Dialectical Behavior Therapy Exposure Orientation

DBT Exposure Therapy Orientation

• Full orientation to the treatment includes goals, targets, and interventions
• DBT stage II teaches clients how to validate themselves
• If focus is on primary emotions, secondary emotions need to be blocked
• Action urges associated with emotions need to be identified
• Acting opposite to unjustified emotions can lead to middle path solutions
• It is imperative that goals and assumptions are fully assessed
• Self-monitoring for relevant targets is maintained using behavior analysis
• The current maintenance of a behavior may be different than its initial
development

This Packet includes

• Treatment rationales
• Education about emotional processing and SUDS
• Observations during homework exercises,
• Reinforcement measures for learning in session,
• Presents model for gradual in vivo exposure

Emotional processing theory

Fear operates in the memory as a structure of thinking applied to escape danger. The
fear structure includes representations of feared prompts, the fear responses, and the
meaning associated with the prompts and responses. When a fear structure represents
a realistic threat, we refer to be as a normal fear structure that acts as a template for
effective action to threatening situations. (Foa, et al, 2007 p. 12)

A fear structure becomes problematic when:

• Associations among prompting elements do not accurately represent the world
• Physical and escape/avoidance responses are evoked by harmless prompts
• Response elements are erroneously associated with threat meaning.
• Excessive and easily triggered response elements interfere with adaptive
behaviors

Modifying problematic fear structures are the essence of emotional processing:

• The fear structure is activated

• New information incompatible with erroneous information embedded in the
fear structure introduces into the environment and incorporates into the fear
structure.

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 Dialectical Behavior Therapy Exposure Orientation

SUDS: Subjective Units of Distress Scale

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 15 90 95 100

Low Distress Window of Tolerance High Distress

The Subjective Units of Distress Scale or SUDS for short is a 0 to 100 point scale an
individual uses to measure his or her level of distress at any given time. Developed over
30 years ago, it remains relevant because it is simple and easy to apply.

SUDS and DBT

In DBT, SUDS is a means to mindfulness because SUDS cultivates awareness to a
present state, in this case, the present state is distress. By observing your personal
SUDS numbers in various situations, you can begin to clarify the intensity levels that
lead to problematic urges and behaviors. This provides valuable information that is
useful in analyzing problem behaviors, generating solutions, and conducting exposure
therapy.

SUDS Tips
• In SUDS, Window of Tolerance refers to the range where there is enough distress
that it is uncomfortable, but not so much distress you cannot access skills or wise
mind

• Skills Breakdown Point refers to your SUDS number where your distress level
reaches the point where you can no longer access skills or wise mind.

• Whenever engaging in a difficult or distressing DBT task or skill, monitor your SUDS
periodically and use short breaks with paced breathing to keep you engaged and
within your Window of Tolerance

• When using paced breathing to bring down your SUDS level, take as much or as
little time as needed to get back into wise mind.

• When engaging in exposure, rate and record your SUDS before and after tasks

• Sharing your SUDS helps others understand your level of distress quickly at any
given time.

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 Dialectical Behavior Therapy Exposure Orientation
Dialectical Behavior Therapy Exposure Orientation Packet

My SUDS
In the following table record your personal SUDS numbers

Smallest SUDS Number Within My Window of Tolerance

Largest SUDS Number Within My Window of Tolerance

My SUDS Baseline Number (Average Neutral State)

My SUDS Skills Breakdown Point

My Behavioral Goals for Exposure

Behaviors I want to increase Behaviors I want to decrease

Things that will increase desired behavior Things that will decrease desired behavior

Things that will increase unwanted behavior Things that will decrease unwanted behavior

Distress Responses (Circle all that apply to you)

Blurry Vision Ringing in the ears
Heart Racing
Headache Shortness of breath
Dizziness
Hot & Sweaty Diarrhea
Nausea
Chills Flushing/blushing
Feeling Suffocated
Watery Mouth Tightness in the chest Tingling
Pain in the chest Disassociation
Shakiness

Other Distress Responses ______________________________

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 Dialectical Behavior Therapy Exposure Orientation
Dialectical Behavior Therapy Exposure Orientation Packet

Preparing for Exposure

Rationale for treatment
• Potential benefits of exposure
• Potential consequences of exposure
• Structure of sessions
• Participation guidelines
• Program structure = 10-15 weekly sessions
Identify:
• Emotions associated with self-incompetence
• Emotions associated with others incompetence
• Self-construct checklist
• Individually designed exposure hierarchy
• Signals to self and others of under-engagement
• Signals to self and others of over engagement
• Ways others can encourage effective engagement in exposure tasks

Doing Exposure
Emotional Processing questions
• What are you feeling right now?
• What are you thinking about?
• What does the emotion feel like in your body?
• Notice sounds, What do you hear?
• What is your SUDS number (subjective units of distress scale from 0-100)
right now?
Providing Feedback
• Share thoughts and feelings about the experience
• Articulate life meanings related to target
• Refrain from telling one how she should think or feel
• Highlight expressions of unrealistic or excessively negative views of self
• Repeated in vivo exposure as homework assigned between sessions
• Repeated imaginal exposure revisiting traumatic memories in session with
narrative audiotaped
• Repeated prolonged imaginal exposure to trauma memories

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 Dialectical Behavior Therapy Exposure Orientation
Dialectical Behavior Therapy Exposure Orientation Packet

Exposure Preparation Worksheet

Name: Date:

1. Emotions & thoughts associated with self-incompetence

2. Emotions & thoughts associated with others incompetence

3. Signals to self and others of under-engagement in exposure

4. Signals to self and others of over engagement in exposure

5. Ways others can encourage my engagement in exposure tasks

6. DBT Skills and/or strategies to keep my SUDS within my Window of Tolerance

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 Dialectical Behavior Therapy Exposure Orientation
Dialectical Behavior Therapy Exposure Orientation Packet

DBT 6 Levels of Validation

Level 1 Validate by demonstrating Interest:

• Listen to and observe what you and others are saying, feeling and doing in an
unbiased manner with complete awareness.
• Resist urges to interrupt others while they are speaking.
• Make eye contact.
• Ask questions that show you want to understand what you are hearing.
• Be genuine and non-judgmental. Remember important information.

Level 2 Validate by Paraphrasing

• Accurately reflect feelings, thoughts, assumptions, and behaviors.

• Communicate understanding by restating information so that it is more coherent
while keeping with the essence of the original conveyance.
• Be mindful not to be a “parrot” or repeat the shared information word for word

Level 3 Validate by Mind Reading:

• Articulate thoughts, emotions, and/or behavior patterns not directly expressed.

• Verify the facts of a situation and intuitively reflect them in terms of how they
relate to the difficulty of the situation.

Level 4 Validate Based on History:

• Recognize that every outcome has a cause and that for all responses there is a
chain of events that lead up to it.
• Validate that a response is reasonable given the individual’s past experiences

Level 5 Validate Based on Current Situation:

• Articulate the ways in which a response is reasonable given the current situation.
• Acknowledge the value in the other person’s intuition regarding the matter
• Describe how the response makes sense in that it is effective for short-term
gains.

Level 6 Validate by Demonstrating Radical Genuineness:

• Act directly, ordinarily, and as if you are talking directly to an equal.

• Do not treat the other person as fragile, incompetent or like a child.
• Convey credibility through a natural flow of communication.
• Speak in terms and language the other can sufficiently understand
• Use a warm communication style that shows interest, sincerity & respect

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 Dialectical Behavior Therapy Exposure Orientation

Labeling Emotions
The more ways we have to label a single emotion, the more succinct we can be in
identifying our emotional experiences. Label your emotions during exposure

Anger Fear Love

Aggravated Anxious Adoring
Agitated Apprehensive Affectionate
Bitter Frightful Attractive
Frustrated Horrified Caring
Furious Hysterical Compassionate
Grouchy Nervous Desiring
Hostile Panicked Enchanted
Irritated Shocked Fond
Outraged Tense Infatuated
Wrathful Uneasy Passionate
Disgust Jealousy Shame
Aversive Cautious Contrite
Contemptuous Clingy Culpable
Disliking Clutching Dismayed
Disdained Defensive Embarrassed
Distasteful Mistrustful Humiliated
Hateful Possessive Mortified
Loathsome Self-protective Self-conscious
Repulsive Suspicious Shy
Scornful Wary Sadness
Spiteful Watchful Despairing
Envy Joy Grief-stricken
Craving Amused Miserable
Discontented Hopeful Disappointed
Displeased Blissful Alienated
Dissatisfied Satisfied Pitiful
Greedy Cheerful Rejected
Longing Euphoric Sorrowful
Petty Contented Lonely
Resentful Delightful Unhappy
Wistful Optimistic Depressed
Wanting Elated Morose

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 Dialectical Behavior Therapy Exposure Orientation

Working with Primary & Secondary Emotions

The easiest way to figure out whether you are experiencing a primary or secondary
emotion is see whether the emotion fits the facts and that it is appropriate in level of
intensity. If your emotion fits the facts it is usually a primary emotion, if it does not fit the
facts it is usually a secondary emotion. Use the following flowchart to help you figure out
what emotion regulation skills to use for primary and secondary emotions.

What is the emotion I am experiencing? _____________________________________

ASK  
Does  the  emo)on  fit  the  facts  and  is  it  
appropriate  in  level  of  intensity?  

YES   NO  
Primary  Emo)on   Secondary  Emo)on  

Solu*ons     Solu*ons  
-­‐  Radically  Accept  the  Emo)on   -­‐  Radically  Accept  the  Emo)on  
-­‐  Act  on  Emo)on,     -­‐  Change  Thoughts  to  Fit  Facts  
-­‐  Mindfulness  to  Current  Emo)on   -­‐  Opposite  Ac)on  
-­‐  Accept  Consequences  Gracefully   -­‐  Problem  Solve  

Was my emotion a primary (fits facts) or a secondary emotion (doesn’t fit the facts)?

Primary Emotion Secondary Emotion

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 Dialectical Behavior Therapy Exposure Orientation

Check  the  Facts  of  Emotional  Responses  

The following table provides a list of emotions and factors to help you determine
whether an emotional response and/or its level of intensity is appropriate and fits the
facts of a problematic situation.

Fear fits the facts when:

ó Your life or that of someone you care about is threatened
ó Your health or that of someone you care about is threatened
ó Your well-being or that of someone you care about is threatened

Anger fits the facts when:

ó An important goal is blocked
ó You or someone you care about is attacked or hurt
ó You or someone you care about is insulted or threatened

Disgust fits the facts when:

ó Something you are in contact with could contaminate you
ó Somebody whom you deeply dislike is touching you or loved one
ó You are around a person or group whose behavior or thinking could
seriously damage or harmfully influence you or the group you are part of

Envy fits the facts when:

ó Another person or group gets or has things you don't have that you want
or need

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 Dialectical Behavior Therapy Exposure Orientation

Check the Facts of Emotional Responses (continued)

Jealousy fits the facts when:

ó A relationship or thing in your life is very important and desired by you
ó An important relationship or thing in your life is in danger of being damaged
or lost
ó Someone is threatening to take a relationship or thing important in your life
away from you

Love fits the facts when:

ó Who or what is loved does things or has qualities that you value or admire
ó Loving the person, animal or object enhances the quality of your life or of
those you care
ó Loving the person, animal or object increases your chances of attaining
your own personal goals

Sadness fits the facts when:

ó You have lost something or someone irretrievably
ó Things are not the way you wanted or expected and hoped them to be.

Shame fits the facts when:

ó You will be rejected by a person or group you care about if characteristics
of yourself or your behavior are made public

___________________ fits the facts when

ó
ó
ó
ó

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 Dialectical Behavior Therapy Exposure Orientation

Opposite  to  Emotion  Action  

Use opposite action when your emotion does not fit the facts

The Opposite Action for Fear is:

• Do what you are afraid of doing over and over again
• APPROACH events, places, tasks, activities, and people you are afraid of.
• Do things to give yourself a sense of CONTROL & MASTERY over your fears.

The Opposite Action for Anger is:

• Gently AVOID person you are angry with (rather than attacking)
• Take a TIME-OUT and breath in and out deeply and slowly
• Do something a little bit NICE (rather than mean or insulting
• Do the OPPOSITE of other angry action urges

The Opposite Action for Disgust is:

• MOVE CLOSE. Eat, drink, stand near, or embrace what you found disgusting.
• Be KIND to those you feel contempt for; step into the other person's shoes

The Opposite Action for Envy is:

• Inhibit destroying what the other person has
• Do the OPPOSITE of envious action urges
• COUNT YOUR BLESSINGS
• Make a list of the things you are thankful for

The Opposite Action for Jealousy is:

• LET GO of controlling others' actions
• SHARE what and who you have in your life

The Opposite Action for Love is:

• AVOID the person, animal or object you love
• DISTRACT from thoughts of the person animal or object
• REMIND yourself of the "cons" of loving
• Do the OPPOSITE of other loving action urges

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 Dialectical Behavior Therapy Exposure Orientation

Opposite to Emotion Action Continued

Use opposite action when your emotion does not fit the facts

The Opposite Action for Sadness is:

• Get ACTIVE; approach, do not avoid.
• Do things that make you feel COMPETENT and CONFIDENT.

The Opposite Action for Shame is:

When your behavior does not violate your own moral values
• Make your personal issues PUBLIC with people who won’t reject you
• Engage in behavior that sets off shame OVER AND OVER in public
• Do the OPPOSITE of other shame action urges

When your behavior does violate your own moral values

• APOLOGIZE publically
• REPAIR the transgression
• MAKE THINGS BETTER; or work to prevent or repair similar harm for others
• COMMIT to avoiding that mistake in the future
• ACCEPT the consequences gracefully

The Opposite Action for Guilt is:

• When you WILL NOT be rejected if found out
• Make your personal characteristics PUBLIC with people who won't reject you
• Engage in behavior that sets off gu1lt OVER AND OVER AND OVER in public
• When you WILL be rejected if found out
• HIDE or USE SKILLFUL MEANS if you want to stay in the group
• Join a NEW GROUP that fits your values
• Do what makes you feel guilty OVER AND OVER with your new group

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 Dialectical Behavior Therapy Exposure Orientation

DBT PE Proposed Sessions

Session 1:
• Present overview of the program 25-30 minutes
• Discuss Treatment procedures that will be used in the program
• Explain the focus of the program (PTSD Symptoms or ?)
• Collect information relevant to trauma
• Introduce breath retraining
• Assign homework

Session 2:
• Review Homework
• Present agenda for session
• Educate clients on common reactions to trauma
• Discuss the rationale for in vivo exposure
• Introduce the SUDS scale
• Construct in vivo Hierarchy- 5 situations of at least 2 in 40-50 Suds range
• Homework is to add more avoided situations to the list that will eventually total
15-20 situations
• Commonly Avoided situations
− Situations Perceived as Dangerous
− Situations that are reminders of past traumatic events
− General lost of interest due to depression related avoidance

Session 3 - Record session

• Review homework 10-15 minutes per member
• Present agenda - 3 minutes
• Present rationale for imaginal exposure
• Conduct imaginal exposure 45-60 minutes
• Process imaginal exposure 15-20 minutes
• Assign homework 5 minutes

Intermediate sessions
• In session 5-15 focus on hot spots progressively more as therapy advances.
Return to recounting entire memory when anxiety associate with hot spots
has sufficiently reduced
• Discuss in Vivo exposure

Final Session
• Review homework
• Present agenda
• Conduct imaginal exposure
• Review progress and make suggestions for continued practice
• Terminate therapy

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 Dialectical Behavior Therapy Exposure Orientation

Exposure Task Tracking Sheet

Date Exposure Task SUDS Pre SUDS Post

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 Dialectical Behavior Therapy Exposure Orientation

References
Foa, Edna B., Hembree, E.A., Rothbaum, B.O. (2007) Prolonged exposure therapy for
PTSD: Emotional processing of traumatic experiences. New York, NY. Oxford
University Press.

Harned, M.S., Korslund, K.E., Foa E.B., Linehan, M.M. (2012). Treating PTSD in
suicidal and self-injuring women with borderline personality disorder:
Development and preliminary evaluation of a dialectical behavior therapy
prolonged exposure protocol. Behavior Research and Therapy. 50, 381-386.

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