I WALK THE LINE Borderline Personality Disorder Presentation by Summer Brunscheen, Ph.D., LP, HSP,...

I WALK THE LINEI WALK THE LINEBorderline Personality Borderline Personality

DisorderDisorderPresentation by Presentation by

Summer Brunscheen, Ph.D., Summer Brunscheen, Ph.D., LP, HSP, LMHCLP, HSP, LMHC

Central Iowa Psychological ServicesCentral Iowa Psychological Services319 Lincoln Way319 Lincoln WayAmes, IA 50010Ames, IA 50010515-233-1122515-233-1122

[email protected]@iowacounseling.com

I walk the line: Johnny Cash

Personality DisordersPersonality Disorders

PD’s enduring, pattern of inner experience PD’s enduring, pattern of inner experience and behavior that deviates markedly from and behavior that deviates markedly from the expectation’s of an individual’s the expectation’s of an individual’s culture, culture,

Pervasive and inflexiblePervasive and inflexible Onset in adolescence or early adulthoodOnset in adolescence or early adulthood

PD PD patternspatterns can be dx as young as age 5! can be dx as young as age 5! (chaotic, disorganized, bizarre, annihilation (chaotic, disorganized, bizarre, annihilation anxiety)anxiety)

Stable over time, leads to distress or Stable over time, leads to distress or impairment (Axis II “is” vs. Axis I “acts”)impairment (Axis II “is” vs. Axis I “acts”)

Personality DisordersPersonality Disorders

Cluster BCluster B Antisocial, Borderline, Histrionic, Antisocial, Borderline, Histrionic,

Narcissistic (dramatic, emotional, erratic)Narcissistic (dramatic, emotional, erratic) BPD affects:BPD affects:

2% of the general population2% of the general population 10% of an outpatient population 10% of an outpatient population 20% of an inpatient population, 20% of an inpatient population, 74% of people diagnosed with BPD are 74% of people diagnosed with BPD are

femalefemale

Borderline Personality Borderline Personality DisorderDisorder

BPD is often comorbid with ADHD, BPD is often comorbid with ADHD, addictive DO’s, and mood disordersaddictive DO’s, and mood disorders

People with BPD are often poly-People with BPD are often poly-substance abusers/self-medicating substance abusers/self-medicating (avg 4.5 medications)(avg 4.5 medications)

BPD per DSM-IV-TR (4 of BPD per DSM-IV-TR (4 of 9)9)

Frantic efforts to avoid real or Frantic efforts to avoid real or imagined abandonmentimagined abandonment

Unstable, intense interpersonal Unstable, intense interpersonal relationships, alternating between relationships, alternating between love and hatelove and hate

Identity disturbance, unstable sense Identity disturbance, unstable sense of selfof self


Impulsiveness in at least 2 areas Impulsiveness in at least 2 areas that are potentially self-damagingthat are potentially self-damaging spending, spending, sex, sex, substance use, substance use, shoplifting, shoplifting, reckless driving, reckless driving, binge eating, binge eating, cuttingcutting


Recurrent suicidal behaviorRecurrent suicidal behavior least likely to attempt when emotionally least likely to attempt when emotionally

upsetupset 8-10% suicide rate8-10% suicide rate Higher among those with SAHigher among those with SA 400 times the rate of general population400 times the rate of general population 800 times the rate found in women 15-34800 times the rate found in women 15-34 5-7 DSM characteristics = 7% suicide rate, 5-7 DSM characteristics = 7% suicide rate,

8 = 36% suicide rate so check, document, 8 = 36% suicide rate so check, document, and increase interventionsand increase interventions


Affective instability (rarely last more than Affective instability (rarely last more than a few hours, even more rarely more than a few hours, even more rarely more than a few days)a few days)

Chronic feelings of emptinessChronic feelings of emptiness Inappropriate, intense anger or lack of Inappropriate, intense anger or lack of

control of anger, frequent displays of control of anger, frequent displays of temper, constant anger, recurrent temper, constant anger, recurrent physical fightsphysical fights

Transient stress-related paranoid Transient stress-related paranoid ideation, severe dissociative symptomsideation, severe dissociative symptoms

Additional Additional CharacteristicsCharacteristics

Disturbance in Self conceptDisturbance in Self concept Low Social Functioning/Unstable Low Social Functioning/Unstable

interpersonal relationshipsinterpersonal relationships Negative affect/Labile affectNegative affect/Labile affect Dichotomous thinkingDichotomous thinking


Cognitive DisturbancesCognitive Disturbances Unrelenting crisesUnrelenting crises Active passivityActive passivity Expressively SpasmodicExpressively Spasmodic


SplittingSplitting Self-Perpetuating Intrapsychic and Self-Perpetuating Intrapsychic and

Interpersonal ProcessesInterpersonal Processes Counter Separation ManeuversCounter Separation Maneuvers Impulsive behaviorsImpulsive behaviors


Sleep DisordersSleep Disorders Intimacy TerrorIntimacy Terror Catastrophic ThinkingCatastrophic Thinking ManipulativeManipulative Functional FailuresFunctional Failures

Differential DiagnosisDifferential Diagnosis

GET A REALLY COMPLETE GET A REALLY COMPLETE ASSESSMENT (including past treatment ASSESSMENT (including past treatment history)history)

Mood DisordersMood Disorders BPD: Bipolar = QUICK mood changes, when BPD: Bipolar = QUICK mood changes, when

depressed is still impulsive, bipolar shifts are depressed is still impulsive, bipolar shifts are neurological, BPD shifts are environmental neurological, BPD shifts are environmental (can see what is triggering the mood shifts)(can see what is triggering the mood shifts)

BPD: Depressive Suicidality = BPD BPD: Depressive Suicidality = BPD motivated by wish to gain sympathetic and motivated by wish to gain sympathetic and binding response, depressive motivated by binding response, depressive motivated by despair and hopelessnessdespair and hopelessness

Differential DiagnosisDifferential Diagnosis

PTSDPTSD Eating DisordersEating Disorders Substance AbuseSubstance Abuse From other PD’sFrom other PD’s

Tools for AssessmentTools for Assessment

Clinical interview: Clinical interview: historical patterns, historical patterns, relationship patterns, relationship patterns, suicide attempts/self harm, suicide attempts/self harm, psychotic symptoms, psychotic symptoms, abuse historyabuse history

Tools for assessmentTools for assessment

Self-Report (Interview) Instruments: Self-Report (Interview) Instruments: Diagnostic Interview for Borderline Diagnostic Interview for Borderline

Personality Disorders-Revised, Personality Disorders-Revised, Structured Clinical Interview for DSM-Structured Clinical Interview for DSM-

III-R Personality Disorders, III-R Personality Disorders, PAI, PAI, Borderline Personality Inventory, Borderline Personality Inventory, Objective Behavioral IndexObjective Behavioral Index

AssessmentAssessment

Self Harm InventorySelf Harm Inventory Beck Scale for Suicidal IdeationBeck Scale for Suicidal Ideation Suicide Probability ScaleSuicide Probability Scale MMPI-2MMPI-2 RorschachRorschach MCMI-IIMCMI-II

Suicide AssessmentSuicide Assessment

Previous suicidal attempts, lethal in Previous suicidal attempts, lethal in naturenature

SpecificitySpecificity Level of commitmentLevel of commitment Availability of instrumentsAvailability of instruments Level of impulsivityLevel of impulsivity Substance useSubstance use Social support availabilitySocial support availability

Self Harm Behaviors: Self Harm Behaviors: Attempts to “kill the pain”Attempts to “kill the pain”

Cutting: e.g. Cutting: e.g. arms, legs, arms, legs, stomach (80%)stomach (80%)

Bruising (24%)Bruising (24%) Burning (20%)Burning (20%) Head banging Head banging

(15%)(15%) Biting (7%)Biting (7%)

SpendingSpending GamblingGambling Substance AbuseSubstance Abuse PromiscuityPromiscuity ShopliftingShoplifting Reckless drivingReckless driving Binge eatingBinge eating

Self harm behaviorsSelf harm behaviors Gestures, threats, attempts, Gestures, threats, attempts,

parasuicidal acts, self-mutilation parasuicidal acts, self-mutilation As a way to communicate distressAs a way to communicate distress 90% show self-destructive behavior 90% show self-destructive behavior

in the broad sensein the broad sense 75% have at least 1 self-damaging 75% have at least 1 self-damaging

act, act, 75% of acts occur b/n 18-45 years 75% of acts occur b/n 18-45 years

oldold

Self harm behaviorsSelf harm behaviors

We have three pain systemsWe have three pain systems SharpSharp Hot/coldHot/cold BluntBlunt

Can find out what the “just right” Can find out what the “just right” sensation is and then do cognitive sensation is and then do cognitive construction of WHY do itconstruction of WHY do it

Self harm behaviorsSelf harm behaviors

Presence of self-injurious behaviors Presence of self-injurious behaviors doubles the likelihood of suicidedoubles the likelihood of suicide

Suicidal behavior NOT necessarily Suicidal behavior NOT necessarily related to comorbid depressionrelated to comorbid depression

Self harm acts often start as self-Self harm acts often start as self-punitive measures or ways to control punitive measures or ways to control affect then take on increasing affect then take on increasing awareness and purpose of awareness and purpose of controlling otherscontrolling others

Research into the Cause Research into the Cause of BPDof BPD

Psychoanalytic/Psychological/Psychoanalytic/Psychological/Developmental ModelsDevelopmental Models

Trauma (Abuse) ModelTrauma (Abuse) Model Interpersonal/family psychological Interpersonal/family psychological

modelsmodels Genetic/biological modelsGenetic/biological models

Therapeutic Therapeutic ApproachesApproaches

Management contextManagement context

Interventions done TO the clientInterventions done TO the client Competency desired (not designed to create Competency desired (not designed to create

self internal change)self internal change) Reduce chaos, avoid worsening, manage Reduce chaos, avoid worsening, manage

crises, try to correct distorted relations with crises, try to correct distorted relations with helping systemshelping systems

Use when history of: failed tx, worsening in Use when history of: failed tx, worsening in tx, abusing the system, no motivation for txtx, abusing the system, no motivation for tx

Use when the individual is not your Use when the individual is not your psychotherapy clientpsychotherapy client

Therapeutic ApproachesTherapeutic Approaches

Dialectical Behavior TherapyDialectical Behavior Therapy Medications: Medications:

MAOI’s, SSRI’s, TCA’s, Neuroleptics, MAOI’s, SSRI’s, TCA’s, Neuroleptics, Lithium Bicarbonate, Anticonvulsants, Lithium Bicarbonate, Anticonvulsants, Opiate Antagonists, Benzodiazepines Opiate Antagonists, Benzodiazepines

Psychodynamic ApproachPsychodynamic Approach Interpersonal Psychotherapy Interpersonal Psychotherapy Cognitive PsychotherapyCognitive Psychotherapy

Therapeutic approachesTherapeutic approaches

Psychoanalytic Approach Psychoanalytic Approach Cognitive Analytic TherapyCognitive Analytic Therapy Relapse PreventionRelapse Prevention Group PsychotherapyGroup Psychotherapy Psycho-Educational TherapyPsycho-Educational Therapy Family TherapyFamily Therapy

Dialectical Behavior Dialectical Behavior TherapyTherapy

developed by developed by Marsha M. Marsha M.

LinehanLinehan

DBTDBT

Developed in the 1970’s by Marsha Developed in the 1970’s by Marsha Linehan and colleaguesLinehan and colleagues

Originally designed to treat suicidal Originally designed to treat suicidal behaviorsbehaviors

The only currently Empirically Validated The only currently Empirically Validated Treatment for BPDTreatment for BPD

Long term therapy not short term: best if Long term therapy not short term: best if in both individual and group DBT therapyin both individual and group DBT therapy

faculty.washington.edu/linehan

Goals of Skills Training Goals of Skills Training in DBTin DBT

Behaviors to Increase (Skills)Behaviors to Increase (Skills) MindfulnessMindfulness Distress toleranceDistress tolerance Emotion RegulationEmotion Regulation Interpersonal EffectivenessInterpersonal Effectiveness Walking the Middle Path/Finding the Walking the Middle Path/Finding the

BalanceBalance

Goals of Skills Training Goals of Skills Training in DBTin DBT

Behaviors to Decrease Behaviors to Decrease (Problems)(Problems) Confusion about yourselfConfusion about yourself ImpulsivityImpulsivity Emotional InstabilityEmotional Instability Interpersonal ProblemsInterpersonal Problems Adolescent & Family DilemmasAdolescent & Family Dilemmas

DBT AssumptionsDBT Assumptions

You are doing the best you can.You are doing the best you can. You want to improve.You want to improve. You need to do better, try harder, You need to do better, try harder,

and be more motivated to change.and be more motivated to change.


You may not have caused all of your You may not have caused all of your own problems but you need to solve own problems but you need to solve them anyway.them anyway.

The lives of suicidal & depressed The lives of suicidal & depressed adolescents are painful as they are adolescents are painful as they are currently being lived.currently being lived.

It will generally be more effective for It will generally be more effective for you to learn new behaviors in all the you to learn new behaviors in all the important situations in your life.important situations in your life.


There is no absolute truth.There is no absolute truth. It will generally be more effective if It will generally be more effective if

you and your family would take you and your family would take things in a well meaning way rather things in a well meaning way rather than assuming the worst.than assuming the worst.

You cannot fail in DBT.You cannot fail in DBT.

DBT SkillsDBT Skills

DialecticsDialectics Finding the middle pathFinding the middle path ValidationValidation

AcceptanceAND

Change =Middle Path

Acceptance Change

DialecticsDialectics

Dialectics:Dialectics:Finding the Middle Path- Finding the Middle Path-

BalanceBalance

Holding on too tight

Forcing independence

GIVING YOURSELF/YOUR ADOLESCENT GUIDANCE, SUPPORT,AND RULES TO HELP YOURSELF/YOUR ADOLESCENT FIGUREOUT HOW TO BE RESPONSIBLE WITH YOUR/THEIR INCREASED

FREEDOMAnd at the same time

SLOWLY GIVING YOURSELF/YOUR ADOLESCENT GREATERAMOUNTS OF FREEDOM AND INDEPENDENCE WHILE ALLOWING

AN APPROPRIATE AMOUNT OF RELIANCE ON OTHERS

Learning to think dialectically: Learning to think dialectically: Practice Practice

ID the dialectic statement:ID the dialectic statement:

a) No one ever listens to me.a) No one ever listens to me.

b) People are always available to me and listen to b) People are always available to me and listen to whatever I feel.whatever I feel.

c) Sometimes I do not feel listened to and it is c) Sometimes I do not feel listened to and it is very frustrating.very frustrating.

Learning to think dialectically: Learning to think dialectically: PracticePractice

ID the dialectic statement:ID the dialectic statement:

a) I may not have caused all of my problems, a) I may not have caused all of my problems, but I need to solve but I need to solve them anyway. them anyway.

b) It is not my fault that I have these problems so b) It is not my fault that I have these problems so I am not going to even try.I am not going to even try.

c) All of my problems are my own fault.c) All of my problems are my own fault.

ValidationValidation

What is validation?What is validation? Validation Validation communicates to another personcommunicates to another person

that his or her responses (feelings, thoughts, that his or her responses (feelings, thoughts, actions) make sense and are actions) make sense and are understandable understandable to youto you in a particular situation. in a particular situation.

Acknowledgement (observing & describing Acknowledgement (observing & describing nonjudgmentally) “I can see that you are really nonjudgmentally) “I can see that you are really upset now”upset now”

Acceptance: “I know you are upset.” “I am upset”.Acceptance: “I know you are upset.” “I am upset”.

ValidationValidationREMEMBER:

VALIDATING IS NOT NECESSARILY AGREEING

VALIDATING DOES NOT MEAN THAT YOU LIKE WHAT THE OTHER PERSON IS DOING, SAYING, OR

FEELING

Validation/Invalidation Levels Validation/Invalidation Levels and Typesand Types

ValidationValidation Basic attention, listening, Basic attention, listening,

ordinary non-verbalsordinary non-verbals Reflecting or Reflecting or

acknowledging the other’s acknowledging the other’s disclosures; what she/he is disclosures; what she/he is thinking/feeling/wanting; thinking/feeling/wanting; or functionally responding or functionally responding to her/him by answering or to her/him by answering or problem-solvingproblem-solving

Articulating/offering ideas Articulating/offering ideas about what the other about what the other might want/feel/think, etc., might want/feel/think, etc., in an empathic way; in an empathic way; helping the other clarify; helping the other clarify; asking questions to help asking questions to help clarifyclarify

InvalidationInvalidation Not paying attention, Not paying attention,

distractible, changes, distractible, changes, changes subject, anxious changes subject, anxious to leave or to end the to leave or to end the conversationconversation

Not participating actively, Not participating actively, missing ordinary missing ordinary conversational validation conversational validation opportunities, not opportunities, not providing evidence of providing evidence of tracking the other person; tracking the other person; functionally unresponsivefunctionally unresponsive

Telling the other person Telling the other person what she/he DOES what she/he DOES feel/think/ want, etc. even feel/think/ want, etc. even when the other provides when the other provides contradictory statements; contradictory statements; or telling what she/he or telling what she/he SHOULD feel/etc. SHOULD feel/etc.

Validation/Invalidation Levels Validation/Invalidation Levels and Typesand Types

ValidationValidation Recontextualizing the Recontextualizing the

other’s behavior; putting other’s behavior; putting more positive spin on it; more positive spin on it; acceptance because of acceptance because of history; reducing the history; reducing the negative valence.negative valence.

Normalizing other’s Normalizing other’s behavior given present behavior given present circumstancescircumstances

Empathy, acceptance of the Empathy, acceptance of the person in general; acting person in general; acting from balance about the from balance about the relationship; not treating the relationship; not treating the other as fragile or other as fragile or incompetent, but rather as incompetent, but rather as equal & competent.equal & competent.

Reciprocal vulnerability/ Reciprocal vulnerability/ self-disclosure in context of self-disclosure in context of the other’s vulnerability, & the other’s vulnerability, & the focus stays on the other the focus stays on the other personperson

InvalidationInvalidation Agreeing with other person’s Agreeing with other person’s

self-invalidation when self-invalidation when behavior makes sense in behavior makes sense in terms of history & could be terms of history & could be spun differently; increasing it spun differently; increasing it negative valencenegative valence

Criticizing other’s behavior Criticizing other’s behavior when it is reasonable or when it is reasonable or normative in present normative in present circumstancescircumstances

Patronizing, condescending, Patronizing, condescending, &/or contemptuous behavior &/or contemptuous behavior toward the other; treating the toward the other; treating the other as not equal or other as not equal or incompetent; character incompetent; character assaults/ over-generalizing assaults/ over-generalizing negatives.negatives.

Leaving the other person Leaving the other person hanging out to dry; not hanging out to dry; not responding to his/her responding to his/her vulnerable self-disclosures, vulnerable self-disclosures, thereby assuming a more thereby assuming a more powerful position.powerful position.

Mindfulness Handout 1Mindfulness Handout 1

Taking Hold of Your Taking Hold of Your Mind:Mind:

Reasonable Mind

Emotional Mind

Wise Mind

States of Mind


MindfulnessMindfulness Emotional MindEmotional Mind Analytical MindAnalytical Mind Wise MindWise Mind HOW skillsHOW skills WHAT skillsWHAT skills

DBT skillsDBT skills

Distress ToleranceDistress Tolerance Crisis SurvivalCrisis Survival

ACCEPTSACCEPTS Self-SoothingSelf-Soothing IMPROVE the momentIMPROVE the moment Thinking of Pro’s and Con’s (ST and Thinking of Pro’s and Con’s (ST and

LT)LT)

Remember…Remember…

ACCEPTANCE OF REALITY IS NOT ACCEPTANCE OF REALITY IS NOT EQUIVALENT TO THE APPROVAL EQUIVALENT TO THE APPROVAL

OF REALITYOF REALITY

Coping with Urges & Feelings:Coping with Urges & Feelings:Why Bother Why Bother

Coping with emotional pain is important Coping with emotional pain is important for three main reasons:for three main reasons: Pain is a part of life & can’t always be Pain is a part of life & can’t always be

avoided.avoided.

If you can’t deal with your pain, you may act If you can’t deal with your pain, you may act impulsively.impulsively.

When you act impulsively, you may end up When you act impulsively, you may end up hurting yourself or not getting what you want.hurting yourself or not getting what you want.

Radical AcceptanceRadical Acceptance

Suffering is not accepting painSuffering is not accepting pain Acceptance is:Acceptance is:

Letting go of fighting realityLetting go of fighting reality Turning suffering you can’t cope with Turning suffering you can’t cope with

into pain you can cope withinto pain you can cope with Acceptance is NOT approvalAcceptance is NOT approval

Acceptance MythsAcceptance Myths

Three myths about acceptance:Three myths about acceptance: If you refuse to accept something, it will If you refuse to accept something, it will

magically change.magically change.

If you accept your painful situation, you If you accept your painful situation, you will become soft & just give up (or give will become soft & just give up (or give in)in)

If you accept your painful situation, you If you accept your painful situation, you are accepting a life of painare accepting a life of pain

WillingnessWillingness

Cultivate a willing response to each Cultivate a willing response to each situationsituation Willingness is Willingness is doing just what is doing just what is

neededneeded in each situation. It is focusing in each situation. It is focusing on effectiveness.on effectiveness.

Willingness is listening very carefully to Willingness is listening very carefully to your your wise mindwise mind, acting from your inner , acting from your inner selfself

(Over) Willfulness(Over) Willfulness

Replace willfulness with willingnessReplace willfulness with willingness Willfulness is Willfulness is sitting on your handssitting on your hands when when

action is needed, refusing to make changes action is needed, refusing to make changes that are needed.that are needed.

Willfulness is Willfulness is giving upgiving up.. Willfulness is the Willfulness is the opposite of “doing opposite of “doing

what works”what works”, or being effective., or being effective. Willfulness is trying to Willfulness is trying to fixfix every situation. every situation. Willfulness is Willfulness is refusing to toleraterefusing to tolerate the the

moment.moment.


Emotion RegulationEmotion Regulation Reducing vulnerability: STRONG skillsReducing vulnerability: STRONG skills Increase positive emotionsIncrease positive emotions Opposite ActionOpposite Action

Short List of EmotionsShort List of Emotions

LoveLove HateHate FearFear JoyJoy ShameShame

GuiltGuilt AnxietyAnxiety LonelinessLoneliness AngerAnger FrustratioFrustrationn

SadnessSadness ShynessShyness BoredomBoredom SurpriseSurprise NumbnesNumbnesss

ConfusioConfusionn

CuriositCuriosityy

SuspiciousnSuspiciousnessess RageRage InterestInterest

DepressioDepressionn

WorryWorry HopelessnesHopelessnesss

IrritabiliIrritabilityty

PanicPanic

JealousyJealousy OptimisOptimismm

EmbarrassmEmbarrassmentent PainPain SympathySympathy

Research suggests all emotions can be categorized by the 7 basic emotions

The Interaction of Emotions The Interaction of Emotions With Thoughts & BehaviorsWith Thoughts & Behaviors

Actions

Thoughts about the event

Body Reactions

Emotions about event

Event

Taking Charge of Your Taking Charge of Your Emotions:Emotions:

Why Bother? Why Bother? Taking charge of your emotions is Taking charge of your emotions is

important because:important because: Suicidal & depressed adolescents often Suicidal & depressed adolescents often

have intense emotions, such as anger, have intense emotions, such as anger, frustration, depression or anxiety.frustration, depression or anxiety.

Difficulties controlling these emotions Difficulties controlling these emotions often lead to suicidal & other self-often lead to suicidal & other self-destructive behaviors.destructive behaviors.

Suicidal & other self-destructive actions Suicidal & other self-destructive actions are often behavioral solutions to intensely are often behavioral solutions to intensely painful emotions.painful emotions.

Pleasant Activities ListPleasant Activities List

Make a list of fun, SAFE, things you Make a list of fun, SAFE, things you can do to DISTRACT, SELF-can do to DISTRACT, SELF-SOOTHE, increase positive SOOTHE, increase positive emotions, lower negative moods, can emotions, lower negative moods, can be opposite actionsbe opposite actions

Opposite ActionOpposite Action

Step 1Step 1 Figure out what emotion you are Figure out what emotion you are

experiencing. You may need to do step experiencing. You may need to do step 2 first if this is difficult.2 first if this is difficult.

Step 2Step 2 Determine the action urge, in other Determine the action urge, in other

words, what you feel like doing.words, what you feel like doing.

Opposite ActionOpposite ActionAction Urge for the 7 Basic Action Urge for the 7 Basic

EmotionsEmotions

EMOTIONEMOTION ACTION ACTION URGEURGE

InterestInterest ----------------------------------------------

ExploreExplore

SadnessSadness ----------------------------------------------

WithdrawWithdraw

AngerAnger ----------------------------------------------

AttackAttack

ShameShame ----------------------------------------------

HideHide

FearFear ----------------------------------------------

Run/AvoidRun/Avoid

LoveLove ----------------------------------------------

ApproachApproach

JoyJoy ----------------------------------------------

Being ActiveBeing Active


Step 3Step 3 Ask yourself, “Do I want to reduce this emotion?”Ask yourself, “Do I want to reduce this emotion?”

It is very difficult to actually do Opposite Action if you It is very difficult to actually do Opposite Action if you are not genuinely interested in changing the emotion. In are not genuinely interested in changing the emotion. In some situations a person might have a negative emotion some situations a person might have a negative emotion that he or she would prefer not having, but does not that he or she would prefer not having, but does not want to change, as in grief at the loss of a loved one.want to change, as in grief at the loss of a loved one.

Set 4Set 4 Figure out the emotion’s opposite action.Figure out the emotion’s opposite action.

Step 5Step 5 This involves actually doing Opposite Action all This involves actually doing Opposite Action all

the way.the way.


EmotionEmotion ActionAction Opposite ActionOpposite Action

Afraid/FearAfraid/Fear Run/AvoidRun/Avoid ApproachApproach

AngerAngerAttack/Attack/Judgmental Judgmental ThoughtsThoughts

Gently AvoidGently Avoid

SadSad WithdrawWithdraw Get ActiveGet Active

ShameShame HideHide ApproachApproach

DBT skillsDBT skills Interpersonal EffectivenessInterpersonal Effectiveness

Keeping a good relationshipKeeping a good relationship GIVE skillsGIVE skills

Getting someone to do what you wantGetting someone to do what you want DEAR MAN skillsDEAR MAN skills

Keeping your self-respect Keeping your self-respect FAST skillsFAST skills

Ask for Something? Ask for Something? Say No to Something? (Cont)Say No to Something? (Cont)

In order to decide whether to ask for In order to decide whether to ask for or say no to something, the things one or say no to something, the things one needs to consider include:needs to consider include: PrioritiesPriorities CapabilityCapability TimelinessTimeliness AuthorityAuthority RightsRights RelationshipRelationship

What Stops You From Achieving What Stops You From Achieving Your Goal? Your Goal?

Lack of skillLack of skill You actually don’t know what to say or how You actually don’t know what to say or how

to act.to act. Worry thoughtsWorry thoughts

You have the skill, but your worry thoughts You have the skill, but your worry thoughts interfere with doing or saying what you interfere with doing or saying what you want.want.

EmotionsEmotions Can’t DecideCan’t Decide EnvironmentEnvironment

Questions? Comments?Questions? Comments?

[email protected] 515-233-1122515-233-1122

Thank you for coming!Thank you for coming!

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