Dbt

DBT Skills – Emotional Regulation

This post is part of a series where I discuss Dialectical Behavioral Therapy Life Skills. 

What are emotions?

Emotions are mental states, experienced as physical sensations in response to our perceptions.  These perceptions are byproducts of the brain’s ongoing mental efforts to interpret sensory information. It is through this ongoing effort that a mind-body connection is created.   It then makes sense that “emotions are signals within our body that tell [us] what’s happening (McKay, et al, 2007, p. 130).”  In this respect emotions can be considered as byproducts of an individual’s interaction with the environment.  Appraisal theories, common in the social sciences, focus on how people understand and interpret their environment when examining the nature of feelings (Ellsworth, 1994).  In contrast, universal theories reflect a biological perspective, which focuses on emotions as hardwired byproducts of primitive brain function (Ellsworth, 1994).

How are emotions generated?

imageSince emotions are byproducts of our interactions with the environment, it is important to understand how these factors interact to generate our emotional experiences.   Since emotions are byproducts of our interactions with the world around us, several solutions are available to help us regulate our emotions. Emotional regulation is a vital coping skill that allows us to influence what we feel at a particular moment & how we express this feelings.  According to Dialectical Behavioral Therapy (DBT) four key factors play a role in the generation of emotions.

The Situation

imageAs the saying goes “life happens when you’re doing other things.”  This statement reminds us of life’s inherent unpredictability.  All well-laid plans must therefore do amenable to change since life inevitably throws us the occasional monkey wrench or two.  Dealing with these curveballs is disconcerting to say the least.   The generation of emotional reactions starts when we encounter a situation that doesn’t go as we may have predicted.  How can you describe the movie reel experience you’re reacting to right now?  What happened?  Who was there?  List the specific sequence of events.

Our Attention

imageWhile life can be unpredictable & uncertain, we aren’t helpless victims.  The manner in which we choose to take in life experiences profoundly influence the impact of life events.   There’s definitely more than a grain of truth to the idea that “its all in how you choose to take it”.   Oftentimes we’re so focused on the event itself, that we fail to consider how we’re choosing to take it in.  For example, my endless fretful worry about finding a new internship, has been highly anxiety-producing.   The problem often isn’t the situation itself, but how I’ve chosen to take it.

Our Appraisal

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As new and unexpected life situations present themselves, we immediately set about determining how we should respond to it.  Before we are able to react effectively to a situation, we must interpret it. What sort of emotional reaction is appropriate given what we know about the situation?   I discuss this subject in more detail in a post titled “Stolen Watermelons Taste Better,” where I discuss the subject of affective forecasting.

Our Reaction

When we act upon our appraisal to a situation, our reactions are guided by our perceptions and beliefs.  In this  respect, that our beliefs are able to influence our life experiences, and act as self-fulfilling prophecies. It is in this respect that we often “grow into” what we believe we are, and acquire what we believe is possible.

What is Emotional Regulation?

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It is by understanding how emotions are generated that we can begin regulating them.  In my old DBT Skills group, emotional regulation was defined as “the process by which we influence the emotions we have: when we have them, how we experience them, and our manner of expressing them.”  We can regulate emotions by selecting and modifying the situations we find ourselves in.  We can modify our emotional states by re-examine how we attend to and appraise these situations.  Finally, we can modify our emotional by modifying our reactions to situations….

Situational Selection

Sometimes we find ourselves in situations that are not of our own choosing.  However, it is possible to be mindful of what situations we gravitate toward and what situations we avoid.  Examining this requires us to look closely at the expectations guiding our situational selection process.  What belief systems are these expectations based on?  What personal insecurities & past experiences guide our decisions to avoid certain situations and avoid others?

Situational Modification

Modifying the situations we find ourselves is also a useful emotional regulation tool.  What options are available to us to change the situation?  Stepping back to examine our options and carefully considering them is also useful.  Do you need to step back from a difficult situation?  Or does addressing this difficult situation require you to make your options known?

Attentional Deployment

I have a bad habit of ruminating endlessly over aspects of a situation that have elicit strong emotions within me. When I do this, my desire is to control those aspects of a situation that elicit strong emotions.  I become hell bent to “fix the situation” or produce a remedy for the stress/anxiety/etc.  Oftentimes, this hurts more than it helps.   Immersing myself into what needs to be done in the moment helps, distract my mind from those aspects of a situation that cause stress.

Cognitive Change

Examining your appraisal of a situation is useful as a means of altering its impact on you.  What is the significance of the situation?  Stepping back and examining how you construe life events, can often help us realize it isn’t what we see but “how we see it” that causes problems.

Response Modulation

Expressive suppression is useful in decreasing our chances of reacting harshly to situations in a manner that we might regret latter.  Managing our overall physiological responses to situations is also useful through mindfulness and relaxation techniques.  Finally, discussing the situation with someone you trust in order to attain another perspective of matters , does help.

Click here for a worksheet to understand & describe your emotions

3 Emotional Regulation Exercises

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In my own DBT Skills Group – many years ago – I was taught three emotional regulation exercises.  The first skill involves simply describing and observing emotions.  The second involves improving our overall level of self-care in order to reduce our vulnerability to emotions.  Finally, increasing positive emotional experiences can also help improve our overall mental health.  I review these three below.

Describing & Observing Emotions

imageThere’s a big difference between thinking with your emotions and thinking through them.  When you thinking with your emotions, they exist as an all-powerful dictator within your brain.  Everything you encounter in life, becomes a definitive subject to your emotional state.  As you feel it, so it shall become for you in your lived experience.  What follows is an example that applies key steps in observing our emotions:

Name the Emotion – I am very anxious.
 Describe the Event – The Internship Interview.
What are your Thoughts & Assumptions – I’ve had four interviews so far and none have gone very well.  I’m told “we’re considering other options”, etc.  I worry if anyone will ever see what I have to offer.  Will I be able to find an internship opportunity?  How long will this take?
What are your Bodily Sensations –  Sweat drips down my armpits & my hands shake uncontrollably as my hard starts pounding outside my chest.
What is your body language & facial expression – With a stupid blank smile plastered across my face and cross my arms, in an attempt to hide my shaking hands.
What do you feel like doing & saying?  Part of me wants to run from the room screaming.  Within me is a deep well of frustration & anxiety.  I want to just stand up to this person and say “give me the dang job damnit”…
What do you actually do?  I tell myself to calm down.  I focus on the present moment & set aside these irrational concerns.  Instead I immerse myself in the conversation.  I listen about the internship opportunity available & his career experience.
Aftereffects of the Event?  I get the job.  It goes well.  I’m beyond elated.

Reduce Vulnerability

The second emotional regulation exercise is actually better characterized as an overall lifestyle change. Improving our level of self care is critical in reducing our vulnerability to emotions.  In class, we learned the acronym “PLEASE MASTER” to remember the following key tips for improving our overall well-being

*P*L*E*A*S*E* *M*A*S*T*E*R*
treat PhysicaL illness
balanced Eating
Avoid mood-altering drugs
plenty of Sleep
get Exercise
build MASTERY by doing one thing at a time to feel in control.

Increasing Positive Experiences

What activities can you include in your daily routine that improve your overall emotional state? I love blogging, hanging out with my family, and anything that allows me to utilize my creativity.  Additionally, I don’t live to work, I work to live.  As a working mother who is completing a graduate degree, scheduling regular “playtime” for mommy is essential.  All work and no play is a shitty way to live.

Click here for a worksheet to help you observe & describe you emotions.
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References

Ellsworth P.C. (1994). Sense, culture and sensibility. In S.E. Kitayama, & H.R.E. Markus, (1994). Emotion and culture: Empirical studies of mutual influence. (p.p. 23-50). American Psychological Association.
Mckay, M., Wood, J., & Brantley, J. (2007). The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation & distress tolerance. New Harbinger: Oakland, CA.

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DBT Skills – Interpersonal Effectiveness

First a Little Backstory….

I am an outlier.  At key points in my childhood, certain critical developmental needs weren’t fulfilled.  As a result, I often find myself situations where I’m left to attempt to “fake normal”. The social ostracism was eons ago, however I still feel awkward in social situations.   Inevitably, the reality of my different-ness springs up from time to time.  I find myself mourning an abstract loss of something I “missed out on”. I regret the baggage left behind.

This post reviews interpersonal skills taught in DBT Skills Groups.  I participated in one some time ago, when I first sought counseling.  As a student therapist, I find myself relying on many of these basic life skills.  I’m learning quickly that my quirks, insecurities, personality traits, and life history, are incorporated within my work.

“Interpersonal effectiveness skills are a composite of social-skills training. Keeping your relationships healthy and alive requires interpersonal skills.” (McKay, et al, 2007).

What are Your Interpersonal Goals?

When you find yourself in a situation that requires the conscious use of interpersonal skills.  The first question to ask yourself is what are your goals for this situation?  Here’s a list of interpersonal goals I’ve been struggling with lately:

*ATTENDING TO A RELATIONSHIP:  My sister and I have been attempting to rebuild our relationship.  She’s was diagnosed with breast cancer earlier this year, and has been struggling in her recovery.  Meanwhile, I’ve been interning throughout the summer and working full time.  This has left me with a heavy work load of almost 70 hours a week.  The mom & sister guilt has builded significantly these last three months.  I’ve decided to step back and take a quarter off.
*BALANCING PRIORITIES vs. DEMANDS: I have so many demands on my time lately, my perfectionist standards and inner “energizer bunny” have taken over.  I “lean into” the work, down coffee by the gallon, and amp up my energy level, refusing to give into a challenge.  However, feedback from my therapist, mother and husband have forced me to reconsider this strategy.  I need to step back and reprioritize.
*BALANCING WANTS vs. SHOULD’S:  I’m re-examining the demands left by others, as well as my own needs. What are the should’s?  Wants consists of things important to me, like quality time with family.  Should’s are responsibilities of others in order of importance.   Essential should’s pertaining to my role as a healthcare worker, mother, and wife.  All else is a secondary issue, to be balanced around these priorities.  
*BUILDING MASTERY & SELF-RESPECT:  Finally, learning to interact with others masterfully while meeting their needs, and asking for specific requests is critical.  How do I want to feel by about myself afterwards?

Three Key Relationship Goals.

DBT Interpersonal Skills are designed to address three key categories of relationships goals: (1) getting others to do what you want, (2) keeping relationships healthy & (3) retaining your self respect.

*KEEPING A GOOD RELATIONSHIP – Remember  *G*I*V*E*
*GETTING OTHERS TO DO WHAT WE WANT – Remember *D*E*A*R*M*A*N*
*RETAINING SELF-RESPECT – Remember *F*A*S*T*

Analyzing a situation & defining interpersonal goals.

Above, I provide examples of several interpersonal goals.  I’ve obviously had time to think about these situations.  In DBT Skills groups, practice exercises are utilized in order to determine what specific interpersonal skills are needed to meet our goals in a situation.

*STEP ONE:  Describe the event.  Who is involved in this situation?  What problems and/or issues need to be addressed?  
*STEP TWO:  Consider each of the three main categories of personal goals.  what results do you desire for this situation.  For example, is there something you want somebody to do? What are your long-term goals for this relationship in order to keep it healthy?  Finally, how do you want to feel about yourself when all is “said and done”? 
*STEP THREE:  Re-examine and prioritize these three goals.  What is most important?  For example, my primary goal with my sister is a long-term healthy relationship.  Other issues are secondary.  In contrast, as an intern seeking a new site, I’m hoping to elicit positive responses.  Finally, retaining my self-respect has been critical in my decision to take a quarter off.  It has required me to put my needs before others (something I’m not good at).  

What Interferes with Your Interpersonal Goals?

imageMany factors exist which can interfere with our interpersonal goals.  Some involve personal insecurity or unmanageable emotions.   However, many of these factors are beyond our control. Its hard to accept the fact that we can’t control anyone or anything beyond ourselves.   We can make a person do something we want.  We may desire self-respect, but that doesn’t mean we will receive it from others.  We may want to preserve a relationship and keep it healthy, however things don’t always go as we might hope.  What follows is a quick list of factors that interfere with our ability to utilize interpersonal skills effectively:

*LACK OF INTERPERSONAL SKILLS:  My mother is from the Philippines & was very strict when it came to dating. It also didn’t help that I was a “SOCIAL LEPER”.  My dating life started in college.  I left home a chronological 18-year-old, but emotionally, I was the same age as my 12-year-old sister.  A Lack of personal skills makes it difficult to achieve our interpersonal goals.  
*WORRI-FUL” THINKING:  I am a worry wart & have a bad habit of ruminating endlessly.   I’ve paid a huge price for the bullying I endured as a child.   I missed out on valuable socialization opportunities and have learned to accept that I will never have a chance to gain what was lost.  I will never feel act as confidently or natural in social situations as others.  Managing my social anxiety is critical to becoming more effective in social situations.  
*EMOTIONS:   Emotions interfere with our ability to utilize interpersonal skills effectively.  Stress, anxiety, anger, & sadness are huge impediments for me.  Finding opportunities to process them.  When emotions are allowed to control my thoughts, behaviors, and actions, the outcome is often quite bleak.  
*OTHER PEOPLE:  You can’t control other people.  You can only control yourself.   Lately, I’ve been spending every spare minute I can, seeking a new internship site.  I have difficulty accepting that I can’t control anyone’s response.  I am also unable to control their impressions of me.  I can put my best foot forward, but their impression is as it is.
*INDECISION:  A lingering uncertainty regarding your interpersonal goals can act as an impediment in your ability to manage vital relationships.  Its for this reason, that its first vital that you examine your interpersonal goals and prioritize them…
*ENVIRONMENT:  In some social environments it is difficult – if not impossible – to act as a skilled person.  Other people may be too powerful or threatened by your utilization of effective interpersonal skills.  Situations like this, require us to determine whether its time to stay or go? 

 *G*I*V*E*

This acronym that stands for

(be) GENTLE – Avoid attacks, threats, or judgments.
(act) INTERESTED – Listen patiently & without interruption.
VALIDATE (feelings) Acknowledge the feelings, beliefs and thoughts of others.
(use an) EASY MANNER – (i.e. light-hearted, open, accepting).

When is it used?

When your goal is to keep a relationship healthy or positive “GIVE” Skills are important.  For example, I’m hoping to maintain the open communication with my 16-year-old.  As he has entered his teens, I’ve had to learn to alter my parenting style according to his changing needs. He starts college in just under two years.  I provide parameters and pragmatic considerations to keep in mind.  However, I give him some opportunities to make up his own mind and learn his own lessons.  It’s a delicate balance.

*D*E*A*R*M*A*N*

This acronym that stands for

DESCRIBE – the current situation so they know what you’re reacting to.  
EXPRESS – your feelings and opinions regarding the situation.  Use I statements.
ASSERT YOURSELF – State what you want.  Be clear about what you’re asking for.
REINFORCE REWARDS/CONSEQUENCES:  Tell the person consequences of doing and/or not doing something. 
(stay) MINDFUL  – Stay focused on your objectives, maintain your position.  
(appear) CONFIDENT – Use a confident tone of voice.  Communicate certainty in your position.
NEGOTIATE – Be willing to give to receive, and ask the person what they need.

When is it used?

When there is a situation where you need ask people to do something, these skills are important.  For example, are you trying to assert your legitimate rights in a situation? Are you trying to get others to take your opinion seriously?  Or are your trying to resolve a conflict? These skills were useful when I decided to communicate to my sons they needed to help out more around the house  They were also utilized when I asked for a reduction in the amount of hours I was spending at my internship site.

*F*A*S*T*

This acronym that stands for

(be) FAIR – Be fair to both yourself and the other person.
(no) APOLOGIES – Don’t apologize when it isn’t necessary (i.e. sharing opinions, disagreeing, or making requests)
STICK TO YOUR VALUES – Have the integrity to stick to your personal values. State them clearly.
(be) TRUTHFUL – No “lying by omission”  don’t exaggerate or water-down the truth.  

When is this used?

When your goal is to retain your own self-respect and leave a situation feeling good about yourself, these skills are important.  Know what your values and beliefs are regarding a specific situation.  State clearly your conclusions and actions based on these values.  Communicate them clearly.

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Here’s a Printable Handout of These DBT Interpersonal Skills…

References

Mckay, M., Wood, J., & Brantley, J. (2007). The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation & distress tolerance. New Harbinger: Oakland, CA.

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DBT SKills – Distress Tolerance…

“At some point in our lives, we all have to cope with distress and pain…While we can’t always control the amount of pain in our lives, we can control the amount of suffering we have in response to…pain…” (McKay, et al, 2007)

Lately, my life has been quite stressful.  I find my level of self-care and overall wellness falling into the crapper.  For this reason, I’ve decided to see my old therapist once a month.  I appreciate having somebody to “bounce things off of”.  Currently, my educational goals are up in the air.  I worry about finding a new internship placement.  I worry about getting a job when it’s all over.  Will all things fall into place?  Against this backdrop of stress, I’m faced with many responsibilities, and an infuriating realization that so little is in my control…

In this post I’m reviewing distress tolerance skills, I learned in a dialectical behavioral therapy skills group.

Mental Distraction Skills

“The first distress tolerance skills you’ll learn in this chapter will help you distract yourself from the situations that are causing you emotional pain (McKay p, et al, (2007).”

About three years ago, I was diagnosed with PTSD.  In reality, I’ve had it quite a while as an undiagnosed disorder.  The consequences of this are difficult to describe.  The reality is, some hurts from our past leave their marks upon us.  Like the death of a loved one – you can’t just forget it and move on.   These things stay with you, and leave you forever changed….

….After a crapload of therapy and lots of hard work, I’m quite proud of where I’m at.   The self-soothing skills below, were taught to me early in therapy and were a life-saver…

A*C*C*E*P*T*S

DBT Skills Groups are intended to provide clients a essential coping skills.  What I liked were the acronyms that made the advice so easy to remember…  Here “ACCEPTS” stands for the following list of distracting activities,

“A” = Activities

I have a bad habit of ruminating endlessly over things that worry me. When I catch myself doing this I distract my mind from what worries me.  For example  I will clean, exercise, blog 🙂 , or snuggle with my piglet.

“C” = Contributing

Contributing to the well-being of others is also a useful in coping with distress.  Lately, this internship had provided a constant reminder that I have lots to learn and success isn’t guaranteed.   For this reason, my job has actually been a respite from the stress. I am competent and everyone thinks highly of me.  Contributing to the wellbeing of others as a healthcare worker takes focus off my own mundane concerns.

“C” = Comparisons

I get constant reminders at work of how lucky I am. I’ve enjoyed over 40 years of perfect health.  At my internship are more reminders of my good fortune.  I was raised in an upper-middle home.  I make about 50k as a CNA.  I’ve been happily married 17 years and have two amazing boys.  I can’t complain really…

“E” = Emotions

Doing things that provide the experience of opposite emotions is essential.  I like to listen to great music on my iPhone and exercise in the park.  I love to draw and write.  Netflix binge sessions on a day off are another favorite.  Last but not least, hanging with my family doing just about anything brings me joy.

“P” = Pushing Away

When I notice myself ruminating over something that I can’t change/alter/remedy, I’m torturing myself needlessly.   For example, worrying about finding a job when I graduate is useless. I can’t address the issue right now, so just shove those thoughts aside.  Focus on right now, and worry about later – later 🙂

“T” = Thoughts

Thoughts that bring pleasure, hope, and excitement can eliminate or reduce distress significantly.  Imagining myself as a successful therapist is much more useful.  I will eventually land on my feet, and find myself where I’m meant to be.

“S”= Sensations

Pleasurable sensations are also useful in alleviating distress and tension.  I like the way I feel after exercise & hot whirlpool baths…

Self-Soothing Skills

“The second group of distress tolerance skills you’ll learn….are self-soothing skills…necessary…before you face the cause of your distress. (McKay, et al, 2007)”

There are also distressing situations you’re thrown in that you can’t run away from.  For example, I can’t run away from the therapy groups entirely.  I must find ways to cope with the stress.  What follows is another acronym of self-soothing skills….

I*M*P*R*O*V*E

“I” = Imagine

As a bullied child, I constantly found myself in inescapable situations that caused great distress and pain.  My imagination was a salvation & respite from the distressing situation.  I woud get lost in my own world, and mentally check out at school.  I was there in body but not person,  Today, I imagine relaxing situations at home & realize when the day is over, that’s where I’m going.

“M” = Meaning

Discovering the meaning & underlying purpose in today’s distressing events is also useful as a coping tool. My husband and I have talked at length about this.  We work hard for our family, to provide them something better.   Adding to this meaning, is the clear underlying purpose in my chosen line of work.  I am a Kiersey Healer/INFP type.  I derive greate meaning in my work as a caregiver /counselor. I enjoy opportunities to make an impact on people’s lives.

“P” = Prayer

I am agnostic, but still find great benefit in prayer.  Having faith in something greater than yourself is comforting.  Admittedly, I struggle to fully accept organized religion.  However, a relationship with “my creator is essential…

“R” = Relaxation

When my husband is stressed, he responds by slowing down and relaxing at the end of a long day.  In contrast, when I’m stressed, I go into high gear.  I push through to overcome, hell or high water.  This ego-driven adaptive response causes more problems than anything,  I make mistakes when I rush through.  Slowing down & relaxing can help my mind focus more on the task at hand.

“O” = One Thing

When I get stressed, I’m like a chicken with her head cut off.  Stopping a minute to ask myself what needs to get done right now is critical.  Focusing on one thing at a time – One-Mindfully is how I enter the moment fully present in it.

“V” = Vacation

Finding ways to take mini-breaks is useful.  Last week a new intern started.  Sensing my stress, she invited me to lunch.  I enjoyed toe time we took to chat.  It allowed me to regain some emotional equilibrium so I could focus on the task at hand.

“E” = Encourage yourself

I am unnecessarily hard on myself.  My inner critic likes yelling at me whenever my performance is “less-than-stellar”.  I need to be gentle and nurturing with myself.   Encouragement needs to start within.

check out this online resource for more information…

References

Mckay, M., Wood, J., & Brantley, J. (2007). The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation & distress tolerance. New Harbinger: Oakland, CA.

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DBT Skills – Mindfulness….

In a previous post, I provide an overview of Dialectical Behavioral Therapy (DBT).  For those not interested in reading it, here’s the cliff-notes-version of the post….

“DBT” is a therapy approach developed by Marsha Linehan.  It is based on insights from Cognitive Behavioral Therapy as well as eastern meditative traditions such as Buddhism.  The word “dialectical” refers to a concern with opposing ideas.  Linehan’s DBT approach utilizes a combination of change and acceptance strategies.  In this respect, a DBT approach upholds insight found within the serenity prayer:

God grant me the serenity
To accept the things I cannot change;
Courage to change the things I can;
And wisdom to know the difference.

DBT Basic Mindfulness Skills…

“Mindfulness is the ability to be aware of thoughts, emotions, physical sensations, and actions – in the present moment – without judging or criticizing – yourself or your experience” (Mckay, 2007, p. 75).”).

8242961713_ace5438905_zThe concept of mindfulness is actually pretty simple (in theory): being fully present “in the here and now”.   This sounds simplistic enough, but it requires two seemingly contradictory tasks.  On one hand, mindfulness requires us to be fully present so we can fully experience our sensations and emotions.  On the other hand, it requires this fully experience from a nonjudgmental perspective. In other words,   mindfulness also requires us to examine our thoughts and feelings without becoming attached to them or identifying with them.  In order to describe these two divergent perspectives, Marsha Linehan uses the terms emotional mind, logical mind, and wise mind:

The Logical Mind – Trusts facts and utilizes an empirically based thought process when making decisions.  While critical in dealing with reality, the logical mind doesn’t handle emotions or interpersonal relationships very effectively.
The Emotional Mind – The emotional mind is ruled by passionate feeling states.  The emotional mind is useful in handling matters of felt value as a reference point of understanding.  For this reason, abstract values such as love are best understood from this viewpoint.  However, the emotional mind is rather ineffective in handling pragmatic affairs of daily life.
The Wise Mind is the ability to make healthy decisions about your life based on both your rational thoughts and your emotions…It is a decision-making process that balances the reasoning of your thoughts with the needs of your emotions” (McKay, et al, 2007, p. 75).  

DBT Wise-Mindedness Worksheet

STEP ONE: What Skills

212108114_e3a154b2c1_zObservation skills are a key component of wise-mindfulness.  As an INFP Myers-Briggs Temperament, I find these skills critical.  I believe firmly there’s a huge difference between thinking through your emotions and thinking with them.  This skill provides allows us to use our wise-mindedness and see things “as they are” without judgment.  Here’s the cliff-notes overview of how this skill works:  

Observe without judgment.
Describe what is – “Just Notice”.
Fully participate in life.

OBSERVING –

I like to think of this as a “mental game”.  Firstly, I set aside all judgments, emotions and beliefs.  I let go of a need to cling to, run from, or push away facts.  Instead I play a “devil’s advocate” position.  I detach myself as if a disembodied teflon mind.  Looking down at my life from this “safe distance”, what can I simply observe?  While controlling my attention to what is happening, I witness inward the thoughts, sensations, and feelings that bubble up.  Mind you, I’m not my feelings, instead I’m an observer of them.

DESCRIBING –

Next I blog 🙂 🙂 . This involves putting words to the experiences and emotions.  With vivid and rich detail, describe the goings on around you and within you.  For those of you who are not “verbal processors”, I suggest getting an old camera and videotaping yourself.  I did this when my kids were young and I didn’t have time to blog.  I simply taped my thoughts and feelings in that moment.  I would review it at a later time with my husband.  The results were quite illuminating.

PARTICIPATE FULLY….

Becoming immersed with your experience requires you to forget yourself.  Practice on losing your self-consciousness.  Let go of the past, you can’t change it.  Let go of your future, it hasn’t happened it. Admittedly, this is a tough one, but with practice you get better at it…

STEP TWO: How Skills

As I understand it, “how skills” describe this wise-mindfulness from a different perspective.  How does it “look like” in action?  How do you observe, describe, and participate?

Nonjudgmentally –

Setting aside our beliefs, thoughts, and feelings for the time being, what are we observing.  Looking around us what do the senses tell us about what’s happening.  Looking within, what are you noticing about your reactions?  What feelings and thought processes spring into your brain?  How are you compelled to respond?

One-Mindfully –

This is a tough one for me.  First, letting go of future worries and past regrets, focus on right now. Next, since the brain is terrible at multitasking, focus on one thing.  Do one thing at a time, prioritize, and let go of any need to “do it all at once”.  Finally, resist any need to mentally or physically check out, (this is a tough one but its important).  Stay here in the present, taking it all in.

Effectively –

I’m not good at this either.  I was never known for my pragmatism.  Step back, consider your goals. What is necessary to achieve them?  What can you do in the present moment to bring yourself a step closer toward your goals?

As I stated earlier, this is easier said than done, but worth the effort.

“How & What Skills DBT Worksheet”

Images 1, 2, 3

References

Mckay, M., Wood, J., & Brantley, J. (2007). The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation & distress tolerance. New Harbinger: Oakland, CA.

 

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What is DBT?

As I see it, a perplexing dualism exists within the counselor’s mind while providing therapy.  On the one hand, you have a Rogerian unconditional positive regard as an essential element in the therapeutic relationship.  On the other hand, you have the sort of confrontational style found with addiction counseling’s history.  Where is there a middle ground between these extremes? – Understanding & Handling Resistance

After reading my last post, It occurred to me that more can be said on the matter.  In fact, this issue of change vs. acceptance reminds me of Linehan’s DBT.  My first introduction to it was as a client.  I use many of the DBT coping skills today.   As yet another hectic week of interning comes to a close, the importance of these needs emerge in my interactions with clients.  It also reminds me of my youth as a depressed teen….

I felt hopeless and alone.  Enveloped by an unending well of self-pity, I felt suicidal yet “didn’t have the guts to go through with it”.  My memory of this time sticks with me.  I’m grateful to have survived it.  These feelings can goad you toward seeking a solution – any solution – to making the “hurt stop”.  Reality is worse than a death since the pain you feel is never-ending.  With no solutions available, all I could do is marinate in my misery.

From within this mindset two seemingly counterintuitive needs existed.  I wanted someone who understood my pain without needing to fix things.  My favorite advice to all the bullying: ‘Just Ignore Them’ & Be Yourself”.  It never worked.  I was that teenager with a “you don’t understand me” mental filter.  If you “didn’t understand” you weren’t worth listening to.  If someone had taken time to truly listen, I may have been open to their offering of changed-based solutions…..

Against this personal backdrop, I see a bit of myself in my clients.  Its for this reason, I wish to review DBT’s basic principles….

Linehan’s Biosocial Theory….

DBT is a useful in approach helping individuals “manage overwhelming emotions…[and] strengthens…[their] ability to handle distress without losing control” (McKay, et al, 2011, p. 11).  The coping tools taught within DBT Skills Groups are useful in managing emotional dysregulation, (when an individual’s ability to modulate their responses to life situations is ineffective).  According to Linehan’s biosocial theory, pervasive emotional dysregulation is the result of an interaction between biological vulnerability and an invalidating environment (Koerner, 2012). Biological vulnerability is the result of three individual characteristics: (1) heightened sensitivity, (2) heightened reactivity, and (3) prolonged arousal (Linehan, et al, 1999).

Emotionally invalidating environments provide the second causal component in Linehan’s biosocial theory.  Defined as a failure to show respect for and acknowledgement of someone’s feelings; invalidation makes us feel our emotions are being neglected, mocked, and ignored (Linehan’s, et al, 1999).  Emotionally invalidating environments provide consistently invalidating responses to our maladaptive emotional regulation strategies, thereby reinforcing them, (Koerner, 2012). When these two factors coexist, the result is a poor fit between one’s emotional needs and their environment.

“Let us imagine the following: a child grows up and never experienced any validation of thoughts or feelings. He is an emotionally feral child, but lives within a community of other people who ignore validation. His parents have a radical behaviorist approach…adhering to the strictly behavioral position that emotions and cognitions are meaningless constructs” (Gilbert, 2005, page 199).

DBT’s Unique Solution…

A Dialectical Perspective

The word “dialectic” is defined as a perspective that aims to contend with opposing ideas. When I think of dialectic philosophy, Hegel’s work immediately comes to mind. In a nutshell Hegel’s dialectical perspective can be summed up in the fact that the whole is not equal to the sum of its parts.   Each component part, of this whole, has pieces missing.  Additionally, these component parts, focus only on certain elements of a situation.  Attaining wholeness requires us to see what you’re missing. DBT is based on this insight that reality is comprised of interrelated parts that must be seen holistically for the sake of clarity (Lynch, et al, 2006). Dialectical philosophy sees solutions as arising from opposing viewpoints that can be combined into a holistic perspective. DBT applies this philosophy to its treatment of emotional dysregulation with the use of change strategies, acceptance strategies, and dialectical techniques (Koerner, 2012).

  1. CHANGE STRATEGIES include the utilization of techniques to encourage change and behavioral modification (Koerner, 2012). DBT skills such as distress tolerance, chain analysis, and opposite action are useful in addressing pervasive emotional dysregulation (McKay, et al, 2010).

  2. VALIDATION STRATEGIES exist as a useful counterpoint to these techniques and emphasize acceptance and empathy (Koerner, 2012). These strategies are based on the fact that deep emotional wounds can’t be healed with logic (Lynch, et al, 2006). Validation reduces physiological responses to dysregulated emotion and allows a therapeutic alliance to develop (Linehan, et al, 1999).

  3. DIALECTICAL STRATEGIES address a “tension between the need to accept a client’s…vulnerabilities [while encouraging] them to make necessary change[s]” (Koerner, 2012, p15). DBT skills such as wise-mindedness and radical acceptance provide clients with the insight that underlies this dialectical balance. (McKay, et al, 2010)

Treatment objectives.

Initially, DBT was developed as a treatment for Borderline Personality Disorder, however research has shown it as effective in a wider array of clinical situations (Dimeff & Koerner, 2007). As an empirically supported approach, it is used in inpatient as well as outpatient settings.  It is also effective in group therapy, individual therapy and family therapy (McKay, et al, 2010).

In order to standardize DBT across all these contexts Linehan states that DBT should address five key objectives (Koerner, 2012).

  1. DBT provides clients with skills training to regulate emotions (Koerner, 2012).
  2. DBT strengthens a client’s motivation for change (Koerner, 2012).
  3. DBT helps clients apply skills in their daily lives (Koerner, 2012).
  4. DBT provides therapists with the skills needed to assist clients (Koerner, 2012).
  5. DBT provides a nonjudgmental, structured, and safe environment that allows both therapist and client to function effectively (Koerner, 2012).

Validation & Acceptance

When it’s missing….

While treating chronically suicidal patients with BPD, Linehan noted a critical shortcoming in traditional behavioral and cognitive approaches (Lynch, et al, 2006).   In particular she states the following:

“Focusing on client change, either of motivation or by enhancing capabilities, is often experienced as invalidating by clients who are in intense emotional pain.  In many clients it precipitates noncompliance, withdrawal, and at times, early drop from treatment”  (Linehan, 1997, p. 354).

Traditional behavioral approaches fail to address certain critical needs: validation and acceptance of how one feels.  Admittedly, from a pragmatic viewpoint, the idea of validating a suicidal patient’s feelings might seem idiotic.  After all, doesn’t validating a suicidal patient’s feelings mean we implicitly approve of their actions??? This attitude is quite prevalent in the hospital settings I work in.  Fortunately I’ve have the benefit of seeing things from both “sides of the fence”.

The other side of the fence…

All actions to save my life, however well-intended, resulted me feeling like a prisoner.  (This was after I left “it”.) I did a bad and needed to be constantly reminded of this.   It didn’t matter why I was doing it.  It didn’t matter what I felt or what I was going through.  I did a bad thing….

My mind is now flooded with fuzzy images of that event.  Medical personnel hovered around me as I remain strapped to the gurney.  One tech called me crazy nut and started cursing at me.  Strange hands started grabbing me all over as a tube with black crap was shoved down my throat. I screaming silently inside.  I was scared, hurt and alone.  Didn’t they understand?  Why wasn’t my family there?

After a period of rest, a student doctor sat down briefly to talk.  He was different.  He sat next to me, grabbed my hand and listened.  HE LISTENED.  He didn’t tell me I was bad or wrong.  He didn’t rush to judgment. I didn’t get a lecture. Instead he listened to how I was feeling and told me he was here if I needed to talk.  Just to ask for him…..

It’s been 20+ years since I attempted suicide. Right now I work as a CNA for a large hospital system.  Consequently, I often see patients like this – ALL THE TIME.  On occasion I am assigned as a “Safety Advocate”, for one.  This means staying within an arms reach of them at all times, to ensure safety.  My own experiences on the other side of the fence remain with me.   I witness as hospital personnel work fulfill their list of duties.  They are stressed & have lots on their mind as they attempt to stablize the patient.  They act with the best of intentions, and are guided by a strick moral code.   However, one thing is often missing: counseling experience.

They forget the human being sitting next to them is simply in pain.  They don’t take time to listen to their story.  It doesn’t occur them to ask: “How is it, that this patient’s emotional state can be understood from within the context of their life situation?”

Encouraging Change

When Acceptance Alone is Inadequate….

When a person validates your feelings, they acknowledge the reality of your lived experience “[as] understandable within [your] current life context or situation (Linehan, 1993, p. 222-223).”   You feel an implicit empathetic acknowledgement of who you are as a human being in pain.  You notice your emotional responses are taken seriously and not discounted, trivialized or mocked.  However, despite its vital importance alone it is inadequate as an approach to therapy…

“focusing treatment [of suicidal patients] on exploration and understanding, in the absence of a clear focus of efforts to help the client change, is often experienced by these same clients as invalidating because it does not recognize the ‘unendurability’ and therefore the necessity for immediate change (Linehan, 1997, p. 354).”

This statement resonates with another personal experience of mine.  As a high school student, I was depressed and alone.  I had no friends and only my school counselor to talk to.  A comment made during one of our sessions sticks with me to this day.  I shared with her the bullying I was dealing with.  She expressed sympathy and added that its just a matter of waiting it out.  “Once you graduate you’re out of here”.  When I asked her what she meant by this, she noted this small school was very cliquey & that finding friends would be difficult for me.  My reputation was pretty much cemented in the minds of my classmates and there was no changing opinions at this point. Her solution: Just wait it out.  I was already half way through high school and in the grand scheme of things, two years was nothing.

While I don’t recall my exact response to this explanation an inescapable sense of hopelessness fell over me like a foreboding and dark cloud.  It then occurred to me that my parent’s advice had a similar message to it: “They’re in cahoots!”

In retrospect, I remember my first experiences with dissociation in this moment.   This out-of-body “unreal-ness” was my only coping tool to the emotional traumas of bullying.  With no other solution at hand, this was my only coping mechanism.  It has taken much of my life to work through…..

The need for “a way out”

As I noted earlier, DBT provides a balanced solution that includes both acceptance and change-based strategies.   Based on the idea that the whole doesn’t equate to the sum of its components, the solution is to see those things you’re missing.  Hegel describes a process of transformation much like this in his philosophy,  It is a perspective that’s applicable to mental health, fields of study, and even society as a whole.

Hegel’s dialectical stages of growth begin with a THESIS, (another fancy word for idea, i.e. change is bad).
Change happens when this THESIS encounters an ANTITHESIS, (a fancy word for a contradictory idea, i.e. change is good).
When an individual resolves two conflicting ideas, (THESIS vs ANTITHESIS), the result is SYNTHESIS...(change can be scary but isn’t always a bad thing).

Wrestling with seemingly counterintuitive ideas like, leads to a cognitive dissonance, that urges us towards resolution. Using my example above, I’ve learned that my fear of change isn’t always warranted. While its not bad to move forward with caution, avoiding change at all costs results in stuckness. Sometimes a unique approach to things can create new solutions and positive transformation.

“The most fundamental dialectic is the necessity of accepting clients just as they are within a context of trying to help them change (Linehan, 1997, p. 354).”

It is a goal of mine to learn more about this method, and utilize it as a key approach in my future practice….

References

Koerner, K (2012). Doing dialectical behavior therapy: A practical guide. New York, NY: Guilford Press.
Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press.
Linehan, M. M. (1997). Validation and psychotherapy. Empathy reconsidered: New directions in psychotherapy, 353-392.
Lynch, T.R., Chapman, A.L, Rosenthal, M.Z., Kuo, J.R., & Linehan, M.M. (2006). Mechanism of change in dialectical behavior therapy: Theoretical and empirical observations. Journal of Clinical Psychology. 62(4), 459-480
Mckay, M., Wood, J., & Brantley, J. (2007). The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation & distress tolerance. New Harbinger: Oakland, CA.

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Radical Acceptance…

Forgiveness is giving up hope that the past could have been different” – Oprah

The above quote comes from a youtube video that inspired my last post on forgiveness.   Forgiveness is a process that takes time and conscious effort.  In addition to giving up hope that the past could be different, we must accept certain truths about our present-day reality.   Essentially forgiveness produces change as we letting go of a past in order accept a new future.  One resource I found states: “Forgiveness is a dialectical process through which people synthesize their prior assumptions of a transgression into a new understanding of….this reframing process [is] the construction of a ‘new narrative’ (Thompson, et al, 2005, p. 318).” When I read this quote, I was reminded of the concept of “Radical Acceptance” which I’d like to discuss briefly in this post…

A Quick & Dirty Overview of Dialectical Behavioral Therapy…

imageAbout 7 years ago, I entered therapy because I felt stuck.  While in individual therapy, I also participated in a DBT (Dialectical Behavioral Therapy) Skills Group.  In my ongoing efforts to heal & forgive, the concept of radical acceptance has been essential.  DBT was initially designed by Marsha Linehan for Borderline Personality Disorder (BPD). While treating chronically suicidal patients with BPD, she noted a critical shortcoming in traditional behavioral and cognitive approaches (Lynch, et al, 2006). These approaches failed to address a dialectical dilemma apparent in the treatment of these clients. The validation and acceptance these clients require must be provided in balance with approaches that enable change (Lynch, et al, 2006).   As a result of this clinical observation, Marsha Linehan developed this strategy based on the Hegelian idea that reality is comprised of interrelated parts.  Dialectical philosophy defines transformation as a byproduct of two opposing viewpoints that are combined into a holistic perspective. DBT applies this philosophy to its treatment of emotional dysregulation with the use of change strategies, acceptance strategies, and dialectical techniques (Koerner, 2012).   Change strategies include the utilization of techniques to encourage change and behavioral modification (Koerner, 2012). DBT skills such as distress tolerance, chain analysis, and opposite action are useful in addressing pervasive emotional dysregulation (McKay, et al, 2010). Validation strategies exist as a useful counterpoint to these techniques and emphasize acceptance and empathy (Koerner, 2012). These strategies are based on the fact that deep emotional wounds can’t be healed with logic (Lynch, et al, 2006). Validation reduces physiological responses to dysregulated emotion and allows a therapeutic alliance to develop (Linehan, et al, 1999). Dialectical techniques address a “tension between the need to accept a client’s…vulnerabilities [while encouraging] them to make necessary change[s]” (Koerner, 2012, p15). DBT skills such as wise-mindedness and radical acceptance provide clients with the insight that underlies this dialectical balance. (McKay, et al, 2010).

Of all the concepts from this therapy group, “radical acceptance”, really stuck the most.  It provided a serene backdrop against which clarity could develop, yielding lasting change.

So What is Radical Acceptance?

imageMarsha Linehan (2005) defines radical acceptance as a complete and total acceptance of reality from the depths of your soul, in your mind heart and body.  In this respect, radical acceptance allows us to focus on the current moment, seeing reality as it is, without judgment.  Rather than fighting with reality or asking why, you choose to go with what is so you can function.  In this respect, acceptance doesn’t mean giving up, it means you choose to not fight reality. Suffering, in an instant, transforms into a tolerable pain…

Pain + Nonacceptance = Suffering:  Pain creates suffering only when you refuse to accept reality.   Acceptance helps to end suffering by turning something you can’t cope with into something you can.
Acceptance ≠ Approval:  Accepting reality doesn’t necessarily equate to a positive endorsement of what is happening. To accept something is not the same as judging it as good. Instead, think of acceptance as an acknowledgment of reality.

Turning the Mind….

In my own life, Oprah’s definition of forgiveness has been essential.  In order to move forward and become unstuck, life required me to let go of my wishes for a different life history.  By choosing to stop asking “why”, I ended much of the personal suffering I created.  Radical Acceptance is a choice Linehan (2003) describes as “turning of the mind”….

  1. STEP ONE: COMMITMENT.  The first step toward radical acceptance is simply making an active choice in the present moment to deal with reality as it is…
  2. STEP TWO: LOOK OUT FOR RESISTANCE.  As a desire to resist reality and deny its very factual nature, it is important to keep a look out for resistance.  Rumination  & resistance are forms of sadomasochistic mental torture.
  3. STEP THREE: BE AWARE OF REALITY ESCAPES & BLOCKERS.  Are you blocking certain aspects of reality out of your awareness as a form of self-deception?  What are you doing to escape reality and self-medicate (food, drink, etc)???
  4. STEP FOUR: UNDERSTAND THE CAUSE.  This step simply involves recognizing that all things have a cause.  Seeing things as they are is empowering and allows you to attain the clarity necessary to produce lasting change.   This means not asking why it happened and instead how it occurred.

Willingness vs.  Willfulness…

I’d like to conclude this post by comparing the mindset of willingness with willfulness.  These two perspectives provide a useful illustration of how accepting reality compares with a rejection of it.  In the table below, I provide a comparison of these two mental states….

willingness

willfulness

Accepting Reality
  Rejecting Reality
Participate in life
  Not Tolerating “Now” 
Acknowledging what Is 
Fixing the Unfixable
Doing What is Needed
 Sitting on Your Hands
Choosing Healing 
 Playing Victim  

References

Lynch, T.R., Chapman, A.L, Rosenthal, M.Z., Kuo, J.R., & Linehan, M.M. (2006). Mechanism of change in dialectical behavior therapy: Theoretical and empirical observations. Journal of Clinical Psychology. 62(4), 459-480
McKay, M., Wood, J. C., & Brantley, J. (2010). The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation & distress tolerance. Oakland, CA: New Harbinger Publications.
Marsha Linehan (2005), From Suffering to Freedom: Practicing Realty Acceptance. New York, NY: Guilford Press
Thompson, L.Y., Snyder, C.R., Hoffman, L., Michael, S.T., Rasmussen, H.N., Billings, L.S. & Roberts, D.E. (2005). Dispositional forgiveness of self, others and situations. Journal of Personality, 73(2). pp. 313-354.

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