What are Dialectics and Dialectical Behavior Therapy Skills?

What is Dialectics?

Dialectics is based on the idea that two opposing concepts can both be equally true. One truth does not trump or rule out another, which undercuts the dichotomy of a “I am right you are wrong” type of relationship. A common dialectic is that you are perfect as you are (acceptance), and that in order for things to turn out differently in your life, you need to do things differently (change). One is not more true than the other, and one truth does not rule out the other truth. Sometimes people need acceptance, and sometimes people need to be challenged. Both belonging and growth are an inherent part of being in relationship.

Dialectics challenges the idea that one person is always “right”, because when you take into account diversity of perspective, other truths often arise. Being “right” often fails to take into account effective communication and the value of the relationship. Experience and emotions get ignored. A set agenda of being “right” often gets people stuck in a very rigid, dichotomous, black and white, non-dialectical stance. Dialectics are important in that sometimes you can find the one thing you have in common with your enemy instead of focusing in ways you are different. Relationships exist in context of conflicting truths, yet relationships are the glue that carries us through life.

What are the four Dialectical Behavior Therapy Skills?

DBT is a complex treatment that has confusing origins in terms of how it was developed and who it was for, and has been tailored to a wide range of populations and settings. The DBT skills are universally applicable materials that help people with extreme and painful emotions, intolerable life situations, and relationships. The four skills sets are as follows:

Core Mindfulness: Mindfulness is a skill that helps people focus attention, regulate arousal, calm the brain, quiet the mind, and settle in. Being mindful is a way to steady and anchor oneself in order to observe quietly and not “react” to what is going on. It is inherent in all of the other skills in that it requires a steady, quiet, secure stance in the face of demanding life situations. It takes spaciousness to know what is going in with your body, your self-experience, your wants and desires, and your life. If you don’t pause the moment and check in with yourself, it is easier to get “caught up” in the banging and thrashing of what life throws in your direction. Mindfulness can be a spiritual practice of quiet contemplation, a way to press the pause button, and way to regroup. Core mindfulness skills taught from the DBT material include skills of observing and describing without judgement. Other traditions, spiritual practices, health care services, and therapies teach mindfulness, so it is not “new” nor is it confined to just DBT skills; its roots are actually in Zen Buddhism. There are multiple ways of accessing mindfulness including mindfulness based programs, meditation groups, trainings, and apps. DBT groups are known for implementing a mindful practice or exercise in every group, and like many spiritual traditions are simply considered part of a daily practice.

Emotion Regulation: This is a set of skills that helps people to observe and describe what they feel (you can see the overlap with mindfulness) in order to help regulate arousal, understand what they feel, and know the reasons why they feel the way they feel. Skills cover ways to reduce emotional suffering through mindfulness and opposite action, and ways to reduce vulnerability to emotional suffering. Skills are quite complex and take practice, feedback, and validation. Since emotions can be tricky, elusive, (and just plain unbearable at times) the emotion regulation content is not something you could “quick learn” and be done with it. Sometimes people are not always aware of how or what they feel in general, and there is nothing pathological about this. It is a process! Knowing oneself and knowing one’s emotions is a lifelong task not subjected to any particular type of disorder, and does not end just because you have had a first exposure to all of the skill content. That is why working together on ways to regulate arousal given varying life circumstances can best be done over time in small group settings that promote cohesion and intimacy.

Distress Tolerance: In order to regulate emotional arousal, finding ways to endure the “I-can’t-stand-it-itis” of painful and extreme emotions is critical. Surviving painful life circumstances well means doing so in a way where people do not lose self-respect, forget their values, give up what is important to them, or react in such a way that makes things worse. Sitting in the fire and not reacting is often harder than picking a fight, poking the fire, making others suffer in order to prove a point, exacerbating pain to let others know how bad things are, undermining a person where it hurts, forcing the university to prove its point, perseverating on being “right”, asking “why me”, or engaging in self-defeating or relationship destroying behaviors. Being willing to tolerate the unknown, be zen with the universe, stop fighting reality, and do what works is skillful practice. We all want things to do our way or to turn out for the best. In reality, a lot of people are suffering a great deal and need everything they can to survive well. Distress tolerance skills encompass not only change strategies (if you can do one thing make it better, why wouldn’t you?), but acceptance and willingness skills. Anyone who has successfully undergone any type of exposure treatment for anxiety knows that the benefit to tolerating anxiety is a decrease in overall anxiety. There is an inherent truth that reality is easier to face once you stop fighting it, thus freeing you up to do what is needed to effectively solve problems.

Interpersonal effectiveness: True to the concept of the dialectical philosophy of DBT, it is better to be effective than it is to be right. The interpersonal skill content encourages readers to identify objectives in situations (what exactly it is you want or don’t want), how the relationship may be impacted, and if self-respect is at stake. Balancing the three helps people to look at natural barriers and consequences of interacting, and enables readers to problem solve the cost/ benefit of ignoring each. For instance, you can ask for what you want at the expense of the relationship, or you can give into a relationship but sacrifice self-respect. The balancing act of relationships is an ongoing challenge for everyone, and some give and take is part of how people stick together, find intimacy, and keep people close. Interpersonal skills also include ways to get out of or decrease contact with toxic or unwanted relationships, set limits, say no, and to identify barriers to doing so. Direct rehearsal in terms of “what to say and how to say it” benefits group members in that they can try out and receive feedback in both verbal and non-verbal forms.

A book of all the DBT skills is available for purchase via this link: https://tinyurl.com/y2qad6sk

What You Should Know If You Have Been Diagnosed With Borderline Personality Disorder

Here is the truth: BPD, or Borderline Personality Disorder, has a historically bad rap with mental health professionals. I’m going to give you some truths to what you should know to not only think about this clearly, but to consider your options in terms of the person you want to be and the person you want to become.

BPD was historically known for “bordering” on the lines of neurotic vs. psychotic. In the olden days, clinicians who didn’t know if a person was living in the confines of “reality” could put them in a category that didn’t really fit either one. Historically neurosis has to do with issues related to anxiety, mood, and depression. Neurosis can also be related to trauma, vigilance, and paranoia about bad things re-occurring. Psychosis is related to problems hearing and seeing things that others do not see or hear, and is often associated with schizophrenia. “Borderline” has often been referred to as a category that doesn’t really fit any category, and in some cases has been the in- between of no-place.

BPD is also historically written about from an extremely pejorative and hopeless point of view. Words like “manipulative, gamey, cagey” are often used, and mental health professionals often refer to this diagnosis when talking about people that bug them, that they do not like, that get them enraged, and people that can tie up crisis hotlines and emergency rooms. In many cases, labeling someone with BPD has become a substitute for observing and describing behavior, providing useful feedback, and encouraging people to behave in ways that make them competent and more effective.

Here are some truths that you should keep in mind if a mental health professional has “informed” you that you have BPD:

Mental health diagnoses are not valid nor reliable. This means that (in terms of validity), if the same professional assessed a person over time (such as an assessment 20 years ago, 10 years ago, and 5 years ago), the likelihood that that professional would give the same person the same diagnosis is unlikely. It also means that if many different mental health professionals assessed the same person it is highly unlikely the all of them would come to the same conclusion about diagnosis. This is assuming that the only measure of giving a diagnoses is a working familiarity with the DSM-TRV, or the “psychiatric Bible” of diagnostic criteria (which is highly controversial. Be aware that homosexuality was once considered a psychiatric disorder, and now it is not). Mental health diagnosis may be more reliable and valid if the diagnosis is given based on a range of valid and reliable assessment batteries; thus if you have had some comprehensive personality assessment and testing this may be less of the case for your situation. Bear in mind that most people in the counseling profession are doing nothing more than giving you their clinical opinion; hence my point about reliability and validity. Also, there are some counseling programs that don’t cover concepts such as instruments of mental health measurement.

For some mental health professionals, telling someone they have BPD can sometimes be a communication of frustration. In a helpful world, telling someone what diagnoses they have can be useful and even helpful- it can validate if a person really is depressed or help figure out specific treatments. In the case with BPD, the “right treatment” is more complicated and may not be readily available. If your mental health professional is telling you have BPD, you might want to consider: So what? How it is it helpful or useful? Does it help people have the resources or tools for solving painful problems? Is it specific enough to describe what behavior shows up- and how behavior can be changed? Does it provide access to literature that is actually helpful? For some people, being diagnosed with BPD can only serve to increase shame and self-loathing. Literature is not always helpful and mental health professionals don’t always shore up resources for how to move forward to obtain resources and supports. Is the expectation to hide in a corner the rest of your life and not tell people who you “really” are? And do you seriously want to live this way?

There is a lot of confusion for most people around diagnosis being a cause. Diagnoses are actually descriptions of behavior, and mainly identify patterns of responding or behaviors that are typical for a person. Many people, including some mental health professionals, actually believe that they are describing reasons or causes of behaviors when giving someone a diagnoses. For instance, if the way that you behave is because you have a disorder, then someone people think they have adequately not only explained the reasons you behave the way you do, but they think they know why you behave the way you do. In terms of diagnosis, this really is not the case. The failure of the mental health system is that people think they are being helpful (“You have problems because you have a disorder”) rather than addressing causes and potential solutions for behavior change. In this case, many problems of pain are not being solved as the focus of attention is on the “correct” diagnosis, which, in my opinion, is a rather useless pursuit. It can be akin to a parent who has several children; one of them is determined to be “bad.” Instead of figuring out how to prevent problem behavior, solve problems, and tend to the child’s needs; the parent simply attributes all problem behavior to the child being “bad.”

What you can do if you have, or think you have, or someone else thinks you have BPD:

Don’t think you are permanently impaired, hopeless, or beyond help. Fear and shame keeps may people paralyzed from acting with self-respect, doing things that are meaningful, and putting oneself out there in the universe. Universally, fear and shame can prevent anyone from living a decent life. You are not an exception.

Learn to talk about yourself and your behaviors in a descriptive, non-judgmental, and matter-of-fact ways. This will make you competent, understandable, and respectable. This also means that if you go around and tell everyone you are disordered, people may treat you as fragile, incompetent, incapable, or helpless. Create and practice ways to talk about yourself outside of the realm of “mental illness.”

Pay attention to providers, mental health professionals, or family members who attribute your behavior to being “mentally ill” or “bad” or “personality disordered.” Realize that everyone has vulnerabilities and that many, many people struggle with giving accurate, helpful, and specific feedback. Consider how giving and receiving feedback is either helpful or not helpful, and don’t seek out relationships where blame seems to be an acceptable solution for reducing pain or resolving differences. Finding “fault” only works if the consequence is taking responsibility and making changes; not amplifying shame and paralysis of action.

Be aware that if you do delve into literature on BPD, you may encounter a wide range of confusing terminology that attempts to define you; which may not only be disconcerting but also downright confusing. You might encounter terms like object relations, transference, countertransference, self-objects, self-soothing self-objects, object mirroring, intrapsychic processes, or projections. Don’t get bogged down by mental health-ese. Bear in mind that some mental health professionals have a lot of trouble observing and describing behavior and giving useful feedback and sometimes hide behind their own jargon.

Find other things that provide you a sense of identity, that define you, that make you the person you are, and that you value. Consider roles you take on in society; engage in them and be proud of them. What is important to you? Why would you let a diagnoses get in your way with pursuing what is important to you? In what ways do you not “show up” because you have shame around a diagnosis? Life is bigger than the world of “mental health.”

Bear in mind that many mental health professionals are obsessed with political leaders that they believe to be personality disordered. In truth, political leaders are still political leaders, and political leaders have made great gains, influenced many, changed laws, and maintained power. Being diagnosed with something “bad” hasn’t deterred people from being politically active, advocating, having power, or being influential. There is no good reason why you have to be shamed from participating in the universe just like everyone else- people with a lot of problems still manage to be successful and competent in a myriad of different ways.

Finally, feel free to visit the National Education Alliance for Borderline Personality Disorder, a nonprofit that may be more helpful than the general google search. Their website (www.borderlinepersonaltydisorder.com) has some useful non-pejorative literature, trainings, and free services for friends and family members.

Manchester By The Sea- A Psychologist’s Point Of View On How To Work With Lee

Recently I went to see an excellent movie: Manchester By the Sea. Here are some thoughts I have about how I would work with Lee.

As a provider of clients who experience intense, severe, and painful emotions; Lee really does fit the bill. General questions that I might consider asking include: What would it take to reduce pain, survive loss, and manage or cope in a way that made things better? What would help Lee feel less stuck? What resources or connections could sustain him better, enable him to bear the weight of his pain, or enhance his quality of life? What could him grieve more fully and to get through this crisis? What is he doing that is working, and what is he doing that is not working? Could he be more likable to himself, sustain the burden or his guilt, or have more fulfilling relationships?

One agenda item I have is getting Lee to stop doing things that could potentially make his current situation worse. Often times I have clients who have severe emotional pain and it is so intense and unbearable that they are looking for any distraction to take away the pain. The distractions sometimes have a short-term effect of feeling better, which makes them hard to stop. However, in most cases these distractions can make problems worse- and are not effective long-term strategies to mitigate the severity of what they feel.

So one treatment agenda is to reduce risk taking or crisis-generating behavior. Specifically, Lee tends to get drunk, pick fights, and throw punches. The natural consequences for this behavior can result in serious injury, concussions, brain damage, head injuries, broken jaw, soreness, swelling, or other various medical trauma. Drinking heavily can result in poor decision-making, hangovers, dehydration, and liver damage. Other natural consequences of his behavior include legal problems, court dates, jail time, being seen as a threat in the community, increased relationship conflict, and isolation. Grabbing the gun of an officer might result in unintended harm to other people. Not only would Lee have the current dilemma of living with the intense and painful losses he has suffered, but he would have to address the above consequences in addition to everything he has already gone through.

Some people actually believe Lee’s behavior is justified. They would say that because he is in unbearable pain, he should be able to act the way he does. Or he should be let “off the hook” because his behavior is understandable. I would encourage those people to consider: Would you recommend your closest confident or best friend- who is deeply hurting- do something that could result in head trauma? Liver disease? Incarceration?

Another “justification” for Lee’s behavior is that he has significant guilt and self-hatred and he is trying to punish himself. After all, the law did not punish him enough! What would be an effective punishment, and how long does he need to punish himself for his actions? Are self-inflicted/ high-risk behaviors actually effective in making him feel less guilty? What if a police officer was shot by accident? What type of effective repair work needs to be done? What lifestyle habits could he change to prevent bad things from happening in the future? What would he need to do to redeem himself in the community? And what would it take for members in the community to find forgiveness, employ him, or tolerate him being around?

How would treatment move Lee towards growth, movement, and decreased pain? There are several ways to approach this- the key being a sensitivity and flexibility to what Lee would be able to handle at the time he seeks help. One is a baseline ability to talk about what happened. As he pieces together his story, there may be parts that are difficult to talk about. Avoiding these topics might show up in the form of escaping, not talking about it, dissociating, becoming numb, becoming argumentative, keeping one’s distance, staying detached, avoiding intimate relationships, leaving, drinking, or even picking more fights. The difficulty is that there are multiple reminders (or stimuli) that will show up throughout his life that he may not be able to avoid. These may include:

  • Conversations about young children
  • Seeing a house fire in the news
  • Talking to his ex, Randi
  • Seeing Randi’s newborn
  • Getting news that young children die or are dying
  • Randi saying “I love you”

For instance, what if he is watching the evening news and suddenly there is coverage about a house fire? What if Lee has a building tenant who loses a child to death, and Lee is present when the tenant tries to discuss it with him? What if Randi tries to contact him again or “shows up” in an unexpected manner? Maybe Lee can try to avoid these situations in the short term, but inevitably life, reminders of life, and young children are the life that surrounds us.

Therapy would work on staying present with emotional discomfort when these topics come up; and doing so in the presence of one or more people. That means not attacking, hiding, or getting drunk. It means being willing to experience grief, pain, discomfort, or tears. It means staying in a conversation and having a willingness to tolerate the stuff that seems unbearable. The more Lee does to avoid it, the worse it is going to get.

Healing results when a person’s grief can be managed, survived, and tolerated. Healing is about experiencing, talking about, and coming to terms with what happened in the presence of others. Healing happens when people can forgive themselves and each other and can make changes to prevent bad things from happening in the future.

Healing doesn’t happen when a person is literally “stuck” in blocking out all things reminding them of pain, and lives a life where they are blind and deaf to such triggers; avoiding any stimulus in real life that will inevitably show up at some point.

Healing doesn’t happen when emotions literally control lives, and people can’t engage a full, meaningful, rich, and productive life as a result. Healing doesn’t happen when there is no compassion for self or others, when there is no forgiveness, and when there are no second chances.

 

What if I’m wrong?

Here are a couple of thoughts on the business of being “wrong.” First, the question itself begs a certain dichotomy to form in a relationship. It implies a one-up, one-down position. It can make one person more powerful, keep another at a distance, or in extreme circumstances serve as an opportunity to belittle or berate. What does being “wrong” imply about the relationship, the importance of keeping a relationship, or the way that people will continue to relate to each other? Is it worth it to damage or hurt a relationship to be “right”? If one person is “wrong”, then how is the relationship handled in the future? How do people move forward?

Next, being “wrong” might be rephrased as being technically inaccurate. If you are responding in a way to that does not match reality in a reasonable sort of way, you may be considered “wrong.” However, in some circumstances this begs the question of differences in opinion, perception, feelings, and agendas. A person can have a valid point of view, see things differently, or see aspects of a situation that another person is not able to see. This can prevent communities from being rigid, thinking “inside-the-box”, refusing to consider alternatives, or being racist or non-diverse in their thinking. Trying to understand the validity in where others come from can help us be more understanding, have better relationships, be more forgiving, and become less “stuck” in the right/wrong dichotomy. If you are technically “wrong”, this also might be your opportunity for self-correction, learning, or growth. Consider teasing out the differences of being “wrong” vs. being technically accurate, and if being “wrong” has anything to do with conflict around perspective, perception, intention, or emotion.

In addition, there is a certain cost to being “wrong.” Everyone at some point in their life has probably had an experience in which they thought something to be true, accurate, or reasonable but found this to not be the case. The cost to being “wrong” is often related to embarrassment, shame, humiliation, or perhaps the loss of trust or leadership. Are you able to correct your actions based on what happened? Can you tolerate the pain of your own humiliation and consider what really matters? If the inability to bear the cost of being “wrong” results in isolation, criticism, withdrawal, and becoming more adamant that you were “right”; you may want to give some thought to what it is costing you in terms of your relationships.

Here are some final questions for you to consider:

  • What are your intentions? Sometimes we are in long term work, romantic, or family relationships that must be giving careful consideration.
  • What are the intentions of the other person? (Are you sure, or are you assuming? What evidence do you have?)
  • What is the true cost of being told you are “wrong”? What do you have to gain by making sure others know you are “right”?
  • If you are “wrong,” can you tolerate your embarrassment enough to grow, learn, regroup, or reconsider how you will handle future situations?
  • Is it more important to be right than to be effective? (Consider what the relationship means to you and if your own self-respect in handling the situation is on the line).
  • Are you unforgiving of other people when they are “wrong”, thus unable to forgive yourself? Is your own criticism preventing you from moving on, getting unstuck, or responding in a way that is potentially painful but perhaps necessary?

When Things Fall Apart by Pam Chordron

Here are some paragraphs from this book:

“When the bottom falls out and we can’t find anything to grasp, it hurts a lot. It’s like the Naropa Institute motto, ‘Love of the truth puts you on the spot.” We might have some romantic view of what that means, but when we are nailed with the truth, we suffer. We look in the bathroom mirror, and there we are with our pimples, our aging face, or lack of kindness, our aggression and all that timidity– all that stuff.

This is where the tenderness comes in. When things are shaky and nothing is working, we might realize that we are on the verge of something. We might realize that this is a very honorable and tender place, and tenderness could go either way. We can shut down and feel resentful or we can touch and I met throbbing quality. There is definitely something tender and throbbing about that groundlessness.

Things falling apart as a kind of testing and also a kind of healing. We think that the point is to pass the test or to overcome the problem, but the truth is that things don’t really get solved. They come together and they fall apart. Then they come together again and fall apart again. It’s just like that. The healing comes from letting there be room for all of this to happen: Room for grief, for relief, for misery, for joy.”

(pages 7-8).

What to do instead of criticize yourself

Try softening your stance, gently relax your face, and allow your muscles to become loose and less tight. Put a hand over your heart with an intention of lovingkindness, and try repeating the following statements with a tone of voice that conveys self-compassion:

May I bear this pain with kindness to myself

May I safely endure this pain

May I accept the circumstances of my life

May I find peace in my heart

May I let go of what I can not control

May I remember that others are also suffering

 

A mindful approach to self-hatred and self-criticism

Often people with self-hatred, shame or self-criticism get “caught up” in a thought process that includes a fair amount of self-attacking. This thought process can include arguments with oneself, reasons a person should not be the way he/ she is, or a rationale for how he/she “should” be feeling. Sometimes this thought process is associated with muscle tension, headaches, the suppression of emotion, the inhibition of interactions, or the shutting down of expression and experience.

People sometimes think that by punishing themselves in a self-hating dialogue is an effect way to change thoughts, feelings, or reality. Almost as if they are somehow being “deserving” of “bad” things someone sets things right. The difficulty is, it typically is not an effective strategy for changing thoughts or feelings! It might temporarily suppress feelings, shut down hurt or sadness, make one feel more empowered or less vulnerable, or even distract from other problems. But the bottom line here is this: Does actually work to reduce suffering? Does it get rid of emotions in the long term?

Being mindful, or starting to observe this process, is really the first step towards making some changes in this process. Being able to notice the thought, step back, practice using a gentle tone of voice, and practice saying “I am noticing the thought that…” is one way to start to just notice thoughts, rather than try to change them.

Next, assess your willingness to “shift gears.” Often people who are stuck in a ruminative process somehow believe that if they keep ruminating, something will change. That’s not to say you have the power to immediately “stop” ruminating, it just starts to get you thinking about an alternative.

If you feel miserable, want to stop hating yourself, and invest a lot of unproductive energy into engaging in self-hating thoughts, the option of doing something different just might be appealing. Once you decide to try something different, you can try softening your facial expression and relaxing your shoulders. Consider being curious about the physical sensations in your body that accompany the thought. What uncomfortable sensations might you be pushing aside in order to invest in the thought? Practice accepting physical discomfort and think about how you might approach or move towards it instead of away from it. If you could be curious about your pain and your emotion, you might be able to work with it a little bit differently. Remember to stay non-judgmental.

Finally, try out the phrase, “May I be at peace.” Try stating this phrase quietly and softly to yourself. Make sure you keep your face and shoulders relaxed, and practice acceptance. Try doing these steps several times throughout particularly difficult days, knowing that practicing new behaviors (and getting “good” at them so they are more automatic) takes effort and rehearsal.

Boston DBT Parent Class: Parenting the Emotionally Extreme Teen

 How did this class help you? Here is the feedback from four parents who took the Spring 2015 class:

 

“To try and react better..To try and anticipate my daughter’s behavior triggers..try to find out what is causing the extremes and deal those triggers… By accepting emotions and where they are coming from; not to deny my emotions but they are there for a reason. To validate how I feel as well as my daughter. To be calmer. “- Parent 1

“To better understand my emotions, and that they have a purpose…To explore that purpose. Better able to identify escalation in my daughter. I’ve learned to buy time, to put some time in between responding to my daughter and others. What was most helpful was the overall impact of the course which has left me better equipped and more curious about DBT.” -Parent 2

“It made me more willing to bit my tongue, take a deep breath, and not focus on ‘fixing things’. Acceptance was important, both dealing with my own emotions and allowing for acceptance of my child’s emotions. Using mindfulness techniques to tone down my level of arousal was also important. Understanding that emotions might be valid but ineffective in some circumstances. I thought the (video content shown in class) outlined some very pragmatic examples and techniques.” -Parent 3

“To be more present with my emotion. To validate how I feel as well as my daughter. To be calmer, to think things through. Being able to listen to others’ experiences. Each class was built on each other. Have learned many skills to be more effective with my daughter.” -Parent 4

Please contact

drhoekstra@bostondbtgroups.com

 if you would like

more information about

upcoming classes.