Join me on my YouTube channel DBT Skills with DrReneeHoekstra to identify some of the barriers to figuring out what you feel.
What are Dialectics and Dialectical Behavioral 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
Here is a short video of me on YouTube with an overview of the skills: What Are the DBT Skills? DBT Skills with DrReneeHoekstra
Why Your Psych Meds Aren’t Working- A Bitter Pill To Swallow?
Psychiatric meds actually do work, and they very well may be working. Psychiatric medications have helped numerous people with many different things, including nightmares, anxiety, symptoms of bulimia, public speaking, mood regulation, paranoid thoughts, and depression.
However, there is one thing that medications will never do, and that is get rid of emotions. Emotions are hard wired, biologically adaptive responses to situations that help people survive. They give people important information about threatening situations and painful circumstances. The allow people to know what matters, what to hold close, what to pursue, what risks to take, and what to avoid. Without emotions we would not have important information about ourselves, our circumstances, our environment, and other people.
People have tried numerous and unsuccessful things to get rid of emotions. This might include drinking, drug use, numbing out, hurting oneself, picking fights, avoiding, sleeping, dominating a conversation, being coercive, smoking marijuana, or being violent. The simple truth is, emotions can’t be eliminated. If they are temporarily eliminated, they come back.
Some people don’t like their emotions because their emotions show up when other people tell them what to do, how to think, how to feel, or how to react. Thus they minimize or inhibit their emotions in these situations because they are trying super hard to fit in, avoid conflict, live up to someone’s standards, please a parent, or survive in their environment. However, this can lead to a very unhappy life and can be very painful.
Sometimes people are very sensitive to emotions, thus they tend to have strong reactions to things that may, to others, not seem like that big of a deal. While this can lead to bigger, out-of-control emotional problems, it is also important to learn how to discern when a threat is actually a threat, vs. when a person develops a fear or phobia about something that is not a threat.
Emotions are often related to eccentric, atypical, or problematic behavior. If you have a behavior that you are trying to stop doing, just consider if not doing that behavior brings up any discomfort, anxiety, or restlessness for you. Asking people to stop doing behaviors such as self-harm, drinking, escalating an argument, threatening suicide, doing a behavior excessively or repetitively, or picking a fight is quite hard. The benefits if these behaviors can sometimes include getting a point across, expressing an emotion, getting taken seriously, reducing anxiety, or getting another to be validating or affirming. Sometimes significant others don’t react at all until another person escalates or flips out, which makes the problem behavior even harder to stop. (After all, it worked!).
If you think your psych meds aren’t working it may be worth asking yourself: What feelings do you have that are intolerable? What do you think your feelings might be telling you? What feelings do you try to ignore? What feelings are trying to get your attention? How willing are you to bear with some of the discomfort of what is going on for you? If you honored your feelings and what they were telling you, what sort of action would you take?
Understanding, naming, managing, and controlling moods are a lot of work. Thankfully, there is are services available that are focused on doing just that- and aren’t focused on dosages or prescriptions. While meds do wonders for people- they are not, thank goodness, the only way of helping a person solve emotional problems. In fact, the entire basis of the group services that I provide help people with all of this- managing mood, understanding emotions, listening to one’s wisdom, and taking necessary steps to tolerate feelings better. Getting rid of what you feel is just not an effective long term strategy for solving emotional problems.
“There Is No Good Reason To Feel The Way I Feel”
Is this something you find yourself saying? This is something people frequently tell me. Unfortunately a lot of people think this is true. When people think it is true, they often stop trying to figure out the significance of how emotions show up in their life. People will say their emotions come out of the blue, show up for no reason, don’t make any sense, and even create problems in their lives that they wish they didn’t have to deal with.
I actually don’t think that people have no good reasons for feeling they way they feel. In fact, I think reasons are there, but people are often not aware of them. My belief is that emotions show up for a reason, and are important and critical to our existence. However, because emotions can be nebulous, hard to pinpoint, and often elusive; they are sometimes hard to understand and even identify.
All emotions have certain functions. Functions work to serve a purpose or accomplish a task. Functions of emotions include communication, validation, or action. The emotion of sadness, for instance, is an invitation to figure out what is important, grieve losses, search for what is missing, or acknowledge how important something was in our life. Without sadness we would not know what matters, who we love, or what is missing. Sadness gives us important information about all of these things.
Primary emotions are emotions that we have about certain situations, persons, or events in our lives. They are what shows up when stuff happens. They provide valuable information that, if ignored, can create even more problems. Secondary emotions when people have emotions about emotions. For instance, if you feel angry that you are sad, ashamed that you are distressed, or embarrassed that something angers you, you are experiencing a secondary emotion. Secondary emotions generally cause more problems for people because they are ways to judge (or not accept) a primary emotion. When we work really hard to inhibit, hide, minimize, or judge what we feel in the first place, we can create even more problems for ourselves. Sometimes people focus on secondary emotions as a way to avoid focusing on primary emotions. (“If I talk about how angry I am, you won’t really get how much I am hurting.”)
The key point is that people who learn to accept and even value their primary emotions generally have less distress than those who go out of their way to inhibit, hide, or suppress what they feel. If we treat our emotions as useful and valuable means to provide information about ourselves and our environment, the task of addressing emotional pain will be easier. Getting rid of emotional pain because it is uncomfortable doesn’t teach us to be open, present, and accepting of our emotions. While this may seem counter-intuitive, having less shame about how we feel helps us solve the problems of life a bit more easier. (“I am upset because something happened” vs. “Because I am upset I am ashamed, then angry at myself for being ashamed, then guilty for snapping at people because I was angry, then humiliated for how I handled this. Because I have no good reason to be upset.”)
Here are some tips to help you work on your emotions:
- Treat your emotions as useful
- Approach how you feel with curiosity, not judgment
- Assume your emotions are trying to give you important information
- Be willing to experience the intensity and painfulness of emotions
- Observe any action urges that come along with emotions
- Pay attention to how you feel about things more closely
- Be aware that low levels of distress is still stress, and that minimizing it can sometimes result in a blow up later on
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.
Depressed? Anxious? Here’s What You Can Gain and Obtain
Most people who have more than their fair share of depression and anxiety are often seeking ways to decrease depressive and anxiety symptoms. In other words, they want to not be depressed and not have significant anxiety. If the symptoms are extreme or significant the person may start to avoid a lot of things, such as getting out of bed and going to places to that prompt panic attacks. Lifestyles can become restricted and the person may stop going to events or venues where they have the feelings they don’t want. Medications might be pursued, evaluated, and re-evaluated to see if they “work” or they “don’t work”.
If you are a depressed or anxious person, it might be worth considering what it is that you want more of, you would like to have, or what you value in your life. Instead of thinking what do I want to avoid start thinking about what you want to have more of in your life. What is it that would make your life more fulfilling, more engaging, more interesting, more desirable, or more alive? What is actually important to you? Sometimes people are so focused on what they are trying to get rid of they stop pursuing what they want.
Figuring out what you want more of ties in to your values, your energy, and your time. Are you sacrificing what is important to you because you are avoiding negative feelings? Have you stopped seeking activities that give you pleasure, fulfillment, obligation, a sense of contribution, or the opportunity to enhance an important relationship? If depression and anxiety interfere, this is a good time to evaluate what you might have to tolerate to go after more of what you want.
Sometimes, if people have more of what they want, their buffer against depression and anxiety can be tolerated more naturally. Some people get panic attacks at work, but because their job is important to them, they find a way to bear with them. Sometimes people get depressed when important things are lost, but because they have other important and meaningful activities in their life, the depression is bearable.
People who have fulfilled lives often have a wide range of things that give them pleasure, provide a sense of work/ mastery, invest in important relationships, and find new relationships when important ones end. Diversity and stability of the good things can help people shore up more resources when things go south and important jobs and relationships end.
The Power of Vulnerability
Not happy? You must watch this short video
Feeling anxious about feeling anxious? A short clip to analyze your feelings
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