Meeting Karyn Hall and a Mindfulness Activity: Observe and Describe Your Thoughts

Karyn Hall is one of the most talented psychologists I have ever met.  Her practice, the DBT Center- Houston, provides clients with options for comprehensive treatment teams with psychiatrists and DBT therapists.  Her books about validation and mindfulness activities are available on Amazon; click here to see "The Power of Validation" by Karyn Hall and Melissa Cook and click here for "Mindfulness Exercises" edited by Karyn Hall.

Karyn will call a spade a spade in an irreverent, non-judgmental way.  In the training exercises, she was dramatic in the role plays and captured the emotions presented in the dialogue.  With her, there are always teachable moments for reflection and new concepts to incorporate into schema about the therapeutic processes in DBT.  Her expertise in validation was evident, and, by the end of the activity, she had reached all of the levels of validation. 

 

She weaved mindfulness skills into the conversation, while teaching the DBT skills and explaining them in a clear, behaviorally-specific way. 


During the first training session at the Menninger Clinic, Karyn led one of my favorite mindfulness activities: Observe and Describe Your Thoughts.  DBT has a specific language that you adopt as you learn the skills and treatment protocols.  The What and How skills of Core Mindfulness are a good place to start. 

 

Mindfulness is about paying specific attention in a particular way on purpose. 

 

In Observe, you are directed just to notice your thoughts without attaching words, judgments, or preferences, as though you're watching waves come and go at the beach.  A wave is a wave. 

 

In Describe, you attach words to your thoughts. 


This is a place for the How Skills of Core Mindfulness. 


Shari Manning's explanation started in the heart of English grammar. 

• The What Skills (Observe, Describe, and Participate) are the verbs. 
• The How Skills (Non-judgmentally, One-Mindfully, and Effectively) are the adverbs.   

Adverbs are connected to verbs, in that adverbs provide context or thorough descriptions to show time, manner, place or degree.  
 

 The wonderful aspect about the Core Mindfulness skills is that you learn something new about yourself, your client, and your world outside your office. 

Factors to Consider in Finding a DBT Treatment Center

A parent may ask, “In doing research online, I’ve seen and heard about cognitive behavioral therapy. What is the difference?”  Dialectical behavior therapy began as a cognitive behavioral therapy that soon added dialectics and validation.  CBT principles are used to target suicidal and other problem behaviors.  However, the unique foci of DBT are on dialectics, validation, and the dialectic of acceptance-oriented and change-oriented skills and strategies (Manning & TIC, 2013). 

In looking at selecting a treatment center for the individual, be sure to ask the center if their clinicians are members of a DBT consultation team who have attended the Core Clinical Training© in DBT, use diary cards in sessions to monitor behavioral changes over time, and follow the processes in Linehan’s treatment manuals (1993a; 1993b).  

There are inpatient and outpatient options in Houston, Texas.  The Menninger Clinic uses a combination of clinical approaches, including mentalization-based treatment (MBT) and DBT.  The Dialectical Behavior Therapy Center offers outpatient treatment with an intensive outpatient program (IOP) with skills groups and individual therapy with a DBT therapist, skills groups that meet each week, individual therapy, and medication management with board certified psychiatrists.  There are treatment sites in other locations across the U.S. and Canada.  There are often waiting lists to join a DBT program. 

In DBT, individual therapists focus on targeting specific behaviors that the client has agreed to work on changing, as arranged in the following hierarchy: life-threatening behaviors, therapy-interfering behaviors, and quality of life behaviors.  “You only get what you target. . . and what changes is what you work on” (Manning & TIC, 2013).  In adolescents with borderline personality disorder, common behavioral targets include: cutting, intentional overdosing, suicidal ideation, driving over the speed limit, purging, and restricting.  Consider the individual's concerns and behaviors when looking for the treatment plan that is a good fit for her.

The relationship between the individual and her therapist is essential in pushing for change while simultaneously accepting the adolescent in the moment and helping her radically accept herself; acceptance is not approval or agreement with the behavior or thought.  “Those who practice DBT are compassionate and dedicated to understanding the experience of BPD but at the same time believe, unwaveringly, that the most compassionate thing we can do is help people with BPD to change” (Manning, 2011). 

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.

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.