Introduction
As an Organisational Psychologist, I spend most of my time thinking about how people impact organisations and vice versa. However, my reading of Freud and Adler has made the world of Clinical Psychology increasingly interesting to me. How individuals have the power to remake themselves with the help of an effective therapist. To satiate my interest in the world of Clinical Psychology I have been undertaking various training in the area. I started with a course on Dialectical Behaviour Therapy run by The Psych Collective. This blog is a summary of the key takeaways from the course. Whilst this therapy is focused on support individuals with Borderline Personality many of the skills are applicable across a range of mental health difficulties.
Who would I recommend this training to? For me, this short course was a perfect introduction and gave me the insight I desired at an appropriate level. Anyone interested in expanding their toolkit of therapeutic techniques would benefit. For people interested in delivering Dialectical Behaviour Therapy (DBT) group workshops, this course will serve as a strong foundation. However, a deeper knowledge from reading the DBT Guidebook would be necessary to translate this foundation into the recommended 16 weekly group sessions.
Overview of Dialectical Behaviour Therapy:
Created by Marsha M. Linehan in the 1970’s Dialectical Behaviour Therapy got its name from the philosophical discussions people have with differing opinions (A dialectic). Or as Wikipedia puts it “Two or more people holding different points of view about a subject but wishing to establish the truth through reasoned argumentation.” Dilemmas in life can be hard to reconcile, for example, how should we behave when something bad happens? Do we become completely emotional when things go wrong or coldly and practically work through our problems? The emotional route may work when you are supporting someone who is grieving but cold rationality may not be helpful in such circumstances. If for example, you are planning a funeral, being able to put your emotions aside to get the job done may be helpful. These ‘dialectics’ are wide varying and even a healthy adult can find it hard to figure out how to respond to various circumstances. However, those with Borderline Personality Disorder can find these dilemmas particularly difficult to navigate. Many grew up being told not to show any emotion or not having their emotions validated. Because of this, they find it very hard to walk the line in the middle where they use their emotional mind and logical mind in a balanced way. What DBT calls the “Wise Mind”. For more information on the specific characteristics of BPS see the Australian BPD Foundation’s website.
DBT was designed to give individuals an answer to the dialectic of “how do I both accept what is, as well as change for the better.” It does this by teaching people four key skills which when implemented help with navigating daily life, finding a balance of healthy emotionality and practical action.
Below is an overview of the four core skills that participants are expected to learn and the various sub-skills within them. You will notice that there are many acronyms within this form of therapy. This is because it was designed to be more easily absorbed by learners in a group setting.
You will notice I have put the information behind dropdown toggles. This will help with learning the acronyms as you can use them to test yourself on the content of a section before revealing the answer (Once you have absorbed the content first of course). Active recall is a proven effective way to improve learning, for more evidence-based revision tips I highly recommend Ali Abdaals youtube videos on the topic.
Mindfulness
Mindfulness isn’t about “focusing on your breathing”, it’s about noticing. Whatever you decide to focus on (breathing, a candle, a prayer etc.) your mind will wander. Every time you notice and bring your attention back to whatever you are focusing on you do one ‘rep’ of mindfulness. This is a vital skill because when life is coming thick and fast being able to notice is the first step to acceptance before one can hope to change anything else. If you can’t stop and notice what is going on you can’t hope to begin to change automatic responses to a situation.
Mindfulness is the foundation for the other three DBT skills. For example, it aids in the practice of Distress Tolerance by helping a person notice high levels of distress within themselves so they can then stop and put a new behaviour into practice. Or mindfulness can help someone notice when their interactions with someone are upsetting them, then intervene with a more Interpersonal Effectiveness.
How can I practice mindfulness?
Step 1: Focus on one thing at a time. Can you simply notice when your mind wanders?
Step 2: Engage non-judgementally. Can you label what your mind wandered to?
Step 3: Effectively participate. Can you participate mindfully?
Distress Tolerance
By understanding and managing the Distress Cycle a person can stop early and prevent undesired behaviours from occurring. Click here for resources fully explaining the Distress Cycle by the Psych Collective.
Distress Tolerance skills Include:
STOP
Stop
Take a step back
Observe Mindfully
Participate skilfully
TIPP
Tip your temperature: by turning on the Mammalian Dive Reflex
Intense physical activity: until huffing and puffing: this increases CO2 Production
Paced Breathing: Breathe 4 times per minute. 1 breath in, then hold for 10 seconds (does not need to be a super deep breath as this increases O2)
Progressive muscle relaxation: you can find a video by the training team here
Self-Soothe
Think of each sense and how you might self-soothe it.
Smell: A relaxing smell of vanilla
Touch: A blanket, throwing something
See: A nice sunset, browse Pinterest
Taste: A comforting food you like
Hear: A favourite song
IMPROVE
Imagery: Find your happy place
Meaning: See the silver lining
Prayer: Ask God for help
Relaxation: Slow breathing, Progressive Muscle Relaxation
One-Mindful: Mindfully act. Paying attention to one thing at a time.
Vacation: Do something you might do on a vacation. Get breakfast out. Read a good book
Encouragement: Be your own cheerleader, encourage yourself however you can
Radical Acceptance
Pain + Non-Acceptance = Suffering
Acceptance is a courageous move
“God grant me the serenity to accept the things I cannot change, Courage to change the things I can, and the Wisdom to know the difference.”
If you get a cut, in order to heal you have to stop picking at it.
Radical Responsibility
Take responsibility for your life, your thoughts, and your actions. This step can often only be enacted further down the road after a person has gone through the other steps and is in a better place.
Emotional Regulation
Emotional Regulation is all about employing skills to look after yourself as emotions arise. Remembering it is not about getting rid of emotions but having a ‘wise mind’ and working with them correctly.
In the training course, the presenter drew the below diagram to show how emotions arise from needs being/not being met. Starting with Needs on the left, moving through a Drive, Motivation, and subsequent outcomes which generates emotions based on our appraisal of obtaining or not obtaining our need. When the same needs are met/not met again and again an overall mood state emerges. It was a fantastic way to see the complete story of emotion from start to finish.
Emotions can be hard to deal with for a variety of reasons. It could be because of our temperament, being naturally more sensitive, a lack of skills to understand and regulate our emotions, or being consistently in a challenging environment.
Below are some of the DBT skills which can be put into action to help regulate our emotions.
Understand Emotions LEAN:
Location of the emotion: Physical response in Body
Expression: What social expression does it have, how does it communicate to the world its existence to the world
Action Motivation: What behaviour is this emotion trying to get me to do? Run? Punch?
Name: What is this emotion called? Try using an emotion wheel to help with labelling
RESPOND
Regulate: Be willingly skilful
Express: “I feel”
Snap Judgement: Identify the thought that triggered the emotion
Participate skilfully: Use skills to reduce the emotions intensity
Opposite Action: Do the opposite of the urge (if the urge is regrettable)
Nurture and Validate: Self-Soothe and acknowledge how it affected you
Discharge the Emotion: Let it out by talking, exercising, writing or crying
PLEASE
You have to look after yourself and make sure your needs are being met. These are the core needs of your body. Just as children need them to stop being grumpy so do adults.
Physical health: Doctors appointments, check-ups dentist
Light: Are you getting enough light at the right times?
Eating: What are you eating? You need magnesium, Zync, and B6 and 12 in order to create Seratonin and Melatonin
Avoid Substances: Substances affect everything including sleep. More than 2 standard drinks and your sleep will be impacted.
Sleep: Get enough sleep. Keep good sleep hygiene.
Exercise: Getting enough exercise is key.
Opposite Action
Doing the opposite action can help you stop a behaviour in its tracks.
If you want to be angry instead practice mindfulness.
If you want to be sad and curl up in a ball. Get up and run.
Interpersonal Effectiveness
Interpersonal effectiveness is like a see-saw, with Self Respect as the pivot at the bottom and Give and Take behaviours at the top.
Before a person can hope to give and take effectively they will need to have some self-respect.
Self-Respect: FAST
Fair: Keep things fair between you and others
Apologies: Don’t over apologise
Stick to Values: Consider what you value and set boundaries around them.
Truth and Accountability: Take responsibility for yourself and act with integrity
GIVE:
Gentle: Engage respectfully without attacks, threats or sarcasm
Interested: Show an interest in what they have to say or what is important to them
Validate: Show that you understand what they are feeling. Look at things from their point of view.
Easy Manner: Be agreeable and kind.
Fences: We can think of ourselves as having a fence, some people have run down fences that anyone walks through and others have tall impenetrable fences. We want to have a sturdy fence with a gate. We control the gate and only let through what we deem suitable.
Take: DEARMAN
What:
Describe: The situation factually
Express: I feel _________
Assert: I want/need/would like
Reinforce: What is in it for them
How:
Mindful: Stay on topic
Appear: Confident
Negotiate: Be willing to GIVE and get.
The Agreeableness Flip (This is my own addition):
People find it difficult to be assertive because they feel it is rude. For example, if someone is vulnerably sharing a story with you but it is also upsetting you how do you stop them from sharing without being rude? One way is by flipping what you think being agreeable means. You could say it is actually rude to listen to the person and not nice at all because by listening they aren’t getting the appropriate help they need. It would be much more agreeable to stop them and help them get a professional to talk to.
Monitoring for Change
Diary Cards: We use Diary Cards daily to track behaviours and emotions over time. In the beginning, the urge to engage in undesired behaviours will be strong, and people will slip up. Next, you will notice the desire being strong, but individuals will use the skills so that the behaviour occurs less frequently. Finally, when tracking within a diary card you will see the urge drop off as well. When using diary cards, accountability is essential.
Chain analysis: This activity is for when someone engages in unwanted behaviour. Chain analysis identifies vulnerabilities in the chain of events that led to the behaviour. Clients can then can put things in place to prevent this from happening in the future.
Missing Link: Missing Link is used to identify why someone might miss an opportunity to be skilful: The reasons could be:
1. They weren’t aware. In this case more mindfulness and STOP skill is needed.
2. They didn’t want to engage in the behaviour. In this case, you can discuss what the client could put in place to help them change this behaviour when the moment comes.
Where do these techniques fit in with Cognitive Behavioural Therapy?
For many Australian Psychologists who are most experienced with Cognitive Behavioural Therapy you may be wondering, how can incorporate these methods and skills within my existing framework for individual therapy with my clients?
If the situation is the problem employ Structured Problem Solving Skills
If the thoughts are the problem Check the Facts and Challenge the thoughts (CBT cognitive distortions)
If the feelings are the ‘problem’ Use LEAN and RESPOND skills
If there’s an urge to engage in regrettable behaviour or the wrong behaviour employ Opposite Action.
Additional Resources:
If any of the topics above might prove useful for your clients I highly recommend diving deeper with one of the Psych Collectives Training Courses. They also have a whole suite of free resources for mental health professionals. Their Distress Survival Guide is particularly useful as a handout.
The DBT Tools website below summarises many of the tools available in DBT in a similar fashion to what I have constructed above. It is a great reference tool as you learn more about this topic.
Further Reading:
If you are ready to start creating your own group therapy sessions for BPD based on the DBT methodology, the next step is to grab a copy of the manual and supporting worksheets by Marsha Linehan.
