A Dialectical View of Change

Knowing is not enough;

we must apply. 

Willing is not enough;

we must do.

(Goethe)  

With knowledge comes an understanding that there is a need for action, that we are not passive in this world. We are active agents in the course of our lives.  As humans we interact with others, therefore impacting them as well.  We influence their lives in ways that we cannot understand or appreciate in the moment.  One breathed word travels through waves to crash on the ears of another, bringing with it a message.

We cannot turn back to our previous selves because of the changing power of a message. Knowing more has set the stage for change.  With this new information comes a new perspective, an opportunity to see the dialectic. 

Let's explore dialectics.  Dialectics are the “synthesis of opposites” (Linehan, 1993a), or the merging of two opposing perspectives into a third new perspective that has elements of both perspectives.  The concept is similar to blending paints.  One splash of blue paint combines with a splash of yellow paint creates green paint.  We can see the value in all colors, just as we can see value in different perspectives.   

In dialectical thinking, the answer may be found in shades of gray, as opposed to the black-and-white world of absolutes and all-or-nothing views.  Maintaining a dialectical stance is essential because it allows us to see truth from many perspectives, not just our view, the adolescent’s view, or her family’s view.  

Incorporating multiple perspectives gives an increased knowledge base and may help in finding Wise Mind.  Wise Mind seeks the balance in emotions and thoughts to yield balanced behavior. 

"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 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.