DBT for Trauma: Dialectical Thinking and Distress Tolerance
By Sheri Van Dijk, MSW, RSW & Dr. Kirby Reutter, Ph.D., DBTC, LMHC, MAC.
This presentation is an excerpt from the online course “DBT Expert Interviews: From Trauma to Eating Disorders“.
In this segment, Dr. Kirby Reutter, Ph.D., explores specific strategies for teaching the following skillsets to traumatized individuals: dialectical skills to balance underthinking vs overthinking; distress tolerance skills to balance underreacting vs overreacting; emotion regulation skills to balance under-feeling vs over-feeling; and interpersonal effectiveness skills to balance too much independence/aggression vs too much dependence/passivity.
Throughout this segment, Kirby explains how he customizes each of these skill sets specifically for trauma symptoms, including an extended garden analogy.
How to Use Dialectics for Trauma
Sheri: How do you use dialectics on trauma?
Kirby: When I’m doing DBT with clients who have gone through a traumatic situation, I’m dealing with the dialectical dilemmas and teaching them how to think more dialectically.
I’ve developed the acronym TOM and I call this working the TOM. It stands for thought, opposite, middle. The point is for the clients to catch some of their extreme thoughts and notice them, then go to the opposite of that extreme thought, and land somewhere in the middle.
For example, if they notice the extreme thought of “I am such an idiot. I can’t do anything right,” the complete opposite would be “I am an absolute genius in everything in life. I am perfect.” Something in the middle would be “There’re some things I’m good at. There’re some things that I need to grow in.”
Another way I teach dialectics to my clients is using the pros and cons skill. If you can help clients sort through, “What are the pros and cons of doing things how I normally do them vs the pros and cons of using one of my skills?” you’re helping the client think from multiple angles. This is the whole point of dialectics. Instead of being fixated on just one potential response, we’re going to broaden our spectrum.
We all tend to have a negative bias. We tend to see things as more negative than they are in real life. Using words with a negative connotation is a good indicator of a strong negativity bias. The dialectical synonyms can correct that. For example, if you have a judgmental thought about someone, “He is so cheap and stingy,” instead say, “He’s very frugal.”
It’s a slightly different way of saying the same thing but with a positive spin to counteract that negativity bias.
Distress Tolerance and PTSD
Sheri: Do you use distress tolerance skills with PTSD?
Kirby: Absolutely. One of the symptoms of PTSD is experiencing intense psychological and/or physiological reactions to trauma reminders. Someone with PTSD will underreact, overreact, or both to trauma reminders. Therefore, distress tolerance is important. I teach the same distress tolerance skills from DBT from Marsha Linehan’s manual.
There are a lot of acronyms in DBT. This can be a pro or a con, depending on your preference. A lot of my clients get overwhelmed by too many acronyms. That’s why I teach them the basic skills from the manual but without the acronym. I teach them to change their temperature, to take many vacations, to do paced breathing, self-soothing with their 5 senses, and muscle relaxation, without the acronym.
I help the client come up with their own personalized, customized coping card. This can be an index card, something that they could put on their key chain, or it can be an app on their phone. There are plenty of options to use technology.
The coping card needs to be immediately accessible to the client, within reach at all times. The coping card is their temporary wise mind or balanced mind. If they lose their coping card, they’ve lost their wise and balanced minds. The coping card is basically what they need to do when they’re not in their balanced mind.
Then I teach my clients to learn to visualize these coping skills. The reason for that is because they’re not always going to be able to use one of their coping skills. Therefore, the best thing to do next is to use imagery to visualize using the skill.
DBT also has this idea of cope ahead. Don’t wait until the next crisis to try out one of your coping skills. Practice it ahead of time. Visualize it ahead of time before the crisis.
Applying Emotion Regulation
Sheri: How do you apply emotion regulation skills with PTSD clients?
Kirby: I use the same basic skills from Marsha Linehan’s manual and I’ve also developed the garden analogy to help explain all of these different emotion regulation skills.
For example, if your goal is to have a garden full of vegetables by the end of the summer, it’s not going to do any good to manipulate, judge, or yell at your vegetables. What you need to do is to take care of the garden, nurture it, cultivate it.
A lot of times, we want to control, manipulate, or judge our emotions. That’s not how you take care of a real garden or your emotions. This analogy helps plant the seed for a paradigm shift. We need to have a different way of relating to our emotions.
DBT has this idea that you need to learn to take care of your body because there’s an obvious mind-body connection. If your body’s out of whack, your emotions will be too. I call that planting the SEEDS.
The first thing we need to do to have a healthy garden of emotions is to plant the right SEEDS. SEEDS stands for symptoms, eating, exercise, drugs, and sleep. If any one of those systems is out of whack, your emotions will be out of whack too.
We teach our clients to take care of their physical symptoms. For example, it’s hard to be emotionally stable when you’re in chronic pain. I also teach clients to have healthy, balanced, portioned eating habits and basic levels of exercise.
In a real garden, even if we’ve planted the right seeds, we still need to do some maintenance and weeding. One of the things we need to help our clients weed out are misconceptions they have about emotions themselves. What is their theory of emotions? Do they have beliefs such as “Emotions are just stupid and I’d be much better off if I didn’t even have them”?
Something else we need to do in a real garden is to check the soil. With emotion regulation, we need to help our clients with fact-checking. Make sure they’re grounded in the right information. DBT has skills for that.
Something else we need to do in a real garden is some basic pest control because no matter how well we’re maintaining this garden, if predators are attacking it, we’re not going to have much of a garden left. Part of DBT emotion regulation is teaching our clients better problem-solving skills.
Sometimes our clients will have the day in which they don’t give a rip about this garden of emotions anymore and they want to destroy it. That’s when we teach our clients to act opposite. I prefer the term act opposite rather than opposite action because when you’re doing the opposite of what you feel like doing, it doesn’t feel natural. I tell clients, “It doesn’t have to feel natural. It’s just an act anyway. We’re just going to act opposite.” That’s when we help clients go in the opposite direction of their urge. When they feel like blowing up this garden, do some basic maintenance.
Finally, in a real garden, we also need to fertilize. DBT has some ways that we can help fertilize our emotions. This is Marsha Linehan’s ABC acronym. These are things clients need to do to their garden of emotions every single day.
The A is add positives. Don’t wait for something positive to happen. Every single day, make sure there’s something positive that happens on your schedule. The B stands for build mastery. Every single day, do something that helps you feel constructive or productive as a person, to build self-efficacy. The C stands for cope ahead. Don’t wait for the next crisis to try out your skills. Apply your skills every single day. I’ve added a D, so my acronym is ABCD. The D is every single day, do something personally meaningful for you because DBT is about building a life worth living.
With the garden analogy, we shift the focus from trying to control your emotions to nurturing and cultivating them, just the same way we would with a garden.
Interpersonal Effectiveness Skills and PTSD
Sheri: How do you use interpersonal effectiveness skills with clients with posttraumatic stress disorder?
Kirby: One basic skill is the DEAR MAN skill. When I’m applying DBT to my clients who have gone through a traumatic situation, I tweak it. I call it DEAR Adult. I wanted to make the skill a little more gender-neutral.
At a more practical clinical level, the majority of my clients have been traumatized by men. So if I’m teaching them this interpersonal effectiveness skill called DEAR MAN, the skill itself can be triggering based on the name alone.
DEAR is an acronym that stands for—according to Marsha Linehan’s manual—describe, express, assert, reinforce. I still use D for describe. If you’re going to have a difficult conversation, first describe with facts the situation that needs to be addressed.
The E stands for express. Express how you feel about that situation using “I feel” statements. I’ve expanded the E to also include empathize.
The A stands for assert. I use the A for assert, appreciate, and apologize.
The R stands for reinforce. What I’ve found is that probably the best way to reinforce the relationship itself is to make sure you frame your request as a win-win. Otherwise, I’m simply describing, expressing, asserting from my perspective alone.
What I tell clients is, “At some point in the skill, the ’me’ has to become a ’we.’” The M has to turn around and become a W for this to work.
Instead of DEAR MAN, I have a DEAR Adult. I use the adult as a reminder to stay grounded in the middle. Clients who have been traumatized tend to go to either one extreme or the other when they’re triggered in relationships.
One extreme is when they use the parent voice that’s yelling, screaming, and lecturing. The other extreme is using the child voice that’s whining, pouting, and throwing a temper tantrum. The middle ground between those 2 extremes is to use the adult voice.
- Since people who have gone through traumatic experiences are caught at the extremes of both underthinking and overthinking, the following dialectical thinking skills help clients find more balanced thought patterns: pros and cons, dialectical synonyms, and working the TOM (thought, opposite, middle).
- Since people with PTSD are caught at the extremes of both underreacting and overreacting to trauma reminders and other life stressors, distress tolerance skills help clients find more balanced ways to manage their triggers. In particular, clients need to learn to visualize their coping skills and create a coping card, which can be either paper or electronic, as an accessible reminder for more balanced functioning.
- Since people who have gone through traumatic experiences are caught at the extremes of both under-feeling and over-feeling, emotion regulation skills can help clients find more balanced ways to nurture their emotions. The garden analogy aims to help clients understand the necessary paradigm shift away from attempting to control or coerce their emotions towards learning to cultivate healthier emotional habits.
- Since people with PTSD are caught at the extremes of too much aggression/independence vs too much passivity/dependence, interpersonal effectiveness skills help clients find more balanced ways to manage their relationships. The DEAR Adult skill helps clients learn to describe, express, empathize, assert, appreciate, and apologize in ways that reinforce the relationship through win/win thinking and use of the adult voice, which is the middle path between the parent voice vs the child’s voice.
More DBT Expert Interviews: From Trauma to Eating Disorders
- DBT for Chronic Pain: Distress Tolerance and Emotion Regulation
- DBT for Substance Use: Radical Acceptance, Grief, and Recovery-Interfering Behaviors
- DBT for Teens: Teaching Distress Tolerance, Emotional Regulation, and Interpersonal Effectiveness
- DBT Skills for Emotional Dysregulation in Psychosis: A Clinical Case Study
- Emotion Regulation and DBT Skills for Eating Disorders
- DBT for Bipolar Disorder: Informal vs Formal Mindfulness