Improving your memory, Part 2

As regards memory, I believe there’s something to the notion “use it or lose it.” People who are convinced that they don’t have a good memory often don’t work to improve it. Excepting those who have a neurological memory deficit, it can become a negative cycle, a self-fulfilling prophesy. If you don’t trust your memory, you don’t use it; and because  you don’t use it, you don’t trust it.

In my last post I gave examples of mnemonic devices that you can use to improve your recall. I also described how I used a mnemonic device in concert with a behavior modification technique to change a targeted behavior problem. In this post I’ll share some things I’ve discovered about other mnemonic aids.

For instance, I’ve had a bad habit of leaving the stereo amplifier on – sometimes for a day or more – after playing a cd. I just didn’t notice that the little red power light was on. So I “amplified the signal”  by putting the cd jacket on the floor beside the sound system, and not picking it up until I’ve turned off the stereo.  Temporarily placing things where they don’t belong, but where you’re bound to notice them, is a simple mnemonic aid, when associated with a specific behavior.

Turning routine behavior patterns into mindful rituals has saved me a lot of frustration. I’ve programmed myself to always put my car key and my house key in the same place when I come home. This is probably obvious to most of my readers, but I’ve known a lot of people with memory problems who haven’t developed this simple habit. You can learn to do something mindfully until it becomes automatic. I have some obsessive-compulsive traits, and if I’m “on autopilot” when I leave the house, I might have anxious thoughts after I drive away: “Did I lock the door?” So, I’ve learned to lock the door mindfully, recording the act with the camera of my eyes. It’s a ritual, and it works. Teach yourself to be more frequently mindful of common tasks, and you’ll simplify your life. Never in my life have I lost a wallet, a credit card, or an important key. If I have a good memory, it’s because I’ve worked at it. You can, too.

As a writer, I’ve developed my own system to help me remember things and to connect ideas. I always keep index cards and a pen handy – in my shirt pocket when I’m out and about. If I have an  idea or come across something I want to remember, I jot it down. When the card gets crowded with ideas, it goes on The Pile, on my writing desk. Recent ideas are easy to find, near the top of The Pile. Then, every few weeks, I break out a legal pad and go through The Pile. Some pages on the pad are labeled, by topic or writing project. I record some items/ideas on the pages, line through others that I can’t use (“why did I write that down?”), and trash the index cards. Robert Pirsig, author of Zen and the Art of Motorcycle Maintenance, describes using a similar system in his follow-up book, Lila.

Sometimes I tear a blank page from a legal pad and use it to organize my thoughts for a project. I write down a working title and the first words that come to my mind (or from my index cards) on the topic. Then I “shotgun” any key words or related ideas from my head, onto the page. When I see associations, I may draw lines to connect items; or I may number items, to form a sequential outline. Most of my blog posts start with key words or index card notes, and what you read is a polished third draft. I write my first draft on a legal pad, my second on WORD, on my PC, and continue to refine from the WORD document as I transcribe my finished post.

Journaling is an excellent memory aid, especially if you’re a writer. Recording both thoughts and events aids your recollection of details in the months and years that follow, and is very helpful if you ever want to write a memoir or an autobiography. We tend to subconsciously edit our memories, and an honest journal can help you to remember what really happened. I kept a journal for the two years I served in the Peace Corps in Jamaica, and it enabled the writing of my first published book: Two Years in Kingston Town – A Peace Corps Memoir.

I’ve kept quotebooks since I was in grad school, so I have access to all of my favorite quotes. Ralph Waldo Emerson suggested that you “. . . make your own Bible. Select and collect all the words and sentences that in all your reading have been to you like a blast of triumph.” Over the years, I’ve started personalized quotebooks as unique gifts for family members and close friends, seeding them with quotes that I think will mean something to them, and leaving the bulk of the pages blank, to be filled with their own favorite quotes.

Finally, I’ve learned over time to use calendars as memory aids. Not only do I use the wall calendar in our kitchen to record upcoming appointments and trips, but I record birthdays for the coming year, and things like the date when the hummingbirds arrived last year – so I’ll know when to put out the hummingbird feeder. I now save each year’s calendar, as a historical record of when we did what. I hope that some of these suggestions have been useful in helping you to learn to trust, and improve, your memory.

Improving your memory

I know people who don’t trust their memory and don’t rely on it as much as people who do. It can be a self-fulfilling prophesy. I also know  people who habitually misplace things like wallets/purses, keys and cell phones. Just as you can strengthen a muscle by exercising it, I believe that you can strengthen your memory by actively using it. You can learn to rely on it more often by using mnemonic devices. These are images, acronym words and phrases, or rhymes and songs, used as memory aids. The more you use them, the more confident you can be about your memory.

Teaching college courses in psychology, when we studied memory, I’d demonstrate a mnemonic device that uses imagery to quickly memorize a list. I’d ask the class to name ten items on a food shopping list, taking a few seconds between items to conjure up an image. Later in the class I’d recall and recite all ten items, in order. I never once failed to remember all of the items. The technique I used requires memorizing ten words, each of them rhyming with a number between one and ten: bun, shoe, tree, door, hive, sticks, heaven, gate, line and pen (as in pig pen). If the first shopping item is bananas, I quickly visualize  a whole banana in a hamburger bun. If the second item is honey, I visualize a shoe filled to overflowing with honey. If the third item is chicken, I visualize a chicken tree. And so forth. The weirder the image, the better. Each of the ten words/images I use serves as a mental “peg” to hang an image of the item on. Try it out; impress your family and friends.

A variation, dating back to ancient Greece and Rome, is called the method of loci (Latin for places), or the memory palace. You visualize a building you’re very familiar with, such as your home or the house you grew up in. Memorize ten locations, in the order in which you’d see them, coming home, i.e. the driveway, the walkway to the front door, the front porch, the doorway, the table against the wall in the hallway where you stash your keys, etc. Each location is a visual peg on which to hang an image of an item on your list. If the first item is eggs, you might imagine a giant fried egg covering the driveway. Etc.

The use of acronyms (i.e. NIMBY for “not in my back yard”) is also a kind of mnemonic device. It’s easy to remember the colors of the spectrum by memorizing the invented name “Roy G. Biv”: red, orange, yellow, green, blue, indigo, violet. You can remember the names of the planets in our solar system, in the order of their distance from the sun (Mercury, Venus, Earth, Mars, Jupiter, Saturn, Uranus, Neptune) by memorizing the sentence, “My very educated mother just served us noodles,” or by coming up with your own sentence. Once you grasp the technique, you can memorize lists by crafting acronym words or sentences.

Short-term memory is limited to approximately seven numbers/items at a time, but chunking – breaking up a longer sequence into chunks – makes memorizing easier. It takes a while to memorize a ten-digit phone number (8054769238), but it becomes easier to remember in the form 805-476-9238. Rhyming and singing can also be used as memory aids. I still use the rhyme I learned as a child to remember the number of days in each month: “Thirty days hath September/ April, June and November./All the rest have thirty-one/except the second month alone./To it we twenty-eight assign/’til leap year gives it twenty-nine.” Many children learn the letters of the alphabet, in order, by singing the “ABC song,” to the tune of “Twinkle, twinkle, little star.”

You can use mnemonics and a behavior modification strategy to become more mindful and change bad habits. I used to leave stove burners on after cooking – a bad habit that could potentially ignite a kitchen fire. So, I did two things to modify my behavior. I got in the habit of turning on the stove light whenever I used a burner or the oven. I would only turn off the light after I’d checked, and turned everything off. I used the stove light as a mnemonic device. That helped me to decrease the frequency, but I still left a burner on sometimes. So, I got in the habit of making a mark on the kitchen calendar every time I left a burner or the oven on. Not only was it (in the language of behavior modification) a mildly “aversive consequence” to admit and record each failure, it was an exact record of the frequency of my failures. Over time, I saw a decrease in the frequency, and it’s been over a year since my last failure.

I set a goal, made a plan, and modified my behavior. You can do that, too. Rubber bands can be helpful in modifying some undesirable behaviors. If you tend to lose track of where you put your cell phone, wrap it in a rubber band between calls. When you use your phone, wrap the rubber band around several fingers, tight enough that you feel it. When you finish the call, the rubber band reminds you to be mindful of where you put the phone, before you transfer the rubber band from your hand, back to the phone. You can learn to be more mindful about keeping track of your phone, and eventually do away with the rubber band.

Set a goal, make a plan, and you can improve your memory and replace bad habits with good ones.

 

 

Mind Magic

Being a psychologist, I’ve done a lot of thinking and studying about the human brain – the organ that makes us “the magic animal.” Humans can not only see things as they are, but as they could be. Our cognitive abilities and our imaginations allow us to create cultures and cities and symphony orchestras and entertaining stories about things that never happened.

It was my privilege, as a therapist, to be a witness to people changing their lives in positive ways. I’ve seen parents become better at raising their children. I’ve seen violent people learn that anger needn’t lead to violence, and learn to control their behavior no matter how angry they got. I’ve seen couples discover deep emotional intimacy while respecting one another’s boundaries. I’ve long suspected that major changes in a person’s behavior patterns (i.e. mastering anger management) was probably causing structural synaptic changes in their brains. Synaptic pathways mediate both emotions and behaviors.

My suspicions have been validated in recent years by research on brain neuroplasticity. Our brains have the ability to reorganize themselves structurally and functionally, by forming new neural connections. Brains can “re-wire” themselves to compensate for injury or disease, and to adjust to new or changing situations. My guess is that the brains of bilingual people have more complex neural pathways related to speech and language than people who only speak one language. I suspect that it gets easier over time for formerly violent people to use their anger management skills, because daily practice creates new neural connections, new reflex behaviors.

The human brain has a wide repertoire  of states of consciousness (SOCs). The very notion of “altered states of consciousness” presupposes that there’s a “standard” SOC – which is clearly not the case. Your SOC is different when you solve a math problem, or listen to music, or perform in front of an audience, or make love. So, I submit that we have a range of standard SOCs, which everyone experiences, as well as a range of alternate SOCs – some of which not everyone will experience. Taking drugs – including alcohol and nicotine – reliably alters consciousness in a variety of predictable ways. I won’t get into drugs as a means of altering consciousness in this post, other than to recommend Michael Pollan’s  book, How To Change Your Mind, which is about the potential of psychedelic experiences to bring about  lasting positive changes in peoples’ lives – even after a single “trip.”

I’d like to briefly share some of the things I’ve learned about our potential to “change our minds” without using drugs. Rational thinking  is a learnable skill. We all have rational and irrational thoughts. Many people can’t tell the difference between  them and sometimes act on irrational thoughts, complicating their lives. Rational thinkers are people who can differentiate their rational thoughts from their irrational thoughts, and make rational decisions. I believe that the brains of rational thinkers are wired differently – through practice – than the brains of those who can’t tell the difference. Active listening is a learnable skill that improves receptivity to nuances of interpersonal dialogue and music appreciation, among other things. Over decades of listening to classical music, I’ve become a better listener. Listening is often a passive process, but active listening is mindful listening, with no intruding thoughts.

Hypnosis is generally understood as a SOC “induced” by a hypnotist, where the brain is receptive to suggestion. People who are good hypnotic subjects can learn self-hypnosis to relieve pain, overcome bad habits, and otherwise improve their lives. Meditation is similar to active listening only in that it involves mental focus. But in active listening, the mind is focused on some external thing, whether words or music. Experienced meditators can maintain awareness,without any object of that awareness. There are things to be learned by simple, sustained awareness that can’t be learned by thinking, or be put into words. Mindfulness is a kind of meditation where the meditator is focused on their immediate experience, to the exclusion of thoughts about what they’re experiencing – especially judgments like good or bad, beautiful or ugly. Walking or chopping wood can be the focus of mindfulness meditation.

Not everyone experiences all of these SOCs; some require preparation and effort. Training that I received from anthropologist and practicing shaman Dr. Michael Harner enabled me to experience the shamanic state of consciousness, in which I’ve had vivid experiences of “journeying” in Dreamtime and encountering spirit animals. You can learn more about the techniques of shamanic journeying at http://www.shamanism.org, the website of the Foundation for Shamanic Studies, which Dr. Harner founded.

While I agree with Michael Pollan that psychedelic “trips” can, under the right conditions, be profound, positive life-changing experiences, I wrote this post as an overview of non-drug SOCs that can change our minds and lives. If you want to know more about any of these tools for personal growth, I’ve written in more detail about psychedelic consciousness, shamanic journeying, rational thinking, active listening, hypnosis, meditation and mindfulness in previous posts. You’ll also find a few entertaining stories about things that never happened.

Your mind is magical.

Turning off your mental radio

Although this post is about meditation, and I’ve taught basic meditation techniques to people for years, I’m not a daily meditator, myself. I think of meditation as an ancient, effective psychotechnology – a tool/skill for controlling mental activity. I’ve found it to be helpful in many situations, and have described learning to meditate as learning to “turn off your mental radio” at will.

A Buddhist text describes the mind as a “drunken monkey bitten by a scorpion,” and thinking is the source of much human suffering. Many people that I worked with as a therapist often felt overwhelmed by the unending press of their own thoughts, resulting in high levels of stress and distress – often in the form of anxiety and depression. People suffering from insomnia complained that they couldn’t stop thinking when they needed to be sleeping. I’ve written about rational thinking as a learnable skill in previous posts, but meditation gets at the root problem of runaway thoughts – regardless of content. Practicing it can prevent a thought from becoming an unwanted “train of thoughts” that might take you to places you don’t want to go. In a meditative state one can be aware, without being aware of any thing.

I’ve never had chronic sleep problems, but my rare experiences of insomnia used to be hellish, as I tossed and turned in bed, telling myself that I was having a terrible time. Now, when I have trouble falling asleep, I can avoid being aroused by the content of my thoughts. I can turn off my mental radio and experience getting needed rest, until I fall asleep again. I no longer torment myself with unwanted thoughts that keep me awake. There are other benefits that come from learning to meditate. You can learn it all by yourself. All it takes is practice.

There are many ways to learn how to meditate, and you don’t have to learn yoga or tai chi to discover how to control your mental activity. Daily meditators extol the benefits of their practice, but even occasional meditation can be a helpful skill, enabling you to keep your focus and to reduce your stress. As a therapist, I felt obligated to remain 100% present in the here-and-now with each client. Sometimes I would do a brief meditation between therapy clients, to clear my mind.

I started out with what I call one-point meditation, and went on to learn to maintain awareness, without any object of my awareness – no-point meditation. There are many different focal stimuli that can be used to learn one-point meditation. Probably the most popular method is to focus on your breath, to the exclusion of all thought. But learners can also focus on a visual stimulus such as a candle flame in a dark room or a mandala, or an aural stimulus – a ringing bell or a mantra such as “Om.” In mindfulness meditation, you focus on your present surround or activity, to the exclusion of thoughts about the situation or activity. Walking, or washing the dishes, can be a meditation.

Other than mindfulness meditation or movement meditations such as tai chi, most meditators sit, keeping a straight spine. As you follow your breathing, or try to lose yourself in a mandala or a candle flame or a mantra, thoughts will intrude on the purity of your concentration. One thought can easily lead to a train of thoughts that distracts you from your focal point. Learning to meditate involves learning not to let these thoughts carry you away from the object of your concentration. You notice the thought but don’t follow it, letting it pass, while focusing back on the candle flame, the mantra, your breath, or the activity you’re engaged in. When you first achieve a meditative state, you’ll know it; but as soon as you think, “I’m meditating!” you’re not. Repeat. With practice, you can extend the time that your awareness is one-pointed, uncontaminated by thought.

Once you make progress in one-point meditation, and can let intrusive thoughts drift by without distracting you from simple awareness, you can start to practice turning off your mental radio altogether, with no focal stimulus. I know from long experience that I can be alert and aware, without being aware of any thing, including my own thoughts. In the meditative state, I’m free from stress. I can meditate briefly, to clear my mind between mentally taxing activities. I can clear my mind of intrusive thoughts when I want to fall asleep.

Rhythmic breathing is central to learning meditation, even if you’re focusing on a candle flame or a mantra or an activity. Breathing is a constant, automatic activity. When you bring it into conscious awareness, you can learn to empty your mind of thought – if that is your goal. (Pranayama yoga teaches people to alter their consciousness in a variety of directions, by altering their breathing in prescribed ways.) Your initial practice sessions need not last long. If you set aside ten or fifteen minutes, several times a week, you can teach yourself how to turn off your mental radio.

 

 

Changing habitual behaviors

Everyone has habits – some good, some bad, some inconsequential. One study suggests  that something like 43% of our behavior is habitual. This includes sequences of behavior that we’ve “chunked” together, and often perform automatically, so we don’t have to make myriad decisions every day. When you get in your car to drive to your friend’s house, you’re probably thinking about your destination or what you want to say to your friend. You don’t have to decide on each action as you automatically depress the clutch, turn on the ignition, fasten your seat belt, release the parking brake, shift into first gear or reverse, and  step on the gas pedal while easing off on the clutch. You don’t always have to be mindful about driving until you’re in traffic. We spend part of each day on “automatic pilot,” not having to make individual decisions about routine behavior sequences – which can include such things as drug abuse or “screen addiction.”

Throughout most of history, an individual’s habits arose from the culture and that individual’s circumstances and proclivities. These days, many of our habitual behaviors have been conditioned by corporate social engineers, applying principles of social science in the fields of advertising, marketing, public relations, and political consultancy. Using classical (Pavlovian) conditioning and other psychotechnologies of influence, they “invisibly” shape habitual behavior on a mass scale. I’m convinced that America’s obesity epidemic is largely due to the constant barrage of advertisements for tasty, if not necessarily healthy, foods. I’ve written about this corporate social engineering in my book, Ad Nauseam: How Advertising and Public Relations Changed Everything.

Everybody knows how hard it can be to change a bad habit. During my career, I had many clients who entered therapy because they needed professional help in order to change a bad habit. Willpower by itself is seldom sufficient to establish a desired change, because you have to maintain mindful awareness of your triggers and urges/cravings every waking hour, and to persistently resist temptation. The rewards of (for instance) dieting are long-term; the reward of giving in to a food craving is immediate. The good news is that once you’ve successfully changed a habit, it gets easier and easier to  maintain the change as time goes on. Quitting smoking, my nicotine cravings used to last all day. Eventually they only lasted for seconds, and now I haven’t had one for years.

Whether smart phone use can be addictive depends on your definition of addiction. I’m “old school” on the subject and believe that tolerance (needing more over time to meet your need) and physiological withdrawal are hallmarks of true addiction. Sex and gambling and screen time don’t qualify as addictions by the classic definition, but the physiological responses of gambling/sex/smartphone/gaming “addicts” are very similar to the responses of drug addicts. There may be withdrawal, in the form of cravings, but they’re psychological in origin.

Changing a habit often requires  a strategic approach to the problem. What mental, emotional, and social factors tend to keep the undesirable behavior in place? Once you’ve analyzed the factors that support your bad habit, make a plan. Visualize how your life will be better when you’ve succeeded.

Here are four things you can do to replace a bad habit with a good one. (1) Your plan should take into account the things related to the bad habit, such as time, place, emotional states, and social factors ( i.e. It’s not a good idea to hang around with your drinking buddies early in sobriety). (2) Declare your intention and your criteria for success to friends and family. This gives you an added social incentive to succeed. (3) Build-in  consequences, positive or negative. They can be natural consequences, or constructed. A natural, positive consequence if you’re quitting smoking is to add up the money you’re saving, and when you accumulate enough, treat yourself to a trip to Disneyland, or Vegas, or wherever. A negative, constructed consequence might be writing a $100 check to some organization that you despise, and giving it to a friend, to be mailed if you fail to change the targeted habit. (4) Don’t rely on good intentions and willpower, but structure your environment to make the bad habit more inconvenient. You can’t binge on cookies and ice cream while watching TV if you don’t buy them and bring them home in the first place. Other environmental factors are social – enlisting the support of those around you to help you meet your goal, and avoiding those who might undermine your resolve.

I’d never say “Good luck” to someone who announced his or her intent to kick a bad habit. Luck has nothing to do with it, and willpower is only one of the things you’ll need to succeed.

Dialectical Behavior Therapy, Part 2

Working in a DBT program requires strict adherence to the treatment model, which is why all clinicians are members of the consultation team. The idea is that nobody should have to work with this challenging population without peer supervision and support. I won’t get into the dialectical framework here, except to say that there are strategies that facilitate balance – the synthesis between opposites. Hegel wrote about how the dialectic between thesis and antithesis leads to synthesis. Similarly, wise mind is a synthesis of reasonable mind and emotion mind. A good DBT therapist has to think dialectically, and DBT is a highly strategic therapy.

My education in the model introduced me to the concept of parasuicidal behaviors: non-lethal self-destructive behaviors that are the result of the same impulses that lead to suicide attempts. These behaviors include the abuse of alcohol and/or illegal drugs, abuse of prescription drugs, self-mutilation, and other self-destructive acts. People who perceive themselves as living in Hell often have a profound ambivalence around the issue of living v. dying. If you define your life as “the problem,” then suicide can seem to be “the solution.” Many preventable suicides occur as a mood-specific behavior (i.e. nobody attempts suicide in a happy mood), because of such irrational formulations.

Being a therapist isn’t a one-way street. If I’ve helped some people to improve their lives, my own life has been enriched by working with quietly heroic people who have striven mightily to change themselves. This is true of people across the diagnostic spectrum; but I felt privileged to work in a DBT program, and to watch emotionally unbalanced people learn balance, and learn to build lives worth living. It’s some of the most difficult work I’ve ever done, intellectually, and some of the most rewarding. People diagnosed with BPD used to be regarded as untreatable by many in the mental health field. DBT is an empirically validated cognitive-behavioral therapy. That means there’s scientific evidence that it works.

Marsha Linehan has courageously revealed that DBT came from her own journey out of Hell. She started her career studying highly suicidal people, and coming up with survival tactics and strategies for emotionally volatile people who are trying to finds reasons to go on living. Another feature of BPD – or having “borderline traits” – is being extremely judgmental, both of self and others. That’s why an important component of DBT mindfulness training is learning to notice details in your here-and-now experience without making judgments. People with the BPD diagnosis tend to frequently attribute their emotions and behaviors to external things (relationships, circumstances), and the DBT program teaches skills that help clients to own their own choices, and learn to make better ones.

With DBT clients at high risk of suicide, the primary goal of treatment is to keep her alive until the benefits of the program start to rick in, and suicide risk diminishes. Sly humor is sometimes appropriate in individual therapy sessions, and I remember saying to a client, with a straight face, “One thing that’s clear from the research is that this therapy can’t work if you’re dead.” Suicide prevention is where some of the treatment agreement contingencies come in. With what I knew about mental health clients with the BPD diagnosis early in my career, I never could have imagined that someday I’d give one my home phone number in case of emergencies. But I did, and never regretted having done so.

People with the BPD diagnosis often have long histories of suicide attempts, and for putting crisis line workers in a difficult position, threatening suicide unless _____ happens. As a DBT therapist, I was available at home to my individual therapy clients on evenings and weekends – but I got to set my own boundaries. Mine were not before nine in the morning and not after nine in the evening, and my clients never once abused their contact privilege. DBT clients know that the processing of details (therapy on the phone) wouldn’t be tolerated, that the call would only last five-to-ten minutes, and that the focus would be on skills: What skills have you already tried? What skill has worked for you in this kind of situation before? What skill do you plan to try next? Just knowing that their therapist was available to them in times of crisis, if only for a brief consultation, was helpful in itself. They understood that if they attempted any “suicide blackmail” games, their therapist would call 911.

One built-in contingency was that the client could call her therapist at home only if she hadn’t already engaged in parasuicidal or suicidal behavior prior to calling. Once she had cut herself or taken an overdose, she lost her privilege of calling for help. This was a highly effective contingency. Another contingency had to do with the weekly individual therapy session. Most DBT clients value their limited time with their individual therapist, and often have specific issues they want to talk about in session. But individual therapy sessions generally begin with a review of the week’s diary cards. For the client to get to select the topic of discussion was contingent on not having engaged in suicidal or parasuicidal behaviors during the prior week. Any self-destructive incident would be the automatic focus of the therapy hour. In that instance the client knew that her therapist would engage with her in a detailed “behavior chain analysis” of thoughts, feelings and actions that led up to the self-harm. These therapeutic contingencies help clients to resist impulses to harm themselves. Impulse control is a learnable skill set for most people. It saves lives.

Dialectical Behavior Therapy, Part 1

For two years I worked in a Dialectical Behavior Therapy (DBT) program at Columbia Area Mental Health Center. The program director was Dr. Sherri Manning, trained by Dr. Marsha Linehan, who had devised DBT for people (mostly women) diagnosed with Borderline Personality Disorder (BPD). People with that diagnosis are notoriously difficult to treat, and DBT provided the first effective, empirically validated therapy for that disorder.  Working in a DBT program requires the study of Dr. Linehan’s groundbreaking textbook, Cognitive-behavioral Treatment of Borderline Personality Disorder and the accompanying Skills Training Manual for  Treating Borderline Personality Disorder.  Every clinician in a DBT program is a member of the “consultation team,” which supports the team members in their challenging work.

Borderline Personality Disorder is characterized by extreme emotional dysregulation, or imbalance. Personality disorders are  diagnosed on Axis II of the DSM (the “Bible” of psychodiagnosis), apart from Axis I diagnoses like depression, anxiety disorders and schizophrenia. According to Dr. Linehan, all people with BPD have an underlying Axis I pathology, but have also experienced trauma that has shaped their behavior in persistent, dysfunctional ways. People with the disorder are often suicidal, and frequently engage in self-destructive behavior, including drug abuse and/or self-mutilation. They go to extremes in over-valuing and then rejecting significant others – sometimes in the same day. Dr. Linehan describes them as living in Hell and not knowing there’s a way out.

In order to be accepted in a DBT program, the client has to sign a year-long treatment agreement, to be renewed at year’s end if the client wants to stay in the program. She agrees to keep a daily diary card, charting moods, thoughts, and behaviors; and agrees to keep individual and group therapy appointments. Participation in the program is contingent on living up to the terms of the treatment agreement, and the client also agrees to other specified contingencies, which I’ll write about later. In the DBT program I worked in, patients were seen once a week for individual therapy and twice a week for skills training group sessions. Although individual therapy plays an important role in DBT, the skills training groups are at its heart. There’s no processing of issues in these sessions, but rather the presentation of skills by the group leaders, and coaching in their use.

One of the skills taught to DBT therapists is radical validation. Whereas I might equivocate if someone said I’d yelled at them, under normal circumstances (i.e. “I didn’t yell, I raised my voice because I felt frustrated.”), if a client in the program accused me of yelling at her, I’d validate her perception and immediately apologize for yelling. People with the BPD diagnosis are frequently blamed for things they can’t control. Many have never heard validating messages like, “You didn’t choose to be like this. If you knew better ways of  dealing with your pain, you’d use them. I believe in you and your ability to create a better life for yourself.”

Four modules are taught in DBT skills training groups: Core Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. Group leaders are trained in specific techniques to facilitate skill acquisition, strengthening and generalization. There are a lot of handouts and homework assignments. The groups reinforce what the clients are learning by keeping their daily diary cards. DBT is a cognitive-behavioral therapy in that it helps clients to learn the connections between emotions, thoughts and behaviors, and to apply that knowledge. A primary goal of the therapy is to help the clients achieve balance in their lives.

Marsha Linehan studied meditation with a Buddhist roshi (master) and a contemplative Catholic priest, and mindfulness is at the core of DBT skills training. Group members are taught that there are three primary states of mind: reasonable mind, emotion mind, and wise mind -the last of which is an integration of the first two. That they have a wise mind is a revelation to most clients. Being in the state of wise mind adds intuitive knowing to emotional experiencing and logical analysis. It’s explained as, “learning to be in control of your mind, instead of letting your mind control you.” One of the skills taught in the Core Mindfulness module is how to be mindful without judging.

The Interpersonal Effectiveness module helps clients to learn how to ask for things they want and how to say “no.”  It teaches them to prioritize and self-validate in setting relationship boundaries. It teaches “what” and “how’ skills for getting reasonable things you want and not caving-in to pressure to do things you don’t want to do. The Emotion Regulation module helps clients to learn the role of emotions, positive and negative, and to deal with them in a balanced manner. It teaches them how to build positive experiences and avoid negative experiences, and to feel a sense of agency in their reactions to emotions. The Distress Tolerance module teaches such skills as distraction, self-soothing, and improving the moment. It includes thinking skills and physical techniques for tolerating stress without responding in extreme, self-destructive ways. It teaches the concept of “radical acceptance” of things that can’t be changed.

After finishing the Distress Tolerance module, the group starts on Core Mindfulness again; so group members get multiple exposures to all four modules. I personally think that the skills taught in DBT groups can also help people with other diagnoses. I’ll continue to write about DBT in my next post.