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.

 

What the hippies got right

I didn’t attend Woodstock – I was in ROTC summer camp at Fort Bragg – and never made a pilgrimage to Haight-Ashbury, but there was a time in my life when I considered myself a citizen of the Woodstock Nation. Recently, looking over my faded and dog-eared copy of one of the Whole Earth Catalog editions that came out in the sixties and early seventies, I reflected on what the hippies got right.

Each Whole Earth cover displayed that first iconic image of Earth seen from space and bore the subtitle “access  to tools.” The series was like a Sears & Roebuck catalog (ask your grandparents) of resources for alternative lifestyles, with all you needed to know about guides to living off the land, healthy lifestyles, sustainable energy, spiritual development, affordable shelter – including geodesic domes – and anything else you might need to drop out and start a farming commune. In retrospect I see the Whole Earth Catalog as the Bible of the hippie ethos. I had never heard about ecology or the benefits of meditation until I read the catalogs, and editor Stewart Brand became one of my primary culture heroes. Steve Jobs described the catalogs as a predecessor of the World Wide Web.

I came to hippiedom long after the funeral for the movement had been held in San Francisco, and five years after Woodstock. I’d been a Citadel cadet during the Summer of Love and an Army officer until 1974. But in grad school I grew my first beard, let my hair grow out to shoulder length, and rebelled (culturally, at least) against The Establishment for a few years. But once I had my degree and was starting my career I decided, like so many of the idealistic flower children of my generation, to drop the costume and the self-indulgences of the movement and “join the System to change it from within.”

Hippies were essentially a media invention to explain a very real generational rebellion. I expect  that when most people who never identified with the movement think about it, they think about long hair , tie dyed clothes, drugs and free love. But those were only the outer trappings. Some of the hippest folks I knew in the day dressed conventionally, and didn’t do drugs or sleep around. True hipness is a state of mind, not a conformity to unconventional dress and habits. Most hippies believed that marijuana should be legalized, long before the mainstream became tolerant of its use and recognized its medicinal benefits. Free love never went mainstream, but I think the hippies’ tolerance for sexualities other than heterosexuality was influential in the gradual mainstream acceptance of LGBTQ persons. And hippies were part of the core of early feminists.

When I look at certain positive trends in the 21st century, I see their origins in the hippie counterculture. The notion that we should question authority and conformity has proliferated in my lifetime. Unconventional hairstyles are no longer “freak flags” that brand the wearer a presumed pot-smoking anarchist; they’re simply preferences in style. The hippies challenged the idea that being “normal” (conventional) was a virtue. I think that the “Rainbow Tribe” view of mankind – tolerance for people who don’t necessarily look like you or act like the majority acts – has endured and spread within our culture.

The whole Green Movement, everything from organic farming, recycling and composting, to renewable energy got its initial momentum from the Whole Earth crowd. The hippies promoted the notion of the Earth as our mother – or alternately as Spaceship Earth, on whose life support system we all ultimately depend. “You are what you eat” was a hippie mantra. Hippies were ridiculed as granola eaters and “health food nuts,” but now we have public service campaigns about healthy diets, and detailed nutritional information is printed on the packaging of most processed foods, to help us make better choices. Granola, yogurt and tofu have gone mainstream, and vegetarians/vegans are no longer regarded as weirdos.

Hippie resources like the Whole Earth Catalog introduced many of my generation to yoga and other forms of meditation. What we called living in the here-and-now is now widely known as mindfulness. Such practices have been scientifically validated as activities that promote wellness, and have become mainstays of behavioral medicine. Now yoga and meditation have gone mainstream.

The hippie ethos was a rejection of the unquestioning conventionality of the post-war era and an embrace of new possibilities. Some of its seeds have taken root in the wider culture and flowered, helping to cultivate more tolerant, free-thinking, health-minded, and environmentally conscious Americans.

 

Mindfulness and meditation

Mindfulness has become a buzzword, not only in psychotherapy, but in the mass media. Mindfulness is when you “stop and smell the roses.” Some people are making a lot of money marketing mindfulness training, but learning to practice it costs nothing beyond an investment of your time. An age-old Asian aphorism is that the mind is like a drunken monkey bitten by a scorpion. One of the benefits of this time investment is learning to tame your monkey mind.

Fritz Perls said that past and future are fictions: our lives are spent exclusively in the here-and-now. Buddhism teaches that all suffering arises from attachments, and in that regard it correlates to cognitive behavioral therapy. Self-talk is like a constant mental radio broadcast that most people don’t know how to turn off, as much as they might wish to sometimes. In my career I’ve had many clients who lived their lives in thrall to their frequent or constant irrational thoughts. Learning meditation gives you a way to turn off the mental radio at will.

Mindfulness is a kind of meditation that’s always available to us. It doesn’t require silence, or sitting in the lotus position, or chanting, or concentrating on a mandala, or doing yoga breathing – although all of these practices are valid methods  for learning to meditate.  Mindfulness simply means getting out of your head and being fully present in the here-and-now, the only time there is, without letting your mind wander and without making judgments.

Before I specifically get into mindfulness further, I’ll first share my understanding of meditation in general. I learned to meditate in grad school, and found that there are many methods for learning to stay in a meditative state of consciousness, some of which I listed above. I’ve experienced two distinct levels of meditation. I started out with what I call single-pointed meditation, which means learning to focus on a single thing – a candle flame in a darkened room, a mantra (chant), focusing on your breathing to the exclusion of all other thought. Unrelated thoughts will inevitably intrude, but with practice you can learn to ignore them, let them go, and return your focus to the single point. At first it’s a balancing act, like walking a mental tightrope. When you first realize that you’ve achieved a meditative state, you think “I’m meditating!”, but the instant you think that, you’re not – you’re thinking again. With sufficient practice you can lengthen the time you stay in the meditative state, and develop confidence in your ability to meditate whenever you choose to.

Once I’d learned to stay focused on one thing exclusively, without letting my mind wander to other things, I was able to move on to a new level of meditation – pure awareness. I learned that it’s possible to be awake and aware, without being aware of any thing. Learning to suspend object-consciousness and judgement is a liberation. You can tame your monkey mind, turn off the mental radio. The silence is golden. It’s a distinct state of consciousness that teaches you what thinking cannot teach. It calms the body and the mind.

Mindfulness is a kind of single-pointed meditative state. You can be mindful while performing a task, taking a walk, taking a bath, having a conversation, doing Tai Chi, or standing in a crowd. You can be mindful of your self-talk. Mindfulness means staying focused on your here-and-now experience, to the exclusion of extraneous thoughts and without making judgments like good/bad, beautiful/ugly, or right/wrong.

Many times in public I’ve played a mindful game with myself, a game that teaches me things about my ordinary (non-mindful) consciousness and my monkey  mind. Normally when I’m in public, people-watching, I’m constantly categorizing and judging and speculating about all the people I see: whether or not I find them attractive, whether they’re fat or thin, graceful or clumsy, whether  they seem smart or dumb, likeable or unlikeable, etc.  Sometimes when I catch myself making these instant evaluations, I decide to play “the Buddha game.” I mindfully suspend my monkey mind and imagine that everybody I see is a Buddha – perfect, God in disguise. Just as I believe that meditation has changed my ordinary consciousness over time, I believe that playing the Buddha game has helped me to be less judgmental and more compassionate.

Mindfulness training is at the core of Dialectical Behavior Therapy (DBT), a highly effective therapy developed by Dr. Marsha Linehan to treat people who meet the diagnostic criteria for Borderline Personality Disorder. While she was devising the core strategies of DBT, Dr. Linehan studied meditation with a Catholic priest in a contemplative order and with a zen master. The people for whom DBT was designed tend to be extremely judgmental (of themselves and others) and emotionally volatile. Dr. Linehan became convinced that practicing mindfulness would help them to find balance in their deeply conflicted lives. Having co-led DBT skills training groups and seeing first-hand the effectiveness of mindfulness training, I believe that it’s beneficial for mentally ill people with other diagnoses, too. But as I’ve said many times, you don’t have to be sick to get better. Mindfulness is a learnable practice that can improve your life, if you invest some time in it.