Archive for the ‘Skills for a Life Worth Living’ Category

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.