- Boston DBT Groups

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

What Is Mindfulness, What Does It Have To Do With You, And Why Is It So Necessary?

Mindfulness is a particular way of paying attention to 1) expand awareness or 2) focus attention. Below is some brief information on these two applications of mindfulness as it relates to your life and to the practice of psychotherapy.

AWARENESS

What are the benefits of awareness?

Increasing awareness increases options (less experiences of feeling or getting “stuck”)
Increasing options for how to react to stressors increases a sense of confidence and self control when confronted with life circumstances
Increasing awareness helps people understand why they behave the way they do and what controls their behavior
Increasing awareness helps people to identify patterns of responding, or repeating themes that may show up again and again, and can be better understood with curiosity and analysis
Increasing awareness helps to clarify, understand, and organize behavior in a more meaningful way
Increasing awareness (ie, awareness of anger) helps people to be assertive/ proactive, solve problems, and organize action

What problems accompany limited awareness?

Repeating patterns of getting stuck
Minimizes flexible and adaptive coping
Can be likened to zoning out, dissociating, not paying attention, missing out, or failing to show up for one’s life
Can increase vulnerability to do, say, or behave in ways that are acquiescent/ compliant; no self-awareness leads to responding/ reacting to environment (reduced autonomy, reduced control, reduced capacity for interpersonal influence/ power)
Limited awareness is associated with not knowing oneself, what one likes/ doesn’t like, wants/ doesn’t want
If you can’t know yourself (trust experience) how you can you know how to pursue a life that would be fulfilling and rewarding to you

Ways Awareness can bring pain

Losses associated with missing out on ones life
Grieving times/ time in life when things could have been better (had a person been more aware)
Awareness of hope and possibility can feel risky or unfamiliar
Familiarity and predictability help people feel consistency/ stability, thus awareness of alternatives can be uncomfortable/ unfamiliar
If a past history of problematic responses evoked a particular set of behaviors (escalated conflict results in nurturing/ attentiveness from partner), awareness of alternative ways of behaving may be initially aversive / won’t get immediate desired response

Things to be aware of:

Emotions, actions, urges, desires, hurts, want
Physical sensations, sensitivities, breath, body awareness, gut feelings, instincts, intuitions
Your behavior; how you behave/ change behavior, react in certain situations, which people, in different contexts
Your history of behavior; how behavior started, what it means/ meant, how it served a purpose/ had a function or role for you
How your behavior impacts others
How others’ behavior impacts you

FOCUSED ATTENTION

Why is obtaining skill to focus one’s attention important?

Thoughts, emotions, pain, sensation, restlessness, boredom, etc. can sometimes interfere with a person’s ability to live their life in a valued direction.
Thoughts and emotions can create problems, be distracting, and get us derailed
Obsessive thoughts, unwanted thoughts, self-defeating thoughts, self-hating thoughts, anxiety thoughts, and non-useful thoughts can threaten to take over attention, control action, and inhibit needed action
Staying focused can help a person be less prone to intense, unwanted, or problematic thoughts or beliefs
Action urges, emotional reactivity, and other behaviors often happen “automatically”, thus practicing focused attention increases your options for limiting your reactivity (For instance, if you are a person that “flies off the handle” staying focused can help you stay grounded)

Does focusing attention get rid of pain?

No, focusing attention helps a person not get consumed by other things that threaten one’s focus (ie, obsessing, ruminating). Pain is considered a normal part of the human existence; focusing mindfulness activities are not done with the purpose to destroy, get rid of, or inhibit pain.

Focusing on sound exercise. For the next 3 minutes (set a timer if you’d like), try to focus all of your attention on sounds you can hear. Pay all of your attention to the sound, and see if it is possible to do this for 3 minutes. You will likely have multiple other thoughts, sensations, experiences, or distractions that don’t keep you 100% attentive to “just sound.” Likely if you had a painful thought, the thought took you out of the exercise. So, instead of heeding that thought your attention (buying into the thought, thinking the thought, rehashing, problem solving, etc.) you simply be aware of that thought (“oh that thought is showing up again”) and gently return to focusing on sound.

Remember:

No one is denying you are in pain
You are not denying you are in pain
You are not refusing to think about that situation, you are simply redirecting your attention for the time you try mindfulness
You are increasing your control of what you pay attention to and when
You may need to come back to your pain at some point and solve some problems, but for the three minutes this is not your task
Urges, cravings, desires, urges to take action/ do something, urges to eat something, etc. may all come and go
You are learning over time to increase control of all of this

Often, if your life is disrupted by intense, extreme, demanding emotions your actions often follow. You may feel as if you are controlled by your emotions and your actions. Focusing attention helps people to be more “aware” of urges, emotions, disruptions, or urgency around fixing or doing something NOW. Learning to control what you pay attention to will help you control yourself; your emotions may DEMAND your attention. Focusing attention exercises can help calm you down, settle you in, and even relax you a bit.

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.

Three mindfulness exercises to use right now to quiet your mind and focus your attention

One of the reasons mindfulness is used is to get yourself calm. If you are a person with a lot of anxiety, your anxiety might get in your way of handling problems, thinking clearly, or addressing something with your full attention.

Mindfulness is one way to lower emotional arousal, center yourself, and help you get back on track. When emotional arousal returns to baseline, accessing the problem solving part of your brain becomes easier.

1) Inhale to the count of one, exhale to the count of two. Keep going until you get to the bottom of six. Start over. Do this for about three minutes. If you get lost or distracted simply start over. The point is to have something to focus your attention on; which helps cut the distractions of your mind.

2) Trace your hand. Inhale on the way to the tips of your fingers, exhale on the way to the crevice. This can be done with pen/ pencil on paper or with the finger of the opposite hand. This is a tactile way to “trace” your breath and focus your mind. Keep your attention on your breath.

3) Pause for three minutes and focus your attention entirely on sound. Try to tune in to every possible nuance of sound. See what you can hear that you typically don’t pay attention to. If your mind drifts, bring it gently back to the experience of hearing.

10 Reasons why you need The Emotional Extremist’s Guide to Handling Cartoon Elephants book this holiday season

1. The Cartoon Elephant book, after being temporarily unavailable through Amazon, is now back on the market. The retail price is $26.95, but sometimes Amazon will let it go for a bit less.

2. Cartoon Elephants approach painful emotions with humor. If there is an elephant in the room in your family, this book is the starting point for approaching avoided conversations. You will recognize yourself and others in this book. There is no finger pointing or blaming.

3. Cartoon Elephants is something you can put on your coffee table. Because it is a graphic book with pictures and fun fonts, it is an easy read. The elephants will fit nicely next to big picture books about Africa and Asia.

4. The Cartoon Elephant book is being used to teach people in Dialectical Behavior Therapy skills groups about emotions. Loaded with psycho-educational material and teaching points, it cleverly accomplishes the task of making people think they are reading something fun yet giving them something valuable.

5. This book is not hard to read. There is no “plugging away” at chapters. If you want to bring something to someone’s attention in a way that is universally applicable, this book will do the trick. You don’t need to have painful emotions to appreciate elephants- you just need to have emotions.

6. If you are going to buy someone a self-help book for Christmas, this is safe bet.
Whether they believe it or not, everyone has cartoon elephants. The research proving this to be true is cited in the back of the book.

7. This book can be used and re-used, read and re-read. You can share it with family members, friends, or long lost relatives. It won’t go out of style. Emotions, as a rule, will be with you as long as you live.

8. You will get some food for thought about how and where you see yourself in relationship to your elephants. This is great for discussion groups, weekend retreats, and writing workshops.

9. This book is great for people of all ages. If you’re trying to get your kid to read something important, heavy, and deep, you can give them this book. It won’t take long to read and it is much more fun with illustrations.

10. The book will be the perfect introduction for my live series on emotions starting January 20, 2014. Of course you don’t need the book to sign up, but if you have the book you will have a better appreciation for cartoon elephants in general.

Cartoon elephants (emotions!) up close and personal: When you don’t like what you see

Sometimes, if you look closely at what actually feel, you won’t like what’s there. Sometimes it’s just too much. Here are some tips on what to do when you get up close and personal with your elephant, and this

may be what you find.

Start with whatever is present in the moment. See if you can notice and allow for what is there vs. actively trying to ignore or push away.
See if you can get yourself to willingly tolerate all sensations, discomfort, or urges associated with the emotion. Noticing if there is anything holding you back from doing so.
Bear in mind that the better able you are to tolerate, you will be better equipped to survive the moment. Redirect your attention back to your elephant and practice the gentle yet curious gaze.
Tolerating sensation does not mean that you have to approve of reality, take action, or fail to take action.
An unwillingness to tolerate what is there will not make cartoon elephants disappear. (You can’t have a life without cartoon elephants!) A refusal to tolerate can actually create more problems later.
What you pay attention to= what your life is about. Do you want your entire life to be characterized by the struggle of not looking at your cartoon elephants?

The cartoon elephants are here!

Click here for The Emotional Extremist’s Guide to Handling Cartoon Elephants: How to solve elephantine emotional problems without getting run over, chased, flattened, squished, or abandoned by your true cartoons.

Here is a sneak preview of the book chapters:

Part I: The problems of cartoon elephants

The non-existence of cartoon elephants
The weight of cartoon elephants
The equilibrium of cartoon elephants
Stampeding, out-of-control elephant situations

Part II: The basic steps for solving elephantine problems

Part III: When your cartoon elephants are in danger: How to cope with critical obstacles

Part IV: When solving elephantine problems seems impossible: What to do when stuck beneath an elephant’s foot

Part V: What to do when elephants end up on your back

Part VI: What to do when your cartoon elephant turns blue

Here are some FAQ’s about the book:

Is this book for children? The intended audience for this book is adults (hey, adults need cartoons too!) and is fine for adolescents. Younger age ranges may have some difficulty with the abstract reasoning and the metaphors, and may not grasp all the concepts and big words. However, the big pictures, changing fonts, and fun graphic design makes this an attractive book for young kids (my 9-year nephew zipped right through it).

Why are the elephants in the male gender form? I used “he” and “him” when referring to the elephant to make the book simple and less wordy. I did not have any gender specific intentions. If you experience your elephants in the female form, you are welcome to take your own copy of the book and change all the pronouns.