Learning Objectives After this training, participants should be - - PowerPoint PPT Presentation

DBTDistressToleranceSkills

AnnaHink,MSW,LICSW

ClinicianTrainer UWAIMSCenter

LearningObjectives

Afterthistraining,participantsshouldbeable to:

• DeterminewhentouseDBT’sDistress

Toleranceskillswithyourpatients

• ListtheDistressToleranceskills
• IntegratetheuseofDistressToleranceskills

intoyourpractice

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CaseExample:DS

54y/oHispanicwoman,liveswith husband,somecollege KeyComplaints “There’snothingIcandowhenI’m inpain;I’marguingwithmy husbandallthetime;I’mworried aboutcancerreturning” OUD.Stoppedopioidsx1week. Longstandinganxiety&depressive symptoms: BaselinePHQ9=10(mild) BaselineGAD7=15(moderate) BuprenorphineNaloxone248mg qd VenlafaxineXR275mgqd

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WhatIsACrisis?

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Aseriousproblemthat can’tbesolvedrightnow

Crisis

Thereispressuretosolve theproblem,anditis difficulttostoptrying Emotionsarehigh,sothe problemisdistressing

Highemotionsgenerally makethingsworse

It’sshortterm

Ifitishappeningallthetime, itisnotacrisis.Itisyourlife!

CanYouSolveTheCrisis?

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IfYes…

IfNo

(ornotright now)…

• STOP tryingtosolveit
• Tryingtosolvetheunsolvablecanmakeit

worseorsendemotionsthroughtheroof

• FocusonDistressTolerance skills
• Stickwithit
• Don’ttakeyoureyeofftheball
• Dowhatittakes!

DTskillsare designedjustfor anunsolved crisis

WhoAreDistressToleranceSkillsFor?

• Painflares
• Frustrationswithmedicalcare
• Intenseemotions
• Familyconflicts
• Housingissues
• Moneyissues
• Drugsandalcohol
• Dangerousneighborhoods
• Longwaitsforsocialservices
• Largecaseloads
• Difficultandsickpatients
• Hearingmanytraumaticstories
• Inabilitytohelptheirpatients
• Lackoftimeorresourcestohelp

theirpatients

• Frustratinginteractionswith

socialservices

• Unhelpfulrulesorregulations
• Paperwork

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Patients

facemanystressors

Clinicians

facemanystressors

PurposeofDistressToleranceSkills

• Helpyousurvivethecrisisbynotmakingthe

situationworse

• Notintendedtomakeyoufeelbetter(though

sometimesyoumight)

• Ifskillspreventthecrisisfromgettingworse,

butyoudonotfeelbetter don’tstop!

– Anescalatedcrisismaymakeyoufeelworse

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Waysto Worsen aCrisis

Yellingat someone Usingdrugsor alcohol “Retail therapy”with moneyyou can’taffordto spend Eatingtoo muchortoo little Complainingso muchfolks don’twantto talktoyou Givingupon life

BenefitsofDistressToleranceSkills

• Learntosurvivea

crisiswithout makingitworse

• Becomemore

confidentand capableof navigatingfuture crises

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DBTDistressTolerance:The4Steps

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Step1:

Behavioral Assessment

Step2:

MakethePitch

Step3:

Choose Strategy& Determine Homework

Step4:

Followup, Evaluateand ProblemSolve

Step1:BehavioralAssessment

AskThreeQuestions:

• 1. Whattriggersthedistress?

– Bebehavioral(i.e.,talkingwithafamilymember, thinkingathought)

2.Howdidthepatientrespondtodistress?

– Bebehavioral(i.e.,yelled/startedafight,stayedin bedallday) – Listenforhelpfulanddestructivebehaviors

3.Howdidtheirresponsemakethingsworse?

– Fromthepatient’sperspective(notyoursasthe provider)!

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Step1:BehavioralAssessment

RevisitingCaseExample DS

• 1. Triggers
• Intensebackpainflaresforhours
• Tendstooverdothingswhenfeelingbetter
• 2. Response
• Bedbound
• Doesnoteatorhydrate
• 3. WhatMadeitWorse
• “IfeelsoguiltyafterIyellatmyhusband.He’s

justtryingtohelp”

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• isolatesself
• yellsathusband

DBTDT:The4Steps

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Step1:

Behavioral Assessment

Step2:

MakethePitch

Step3:

Choose Strategy& Determine Homework

Step4:

Followup, Evaluateand ProblemSolve

Step2:MakethePitch

• Explaintheconceptofdistresstolerance

– “Theseareskillstohelpyouwith(1.triggers). You’vetoldmeyoutendto(2.response).”

• Explainthegoalofdistresstoleranceskills

– “Thegoalistonotmakethingsworse.Thisis verydifferentthan‘feelingbetter.’” – “DTskillshelpyoubringdownyouremotionsso youthinkmoreclearly.” – “You’vetoldmethingsareworsewhenyou(3. whatmadeitworse).”

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Step2:MakethePitch

RevisitingCaseExample DS

“Theseareskillstohelpyouwiththeintensepain flaresyouexperience.You’vetoldmeyoutendtoneed tostayinbedformanyhours,noteatordrinkwater, isolateyourselffromyourfamily,andyellatyour husband. Thegoalistonotmakethingsworse.Thisisvery differentthan‘feelingbetter.’DTskillshelpyoubring downyouremotionssoyouthinkmoreclearly.You’ve toldmethingsareworsewhenyouyellatyour husband.”

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DBTDT:The4Steps

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Step1:

Behavioral Assessment

Step2:

MakethePitch

Step3:

Choose Strategy& Determine Homework

Step4:

Followup, Evaluateand ProblemSolve

Step3:ChoosingStrategies

DistressToleranceskills

• Distract
• SelfSoothe
• IMPROVEtheMoment

Howtochooseastrategy

• Patientpreference
• Whathasworkedinthepast?

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Distract

• Distractionis

deliberately turningyour attentionaway fromthecrisis

– Remember:Wise MindACCEPTS

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Activities Contributing Comparisons

OppositeEmotions

PushingAway Thoughts

Sensations

SelfSoothing

• Howwouldyoucomfortalovedonegoing

throughacrisis?

– Dothesameforyourself!

• Don’tmakeasituationharderbybeingmore

uncomfortablethanrequired

– Forinstance,don’tweartightshoestothe dentist

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SelfSootheWithFiveSenses

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Vision

Decorateyourspace,gosomewhereinspiring Decorateyourspace,gosomewhereinspiring

Sound

Music,soothingvoices,naturesounds Music,soothingvoices,naturesounds

SelfSootheWithFiveSenses(cont’d)

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Smell

Cooking,lavender,thebeach Cooking,lavender,thebeach

Touch

Comfortableclothes,petanimal,footmassage Comfortableclothes,petanimal,footmassage

Taste

Favoritefood,hardcandy/mint,goodcupofcoffee Favoritefood,hardcandy/mint,goodcupofcoffee

Checkpoint

Thinkofatimewhenyouexperiencedacrisis atwork:

• Whatdistresstolerancestrategieshaveyou

used?

• Whatwastheimpactofusingtheskill?

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IMPROVE theMoment

• Strategiesfor

acceptingpain andreducing suffering

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Imagery Meaning Prayer Relaxation Onethinginthemoment Vacation Encouragement

Checkpoint

• Whatadditionalskill(s)wouldyouliketotry?

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Step3:ChoosingStrategies

RevisitingCaseExample DS

• Distraction:watch

movies,listentomusic

• Selfsoothe:sitina

comfortablechair

• IMPROVEthemoment:

minibreakfrom householdchores, spendingqualitytime withhusband, relaxation,deep breathing

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Isolatesself Bedbound Yellsathusband Doesnoteat Doesnotdrink

MakeaSpecificPlan

• Whenplanning,consider:

– Dateordaysoftheweek – Timeofday – Forhowlong? – Withwhom? – WhatisPlanB?

• Askpatient:

– Howlikelyareyoutodothis? – Whatwillyoudoifyoudon’tfeellikedoingit?

• Themoredetailedtheplan,themorelikelyitwill

befollowed

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DBTDT:The4Steps

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Step1:

Behavioral Assessment

Step2:

MakethePitch

Step3:

Choose Strategy& Determine Homework

Step4:

Followup, Evaluateand ProblemSolve

Step4:Followup,Evaluate,And ProblemSolve

• ALWAYSaskabouthomeworkatfollowup
• Expectpatientsmightnotdothehomework

– Whatbarriersstoppedthemfromdoingso?

• Donotjudge

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Step4:Followup,EvaluatetheOutcome andProblemSolveBarriers(cont’d)

• Iftheydon’t

tryDistress Tolerance, askthese three questions:

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Dotheyhavebuyintothe treatment? Didtheysimplyforget? Didtheydotheplan,butit didn’tmeetgoal?

StrategiesForAmbivalence:Pros& Cons

Pros Cons

Makingitworseby:

• _______________
• Toleratingdistressby:
• ________________
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RevisitingDSCaseExample:Intense PainFlare

Pros Cons

Makingitworseby:

• Stayinginbedand

isolating

• won’thavetobe

aroundothersand trytocontroltemper

• notbeingtherefor

husband

• notgettingsupportfrom
• thers
• life“onhold”

Toleratingdistressby:

• Distractingwith

activities,selfsoothing,

• rchoosingto

IMPROVEthemoment

• emotionmaygoin

thebackground

• qualitytimew/

husband

• lifecontinues
• maygetmorefrustrated
• ntopofhurting
• tempermaystillbean

issue

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TipsForDistressToleranceSkills

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Tip1:MatchSkillToLevelOfDistress

• MakesuretheDTskillchosenisappropriatefor the

intensityofthedistress

– Ifyouhavetheurgetodie,ironingisprobablynotgoing tohelp!

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Tip2:MatchSkillToSituation

• DistractingwithSensationsdoesn’tlastlong

– Ifcrisiscontinues,pairwithActivitiesor Contributing

• DistractingwithThoughtslastsforminutesto

maybeanhour

– Goodforthebus,traffic,staffmeetings,orthe lineattheDMV

• Takea“vacation”foraslongastimeallows

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Tip3:BeWaryofOverusingDTSkills

• Thiscanmakethingsworse

– Soothingbytasteisnotagoodchoiceifyoueat compulsivelyoraregainingweight – Takingtoomanyvacations =neglectingtasks – DistractingwithTVornovelscantakeoveryourlife

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Tip4:Don’tDistractWhenYouCan’t AvoidTheSituation

• Distractioncanseemliketheonlywaytocope

whenyoucan’tsolvetheproblem

• Sometimesyouneedtostaywiththecrisis

– e.g.,stayinginclass,atyourworksite,orwithyour childrenorclients

• RemembertoSelfSootheandIMPROVEthe

MomentasmuchasDistractinthesesituations

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DBTDTEducationalResources

• MarshaLinehan’s SkillsTrainingManualfor

TreatingBorderlinePersonalityDisorder

https://www.guilford.com/books/DBTSkills TrainingManual/Marsha Linehan/9781462516995/reviews

• Manyonlineresourcesandhandoutsby

searchingfor“DBTdistresstolerance”

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Acknowledgments

• KateComtois,PhD;CHAMMPUniversityofWashington
• StacyShawWelch,PhD;EvidencedBasedTreatmentCenters
• fSeattle
• UniversityofWashingtonAIMSCenter
• MentalHealthIntegrationProgram
• CommunityHealthPlanofWashington
• PublicHealth– Seattle&KingCounty
• WashingtonStateDepartmentofLabor&Industries

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