Dialectical Behavior Therapy Skills Part 4: Distress Tolerance

Dialectical Behavior Therapy Skills Part 1: Mindfulness

DBT, which has empirical support as a treatment for borderline personality disorder, bulimia nervosa and binge eating disorder requires that clients partake in individual therapy as well as group therapy, in which skills are taught and practised with other clients. The skills training is comprised of four modules: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. In today’s article, I will focus on mindfulness, which is a pivotal facet of all phases of DBT.

Defining mindfulness is fairly difficult, but at its core, it involves learning to control your attention and keep your focus entirely on the present moment. Every now and then, everybody finds themselves ruminating or worrying in response to stress. We even do these things in the absence of stress at times. Our focus shifts from what is in front of us to what happened earlier or what might happen when we leave the current situation. Mindfulness skills in DBT are discussed as a way to take a step back when upset so as to allow intense emotional experiences to run their course naturally, enabling clients to make better behavioural decisions and remain calmer while responding only to what is directly in front of them.

I know this seems fairly abstract but bear with me because these skills can be applied in anyone’s life, regardless of whether or not they meet the criteria for a disorder for which mindfulness is an empirically supported treatment component. Clients are taught mindfulness through a series of skills and exercises. Marsha Linehan, in her Skills Training Manual for Treating Borderline Personality Disorder, explains the role of mindfulness in treatment as a way to find a balance between reason and emotion in a state of mind she refers to as “wise mind.” In wise mind, she explains, individuals are not controlled by their emotions or reason, but instead, they acknowledge the presence of both and synthesize them into a single, composed state of mind. In a wise mind, an individual does not try to reason away her emotions (e.g., “you shouldn’t feel sad – other people aren’t sad about this”) or use emotions to blunt her reason (e.g., “I don’t care what the consequences are right now, I’m sad and that’s all that matters). Balance requires that both sides be considered, allowing for a better resolution (e.g., “I feel sad right now, but I need to find a way to feel better that won’t cause me bigger problems”). Linehan teaches clients that they can attain the balance of wise mind through the “what” skills and “how” skills.

The “what” skills include three distinct approaches: observing, describing, and participating. Observing, although seemingly simplistic, is extremely difficult, as it involves simply observing your environment without using words to describe what you perceive. The rationale for this is to teach clients to slow down their automatic thoughts and reduce their vulnerability to subsequent negative emotions. Describing is the reaction to observing and involves applying words to your perceptions. Linehan is careful to point out, however, that these words should describe only facts, not interpretations. In other words, an effective description of the next lecture I will give in my Abnormal Psychology class would be: “the teacher is describing the symptoms and treatments of various personality disorders. He is detailing the DSM criteria and explains what he refers to as the strengths and weaknesses of each diagnosis.” If that description had read: “This lecture is shockingly boring and the teacher lacks the basic social skills required to speak to a room full of students,” this would be less consistent with the goals of the describing skill, which aims to teach clients to see thoughts as thoughts rather than facts and to separate interpretations from actualities. The participation skill teaches clients to fully engage in their current activity rather than allowing their mind to wander elsewhere. Whereas observing and describing can, at least at first, seem somewhat bizarre to clients, this skills is one with which most readily identify, as we can all think of times during which we have been doing something, but our mind has been elsewhere. Have you ever talked on your cell phone while driving and suddenly realized that you do not remember the last ten minutes of your drive? Have you ever been in a conversation with somebody and realized that you had spent the previous minute replaying another conversation in your head and now have no idea what the person is talking about? Has a movie ever reminded you of something, taken your mind back to a memory, and left you clueless as to what happened in the last scene? In these examples and countless others, participation is lacking. The individual is so focused on a scenario unfolding his head that he simply is not attending to the stimuli in front of him. What’s frustrating about this is that, as we ignore our environment and focus on the scenario in our mind, we often become increasingly upset. Given that nothing in our environment is causing us to become upset and we are responding only to our own thoughts, this is obviously an unfortunate and unhealthy situation. As such, the participation skill teaches clients to focus their attention only on what is in front of them. When other thoughts enter their heads, the clients are taught not to judge themselves for losing focus, but rather to simply acknowledge that their mind had wandered and to bring their thoughts back to the current environment.

The “how” skills, which are methods by which clients can accomplish the goals of the “what” skills, consist of three components: the nonjudgmental skill, focusing on one thing in the moment, and being effective. The nonjudgmental skill teaches us to dampen our natural tendency to apply evaluative labels to our experiences. The rationale for this is that, quite often, our labels are based on distorted automatic thoughts, are vague, and leave us without any guidance as to how to resolve the situation. In this sense, the skill is quite similar to cognitive restructuring, which we described in detail in a prior article. Instead of thinking “I’m stupid,” a student is trained to think “I received a failing grade on this test, and I am frustrated by that, so I need to meet with my teacher and change my approach in order to reach the final grade that I need.” In teaching clients to focus on one thing in the moment, the second “how” skill, DBT again emphasizes the importance of breaking ruminative cycles that are certain to increase the longevity and severity of our negative emotions. In the third “how” skill, being effective, clients are taught to shift their focus away from how they wish things were, instead choosing to engage in behaviours that are the most likely to help them accomplish their goals. The rationale behind this skill, much like several of the others, is to help the client prioritize proactive solutions to problems and to diminish the tendency to lose control of their thoughts and spiral into rumination.

Okay, having explained the mindfulness skills as described in the Skills Training Manual for Treating Borderline Personality Disorder, I suspect that this topic still remains a bit more theoretical than most readers anticipated given the topics we have covered thus far on PBB. That being said, let’s try and consider what I described above in the context of every day life. All of us can relate to times when we have been upset and become lost in our own thoughts. Invariably, even when such thought spirals feel productive at the time, we eventually realize that we were exerting very little control over what we were thinking about at the moment. Mindfulness teaches how to attain that control. The best way for anyone to fully understand the meaning of mindfulness is through practice. As such, I want to conclude this article by explaining a few quick mindfulness exercises. Ideally, I would love for this to result in at least two types of responses. First, responses from readers regarding their varying levels of success with the exercises – what went well, what did not. Second, responses from readers regarding other mindfulness exercises worth trying. Not everyone responds to each exercise the same way. The key is finding something that works for you that you can apply in just about any situation when you start feeling upset. Learning to do so will help you prevent overly powerful emotional spirals before they reach their peak.

Focus on breath

In this exercise, often the first one taught in a group, your aim is to focus only on your breath. Feel the air as it passes down to your lungs. Notice everything about the physical sensations associated with the passage of air with each breath. Each time you complete a cycle of inhale/exhale, count it. Start with one, count up to ten, and then reverse back down to one. Here’s the trick though, any time you have a thought other than a description of your breath and the number of breaths you have taken, start over again. That includes thoughts like “this is hard,” “I’m focusing on my breath right now,” and “mindfulness is crazy.” Remember, we’re being nonjudgmental here, so do not be critical of yourself. Simply notice that thought crept in and move your attention back to your breath. It is extremely difficult if not impossible to accomplish a one to ten and back to one progression of counting, so the goal isn’t really to finish, but rather to give you a neutral stimulus to focus on rather than your own emotionally charged thoughts. After a few minutes of doing this (maybe even less), you’ll likely feel less emotional and be in a better position to address whatever was making you upset. There is nothing magical about your breath, but focusing on your breath instead of ruminating is a sure fire way to attain wise mind and thus put yourself in a position to make healthy behavioural choices.

Focus amidst distractions

We often need to use mindfulness skills when the world around us is chaotic. As such, this skill teaches you to choose a thought amidst stimuli competing for your attention. Choose a song to play. Before you start the song, decide on where you will focus your attention, but choose something other than the song. In other words, I might choose to focus on an image in my head of the beach on Sanibel or on a box of tissues on the table in front of me. As the song plays, maintain your focus on the thought you chose. Observe and describe it, using only facts and withholding judgment. Each time your thoughts wander, pull them back to your original thought rather than allowing the song to dictate your focus.

Mindfully attend to a pet

If you have a pet, they will love this one. Spend the next five minutes petting your animal. Notice what its fur feels like, the pace at which it is breathing, the colour of its eyes, or anything else about the pet that you notice. Do not allow your mind to wander back to memories with your pet. Keep your focus entirely on the sensations present in that moment.

In all likelihood, as you attempt these skills, you’ll find that it is exceptionally difficult to maintain complete control over your attention. You’ll notice things that you previously did not attend to, like the clicking of a clock, the sound of a fan, or the temperature of the surface on which your hand is resting. Now imagine how hard it would be to do this if you were upset. Taking it one step further, imagine how difficult it is for somebody who has difficulties regulating their emotions in general. These skills require patience and practice, so do not expect to notice changes overnight, but trust that mindfulness can offer impressive reductions in stress and an increased tendency to fully enjoy your surroundings.

I hope you will enjoy this little series of posts going through the basics of DBT as it really can help people with BPD, provided you are willing to implement its teachings.

This post is by Mike Anestis who is a doctoral candidate in the clinical psychology department at Florida State University

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