Biosocial Theory in a Nutshell

The theoretical orientation of dialectical behavior therapy (DBT) is the biosocial theory.  Here, there is a biological component and environmental component to understanding behavior.

From genetics, we know that some people have more sensitivity, or predisposition, to triggers.  In borderline personality disorder, there is a biological side of the emotional reaction that starts with heightened reactivity that spikes faster than others and takes longer to go back to baseline.  It is physiological.  Individuals with borderline personality disorder may need 20% more time to return to baseline for most emotional reactions.

Having this heighten emotional response can be off-putting for people who are not as sensitive.  Some may draw comparisons to the reactions of others, which can be invalidating.  For example, "Your brother didn't even cry when his dog ran away, and here you are being a cry-baby about your dog being at the vet's office to have his teeth cleaned.  It's really not that big of a deal.  He'll be back to normal in soon, so just stop crying."

This sensitivity is not inherently bad or a signal that someone is "broken and just needs to be fixed."  The world is enriched by the passion and excitement of emotionally sensitive individuals.  Marsha Linehan is an intellectual example of this, as she too carries the diagnosis of borderline personality disorder.  It is true in art, music, writing, sports, science, and almost anything we do.  

In looking at problem solving, there can be an oversimplification of problem solving.  No one is born knowing how to regulate emotions.  We watch others and they show us how to regulate our emotions in a healthy way. 

Change is hard.  Change is gradual.  Change is a process.  Remember, one goal is progress, not perfection.  As the main dialectic in DBT, we have radical acceptance of the person and the need for change.  Change can definitely be worth the work.

The second part of the biosocial theory is the invalidating environment.  Invalidation is independent of the actual validity of the emotion or behavior (Manning & Hall, 2013).  Invalidation is not necessarily intentional or malicious, so this is not to blame others for the person's problems. 

In looking at invalidation, families can negate the person's private experiences. 

Parent: "How could you possibly be hungry?  You just ate!" 
Child: "But my tummy is growling and I am hungry."
Parent: "No, you just ate.  Ignore that.  You will be fine soon."

In this situation, the parent has invalidated the child's experience and has told the child what his body is really telling him.  Soon, the child will distrust his body's signals that he is, in fact, hungry.  

If the environment punishes emotions, the person may escalate the emotional response.  This results in dysregulation, meaning a disruptive emotional, cognitive, and/or physiological response.  Others may react to the dysregulated person and give them what they want.  Behaviorally, the problem with this is that the dysregulated behavior has been reinforced.  In reinforcing the behavior, this may become a pattern that increases over time. However, it is important to validate the person's emotional experience and not be judgmental or accusatory, in content, process, and tone. 

Others can label the internal experiences or exhibited behaviors as a pathological problem, such as calling the person lazy or selfish.  This, too, is invalidating.

The environment can teach unrealistic problem solving skills.  Examples of this include magical thinking and oversimplification.  "Magical thinking is thinking that one's thoughts by themselves can bring about effects in the world or that thinking something corresponds with doing it" (Colman, 2012).   

The discussion of the emotional vulnerability and invalidating environment is more of an explanation as to what has happened, what is happening, and what we can do about it.  The DBT skills are a part of how to regulate emotions, to tolerate distress, and to be more effective in interpersonal relationships.

Meeting Shari Manning

On a rainy evening in May, I was looking through YouTube videos about borderline personality disorder.  I found Carla Sharp's lecture at Menninger last November.  I was one of the first to sign up for the conference, but caught a cold and couldn't go.  Dr. Sharp's lecture is very research oriented and filled with data, statistical analyses, and references.  Be sure to check the video of her lecture at the link below.

Borderline Personality Disorder in Children and Adolescents by Carla Sharp, Ph.D.

After watching the lecture, a video with Shari Manning at the same conference popped up on my screen.  Excited, I clicked on the video.   

Loving Someone With Borderline Personality Disorder: A Model of Emotional Regulation by Shari Manning Ph.D.

The first words that came to mind were "she is intense," so I was a little nervous when I walked to the front table to introduce myself.  "Hello, Dr. Manning.  My name is Sarah Turner.  I am so glad to be here."

"Not Dr. Manning, Sarah, it's Shari.  So you're the student."  

"Yes.  Thank you for letting me come," I replied, as I looked around the room of the PhDs, MDs, LPCs, LMSWs, and me.  I felt out of place at first, like I wasn't ready for this, but Shari's bell for the call of attention for mindfulness brought "my mind where my feet are." 

As the week continued, I saw Shari's passion for dialectical behavior therapy and the need for further research.  I had so many questions about DBT research, yet I knew that it was time for lunch.  I asked Shari if she would have lunch with me.  She agreed that we would meet on the fourth day of the training, a Sunday in May.  

I had learned the hard way that it is essential to be prepared for meetings, so I started reading about other DBT researchers, including Shireen Rizvi and Linda Dimeff.  I sifted through the literature for the integration of technology in mental health.  I found great journal articles by Shireen Rizvi.  I poured my energy into getting ready for the meeting.  

One of my more helpful ways to cope with anxiety is to prepare for the meeting until it's almost time for bed, and then curl up with a fun book and my journal.  I did enjoy Calvin and Hobbes.

Shari and I were in line for lunch at Menninger.  Shari placed her order and said, "I'm paying for me and the girl behind me.  (Turns to me) You can pay for lunch when you are a professional.  Graduate students never pay for lunch with me."  I was so surprised and honored, a feeling that stays with me when I think of her.

As soon as lunch started, we were knee deep in concepts and applications of DBT research; it was like wading into a teeming river of ideas.  I was so excited to have an intellectual conversation about the skills and ways to teach others about DBT, a therapy we believe can change lives.  We have a common goal: to make DBT more accessible and available to more clinicians and clients.  

The DBT training in Houston is the first of many steps for me.  I will be pursuing mixed methodology studies in the upcoming years.  My current passion is qualitative research.  I will be learning more about quantitative methods soon, as much of the current DBT research is primarily quantitative.  

Shari has been so welcoming of new ideas throughout the training.  I will look forward to reading her book, Loving Someone with Borderline Personality Disorder: How to Keep Out-of-Control Emotions from Destroying Your Relationship

I asked her to sign my copy.  This is the note:

To Sarah- 

Best wishes in your career as a DBT researcher and thank you in advance!

- S. Manning

As we said goodbye next day, she gave me a warm hug and smiled.  Her encouragement has increased my confidence in my ideas and aided me in moving forward in my career as a researcher.

I will look forward to the online section of the training over the summer.

Mindfulness 101: Mindful Worrying

This is the time for the kick-start to charge into the summer, fueled by caffeine and adrenaline.  Deadlines and pressure to meet them seem to come at us from every side, leaving us stressed out, irritable and utterly sleep deprived.  

While a triple shot of espresso might be a short term solution to increasing mental stamina, researchers Marsha Linehan and Jon Kabat-Zinn offer a modern twist to focus the mind and body, yielding constructive, balanced reactions to the stress of school, through mindfulness.  

“Mindfulness means paying attention in a particular way: on purpose, in the present moment, and non-judgmentally,” wrote Kabat-Zinn in his 1994 book Wherever You Go, There You Are. Practically, mindfulness is a mechanism “to be more in touch with the fullness of your being through a systematic process of self-observation, self-inquiry, and mindful action,” wrote Kabat-Zinn.   

Another way to think about it is “putting your mind where your feet are” (Hall, 2009), meaning your mind is focused only on the information directly in front of you- not the outcomes.   Thoughts of impending doom of taking the exam and your expectations of the grade you receive get in the way of your attention and focus on the reading assignment or problem set.

Mindful worrying can be a great way to begin a study session or group work.  It may seem counterintuitive to write a list of the issues you’re worried about concerning your work, but in doing so you identify and label your fears to develop a way to approach them.  The exercise is to select one of the fears or worries and think, talk, or scream about it for a specific period of time, typically 3 to 5 minutes. 

If the fear comes back as you work, acknowledge that it exists, and then consciously say to yourself, “Yes, it scares me that I don’t know the difference between a beta-blocker and a meta-analysis, but I’m going to keep working and I am not going to give any more attention to my fear.”   

You’ve acknowledged that the fear exists, validated your emotional experience, and given yourself the steps you need to succeed. 

Validation has several levels, and they are better discussed by Karyn Hall and Melissa Cook, The Power of Validation: Arming Your Child Against Bullying, Peer Pressure, Addiction, Self-Harm, and Out-of-Control Emotions.  Click here to learn more about The Power of Validation" by Karyn Hall and Melissa Cook.



One last thought about mindfulness and the nature of worry when troubles and stress surround us.  This is an example of a DBT skill called Vacation.  It is a part of IMPROVE the Moment. 

"I hadn't understood the nature of letting go": A Metaphor of Acceptance and Letting Go

I hadn't understood the nature of letting go until this week, after the DBT training in Houston had ended.  

When I think of letting go, I picture this: hands with fingertips extended and palms facing the sky.

It has been so easy to switch from having these open hands, only to clench my hands again in tight fists, grasping the very things I thought I had released.  This is so easy to say, "Yes, I will let this go and surrender," as the possibility of grabbing it again.  

My friend said that letting go means having open hands with your palms facing the ground.  Whatever you were holding onto so tightly has fallen to the ground.  Albert Einstein wrote, "The most beautiful thing we can experience is the mysterious.  It is the source of all true art and science."

Letting go is a form of acceptance.  It is also a process.  Letting go with your palms facing the ground is radical acceptance.  Here, radical means complete and total.  It does not mean that the issue is gone forever or that this will always be a struggle.  Radical acceptance is a decision, a choice that is made moment by moment. 

DBT Training Wrap Up from May 2013

This week has been as much fun as summer camp!  It was intense to work with Shari Manning and Karyn Hall for a week.  I am kind of bookish, so it was a perfect fit for a graduate student who is eager to learn and apply...and run with the big dogs in the treatment world. 

When I arrived at Menninger for the training, I had barely slept and didn't need to with such anticipation and excitement.  I was one of the first to arrive, so I had a moment to look around the room and soak in the reality of the moment- here I am as a student- surrounded by some of the top practitioners and clinicians in mental health.  I had my binder and was ready to go. 

Before the introductions, Karyn smiled at the group and led the first mindfulness.  Observe is the first core mindfulness skill, so it was the perfect place to start.  When you practice mindfulness, you do so with your eyes open, so that you are fully present and aware of your environment.  The target was to track the thoughts, as one would track the clouds moving across the sky.  In Observe, there are no labels, judgments, or words assigned to what you see or think.  The goal is to just notice the thought and let it go.  

I watched my thoughts.  With each breath, I let go of the expectations that had filled my mind with wonder in the car and still lingered as I sat.  I was sitting in my chair and began to realize that this is real- the day has finally come and I am here to embrace it and to live in it. 

I let go of the comparison of being less experienced, realizing we all have different areas of specialty and understanding.  "Comparison is the thief of joy" - Theodore Roosevelt.  And he is right.  From the moment I realized and accepted that I was "enough," the tension in my shoulders left and I could be fully present. 

Remember, all we have is this moment.  Live in it.

What I have learned from DBT: Suicide

What I have learned about suicide from DBT is hard for me to portray with succinct phrases.  

The first lesson was that suicide must be off the negotiating table with the client.  With suicide as a legitimate option, it is very hard to move forward into building a life worth living.  

In looking at it scientifically, there is no evidence that suicide will make life any easier.  Common beliefs are that "all of my problems would be over if I were dead" and "my pain would stop if I killed myself."  Both lack evidence to support these claims.  Perhaps you could look at the dialectic, asking what would make life harder if you tried to kill yourself. 

The second lesson was that knowing the suicide and risk assessment protocols are essential, with both classmates and clients.  Knowing how to respond to these issues can save lives.  The questions can be awkward and seem like an attack, but I imagine that the benefit of helping the suicidal person get the care she needs outweighs the risk of awkwardness.

The third lesson is that mind-reading with sick people is not effective: "You only know until you ask" and are open to their point of view.  It can be harder with individuals with borderline personality disorder because masking emotions can be a part of how they regulate their emotions.  At times, the facial expressions reflect what the borderline individual wants you to see, like putting on a smile when you feel horrible and sad on the inside.  The internal state and the external expression may not always match, so it is important to probe and explore these emotions and emotional reactions.

I will look forward to adding to this list as I continue in my DBT training.  Until then, think about the lessons you've learned from working with suicidal individuals.  Let me know what you think!

 

DBT Behavior Chain Analysis Checklist

Behavior analysis is a key part of dialectical behavior therapy.  In finding the patterns of behavior, we can better understand what happens, when it happens, and how we can shape the response in a more adaptive way by figuring out alternative solutions. 

Natalie Hill has a great blog post about behavior chain analysis in DBT. 

Here is a link to Practice Wisdom: http://practicewisdom.blogspot.com/2012/10/behavior-chain-analysis.html

One of the cool images is a visual chain analysis.

I will approach the behavior chain analysis from a checklist perspective, as found in Marsha Linehan's Cognitive-Behavioral Treatment of Borderline Personality Disorder (The Big Red Book; 1993; p. 256).

Step One: The therapist helps the client DEFINE THE PROBLEM BEHAVIOR.  
- The therapist helps the client formulate the problem in terms of behavior. 
- The therapist helps the client describe the problem behavior specifically, in these terms: FREQUENCY of behavior, DURATION of behavior, INTENSITY of behavior, and TOPOGRAPHY of behavior.
- The therapist weaves validation throughout.

Note: These topics can be very dysregulating for the client, potentially bringing out shame, angry, sadness, guilt, despair, hopelessness, and even suicidality.  Be sure to avoid shaming the client or instituting a punishment.  Why? Punishment is not effective in the long-term; as DBT therapists, our goal is to use reinforcement to shape behavior.  She likely feels enough guilt or shame already, so there is no need to add more.  In looking at guilt and shame, there is a key distinction: shame is feeling bad about who you are, while guilt is feeling bad about something you did.

Step Two: The therapist conducts a CHAIN ANALYSIS
- The therapist and client choose one instance of a problem to analyze.
- The therapist attends to small units of behavior (the links of the chain), with attention to defining the chain's beginning (antecedents), middle (the problem instance itself), and the end (consequences) in terms of the following: EMOTIONS, BODILY SENSATIONS, THOUGHTS and IMAGES, OVERT BEHAVIORS, and ENVIRONMENTAL FACTORS.
- The therapist conducts brief chain analyses as necessary of events in the session.
- The therapist maintains client's (and own) cooperation.
- The therapist helps the client develop methods to monitor her behavior between sessions.

Step Three: The therapist GENERATES HYPOTHESES with the client about variables influencing or controlling the behaviors in question.
- The therapist uses the results of previous analyses to guide the current one.
- The therapist is guided by DBT theory.

Now that we have an outlined list of what to do, let's explore what not to do.

Avoid avoiding behavior chain analyses.  I know they're tedious and can be triggering for the therapist and the client.  But think of the rich data that comes in knowing what happened and the potential for finding patterns that can isolate the environmental factors that influenced the target behavior.

As a therapist, avoid insisting that your hypothesis is the right hypothesis.  A) Forcing your conclusion on the client can invalidate her perspective, as this perpetuates the cycle of invalidation.  B) This is not dialectical.  The dialectical perspective would find a way to take the "truth" of each perspective and integrate them. 

As a therapist, avoid putting on the blinders in the case conceptualization and treatment.  As in horse racing, when the therapist has a limited view of what she views as the problem behavior, she runs straight down the path and misses information on either side.  Searching for the observations/data that match your hypotheses is biased and not scientific.

Dialectical View of Dealing with Expectations

A sense of being a failure, one who falls short of expectations, can be seen in so many populations, not just individuals with borderline personality disorder.  There are several perspectives about expectations.  The expectations we hear can come from the words we speak to ourselves, the direct words we hear from others, and the wordless comments that we perceive from others.  

Trying to live up to expectations can take the fun out of life.  For the client, her expectations for herself could be too grandiose to accomplish.  The expectations we hear from others may create dissonance, in the pursuit of trying to meet the expectations of others and trying to be yourself.  The expectations she perceives from others may be the result of mind-reading.  

So what do we do with these expectations?  We have many options, like weighing the facts, the What Skills of Mindfulness (observe and describe), chain analysis, and finding the kernel of truth.  

Let's start with Observe and Describe.  Observe, Describe, and Participate are the three What Skills of Mindfulness.  Observing is just noticing without attaching words, judgments, or meaning.  Describing is adding words to the observations, while still maintaining a one-minded, effective, nonjudgmental stance.  We'll talk about Participate in a later post, but generally Participate means whole-heartedly diving into an activity; I have heard others say that Participate is a similar concept to Mihaly Csikszentmihalyi's Flow. 

Let's go to weighing the facts.  In this context, it's a little on the Reasonable Mind side of Wise Mind; focusing on the facts can draw us out of Emotion Mind.  Questions could include: Who was talking?  What was said?  We're looking for the actual words, not interpretations.  What is the context of the discussion?  When did the discussion start?  We're looking for this most recent, specific discussion; try not to dig in the pain of the past.

Chain analysis is a key process in DBT, as the roots of DBT are in behavioral analysis and cognitive behavioral therapy.  Essentially, chain analyses link the triggering event to the emotions, perceptions, actions, and consequences.  More will be coming about chain analyses.  

Last, finding the kernel of truth involves dialectical thinking.  There are many ways to view an event.  In looking at the stated expectations from another person, try to see her perspective.  What does she see?  What is she saying?  Take these questions into consideration, especially when trying to find the dialectic.  Find what your Wise Mind knows to be true.  Now integrate these concepts. 

DBT Core Mindfulness Skills: States of Mind

The DBT Training starts on Thursday.  I could not be more excited.  I will be meeting people who are as fascinated by the DBT skills and illness as I am.  

So the four structural posts of DBT are Core Mindfulness Skills, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance.  In the next three days, we will have an overview of these modules and questions for consideration.
 It can be hard for individuals with borderline personality disorder to trust their perceptions, in part because the emotional reactions can be so strong and pervasive invalidation can be detrimental in trusting your perspective.  In working with individuals with borderline personality disorder, remember that there is not a single "right way" to look at a situation.  There are often dialectics that can be explored. To explore these different perspectives, turn to the source.

So let's look at the States of Mind.  No one can live exclusively in one mind, so expect to see a mixture of Minds.  

Marsha Linehan defines Reasonable Mind as "your rational, thinking, logical mind.  It is the part of you that plans and evaluates things logically.  It is the cool part" (Linehan's Little Red Book, p. 65)

She also describes being in Emotion Mind as: ". . . your emotions are in control- when they influence and control your thinking and behavior" (Linehan's Little Red Book, p. 65).

So DBT emphasizes the synthesis of opposites.  Wise Mind is the synthesis of logical thinking and passion.  It takes the most effective aspects of the Emotion Mind and Reasonable Mind and integrates them into the processing of situations, moods, emotional reactions, and time for contemplative thought.

Marsha Linehan describes Wise Mind as "that part of each person that can know and experience truth" (Linehan's Little Red Book, p. 66).  

I like to call Wise Mind truths the things we know in our bones.  Like a skeleton, these thoughts help us to have structure and mobility to act on what we know to be true.

I found this poem recently.  It is true for me and the battles that we face in the realization of dwelling in the poles of Reasonable Mind and Emotion Mind, but also in Fixed Mind.

Found myself here in this place again
caught up in this moment
seeing that slavery brings security,
but in what, for what, and by what means?
It is moving from the known-
the constants and forces of what works within me-
to the uncertainty of hope and the freedom it brings.

Fixed Mind and Choosing the Crown You Wear: 10 Days Remain!

The fixed mind is like a crown of thorns. Everybody who truly knows you can see its sharp spikes rammed into the sides of your skull and the trickles of blood flowing down into pools on your shoulders. This crown was woven piece by piece, just as each aspect of the fixed mind was and is accrued over time. The rigid rules are just as cutting and painful as the thorns.

But wait, there’s good news. Just as the crown of thorns came together one piece at a time, it can also be deconstructed one piece at a time.

Yes, there will be pain as the fixed mind is pulled apart. With the pain comes joy that rivals any I have ever known. I look forward to the day when the fixed mind reveals itself not as a crown of thorns, but as a fluid mind and a crown of laurels- with its signal of victory.

Recovery and Radical Acceptance- Day 11 of the Countdown to the DBT Training at Menninger Clinic

"My grace is sufficient.  My power is made perfect in your weakness."   The story of acceptance begins here.  We are fundamentally imperfect...and that's okay.  Perfection is an impossible goal, one that leads to frustration, recognition of inadequacy, and the pain that accompanies there realizations.  It is resolved in radical acceptance.  

Radical acceptance is essential.  Marsha Linehan describes radical acceptance as a continual process, one that rises with us in the morning in the choices and decisions we make.  Radical acceptance is not easy; to me, radical acceptance is the hardest skill to use in a tough, emotionally-charged situation.  People make decisions we don't like.  People treat us unfairly.  Even our decisions can backfire and block our paths toward a life worth living.  Our own actions may reflect our Rational Mind and Emotion Mind states.  Wise Mind helps us to find acceptance of self and others.

Recovery comes when application and action meet Wise Mind, radical acceptance, and chain-breaking freedom.  Acceptance is critical in recovery, whether the condition is open heart surgery or bipolar disorder.  Life can be classified as before, overwhelming struggles, moments of clarity, hope for change, and walking forward.  Like the scar, there are physical reminders of what happened.  

Acceptance fits in the process of knowing that there will be lifestyle changes and this process cannot be rushed.  You sit with acceptance.  You release the grip of what is holding you back from living a life worth living.  But life truly begins when you let go, opening your hands to receive grace and mercy.  Acceptance and owning this acceptance aren't especially different, except in degree and effect size.  

Owning acceptance is a path to freedom, moving the focus away from the pain of the past and into the uncertainty of the present and near future.