DBT Assumptions about Patients

In Marsha Linehan's Cognitive-Behavioral Treatment of Borderline Personality Disorder (The Big Red Book of DBT), there are eight assumptions about patients and therapy; the DBT assumptions about therapy will be discussed in an upcoming post.  This section can be found on pages 106 to 108 of the Big Red Book of DBT.  

Shari Manning and Kelly Koerner have published that there are seven assumptions about clients and many DBT assumptions about therapy, so right now we'll focus on the DBT assumptions about the patient or client.  Before we look at the assumptions, let's look at the terms.

To clarify, assumptions are not facts, so these assumptions might not fit with every client 100% of the time.  They do, though, set the context for the for treatment planning (Linehan, 1993, p. 106).  

Also, the terms in the Big Red Book (1993) and the Skills Training Manual (the Little Red Book; 1993) differ in how the text refers to the individual in treatment.  The Big Red Book uses the term patient, while the Little Red Book uses the term client.  To address this, Marsha Linehan's response in the Skills Training Manual is that "a case can be made for using either term" (1993, p. 7).  In this blog, the terms will be left as they were written by the author.  While this can be confusing to have inconsistencies, I would like for the author's direct terms to be left intact. 

First, patients are doing the best they can.  This is why the terms resistant and self-sabotaging are not used to describe the patient.  Metaphorically, individuals with borderline personality disorder can be described as having very thin emotional skin or having third degree burns, so the slightest touch, be it criticism or general comment, can be very painful.  This heightened sensitivity can lead to pain and suffering, so they look for something to deal with these emotions, thoughts, and physiological responses.  

"In my experience, borderline patients are usually working desperately hard at changing themselves.  Often, however, there is little visible success, nor are the patient's efforts at behavioral control particularly obvious much of the time.  Because their behavior is frequently exasperating, inexplicable, and unmanageable, it is tempting to decide that they are not trying. . . The tendency of many therapists to tell these patients to try harder, or imply that they indeed are not trying hard enough, can be one of the patient's most invalidating experiences in psychotherapy" (p. 106).  

Second, patients want to improve. "Assuming that patients want to improve, of course, does preclude analysis of all factors interfering with motivation to improve. . . The assumption by therapists that failures to improve sufficiently or quickly are based on failure of intent, however, is at best faulty logic and at worst one more factor that interferes with motivation (Linehan, 1993, p. 106).  

Kelly Koerner adds that the first two assumptions, that patients are doing the best they can and they want to improve, "lead us back to examine factors that interfere with needed behaviors" (Koerner, 2012, p.23). 

Third, patients need to do better, try harder, and/or be more motivated to change.  "The task of the therapist, therefore, is to analyze factors that inhibit or interfere with a patient's efforts and motivation to improve, and then to use problem solving strategies to help the patient increase her efforts and purify (so to speak) her motivation" (Linehan, 1993, p. 107).

How do we do this?  We can help them stay motivated through reinforcement and validation; coaching the patient to self-validate and find skillful ways to reinforce himself/herself is a way for the patient to build mastery and work toward the life worth living goals.

Fourth, patients may not have caused all of their own problems, but they have to solve them anyway.  "A borderline patient has to change her own behavioral response and alter her environment for her life to change. . . Improvement will not result from the patient's simply coming to a therapist and gaining insight, taking a medication, receiving constant nurturing, finding the perfect relationship, or resigning herself to the grace of God.  Most importantly, the therapist cannot save the patient. . . Surely if we could save patients, we would save them" (p. 107).  

Fifth, patients' lives are unbearable as they are currently being lived.  "Given this fact, the only solution is to change their lives" (Linehan, 1993, p. 107).  What do we do with the knowledge that his or her life is unbearable?  We look at the dialectic, acknowledge that it is unbearable, and work together about how to make it bearable (Manning & TIC, 2013).

Sixth, patients must learn new behaviors in all relevant contexts.  "Times of stress are the times to learn new ways of coping" (p. 107).  

Seventh, patients cannot fail in therapy.  "When patients drop out of therapy, fail to progress, or actually get worse while in DBT, the therapy, the therapist, or both have failed" (p. 108).  Prior to Stage 1 treatment, the client makes a commitment to therapy for a specific number of months.  

Dropping out is the only way for a client to leave DBT.  If the client misses four individual sessions or skills group sessions in a row, the Four Miss Rule comes into effect.  So as therapists, we need to motivate and encourage the clients to come back to group.  Participating in group and individual therapy is often mentally and emotionally taxing.  Look for creative ways to keep the clients and therapists motivated.  

Marsha Linehan's eighth DBT assumption about patients and therapy is that therapists treating borderline patients need support.  We will look into this in an upcoming post.

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. 

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.

The Dialectic of Life, Loss, and Acceptance

I wrote this poem this morning.  Loss is a tricky concept because even when the person departs, our shared memories and truths that we know in our bones live on and walk with us.  When radical acceptance comes, the dialectic is more salient and, at times, comforting in the darkest of times. 

For some, the time before dawn is the darkest hour...logically yes, but the dawn is troubling, too, because it can be a recognition of beginning another day without them.  

The Zen response to this may be that "all is as it should be," yet that is not say that everything is perfect in the moment, "but rather to the dependent unfolding view of reality (given the pre-existing conditions, how could things be different?) and the recognition of valuation as human-generated rather than universally intrinsic (perfect for whom, based upon which criteria?)."  This concept is explored in Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition (Robins, Schmidt, & Linehan, 2004, p. 38).

 

Let's look at Marsha Linehan's point of view on acceptance.  "The experience of acceptance. . .is that of 'getting it,' opening oneself to the context, striving to wait for understanding rather than leap in precipitously, acknowledging distress as an outcome. . .rather than as a problem to be solved. . .Thus, acceptance as a state or experience may reflect the wisdom of wanting to gather rather than disperse, catching the context while enduring the moment"
(Robins, Schmidt, & Linehan, 2004, p. 38). 

The dialectic of loss is difficult for me, and I know that I'm not alone in this.  Although we may not see them, their influence lasts a lifetime.  

In us, the stories and legacy continue and cannot die.

I rose before dawn to talk to you.

It is in darkness that I see you with clarity,

And hear your voice in my head,

And feel your support in helping me move forward.

Your hands reach for mine.

My heart reaches for your sure hands

And seeks that knowing smile.

I talk to you and imagine

That you just heard my voicemail,

Just like always.

My mind can only hope for so long,

But my heart refuses to give in to the reality

That you’re not with me.

I miss you, but this is not a time for goodbyes,

Only see you soon.

And it is a time to look forward

To our next time,

And it will be so.

For a more in-depth approach to acceptance and mindfulness, check out 
Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition

 

Living Behind the Wall: Longing for Connection and Dealing with the Fear of Uncertainty

The following journal is a snapshot of working through the barriers that hinder our connections with others.  We all have walls.  They are intended to protect us from difficult situations, people, and life events. 

When I am alone, give me the strength and courage to stand, to see, to reach out. Randy Pausch says brick walls are there to show us how badly we really want something- whether it's a relationship, an academic goal, or a childhood dream. But I'm talking about a different kind of brick wall. It's made of glass blocks that let in the light but distort the outside world. It was built piece by piece, each with promises that I would be safe and protected. What I didn't realize that in walling myself in, I shut others out. The walls promised safety in living behind them. 

Piece by piece, I'm starting to consider the pros and cons about staying within the realm of what is expected and predictable. So badly I want to connect with the people I see when I climb the ladder to the top of the wall. They laugh. They smile. They walk forward into a world where the only expected outcome is uncertainty, while the promise is to find peace, community, hope, and love from the One who gives and takes away.

I don't have to understand everything about the outside world to make a decision that living behind the wall is staying within the trap- one that doesn't allow me the chances to live and to be known. I don't know how or when the walls will not be quite so tall, but it gives me hope that true life is waiting and can't wait to see me.

Day Five: The Synthesis of Opposites

 The basic model of dialectical thinking involves the merging of two perspectives, the synthesis of opposites.

In dialectical thinking, there is value in each perspective.  One way to frame dialectics is to connect phrases with "both. . .and. . ."

Example:

"I have made a lot of progress, and there are still things I would like to change."

"I feel vulnerable when I talk about my depression with others, and I feel support when I meet my friends at our favorite coffee shop."

"You have your perspective and I have mine.  We can both be correct."

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.  The existence of black-and-white thinking is often seen in individuals with borderline personality disorder and eating disorders.

In this example, there are some cheerleading statements woven into the dialectical framework of acceptance of current self and the need for change.

Example:

"I'm working really hard at accepting who I am now- the one who wants to get better.  I still have not so great days.  I am proud that I am having more good days.  My goal is to be skillful on tough days."

Another way to think about dialectics is to think about seeing the situation from the other person's point of view.  What does she see?  What do I see?  How has he responded when faced with similar circumstances?  What did I do last time I was in a situation like this?