Learning � Objectives After � this � training, � participants � should � be � able � DBT � Distress � Tolerance � Skills � to: • Determine � when � to � use � DBT’s � Distress � Tolerance � skills � with � your � patients Anna � Hink, � MSW, � LICSW Clinician � Trainer • List � the � Distress � Tolerance � skills � UW � AIMS � Center � • Integrate � the � use � of � Distress � Tolerance � skills � into � your � practice 2 What � Is � A � Crisis? � Case � Example: � DS Key � Complaints There � is � pressure � to � solve � A � serious � problem � that � “There’s � nothing � I � can � do � when � I’m � can’t � be � solved � right � now the � problem, � and � it � is � 54 � y/o � Hispanic � woman, � lives � with � in � pain; � I’m � arguing � with � my � husband, � some � college difficult � to � stop � trying husband � all � the � time; �� I’m � worried � about � cancer � returning” Crisis OUD. �� Stopped � opioids � x1 � week. Buprenorphine � Naloxone � 24 � 8mg � Emotions � are � high, � so � the � Longstanding � anxiety � & � depressive � It’s � short � term � qd symptoms: �� problem � is � distressing � If � it � is � happening � all � the � time, � Venlafaxine � XR � 275mg � qd Baseline � PHQ � 9 � = � 10 � (mild) � High � emotions � generally � it � is � not � a � crisis. � It � is � your � life! Baseline � GAD � 7 � = � 15 � (moderate) � make � things � worse 3 4
Can � You � Solve � The � Crisis? Who � Are � Distress � Tolerance � Skills � For? � Patients Clinicians • Stick � with � it face � many � stressors face � many � stressors If � Yes… • Don’t � take � your � eye � off � the � ball • Do � what � it � takes! � • Large � caseloads • Pain � flares • Difficult � and � sick � patients • Frustrations � with � medical � care • Hearing � many � traumatic � stories • Intense � emotions • Inability � to � help � their � patients • Family � conflicts If � No • STOP trying � to � solve � it • Lack � of � time � or � resources � to � help � • Housing � issues • Trying � to � solve � the � unsolvable � can � make � it � their � patients • Money � issues (or � not � right � worse � or � send � emotions � through � the � roof • Frustrating � interactions � with � • Drugs � and � alcohol • Focus � on � Distress � Tolerance skills social � services � now)… � DT � skills � are � • Dangerous � neighborhoods � • Unhelpful � rules � or � regulations designed � just � for � • Long � waits � for � social � services • Paperwork an � unsolved crisis 5 6 Purpose � of � Distress � Tolerance � Skills Yelling � at � someone • Help � you � survive � the � crisis � by � not � making � the � Giving � up � on � Using � drugs � or � situation � worse life alcohol • Not � intended � to � make � you � feel � better � (though � Ways � to � Worsen ����� sometimes � you � might) a � Crisis � “Retail � • If � skills � prevent � the � crisis � from � getting � worse, � Complaining � so � therapy” � with � much � folks � money � you � don’t � want � to � but � you � do � not � feel � better �� don’t � stop! � can’t � afford � to � talk � to � you spend – An � escalated � crisis � may � make � you � feel � worse Eating � too � much � or � too � little 7 8
Benefits � of � Distress � Tolerance � Skills DBT � Distress � Tolerance: � The � 4 � Steps • Learn � to � survive � a � crisis � without � Step � 3: making � it � worse Step � 4: Step � 1: Step � 2: � Choose � Follow � up, �� • Become � more � Behavioral � Strategy � & � Make � the � Pitch Evaluate � and � Determine � Assessment Problem � Solve confident � and � Homework capable � of � navigating � future � crises 9 10 Step � 1: � Behavioral � Assessment � Step � 1: � Behavioral � Assessment Revisiting � Case � Example �� DS Ask � Three � Questions: � 1. Triggers � 1. What � triggers � the � distress? � Intense � back � pain � flares � for � hours – Be � behavioral � (i.e., � talking � with � a � family � member, � � Tends � to � overdo � things � when � feeling � better thinking � a � thought) 2.How � did � the � patient � respond � to � distress? 2. Response � – Be � behavioral � (i.e., � yelled/started � a � fight, � stayed � in � � isolates � self � Bedbound � bed � all � day) � Does � not � eat � or � hydrate � � yells � at � husband � – Listen � for � helpful � and � destructive � behaviors 3. What � Made � it � Worse 3.How � did � their � response � make � things � worse? � “I � feel � so � guilty � after � I � yell � at � my � husband. � He’s � – From � the � patient’s � perspective � (not � yours � as � the � just � trying � to � help” provider)! 11 12
Step � 2: � Make � the � Pitch DBT � DT: � The � 4 � Steps • Explain � the � concept � of � distress � tolerance – “These � are � skills � to � help � you � with � (1. � triggers). � You’ve � told � me � you � tend � to � (2. � response).” Step � 3: Step � 4: Step � 1: • Explain � the � goal � of � distress � tolerance � skills � Step � 2: � Choose � Follow � up, �� Behavioral � Strategy � & � Make � the � Pitch Evaluate � and � – “The � goal � is � to � not � make � things � worse. � This � is � Assessment Determine � Problem � Solve Homework very � different � than � ‘feeling � better.’” � – “DT � skills � help � you � bring � down � your � emotions � so � you � think � more � clearly.” � – “You’ve � told � me � things � are � worse � when � you � (3. � what � made � it � worse).” � 13 14 Step � 2: � Make � the � Pitch � DBT � DT: � The � 4 � Steps Revisiting � Case � Example �� DS “These � are � skills � to � help � you � with � the � intense � pain � flares � you � experience. � You’ve � told � me � you � tend � to � need � to � stay � in � bed � for � many � hours, � not � eat � or � drink � water, � Step � 3: Step � 4: isolate � yourself � from � your � family, � and � yell � at � your � Step � 1: Step � 2: � Choose � husband. Follow � up, �� Behavioral � Strategy � & � Make � the � Pitch Evaluate � and � Assessment Determine � Problem � Solve Homework The � goal � is � to � not � make � things � worse. � This � is � very � different � than � ‘feeling � better.’ � DT � skills � help � you � bring � down � your � emotions � so � you � think � more � clearly. � You’ve � told � me � things � are � worse � when � you � yell � at � your � husband.” � 15 16
Distract Step � 3: � Choosing � Strategies • Distraction � is � A ctivities Distress � Tolerance � skills � deliberately � C ontributing • Distract turning � your � C omparisons • attention � away � Self � Soothe from � the � crisis • IMPROVE � the � Moment Opposite � E motions – Remember: � Wise � How � to � choose � a � strategy P ushing � Away Mind � ACCEPTS • Patient � preference � T houghts • What � has � worked � in � the � past? S ensations 17 18 Self � Soothe � With � Five � Senses Self � Soothing � Vision Decorate � your � space, � go � somewhere � inspiring Decorate � your � space, � go � somewhere � inspiring • How � would � you � comfort � a � loved � one � going � through � a � crisis? Sound Music, � soothing � voices, � nature � sounds Music, � soothing � voices, � nature � sounds – Do � the � same � for � yourself! • Don’t � make � a � situation � harder � by � being � more � uncomfortable � than � required – For � instance, � don’t � wear � tight � shoes � to � the � dentist 19 20
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