and conflicts helps you become more flexible and approachable and it helps you to avoid assumptions and blaming others next we're going to talk about validation and to me validation is the most important thing you can do to support your child it's the one thing that has had the biggest impact on my life and helped me with my relationships it communicates to other people that their thoughts their feelings and sometimes their actions make sense and you're not judging them for them doesn't necessarily mean that you agree with everything but that you do understand where they're coming from one thing that's really important is it must be sincere and you can validate people's feelings without validating their action so if your child's really angry at you because you didn't let them go to some party because you knew people were going to be drinking and doing drugs there and they're angry and they're tearing up their room you can validate their anger you can tell them that you understand that they're angry because they can't do something they really wanted to do you know that you understand being a teenager and this is going to be a would be something that's hard for them to accept without validating the behaviors validation can really bring down the intensity of a situation so one time on the unit we had a patient who had been there for a really long time and she wasn't going back home she was going to a different placement it was hard for her and other patients were coming and leaving and coming and leaving and this one day she was having a horrible horrible day and she was doing everything that was destructive to herself to the unit and to us and all we wanted to do was help her to not feel bad we'd say do you want a cup of tea do you want to take a walk do you want to listen to some music do you want to play cards do you want to do you want do you want and all we wanted to do was take away her pain and make her feel better so i stopped and thought because nothing was working and i thought well of course she's angry and of course she's frustrated and she's scared there's a lot going on and we've never validated those feelings you don't have to take someone's feelings away sometimes you can just validate them so i sat down next to her and i said she said miss gloria i don't even want to hear what you have to say and i said well i'm going to talk anyhow because that's what i do and i said you're having a really tough day and i understand this is hard a lot's going on and this is scary and it makes sense that you're having a tough time and it's okay you know we're not here to judge you we're just here to support you and if there's anything we can do we are here for you and that was all i said and she stopped and she cried and cried and cried and moved on so sometimes you just need to tell people that you understand their feelings think about if you're having a tough time and you don't want to come home and hear why you shouldn't be feeling that way or people to try to take your feelings away you know sometimes it's just important for people to acknowledge those feelings this graph here shows an experiment that was done with adults and it was two groups of adults and they were monitoring their body's response to stress as they were giving them these difficult problems to solve and with both groups they're giving them the problems to solve and their body's response to stress goes up up up up up the first group they validate they said we know these are hard it makes sense that you're struggling just continue to do your best and continue to give them these problems to solve and their body's response to stress comes down like this the second group they didn't say anything just continued to give them the problems and their body's response to stress stayed up here so just the act of validation brought the stress level down to this point and when you're down here you can often think clearly and problem-solve up here it's really difficult so just validation had that much impact on someone so by validating people you can really improve relationships and improve communication i think it's the one thing that you're going to be able to do to improve communication with your child and like i said it can de-escalate conflicts and intense emotions i have a little um clip here from a book an audio book how to list how to talk so little children will listen and i want to play it but it's meant to be a little funny but it's a woman going to work and she works at a daycare center and she doesn't feel well it doesn't feel like going to work at this time and she runs into a co-worker while she stops for coffee and it's a conversation and i think it's some of the things that we say to our children and it just shows you how it sounds you can feel a headache coming on you stop to get some coffee before going to work at the preschool and run into a co-worker you say to her boy i don't want to go into work today and face all those loud quarrelsome kids i just want to go back home take some tylenol and spend the day in bed what would your reaction be if your friend denied your feelings and scolded you for your lousy attitude hey stop complaining the kids aren't that bad you shouldn't talk about them that way anyway you know you'll have a good time once you get there come on let me see that smile or gave you some advice look you've got to pull yourself together you know you need this job what you should do is get rid of that coffee drink some soothing herbal tea and meditate in the car before school starts or perhaps a gentle philosophical lecture hey no job is perfect that's just life there's no use complaining about it dwelling on the negative is not productive how about if she compared you with another teacher look at liz she's always cheerful about going to work and do you know why because she is ultra prepared she always has really great lesson plans ready weeks ahead of time what questions be helpful are you getting enough sleep what time did you get to bed last night do you think you might be getting a cold are you taking vitamin c have you been using those sani wipes they have available at the school so you won't catch germs from the kids here are some of the reactions we get when we present this kind of scenario in our group i'm never talking to you again this is no friend of mine you have no clue i hate you go to hell blah blah blah shut up i'll never talk to you about my problems again i'm sticking to topics like the weather from now on i feel guilty for making such a big deal about this i wonder why i can't handle the kids i feel pitiful i hate liz i feel like i'm being interrogated i feel judged you must think i'm stupid i can't say it out loud but i'll tell you the initials f you that last response perfectly expresses the intensity of hostility that we sometimes experience when someone denies our negative feelings we can go quickly from unhappiness to rage when talked to this way and so can our children so what would be helpful to hear in a situation like this my guess is that some of your misery would be soothed if someone simply acknowledged and accepted your feelings oh it's awful to have to go to work when you don't feel well especially when you work with kids what we need is a nice snowstorm or maybe a very small hurricane that would shut the school down for just one day when their feelings are acknowledged people feel relieved so i know that it was meant to be a little funny but i do think that we say things like that to our kids and it really is going to kind of cut down on the communication with them nobody wants to talk to someone about their problems when they get those responses another thing i think we do as parents is we try to we don't want our kids to feel bad so we don't want them to have these negative or sad feelings or angry feelings so we try to convince them to why they shouldn't so if they come home and they've just had a breakup with a boy and you say things like you know what he was no good for you anyhow i'm glad he's gone you're going to meet someone so much better well nobody wants to hear that you know it's not going to make them feel any better you just have to acknowledge their feelings sometimes it's just important to say you know what that sucks i'm sorry you went through that you know that sounds like it was tough or if they've had a bad day so really validating and acknowledging their feelings can improve your communication with your child and your relationship with them it does show them that we're listening and we understand we're not judging and we care about the relationship so it has been the one thing that's had the biggest impact on relationships and supporting people of all of the things that i have learned in dbt my other one that was really helpful to me was dialectical thinking because i struggled with that as well i used to feel like if i thought something if it made sense to me i couldn't understand why people didn't see it that way and didn't want to do it that way i really had no concept of dialectical thinking of two things being true so those were the two things that i have found the most benefit from in dbt i think that everybody will just walk away with you know taking away from here what is the most helpful to you that's why i go over so many different things you can find where you have a deficit or a weakness where you can benefit from some of these skills so i just put some resources in here some things that i have found helpful there's some apps there's an app called calm and headspace and they really have a lot of meditation relaxation exercises sound machines a lot of things that you may find useful we use them sometimes with the kids on the unit if they're stressed we may put a short meditation one you can just pick three minutes five minutes whatever you want there are some books that have been really helpful parenting a teen who has intense emotions by pat harvey and parenting a child who has intense emotions also by pat harvey and they both talk about these dbt skills and how you can apply them to your life and then the next book is how to talk so kids will listen and listen so kids will talk and that was by the same author that had that little blurb on the person going to school but it just gives you some different ways of looking at things a different perspective also there is some websites behavioral tech which is a line of hand institute training company and that was developed by the person who developed dbt uh marsha linehan and there's a lot of resources for dbt there and on social media there's a few groups that i follow one is trauma-informed parent and the other is big little feelings and they just have some good insight and some nice things to look at so i hope you've enjoyed this presentation and can find some of these skills useful to support yourself and your family thank you