DBT and Addiction Care
Phil Bender-Stone LCSW
Direct: 303-467-4993
Office: 303-467-4000
Email: benderpj@exempla.org

What is DBT?
• Learning to Balance Dialectics in Life
• Created to serve Borderline Personality Disorder
• Designed for Outpatient setting: Group &
Individual Sessions
• Evidenced Based and Effective
• Made up of Skills in hundreds of acronyms
• Behaviorism + Validation

What are Dialectics?
Dialectics are the art of:
• holding 2 or more things in balance that are in conflict, contrary or mismatched and yet they are both real and true
• It is about synthesizing things that seem to be in opposition

What are Dialectics?
Dialectics are the art of balancing:
Wants and Needs
Feelings and Thoughts
Problems and Solutions
Contemplation and Action
Recreation and Responsibilities
Being Right and Making Mistakes
Self-Interest and Interest in Others
Skill Enhancements and Self-Acceptance
Problem Solving Alone and Being Able to Ask for Help

Walking the
Middle Path
Hints for thinking and acting dialectically:
• Move away from “either-or” thinking to “both-and” thinking. Avoid extreme works: like Always , Never , You make me . Be descriptive.
• Example: Instead of saying “Everyone always treats me unfairly,” say, “Sometimes I am treated fairly and other times I am treated unfairly”
• Practice looking at all sides of a situation / all points of view. Find the kernel of truth in every side.
• Remember: No one has the absolute truth. Be open to alternatives.
• Use “I feel…” statements, instead of “You are…,” “You should…,” or
“That’s just the way it is” statements.

Walking the
Middle Path
Hints for thinking and acting dialectically:
• Accept that different opinions can be valid, even if you do not agree with them (“I can see your point of view, even though I do not agree with it”).
• Do not assume that you know what others are thinking; check your assumptions (what did you mean when you said…?”)
• Do not expect others to know what you are thinking (“What I am trying to say is…”).

Assumptions in DBT:
From the Client’s perspective
Marsha Linehan Treatment of the Borderline Personality Disorder
• We are doing the best we can
• We want to improve
• We need to do better, try harder, be more motivated for change
• We may not have caused all of our problems, but we have to solve them anyway
• Our lives are unbearable as they are currently being lived
• We must learn new behaviors in all relevant contexts
• We cannot fail in therapy
• You (the therapist) treating the borderline patient will need support

The Role of Therapist
• The Therapist is a Skills Trainer
• More Teaching Little to No Processing
• A Highly skilled Behaviorist-Shaping behavior, reinforcing positive, extinguishing negative
• Acting from Wise Mind: Observe, Describe, Participate,
Non-Judgmental, One-mindful, Effective (Focus on what works)
• Observe Limits without judgment or fear from others
• Search for non-pejorative, non-judgmental, empathic ways to describe patient’s behavior
• IRREVERANT-use confrontation, humor, sharp wit to get through to your clients (paradoxical techniques)
• Accept that all therapists are fallible

DBT Group Format
• CHECK-IN USING DIARY CARDS
• MINDFULNESS PRACTICE
• TEACHING SECTION
• EXPERIENTIAL / ROLE-PLAY
• AT WEST PINES: IOP FORMAT
• ALSO: STRUCTURED CLINICAL
SUPERVISION

DBT: Core Mindfulness
States of Mind

REASONABLE /
RATIONAL MIND
IS:
COOL
RATIONAL
TASK-FOCUSED
WHEN IN
REASONABLE MIND
YOU ARE RULED BY
FACTS
REASON
LOGIC
PRAGMATICS.
VALUES AND
FEELINGS ARE NOT
IMPORTANT
DBT: States of Mind
WISE MIND IS:
THE WISDOM WITHIN EACH PERSON
SEEING VALUE OF BOTH
REASON AND EMOTION
BRINGING THE LEFT BRAIN
AND THE RIGHT BRAIN TOGETHER
- THE MIDDLE PATH -
EMOTION MIND IS:
HOT
MOOD-DEPENDENT
EMOTION-FOCUSED
WHEN IN EMOTION
MIND YOU ARE
RULED BY YOUR
MOODS
FEELINGS
& URGES TO DO
OR SAY THINGS.
FACTS, REASON,
AND LOGIC ARE
NOT IMPORTANT.

Core Mindfulness
Emotion Mind
Words or Characteristics that define
• Relating
• Empathetic
• Creative
• Passionate
• Values/Convictions
• “Being able to feel”
• Urges and Drives
• Unpredictable
• Impulsive
• Reactive
• Others?

Emotion Mind Examples
Charlie Sheen:
Winning!
Chris Farley living in a VAN
DOWN BY
THE RIVER!!!
Tom
Cruise on
Oprah
Happy Gilmore cussing at a Golf Ball
Ace
Ventura
Pet
Detective
Holly Hunter as the Rogue Cop
Dr. McCoy:
Dammit Jim!
I’m a Doctor not a…
Indy
Jones

DBT: Core Mindfulness
States of Mind
Words or Characteristics that define
• Linear
• Sequential
• Detail-oriented
• Analytical
• Logical
• Ruled by rules
• Rigid
• Lack of emotion
• No warmth or connection
• Others?

Reasonable / Rational Mind
The Robot in Terminator
7 of 9 says:
Your feelings are irrelevant.
Dr. House
He doesn’t care about the patient.
He just wants to be
‘Right.’
Dwight from the Office will do whatever it takes to make the sale
He is Emotion
She is Rational
Court Cases are based on evidence and testimony
Professor Jones
Accountants think using numbers.
Would you want Lucy doing your taxes?

DBT: Core Mindfulness
States of Mind
Words or Characteristics that define
• True Self
• Center
• Being
• Spirit
• Conscious
• Peace of mind
• Ultimate Reality
• Insightful
• Balanced
• Chooses considering both Reasonable and
Emotion Mind
• Deep inner knowing
• Intuition vs. Impulse
• Other?

Other Wise Mind Examples
Morgan
Freeman
As God in
Bruce Almighty
Mother Teresa:
What you spend years building, someone could destroy overnight;
Build it anyway.
Jesus
Who spoke in Parables
Buddah:
What you THINK ---
You Become.
Dr. Martin Luther
King Jr. who practiced peaceful civil disobedience
Someone in YOUR life that is Wise?
A parent?
A brother or sister?
A Teacher? A Friend?

Core Mindfulness
Mindfulness
Awareness without judgment of what is via direct and immediate experience
Mindfulness Practice
The repetitive acts of directing attention to only one thing:
This one moment

Mindfulness:
Observing
Observing is…
• Bringing Awareness
• Allowing
• Just noticing the experience
• Controlling Attention
• Being like a guard at the palace gate: ALERT!
• Having a “Teflon Mind”

Mindfulness:
Observing

Mindfulness:
Opening The Mind

Core Mindfulness:
NOTICE
• THE EXPERIENCE. Have a “TEFLON MIND,” letting experiences, feelings, and thoughts come into your mind and slip right out.
• CONTROL your attention, but not what you see. Push away nothing. Cling to nothing.
•
Step inside yourself and observe. WATCH your thought coming and going, like clouds in the sky. Notice each feeling, rising and falling, like waves in the ocean. Notice exactly what you are doing.
•
Notice what comes through your SENSES
– your eyes, ears, nose, skin, tongue. See others’ actions and expressions. “Smell the roses.”
DESCRIBE
•
PUT WORDS ON THE EXPERIENCE. When a feeling or thought arises, or you do something, acknowledge it. For example, say in your mind, “Sadness has just enveloped me.” … or … “stomach muscles tightening” … or… “A thought ‘I can’t do this’ has come into my mind” … or … “walking, step, step, step…”
• PUT EXPERIENCES INTO WORDS. Describe to yourself what is happening. Put a name on your feelings.
Call a thought just a thought, a feeling just a feeling. Don’t get caught in content.
PARTICIPATE
• Enter into your experiences. Let yourself get involved in the moment, letting go of ruminating. BECOME
ONE WITH YOUR EXPERIENCE, COMPLETELY FORGETTING YOURSELF.
• ACT INTUITIVELY from wise mind. Do just what is needed in each situation – a skillful dancer on the dance floor, one with the music and your partner, neither willful or sitting on your hands.
• Actively PRACTICE your skills as you learn them until they become part of you, where you use them without self-consciousness. Practice:
• Changing harmful situations.
•
Changing your harmful reactions to situations.
• Accepting yourself and the situation as they are.

Core Mindfulness:
NON-JUDGMENTALLY
• See but DON’T EVALUATE. Take a non-judgmental stance. Just the facts. Focus on the “what,” not the
“good” or “bad,” the “terrible” or “wonderful,” the “should” or the “should not.”
• UNGLUE YOUR OPINIONS from the facts, from the “who, what, when and where.”
•
ACCEPT each moment, each event as a blanket spread out on the lawn accepts both the rain and the sun, each leaf that falls upon it.
• When you find yourself judging, DON”T JUDGE YOUR JUDGING.
ONE-MINDFULLY
• DO ONE THING AT A TIME. When you are eating, eat. When you are walking, walk. When you are bathing, bathe. When your are working, work. When you are in a group, or a conversation, focus your attention on the very moment you are in with the person. When you are thinking, think. When you are worrying, worry. When you are planning, plan. When you are remembering, remember. Do each thing with all your attention.
• If other actions, or thoughts, or strong feelings distract you, LET GO OF DISTRACTIONS and go back to what you are doing
– again, and again, and again.
• CONCENTRATE YOUR MIND. If you find you are doing two things at once, stop and go back to one thing at a time.
EFFECTIVELY
• FOCUS ON WHAT WORKS. Do what needs to be done in each situation. Stay away from “fair” and
“unfair,” “right” and wrong,” “should” and “should not.”
• PLAY BY THE RULES. Don’t “cut off your nose to spite your face.”
•
Act as SKILLFULLY as you can, meeting the needs of the situation you are in. Not the situation you wish you were in; not the one that is just; not the one that is more comfortable; not the one that …
•
Keep an eye on YOUR OBJECTIVES in the situation and do what is necessary to achieve them.
• LET GO of vengeance, useless anger, and righteousness that hurts you and doesn’t work.

Doing Mind Being Mind

Distress Tolerance
Suicidal threats/attempts, self-damaging, impulsive behaviors, parasuicide, alcohol/drug abuse
Crisis Survival Strategies: T.I.P. Skills
T – TEMPERATURE
• Cut dissociation by immersion in ice water. Hold your breath and immerse your face in a bowl of ice water (48 degrees or below) for
30 seconds.
• Take warm water bath with lavender to relax.
I – INTENSE exercise
• Discharge emotional energy through cardio-vascular exercise
(running, walking very briskly, aerobic exercise, bicycling…) for at least 20 minutes.
P – PROGRESSIVE relaxation
• Progressively relax by squeezing (tightening each muscle group for
5 to 7 seconds), then let go and relax. Start with hands, then biceps, triceps, shoulders, face, chest, abdomen, pelvis, buttocks, thighs, legs, feet and toes.

Tolerating the
Distress
NOT Tolerating
The Distress
Distress Tolerance
Pros and Cons
Pros Cons

Distress Tolerance
Other Skills

Distress Tolerance
Reality Acceptance
Radical Acceptance:
Everything is as it should be
• Freedom from suffering requires ACCEPTANCE from deep within of what is. Let yourself go completely with what is. Let go of fighting reality.
• ACCEPTANCE is the only way out of hell.
• Pain creates suffering only when you refuse to ACCEPT the pain.
• Deciding to tolerate the moment is ACEPTANCE.
• ACCEPTANCE is acknowledging what it is.
• To accept something is not the same as judging it good.

Distress Tolerance
Observe the Breath
OBSERVING YOUR BREATH : Focus your attention on your breath, coming in and out. Observe your breathing as way to center yourself in your wise mind, dropping off non-acceptance and fighting reality.
Deep Breathing
Lie on your back. Breathe evenly and gently, focusing your attention on the movement of your stomach. As you begin to breathe in, allow your stomach to rise in order to bring air into the lower half of your lungs.
As the upper halves of your lungs begin to fill with air, your chest begins to rise and your stomach begins to lower.
Don’t tire yourself. Continue for 10 breaths. The exhalation will be longer than the inhalation.
Measuring your Breath by Your Footsteps
Walk slowly in a yard, along a sidewalk, or on a path. Breathe normally. Determine the length of your breath, the exhalation and the inhalation, by the number of your footsteps. Continue for a few minutes. Begin to lengthen your exhalation by one step. Do not force a longer inhalation. Let it be natural. Watch your inhalation carefully to see whether there is a desire to lengthen it. Continue for 10 breaths.
Counting your Breath .
Sit cross-legged on the floor (sit in the half or full lotus position if you know how); or sit in a chair with your feet on the floor; or kneel; or lie flat on the floor; or take a walk. As you inhale, be aware that “I am inhaling, 1.” When you exhale, be aware that “I am exhaling, 1.” Remember to breathe from the stomach. When beginning the second inhalation, be aware that “I am inhaling, 2.” After you have reached 10, return to 1. Whenever you lose count, return to 1.
Following your Breath while Listening to Music
Listen to a piece of music. Breathe long, light, and even breaths. Follow your breath; be master of it while remaining aware of the movement and sentiments of the music. Do not get lost in the music, but continue to be master of your breath and yourself.

Distress Tolerance
Accept reality with your body.
Relax ( by letting go or by just tensing and then letting go) your face, neck, and shoulder muscles and half-smile with your lips.
A tense smile is a grin (and might tell the brain you are hiding or masking).
A half-smile is slightly up-turned lips with a relaxed face. Try to adopt a serene facial expression.
Remember, your body communicates to your mind.

Distress Tolerance
Turning the Mind
• Acceptance of reality as it is requires an act of
CHOICE. It is like coming to a fork in the road. You have to turn your mind towards the acceptance road and away from the “rejecting reality” road.
• You have to make an inner COMMITMENT to accept.
• The COMMITMENT to accept does not itself equal acceptance. It just turns you toward the path. But it is the first step.
• You have to turn your mind and commit to acceptance
OVER AND OVER AND OVER again. Sometimes, you have to make the commitment many times in the space of a few minutes.

Distress Tolerance
Cultivate a WILLING response to each situation.
• Willingness is DOING JUST WHAT IS NEEDED in each situation, in an unpretentious way. It is focusing on effectiveness.
• Willingness is listening very carefully to your WISE
MIND, acting from your inner self.
• Willingness is ALLOWING into awareness your connection to the universe - to the earth, to the floor you are standing on, to the chair you are sitting on, to the person you are talking to.

Distress Tolerance
Replace WILFULNESS with WILLINGNESS
• Willfulness is SITTING ON YOUR HANDS when action is needed, refusing to make changes that are needed.
• Willfulness is GIVING UP.
• Willfulness is the OPPOSITE OF “DOING WHAT
WORKS,” being effective.
• Willfulness is trying to FIX every situation.
• Willfulness is REFUSING TO TOLERATE the moment.

Emotion Regulation
Emotionally hypersensitive, emotional instability, problems with anger, hostility, abandonment depression
Evolutionary Functions of Emotions
• ANGER : Functions to help overcome obstacles; expression is the most significant aspect for accomplishing goals of importance. Also helps to define what is important in one’s life and relationships, and to communicate that to others.
• DISGUST : helps to expel or get rid of harmful things and people.
• SHAME : supports conformity to group expectations; either conform or hide shameful behavior so as not to get kicked out of the community; No current research that it is useful in our culture; hiding leads to antisocial behavior vs. conformity.
•
ENVY : helps you to figure what you want and how to get it; helps people lift themselves up. Keeps the gene pool going in terms of evolution.
•
FEAR : often sounds like anger; signals a threat, prepares for fight or flight response.
•
JEALOUSY : helps people hang on to what they already have; seen in the animal kingdom in terms of sexual jealousy.
• JOY : leads to happiness; supports making commitments and being productive.
• LOVE : helps with articulation of existing feelings; makes you attach to things vs. getting rid of things you need to survive.
• SADNESS : brings others to you to help; makes you isolative and passive so others are drawn in to support you.
• GUILT : prompts repair, generates pro-social behavior; fundamental emotion stays attached to behavior vs. shame where fundamental emotion becomes identity or is attributed to identity.

Emotion Regulation
Opposite Action
Opposite Action is Acting Opposite to your Emotional Urge
DECIDE: Do you want to change your emotion?
• Think about the pros and cons of changing your emotion.
• Consider whether the emotion promotes your short-term and longterm well-being.
If yes, CHECK THE FACTS : Justified or Unjustified?
If unjustified, ACT OPPOSITE to your urges.
• Do the opposite of your action urges.
• Do it all the way, including posture, facial expression, thinking, what you say and how you say it.
• Do NOT suppress emotional experiences or feelings; let opposite actions, do the work for you.

Emotion Regulation
Opposite Action
Opposite Action Works Best When:
• The emotion or the emotional intensity is NOT
JUSTIFIED by the situation
• It is done ALL THE WAY
• You change how you are thinking about the situation
• You change your facial expression
• You change your body posture
• You change WHAT you say and HOW you say it
Opposite Action is changing WHAT you do and HOW you do it.

Emotion Regulation
Opposite Action
• Anger: Gently AVOID or ….do something a little bit NICE. Do not attack.
• Disgust: Get CLOSE. Be KIND to those you feel contempt for.
Take in what feels repulsive…
• Envy: COUNT YOUR BLESSINGS. Do not destroy or grab what other’s have.
• Fear: APPROACH. Do not avoid or freeze-in-place.
• Jealousy: LET GO of controlling others’ and what you have. Do not protect and control.
• Sadness or Depression: Get ACTIVE; do what makes you feel
COMPETENT. Do not withdraw or act helpless.
• Shame: Do what makes you feel shame (if it does not violate your values)…. OVER AND OVER AND OVER. Make your behavior Public.
• Guilt: Do what makes you feel guilty OVER AND OVER AND
OVER.

Interpersonal
Effectiveness
Interpersonal chaos, unstable relationships, try to avoid loss, weak social support, burn people out, drawn to drama in relationships

Interpersonal
Effectiveness
Interpersonal chaos, unstable relationships, try to avoid loss, weak social support, burn people out, drawn to drama in relationships

Interpersonal
Effectiveness
Factors Reducing I.P.E.
Lack of Skill
You actually DON’T KNOW what to say or how to act. You don’t know how you should behave to achieve your objectives. You don’t know what will work.
Worry thoughts
Worry Thoughts get in the way of your ability to act effectively. You have the ability, but your worry thoughts interfere with doing or saying what you want.WORRIES ABOUT BAD CONSEQUENCES.
“They won’t like me,”
“She will think I am stupid.” WORRIES ABOUT WHETHER YOU DESERVE
TO GET WHAT YOU WANT.
“I am such a bad person, I don’t deserve this.” WORRIES ABOUT NOT BEING EFFECTIVE AND CALLING
YOURSELF NAMES.
“I won’t do it right,” “I’ll probably fall apart,” I’m so stupid.”
Emotions
Your emotions (ANGER, FRUSTRATION, FEAR, GUILT) get in the way of your ability to act effectively. You have the ability, but your emotions make you unable to do or say what you want. Emotions, instead of skill, control what you say and do.

Interpersonal
Effectiveness
Factors Reducing I.P.E.
Indecision
You CAN’T DECIDE what to do or what you really want. You have the ability, but your indecision gets in the way of doing or saying what you want.
You are ambivalent about your priorities. You can’t figure out how to balance:Asking for too much versus not asking for anything.Saying no to everything versus giving in to everything.
Environment
Characteristics of the environment make it impossible for even a very skilled person to be effective. SKILLFUL BEHAVIOR DOESN’T WORK.Other people are too powerful.Other people will be threatened or have some other reason for not liking you if you get what you want.Other people won’t give you what you need or let you say no without punishing you unless you sacrifice your self-respect, at least a little.

Interpersonal
Effectiveness
DEARMAN
D.E.A.R.M.A.N.
• DESCRIBE
• EXPRESS
• ASSERT
• REINFORCE
• (Stay) MINDFUL
• APPEAR CONFIDENT
• NEGOTIATE
G.I.V.E.
• (Be) GENTLE
• (Act) INTERESTED
• VALIDATE
• (Use an) EASY MANNER
F.A.S.T.
• (Be) FAIR
• (No) APOLOGIES
• STICK TO VALUES
• (Be) TRUTHFUL

D.E.A.R.W.O.M.A.N.
• DESCRIBE
• EXPRESS
• ASSERT
• REINFORCE
• (Use) Wise Mind
• Observe
• (Stay) MINDFUL
• APPEAR CONFIDENT
• NEGOTIATE
Interpersonal
Effectiveness
D.E.A.R.H.U.M.A.N.
• DESCRIBE
• EXPRESS
• ASSERT
• REINFORCE
• (Be) HUMBLE
• OBSERVE YOUR FEELINGS
• (Stay) MINDFUL
• APPEAR CONFIDENT
• NEGOTIATE

Interpersonal
Effectiveness
Validation What is It?
Validation communicates to another person that his feelings, thoughts, and actions make sense and are understandable to you in a particular situation.
Self-validation involves perceiving your own feelings, thoughts, and actions as accurate and acceptable in a particular situation.
Remember: Validation ≠ Agreement
WHAT should we validate?
•Feelings, thoughts, and behaviors in:
 Ourselves, Other people
Why should we validate?
 It improves relationships!
 Validation can show that:
 We are listening.
 We understand.
 We are being nonjudgmental.
 We care about the relationship.
 Conflict is possible with decreased intensity.

Vulnerability
Precipitating Event
Behavior Chain
What is your greatest:
Thought Feeling
What did you do?
More Effective Bx
PROBLEM
BEHAVIOR
What Harm did
This cause?
Repair?
Correct?
Over-
Correct?

DBT Resources
Cognitive-Behavioral Treatment of
Borderline Personality Disorder
(Hardcover) by Marsha Linehan
Skills Training Manual for Treating
Borderline Personality Disorder
(Paperback) by Marsha M. Linehan

Dialectical Behavior Therapy
Volume 2 - Companion
Worksheets (Spiral-bound) by Cathy Moonshine
Ph.D./MAC/CADC III
DBT Resources

DBT Resources
Dialectical Behavior Therapy Workbook: Practical DBT Exercises for Learning
Mindfulness, Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance
(New Harbinger Self-Help Workbook) by Matthew McKay
Matthew McKay, Jeffrey C. Wood, Jeffrey Brantley