And now for something completely different
I went to a Dialectical Behavior Therapy (DBT) training today. A lot of the people I work with at my mental health job suffer from borderline personality disorder, and are in this type of therapy. So I asked to please take the training, so I can understand better what they are doing, and respond better when they are having problems. (Y'know, instead of "try using your DBT skills" maybe something more specific like "why not try some distress tolerance techniques, such as ...")
DBT has four major skill components: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. Mindfulness is considered the core skill to the whole DBT "package." Previously, despite knowing this, I've been afraid to do too much with folks on this skill, because I've been worried about the fact that my approach is going to be largely informed by what experiences I've had with Buddhism.
Today I learned that it's a bit late to worry about that: the inclusion of mindfulness training in DBT is a very deliberate addition of Zen philosophy to existing cognitive-behavioral approaches. So not only is it ok if I utilize skills I've learned in "sits" at Buddhist monasteries, but if I include prompts or gathas from my favorite author, Thich Nhat Hahn, it will probably sound very familiar to the folks I'm working with. One of his classic gathas, or a slight variation on it, is one they often use in DBT groups:
Breathing in, I calm myself.
Breathing out, I smile.
Dwelling in the present moment,
I know it is the only moment.
I can see why they've changed the last line. "I know it is a wonderful moment" is not going to go over well with someone feeling so emotionally distressed they want to cut.
So, yay, I'm better equipped than I had realized. Now for distress tolerance.
There's a saying that I've seen on "DBT prompt signs," but haven't understood: Wise Mind ACCEPTS. We went over the "wise mind" concept a bit, as it is also pretty essential to the basic concepts of DBT: learning to play the tension between opposites in order to achieve balance, rather than getting sucked repeatedly from one opposite to another. The pair of opposites in this case is the "rational mind" versus the "emotional mind."
Once the trainer went into this, it seemed self-evident. If we're too entrenched in our rational mind, we're like robots or Vulcans, missing out on the depth of human experience emotions bring. If we're too caught up in our emotional mind, we're in a state of constant chaos, being pulled from ecstatic highs to crashing lows. We all experience that at times, but for someone with borderline personality disorder, this is the baseline. So the challenge, for all of us but particularly people with BPD, is to find the point of intersection of these two opposites, where rationality and emotion meet and overlap, neither denying/repressing emotions nor giving them free reign, and this is what is meant by "wise mind."
Cool, that makes sense. And I can see how it's helpful, either for just anybody who is in an emotionally overcharged state or someone who has trouble with emotional dysregulation, to explicitly spell this out. So what about the ACCEPTS part?
As the capitalization suggests, it's an acronym. So the saying "Wise Mind ACCEPTS" has a couple of layers of meaning. First, like the Serenity Prayer, it serves as a reminder that sometimes we can't change things, and have to learn ways to accept them and move on with life. Second, it points to specific ways to work toward this goal:
activities (take a walk, take up a hobby),
contribution (help someone else),
comparison (it could be worse),
emotion (do something that generates a different emotion than the one that is causing a problem),
pushing the pain away (imagine shoving it off a cliff or something),
thoughts (something that engages just enough of the mind to distract it, like counting the tiles in the floor, the colors in a painting, etc.), and sensations (some strong but not harmful sensation like holding ice cubes, snapping a rubber band on the wrist, or some soothing sensation like using a pleasantly scented hand lotion, particularly useful for people who self-injure).
Most of this I can see the value in. The sensations component gives me pause, but mainly because I don't personally have the experience of wanting to burn or slash myself as a means of derailing emotional pain. Accepting the basic premise that for some folks, creating a strong unpleasant sensation *is* desirable in order to bring out-of-control emotions back to a tolerable level, I can see how utilizing other strong and unpleasant sensations may be able to fill that requirement without requiring a trip to the emergency room.
The one part that I have a hard time with is comparison. And I raised this at the training. I can accept, grudgingly, that it seems to be basic human nature to observe someone whose situation is worse than our own and think, "whew, I'm not as bad off as I thought." In fact, that would seem to be the driving force behind so-called "reality tv." But personal experience suggests that when you're already feeling badly, bringing to mind folks who have it worse can be counter-productive. For me, yes, there might be a moment of feeling grateful that at least I'm not forced to live on the street or whatever the comparison du jour might be, but almost immediately will come guilt and potential self-loathing: "Yeah, I am more fortunate than lots of people. So where do I get off feeling down about X? What kind of self-involved jerk am I that I think I deserve to feel depressed when others have it so much worse?" Which, far from leading *out* of the bad place, leads much further into it.
On the one hand, I can look at my experience with this and just say, so this type of comparison might be useful for some people, even most people, but pretty clearly won't work for all. It definitely doesn't work for me! And while everyone else in the training looked at me like I had three heads when I asked about this, I'm reasonably sure I'm not the only freak on the planet who does that sort of shame spiral. I mean, if I were, then the phrase "shame spiral" probably wouldn't be out there in the self-help books and groups. So that leads me to the other hand, where I'm really concerned about recommending this distress tolerance technique to anyone. How do I know if they'll be someone who responds well to it, or someone who'll do the "shame spiral" thing?
Fortunately, I'm not the DBT therapist, so I don't have to determine whether to introduce them to the idea or not. That's out of my hands, and pretty much guaranteed to have been covered already in their DBT groups. I can just ask them, "would it help to compare your situation to suchandso, which would be (or is) much worse?" And if they say no, then suggest exploring a different technique. There is something to be said for being on one of the lower rungs of the ladder, and I guess this is one of them.
I do wish I was going to be able to attend next week's portion of the course, covering emotional regulation and interpersonal effectiveness skills. I was originally scheduled to attend both parts, when the first would have been on 2/6 and the second 2/13. Then the entire state had a major freak-out that we actually (gasp) had SNOW in New England in February. Not even a lot of it. But everything shut down, and the schedule got shifted a week. Maybe I should hope for another flake or two to hit next Friday so that part 2 moves to the 27th? Oh, wait, I couldn't make that one either. Jury duty. Bleh.
DBT has four major skill components: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. Mindfulness is considered the core skill to the whole DBT "package." Previously, despite knowing this, I've been afraid to do too much with folks on this skill, because I've been worried about the fact that my approach is going to be largely informed by what experiences I've had with Buddhism.
Today I learned that it's a bit late to worry about that: the inclusion of mindfulness training in DBT is a very deliberate addition of Zen philosophy to existing cognitive-behavioral approaches. So not only is it ok if I utilize skills I've learned in "sits" at Buddhist monasteries, but if I include prompts or gathas from my favorite author, Thich Nhat Hahn, it will probably sound very familiar to the folks I'm working with. One of his classic gathas, or a slight variation on it, is one they often use in DBT groups:
Breathing in, I calm myself.
Breathing out, I smile.
Dwelling in the present moment,
I know it is the only moment.
I can see why they've changed the last line. "I know it is a wonderful moment" is not going to go over well with someone feeling so emotionally distressed they want to cut.
So, yay, I'm better equipped than I had realized. Now for distress tolerance.
There's a saying that I've seen on "DBT prompt signs," but haven't understood: Wise Mind ACCEPTS. We went over the "wise mind" concept a bit, as it is also pretty essential to the basic concepts of DBT: learning to play the tension between opposites in order to achieve balance, rather than getting sucked repeatedly from one opposite to another. The pair of opposites in this case is the "rational mind" versus the "emotional mind."
Once the trainer went into this, it seemed self-evident. If we're too entrenched in our rational mind, we're like robots or Vulcans, missing out on the depth of human experience emotions bring. If we're too caught up in our emotional mind, we're in a state of constant chaos, being pulled from ecstatic highs to crashing lows. We all experience that at times, but for someone with borderline personality disorder, this is the baseline. So the challenge, for all of us but particularly people with BPD, is to find the point of intersection of these two opposites, where rationality and emotion meet and overlap, neither denying/repressing emotions nor giving them free reign, and this is what is meant by "wise mind."
Cool, that makes sense. And I can see how it's helpful, either for just anybody who is in an emotionally overcharged state or someone who has trouble with emotional dysregulation, to explicitly spell this out. So what about the ACCEPTS part?
As the capitalization suggests, it's an acronym. So the saying "Wise Mind ACCEPTS" has a couple of layers of meaning. First, like the Serenity Prayer, it serves as a reminder that sometimes we can't change things, and have to learn ways to accept them and move on with life. Second, it points to specific ways to work toward this goal:
activities (take a walk, take up a hobby),
contribution (help someone else),
comparison (it could be worse),
emotion (do something that generates a different emotion than the one that is causing a problem),
pushing the pain away (imagine shoving it off a cliff or something),
thoughts (something that engages just enough of the mind to distract it, like counting the tiles in the floor, the colors in a painting, etc.), and sensations (some strong but not harmful sensation like holding ice cubes, snapping a rubber band on the wrist, or some soothing sensation like using a pleasantly scented hand lotion, particularly useful for people who self-injure).
Most of this I can see the value in. The sensations component gives me pause, but mainly because I don't personally have the experience of wanting to burn or slash myself as a means of derailing emotional pain. Accepting the basic premise that for some folks, creating a strong unpleasant sensation *is* desirable in order to bring out-of-control emotions back to a tolerable level, I can see how utilizing other strong and unpleasant sensations may be able to fill that requirement without requiring a trip to the emergency room.
The one part that I have a hard time with is comparison. And I raised this at the training. I can accept, grudgingly, that it seems to be basic human nature to observe someone whose situation is worse than our own and think, "whew, I'm not as bad off as I thought." In fact, that would seem to be the driving force behind so-called "reality tv." But personal experience suggests that when you're already feeling badly, bringing to mind folks who have it worse can be counter-productive. For me, yes, there might be a moment of feeling grateful that at least I'm not forced to live on the street or whatever the comparison du jour might be, but almost immediately will come guilt and potential self-loathing: "Yeah, I am more fortunate than lots of people. So where do I get off feeling down about X? What kind of self-involved jerk am I that I think I deserve to feel depressed when others have it so much worse?" Which, far from leading *out* of the bad place, leads much further into it.
On the one hand, I can look at my experience with this and just say, so this type of comparison might be useful for some people, even most people, but pretty clearly won't work for all. It definitely doesn't work for me! And while everyone else in the training looked at me like I had three heads when I asked about this, I'm reasonably sure I'm not the only freak on the planet who does that sort of shame spiral. I mean, if I were, then the phrase "shame spiral" probably wouldn't be out there in the self-help books and groups. So that leads me to the other hand, where I'm really concerned about recommending this distress tolerance technique to anyone. How do I know if they'll be someone who responds well to it, or someone who'll do the "shame spiral" thing?
Fortunately, I'm not the DBT therapist, so I don't have to determine whether to introduce them to the idea or not. That's out of my hands, and pretty much guaranteed to have been covered already in their DBT groups. I can just ask them, "would it help to compare your situation to suchandso, which would be (or is) much worse?" And if they say no, then suggest exploring a different technique. There is something to be said for being on one of the lower rungs of the ladder, and I guess this is one of them.
I do wish I was going to be able to attend next week's portion of the course, covering emotional regulation and interpersonal effectiveness skills. I was originally scheduled to attend both parts, when the first would have been on 2/6 and the second 2/13. Then the entire state had a major freak-out that we actually (gasp) had SNOW in New England in February. Not even a lot of it. But everything shut down, and the schedule got shifted a week. Maybe I should hope for another flake or two to hit next Friday so that part 2 moves to the 27th? Oh, wait, I couldn't make that one either. Jury duty. Bleh.