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?

Mindfulness and the Superbowl

During last night's Super Bowl broadcast, one of the commentators made a reference to mindfulness and acceptance! Did you catch it?

Ok, ok, he didn't use quite those words, but he was talking about those concepts. It was during the 34 minute game delay caused by a power-outage that shut down the lights in half of the stadium. The delay occurred early in the second half, when the Ravens had a sizable lead and quite a bit of momentum. As it became clear that the delay would be lengthy, questions were raised about how the teams and players would manage it: Would they be able to stay warmed up? Would the Ravens lose their momentum? Would the 49ers be able to capitalize on the delay to change their game plan? Which team would it benefit/hurt more?

A commentator was asked what he thought the coaches would be saying to their players. His response was that both teams needed to stay focused on the present moment. The Ravens needed to avoid jumping ahead to imagine themselves winning, and the 49ers needed to not get caught up in what they wished they could change about the plays that had already occurred. They needed to do what was needed in the current moment.

Mindfulness, of course, is at its heart an awareness of the present moment. While mindfulness meditation involves quiet observation of our internal experiences (thoughts, feelings, sensations), mindfulness can be applied to more active pursuits. One mindfulness exercise is to "do one thing" in the moment: if you're washing dishes, be fully present in the experience of washing dishes. If you're playing football, be fully present in the current play. Not the last play. Not the next play. Just this one - be here now.

Another element of mindfulness is nonjudgment: observing whatever is present in the moment without judging it. This is where acceptance comes in. This was also another aspect of the commentator's advice to the teams in the midst of the game delay. If they got frustrated or angry or impatient as a result of the delay, that could throw them off their game. Their heads wouldn't be in it anymore, and their emotions could get in the way of executing important plays. Instead, they needed to accept it without judgment: "it is what it is."

How well any of the players last night achieved a state of mindfulness and/or acceptance is something only they could say. The Ravens did in fact lose their momentum, and the 49ers almost eked out a win in the end...almost. The 49ers, like the rest of us, can only adopt that non-present-moment refrain: "Next year!"

Not Judging the Judgments

I was talking with a group about mindfulness and acceptance today - as in the Acceptance part of Acceptance and Commitment Therapy, which teaches people to accept rather than resist unwanted thoughts and feelings. Mindfulness, the skill of observing one's thoughts, feelings, sensations, and other aspects of internal experience without "buying into" them (seeing them as Facts) or acting on them.

We are often taught from a very young age that we should be able to "control" our thoughts and feelings, and our culture suggests that we can avoid or get rid of whatever we don't like. Unfortunately, or perhaps fortunately, neither of these messages is true: we actually can't control our thoughts and feelings (and trying to do so typically causes them to intensify, even if they initially seem "controllable"), and more often than not in life, we can't get rid of things we don't like. In fact, trying to control the uncontrollable may cause more distress than whatever it is we were trying to avoid experiencing.

By deciding to accept (rather than avoid, control, or otherwise fight) an experience (thought, feeling, etc.), we take away this added distress, and free up mental and emotional space for what is truly important to us - our values.

Easier said than done, however! Take, for example, one member of my group. Trying to understand the concept, she said: "So, instead of telling myself I shouldn't have hurt feelings, and not to be so weak, acceptance would be telling myself that everyone is weak sometimes and it's ok?"

Now, she's heading in the right direction by giving herself permission to have hurt feelings. However, she's not quite there yet: she is still judging hurt feelings as "weak."

DBT teaches that mindfulness should (try to) be nonjudgmental of whatever thoughts and feelings we experience. Of course, some of the thoughts rattling around in our heads at any given time are likely to be judgments of one form or another. Mindfulness involves stepping back from judgment by recognizing these thoughts as judgments, without becoming attached to the them as "facts." Acceptance means also accepting that you will have judgments...and treating them like any other thoughts.

As my group member summarized: "So I guess I should not judge the judgments either, huh?" I think she's getting it!

Pleasurable Activities

When we talk about relapse prevention, and overall quality of life, I encourage clients to schedule time each day to do things they enjoy. They often stare at me blankly, in response. Many of them can't actually identify anything they enjoy, and others feel like there are too many more important things or responsibilities they have to meet to "waste time" having fun.

I make sure to tell them that it is not a waste of time. In fact, research supports the value of spending even a brief period of time on positive or enjoyable activities each day in changing brain chemistry and (therefore) mood. Spending 10 minutes "playing" makes the time you spend "working" more productive and less overwhelming. It is well worth it!

For people who don't know what they enjoy, I provide the following list, and encourage them to highlight the things they think they might like, or are curious about. People might also be able to identify things they used to enjoy, or things they heard about that interested them but they haven't tried. Here is the list I've compiled. If you notice anything missing, add on using the comments!

• Shopping
• Event planning and organizing
• Wedding planning
• Camping
• Swimming
• Party planning
• Dog training
• Fitness and aerobic exercise sessions
• Horse riding
• Traveling
• Cooking
• Knitting
• Jewelry making
• Making gift baskets
• Crochet
• Family tree
• Geocaching
• Puzzles (Sudoku, crossword, jigsaw, etc)
• Reiki
• Different types of painting such as:
• Oil painting
• Glass painting
• Acrylic painting
• Faux painting
• Watercolor painting
• Paint by numbers
• Quilting
• Writing
• Interior decorating and designing
• Listening to new music
• Learning to play an instrument
• Home decorating
• Creating wall art and wall hangings
• Candle making
• Learning foreign languages
• Visiting beauty salons, clinics, and indulging in the following:
• Spas
• Manicures
• Massages
• Steam saunas
• Tanning
• Acupressure
• Acupuncture
• New hair accessories, and haircut styles and ideas
• Designer handbags and jewelry
• Embroidery
• Crystal healing
• Learning tarot card reading, astrology, or handwriting analysis
• Buying antiques and unique collectibles
• Going to garage sales and flea markets
• Becoming a collector of anything
• Handcrafted jewelry
• Setting up a fish tank with aquarium fish
• Beading
• Spiritual healing
• Aromatherapy
• Cake decorating
• Handicrafts
• Cosmetics
• Flower arrangements
• Origami
• Sewing
• Indoor gardening and other similar activities such as:
• Growing roses
• Managing flower gardens
• Growing bonsai trees
• Caring for houseplants
• Growing vegetable gardens
• Building a rock garden
• Organic gardening and composting
• Yoga
• Coaching
• Feng shui
• Pottery
• Pursuing mosaic, stained glass and pastel art
• Home based business opportunities
• Start a blog
• Scrapbooking
• Wood carving/crafts
• Learn about investments
• Make a gift for someone
• Watch sports, join a fantasy league
• Fishing
• Watch children or animals play
• Go to plays, concerts, or museums
• Refinish old furniture
• Visit national parks
• Photography
• Kite flying
• Identify a topic of interest and learn more about it
• Play pool or darts
• Sit at a sidewalk café
• Browse used book stores, or consignment stores

Urge Surfing

A novel concept for many clients entering recovery from any problematic or addictive behavior is having - but not acting on - urges or cravings. Urges to return to old habits are inevitable, so it's crucial for clients to learn that (1) thoughts do not have to be acted upon, (2) urges are tolerable, and will stop, even if they are not acted upon.

The skill of experiencing an urge, tolerating it, and allowing it to pass is often called "urge surfing." Based largely on mindfulness practices, urge surfing involves noticing and observing the thoughts, feelings and sensations of the urge without judging, fighting, or getting swept up in any aspect of the experience. The trick is adopting a stance of curiosity about one's own experience while also maintaining a degree of detachment from one's thoughts, feelings and sensations. Doing so allows one to experience the rise, crest, and decline of the urge's "wave" as it grows, peaks in intensity, and then fades.

This, of course, is easier said than done. Especially early on in recovery, when urges are most intense, and alternative coping skills may not yet be well developed, mindfully riding the wave of the urge may not be possible. In this case, distraction is a good strategy to fall back on. While distraction should not be the "go-to" strategy for managing emotions (because, over time, the result is to suppress rather than deal with emotions). However, for time-limited things like urges, distraction is just a way to wait out the natural progression. Distraction can be behavioral (getting up, changing environments, doing some other activity) or cognitive (occupying the mind with something, such as a puzzle, problem, or interesting task that is not quickly finished). The forms of distraction that work best differ based on problem and personal preferences.

I advise clients to practice both mindfulness, and various forms of distraction, when they're feeling relatively safe and stable, so that these skills are honed and available when urges (or other forms of distress) arise. However, I offer one caveat: urge surfing is much less useful when the problematic behavior is NOT doing something. For example, it is useful for Bulimia, where clients have urges to binge and/or purge, but less so for Anorexia, where clients have the urge to not eat. In the latter case, mindfulness and distraction can be useful if used to assist the client in eating, but they are counterproductive if used as ways to delay or avoid the need (urge) to eat.

How do you think about, and help clients cope with urges?

New Year, New You?

I suppose this could be considered a continuation of my last post on New Year's Resolutions, but while that post focused on the change process, today I want to focus on what, specifically, our culture suggests we try to change as we turn over a "new leaf" for the New Year.

I'm struck by the catch-phrase "New Year, New You," seen in print and television ads (and of course, on line), linked with a plethora of products to help us "upgrade" to a newer, better version of ourselves. Many, if not most, of these products are related to weight loss (diet pills, appetite suppressants, scales, nutrition shakes and bars, pre-made low calorie meal plans, exercise plans or equipment, etc, etc, etc). Then, for those who don't want to lose weight, come the "healthy living" products - super foods, supplements of everything under the sun, probiotics, more nutrition shakes and bars, more exercise plans and equipment.... And of course, we have programs and advice for finding that "special someone" - books, events, and dating websites galore. I've also seen books and television clips on making more money, changing spending habits, communicating more effectively, getting a new job or house...you get the idea.

We all get the idea: We're not ok the way we are, and if we're not working to change and improve...something...there's even more wrong with us.

I don't know about you, but I spend a lot of time trying to help my clients to feel better about themselves for who they are, the way they are. Sure, therapy is about change...but often about changing all the problems that have arisen from the client's belief that she or he is not ok, but inadequate, flawed, worthless, ugly, a misfit...etc. Indeed, one of the dialects in DBT is acceptance and change. The premise is that, while a sole focus on acceptance negates change, focusing on change without acceptance of oneself/the client the way one/she or he is can be demoralizing and interfere with change. Conversely, accepting oneself paradoxically makes it easier and less threatening to work toward change.

So, instead of a "new you" this year, considering trying out a new attitude toward the "same old" you. You may be surprised by the results!

Avoiding Avoidance, Revisited

A few months ago, I wrote about the potential for forms of avoidance to contribute to emotional and psychological problems. Most basically, avoiding aspects of human experience that may be uncomfortable or distressing alleviates discomfort/distress in the short-term, but exacerbates difficulties in the long-term by intensifying anxiety about that aspect of experience, and inhibiting the ability to cope with and modulate distress.

The most empirically-supported treatment for the various anxiety disorders (panic, phobias, OCD, PTSD), is called "exposure and response prevention" - in other words, a guided process of exposure to triggers for anxiety while preventing "safety behaviors" (ways of stopping/avoiding the anxiety without dealing with the trigger). The person experiences anxiety in response to the trigger, but waits for the anxiety to dissipate (like other emotions, when allowed to happen, anxiety peaks and then lessens on its own). Each time the person is exposed to the trigger the "peak" of anxiety is less intense, as a result of the previous exposures, until eventually the trigger is no longer triggering.

DBT expands the use of exposure, to apply to any emotion that causes a client problems in functioning (e.g., anger, guilt, shame, fear). It also expands our understanding of exposure to include anything that evokes the immediate or remembered experience of the emotion. Finally, it clarifies that the exposure has to include a "corrective" experience - in other words, the exposure should not reinforce the problematic emotional response, but should "correct" in with incongruent information or an incompatible emotional response. The same principle applies with classic exposure and response prevention - the idea is that when nothing bad happens as a result of exposure to a feared trigger, the fear begins to be disproven.

Based on all of this, it seems obvious that, for therapy to be effective, it is necessary for it to expose clients to the distressing emotions (and triggers thereof) that are causing problems for them. However, while doing so, it's also important to keep the overall level of emotional arousal within the "therapeutic window" - neither so little arousal that there is no real exposure to the emotions, nor so much arousal that the client's internal processing system is overwhelmed and the exposure itself becomes traumatic.

In group therapy, a significant challenge is to keep exposure to emotions within each individual group member's therapeutic window, so that nobody is traumatized, but everyone has the opportunity for growth. I've been filling in at a day program location (while waiting for my own location to open) that has dealt with concern about group process becoming traumatizing for someone by making it their policy to avoid triggering anyone (i.e., to avoid exposure altogether). As a result, everyone tip-toes around the issues, and nobody work through the issues that brought them to the program. Yesterday, one of my clients expressed frustration with this dynamic, and i have to say I'm frustrated too.

So, what is the answer? How do we bring emotional exposure into the therapeutic window, when clients are at very different levels of emotional tolerance/arousal? I'm interested in hearing your suggestions!

What Harry Potter Teaches Us About Mindfulness

Mindfulness is the practice of attending to one's experience of the present moment - including thoughts, feelings, and physical sensations - with a degree of detachment, as an observer (e.g., the "observing ego"). It can be hard to understand how one simultaneously experiences and observes, and it is definitely difficult to learn how to do it. However, we can deepen our understanding of mindfulness by looking at another practice that is difficult to learn - magic.

Specifically, I want to look at how magic in the Harry Potter universe resembles and reflects the practice of mindfulness.

1) Verbal Spell-Casting
     It's not enough to learn the words and wand movements for a spell to work. It's a rare feat indeed for any student to successfully cast a spell the first time they attempt it. No, to make a spell work you have to:

a) Concentrate - Harry has difficulty learning the Summoning Charm in Book 4 because he keeps getting distracted from the spell by thoughts about dragons. To make a spell work, your whole focus and attention must be on the specific spell you're casting. Similarly, the single most important ingredient for mindfulness is focus and attention in and on the present moment. 

b) Visualize - Spells require the caster to visualize the desired outcome. Indeed, the words and wand movements for many spells are a bit vague. Take Riddikulus, the spell used to banish dark creatures called boggarts, learned in Book 3. From the Latin for joke or laugh, the word Riddikulus does not specify what the caster wants to happen. Instead, the caster has to vividly visualize their greatest fear (which the boggart has turned itself into) taking on an amusing form. The visualization, combined with casting the spell, forces the boggart into the amusing form, which causes laughter, which in turn finally banishes the boggart. A way of focusing one's attention, visualization can also be part of mindfulness - for example, visualizing one's thoughts as clouds floating past in the sky can help to foster a degree of detachment. 

c) Intent - One's magic can sense ambivalence or hesitation, and the spell won't work. For example, in Book 5, when Harry tries unsuccessfully to cast the Cruciatus (torture) Curse against the woman who killed his Godfather, she says: "Never used an Unforgivable Curse before, have you, boy? You have to mean them, Potter! You need to really want to cause pain." Now, pain is not the object of mindfulness, but it does help to have a clear intent - and ambivalence or reluctance can short-circuit the whole process.

2) The Patronus Charm
     A special case of verbal spell is the Patronus Charm, which conjures a silvery phantom form from the positive thoughts of the caster; once conjured, the form can serve as a protector or messenger. As we learn in Book 3, to successfully cast the charm, the caster must call up a memory associated with intense positive emotions - that involves vividly visualizing the memory including the emotion associated with it. Similarly, mindfulness may center around a specific emotion, while also bringing to mind the related thoughts, sensations, and experiences.

3) Non-Verbal Spell-Casting
    As we learn in Book 6, casting a spell non-verbally requires a similar mental process to verbal spells, only more so: since no words are being spoken, the mind and will of the caster must be singularly concentrated on the intent and process of casting. The mind must hold the incantation (i.e., the words), the caster's intent, and the visualization of the desired outcome. Getting stuck in any one element (just the words or just the outcome, for example) will cause the spell to fail. In mindfulness, one is also working to simultaneously hold in one's mind the various aspects of experience: thoughts, emotions, and sensations.

4) Apparition
    A special case of non-verbal spell is Apparition - the practice of disappearing from one place and reappearing in another. Also learned in Book 6, Apparition requires that you: "Fix your mind firmly upon the desired destination," "focus your determination to occupy the visualized space! Let your yearning to enter it flood from your mind to every particle of your body!" and "Turn on the spot, feeling your way into nothingness, moving with deliberation!" This is pure mindfulness - focusing all of one's attention on the present moment cognitively (destination), emotionally (determination), and physically (deliberation).

5) Occlumency
    Another special case of non-verbal magic is occlumency, the art of sealing one's mind against external magical intrusion or influence. We learn about it (although Harry is unsuccessful in learning it) in Book 5. The key to occlumency is clearing one's mind of whatever one does not want an intruder to access - especially intense emotion. This is very similar to mindfulness, which shares the goal of detachment from intense emotion, or any other single aspect of experience, instead allowing all of one's experience to flow past one's mind as one metaphorically steps back and observes it.

I'm sure there are other ways Harry Potter elucidates the practice of mindfulness - I've written enough for now, but feel free to add to my list! Hopefully this offers an illustration of the acts of the mind that are part of mindfulness - awareness, focus, will, intent, detachment.

Coping Toolbox

When people seek mental health treatment, it's often because the strategies they've been using to cope with life's challenges - strategies that may have developed over many years - either no longer work, or have begun to cause even bigger problems that the ones they're supposed to solve (think substance abuse, eating disorders, self injury, etc).

A major task early in treatment is developing alternative strategies to manage distress - strategies that are more effective for the client's current difficulties, and/or don't involve risk or cause further problems. There is some trial and error involved in identifying these alternative coping strategies, because each person is unique, and what works for one may not work for another. As my clients begin to experiment with things they're learning in treatment, I often encourage them to start a "coping toolbox" - an actual collection of items and written cues that can be brought out during period of distress.

I've been putting a toolbox together to bring in for "show and tell" in a skills group. Here's what I'm including, by category:

1) Self-Soothing
Self-soothing uses the 5 senses to calm oneself. In my toolbox I have: a sample vial of perfume (scent), a few hard candies (taste), a small stuffed toy and a rock, both with sentimental value, and a stress ball (texture), a relaxation recording and meditation balls that ring (sound), and a pretty object (sight).

2) Mindfulness
I have a miniature finger labyrinth that I use for mindfulness. I also have recordings of progressive muscle relaxation and visualization that I include here.

3) Emotional Awareness
I have a magnet that has various emotions represented as faces, to aid in the identification of the specific emotion. I also have crayons and pen/paper for writing or drawing about the feelings at hand.

4) Opposite-to-Emotion Action
DBT teaches that it's sometimes helpful to counteract distressing emotions that are not helpful in the moment with actions that are associated with opposite emotions. So, I have in my tool box a deck of cards with jokes and riddles on them, and a book of affirmations.

5) Distraction
When all else fails, it can be useful/necessary to take a break from the distress by distracting. I have a card game that can be played by one player, and my ipod that has puzzle games on it.

What would you put in your coping toolbox?