Archive for March, 2010

Skills for a Life Worth Living

DBT is based on the point of view that destructive borderline behaviors are the result of getting really upset (emotional dysregulation) or the attempt to avoid feeling really upset. Accordingly, DBT teaches clients how to deal with emotions and life stress in ways that avoid dysregulation and promote better relationships.

Many different skills are taught, which interweave and support one another to gradually help clients develop lifestyles that work better for them and their loved ones. There is no one magic bullet in DBT, but instead a large collection of techniques that collectively are powerful in helping clients build “a life worth living”.

DBT skills groups teach 4 modules: Mindfulness, Emotional Regulation, Distress Tolerance, and Interpersonal Effectiveness. A fifth basic skill set — Self Management through behavioral techniques of positive reinforcement rather than punishment – is woven through the other modules.

Throughout the skills will be found the fundamental balancing act (dialectic) between acceptance and change. Appearing again and again is the paradox that only through acceptance of what is can be found the means to change it. Insofar as we usually exhaust ourselves in repetitive struggling against how things are, moving into acceptance is a change that opens new possibilities. This theme will be explored further in the pages on the specific modules.

Ideally, DBT skills are learned and supported in a group context. For Bay Area DBT Skills Groups, click here.

However, there are several good Books about DBT Skills below:


Useful Books for Helping Someone with BPD

Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder by P.T. Mason and R. Kreger, (Oakland: New Harbinger, 1998). Written from the perspective of partners of people with BPD.

New Hope for People with Borderline Personality Disorder by Neil. R. Bockian, PhD, with Valerie Porr, MA and Nora Elizabeth Villagran, MA (New York: Three Rivers Press, 2002). Valerie Porr’s chapter “Family Perspective of Borderline Personality Disorder” will be helpful to family members.


Books for Learning DBT Skills

Skills Training Manual for Treating Borderline Personality Disorder by Marsha Linehan (New York: The Guilford Press, 1993). By the creator of DBT, the book has handouts used by most DBT Skills Trainers. The handouts are good for putting up on the refrigerator as reminders, but some additional explanation is needed. The first half of the book includes notes for trainers that could be read as explanation of the handouts.

Don’t Let Your Emotions Run Your Life: How Dialectical Behavior Therapy Can Put You in Control by Scott Spradlin, MA (Oakland: New Harbinger Publications, 2003). This book has useful explanatory text about the skills, as well as exercises and worksheets.

Depressed and Anxious: The Dialectical Behavior Therapy Workbook for Overcoming Depression and Anxiety by Thomas Marra, PhD (Oakland: New Harbinger Publications, 2004). This book also has explanatory text, some very good descriptions of mindfulness, and an alternate set of acronyms for DBT skills.

Mindfulness

To put it simply, mindfulness is about what we pay attention to, and getting more control over where our awareness goes. Most of the time, and particularly when we are agitated, our awareness goes all over the place and becomes identified with thoughts that create a lot of suffering. Mindfulness practices teach us to focus on something other than our thoughts. It takes us out of “problem solving” mode towards “awareness of being alive” mode, which usually allows our emotions to calm down.

Mindfulness can focus on the breathing, other body sensations, music, the colors to be seen in the room or a picture, sounds in the environment, a repetitive soothing word, or one of many other alternatives to stress producing thoughts. The DBT practice of “describing” what is experienced (as in “now I’m aware of reading these words”, “now I’m aware of sounds in the room”, etc) gives the thinking mind a job to do, and may reduce the arising of more distracting thoughts.

In the beginning, mindfulness practice usually needs the support of a therapist or group, in order to encourage the client to keep bringing attention back to the chosen focus after it wanders off. DBT clients are urged to be “nonjudgmental” about what arises in mindfulness practice, and particularly about their perceived progress in doing it. Focusing on “one thing at a time” deepens the energy of awareness, producing a relaxation response and more emotional clarity. Clients are encouraged to remain focused on what “works” in mindfulness and interpersonal situations, rather than on concepts and “shoulds”.

Research studies have shown mindfulness practice to produce significant improvements in emotional functioning. In addition, mindfulness is considered a core DBT tool because it enables clients to discover how their emotions and ways of relating to other people work. Clients learn the “choice points” within these systems in which a new behavioral choice can dramatically affect the way they feel or relate. Because emotional and relationship experiences happen so quickly, it takes sharpened mindfulness skills to perceive what is going on and what could be improved.

As mindfulness brings greater calmness to emotional situations, it becomes more possible for clients to hear what DBT calls “wise mind”, a quiet voice of guidance found at the meeting place of reason and emotions. DBT proposes that this “knowing the right thing to do” is available to all of us, when we know to look for it beneath the turbulence of emotions and judgmental thoughts.

New! See my two-part video on Emotion Regulation and DBT Skills: click on the links for part 1 and part 2.

Emotional Regulation

One might think that people whose emotions get them into trouble would know a lot about those emotions. Actually, the opposite is true, for good historical reasons. In order to try to “stop being so emotional” and fit in with less emotionally sensitive people, clients who meet criteria for BPD have often learned to ignore their feelings, and really don’t know how they are feeling until they are completely taken over by an emotion.

Often, people with borderline behaviors are emotion phobic; they have been trained with an environment invalidating of feeling to suppress awareness of the low and mid-range intensities of emotion. Unfortunately, this serves to make emotional extremes more necessary and frequent. What’s worse is that these people have not been supported to learn how emotions work, and to know about the points within an emotional experience at which the intensity and quality of the experience can be regulated. DBT addresses these deficits by teaching clients how to find these “choice points” and take actions to regulate their emotional experience.

A significant portion of the Emotion Regulation module is spent teaching clients how to track the sensory details and components of their emotions. A diagram of how emotions work is presented, and descriptive words for the different components are given for several basic emotions. Here is a simplified version of the diagram:

To explain the diagram, we begin on the left side: a typical emotional experience begins with something happening in the external world, that “triggers” the emotional response. However, as the arrow coming up from the lower box indicates, one emotion can trigger a “secondary emotion”, as when feeling fear triggers anger, anger triggers shame, or love triggers joy. Once a triggering event occurs, there is usually an interpretation made by the thinking mind about the meaning of the trigger. The sensations that occur in the body and the urges to take action are typically felt to constitute the experience of the emotion, and take place mainly in response to the interpretation.

Vulnerability factors (such as being tired, hungry, pre-menstrual, or physically sick) will strongly affect the emotional experience, however, as well as the interpretation and even the trigger. Emotions are communicated in facial and postural expressions, actions, and words (including those used to describe the emotion). These expressions usually intensify the emotional experience. However, as will be seen below, it is possible to consciously override these expressions in such a way as to change the emotional experience.

Everything on the left side of the diagram — including vulnerability factors, triggers, interpretations, facial and postural expression, actions and words –- can be influenced by clients as they learn DBT skills. Changing these components will inevitably and dramatically change the emotional experience.

The second half of the Emotion Regulation module is spent teaching the skills needed for changing these components:

Emotional vulnerability factors are decreased by getting physical exercise, avoiding non-prescription drugs and alcohol, treating physical illness, getting the right amount of sleep, proper eating, mindfulness practice, etc.

Negative emotional triggers are reduced by improved relationship and distress tolerance skills, and by solving life problems, while positive triggers are increased by planning daily pleasant events, working toward personal goals, repairing and improving relationships, and switching the focus of awareness towards the positive experiences in life.

Interpretations are modified by teaching clients to challenge negative beliefs that create suffering and prevent positive change.

Facial and postural expressions, words and actions can be consciously reversed from what is habitually urged by an emotion, and as this occurs the emotional experience is changed. For example, insofar as the emotion of “fear” urges us to run away, the principle of Opposite Action teaches us to face what we fear over and over until we become confident in our ability to deal with it. “Depression” urges hiding away and giving up, so the Opposite Action is to push ourselves to engage in activities until we feel better. Anger urges confrontation, or even violence, and so Opposite Action prescribes taking a time out, moving away from the person we’re mad at, until we calm down.

Even the tendency to run away from emotions is reversed in DBT as clients are taught to mindfully observe and experience the waves of emotions that arise and disappear within them. This “Mindfulness of Emotion” skill is the acceptance mode counterpart of “Changing Emotions by Opposite Action”. Meeting emotions simply and directly, without trying to repress or exaggerate them, allows the body to go through its physiological process for dealing with them and return to a resting baseline in the most efficient manner. That this can happen, however, is new information to someone who has not been supported to experience emotion and get through it, and this skill takes some time and a lot of support to acquire.

All of these skills, indeed, must practiced repeatedly and “overlearned”, in order to be available to us in an emotional crisis. For this reason, it is extremely valuable to be in the supportive environment of a DBT skills group or individual skills training.

Distress Tolerance

Distraction

I often tell clients that Distress Tolerance is about “getting through a crappy moment without doing something to make it worse.” Most of the self destructive behaviors associated with BPD or chemical dependency are an effort to escape from severe emotional pain. Acknowledging that it will take time before clients learn to effectively reduce the intensity of this pain, DBT offers a large collection of ways to distract attention that are more positive than planning suicide attempts, taking street drugs, or jumping into abusive relationships.

The basic idea is to focus awareness on something other than the hurtful thoughts and emotions. Here is a short list of distraction techniques taken mostly from Marsha Linehan’s Skills Training Manual:

Activities; Get involved in exercise or hobbies, do puzzles, clean the house in a mindful way, call a friend, play computer games, surf the web.

Contribute; Do volunteer work, do something nice for someone else.

Generate Opposite Emotions; Watch comedies on TV, read joke books or funny greeting cards, listen to emotional music (of a different emotion than you’re feeling).

Think about something else; Count to 10, count backwards by 7’s from 100, count the colors (or shades of the same color) in the room or a picture, read detective novels, watch the fish in an aquarium.

Generate strong sensations; Hold ice or a synthetic ice pack (even colder!) in hand, squeeze a rubber ball really hard, stand under a hard, hot shower, listen to very loud music.

Take a brief vacation; Get in bed and pull the covers over your head for 20 minutes, buy a shlocky magazine and eat chocolates while you read it in bed (okay, maybe this is fattening, but it’s better than some things people do when upset).

What makes these distractions work is mindful focus –- being really aware of the sensations involved. Clients who continue to ruminate about their problems and hurt feelings while doing these techniques will experience less benefit. Pick something you can get into, pay attention to the details of it, and bring your focus back if your mind wanders.

Radical Acceptance

The distraction techniques above offer the opportunity to change our experience for a least a brief respite from emotional pain, while we rebuild our strength. The dialectical balance to this emphasis on change is a powerful statement of the idea of acceptance as a way out of extreme distress. The concept of Radical Acceptance suggests that we suffer less if we let go of struggling with what is occurring. This does not mean that we endorse as “good” what is going on, or that we never try to make changes in the long run. Radical Acceptance suggests that in this moment, what is happening is happening, whether we like it or not. Screaming about it in our mind will not help, but merely exhaust us. Acceptance mode is the fastest way out of pain; we save our strength until we can find a way to change the situation.

Pros and Cons

In this technique, we look at our options about dealing with a “crappy day”, and think about whether falling into old habits will really help or “make it worse” in the long run. Do we really want to return to the self-harm behavior, or try (as many times as it takes) more positive distraction techniques, even if they don’t work as fast or dramatically as what we’ve employed in the past? The trick here is to think beyond the immediate moment, beyond the temporary relief offered by the destructive habits, to the guilty, hung-over and set-further-back consequences that always follow those habits. In addition to thinking about these usual consequences, we can also anticipate how good it may feel to have been able to avoid destructive behaviors by trying something else more productive.

Interpersonal Effectiveness

See my new video about Interpersonal Skills! Click here for Part 1 and here for Part 2.

Barbra Streisand sang that “people who need people are the luckiest people in the world.” People who meet criteria for BPD usually fit within this category, but often find relationships challenging to maintain and enjoy, especially when really upset. They may act like doormats, accepting whatever a friend or lover does in order to avoid abandonment, or blow up relationships in a confrontive rage.

Recognizing the central importance of relationships in our client’s lives, DBT offers several concepts useful in improving them. Here are my three favorites from the Interpersonal Effectiveness module.

First of all, in thinking about assertiveness, it is useful to move beyond considering it like an on or off switch, as either asserting one’s view or not. DBT proposes that we consider it like a dial that is marked with levels of assertiveness from 0 to 6. As we turn up the dial, we act more assertively, based on what seems most appropriate to a given situation. At 0 on the scale, we do not even mention what it is we want; at 6 we insist, and do not take no for an answer. In between we may hint indirectly (1) or openly (2), ask in a tentative manner and accept a no (3), ask firmly and accept a no (4), or ask firmly and resist taking a no (5). A similar scale is presented for saying no to a request; again, it involves a graduated response based on the particulars of the situation.

A second useful concept helps us to decide how strongly to push for what we want or resist what we don’t want. This involves learning to prioritize among three possible objectives in any given interpersonal situation: what you want to pragmatically happen (e.g., it’s your roommates’ turn to do the dishes); keeping the relationship harmonious (having them like you after they do the dishes); and keeping your self respect (feeling good about how you got them to do the dishes). Our priorities in a given situation will influence how hard we push for what we want and how we go about asking or saying no. Sometimes we may ask for less in order to increase harmony (we can “pick our battles”), but if we never push for what we really want, our self-respect goes way down. More detailed criteria for deciding how firmly to assert are explored in the DBT materials.

Third, DBT offers guidelines for accomplishing each interpersonal priority in the most effective manner. To make it most likely that you will get what you want, it is recommended that you start off by Describing the situation objectively, to cue it up in a soft manner; Express the feelings that you have about the situation (it will be more helpful to describe the more primary feelings, like fear and sadness, than the secondary defensive ones like anger); Assert your request about what you want the person to do, and Reinforce their cooperation by conveying what’s in it for them to give you what you want; meanwhile, Mindfully keep on track despite whatever distractions they may raise (ignore attacks, for example); Appear confident that you will be able to obtain your objective in a harmonious manner; and be willing to Negotiate about the details of an agreement to resolve the situation. (This is the famous DEAR MAN acronym in DBT).

For keeping the relationship amicable, DBT recommends the GIVE skills: being Gentle (no attacks, threats or judgments); being genuinely Interested in the other person’s point of view; Validating what you can about that point of view (see the Validation discussion elsewhere in the site); and having an Easy manner, with humor, softness and creativity.

For maximizing self-respect, DBT recommends you be Fair to yourself and the other person, avoid overdoing Apologies, Stick to your values without selling out, and be Truthful about your needs and feelings (don’t act helpless when you’re not, or make up excuses). These are the FAST skills.

As with all the skills, these interpersonal techniques take a lot of practice (with support from a group or therapist) in order in be available in the heat of emotional interactions. The mindfulness, distress tolerance and emotion regulation skills are also needed to enable you to be calm enough to remember and utilize the interpersonal techniques effectively.

Helping Someone with BPD

Emotional disorders and self-destructive behaviors are troubling not only to the person who has them, but to the friends, family and loved ones of that person. It may be that you have come to this site in order to find out how you can help someone who may meet criteria for Borderline Personality Disorder (BPD) or related mood disorders.

Perhaps you are also hoping that you will find ways to help yourself and other family members deal more effectively with the anger, unpredictability, depression, substance abuse, cutting or suicide attempts thatthese emotionally vulnerable people often display. People who live with loved ones exhibiting borderline behaviors often become stressed out, and feel like they are “walking on eggshells” to avoid emotional blowups or more destructive behaviors.

It can help to know that you are not alone in struggling with these difficulties, that books and websites are available to provide helpful information, and that mental health professionals now have powerful tools to assist not only your loved one, but you as well. The way that I work with the families of people who exhibit borderline behaviors is based upon Dialectical Behavior Therapy (see What is DBT? for more information).

Getting Professional Help

Families who have sought my help for someone with BPD have usually hoped that I could that I could help get the person into a treatment process that would improve moods and behavior, and help the family members deal with their own stress reactions, communicate in ways that allow them to assert reasonable boundaries without causing huge blowups, and conduct themselves in ways that support their loved ones to get moving in life to become happier. Because people with borderline behaviors often respond defensively (and angrily) to the suggestion from family members that they need help, it is likely to take time, patient persistence, and improved communication skills on the part of family members before the person they want to help becomes involved in treatment.

Therefore I usually begin working with the family members themselves on skills that will help set the limits they need for the happiness of their own lives, communicate as effectively as possible their desire for the person with borderline behaviors (the PBB) to get help and make life changes, accept their own limitations in what they are able to do to make their loved one happy, and discover ways that their efforts to avoid conflict or help the PBB may have inadvertently reinforced the very behaviors that drive the family crazy.

Avoiding conflict

While it is natural, for example, to avoid bringing up difficult topics with someone who is likely to get real upset, in failing to do so family members often end up going along with things that make them unhappy. What’s worse, these attempts to avoid conflict strengthen the borderline brain and behavior patterns of the loved one, and make them more likely to occur in the future. So part of my job in helping family members is to support them to stand up more for their own boundaries, even if this is unpleasant in the short run, so that things get better for everyone (including the PBB) in the long run.

It is very important, however, to carry out this process of “observing one’s own limits” (as DBT calls it) in a skillful manner, balanced by love and empathy for the PBB’s very real difficulties. The skills I teach families are mostly drawn from Dialectical Behavior Therapy. Before describing them in more detail, I want to mention the crucial importance of another DBT concept, Validation.

Validation

There are few things people want more in life than to be told that they are right about what they are thinking, feeling and doing. Upon being told this, people usually calm down and feel better, which makes communicating with them much easier.

Validation basically involves communicating that we understand, appreciate or approve of something in another person, such as their beliefs, emotions or actions. Though we may not be able to validate everything someone feels or does (especially with destructive behaviors) we can learn to find something in the person’s feelings or behaviors that we can understand and agree with. This can be like sorting through a big pile of sand (or in a really tough moment, through a pile of manure) for nuggets of gold. We may need to get out our magnifying glasses (and shore up our faith that there is something worthwhile to find), but when we are able to offer validation it has a tremendously positive effect. This is especially true for PBB’s, because they almost constantly feel misunderstood and blamed, particularly within themselves. If family members can learn to validate what is indeed valid in a skillful manner, they will usually be heard in a whole new way by their PBB.

How to Validate

Learning to validate more frequently involves perceiving what to validate and communicating about that. There’s a DBT saying, “Don’t validate the invalid!” You want to respond positively only to that which you genuinely experience as true and useful, or you will decrease your own sense of self-esteem by violating your values, and you will come across as sarcastic or phony. You can get in the habit of validating more often by asking yourself, “what can I agree with in this person’s behavior?”, or “What about this makes sense to me?” In searching for what to validate, look past the parts that bother you or you disagree with, to what seems the most worthwhile, and start there in your feedback.

As a fallback approach, you can almost always validate on the basis of the person’s history or brain chemistry: “Given what you’ve gone through with [fill in the blank] it makes sense to me that you’re feeling [fill in the blank]. I’d feel that way too if I’d experienced what you have.” However, if you can find something you can agree with in a more direct way (e.g. ” Yes, it sounds like that person really was rude”), that will be more powerful in helping a person calm down and feel understood.

The Validation Sandwich

If you start a conversation with validation, the person you’re speaking with will probably be more receptive to whatever else you have to say. If there is difficult feedback you need to give, you can wrap it in validation before and after, like the meat between pieces of bread in a sandwich. Even more effectively, you can express the difficult feedback in the DEAR MAN format (see the DBT Interpersonal Skills page).

Dealing with Disappointment about Your Loved One

It is natural to feel disappointed if your child or spouse repeatedly behaves in a way that is dramatically (or traumatically) different from what you had hoped. There may need to be a process of facing this grief in a conscious way, in moving toward acceptance of what actually is. Paradoxically, acceptance of things as they currently are supports finding the strength to make the changes we desire – -otherwise we exhaust ourselves in an inner struggle against what is going on. DBT teaches a balancing of Radical Acceptance with other distress tolerance techniques that shift our awareness to nurturing, non-harmful activities that provide an energy rebuilding respite (see Distress Tolerance Skills).

It is also helpful to focus attention on the positive aspects of our families (like the glass half-full of water), despite how extreme the difficulties may be. Learning to have more control of where we place our attention is a primary goal of mindfulness techniques taught by DBT therapists (see Mindfulness Skills).

Dealing with Guilt

Parents or loved ones may feel guilt as a result of believing (or perhaps being told by a blaming mental health culture) that they have caused or contributed to the problems of a person with borderline behaviors. It is important to remember that there is a powerful biological and genetic component to the emotional sensitivity and vulnerability of PBB’s. It has usually been my experience that the families I have worked with have done the very best job they could, given their own life difficulties and lack of knowledge about the techniques that are now available for dealing with sensitive children. It is one of the paradoxes in helping someone with BPD that loved ones have done the best they could, but in order to be happy and more effective they must learn how to do better.

Learning DBT Skills

Research by Perry Hoffman, PhD and others has shown that teaching DBT Skills to family members has positive effects both in helping someone with BPD and helping the family members themselves. When parents learn improved skills in regulating emotion, tolerating distress, controlling attentional focus, and interpersonal relating they can support the development of these skills in the loved one they want to help, and will be calmer and happier themselves.

You will find in these web pages an overview of the DBT Skills (see Skills for a Life Worth Living). There are a least three good workbooks on the subject, listed below, through which you may study them on your own. You may also find it useful to consult a DBT therapist to help you apply them in your family.

Useful Books for Helping Someone with BPD

Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder by P.T. Mason and R. Kreger, (Oakland: New Harbinger, 1998). Written from the perspective of partners of people with BPD.

New Hope for People with Borderline Personality Disorder by Neil. R. Bockian, PhD, with Valerie Porr, MA and Nora Elizabeth Villagran, MA (New York: Three Rivers Press, 2002). Valerie Porr’s chapter “Family Perspective of Borderline Personality Disorder” will be helpful to family members.

Books for Learning DBT Skills

Skills Training Manual for Treating Borderline Personality Disorder by Marsha Linehan (New York: The Guilford Press, 1993). By the creator of DBT, the book has handouts used by most DBT Skills Trainers. The handouts are good for putting up on the refrigerator as reminders, but some additional explanation is needed. The first half of the book includes notes for trainers that could be read as explanation of the handouts.

Don’t Let Your Emotions Run Your Life: How Dialectical Behavior Therapy Can Put You in Control by Scott Spradlin, MA (Oakland: New Harbinger Publications, 2003). This book has useful explanatory text about the skills, as well as exercises and worksheets.

Depressed and Anxious: The Dialectical Behavior Therapy Workbook for Overcoming Depression and Anxiety by Thomas Marra, PhD (Oakland: New Harbinger Publications, 2004). This book also has explanatory text, some very good descriptions of mindfulness, and an alternate set of acronyms for DBT skills.