Four Winds Hospitals incorporateDialectical Behavior Therapy (DBT), a cognitive behavior therapy that integrates traditional CBT with dialectical philosophy and Eastern mindfulness practice, into our treatment for adolescents and adults. DBT is an evidence-based therapy that has proved effective in helping patients develop coping skills that reduce self-destructive behavior and maladaptive patterns of thinking. DBT presents a treatment model that is consistent with the increasingly focused, short-term nature of inpatient treatment. We have found DBT validating and empowering for both patients and team members, with patients leaving the hospital not only feeling better, but also more prepared.
DBT Mindfulness Skills Explained
Observe: Just notice the thoughts, feelings, urges, and sensations inside you. Or just observe your surroundings. It’s helpful to just notice these things without labeling or judging them in any way.
Describe: Now put words, or labels, on what you see and how you feel. This can be a powerful way to unglue actions from thoughts or feelings. For example, when you are salivating over that late-night McDonald’s commercial, saying “I’m experiencing an urge to eat junk food” helps you to remember that urges pass and that you don’t need to act on them. Describe objective facts only, and discriminate between facts and interpretations.
Participate: Throw yourself into whatever you are doing or experiencing in the moment, 100%. Have you ever lost track of time while you were deeply involved in a project? Ever played a pinball game, where you needed all of your focus on the ball? Ever laughed so hard that you forgot everything else? We’ve all experienced moments of 100% participation in our lives…they often feel wonderful, and they are the times when we are most truly alive.
Non-judgmentally: Do your best to let go of judging experiences, people, etc., as either “good” or “bad.” Do your best to let go of judging yourself. Try catching how often you make judgments and keeping count.
Mindfully: In the moment. Try to do just one thing at a time. Multitasking is the opposite of acting mindfully. Moments when you are on “automatic pilot” are times when you are only half living.
Effectiveness: When you focus on describing how a situation actually is vs. your interpretation of the situation (or your wishes about how the situation ought to be), you can learn how to do what works rather than get stuck in wanting to be right. This skill is about letting go of your ego, loosening up on rigid ideas of what should happen, “giving a little” and keeping your larger objectives in mind at all times.
How to Use DBT Skills
Deep breathing – Take slow deep breaths and think only of the breath and how your body feels as you breathe in and out slowly.
Validation – Try to understand the other person’s point of view and let them know that you get how they feel.This helps to calm the other person.Telling them to “calm down” does not help.
Opposite Action – Think about what you feel like doing because of your current emotion.What is your action urge?Now do the opposite (i.e, if you are angry and feel like shouting, smile instead; if you feel like isolating, get involved in an activity with others)
GIVE – If it matters to you what the other person thinks of you then: speak Gently, act Interested, Validate, and use an Easy manner.
Wise Mind – This is the combination of Emotion Mind and Reasonable Mind. Recognize how you are feeling, think of what seems reasonable and let your Wise Mind tell you what to do.
Radical Acceptance – Recognize what you cannot change at this moment and turn your mind towards accepting it until a change can be made.
Staying in the moment – Bring your mind away from past pain and future worry to just this moment. Stay there by reminding yourself and using your five senses.
3-2-1 – This skill is about distraction. Focus on 3 things you see, 3 things you physically feel and 3 things you hear, then 2 things you see, hear and feel and then 1 thing you see, hear and feel.Give each thing your full attention.
The Color Game – This is another distraction skill. Look around and name everything that is green, then everything that is red, then yellow etc. Give each thing your full attention.
Walk the Middle Path –Recognize that there are two sides to every issue and each side has some truth to it. Try to see the “kernel of truth” in the other person’s position and validate that truth even if you do not agree.This opens up the ability to communicate without getting into an argument.
Glossary of Common DBT Terms
Behavioral Chain Analysis: Also known as a BA, a process of analyzing problematic behavior in order to understand a) the triggers, b) the consequences of the behaviors, c) additional factors that might cause a child to be more at risk for acting out, e.g., lack of sleep on the day of the problem behavior, and d) alternative ways to cope with the trigger. At Four Winds Hospital, teens are asked to complete a BA worksheet whenever they engage in problem behaviors. A copy is included in this packet.
Cope Ahead: A skill that involves planning ahead when a child anticipates that he or she might be at risk for problem behaviors. Teens participate in Cope Ahead groups to plan supports and strategies to manage problems they expect to arise on the weekends. Teens fill out a worksheet called the Crisis/Relapse Prevention Plan, which can be found in this packet.
DBT: Dialectical Behavior Therapy, a cognitive-behavioral therapy that incorporates additional concepts such as mindfulness and dialectical thinking.
Dialectics: The notion that truth is constructed based on many viewpoints, and that multiple truths can coexist.
Diary Card: A self-monitoring tool that is completed daily to track ratings of symptoms, coping skills, and other items of interest. Diary cards vary according to DBT programs, but generally include ratings of mood, suicidal urges, medication use, and coping skill use. At Partial, our Diary Card includes ratings of positive feelings, somatic complaints, sleep disturbance, and more.
DEAR MAN: An Interpersonal Effectiveness skill (see packet for detailed explanation).
Distress Tolerance Skills: A set of DBT coping skills used to get through a crisis situation without emotionally acting out and making the crisis worse.
Emotion Mind: A (generally undesirable) state of mind where feelings govern behavior.
Emotion Regulation Skills: A set of DBT coping skills aimed at decreasing negative emotions and increasing positive ones.
Mindfulness: The practice of being aware of one’s inner emotional state and/or immediate surroundings. Mindful attention is focused on the present rather than in the past or the future, and the aim is to observe without judging or trying to “fix” what one notices.
Interpersonal Effectiveness Skills: A set of DBT coping skills aimed at negotiating with others to achieve objectives without sacrificing personal values or damaging relationships.
Radical Acceptance: A coping skill from the Distress Tolerance category of skills taught in DBT. Radical Acceptance is a method of wholeheartedly accepting a situation that cannot be changed in order to eliminate unnecessary suffering and to move forward in positive ways. “Making lemonade out of lemons” is a common saying that captures the essence of Radical Acceptance.
Opposite Action: A coping skill from the Emotion Regulation category of skills taught in DBT. Opposite Action requires acknowledging an emotion, identifying the action urge that accompanies that emotion, and strategically choosing to perform the opposite behavior in order to reduce the emotion. For example, if a man is afraid of a harmless garter snake, he will feel the urge to avoid the snake. His avoidance will lead to continued fear of snakes. Using Opposite Action, the man might approach the garter snake and possibly handle it. Since the snake is harmless, his fear will decrease, and possibly disappear altogether. The same principle holds true for many other emotions, including depression, anger, and shame.
Reasonable Mind: A state of mind where logic, intellect, and rationality govern behavior. Although this would seem to be a desirable state at first glance, it leads to problems when teens ignore their emotions. Teens are encouraged to incorporate emotions and rationality in their approach to problem-solving (see Wise Mind, below).
Skills Coaching: A process whereby a therapist, parent, or peer assists a teen to apply DBT skills to his or her own life in the moment. Outpatient DBT programs have a skills coaching hotline after hours, which teens can call in order to resist engaging in problem behaviors.
Synthesis: The idea that two opposing views and needs can coexist, both be valid, and both be satisfied without the need for compromise. Arriving at a synthesis generally takes understanding the most important needs for each party and creative problem-solving to accommodate the needs of both.
Target Behavior: Identified problem behavior that is currently interfering with a teen’s function. Teens are encouraged to choose one problem behavior at a time, and focus on overcoming it before moving on to another problem.
Target Hierarchy: DBT advocates prioritizing problem behaviors and addressing them in the order of priority. For example, the first target is always life-threatening or self-injurious behavior in DBT.
Three Stage Process of Learning Skills (Acquisition, Practice, Generalization): Skills must be taught in group and individual settings, but the process doesn’t stop there. Teens must practice the skills in the Partial setting, and then learn to take their treatment home, or generalize their new behaviors to the settings where skills are needed most.
Urge Surfing: A technique to resist self-destructive urges, using mindfulness skills.
Validation: The act of showing another person that they are truly being listened to and understood, without judgment. Validation involves the premise that everyone is doing the best he or she can in order to cope with problems, in the best way that he or she knows how to cope.
Walking the Middle Path: A module developed specifically for teens to teach dialectics (see Dialectics in this glossary). Teens are encouraged to welcome and accommodate seemingly incompatible truths, e.g., the need to accept oneself and the need to make changes in one’s life. Teens are taught validation skills (see Validation in this glossary), empathy, and behavioral principles. This module is often helpful in resolving conflicts between teens and parents.
Willfulness: Resistance, or getting stuck in one’s own position. Difficulty adapting to changes in the demands of a situation. Refusing to accept reality of a situation or the need for change, and the propensity to cling to what one wishes was true.
Willingness: The ability to open oneself to suggestions, acceptance of change. The ability to do what works in a situation, and to flexibly try different strategies when the initial strategies are ineffective.
Wise Mind: A balanced, centered state of mind where one relies on both reason and emotion to make choices. Wise mind has been described as an intuitive state of deep knowing. Wise mind can only be reached when emotions are regulated.
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