DBT for LIFE
Skills to Transform the Way You Live
DIANA PARTINGTON
Diana Partington
LPC-MHSP, M.Ed
Illustrations by NIlufer Ustuner
Supplemental Illustrations by Nataliia Mazepa
Blue Lotus Press
This book is dedicated my mentors, teachers, and therapists, my clients, my friends, my mother and my children. Thank you for your support and encouragement. Thank you for all of the ways you show up in my life. My love and gratitude, always.
Introduction............................................................................................................................... 7 How to use this book 7 And…just a little bit about me, your guide ......................................................................................... 10 Soooo, what exactly is DBT?.... 13 Cognitive Behavioral Therapy 15 Dialectical Philosophy ........................................................................................................................... 17 Buddhist Psychology ............................................................................................................................. 18 Unit 1: Mindfulness ........................................................................................................ 23 Benefits of Mindfulness ........................................................................................................................ 24 This emotion is a wave 26 Chapter 1: Mindfulness as a practice ................................................................................... 27 Barracudas, a story about Mindfulness .............................................................................................. 28 Exploring Mindfulness as a skill 32 Ideas for practicing Mindfulness 34 Notes, insights, ideas ............................................................................................................................ 36 Chapter 2: Wise Mind ...................................................................................................... 37 Love Crimes, a story about Wise Mind 38 Exploring Wise Mind ............................................................................................................................. 43 Ideas for practicing Wise Mind 45 Weighing Pros and Cons, a DBT Skill 46 What does your Wise Mind sound like? ............................................................................................. 50 Chapter 3: Observe and the STOP ................................................................................... 51 Saving Thanksgiving, a Story about Observe and STOP, Part I 53 Give yourself a moment to practice the STOP ................................................................................... 57 Saving Thanksgiving, Part II 59 Exploring the STOP skill 62 Exploring the Observe skill................................................................................................................... 63 Ideas for practicing the STOP .............................................................................................................. 64 Ideas for practicing Observe 65 Sacred Pause 66 Chapter 4: Describe ......................................................................................................... 67 Animal Farm, a story about the Describe skill 68 Exploring the Describe skill 73 Ideas for practicing the Describe skill ................................................................................................. 76 Chapter 5: Effectively ...................................................................................................... 77 Trapped and Released, a story about being Effective......................................................................... 78 Exploring the Effectively skill................................................................................................................ 84 Dialectics 85 DBT Assumptions 86 Ideas for practicing the Effectively skill............................................................................................... 90 Ideas for practicing Dialectics 90 Ideas for practicing DBT assumptions 91 Take a moment to BREATHE ................................................................................................................ 92 Table of Contents 3
Unit 2: Interpersonal Effectiveness ............................................................................. 95 Increasing the Effectiveness of your interactions 96 Introduction to Loving Kindness practice 97 Take a moment to practice Loving Kindness ..................................................................................... 98 Chapter 6: Clarifying Priorities ....................................................................................... 99 The Kiss, a story about Clarifying Priorities ...................................................................................... 100 Exploring Clarifying Priorities ............................................................................................................ 108 Objective 109 Relationship 110 Self-Respect ......................................................................................................................................... 111 Ideas for practicing Clarifying Priorities ........................................................................................... 113 How are you influencing the people around you? 114 Chapter 7: The DEAR ...................................................................................................... 116 The Cupcake Committee, a story about the DEAR 116 Exploring the DEAR skill 121 Ideas for practicing the DEAR ............................................................................................................ 123 Small Requests .................................................................................................................................... 123 Big Requests 124 Tips for an important DEAR 126 Chapter 8: Validation .................................................................................................... 127 What’s Popular on TV, a story about Validation 129 Exploring Validation ........................................................................................................................... 134 Body Language .................................................................................................................................... 135 Reflective Listening 136 Mind reading 137 Given everything and Anyone would ............................................................................................... 138 Radical Genuineness .......................................................................................................................... 139 Ideas for practicing Validation 140 Quick guide to the six levels of Validation 141 Take a moment to BREATHE ............................................................................................................. 142 Unit 3: Emotion Regulation ......................................................................................... 145 Raising your emotional set point ..................................................................................................... 146 Functions of emotions ....................................................................................................................... 148 Pleasurable Activities instructions and survey 150 Chapter 9: Check the Facts............................................................................................ 155 Puppy Thief, a story about Check the facts 156 Exploring Check the Facts 164 Core beliefs .......................................................................................................................................... 164 Ideas for practicing Check the Facts ................................................................................................ 168 Common cognitive distortions 170 Chapter 10: Opposite Action ......................................................................................... 171 Don’t Act Crazy in the Psych Ward, a story about Opposite Action … .............................................. 172 Exploring Opposite Action 178 Ideas for practicing Opposite Action 181 Exposure therapy (Opposite Action for anxiety) ............................................................................ 182 Chapter 11: Coping Ahead ............................................................................................. 183 Too Big, a story about Coping Ahead ............................................................................................... 184 Exploring the Coping Ahead skill ...................................................................................................... 192 Ideas for Practicing the Coping Ahead skil 193 Coping Ahead bingo 194 4
Chapter 12: The PLEASE Skill ......................................................................................... 195 Sociopath, a story about the PLEASE skill 196 Exploring the PLEASE skill .................................................................................................................. 204 Behavior Chain Analysis 206 Solution Analysis 207 Ideas for practicing the PLEASE skill ................................................................................................. 208 Tips for a great night’s sleep .............................................................................................................. 210 Chapter 13: Values and Creating a Life Worth Living................................................... 211 Sharp Edges, a story about Values and creating a life worth living ............................................... 212 Exploring your Values and building a life worth living 218 Values vs. goals 218 Vision boards ...................................................................................................................................... 220 Action steps ......................................................................................................................................... 221 Ideas for practicing your Values and building a life worth living 223 Instructions for the Values Assessment Survey 223 Values Assessment Survey ................................................................................................................ 226 Unit 4: Distress Tolerance ........................................................................................... 233 Getting through a crisis without making it worse 233 Distress Tolerance vs avoiding ......................................................................................................... 234 Distress Tolerance decision tree 235 Chapter 14: Radical Acceptance…. ............................................................................... .237 Quiet, a story about Radical Acceptance .......................................................................................... 238 Exploring Radical Acceptance 244 Origins of Radical Acceptance in DBT 245 Willingness and Willfulness ............................................................................................................... 246 Options for responding to a painful situation… 247 Ideas for practicing Radical Acceptance 248 Notes, insights, ideas ......................................................................................................................... 250 Chapter 15: Self-Soothing with the Five Senses .......................................................... 251 Wild Parrots, a story about Self-Soothing with the Five Senses 252 Exploring Self-Soothing with the Five Senses .................................................................................. 260 Ideas for practicing Self-Soothing with the Five Senses ................................................................. 262 Chapter 16: Pushing Away and Distracting with Thought ........................................... 263 Mortified, a story about Pushing Away and Distracting with Thought ......................................... 264 Ho’oponopono 272 Exploring Pushing Away and Distracting with Thought 274 Practicing Pushing Away and Distracting with Thought ................................................................ 278 Make Lists ............................................................................................................................................ 278 Make an appointment to worry 280 Wise Mind Dating Plan 281 Chapter 17: Alternate Rebellion… ................................................................................. 284 Bonfire Girls, a story about Alternate Rebellion 289 Exploring Alternate Rebellion ........................................................................................................... 299 Ideas for practicing Alternate Rebellion .......................................................................................... 301 Take a Moment to BREATHE 302 Conclusion ..................................................................................................................... 304 Glossary of Terms ............................................................................................................................... 308 Index 311 5
Introduction 6
W elcome to the W orld of d ialectical B ehavior t herapy ( d B t ).
This innovative therapy teaches dozens of skills to change how we think, behave, and feel. Using DBT skills can transform the way we live.
Dialectical Behavior Therapy looks at your life and says, “Wow. That has been really hard. Let me show you how to do things differently.”
Are you emotionally sensitive? Most people drawn to DBT struggle with intense emotions. Some of us have a diagnosis, and others don’t.
You can benefit from learning DBT skills even if you don’t have a diagnosis. And if you do have a diagnosis, take comfort. The research shows that DBT is effective for recovery from depression, bipolar disorder, substance use disorder, eating disorders, issues with suicide and self-harm, and borderline personality disorder.
My name is Diana Partington. I am a DBT therapist. I have written this book as a guide to help you learn DBT skills and apply them to your life.
HOW TO USE THIS BOOK
I want you to enjoy learning skills. I have packed DBT for Life with information, hoping that every minute you spend with this book gives you something helpful to apply to your life. Each skill is taught with a story, an explanation of the skill, and ideas for practicing the skill. I have included original illustrations and graphics to make our journey together even more engaging. I hope you find each chapter meaningful, fun, and easy to read.
Three Ways to Engage with Each Skills Chapter
1. Story
Each skill is introduced with a short story about a person using that skill. I hope you feel an emotional connection with each character and grow with them through their experiences with DBT skills. People of all ages, genders, races, cultures, sexual identities, and socioeconomic classes can benefit from these skills. The characters in the stories reflect that diversity.
Perhaps, as you read the stories, you will see yourself in the characters. Sometimes, you will recognize people you love. All the stories draw from authentic experiences and the lives of real people. But the characters are composites—
Introduction 7
meaning the characters represent many different people who have had similar experiences. I have made every effort to protect the identities of people whose stories inspired me. Ultimately, each story is a work of fiction illustrating the use of DBT skills in the real world.
2. Explanation of the Skill
Each chapter offers an in-depth explanation of the featured skill. These sections are filled with information about DBT, specific skills, and other fun psychology tips and insights. I have also included sidebars with additional information. I hope you find these tidbits of knowledge helpful.
3. Ideas for Practice
This section offers you action steps to take the skills from the page into your life. Please try them out.
I have also included an introduction to each of the four units: Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance.
At the end of the book is a comprehensive glossary of DBT vocabulary and an index to help you find your way back to topics when you need them most.
Choose Your Own Adventure
You may want to read the book from start to finish—and devour every chapter in its entirety—but you don’t have to.
Everyone learns differently. Use this book in whatever ways work for you. I imagine some readers will focus on the stories and others will focus on the explanations or the practices.
Reading the chapters in sequence will help you build your DBT vocabulary, which may be helpful as you work through the book. But you can also reference the glossary and index to help with terms you if you want to read the chapters out of order.
This book is for you. Please write in it. Mark it up. Enjoy it.
For Extra Credit
The chapters of DBT for Life correspond with skills from Marsha Linehan’s DBT Skills Training Handouts and Worksheets, 2nd Edition. You can use DBT for Life together with Linehan’s book for maximum benefit. At the end of each chapter, I have noted the corresponding pages in Linehan’s book. The two books complement each other well.
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Sensitive Content
Often, people who benefit from DBT have a history of trauma. Thus, some of the short stories reference childhood and adult trauma, unskillful behavior, and other sensitive topics. Though trauma is not the focus of this book, I have included a range of experiences and situations to show the scope of DBT skills application. You will find a note about sensitive content under the title of some of the stories. Please take a look and make informed decisions about your mental health. Please listen to your wisdom about what’s right for you. If any stories bring up uncomfortable feelings, please process them with your therapist.
Disclaimers
This book can be a valuable supplement to any type of mental health counseling. However, DBT for Life is not a replacement for therapy. If you are suicidal or struggling with life-threatening behaviors, I strongly urge you to find a local therapist trained in DBT.
If you or someone you know is in a life-threatening emergency in the United States, please dial 911. Or you can call the National Suicide & Crisis Lifeline at 988.
In the United Kingdom, the National Suicide Helpline is 0800-689-5652.
In Canada, call Talk Suicide at 988.
In Australia, crisis support is available through Lifeline at 13-11-14.
In New Zealand, the Mental Health Foundation of New Zealand offers talk or text at 1737.
For most other countries, Wikipedia offers a helpful page of the suicide hotline numbers all over the world:
https://en.wikipedia.org/wiki/List_of_suicide_crisis_lines
One more thing: I am not affiliated with Dr. Marsha Linehan, the creator of DBT, or any of her organizations. This book is an independent project based on her teachings.
Hotline In the United States and Canada
Suicide
988
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AND . . . JUST A LITTLE BIT ABOUT ME, YOUR GUIDE
DBT changed my life. I went through DBT as a client first. Then I became a DBT therapist. You’ll get to know me pretty well as we journey through DBT skills together.
Since I was a young girl, I have struggled with depression. I grew up overseas in Nicaragua, the Philippines, and Indonesia because of my parents’ work. I have traveled extensively and bring that sensibility to these stories.
After graduating high school in Jakarta, I moved back to the United States. I spent the next nineteen years in Los Angeles, where I went to university, met my husband, married, and had two children. Eventually, my husband’s work took us to Nashville, Tennessee, and shortly after, he left me for a woman he met at work. This departure destroyed our family and left me alone in a new state.
I struggled with suicidal urges and thoughts most of my life—attempting suicide twice in my teen years. After my husband left, I could no longer manage my suicidality. The situation was dire. But I love my children dearly and could not abandon them through suicide. I needed help. I needed something to keep me alive. By sheer luck, I encountered a therapist who suggested DBT.
Going through DBT as a patient, I found my toolbox and learned skills to change my life, my behavior (most of the time), and how I experience the world. For me, it was like being reborn . . . and just in time.
Why am I qualified to take you on this journey?
I am a licensed professional counselor with a Master’s Degree from Vanderbilt University (2012). My master’s thesis was about effective teaching of DBT skills for different learning styles. I have completed hundreds of hours of training in DBT, including workshops with Dr. Marsha Linehan and her organization, Behavior Tech, as well as other educational organizations. I worked under the supervision of an experienced DBT psychologist for two years.
Since becoming a licensed professional counselor (2014), I have taught thousands of people DBT skills in DBT groups at a local community college, in a community mental health setting, in residential treatment centers, and in various private practice settings. I have also trained other mental health professionals in applying full DBT, as well as how to teach DBT skills.
As I write this book, I am fifty-four years old. A combination of DBT and trauma therapy extinguished my suicidality. The white noise of suicide, which was always in the background from the time I was five years old until I was thirty-nine, is gone.
I have endless gratitude for Dr. Marsha M. Linehan, the creator of DBT, and the many teachers and therapists who guided me on my DBT journey.
I offer you this book as a way of paying it forward.
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SOOOO, WHAT EXACTLY IS DBT?
Are you ready for a deep dive into the history and ideas behind Dialectical Behavior Therapy?
Hopefully, you have a sense of how this book works. Now, you have a decision to make. You can join me in this next section for a thorough explanation of Dialectical Behavior Therapy. Or you can jump ahead to the skills. Remember, the goal of this book is to make DBT skills accessible and enjoyable. Please adapt the book to your learning style.
The Deep Dive
Dialectical Behavior Therapy can be transformative for anyone dealing with intense emotions. Extensive research has proven its effectiveness for all kinds of mental health issues. For people struggling with depression, bipolar disorder, and other challenging diagnoses, mastering DBT skills is life-changing.
DBT was originally developed to treat suicide and self-harm. For people with persistent suicidal ideation, DBT can be lifesaving.
Do you struggle with suicidal thoughts? Are those thoughts always in the background, almost like white noise? Perhaps you don’t notice them all the time. But when something goes wrong, do those thoughts get much louder? They can be pretty overpowering.
Many people on the DBT therapy journey have struggled with suicidal thoughts their whole lives. Then suddenly, one day, something bad happens, and they listen for their suicidal thoughts— and realize those thoughts are gone.
This can happen for you too.
Dr. Marsha Linehan is the creator of DBT. As a young woman, she was in emotional agony. At eighteen, Linehan was put in a secure psychiatric hospital to keep her from harming herself. She lived there for two years. In her memoir, Building a Life Worth Living, she describes how her faith and a sense of purpose drove her recovery.
After being released from the psychiatric facility, Linehan set out to create the treatment she needed. She got her PhD in research psychology as part of her lifelong journey to help people grow out of a tormented existence into a meaningful life.
In 1993, after years of research, trial and error, and creativity, Linehan published Cognitive-Behavioral Treatment for Borderline Personality Disorder, introducing the world to Dialectical Behavior Therapy.
To create DBT, Linehan drew from Cognitive Behavioral Therapy, Dialectical Philosophy, and Buddhist psychology.
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Dr. Marsha Linehan, creator of Dialectical Behavior Therapy, uses the analogy of escaping from hell to describe the intense emotional suffering and the difficult work of recovery:
“I made a vow to God that I would get myself out of hell and that, once I did, I would go back to hell and get others out.”
Linehan extends the metaphor, imagining that the only way out of hell is to grip the rungs of a steel ladder. At the beginning of the ladder, the metal is scorching hot. It burns! But this is the only way out.
Climbing out of an emotional hell is hard work. Sometimes it’s too hard. And we have to do it anyway. I like to imagine Marsha Linehan at the top of that ladder, encouraging us to keep climbing—and keep using skills.
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Cognitive Behavioral Therapy
Linehan started her research by treating suicidal patients with Cognitive Behavioral Therapy (CBT). The basic idea with CBT is: change your thinking and behavior to change your emotions.
As you grow up, you develop Core Beliefs about yourself. These Core Beliefs can be intensely painful, like I am worthless, or I am unlovable, or Something is wrong with me. They drive our brains to have Automatic Thoughts in response to our environment.
For example, suppose you are starting a new job, and the people aren’t friendly. If you have a Core Belief about no one liking you, you might have the Automatic Thought of Everyone here hates me. However, if you believe people tend to like you, your Automatic Thought might be something like These people don’t seem friendly. I wonder what’s going on?
So much agony grows out of negative Core Beliefs. In Cognitive Behavioral Therapy, the therapist works with you to challenge those Core Beliefs. This transforms the kind of Automatic Thoughts you have, significantly reducing your suffering.
In her research, Linehan found CBT’s focus on change was too invalidating for her suicidal clients. They felt unseen. Many emotionally sensitive people are so used to having their experience invalidated that the emphasis on challenging core beliefs can feel like another round of “You’re overreacting.” The logic-oriented strategies of CBT were not the route out of hell for this population.
Change your thinking and your behavior to change your emotions.
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15
Acceptance vs. Change
Linehan then tried therapies focused on acceptance instead of change. These approaches support and validate the client’s painful life experiences in a way CBT does not.
My journey as a patient started with psychodynamic therapy, focused on acceptance. Some excellent therapists helped me understand why I was so emotional and suicidal. My pain was validated. They helped me understand I had good reasons for being so sensitive.
I knew how I got here, but I didn’t know how to do anything differently. I felt doomed by my past. How would I ever be able to change anything? I wanted someone to show me how. I wanted a tool kit—with tools I could apply to every situation. It turns out this experience is common for many people who end up in DBT.
According to Linehan’s research, therapy that focuses on acceptance and validation leaves people who have suicidal urges feeling stuck and frustrated.
With this knowledge, Linehan determined DBT needed to include profound acceptance as well as targeted strategies for change. People like me (and maybe you?) need to feel deeply accepted and understood as we are. We also need tools and guidance for changing our lives.
“You have considerable power to construct self-helping thoughts, feelings, and actions, as well as to construct self-defeating behaviors. You have the ability, if you use it, to choose healthy instead of unhealthy thinking, feeling, and acting.”
“When someone really hears you without passing judgment on you, without trying to take responsibility for you, without trying to mold you, it feels damn good.”
Dr. Carl Rogers Father of Humanistic Therapy, focused on Acceptance
Dr. Albert Ellis
Cognitive behavioral psychologist, focused on Change
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Dialectical Philosophy
Dialectical thinking recognizes that two opposing truths can be true at the same time. It’s the opposite of black-and-white thinking or all-or-nothing thinking. I think of it as brain yoga because it makes your brain more flexible.
Balancing a stance of acceptance while pushing for change is very Dialectical. When a colleague pointed out the dialectical nature of the treatment Linehan was developing, she responded, “What are Dialectics?”
And voilà! After Linehan visited with the philosophy department at the University of Washington, Dialectical philosophy became a central part of the treatment. Linehan decided that a Dialectical perspective must be incorporated into every aspect of the therapy.
Try flexing and stretching your brain by contemplating some of the Dialectics from Linehan’s DBT Skills Training Handouts and Worksheets, 2nd Edition (page 152):
• You can be by yourself and still be connected to others.
• You may have a valid reason for believing what you believe, and you may still be wrong.
• You can be independent and also want help.
• You need to be accepted exactly as you are, and you need to change.
Two opposing truths can both be true at the same time.
TRUTH TRUTH Introduction
17
Buddhist Psychology
Buddhist psychology is based on the teachings of the Buddha. In the fifth century BCE, a prince named Siddhartha Gautama set out to understand the causes of human suffering and how to overcome them. How do we resolve the suffering caused by death, aging, disease? Loss? And longing?
Siddhartha’s search for these answers led him to many teachers. After years of searching, learning, and practicing the teachings of many gurus, he sat under a bodhi tree, faced numerous challenges, and . . . ultimately, he achieved enlightenment. He was free from the endless cycles of craving and suffering that plague all humans. He became a Buddha (enlightened one) through Mindfulness, nonattachment, and accepting the impermanence of all things.
I think of the Buddha as the first great psychologist. His teachings are highly Effective for reducing suffering in this life. Mindfulness is foundational to his teachings. These Mindfulness strategies have become popular in Western psychology because they are so effective. The first unit of DBT is devoted to powerful Mindfulness practices that can create significant shifts in the way we live our lives.
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THE SIGNIFICANT DIFFERENCE
BETWEEN DBT AND OTHER THERAPIES: THE SKILLS
As Linehan experimented with effective treatments, she added elements of Dialectics and Buddhist psychology, blending them with Cognitive Behavioral Therapy to create something entirely new.
She also drew on many other therapies and ideas to compile DBT skills to help clients learn how to do things differently. This is where the real magic of DBT happens. Over a hundred skills are taught in Dialectical Behavior Therapy. Linehan culled many of these skills from other therapies, and she invented some herself.
DBT skills are an invaluable tool kit for building a life worth living. Skills give us a way to change how we manage our internal and external lives. Imagine being able to navigate a crisis without having it destroy you or walking through a challenging interpersonal conflict with grace and self-respect.
The more you use skills, the more you’ll want to use them— because they will transform your life.
Deep integration of these skills takes a lot of support and work. I hope this book will be a starting point for your journey or supplement other valuable work you are doing in therapy.
Standard DBT, as developed by Linehan, is comprehensive. The standard treatment includes participation in three modes of therapy:
1. DBT skills training group: In this class format, a DBT Skills trainer teaches skills in a group therapy format. With a group of your peers, you learn the skills through lecture, discussion, exercises, and homework.
If you are interested in learning skills in an online environment, I offer skills training groups for people all over the world, as long as they are working with a licensed local clinician. For more information, please visit my website at www. DBTforLife.com. From years of leading DBT Skills Training groups, I firmly believe that we learn and heal most effectively in community.
2. Individual therapy: These sessions focus on applying DBT skills to your life. You work with a therapist one-on-one to reduce unskillful behaviors (like suicidal thoughts and urges, self-harm, explosive anger, drugs, alcohol—basically, any behaviors that mess up your life). You also work on creating a life worth living.
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3. Phone coaching: These are short, as-needed sessions over the phone with your therapist. When you’re really emotional, it’s hard to remember skills. Because of this, phone coaching is a significant part of the treatment. When you’re too upset to think of skills, you call your therapist. Your therapist suggests skills you can use in that moment.
Initially, phone coaching makes you more dependent on your therapist. Instead of exhausting friends and loved ones with calls for help and reassurance, you turn to your therapist for help navigating the situation skillfully in the moment. Gradually, you figure out what skills you need on your own. Eventually, the skills become habits, and you stop relying on your therapist.
Introduction
Any exposure to DBT skills can be helpful. This book will introduce you to many important skills. Please remember that reading this book is no substitute for participating in therapy with a licensed clinician. Doing a full DBT program is the most effective way to learn skills. Research has shown that DBT skills training groups can also be helpful as a stand-alone treatment for depression.
I hope you find this book helpful on your DBT journey, whether you are just starting or have already done a lot of work.
As you read, look for the familiar and the unfamiliar. Some DBT skills will be things you have been doing for years, only you didn’t know they had a name. Some skills will feel familiar. And some skills will revolutionize how you do everything.
As you learn the skills, use them. And create DBT stories of your own.
DBT skills are an invaluable tool kit for building a life worth living.
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Unit 1
