M26 DBT in Addiction Counselling

Section 1: Introduction to DBT

• Dialectical Behavior Therapy (DBT) helps people with mood disorders and maladaptive behaviors like self-harm, suicidal thoughts, and substance abuse (2017).

• It enhances emotional and cognitive regulation by identifying triggers and applying coping skills to manage reactions.

• DBT posits individuals are doing their best but lack skills or are affected by reinforcement that hinders proper functioning.

• Developed by Marsha M. Linehan in the late 1980s, DBT is a modified form of CBT initially for borderline personality disorder (BPD) and chronic suicidal tendencies (2017).

• Research supports DBT's effectiveness for traumatic brain injuries (TBI), eating disorders, and mood disorders (Linehan & Dimeff, 2001).

• It may benefit patients with spectrum mood disorders, including self-injury (Brody, 2008), sexual abuse survivors, and those with chemical dependencies.

• DBT integrates cognitive behavioral techniques for emotion regulation and reality-testing with distress tolerance, acceptance, and mindfulness from Buddhist practices.

• DBT is the first therapy proven effective for treating BPD.

• The first randomized clinical trial of DBT showed reduced rates of suicidal gestures, psychiatric hospitalizations, and treatment drop-outs compared to treatment as usual (2017).

• A meta-analysis found moderate effects of DBT on individuals with borderline personality disorder.

• The module is experiential and task-oriented, using materials from “The Dialectical Behaviour Therapy Skills Workbook” (McKay, Wood, & Brantley, 2007) and “Dialectical Behavioural Skills Training” (Theron, 2014).

DBT in Substance Abuse Treatment

• Various treatment approaches exist for Substance Use Disorder (SUD), including moral, disease, and sociocultural models, twelve-step programs, and motivational interviewing (Capuzzi & Stauffer, 2012).

• SAMHSA's National Registry lists over 100 interventions for SUD treatment, such as Acceptance and Commitment Therapy (ACT), Brief Strategic Family Therapy (BSFT), and Motivational Interviewing (MI) (National Registry of Evidence-based Programs and Practice, 2014).

• Dialectical Behavioral Therapy (DBT) is not currently listed, but research indicates it may have a place in SUD treatment (Linehan & Dimeff, 2008).

• Outpatient programs use DBT skills to address relapse, identify triggers, control urges, and manage emotions.

Application for Professionals

• DBT focuses on empowering clients with tools and skills applicable in everyday life.

• It is most effective when used in individual therapy, with a primary therapist managing the treatment plan (Linehan, 2008).

• A strong therapist-client relationship from the start is linked to higher retention rates.

• Before starting, clients commit to staying alive for one year, working on behaviors that interfere with treatment, and participating in DBT skills (Linehan, 1993).

• Treatment hierarchy targets: reducing life-threatening behaviors; reducing behaviors that interfere with therapy; reducing behaviors that degrade life quality; and increasing behavioral skills (Linehan, 2008).

• In outpatient settings, DBT is delivered via individual therapy, group skills training, telephone consultation, and therapy for the therapist (Freedman & Duckworth, 2013).

• Distress tolerance helps clients cope with painful events without substance use by building resilience and providing new coping methods.

• The first distress tolerance skill teaches clients how to temporarily stop thinking about pain to find appropriate coping skills, distinguishing between temporary cessation and avoidance.

• The second distress tolerance skill teaches self-soothing, helping individuals calm down from anxiety or anger before facing difficult situations (Linehan, 2008).

• Mindfulness teaches clients to fully experience the present moment while reducing focus on past pain or future fears.

• Mindfulness provides tools to overcome negative judgments about self and others and is a core DBT skill (Linehan, 1993).

• Mindfulness skills reduce recurring major depression episodes (Teasdale, 2000) and increase coping abilities (Baer, 2003).

• Mindful-based relapse prevention increases awareness of triggers, responses, and patterns, offering a range of choices before action (Felver, 2012).

• Mindfulness teaches a non-judgmental awareness of present experiences, recognizing internal experiences as temporary projections rather than accurate depictions of reality (Felver, 2012).

• Clients learn to be aware of internal and external experiences without judging themselves or their feelings.

• Mindfulness teaches awareness of unnecessary automatic responses to experiences or feelings.

• Thought suppression is linked to substance relapse (Katz & Toner, 2012).

• Mindfulness allows clients to become aware of urges, recognizing they are temporary and will pass, leading to more thoughtful reactions and control.

• Emotional Regulation helps individuals recognize their feelings and observe them without being overwhelmed.

• The goal is to adjust feelings without reacting destructively based solely on emotions.

• In substance abuse treatment, mindfulness deals with the past, future planning, and being present, paralleling the AA philosophy of living in recovery one day at a time (Stevens & Smith, 2009).

• Counselors empower clients to build impulse control and tolerate emotions, teaching that feeling an emotion is not the same as acting on it, and providing positive reinforcement (McKay, Wood, & Brantley, 2007).

• Interpersonal Effectiveness helps clients express beliefs and needs, set limits, and negotiate solutions (McKay, Wood, Brantley, 2007).

• Clients may find less need for substance use by becoming more functional in relationships, protecting those relationships, and treating others with respect.

• Individuals entering recovery often deal with physical, psychological, and social damage from addiction, behavior, or outside forces.

• Living in recovery means living a healthy, meaningful life without drugs or alcohol (Gorski & Miller 1986).

• A key aspect of DBT is teaching individuals to control emotions, reducing the size of the emotion, and helping maintain balance when emotions become overwhelming.

• The first goal is patient commitment to abstain from drug use, during which additional skills are developed.

• Clients are asked to abstain from behaviors or lifestyle choices that interfere with treatment (Bornovalova & Daughters, 2006, p. 9926).

• In substance abuse treatment, recognizing relapse anticipation is important (Linehan, 2008), including behaviors, feelings, and thought patterns that previously led to relapse.

• This may be referred to as a dry drunk or relapse syndrome.

• Gorski and Miller (1986) state the relapse syndrome can be interrupted by bringing warning signs into conscious awareness, marking the start of relapse prevention planning.

The Dialectical Approach to Abstinence

• DBT promotes immediate cessation of drug abuse (change) while accepting that relapse doesn't negate therapy's goal (acceptance).

• It combines insistence on abstinence with problem-solving responses to relapse, including reducing dangers of overdose and infection.

Establishing Abstinence Through Promoting Change

• Therapists expect abstinence from the first session, asking patients to commit to short, attainable periods of abstinence (a day or 5 minutes).

• Patients renew commitment for sure intervals, reaching long-term abstinence gradually.

• This mirrors the Twelve Steps slogan, “Just for Today”.

• The “Cope ahead” strategy teaches patients to anticipate potential cues and prepare responses (Linehan, in press).

• Therapists urge patients to cut ties with their drug-abusing past, changing numbers, informing friends, and discarding paraphernalia.

• The message that drug use is disastrous and avoidable is emphasized.

Supporting Abstinence by Encouraging Acceptance

• DBT views relapse as a problem to solve, not a failure.

• Therapists help patients analyze events leading to drug use for future application.

• Therapists aid quick recovery, aligning with Marlatt’s “prolapse” paradigm to alleviate the abstinence violation effect (AVE; Marlatt and Donovan, 2005) and reduce negative emotions.

• Failing well involves repairing harm, similar to making amends in Twelve Steps (Alcoholics Anonymous, 2006).

  • Increases awareness of negative consequences.

  • Treats justified guilt.

• Once abstinence resumes, the therapist reverts to promoting absolute abstinence.

• Failing well is important for those with BPD and SUD due to their emotional dysregulation.

DBT Strategies for Attachment

• Drug-abusing individuals may be difficult to engage in treatment.

• Some attach easily, while others show episodic engagement, failure to participate, and early termination.

• DBT employs strategies to increase therapy and therapist valence, re-engage lost patients, and prevent consequences during disengagement.

• Therapists actively find and re-engage patients in early treatment until attachment is secured.

• The therapist orients patients to the butterfly attachment problem in the first session and creates a “just in case” plan.

• The plan includes places the therapist might look, and supportive contacts.

• Other strategies include increased contact, bringing therapy to the patient, and adjusting session length.

Clinical Trials of DBT

• Adapting DBT to patients with SUD and BPD aligns with the comorbidity’s life threat.

• The adaptation targets a heterogeneous population across drugs and demographics.

• Nine randomized controlled trials (RCTs) support DBT’s efficacy in reducing problems, including suicide attempts, self-injury, substance abuse, bulimia, binge eating, and depression in the elderly (Koons et al., 2001; Linehan et al., 1991, 2006; Linehan, Heard, and Armstrong, 1993; van den Bosch et al., 2005; Verheul et al., 2003; Linehan et al., 1999, 2002; Safer, Telch, and Agras, 2001; Telch, Agras, and Linehan, 2001; Lynch et al., 2003).

• DBT is more cost-effective than treatment as usual in reducing the medical severity of suicide attempts, hospitalization, emergency room visits, and crisis/respite bed utilization (American Psychiatric Association, 1998; Linehan and Heard, 1999).

• Two RCTs focused on DBT for individuals with SUD and BPD, conducted by Linehan and colleagues (Linehan et al., 1999, 2002).

• Participants were polysubstance-dependent with histories of abuse and prior unsuccessful attempts.

• Comprehensive DBT was provided across 12 months, with a 24-month assessment phase.

• The initial RCT compared DBT (n = 12) with community-based treatment as usual (n = 16) among polysubstance-dependent women with BPD (Linehan et al., 1999).

• DBT recipients were more likely to remain in treatment (64 versus 27 percent), reduced drug abuse, and attended more therapy sessions.

• Only DBT subjects sustained improvements in social and global adjustment at the 16-month follow-up.

• The second trial involved 23 opiate-dependent individuals with BPD and used comprehensive validation therapy with Twelve Steps (CVT+12) as control.

• CVT + Twelve Steps includes acceptance-based strategies with Twelve-Step program participation.

• Therapists validated patients in a supportive atmosphere, provided the behavior was effective for long-term goals.

• CVT +12 subjects attended at least one NA meeting weekly, facilitated by therapists who were NA members.

• All subjects took levomethadyl (ORLAAM), an opiate replacement medication, throughout treatment.

• Three major findings emerged: DBT subjects maintained reductions in opiate abuse during the last 4 months of treatment.

• CVT + 12 was more effective at retaining subjects (100 versus 64 percent in DBT).

• Both treatments reduced psychopathology relative to baseline.

• Further studies are needed to confirm DBT's efficacy for individuals with SUD and BPD; additional research is underway.

• No clinical trials have evaluated DBT for patients with SUD but not BPD; it may be justified for SUD patients with severe co-occurring psychosocial problems or those who have failed other SUD therapies.

Section 2: Overview and Procedures

• Dr. Linehan developed DBT as an application of standard behavioral therapy to treat chronically suicidal individuals (Linehan, 1987, 1993a, 1993b).

• Subsequently, it was adapted for individuals with both severe substance use disorder (SUD) and borderline personality disorder (BPD), a common dual diagnosis.

• The co-occurrence of SUD and BPD causes severe emotional dysregulation, increases poor outcomes and suicide risks.

• DBT includes strategies for overcoming problems like weak engagement and retention.

• The patient’s individual therapist is the primary provider, responsible for developing and maintaining the treatment plan.

• Treatment includes improving motivation, enhancing capabilities, generalizing new behaviors, structuring the environment, and enhancing therapist capability.

• In outpatient therapy, these functions are delivered via individual therapy, group skills training, telephone consultation, and therapy for the therapist.

• Like other behavioral approaches, DBT classifies behavioral targets hierarchically.

• The hierarchy decreases life-threatening behaviors; reduces behaviors that interfere with therapy; reduces behaviors that degrade life quality; and increases behavioral skills.

• The therapist emphasizes the highest order problem behavior in each session.

• For substance-dependent individuals, abuse is the highest order DBT target within behaviors that interfere with quality of life.

• DBT’s substance-abuse–specific behavioral targets include:

  • Decreasing abuse of substances.

  • Alleviating physical discomfort associated with abstinence and/or withdrawal.

  • Diminishing urges, cravings, and temptations to abuse.

  • Avoiding opportunities and cues to abuse by cutting ties.

  • Reducing behaviors conducive to drug abuse.

  • Increasing community reinforcement of healthy behaviors.

What is DBT?

• “Dialectical” means open-minded thinking.

• Dialectical means that 2 ideas can both be true at the same time.

  1. There is always more than one TRUE way to see a situation and more than one TRUE opinion, idea, thought, or dream.

  2. Two things that seem like (or are) opposites can both be true.

  3. All people have something unique, different, and worthy to teach us.

  4. A life worth living has both comfortable and uncomfortable aspects (happiness AND sadness; anger AND peace; hope AND discouragement; fear AND ease; etc.).

  5. All points of view have both TRUE and FALSE within them.

• Being dialectical means:

  1. Letting go of self-righteous indignation.

  2. Letting go of “black and white”, “all or nothing” ways of seeing a situation.

  3. Looking for what is “left out” of your understanding of a situation.

  4. Finding a way to validate the other person’s point of view.

  5. Expanding your way of seeing things.

  6. Getting “unstuck” from standoffs and conflicts.

  7. Being more flexible and approachable.

  8. Avoiding assumptions and blaming.

Guidelines for Dialectical Thinking

• Do:

  1. Move away from “either-or” thinking to “BOTH-AND” thinking.

  2. Avoid extreme words: always, never, you make me.

  3. Practice looking at ALL sides of a situation/points of view.

  4. Find the “kernel of truth” in every side. Remember: NO ONE owns the truth. Be open and willing. If you feel indignant or outraged, you are NOT being dialectical.

  5. Use “I feel…” statements, instead of “You are…” statements.

  6. Accept that different opinions can be legitimate, even if you do not agree with them: “I can see your point of view even though I do not agree with it.”

• Don’t:

  1. Assume that you know what others are thinking, check it out: “What did you mean when you said…?”

  2. Expect others to know what you are thinking, be clear: “What I’m trying to say is…”

• There are 4 main skills that are used in DBT:

  1. Emotion Regulation

  2. Mindfulness

  3. Distress Tolerance

  4. Interpersonal Effectiveness

Basic principles of accepting life on life’s terms

Radical acceptance

• Everything is as it should be.

• Everything is as it is.

• 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 (endure) the moment is ACCEPTANCE.

• ACCEPTANCE is acknowledging what is.

• To ACCEPT something is not the same as judging that it is good, or approving of it.

• ACCEPTANCE is turning my suffering into pain that I can endure.

Turning the Mind

• Acceptance of reality as it is requiring an act of CHOICE. It is like coming to a fork in the road. You should turn your mind towards the acceptance road and away from the “rejecting reality” (“I don’t have to put up with this!”) road.

• You should 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.

Finding the Willingness to Act with Wise Mind

• Willingness: 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.

• Wilfulness: Replace WILFULNESS with WILLINGNESS

• Wilfulness is SITTING ON YOU HANDS when action is needed, refusing to make changes that are needed.

• Wilfulness is GIVING UP.

• Wilfulness is the OPPOSITE OF “DOING WHAT WORKS”

• Wilfulness is trying to FIX every situation.

• Wilfulness is REFUSING TO TOLERATE the moment.

Section 3: Emotional Regulation

• Emotional Regulation is a skill that many people struggle with.

• Intense anger, frustration, depression, and anxiety are emotions far too many people experience frequently.

• For those who have histories of traumatic experiences and those who grew up in emotionally invalidating environments, this emotional intensity and lability are even greater problems.

• Painful emotions are often perceived as the problem to be fixed, when in fact the painful emotions are natural and understandable consequences to the individual’s experiences.

• In attempts to “fix” their problematic painful emotions, clients will often engage in impulsive, dysfunctional behaviors including self-harm and substance abuse.

• Clients often increase their suffering by walling off, avoiding, or fighting with their primary emotional experiences.

• These control tactics often result in secondary emotions, such as feeling depressed, guilty, angry, or ashamed for feeling a particular way.

• Many of the skills in this module are designed to undermine this process by reducing one’s vulnerability to the negative emotions and increasing one’s acceptance of negative emotions when they occur.

• Teaching emotion regulation skills is a difficult task.

• It must be emphasized that these skills are not a way to have absolute control over what one feels, but rather to moderate the intensity, frequency, and duration of painful experiences.

• Complete control is only possible if the environment can be completely controlled – clearly an impossible task.

• Mindfulness skills – especially nonjudgmental observation and description are needed in order to teach and develop emotion regulation skills.

• In order to teach these skills, group leaders must validate the clients’ experiences, as emotional validation is the foundation for the rest of the skill training.

• Too often our emotional responses to events and experiences are evaluated as unreasonable and observed in disbelief.

• Validation is critical to the dialectical process of accepting one’s emotional experiences and responses and responding more effectively in the future.

• Clients will further resist learning and implementing the skills unless they see benefit in doing so.

• A way to engage and join with clients around this issue is having them assess how well their current approach is working for them.

• Though they may get some benefit from having extreme emotional and behavioral displays, most clients will admit that they would like to handle things better.

• Emotion regulation skills are designed to empower clients so that they are able to choose their responses (to environmental events and their own automatic responses to environmental events) and behave more effectively in difficult situations.

• “Anybody can become angry, that is easy; but to be angry with the right person, and to the right degree, and at the right time, and for the right purpose, and in the right way, that is not within everybody's power. That is not easy.” - Aristotle

Why learn these skills?

• Without exception, men and women of all ages, of all cultures, of all levels of education, and of all walks of economic life have emotions, are mindful of the emotions of others, cultivate pastimes that manipulate their emotions, and govern their lives in no small part by the pursuit of one emotion, happiness, and the avoidance of unpleasant emotions. -Antonio Damasio

  1. To quiet the body—an emotional mind leads to high stress (racing heart, fast breathing, muscle tension, etc.).

  2. To quiet our behaviour—intense emotions lead to intense choices (often ones we regret).

  3. So that Wise Mind is easier to find—emotion mind blocks out intuitive, creative, flexible, and value-based thinking.

  4. To be more effective in meeting goals—emotion mind leads us away from our goals and off on distracting emotional tangents.

  5. To improve self-respect—making calm choices leads to better feelings about ourselves.

What is Emotional Regulation?

1.  Emotional regulation refers to the ability to control one’s emotions.
2.  We can control our emotions or our emotions can control us.
3.  When our emotions control us, we FEEL, ACT and only then THINK.
4.  We act like FAT heads and when we finally think, we wish we had acted differently.

How Important is Emotional Regulation?

1.  Emotional regulation abilities are four times more important than IQ in determining who becomes successful and who does not (Sternberg, 1996).
2.  One study of 450 boys found that those who succeeded were able to handle frustration, control emotions, and get along with other people Two-thirds of these boys grew up in welfare families, and one-third had IQ’s below 90 (Goleman, 1986).

Healthy Perspectives on Emotion

1.  Emotions are neither good or bad, right or wrong. Feelings just ARE. They exist. It is not helpful to judge your emotions.
2.  There is a difference between having an emotion and doing something or acting on the emotion.
3.  Emotions don’t last forever. No matter what you’re feeling, eventually, it will lift and another emotion will take its place.
4.  When a strong emotion comes, you do not have to act on your feeling. All you need to do is recognize the emotion and feel it.
5.  Emotions are not facts. When emotions are very powerful they feel just like “the truth”.
6.  You cannot get rid of emotions because they serve important survival functions. Be willing to radically accept your emotions as they arise.

What good are emotions?

• Why do we have emotions?

• Until we begin to understand the functions of emotions, why we have them, what their effect is on others, we cannot expect ourselves to change them.

Three Major Functions of Emotions: Emotions Communicate to and Influence Others.

1.  We communicate our emotions to others with verbal and nonverbal (facial expressions, body gestures or postures) language. Some expressions of emotion have an automatic effect on others. When there is a difference in what a person communicates non-verbally versus verbally, the other person will usually respond to the nonverbal expression. People respond to the facial expressions.
2.  One of the main problems experienced by people is that their nonverbal emotional expressions do not match their inside feelings. So we are often misread. People misunderstand what we are feeling.

Emotions Organize and Motivate Action

1.  Emotions prepare for and motivate action. There is an action urge connected to specific emotions that is hard-wired. "Hard-wired" means it is an automatic, built-in part of our behaviour. For example, if you see your two-year old child in the middle of the street and a car coming, you will feel an emotion, fear, and this emotion will prompt you to run to save your child. You don't stop to think about it. You just do it. Your emotion has motivated your behaviour without you having to take the time to think.
2.  Emotions can also help us overcome obstacles in our environment. An example is the anxiety someone feels when they are about to take a test. This anxiety, though it's uncomfortable, helps to motivate you to study so you will do well in the test.
3.  Anger may motivate and help people who are protesting injustices. The anger may override the fear they might feel in a demonstration or protest.
4.  Guilt may keep someone who is dieting stick to her diet. (This is not saying that you should feel guilty, just that it is the emotion that prompts some people to carry through with a diet or some other difficult project.)

Emotions can be self-validating

1.  Emotions can give us information about a situation or event. They can signal to us that something is going on. Sometimes signals about a situation will be picked up unconsciously, and then we may have an emotional reaction, but not be sure what set off the reaction. Feeling "something doesn't feel right about this" or "I had a feeling something was going to happen and it did" are some of the signals we might get.
2.  Think of some times when your feel for a situation turned out to be right. Is there some time when you felt anxiety or apprehension that turned out to be justified? Or that you had a good feeling about someone that turned out to be right?
3.  If our emotions are minimized or invalidated, it's hard to get our needs taken seriously. So, we may increase the intensity of our emotions in order to get our needs met. And then if we decrease the intensity of our emotions, we may find again that we are not taken seriously.

An Emotion or a feeling?

1.  Emotions are both what is felt by the body (not necessarily by the mind) and what is displayed to others.
2.  Feelings are the subjective aspect of emotion—how the mind responds or does not respond to the arousals.
3.  The word feeling derives from the Middle English felen—and was used to refer to sensory and tactile experiences as well as a range of emotional and affective responses, both pleasurable and painful.

Feeling Facts

• The following facts help you better understand emotion and how emotions and feelings influence behavior.

  1. Feelings begin with a physical arousal.

  2. Think of feelings as signals. The physical arousal that alerts you to a feeling’s presence says, “Pay attention, something is happening.”

  3. Arousals are not always noticed. The arousal might be detected by another person, but it only becomes a feeling when it is noticed and named by the person being aroused.

  4. Controlling an emotion or arousal that does not reach your consciousness is difficult. Some people are more attuned to feelings than others. Some are attuned to only one feeling. Someone may be attuned to anger, but not to the hurt or fear or other emotions that underlie the anger.

  5. Feelings motivate. Feelings want us to do something. Afraid? Your fear says run away and hide. Guilty? Your guilt says stop doing wrong. Angry? Your anger tells you to fight.

  6. What feelings tell you to do is not always the wisest way to act. Even in emergencies, taking a few minutes to think works best. Emotional regulation is about managing feelings.

  7. Some feelings shut you down instead of energizing you. Depression is an example of how a feeling can shut you down. Shutting down can keep you alive in some situations, but isn’t helpful in other situations. The stronger the feeling, the greater the danger the feeling will take over. When a feeling takes over the brain is hijacked, and taken over.

  8. Knowing when a feeling is visiting you, knowing how to keep it from taking over your brain, properly naming arousals, and thinking before acting are key to emotional regulation.

  9. You are emotionally fit when you stay in control of your actions no matter what your feelings suggest doing.

• Remember - ‘You cannot make yourself feel something you do not feel, but you can make yourself do right despite your feelings’. - Pearl Buck

Negative Affect

1.  Negative affect is one of the most prominent factors associated with relapse.
2.  Negative affect is stress, nervousness, anxiety, anger, depressed mood, and feeling of loneliness/uselessness/boredom.

The Adaptive Coping with Emotions Model (Berking, 2010)

1.  Be aware of emotions
2.  Identify and label emotions
3.  Correctly interpret emotion-related bodily sensations
4.  Understand the prompts of emotions
5.  Actively modify negative emotions to feel better
6.  ACCEPT NEGATIVE EMOTIONS WHEN NECESSARY
7.  TOLERATE NEGATIVE EMOTIONS WHEN THEY CANNOT BE CHANGED
8.  Confront (vs avoids) distressing situations in order to attain important goals
9.  Compassionately support/self-soothe oneself in distressing situations to counterbalance potential short-term negative effects

How to Regulate Emotions

1.  Strengthen feeling awareness skills
2.  Learn and use self-soothing skills
3.  Practice a Daily Emotional Fitness Exercise Program
4.  Develop a support system
5.  Develop a philosophy of acceptance. Control what you can and let go of what you cannot control
6.  Live a meaningful life

A Daily Emotional Fitness Program

1.  Be grateful for all you have been given
2.  Remember another’s caring acts
3.  Remember your mission
4.  Move your body
5.  Practice kindness
6.  Be with beauty
7.  Laugh
8.  Indulge in a healthy pleasure
9.  Create something
10. Forgive another
11. Forgive yourself
12. Be grateful, yet again

Reducing vulnerability: staying strong

• How to Reduce the Risk of Painful Emotions Controlling You

• Healthy habits are an important part of managing mood swings, depression, anger, or irritability. Remember to stay “STRONG”

  1. Sleep as much as you need - not too much, not too little.

  2. Take medications your doctor prescribes. When sick take care of yourself.

  3. Resist using street drugs or alcohol.

  4. Once a day, do something that gives you a feeling of being in control, mastering your world.

  5. Nutrition - eat a balanced diet, don’t over or under eat. Don’t make decisions about food based upon your emotional state at the time (I’m too upset to eat). Keep your blood sugar balanced.

  6. Get exercise - try to do 20 minutes a day. Research shows that exercise helps people improve their mood.

Letting Go of Emotional Suffering

Mindfulness of Your Current Emotion

1.  Observe your emotion
    1.  NOTE its presence.
    2.  Step BACK.
    3.  Get UNSTUCK from the emotion.
2.   Experience your emotion fully
    1.  As a WAVE, coming and going.
    2.  Try not to BLOCK emotion.
    3.  Try not to PUSH the emotion AWAY.
    4.  Don’t try to KEEP the emotion around.
    5.  Don’t try to INCREASE the emotion.
    6.  Just be a witness to your emotion.
3.   Remember: you are not your emotion
    1.  Do not ACT on the sensation of urgency.
    2.  Remember when you have felt DIFFERENT.
    3.  Describe your emotion by saying “I have the feeling of _______ ”, rather than, “I am ____.”
    4.  Notice OTHER feelings that you have at the same time you feel the strong emotion.
4.  Practice respecting, loving your emotion
    1.  Don’t JUDGE your emotion.
    2.  Practice WILLINGNESS with your emotion.
    3.  Radically ACCEPT your emotion.

Steps for Increasing Positive Experiences

BUILD POSITIVE EXPERIENCES

1.  Short Term: Do pleasant things that are possible NOW. Make your own list of joyful experiences that you can have every day. Do at least one or two of these experiences MINDFULLY each day and record on your diary card.
2.  Long Term: Make changes in your life so that positive events will occur more often. Build a “life worth living”. Work toward goals: ACCUMULATE POSITIVES.
    1.  Make a list of positive events you want.
    2.  List small steps toward goals.
    3.  Take first step.

ATTEND TO RELATIONSHIPS

1.  Repair old relationships.
2.  Reach out for new relationships.
3.  Work on current relationships.
4.  Learn from your mistakes
5.  Do not take relationships for granted

AVOID AVOIDING: Avoid giving up. BE MINDFUL OF POSITIVE EXPERIENCES FOCUS attention on positive events that happen (even very small ones)

• REFOCUS when your mind wanders to future worries, past regrets, current distractions and other thoughts while you PARTICIPATE mindfully in the joyful experience.

  1. Make a list of things that interrupt enjoyment for you and be prepared to TURN the MIND when these things appear.

BE UNMINDFUL OF WORRIES DISTRACT from:

1.  Thinking about when the positive experience WILL END.
2.  Thinking about whether you deserve this positive experience.
3.  Thinking about how much more might be EXPECTED of you now.

Changing Emotions by Acting Opposite to the Current Emotion

Fear

1.  Do what you are afraid of doing…OVER and OVER and OVER.
2.  APPROACH events, places, tasks, activities, people you are afraid of.
3.  Do things to give yourself a sense of control