What you’re “supposed to feel”

No matter what kind of family or culture we were born into, we got instructed on what we should feel under this or that circumstance. Some of the instructions came in the form of admonitions (“Of course you love him, he’s your father!”) and some in the form of role modeling. As children, we learn a lot from the behaviors we observe being demonstrated by those around us.

Real love is rooted in a naturally-occurring feeling we have for another person, but love is institutionalized in a variety of ways. New mothers are “supposed to” love their babies, but this isn’t always the case. It may be a hormonal thing, as with post-partum depression, or it might be that the child was conceived by rape; but a mother who doesn’t spontaneously feel love for her newborn is usually judged or blamed. Children are “supposed to” love their parents, but not all parents are worthy of their children’s love.

We all have feelings about our feelings. We may feel ashamed for having been afraid, or angry at ourselves for being depressed. A number of people I worked with over the course of my career felt terribly guilty for not loving a parent or other close relative who had neglected and/or abused them. We can’t choose what we authentically feel about anyone, and nobody has the authority to tell you what you’re “supposed to” feel. Real loving feelings either arise spontaneously, or they don’t. It’s not something we owe someone just because we’re blood relatives.

Gestalt guru Fritz Perls said that most people are socialized to be phony. Ideally, a kiss is a genuine expression of affection or love. But many times in some families, children are told to hug and kiss a relative because (s)he’s kin, whether or not the child feels affection or love for that person. Kissing may become a hollow social ritual, performed because it’s expected. In some family situations, a child may be expected to kiss someone who has abused or neglected them, or whom they find “creepy.” In some cultures a child may be required to kiss a dead relative at a funeral. This sort of thing can be a traumatic experience. It can be a perversion of what a kiss is meant to express. You can’t make yourself love someone any more than you can make someone love you. But you might be put in a position where you feel you have to fake it. When Perls called a behavior phony, he wasn’t judging the client; he was observing that the behavior wasn’t an authentic expression of feeling.

I’ve worked with couples in loveless marriages who reflexively claim to love one another, because that’s what’s expected, when they haven’t felt love for their partner in a long time. It’s not always black and white, however. Observing my father’s parents as a youth, I came to understand the term “love/hate relationship.” Love and hate can be closely allied, and it’s been suggested that the opposite of love isn’t hate, but indifference.

Relationships can be emotionally nourishing or, at the other end of the continuum, they can be toxic. People can change, and family systems can change. Often the goal of family therapy is to change the family system and to promote reconciliation between family members. But this isn’t always possible. Bad marriages can be terminated by divorce, but your parents will always be your parents – for better or for worse. I’ve worked with people who’ve tried time and again to reconcile with family members, only to find that the relationship remains toxic to them despite their best efforts. If a client had gotten to the point where they’d concluded that a family relationship would never be anything but painful for them, I’d suggest that she had the option to “divorce” that relative. It’s a sad happenstance, but it’s sometimes necessary for healing to begin.

I’ve also suggested that not all “kinfolk” need be blood-related, that you might have brothers and sisters you haven’t met yet. There are several people in my life that I consider “found” brothers and sisters. Someone who was abused or neglected by a parent might later find a nourishing relationship with an “other mother” or with a man who feels like the father he wishes he’d had. I’ve seen it happen. The mere fact of blood relationships doesn’t necessarily confer lifelong obligations, and certainly not the obligation to feel a certain way about a member of your birth family. We feel what we feel, and there’s no “should.” Rational thinking can free us from the tyranny of “shoulds.”

Multiple personalities?

“Multiple personality disorder,” now known as dissociative identity disorder (DID), is one of the most controversial diagnoses in the field of psychiatry. While dissociation – feeling like you’re not in your body or that you’re not “yourself” – is a recognized psychiatric symptom, some mental health professionals have questioned whether a person can truly experience themselves as having multiple identities. While only a few colleagues in my thirty-plus years as a psychologist have had a client that they believed had DID, I’ve known other clinicians who’d diagnosed it in several clients they’d worked with. Psychodiagnosis, as I’ve said before, isn’t rocket science.

In my opinion, multiple personality disorder was a “fad diagnosis” for a while, influenced by the popular book and movie, The Three Faces of Eve (Joanne Woodward won an Oscar for her portrayal of Eve), and subsequently the TV movie Sybil, with Sally Fields as a woman with multiple personalities. In my career I only had one client that I treated for DID. Some of my colleagues had doubts about my diagnostic impression, because they were skeptical about “multiplicity” as a phenomenological state. But my clinical supervisor validated the diagnosis and helped me to work strategically in my treatment.

My one client with DID – I’ll call her Susan – had corresponded with Chris Sizemore in her quest to understand her experiences of blackouts, and subsequently finding evidence of having done things she had no recollection of doing. Chris was the “Eve” of The Three Faces of Eve, and she’d written a book titled I’m Eve in which she revealed that the psychiatrist who’d written the book about her hadn’t, in fact, cured her of the disorder as he’d claimed. She’d discovered that she had more than the three personalities described in the book, and it took her years of additional therapy with another therapist to resolve the issue and experience herself as a single, integrated person.

With Susan’s permission, I initiated a correspondence with Chris, who validated the therapeutic strategy I’d described to her. Each of Susan’s personalities served a distinct function in her life, and she’d come to unconsciously rely on “them” to do things she didn’t think she was capable of doing, herself. Her “core personality” wasn’t initially aware of all the other personalities, and didn’t grasp that she’d unconsciously created them. Once she understood what was happening, she was terrified at the prospect of facing the world as a single, integrated person, but deeply troubled by her frequent dissociative episodes. She knew she couldn’t go on living that way.

The primary metaphor I used in therapy was that people are like oranges. We all have different aspects of our personalities, just as an orange has multiple sections. (I’ve labeled some of mine: the lieutenant, the teacher, the player, the host, etc.) Most of us, I said, have permeable boundaries between our sections. Each section is aware of the other sections, and is aware that it’s part of a single entity – an orange. I suggested to Susan that people with DID have impermeable boundaries between (at least some of) the sections. Each “personality” was aware of the core personality, but not necessarily aware of all the others, or the complex web of selective interactions among personalities. Some of the personalities that “came out” in sessions seemed open to the notion of eventually integrating with the core personality; others feared extinction. The method of integration was to make the boundaries between the sections permeable: to help each personality to be aware of the others, the function that each served, and the fact that they were all part of the whole person that was Susan.

Over time Susan gained the insight she needed, comprehending that DID wasn’t something that had happened to her, but rather something she was unconsciously doing – and could stop doing. But first she needed to learn to trust that her core personality had all of the capabilities that she’d attributed/distributed to the “others.” She eventually achieved her goal of integrating the splintered parts of herself. We kept in touch for a while after I was transferred to another satellite office of the regional mental health center, and she maintained her awareness of herself as a single personality with multiple facets. Like the rest of us. When she tried to give me credit for her breakthrough, I said what I always said in that circumstance: “You did the work; I just helped.”

I later met Chris Sizemore, who had become an active mental health advocate and public speaker. I saw her again a few years later and got to spend some time with her. She remembered me from our first meeting and “hugged my neck,” as we say in the South, when we met for the second time and when we parted. She was a highly intelligent, warm and generous person, and did a lot to promote awareness of mental illness. I feel privileged to have encountered her.

I still believe DID is a valid diagnosis, but think it’s very rare. I never worked with another person with the diagnosis again. My therapy with Susan was one of the most complex in my career, and I never needed good supervision more than then. I felt like I was walking a tightrope between not invalidating Susan’s experience of having more than one personality, while not validating her belief that the “others” were truly separate from her core personality. I think that my study of phenomenology in grad school really helped me to help Susan to integrate her “split personality.”

Mental pollution, Part 2

In my book Ad Nauseam: How Advertising and Public Relations Changed Everything I wrote, “As a psychologist, it disturbs me greatly to see that our society’s primary systematic application of the principles of psychology has been as a tool for commercial and political persuasion, and for the manipulation of behavior in the service of commerce.” Propaganda, which I wrote about in my last post, is only one psychotechnology  of influence used by the propaganda industries – advertising, public relations and political consultancy. Behavior modification is another. According to psychological learning theory (behaviorism) there are two means of systematically conditioning behavior: classical conditioning and operant conditioning.

Classical conditioning is exemplified by Pavlov’s experiments with dogs and is a passive mode of conditioning. Knowing that dogs reflexively salivate when presented with food, Pavlov conditioned his dogs to have the same reaction to the ringing of a bell, ringing it whenever food was presented. Over time, the dogs came to associate the two previously unrelated stimuli, learning to salivate whenever the bell was rung. This kind of associative learning is routinely used by advertisers and marketers to get consumers to associate their product or brand with something they already like or want.

Operant conditioning is an active mode of conditioning, in which a targeted behavior is systematically reinforced. If you expect from experience to be rewarded for what you do, it increases the odds that you’ll do it. This is the method used to teach rats to press a lever in their cage to get food, and to train dolphins to jump through hoops. An example of this in TV advertising is, “Call in the next ten minutes and shipping is free.”

As promised in my last post, here are some of the techniques used by propagandists to influence and persuade. Probably the most frequently used techniques in the media is assertion – either an outright lie, or stating an opinion as if it were a fact, without first saying “I think” or “in my opinion.” Any ad that says “We’re the best/least expensive” without providing factual evidence falls in this category. I think that the second most frequently used propaganda technique is ad nauseam. A lie repeated and repeated and repeated can come to be perceived as the truth. Three other, related, techniques are lies of omission, card stacking and distortion, where facts are cherry-picked to promote the message and any contrary facts are left out or misrepresented. Sometimes the message mixes facts and lies or half-truths; sometimes facts are blended with unsubstantiated opinions (assertions) in a manner designed to obscure the objective truth.

With transfer, a classical conditioning technique, an attempt is made to create an association (positive or negative) between two unrelated things. Using an American flag as a backdrop for a political message is an example of positive transfer. Showing a picture of the opposition candidate with a Hitler mustache superimposed is an example of negative transfer. Bandwagon suggests that we should follow the in-crowd, join the winning side, avoid being left behind with the losers. (Wouldn’t you like to be a Pepper, too?) Glittering generalities involves the use of emotionally loaded generalities that have no objective basis for definition, such as “freedom lover,” “perfect gift for all occasions,” or “best country in the world.”

Name calling can take the form of sarcasm and ridicule, or can employ the assertion technique, such as calling a political candidate a closet Communist, or a secret ISIS supporter, or “weak on crime.” With ad hominem, instead of dealing with the message, the messenger is attacked: “Don’t believe anything he says,” or “fake news.” Simplification offers simple solutions for complex problems, and is often seen in the form of slogans. Pinpointing the enemy and  stereotyping were used by the Nazi propaganda machine to stoke the fires of anti-Semitism and to justify Hitler’s genocidal “final solution.”

Appeal to authority attempts to create a positive association. Examples are celebrity endorsements, a politician invoking the name of an icon such as George Washington or Abraham Lincoln, or an actor in a commercial wearing a white lab coat to suggest that she’s a doctor or a scientific expert. “Nine-out-of-ten dentists recommend _______” is another example.

There are other propaganda techniques that you can read about in my book, but these are some of the most commonly used by professional persuaders. Some commercials and political messages use several, to disguise the fact that what they deliver is not information. These classic propaganda techniques were identified by the Institute for Propaganda Analysis (IPA), a non-partisan educational organization that, unfortunately, only existed from 1937-42. The IPA distributed information about propaganda analysis to schools and civic organizations. One reason we’ve become a Propaganda Society is that we don’t have anything like the IPA to educate the public at large, and propaganda analysis isn’t taught in our public schools.

In my next post I’ll return to my usual subject matter and look into the pathological condition commonly known as “multiple personalities.”

Mental pollution, Part 1

This post is one of my occasional departures from my usual subject matter. Instead of writing about human growth and psychotherapy, I’ll be sharing some thoughts and information about the polluting of our mental environment. My second published book (my  first was a Peace Corps memoir) is Ad Nauseam: How Advertising and Public Relations Changed Everything (iUniverse, 2015). I received the iUniverse “Editor’s Choice” designation, and Kirkus Reviews wrote: “An illumination and critique of a commercial culture that distorts reality for gain…. In this brief but smoldering tract, a psychologist deconstructs contemporary advertising…. (a) competently written, highly readable primer on how the culture came to this awful point.”

I think that most Americans, asked if their behavior was influenced by propaganda, would deny it. If you think you aren’t influenced by it, you are either adept at recognizing propaganda techniques and other psychotechnologies of influence when you see them, or chances are you are influenced to some degree without knowing it. The most effective propaganda is invisible to most people; that’s how it works. Whether or not something is propaganda isn’t a matter of opinion. Propaganda seeks to influence and persuade people in the guise of informing them. The intention to persuade doesn’t make something propaganda, if the means of persuasion are logic and facts. It’s the use of identifiable deceptive techniques that distinguishes propaganda from information. The propagandist’s art is to make you think you know something to be true or accurate, even if it’s not. Propaganda techniques are important tools – along with rhetorical devices, heuristics and behavior modification techniques – of the propaganda industries: advertising, public relations, and political consultancy. I’m not saying that all advertising and public relations campaigns use these tools, but they’re so pervasive in the popular media that they’re invisible to most of us.

A few years ago, I set out to discover the relationship between public relations and propaganda, only to find that they’re practically identical. The “father of public relations” was a man named Edward Bernays. Although he was one of LIFE magazine’s “100 Most Influential People of the Twentieth Century,” his name isn’t well known outside of the propaganda industries. A government propagandist who worked to persuade the public that the U.S should fight in World War I, after the war he reasoned that propaganda would also successfully influence mass behavior in peacetime. But because propaganda  had gotten a negative reputation, for his purposes he re-named it public relations, and founded a new profession: the public relations counsel (as in legal counsel). In his 1928 book Propaganda he wrote about an “invisible government” of social engineers, which he called “the true ruling power of our country. We are governed, our minds molded, our tastes formed, our ideas suggested, largely by men we have never heard of.” When I discovered Edward Bernays, I knew I had a book.

It’s been estimated that the average American will be exposed to over seven million commercial messages over the course of her lifetime. Who is immune to this daily barrage of persuasive messages, crafted by experts in the molding of mass behavior? Mass persuasion has become an applied social science, with its research, polling and focus group activities. Advertising, public relations and political consultancy wouldn’t be multi-billion-dollar industries if they couldn’t deliver results. Perceptions are often more important than facts in media campaigns designed to persuade consumers and voters.

Effective advertising works, whether you’re selling vitamins or cigarettes. A major reason obesity has become a major public health problem in America is that we’re constantly bombarded with ads for unhealthy food. Children are especially susceptible to this form of persuasion. Public relations firms refer to massive stinking pits of excrement on hog farms as “lagoons” and there’s such a thing, we’re told, as “clean coal.” Attack ads and slogans have largely replaced issue ads in political campaigns, because they’re effective in influencing  voters. I believe that we’ve become a Propaganda Society, and that our democracy can’t survive on a steady diet of propaganda. The result of a successful propaganda campaign is orchestrated ignorance on a mass scale. As I suggest in my book’s subtitle, advertising and public relations have changed everything: diet, medicine, law, education, sports, popular culture – you name it!

The antidote to the infotoxins in our mental environment is education. I’ll present some of the propaganda techniques and other psychotechnologies of influence in a future post. They need to be taught in public school, to immunize young people from the social engineering of the corporate state. If you want to learn more about our Propaganda Society and what we can do about it, check out Ad Nauseam, available online in print and e-book editions. You can read my basic thesis in the sample on my Amazon book page.

I’ll close with words from one of my favorite Bob Marley songs, “Redemption Song”: “Emancipate yourself from mental slavery/None but ourselves can free our minds.”

 

Post-Traumatic Stress Disorder

In the course of my career I worked with many people who had experienced significant trauma. Something I heard from many of them was along the lines, “What’s wrong with me? I think I’m going crazy! I can’t stop crying (worrying/ having panic attacks/having nightmares/having flashbacks/losing my temper/thinking about suicide, etc.) I didn’t used to be like this!” Once I was confident in my diagnosis, I’d respond in this manner: “You’re not going crazy. You’re having a normal reaction to an abnormal, traumatic life event. Your symptoms are consistent with something called post-traumatic stress disorder (PTSD) – the same thing that affects some soldiers who’ve been in combat. In World War I it was called shellshock and in World War II it was called combat fatigue, but it doesn’t only happen to soldiers.”

I’d go on to explain what happens in the brains of some people who’ve had traumatic experiences. The amygdala – which helps us to process emotions and is linked to the fear response – can be activated by trauma and sensitized to react to triggers: things that the brain has come to associate with the original traumatic event. A sudden loud noise might trigger an instant fear response in a combat veteran. Seeing a depiction of an assault on a cop show on TV might trigger a flashback in an assault victim. Sights, sounds and sensations reminiscent of the trauma can re-stimulate the amygdala and trigger symptoms. Thoughts can also be triggers.

Two people might experience the same traumatic event, only one of whom will develop PTSD; and science can’t predict which one. You can’t put a timetable on recovery from trauma, but all too often people suffering from PTSD are blamed for the persistent changes in their behavior. Many get told things like “Just get over it!” and “What’s wrong with you?” – as an accusatory statement in the form of a question.

PTSD can be caused by a single event or by serial traumas, such as ongoing child abuse. It can result from physical or sexual assault, surviving a terrible accident, or witnessing bloodshed and/or death. It can be caused by weeks or months spent in combat zones, even if there was no single major traumatic event. Soldiers are often reluctant to admit to symptoms of PTSD, as the military culture tends to stigmatize the diagnosis as a sign of weakness. But it isn’t; it’s a brain disorder.

My wife Maria and I served as Red Cross Disaster Mental Health Volunteers at a Red Cross Family Service Center near Ground Zero after 9-11. Although we were both licensed mental health professionals, as disaster mental health workers we weren’t there to do therapy. We were there mostly to listen, and to help people understand and process  what they’d gone through on the day when the twin towers fell. We also provided referral information to those we met who might need therapy from local practitioners. One thing I remember saying to a number of trauma victims I encountered was, “You’re not going crazy. You’re a civilian who suddenly found yourself in a war zone. Nothing in your life has prepared you for that. Your (symptom/symptoms) is/are a normal reaction to an abnormal circumstance.”

Hundreds, perhaps thousands, of Manhattanites were traumatized to a greater or lesser degree by the events of 9-11. You didn’t have to be near Ground Zero to be affected, and it seemed that the whole city was on edge, anxious about the possibility of another attack. I met a woman who had watched the falling bodies of people who’d jumped from the burning towers, transfixed by the horror of what she was witnessing. I spoke to a young man who’d ridden the subway his whole life,  ashamed because he was terrified to do it again. I heard story after story from people who wondered if their lives would ever be the same again. Another thing I said to several people I encountered was, “Nobody’s qualified to tell you when you ‘should’ get over this. It may get better as time goes by, or it may not. There’s no guarantee that you’ll completely recover, but don’t give up on the likelihood that you will, in your own time. You may need professional help.”

There are highly effective treatments for trauma victims. Just as physical wounds can heal over time, so can the “invisible wound” of PTSD.

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.