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.

 

Stress Management

We’ve all heard that prolonged stress negatively impacts our health, but stress isn’t necessarily a bad thing. Dr. Hans Selye, one of the pioneers of stress management, said that stress can be “the spice of life or the kiss of death.” He labeled negative stress distress and positive stress eustress. If we choose to ride a rollercoaster, or to scale a cliff, or watch a horror movie, we’re choosing to experience stress. Stress is an unavoidable fact of life, and a stress-free life would be an uneventful life – boring. Sexual excitement is a form of stress, and we all enjoy an adrenaline rush from time to time, especially if we chose the stimulus that triggered it.

Our autonomic nervous system, which regulates automatic behaviors, has two branches: sympathetic and parasympathetic. Both are involved what Dr. Selye called the “fight or flight” response. Activation of the sympathetic response gears us up, preparing us to fight or flee, whether or not we’re in danger. Heartbeat and breathing instantly become more rapid,  delivering more oxygenated blood to the brain and the extremities. Blood pressure and blood sugar rise, muscles tense in anticipation of action, and you may experience a jolt of adrenaline. After the event or situation that triggered the sympathetic response is past, the parasympathetic branch kicks in, reversing the fight or flight response and allowing us to “rest and digest.” We’re told not to go swimming right after eating a meal, because our blood flow has been re-directed from our extremities to our gut, increasing the possibility of a muscle cramp.

The fight or flight response evolved to help our ancestors to avoid being eaten and to hunt dangerous prey. If you’re a soldier in a combat zone, or a cop, or a firefighter, you may experience it on a regular basis. But although only a few of us in modern society frequently face physical peril – other than heavy traffic – we respond to perceived existential threats, even if we’re not actually in immediate danger. Combinations of financial, social and environmental stressors (How am I going to pay the rent? Is my wife being unfaithful?) can result in a high level of distress, sometimes manifesting as anxiety.

Anxiety is similar to fear, although the causes might be multiple and may not be immediate physical threats. A person having an anxiety  attack may experience their fight or flight response as paralyzing. Once you’ve had one, your fear of having another one becomes yet another stressor in your life. If you only occasionally have fight or flight reactions, stress may not be a significant factor in your health. But if you have them frequently, your health may be affected. But frequent fight or flight reactions aren’t the only stress-related threat. Chronic overstress – having more on your plate than you can handle – can kill.

Stress management doesn’t mean eliminating stress. It means controlling the amount of stress in your everyday life and, where possible, eliminating stressors. There are both physical and mental aspects to stress management. But first you need to identify the sources of stress in your life, your triggers for stress reactions, and how stress affects you.

If you need to practice stress management, start with an inventory of your stress factors: job security and satisfaction, finances, safety, residential issues, and personal relationships. Think of how you might be able to reduce unwanted stress in each area. It may mean some tough choices. Then list the kinds of situations and events that tend to trigger stress reactions. Being aware of your stress triggers may help you to prepare for them or learn ways to avoid them. Become more aware of how you typically respond to stress triggers and overstress. Do you somaticize (physicalize) it into headaches or bellyaches or backaches? Do you stay angry or depressed? Do you worry excessively? Anxiety has many faces , including free-floating (generalized) anxiety, panic attacks, and phobias – including social phobias. After doing this analysis of the role of stress in your life, you’re ready to look at physical and mental stress management techniques.

Physical stress management techniques include breath control, learning to relax your muscles, meditation, self-hypnosis, yoga, exercise, good nutrition, and adequate sleep. Avoid self-medicating with alcohol or other drugs. If you’ve listed rapid breathing as a stress symptom, you can learn to slow your breathing when you’re under stress. This helps to bring the fight or flight response under your control. There are many techniques for relaxing tense muscles, and relaxing the body tends to simultaneously relax the mind. I used to teach clients a method of focusing on the sensations in each of the muscle groups of the body in turn, tensing and relaxing each muscle group until they became aware that they could relax them at will by focusing on the changing sensations. It’s a form of mindfulness.

Learning time management or anger management might be part of your stress management plan. The best single mental stress management I’m aware of – besides meditation, which calms both body and mind – is rational thinking. (I’ve previously published several posts on rational thinking as a learnable skill.) Any stressful situation can be made more stressful by the way we think about it, and the effects of stressors in our lives can be minimized by thinking about them rationally. Failing to achieve something you wanted to achieve doesn’t make you “a Failure.”  Telling yourself that you’ll never get over a loss can be a stress-inducing self-fulfilling prophesy. Thinking that they “can’t stand” something has never helped anyone to cope with distress.

Some stressors can be minimized or overcome, others can be tolerated until circumstances change, by developing coping skills. We can all learn to manage our stress to some degree, if we understand it for what it is and make a conscious effort to control its effect on our lives. Coming up with your own personalized stress management plan and implementing it can help you to become more resilient in times of adversity, and might add years to your life.