103 | DBT Skills

[MUSIC PLAYING] Welcome to the Brain People Podcast, a show where four mental health experts team up to bring you practical tools for overcoming mental health challenges. The Brain People don't replace your doctor a therapist, but we will give you some extra tools to help you on your journey. So join us as we fight mental illness, one episode at a time. Welcome to the Brain People Podcast. We're doing another episode for you. And I'm Amanda Angus. And I'm a licensed marriage and family therapist. And I'm here with my co-host. Hi, everyone. My name is Dr. Katie Cruz. I'm a licensed clinical psychologist. And today we're going to talk about something that we've actually talked about before. I think it was us that talked about it, too. But we're going to talk about DBT. And we've already done an overview in a previous podcast. But today we're going to review a little bit, just to catch you up if you haven't watched that one yet. But definitely go back and watch that one as well. But Katie, do you want to share a little bit about or review with us a little bit about DBT? So we're all on page. Yes. So DBT, Guy Lactical Behavioral Therapy, is another common and popular therapy these days. And not going into all the specifics. But basically, DBT took in a lot of different skills of other therapies to create kind of a one toolbox with a lot of different tools. And it has four main modules. So four main sections and within these sections are a lot of skills as well. And one of those modules we'll cover today or introduce today. But before, include mindfulness, distressed tolerance, emotion regulation, and interpersonal effectiveness skills. So I talked to you before this. And we're going to talk about distressed tolerance today. So why don't you tell us a little bit about that? Just give us an overview, even of what that module is. Yeah. So distressed tolerance, some people can start putting that together. Tolerance of distress is basically the main objective of that section is how to tolerate and survive crises. And huge emphasis on survive. This is not to make your life worth living and better and to thrive. It's really like, how do I not make things worse? And when we talk about crises, we're not just talking about, like a huge accident happening. But I'm pretty sure we're talking about what might seem a crisis to us in the moment, even if it's not necessarily seeming like a crisis to someone else. Yeah, exactly. And a big part of that is kind of like an emotional crisis, intense emotion. So what I really appreciate about this module is you often don't find it in other therapies. It's kind of like a hallmark of DBT in which other therapies, including a lot of the cognitive therapies, you really need an engaged, active frontal lobe. But when you're in intense situations, experiencing intense emotions, we know that your frontal lobe is not engaged and that your emotional centers override your ability to think clearly. So then people feel stuck in therapy. And that's one of the complaints of CBT's, like, how can I even reframe my thoughts if I'm highly activated? I'm triggered. I'm highly emotional. I'm angry. I'm having a panic attack, whatever it may be. And so this section specifically talks about surviving, tolerating highly intense emotions, crisis situations, and again, to not make things worse. So if you think about anger, I remember I was talking about this in group, because I lead out the DBT group here. And so I was like, oh, an example of that would be healthy communication. Do we cover that in this section? And I'm like, no, that's thriving. Surviving would be, if I'm about to have an explosion, instead of saying terrible things that will hurt the person or doing something, throwing, hitting, distressed, tolerance with teachers, how not to make things worse, how maybe to not say that thing, or how to call myself down quickly enough to disengage. So it's not making your life better of like trying to really control all of your emotions. It's just trying to tolerate it enough to calm down to then use other skills later on. So it sounds like this is for people who have probably gotten themselves into really bad situations maybe in the way that they've responded to their quote-unquote crisis. And maybe that's happened multiple times. It could be in a work situation. It could be with relatives or family. It could be in any kind of situation. They're the type of person or the person who can utilize this especially is somebody who maybe has made things worse in the past and they don't want to make things worse. Even just starting there. And I like that spectrum that you provided because for our listeners, you might be anywhere on that spectrum. It might be a one-time situation. There have been times where I've gotten anxious or upset where I can utilize these skills to the far end of the other side of the spectrum in which you're having this daily. So think about people with chronic anger issues, people with chronic, intense, anxiety panic, panic attacks, PTSD triggers, and especially within DBT, we talk about chronic emotional dysregulation. But even if our listeners are listening and they say, I don't deal with chronic issues with my emotions, you can still apply these skills in moments where it may be just intense for you. However often it happens. It sounds like-- because we know that DBT is a form of CBT. And so it's almost as though, well, I got to take care of the catastrophe situation before I can even do the other skills of changing the way I think about them. Yeah. And so it compliments really well. But especially when you're in that moment, you just don't know what to do. It's kind of when people talk about being angry, they see the color rep. There's a blackout experience in our brain. And so what do I do then? And some people feel very hopeless, because those are big, big emotions. And then just kind of a side note, some of these things can also apply to kids with big emotions, too, who often have a lot of meltdowns and crises. Kids of all ages. Yeah. So sometimes people who experience these big emotions, maybe they've been through certain things in the past that create the state that they go through when things are happening now. So maybe you can share with us a little bit. What are some of the things that might contribute to us having a distressed state when things are happening? Yeah. So as you mentioned, it can be past experiences, a classic example that would be trauma. Trauma, both in the classic example of PTSD, a big event or even more like complex PTSD where there may be several that what we know what happens in the brain is your brain can actually be wired in a way that's more sensitive to situations in which we might be interpreting things as crises when they may not actually be as dangerous as we're interpreting. So trauma would be kind of a major factor. There may be even things like with panic attacks, other factors in life that have made you more susceptible to even physical conditions. Some people get confused between their heart rate going up and because of a physiological concern, but then they start developing those cognitions that might tell them, oh, this is a panic attack, I'm going to die. There can be just life situations, like a car accident where maybe you're healing from it, but you're still scared and that's completely normal. So there could be a host of different things. Most of it is trauma related. And then I would say that what complements that, it's not just bad things happening, but never learning. It's like the good things that don't happen in a way that no one ever taught you how to deal with big emotion. So I don't want to just highlight trauma. There's also people who've never experienced significant trauma, but maybe they just never learned how to cope with big emotions. And so when it comes, this is where DBT highlights the bio-social theory that explains, well, maybe some people are just born with a wider spectrum of emotions and they are sometimes they identify as empaths and sensitive, but if you never learn how to deal with them, then they become bigger, not because of how big they actually just are, but because you don't effectively regulate them. Yeah, I think that's important to know, because there are people who just haven't learned skills or and it's become a function of survival too to react that way. Maybe it was a protection to getting hurt or something like that. And so now that they're in a normal relationship situation, it doesn't work there. So I think it's, I like what you said, that these things happen not because we're just horrible people or it's a function to get through that situation, but now it doesn't work anymore. So maybe you could tell us a little bit about what happens in the brain that causes this reaction or that sort of thing. Yeah, and I'm glad that we're going to talk about it because Sometimes we just immediately jump to skills, but it's really helpful to know the reason behind the skills. And I know many times people just jump to the skills and it's helpful, but there's a little bit more motivation when you see it's specifically designed for purpose. And also part of what we're going to talk about is when we have really big emotions, we hate those emotions, we try to avoid it, and many times we avoid it through other things that are actually harmful, like addictions. And so we want to replace those as well as start to change our idea of emotions. And one of these days I'll, I love talking about just emotions and the functions behind them, and maybe they'll be an episode about that. But basically God created our bodies and designed them so beautifully that we have to understand that also when dealing with emotion. So yeah, let's, and you'll help me with this because you're familiar with this too, but basically we'll be talking about fight or flight or freeze or fawn. There's the host of it. What happens in our brain and our bodies when we experience crises, whether an actual crises or interpreted crises, and starting, I like to, when I walk through this with patience, I basically do head to toe, right? It's easiest to kind of walk through the body. So with the brain, right, we know that in the limbic system, right, whatever happens, whatever the interpretation may be, our migtilla, and this is an overly simplistic version of all of that. That's good for some of us. Yes, yes. There's so many details to this. But basically migtilla, you know, send some messages to the hypothalamus, which is like the command center, which then commands the rest of the body, right? Starts to send out. Sine body connection. Yes. And so one of the main things many people are familiar with is it releases adrenaline in our bodies. And really, the adrenaline gets most of the body going. So Amanda, what's one of the most kind of common symptoms of anxiety or fight or flight for our patients? Oh man, there's all kinds of things. Anxiety, I think of, you know, like racing thoughts or even trouble breathing or heart rate speeding up and feeling like you're going to die. Yeah. So just highlighting like, let's say the adrenaline goes and it starts to get our heart pumping, which again, beautifully designed. If I see a lion, I used to say bear, but we're actually not supposed to run away from bears. That's a lion. If you can even outrun a lion. Our heart, right, this is very adaptive. It's survival. It crises, crises danger. Heart rate starts to pump, to pump blood to our extremities to fight or to flee. And you even get extra strength from that too. People pick up cars and pull their loved one out from underneath it. Yes. And so our heart rate goes up, starts pumping blood. Now people start interpreting as anxiety and then this is a bad thing. It's very good and very adaptive. You definitely want that if you're in that situation. Exactly. And then you also mentioned, you know, our breathing. This is where some people start to hyperventilate. Now it's adaptive because we're trying to get in more oxygen. But, you know, and we'll talk about it in a little bit of what we do to reverse that. But that's a common sign of anxiety. But it's really just the fight or flight. We call it fight or flight, but it's known as the sympathetic nervous system. Right. This whole system turns on to our brain communicates in different ways to the hypothalamus that then releases adrenaline, starts our body going. The energy piece that you mentioned related to adrenaline is also why people often also feel very shaky and trembling when they're anxious. Right. We have all this energy that's getting built up. And typically we would fight or flee and release that energy. But when we don't, it gets stuck in our bodies. And we can keep on going down even like our liver producing more glucose, which also produces more energy. This is why stress is not good for diabetes and other things. But basically, head to toe, you can start going through all these major changes. Two other ones I want to highlight is body temperature goes up. This is why people often feel very hot when they're anxious or even when they're angry. You can see it in the face, you can the flushing happens. Yes. Yes. And then another one is muscle tension. Right. We brace for danger. Right. For about to get hit in a car, we naturally tense our bodies. And then you've probably seen this time and time again, people in session when they start to talk about something, they start to stiffen or their shoulders start to tense more. And so we see all these changes in our body, which is again, super adaptive. All have different functions. Our pupils dilating all these wonderful things to prepare us for danger. And then typically what we would do is we would utilize all that energy, all the things that are happening in our bodies. And after we use it, we go back to baseline. We go now the parasympathetic nervous system, the rest and digest turns on. But when we have crises, we're not taking any action. So it gets stuck in our bodies. And then this is where we can talk about some skills that then help kind of reverse that process. And one thing I've noticed with my clients too, that experience all of what you've just said is you said it's adaptive. So we use it, but it was never meant to be used as often as we're doing it. So what winds up happening after is not just going back to a baseline, but then feeling completely depleted, loss of energy, no desire to do anything else because it becomes, it's like it's passive stress. I'm not doing anything with my stress. It's just building up and building up and building up and then I become exhausted and non-functioning. Yeah, and that's why we talk about acute stress being helpful and adaptive versus chronic stress. If our body is doing that constantly, it really does wear and tear at our body. Yeah, I wonder, we could talk more about all the other things that come out of it too bodily. So I think it's really beneficial that we learn that this is something that the body does appropriately, but then when it becomes a pattern, then we want to learn skills and everything to help us overcome these things so we don't keep going into that pattern. So speaking of which, then maybe we should start talking about some of those skills to take ourselves from that fight or flight to a more healthy place. Yeah, so one of the best DBT skills and really a skill that I think everyone who struggles with their motions should be implementing in their life and it's really skills. It's a package and we were just talking about DBT has a lot of acronyms and that's tip, TIPP. So we'll walk through it and basically what I want to highlight is how each part of this acronym targets a particular symptom of the fighter flight experience and then reverses it in order to turn off the fighter flight and turn on the rest and digest. So the first one is tipping the temperature, T tipping the temperature. This one's a very easy one. What's amazing to see is actually becoming more popular. I've seen a lot on reels. So it's becoming more just known to the general public that again, a big part of fighter flight is our temperature rising, our body temperature because of the blood pumping and so forth. And so a way to tell our brain and our body, your safe is by changing the temperature. If our temperature is going up, we need to bring it down. And the best way to do that is through the face. And so there's this known phenomenon called the divers response or the divers reflex that when we hold our breath and plunge into cold water, it resets our system. So it dramatically and quickly drops our heart rate, resets kind of our breathing too, reduces blood pressure. That's another symptom of fighter flight. And it's a quick response. And so we can mimic this. We don't all have to become divers. You don't have to get our divers license in everything. But we can get a bowl of cold ice cold water, hold our breath, and then plunge our face into cold water. And it does a very similar thing of resetting our heart rate. And so it targets our heart rate, our temperature, our breathing patterns, and has a really quick response. Now, if you don't have maybe an ice cold bowl of water, you can do ice cubes in your hands. I tell people to be careful with that. Some people do use it as a self-harm strategy where it starts to cause that ice burn. So don't be careful of that. You could do a cold pack to your face. We could go on a tangent talking about cold showers and just ending your showers with that because it also increases dopamine, strengthens your immune system and all other things. And it's good for your face to close the pores. That's true. Yeah. So there's another side benefit. I've seen it. I've seen it where people have taken a bowl, filled it half with water, put it in the freezer, kept it there, and then just when it's time to do it, then they fill it a little bit extra. And you don't have to put your whole head in it, even just your face up to this point will definitely help. So it's not like you have to make a full day out of this because you have to redo your hair and dry it. And they say, especially if you get this section here, right below your eyes and above your cheekbones, there's blood vessels here that are especially important. But yeah, it's a quick thing and that people can do to quickly change your body chemistry, which I love because sometimes in therapy we talk a lot about theoretical, more abstract type of skills, but this is a very concrete, scientific, biological skill. Absolutely. So that's the T, changing the temperature. So what's the I? Intense exercise. Now, remember, this is for crazy, so it's not like we're recommending intense exercise every day. They've done research on marathon runners and other things. It's not healthy. But in crises, think about what it mimics, right? Instead of, if we're not running away from the line, which is intense exercise, I'm sure, we need to be mimicking that. So all the pent-up energy that we have, the adrenaline, the cortisol, all that needs to be used up. And if we're not, again, it's getting stuck in our bodies. So intense exercise targets the adrenaline and cortisol. It targets the heart rate. It targets the breathing patterns, the muscle tension, really one of the most effective because it just targets so much, increases blood circulation. But one thing that's really interesting, somewhere to the cold temperature as well, is it stresses our body out more. But it's a way that mimics, again, what we're supposed to be doing, stresses it out in order to come back to baseline. And that's why you feel so euphoric, including the endorphins and dogginess morphine for our body, really, afterwards. And so about 20 minutes of intense exercise, it doesn't have to be sprinting, speed walking, jumping jacks, whatever it may be, be careful out of clients who are having a panic attack while they're driving. They pulled over and they're like, I need to jump in jacks. Be safe and how you do this. This is where different skills may be applied different times. If you don't have an ice bowl, if you don't have the ability to do intense exercise, different things at different times. I've seen guys sometimes where they'll just get down on their hands and start doing push-ups, real rigorous push-ups to get that taken care of too. Yeah. Yeah. So, doesn't matter really what the exercise is. And some people in general too, if you notice that you just have a constant kind of buzzing, do hit or other types of intense exercises that kind of just brings you back to baseline and uses up all of that, especially as you were mentioning Amanda about the chronic stress. If you have chronic stress, it's really important to utilize exercise as a way to bring yourself back to baseline. And who can't use exercise, you know? So it's not, I always say it's better to practice these things before you need them so that when you really need them, they're already there. There's skills that you've already build muscle memory around. Yeah. And this is where it's good to do exercise every day and there's another DBT skill that talks about that. But I do want people to think intentionally about using intense exercise as a skill. Like if I am extra anxious, I've done this. I go for a sprint. And it really just quickly, I don't have to go for a three mile run. I can just go for a sprint and that will quickly bring me back to baseline, including if I'm not just having physical symptoms, but racing thoughts and other things as well. Yeah. How about the first pee? So this one is probably the most well known, it's pace breathing. We talk a lot about it and that one particularly targets the hyperventilation. So by again, doing the opposite, you're communicating to your body and your brain, you are safe. Now one thing that I like to kind of slip in there that's not part of DBT, just some information is if someone struggles with deep breathing, sometimes your breathing rate is so irregular, you can do what we call a volcano breath is a huge deep breath in through your mouth, which is opposite to deep breathing. You hold and you tense your lungs and then you quickly, immediately, instead of the slow breath out, the slow exhale, a quick exhale out. And that can reset your breathing if you're really in panic and fight or flight and then you would engage the deep breathing. Some people ask me, "Oh, are you talking about the box breathing?" And exactly how many times I ask you about that. And I love to hear your thoughts as well. My approach, which is not everyone's approach, so this is not the standard, I've known patients that get too stressed about the numbers that I tell people just slow, controlled breathing. And generally the principle is longer, exhale than inhale. If you try too hard to be like, "Okay, four," and four hold, four out, some people are really stressed or some people talk about the four eight, half in, half out. But if you're not used to breathing slowly and controlled, the eight can be really stressful. And so I'm just a lot more flexible with that. I don't know about you, Amanda. Maybe just because I'm a visual person to have something to watch. The best choice. I don't focus as much on the number of seconds that they do it more so that they're following it. Then it's also a distraction too from focusing on the crisis situation. So that's the only reason I like the box breathing because I'm a visual person. And so it gives me something to focus on besides just panicking. Yeah. So whatever works for you is basically the thing with the principles of slowed, controlled breathing. Yeah. And that's something for our listeners too, is that sometimes we'll say one percent better. Just go in the direction of the right thing. And if you're not doing exactly the thing that we say for exactly the amount of time, if you go in the direction of it aiming to get closer to that, and if it works for you, great. And then the other principle I forgot to mention is belly breathing. You want to use your belly, your diaphragm muscle. It expands your lungs more completely. And there's more blood vessels at the end of your, at the bottom of your lungs so that you oxygenate your blood more. And then yes, it helps with the breathing, but it also helps with heart rate. And then a big component is it takes oxygen to the part of our brain that is firing with anxiety and panic and anger. And so it really calms your nervous system down. And one thing that people don't realize is we hold our breath more when we're anxious. And that actually constricts the blood flow to the brain. Yeah. And even just focus if you're nervous about something, how often do you notice yourself breathing, not very much? Or they start saying something, they spit it out and they're like afterwards, right? And sometimes I've even said to my clients, hey, let's just slow down and breathe for a second. Because I start noticing in my own body what they're experiencing. Because I'm not breathing as much. And I'm like, wow, I need to slow down. So let's do that together. How about the last pee? Yeah, paired muscle relaxation. So paired with the pace breathing. And this one doesn't, I don't think is as common in the general public. But it's really helpful. Now, it particularly targets the muscle tension. When we're bracing for danger, we're all tense. And especially with chronic stress, we're bracing for danger constantly. We don't realize we are extremely tense. And if we are, not only does our brain communicate with our body, but our body communicates with their brain. And so we need to release-- It's a little system, isn't it? Yes, very connected. So we need to release that tension. So what it looks like is from head to toe, we want to tense our muscle groups for five seconds. And really tense it. Now, if you have any pain issues, you can skip that section. But we want to tense it. And then one thing that people get wrong is oftentimes they'll release slowly. We need to release quickly because we're trying to teach our bodies what's the difference between tension and relaxation. And for so tense all the time, we don't really know the difference. And so it's really important to tense five seconds and then release immediately. And it's amazing. Anytime I do this with a group, with my patients, most of the feedback is, wow, that felt like a massage. That's what I say, too. I tell people, if you do it from head to toe or toe to head, and I usually start with the feet. And then come up to the head. But at the end, you're like, I didn't even get a massage, but I feel the same as if I had. Because it's really a separate. And it's a separate. Yes, yes. And you could take it anywhere. And one thing I tell patients is it's good to do a full exercise. But once in a while, if you don't have the full time, you'll start getting to know your body. Like, I know that, and I think it's because our profession talks a lot. I carry a lot of tension in my face. And so I will do the tension, the tensing of my forehead, my eyes. Those are the two ones I do the most, and then my shoulders. And so then I can target it really quickly in my office of like, wow, that patient really may be stressed. Like, I need to do this as well as it's not mentioned in DBT, but stretching. It's kind of the same. idea if you stretch daily, it helps with the muscle tension, especially if it's something that happens more chronically. But it's a really great unused, untapped into skill that we can implement daily, yes, but especially when we notice that we are in crises or experiencing those intense emotions. Yeah, I like to, and I want to reinforce this, that you do the muscle with the breathing because sometimes when you're tensing the muscle, it's so easy to stop breathing, too. And sometimes when I teach muscle relaxation, it's where you tense it and then relax it afterwards, is that I see the person holding their breath the whole time where they're tensing because you're putting a lot of effort into holding that tension, but you want to breathe through it, too. And so just reinforcing the breath wall you do the muscle tension. Please do. Breathe all the time. It's good for you. Yes. Is there anything else that you wanted to add? Any other skills or anything that you wanted to cover or? No, I will continue to cover different skills and maybe takes a couple years to go through all the DVD skills. It's a lot. I do know there are a lot of acronyms. We've joked about this because there's almost enough acronyms that you're going to forget what words aren't an acronym for something because yes, there are so many. But they are really helpful, even if you just take a toolbox of a few of them that work really well for you. And not everybody's going to remember all of them, but I know you'll share some of your favorites probably or the ones that a lot of your patients like as well. Yes, but just to summarize, I just want to say like again, our bodies are wonderfully made and created in a way that instead of hating it and then like, oh, I hate that I get anxious. I hate that I have panic attacks. I hate that I get angry. Instead, we want to be friend our bodies, recognize like, okay, just because it's, you know, this alarm system is going off all the time. It's kind of I use this analogy with fire alarms. If it's beeping all the time, you don't get rid of the fire alarm. It's good. It's adaptive. You want to know when there are fires. It's just you need to recalibrate it. So there will be other episodes on how to calibrate from the mind perspective thoughts reframing, but at least in at this stage, when your alarm system's going off, when your fighter flight sympathetic nervous system is alarmed, treat it with kindness, realize, okay, I'm experiencing these symptoms. How can I respond now with tip? And I think it's important too that we recognize that, you know, our bodies are trying to tell us something. It's not that we should hate it. It's trying to tell us something and we get the benefit of learning more about ourselves through this process, even as frustrating or painful as it might be at first. The victory comes after you get to know it better and then you can utilize the things that you've learned to help it and help you because that's a part of you. So thank you so much for sharing this with us and I'm excited to hear all of the other things that are going to come as we go through these different DBT principles and modules and also skills that go with the module. So thank you Katie. Yeah. So if you only take one thing away from today's show, remember this. If mental illness is a whole person problem, then it must have a whole person solution. I'm Amanda Anguish. I'm Dr. Katie Cruz and you've been listening to The Brain People Podcast. Thanks for listening. If you enjoyed today's episode, please like and subscribe. Your engagement will help us reach more people who need encouragement. To hear more episodes, learn about our other mental health resources or support us financially, visit thebrainpeoplepodcast.com.