LearningObjectives
                 DBTDistressToleranceSkills                                                                   Afterthistraining,participantsshouldbeable
                                                                                                                  to:
                                                                                                                  • DeterminewhentouseDBT’sDistress
                 AnnaHink,MSW,LICSW                                                                               Toleranceskillswithyourpatients
                 ClinicianTrainer                                                                                • ListtheDistressToleranceskills
                 UWAIMSCenter                                                                                  • IntegratetheuseofDistressToleranceskills
                                                                                                                     intoyourpractice
                                                                                                                  2
              CaseExample:DS                                                                                    WhatIsACrisis?
                                                                  KeyComplaints                                       Aseriousproblemthat             Thereispressuretosolve
                 54y/oHispanicwoman,liveswith     “There’snothingIcandowhenI’m                          can’tbesolvedrightnow                theproblem,anditis
                       husband,somecollege                inpain;I’marguingwithmy
                                                         husbandallthetime;I’mworried                                                                  difficulttostoptrying
                                                             aboutcancerreturning”
                                                                                                                                                     Crisis
                  OUD.Stoppedopioidsx1week.         BuprenorphineͲNaloxone24Ͳ8mg
                 Longstandinganxiety&depressive                     qd                                           Emotionsarehigh,sothe                    It’sshortͲterm
                             symptoms:                     VenlafaxineXR275mgqd                                    problemisdistressing             Ifitishappeningallthetime,
                     BaselinePHQͲ9=10(mild)                                                                       Highemotionsgenerally             itisnotacrisis.Itisyourlife!
                  BaselineGADͲ7=15(moderate)                                                                          makethingsworse
               3                                                                                                  4
             CanYouSolveTheCrisis?                                                              WhoAreDistressToleranceSkillsFor?
                                 •  Stickwithit                                                               Patients                          Clinicians
               IfYes…           •  Don’ttakeyoureyeofftheball                                         facemanystressors               facemanystressors
                                 •  Dowhatittakes!                                              • Painflares                       • Largecaseloads
                                                                                                    • Frustrationswithmedicalcare    • Difficultandsickpatients
                                                                                                    • Intenseemotions                  • Hearingmanytraumaticstories
                 IfNo          • STOPtryingtosolveit                                            • Familyconflicts                  • Inabilitytohelptheirpatients
                                • Tryingtosolvetheunsolvablecanmakeit                       • Housingissues                    • Lackoftimeorresourcestohelp
                                                                                                    • Moneyissues                       theirpatients
             (ornotright       worseorsendemotionsthroughtheroof                                                                                     with
                                • FocusonDistressTolerance skills                                • Drugsandalcohol                 • Frustratinginteractions
                now)…                                                DTskillsare                • Dangerousneighborhoods           socialservices
                                                                    designedjustfor              • Longwaitsforsocialservices    • Unhelpfulrulesorregulations
                                                                    anunsolvedcrisis                                                   • Paperwork
             5                                                                                      6
             PurposeofDistressToleranceSkills                                                                                   Yellingat
                                                                                                                                    someone
             • Helpyousurvivethecrisisbynotmakingthe                                                      Givingupon                  Usingdrugsor
                situationworse                                                                                       life                           alcohol
             • Notintendedtomakeyoufeelbetter(though                                                                       Waysto
                sometimesyoumight)                                                                                               Worsen
                                                                                                                                   aCrisis
                                                                                                                  Complainingso                    “Retail
             • Ifskillspreventthecrisisfromgettingworse,                                                   muchfolks                    therapy”with
                                                                                                                  don’twantto                   moneyyou
                butyoudonotfeelbetterͲ don’tstop!                                                          talktoyou                    can’taffordto
                                                                                                                                                     spend
                – Anescalatedcrisismaymakeyoufeelworse                                                                       Eatingtoo
                                                                                                                                   muchortoo
                                                                                                                                      little
             7                                                                                      8
                BenefitsofDistressToleranceSkills                                                                       DBTDistressTolerance:The4Steps
                • Learntosurvivea
                   crisiswithout
                   makingitworse                                                                                               Step1:                                 Step3:              Step4:
                                                                                                                                                    Step2:              Choose            FollowͲup,
                • Becomemore                                                                                                 Behavioral      MakethePitch          Strategy&        Evaluateand
                                                                                                                              Assessment                                Determine         ProblemSolve
                   confidentand                                                                                                                                       Homework
                   capableof
                   navigatingfuture
                   crises
                9                                                                                                           10
                Step1:BehavioralAssessment                                                                               Step1:BehavioralAssessment
                AskThreeQuestions:                                                                                       RevisitingCaseExampleͲ DS
                1. Whattriggersthedistress?                                                                              1. Triggers
                     –Bebehavioral(i.e.,talkingwithafamilymember,                                                       ൞ Intensebackpainflaresforhours
                        thinkingathought)                                                                                     ൞ Tendstooverdothingswhenfeelingbetter
                2.Howdidthepatientrespondtodistress?                                                                  2. Response
                     –Bebehavioral(i.e.,yelled/startedafight,stayedin                                                   ൞ Bedbound                                  ൞ isolatesself
                        bedallday)                                                                                            ൞ Doesnoteatorhydrate ൞                      yellsathusband
                     –Listenforhelpfulanddestructivebehaviors                                                          3. WhatMadeitWorse
                3.Howdidtheirresponsemakethingsworse?                                                                     ൞ “IfeelsoguiltyafterIyellatmyhusband.He’s
                     –Fromthepatient’sperspective(notyoursasthe                                                              justtryingtohelp”
                        provider)!
                11                                                                                                          12
            DBTDT:The4Steps                                                               Step2:MakethePitch
                                                                                              • Explaintheconceptofdistresstolerance
                                                                                                  –“Theseareskillstohelpyouwith(1.triggers).
                                                                                                    You’vetoldmeyoutendto(2.response).”
                                               Step3:         Step4:
                Step1:        Step2:        Choose
               Behavioral                    Strategy&     FollowͲup,                    • Explainthegoalofdistresstoleranceskills
               Assessment   MakethePitch    Determine     Evaluateand                        –“Thegoalistonotmakethingsworse.Thisis
                                              Homework      ProblemSolve                           verydifferentthan‘feelingbetter.’”
                                                                                                  –“DTskillshelpyoubringdownyouremotionsso
                                                                                                    youthinkmoreclearly.”
                                                                                                  –“You’vetoldmethingsareworsewhenyou(3.
                                                                                                    whatmadeitworse).”
            13                                                                                14
            Step2:MakethePitch                                                           DBTDT:The4Steps
            RevisitingCaseExampleͲ DS
                “Theseareskillstohelpyouwiththeintensepain
                flaresyouexperience.You’vetoldmeyoutendtoneed
                tostayinbedformanyhours,noteatordrinkwater,                                                          Step3:         Step4:
                isolateyourselffromyourfamily,andyellatyour                              Step1:        Step2:        Choose
                husband.                                                                         Behavioral                    Strategy&     FollowͲup,
                                                                                                Assessment    MakethePitch    Determine     Evaluateand
                                                                                                                               Homework       ProblemSolve
                Thegoalistonotmakethingsworse.Thisisvery
                differentthan‘feelingbetter.’DTskillshelpyoubring
                downyouremotionssoyouthinkmoreclearly.You’ve
                toldmethingsareworsewhenyouyellatyour
                husband.”
            15                                                                                16