DBT's Motivational Approach

When we think about ambivalence and motivation, the first approach most of us think of is probably motivational interviewing. However, DBT also includes interventions designed to enhance motivation, and while there are some clear similarities to MI, there are also some differences.

In particular, DBT addresses motivation by targeting a related but distinct concept: commitment. In fact making a commitment or agreement to do something is a strong predictor of actual future behavior. Therefore, DBT sees eliciting and maintaining commitment as a key therapeutic task. Therapists elicit commitment from clients to participate in therapy, to target particular problems, and implement particular solutions. And it is often not enough to make a commitment once. With longer term choices (e.g., staying in therapy, making ongoing changes), commitments may need to be made and remade many times.

According to Linehan, "the therapist is often functioning like a good salfesperson. The product being sold is DBT, new behavior, a renewed effort to change, or sometimes life itself" (p. 286). As a result of this perspective, DBT borrows from social psychology's insights on compliance - the same insights used in sales. Most notably in this category is the "foot-in-the-door/door-in-the-face" technique. These terms refer to door-to-door sales or charity drives. The foot-in-the-door approach begins by making an initial easy request, followed by a more difficult request, based on findings that those who agree to one thing are more likely to agree to subsequent things. The door-in-the-face approach begins by asking for something much larger than what the asker really hopes to get, and then "settling for" something lesser (what the asker was hoping for to begin with). The idea is that people who say no to one thing feel more social obligation to say yes to the next request if it is reasonable.

While these techniques may seem "manipulative," they are based on a cultural reality, which is that most of us expect to do some negotiating in our social interactions. When we try to go directly for the commitment we are hoping for, the end result is often NOT an agreement from the client (it might be a flat-out refusal, agreement without follow-through, or negotiation to a lesser commitment). Linehan suggests that the "door" techniques can be used instead, to more effectively elicit agreement.

These techniques can be used separately, or combined. When combining them, either can be used first. In other words, a therapist might start with a very difficult request, followed by a fairly easy request, and finally progress to a moderately challenging request. Alternatively, the therapist might begin with an easy request, move to a very difficult request, and settle somewhere in the middle. An example of a combined approach would be first asking a client not to engage in a problem behavior at all in the coming week, then eliciting a commitment instead to not use the behavior on at least one day that week, and finally asking the client to use the behavior on no more than 4 of the 7 days.

A variation of the foot-in-the-door approach is to connect new commitments with prior commitments. This approach is particularly useful when the client seems to be losing commitment, or when current behavior is inconsistent with past commitments. Of course, in doing this, it's important to assess whether the client still feels committted to the prior agreement; clarifying, renegotiating, and renewing commitment may be needed.

Social psychology has also demonstrated that people are more likely to make commitments when they believe they have freedom of choice, and/or when they believe there are no other options consistent with their goals. These two conditions can also be combined, so that the therapist is simultaneously highlighting the client's freedom to choose, and the lack of viable alternatives. How is that possible? There may not be an alternative that would allow the client to reach the goals s/he has, but s/he is free to choose different goals if unwilling to do what is needed. However, the client's choice of goals has natural consequences, which the therapist also highlights.

Of course, DBT also uses other strategies to elicit commitment. Like MI, DBT therapists help clients evaluate the pros and cons of a particular commitment or change, particularly highlighting the advantages of the commitment, while developing counterarguments for any identified reservations about it. Also like MI, DBT therapists may "play the devil's advocate," arguing against the commitment in order to move the client to the opposite side of the ambivalence (the side in favor of change).

Have you ever used these, or similar, techniques to "sell" a client on change? Was it helpful/effective? Why or why not?

11 Ways to Be Resilience in the Face of Tragedy

Yesterday, on a beautiful holiday afternoon, my city was rocked - literally - by tragedy when 2 bombs exploded at the finish line of the Boston Marathon. Currently, 3 have died and the number reported injured has climbed to 176; many of these injuries are very serious, including amputations. People around the city, and beyond, are struggling to find ways to make sense of and cope with the shock, grief, and horror.

In times such as this, I think about resilience - the human capacity to recover from, adjust to, or even grow from adversity. In the past 20 years or so, increasing research attention has focused on understanding what allows some people to be resilient in the face of tragedy and violence. This research has identified several strategies that resilient people use. They may be particularly useful as we face the aftermath of this attack.

1) Take Care of Yourself

Keeping our bodies healthy by getting enough rest, eating a balanced diet, drinking enough water, and getting moderate exercise helps to reduce emotional vulnerability and therefore acts as a foundation for resilience.

2) Establish and Maintain Connections

Our relationships with other people are our biggest resource when it comes to coping wtih traumatic experiences. Giving and receiving support and acceptance helps us to feel grounded and held, regardless of what is happening around us. Accept the help and support of people who care about you. Find ways to be around other people in positive ways. Engage with others in a civic or spiritual community. This may be one reason why people find ways to gather together in the aftermath of traumatic experiences. Find solidarity.

3) Find Meaning

Connect to a sense of purpose for your life. Focus on something that feels meaningful. Turning our attention to what is meaningful instead of what is senseless helps orient us beyond the tragedy. It is also easier to sit with painful feelings if we can identify something meaningful that transcends them. News stories focusing on transcendent values such as bravery, sacrifice, and generosity help connect us to a narrative of meaning beyond terror and tragedy.

4) Work Toward a Goal

Identify small things you can accomplish today that move you a step closer toward a goal. Feeling like you're accomplishing something helps you feel competent and productive. Working toward a goal helps you feel hopeful and orients you toward a better future.

5) Laugh

People often feel like it would be a sign of denial, or dishonor the victims of a tragedy to express humor. However, humor is a helpful coping skill, particularly in the most challenging of circumstances. Being able to find a glimmer of humor, or taking time to exposure yourself to finny media (youtube, comics, comedic movies and tv shows, comedy routines, etc.) provides a needed break from the stress and distress. Furthermore, laughing produces a chemical reaction in the body that neutralizes the negative effects of stress.

6) Learn from Experience

Think back on how you've coped with past hardships. Build on things that have been helpful, and avoid things that have not been helpful. Not all coping skills work for all people. Go with what you know works for you!

7) Remain Hopeful

Instead of engaging in "what if" thinking, and dwelling on the past, focus on the future. Look for signs of hope - indications that things can change for the better. Again, this often means looking for those positive values and strengths that shine through a tragedy: the ways people come together in solidarity and generosity, people's courage in facing danger to help others, etc. In some ways, the best qualities of humanity seem to be brought out by the worst.

8) Take Action

We often feel better when we feel like we're doing something to contribute or address the problem at hand. Many people have come forward to donate blood. Staff at all the local hospitals jumped into action, and those who were not scheduled to work got there as fast as they could. People want to DO something when there is a tragedy. Unfortunately, there is not always something that can be done right away. They don't need blood right now, but they may later in the week. However, there are plenty of ways to contribute to your community, wherever you are.

9) Keep Things in Perspective

Trying to keep a long-term perspective and look at events in the larger context of your own lfie and the world. Recognize that things can improve. Avoid blowing things out of proportion or jumping to conclusions. Recognize that sometimes the media does blow things out of proportion (for example, claiming that there were several more explosive devices, when there were only the two that went off). Wait for confirmed evidence and avoid making assumptions.

10) Limit Exposure to the Media

On that note, it is also helpful to limit how much time you spend watching, listening to or reading media coverage of a trauma. While staying informed may be important, flooding ourselves with traumatic images and thoughts is, well, traumatic. Take breaks from it.

11) Practice Stress-Management and Relaxation Techniques

Our bodies go into overdrive in stressful or traumatic situations. It's important to restore balance by regulating our stress responses. Relaxation and calming practices such as breathing, mindfulness, progressive muscle relaxation, and yoga all help with this. Addressing the physiological signs of stress early on can prevent longer-term stress-related symptoms, such as PTSD.

Autism Awareness: Changes in DSM-V

Today is designated as Autism Awareness Day (and April as Autism Awareness Month). The goal is to increase both visibility and understanding of the "Autism Spectrum Disorders," which have also been referred to as "Pervasive Developmental Disorders" (PDD) - disorders involving severe and lasting impairment in several areas of development, most notably social skills and communication, sensory integration, and rigid/repetitive behaviors, interests and activities.

To date, this spectrum has included separate diagnoses: Autistic Disorder, Rett's Disorder, Childhood Disintegrative Disorder, Asperger's Syndrome, and PDD Not Otherwise Specified. However, this is about to change. When the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DMS-V) takes effect next month, there will be a significant change in these diagnoses. Rett's Disorder will continue to be a separate disorder, and no longer considered part of the autism spectrum (which makes sense due to its unique symptoms, including deceleration of head growth between 5-48 months of age, and loss of purposeful hand movements, replaced by repetitive, "stereotyped" hand movement [hand washing or wringing motions]). All of the other diagnoses currently classified as PDD will be be compined into a new diagnosis: Autism Spectrum Disorder (ASD).

The current (DSM-IV) criteria for Autism focus on three categories of symptoms: communication, social skills, and repetitive/stereotyped behaviors, interests, and activities. The new criteria for ASD will include only two categories: social communication, and repetitive/stereotyped behaviors (etc.). The latter category will also reportedly include recognition of issues with sensory integration/stimulation. Language delays will be removed as a criterion, since there can be many reasons for such delays, and delays are not seen universally in those with PDD/ASD. A new diagnosis is also being added for those without repetitive/stereotyped behaviors: Social Communciation Disorder.

While the DSM-IV criteria have been associated with inconsistent diagnoses from clinician to clinician (i.e., low reliability), preliminary results reportedly show good reliability. A retrospective application of the new criteria to individuals with current PDD diagnoses also shows that most continue to meet the revised criteria for ASD. Most of those who no longer meet criteria for ASD do meet the criteria for Social Communication Disorder.

These latter findings address the biggest concern within the Autism community: would those who have a current PDD diagnosis no longer meet criteria and therefore become ineligible for services they currently receive. Those with current diagnoses have also been reassured that they will automatically be able to maintain an ASD diagnosis; the revised criteria will be applied primarily to newly diagnosis individuals with ASD.

Nevertheless, advocacy groups are cautious about the changes, waiting to see results from prospective studies. There is uncertainty about how the criteria will work with very young children and/or adults. There are also some reservations from those who identify with the Asperger's community (or possibly other PDDs) about relinquishing that separate identity. Overall, while the changes seem to be scientifically sound, their actual human impact remains to be seen.

To Make or Keep a Good Relationship, Remember to "GIVE"

As discussed in a previous post, DBT identifies 3 possible goals for interpersonal effectiveness: getting what you want (objective effectiveness), maintaining self-respect, or maintaining a relationship. When the relationship is the most important thing, and the goal is to make or keep a good relationship, remember to GIVE:

(be Gentle

(act) Interested

Validate

(use an) Easy manner

(be) Gentle

• Be courteous and open-minded in your approach. Remeber that old saying, you catch more flies with honey: people respond more to gentleness than to harshness.
• Avoid attacks
• Avoid verbal or physical attacks. No hitting, clenching fists. Express anger by using “I feel …”
• Avoid threats. Tolerate a ‘no’ to requests. Stay in the discussion even if it gets painful. Exit gracefully.
• Avoid judging and guilt trips.  Don't say things like: “If you were a good person, you would…” or “You should…” or “You shouldn’t…”

(act) Interested

• Listen and be interested in the other person. Show your interest with your body language and facial expression.
• Listen to the other person’s point of view. Give them time and space to respond.  Don’t interrupt, talk over, etc.
• Be sensitive to the person’s desire to have the discussion at a later time. Be patient.

Validate

• Validate or acknowledge the other person’s feelings, wants, difficulties, and opinions about the situation.
• If you can, take an educated guess about what a person may be thinking or feeling, and then acknowledge that feeling or perspective.
•  Be nonjudgmental out loud: “I can understand how you feel,” “I realize that this is hard for you,” and “I see that you’re busy, but could we talk for a minute?”

(use an) Easy Manner

• Use a little humor. Smile. Ease the person along, be light-hearted.
• Use a “soft-shell” over a “hard-shell.”
• Be "political"

 

Interpersonal Effectiveness in Making Requests and Saying No

Two of the most challenging situations for interpersonal effectiveness are asking for something, and saying no. Both of these situations involve prioritizing our own needs and preferences as much as - or even more than - someone else's...something many of us have been told is bad (selfish, inconsiderate, etc.). However, the truth is that each of us matters as much as anyone else, and our feelings and preferences are valid.

Of course, it is also true that we don't always get our needs met, and things don't always go the way we'd prefer...but that doesn't mean we shouldn't express our needs and preferences. What it does mean is that it's a good idea (i.e., more effective) to base how strongly we make a request or say no on the demands of the specific situation we're in - there's no such thing as a one-size fits all approach.

DBT outlines a hierarchy of levels of intensity for making requests or saying no:

As you can see, the intensity ranges from insisting or refusing without giving in, on the one extreme, to not even attempting to ask/say no, on the other extreme. In the middle are several intermediate options where we might make a request directly or indirectly, but accept "no" as an answer, or express unwillingness without directly saying no, or say no but be willing to agree if pressed.

Those middle options show that communicating our needs and preferences is not black-and-white: it's not a matter of communicating or not communicating, but instead a matter of how we communicate, and how strongly.

So how do you figure out what intensity to use? Consider these 10 factors:

1) Priorities:

What is most important to you in this situation? If meeting your goals or getting results matters most, increase intensity. If maintaining the relationship matters, and the relationship is tenuous, or you're willing to trade meeting your goals for keeping the other person happy, decrease intensity. If maintaining self-respect matters most, consider your values; you may want to increase or decrease intensity depending on how your values line up with the situation.

2) Capability

If you know the other person is able to give you what you're asking for, the intensity can be higher. If you are unable to do what the other person is asking, you should say no more intensely.

3) Timeliness

If it's a good time to ask for something (the other person is in the right mood to listen, and therefore more likely to say yes) increase the intensity of asking. If it's a bad time to say no, do so less intensely (but if it's not a bad time, say no more intensely). This is largely a judgment call you make based on context clues, and past history with the person.

4) Homework (Have you done yours?)

If you know all the facts needed to advocate for yourself, and can make a clear request with a clear goal in mind, ask more intensely. If the other person's request is unclear or unsupported, you can say no more intensely.

5) Authority

If you have authority, you can ask more intensely. If the other person has authority say no less intensely, but if not (or if s/he is asking for something that is not within his/her authority) say no more intensely.

6) Rights

If you are asking for something you are entitled to, or if the other person would be morally/ethically/legally required to give you what you're asking for, ask more intensely. If you are not morally/ethically/legally required to do what the other person is asking, and especially if the request violates your rights, you can say no more intensely.

7) Relationship

If what you're asking for is appropriate to the current relationship, you can ask more intensely. If what the other person is asking for is not appropriate to the current relationship, you can say no more intensely.

8) Reciprocity

If you've done as much for the other person as you are requesting they do, and/or if you're willing to give something in return, you can ask more intensely. If you don't "owe" the other person anything, and/or the other person does not usually reciprocate, you can say no more intensely.

9) Long versus short term

If not making a request would create longer-term problems, ask more intensely. If saying no makes things less tense in the short-term but could damage the relationship in the long-term, say no more intensely.

10) Respect

If giving in would mean losing self-respect, ask or say no more intensely.

(based on the DBT Skills Training Manual).

Health Consequences of Eating Disorders

Eating disorders are serious, potentially life-threatening conditions that affect a person’s emotional and physical health. They are not just a “fad” or a “phase.” They are real, complex, and devastating conditions that can have serious consequences for health, productivity, and relationships. 

In anorexia nervosa’s cycle of self-starvation, the body is denied the essential nutrients it needs to function normally. Thus, the body is forced to slow down all of its processes to conserve energy, resulting in serious medical consequences:

• Abnormally slow heart rate and low blood pressure, which mean that the heart muscle is changing. The risk for heart failure rises as the heart rate and blood pressure levels sink lower and lower.
• Reduction of bone density (osteoporosis), which results in dry, brittle bones.
• Muscle loss and weakness.
• Severe dehydration, which can result in kidney failure.
• Fainting, fatigue, and overall weakness.
• Dry hair and skin; hair loss is common.
• Growth of a downy layer of hair called lanugo all over the body, including the face, in an effort to keep the body warm.

The recurrent binge-and-purge cycles of bulimia can affect the entire digestive system and can lead to electrolyte and chemical imbalances in the body that affect the heart and other major organ functions. Some of the health consequences of bulimia nervosa include:

• Electrolyte imbalances that can lead to irregular heartbeats and possibly heart failure and death. Electrolyte imbalance is caused by dehydration and loss of potassium, sodium and chloride from the body as a result of purging behaviors.
• Potential for gastric rupture during periods of bingeing.
• Inflammation and possible rupture of the esophagus from frequent vomiting.
• Tooth decay and staining from stomach acids released during frequent vomiting.
• Chronic irregular bowel movements and constipation as a result of laxative abuse.
• Peptic ulcers and pancreatitis.

Binge eating disorder often results in many of the same health risks associated with clinical obesity. Some of the potential health consequences of binge eating disorder include:

• High blood pressure.
• High cholesterol levels.
• Heart disease as a result of elevated triglyceride levels.
• Type II diabetes mellitus.
• Gallbladder disease.

All eating disorders are associated with increased risk of mortality, including death caused by the eating disorder behaviors themselves, substance abuse or suicide, and death from general causes such as cancer, likely because eating disorders impact the immune system. Anorexia has the highest mortality rate of any mental health condition.

 

All of these risks are scary, but treatment is available and recovery is possible. If you or someone you know has an eating disorder, reach out to find help. One option is the NEDA helpline at (800) 931-2237.

 

 

What is "Normal" Eating?

It's hard to be a part of our culture without adopting some disordered eating beliefs, attitudes, and/or behaviors. Half of the commercials on television promote diet or weight loss products. TV shows such as "The Biggest Loser" portray hard-core dieting. Even the "news media" spends a good chunk of time on diet, and whatever the newest diet fad may be. And all of this attention is driven primarily by dollars.

Why is this kind of information so profitable? Not because it's good for us, but because, as a culture, we have become chronically dissatisfied with our bodies. We have an unrealistic ideal about what the body should look like, and believe (in part because of what we see on TV) that we could get our bodies to look like that if we just follow a magic diet and exercise plan. The magic solution changes over time, of course, because it's never quite magic enough.

The result is that many or most people are very misinformed when it comes to what it means to eat "normally." Carbohydrates, for example, have received a bad rap over the last decade. However, carbohydrates are crucial to the body, and particularly to the brain. They are the body's main energy source, and the only type of energy the brain can use. 45-65% of one's diet should be made up of carbohydrates.

Dietary fats are also much maligned, based on the simplistic notion that fat in the diet becomes fat on the body. That's just not true. It happens to have the same word, but that doesn't make it the same thing! Dietary fats are important for many things. They keep us from getting hungry again too quickly, because they get digested more slowly than carbohydrates. They help us absorb fat-soluble vitamins, and help to protect our internal organs. They are a vital ingredient for healthy hair, skin, and nails. They also help produce the myelon sheathes on our nerve cells, allowing our brain to send messages efficiently.

So much for low-fat, low-carb diets! If that's not the answer, what is "normal eating?" The best answer to this question that I have ever come across is that offered by Ellyn Satter:

Normal eating is going to the table hungry and eating until you are satisfied. It is being able to choose food you like and eat it and truly get enough of it -not just stop eating because you think you should. Normal eating is being able to give some thought to your food selection so you get nutritious food, but not being so wary and restrictive that you miss out on enjoyable food. Normal eating is giving yourself permission to eat sometimes because you are happy, sad or bored, or just because it feels good. Normal eating is mostly three meals a day, or four or five, or it can be choosing to munch along the way. It is leaving some cookies on the plate because you know you can have some again tomorrow, or it is eating more now because they taste so wonderful. Normal eating is overeating at times, feeling stuffed and uncomfortable. And it can be undereating at times and wishing you had more. Normal eating is trusting your body to make up for your mistakes in eating. Normal eating takes up some of your time and attention, but keeps its place as only one important area of your life.

In short, normal eating is flexible. It varies in response to your hunger, your schedule, your proximity to food and your feelings.

For more about eating competence (and for research backing up this advice), see Ellyn Satter's Secrets of Feeding a Healthy Family: How to Eat, How to Raise Good Eaters, How to Cook, Kelcy Press, 2008. Also see www.EllynSatter.com to purchase books and to review other resources.

Copyright © 2012 by Ellyn Satter. Published at www.EllynSatter.com.