Therapies
1. Mentalisation Based Therapy
Call us biased and predictable, but we're fans of mentalisation based therapy. No surprises there then. Jon Allen's article in the What is Mentalising? feature is straight from the MBT therapists' pen. Keyboard. And the Links section lists all the MBT books you'll have room to pack for your next holiday.
Here's my take on having MBT.
I’ve got borderline personality disorder. I’ve got all sorts of other things – a dog, two jobs and a strange itch on my shin. But I’m only having psychotherapy for my BPD. And it’s not any old psychotherapy. It’s a relatively new, designer therapy, with the Americanish title of Mentalisation Based Treatment. (Or the even more American version – Mentalization etc.) This information piece is about MBT, written in the hope that it will be helpful for other people fortunate enough to be offered or currently having MBT.
I’ve written elsewhere about my having BPD – if you’re interested, you can find it on a website www.brightplace.org.uk/starbpd.html. So I won’t ramble on about it here, other than to say that of the nine qualifying conditions, my five are bunched around mood swings and self-harm. (The whole thing about qualifying conditions feels a bit like the entry conditions for the Euro. But easier to understand and without spawning quirky breakaway political parties.)
What is MBT?
MBT is a type of psychotherapy created to treat people with borderline personality disorder. It’s also been found to be useful for people with other types of mental illness. As the name suggests, it centres on the concept of ‘mentalisation’. I struggled to understand what exactly this is, which could be further evidence of my need for this therapy or just that I’m a bit dim. But I finally grasped that it’s unscarily straightforward. Mentalisation is simply about recognising what’s going on in our own heads and what might be going on in other people’s heads.
So what’s the big deal? Surely we’re all pretty in touch with what we’re thinking and feeling, and have got as good a chance as anyone else of guessing what others are doing? Er, no. Unfortunately those of us with BPD are unlikely to be top scorers in the Minds’ Awareness League. Not great at accurately identifying what’s happening in our own minds and even less likely to correctly work out what’s in other people’s minds. Especially if we’re feeling stressed out.
And there’s an even more fundamental problem here. When we’re feeling crap, we’re likely to shut down (or at best tone down) our ability to ‘mentalise’. Thinking becomes a real effort, and reasoned thinking about thinking nearly impossible. Certainly for me, when things are tough I often self-harm specifically to avoid thinking, as that’s too painful. Self-harming gives us something very concrete to focus on, which links with another aspect of BPD. Apparently, if we’ve got BPD we tend to find it easier to believe things that we can see rather than imagining what might have led to a particular situation. (No money under the pillow, definitely no tooth fairy.)
MBT is intended both to help us sharpen up our ability to mentalise and to be willing to use it, especially when we’re feeling intense emotions. For example, in a session the therapist might ask us to consider what the other person in a difficult situation might have been thinking, and help us move past our initial assumption, especially if it’s a really negative one.
What’s the difference between ‘mentalising’ and thinking and why can mentalising sometimes be better?
Thinking is thinking. Mentalising is thinking about thinking and feeling, our own and other people’s. Obviously it’s often best just to get on and have thoughts. About whether Borat is the funniest film ever made or a shocking and trashy piece of sexist and racist rubbish. About whether there’s something we can do as a non-punitive alternative to self-harming.
I’ve found it helpful looking at mentalising from the perspective of people with autism. Perhaps it’s because I’ve struggled to understand quite what mentalisation is about that it’s been useful to me to consider a group of people with a totally different disability to mine. People with autism live very much in the here and now. They have been described as having no ‘theory of mind’, as most are unaware of their own thinking processes and have even less recognition that other people think or have feelings. Clearly people with autism think. (An inordinate amount of the time, it seems, about Thomas the Tank Engine, at least when they’re kids.) But it’s a very automatic experience, and reflecting on their own thoughts just doesn’t arise. And the way they see the world is such that although they may notice the manifestation of others’ thoughts and feelings, for example they can see that someone is smiling or hear them shouting, they don’t connect that with the emotions that produce those observable responses. People with autism find it almost impossible to imagine themselves ‘in someone else’s shoes’.
For those of us with BPD rather than autism, mentalising is an acquirable skill, and one which can give us valuable extra perspective on a situation. For example, if I’m planning to take an overdose, just thinking about it tends to take me along a route which lets me confirm this is the ‘right’ thing to do. But if I have to mentalise, I have to look at my thinking. It’s hard for me to do this without concluding that I’m not thinking straight. That my thoughts and feelings about the overdose are caused by feeling seriously crap and that I should at least try to hold off any decision til I’m feeling more settled.
And if I then move on to thinking about others’ thoughts and feelings, it takes me to the painful place of knowing how traumatised my friends are if they find out that I’ve taken an overdose. Let alone the impact on them if the next overdose turns out to be fatal.
None of this mentalising necessarily stops me from taking self-damaging action but it at least gives my self-protective side a decent shot at introducing some logic to the situation.
What’s it like having MBT?
You might expect that a therapy with mentalisation at its heart would involve the therapist endlessly asking “And what was in your mind? And what was in their mind?” But, luckily, this hasn’t happened. It’s all much more nuanced than that. Similarly, although the approach is very non-directive, when I ask for advice or need help in practical problem-solving with something I’m wrestling with, my psychiatrist will often respond in a ‘normal’ way and help me out.
I had cognitive behavioural therapy with a psychologist before I ended up being sectioned. At that stage, I was taken on by a personality disorder unit as an outpatient and have had MBT weekly with a psychiatrist for about 18 months. Both types of therapy feel very similar, despite the psychologist and psychiatrist being very different types of people. Both approaches have felt supportive, non-judgmental and focused on what I’m thinking. I’ve been able to see issues, especially painful ones, from a different perspective and to understand what might be fuelling the tough stuff. Both have made me feel like I’m setting the agenda about what we talk about and that I can say anything, however embarrassing or ridiculous I feel it is. And I know that the self-protective part of me, which tries to resist my self-destructive tendencies, gets crucial reinforcement.
The most noticeable difference in style is that my psychiatrist has very ‘high boundaries’, so I know almost nothing about him and his life, other than what I can pick up from clues around his office. (He either rides a motorbike or is excessively worried about getting a head injury when driving his car.)
Perhaps the most tangible difference I experience is that I’ve only once self-harmed after a session with the psychiatrist whereas I used to do so regularly after my previous sessions. This really puzzled me til I read a couple of books about MBT. These made me realise that while the MBT sessions feel quite normal and ‘spontaneous’, they’re carefully designed to be at a level of intensity, or intrusiveness, that I can comfortably cope with. (This relates back to the business about us closing off if things become too painful.) This doesn’t mean that I’m never moved outside my comfort zone – most sessions we cover things which make me cry. But somehow, overall I don’t end up feeling completely jangled or bursting with feelings I don’t know how to or don’t want to deal with.
Does it work?
Well, I’ve been able to survive 4 years of pretty consistent suicidal feelings and still be around to write this. And studies have shown that it certainly works for a lot of, but not all, patients. One very reassuring thing is that it’s been designed as a result of careful research into both the causes of BPD and the impact of MBT. I don’t really understand all the stuff about how BPD develops, but it goes something like this.
If mothers have problems connecting well with their babies, they respond differently to other mothers. One thing that the research shows is that when the babies are really upset, these mothers don’t calm the babies in a way that helps the babies to ‘understand’ or learn what’s their own distress and what’s the mother’s. It’s a bit like the baby’s distress is magnified and bounced back at the little thing rather than being soothed and dissolved by the mother. As well as emotional mishaps like this, it’s been found that many people who develop BPD often have early experiences of abuse or neglect by parents. These things lead to many of us being unable to soothe ourselves in ways that are conventional, or not self-destructive, again reinforcing our tendencies to self-harm.
Another central proposition of MBT is that when we’re babies and our mothers aren’t able to comfort us in an effective way, we sort of bung onto our mother the parts of ourselves we can’t cope with. This results later on in life with us coping particularly badly with the loss of someone close to us, partly because we might have ‘assigned over’ to them the painful parts of ourselves. This contributes in a rather complicated way to our tendencies to self-harm and be suicidal, apparently to feel re-connected to the outsourced part of ourselves.
The quality of ‘attachment’ in our earliest years continues to affect how we feel and think right through our lives, and if they’ve got off to a bad start we’ll have difficulties with other close relationships. Including potentially the one with our therapist.
The MBT therapist, then, will be very aware of this and will be careful that we don’t just slot back into a pattern of feeling overwhelmed by intensely painful feelings which make us close off thinking, especially about our own and the therapist’s thoughts. Feeling understood by someone we trust (the therapist), is a sound place to be able to move into a calmer, safer way of coping with difficult stuff.
More information about MBT
If you want to know and understand more about MBT… unfortunately there isn’t much information out there. And what there is has been written for therapists rather than patients. The most accessible of this limited literature is Mentalization Based Therapy for Borderline Personality Disorder by Bateman and Fonagy. I’ve only been able to find one thing on the Internet, a press release from the Royal College of Psychiatrists which provides a clear but brief explanation of MBT and its effectiveness: http://www.rcpsych.ac.uk/pressparliament/pressreleasearchive/pr748.aspx
There’s much more written about the obscurely titled Dialectical Behaviour Therapy. So it’s time for those of us getting MBT to start writing as well as reading about it.
2. Dialectical Behavioural Therapy
To prevent me spending too much of my life watching Curb Your Enthusiasm, my MBT is supplemented by DBT, courtesy of my astoundingly wonderful 'crisis therapist' Patrick Doyle. (Patrick's website is http://personfirstsolutions.synthasite.com/). It's a whole other story about having an out-of-hours' crisis therapist, so for now - well, nothing at all about that and here's what the incomparable Wikipedia has to say about DBT:
Dialectical behavior therapy (DBT) is a therapeutic methodology developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat persons with borderline personality disorder (BPD).[1][2] DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of mindful awareness, distress tolerance, and acceptance largely derived from Buddhist meditative practice. DBT is the first therapy that has been experimentally demonstrated to be effective for treating BPD. Research indicates that DBT is also effective in treating patients who represent varied symptoms and behaviors associated with spectrum mood disorders, including self-injury.[3]
Linehan created DBT in response to her observation of therapist burnout after repudiating patients’ motivation to cooperate in successful treatment. Her first core insight was to recognize that the chronically suicidal patients she studied had been raised in profoundly invalidating environments and required a climate of unconditional acceptance (not Carl Rogers’ humanistically "positive" version, but Thich Nhat Hanh’s metaphysically neutral one) in which to develop a successful therapeutic alliance. Her second insight concerned the need for a commensurate commitment from patients to (be willing to) change—subject to their skillfulness in the present moment--based on 'radical acceptance' of their dire level of emotional dysfunction.
Linehan united commitment to the core conditions of acceptance and change through the Hegelian principle of dialectical progress, in which thesis + antithesis → synthesis, and proceeded to assemble a modular array of skills for emotional self-regulation, drawn from Western (e.g., CBT and an interpersonal variant, “assertiveness training”) and Eastern (e.g., Buddhist mindfulness meditation) psychological traditions. Arguably her signal contribution was to elide the adversarial paradigm implicit in the hierarchical modernist therapeutic alliance, using the deconstructive spirit of Hegel and the Buddha to substitute a postmodern alliance based on intersubjectivetough love.
All DBT involves two components:
Mindfulness
Mindfulness is one of the core concepts behind all elements of DBT. Mindfulness is the capacity to pay attention, nonjudgmentally, to the present moment. Mindfulness is all about living in the moment, experiencing one's emotions and senses fully, yet with perspective. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional Buddhist practice, though the version taught in DBT does not involve any religious or metaphysical concepts.
Interpersonal effectiveness
Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.
Individuals with borderline personality disorder frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioral sequence when analyzing his or her own situation.
The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g., requesting that someone do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect.
Emotion regulation
Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. Dialectical behavior therapy skills for emotion regulation include:[4][5]
Many current approaches to mental health treatment focus on changing distressing events and circumstances. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully.
Distress tolerance skills constitute a natural development from mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Although this is a nonjudgmental stance, this does not mean that it is one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.
Skills for acceptance include radical acceptance, turning the mind toward acceptance, and distinguishing between "willingness" (acting skillfully, from a realistic understanding of the present situation) and "willfulness" (trying to impose one's will regardless of reality). Participants also learn four crisis survival skills, to help deal with immediate emotional responses that may seem overwhelming: distracting oneself, self-soothing, improving the moment, and thinking of pros and cons.
Big thanks to Wikipedia for this. And even bigger thanks to Marsha Linehan for creating what was truly a 'breakthrough' therapy for people with BPD.
3. Getting the most from therapy
There's an excellent feature on how to really benefit from therapy:
Therapy 101, How To Succeed in Therapy
http://www.orangecountycounseling.com/relationships/advanced-therapy-guide.html
)
Call us biased and predictable, but we're fans of mentalisation based therapy. No surprises there then. Jon Allen's article in the What is Mentalising? feature is straight from the MBT therapists' pen. Keyboard. And the Links section lists all the MBT books you'll have room to pack for your next holiday.
Here's my take on having MBT.
I’ve got borderline personality disorder. I’ve got all sorts of other things – a dog, two jobs and a strange itch on my shin. But I’m only having psychotherapy for my BPD. And it’s not any old psychotherapy. It’s a relatively new, designer therapy, with the Americanish title of Mentalisation Based Treatment. (Or the even more American version – Mentalization etc.) This information piece is about MBT, written in the hope that it will be helpful for other people fortunate enough to be offered or currently having MBT.
I’ve written elsewhere about my having BPD – if you’re interested, you can find it on a website www.brightplace.org.uk/starbpd.html. So I won’t ramble on about it here, other than to say that of the nine qualifying conditions, my five are bunched around mood swings and self-harm. (The whole thing about qualifying conditions feels a bit like the entry conditions for the Euro. But easier to understand and without spawning quirky breakaway political parties.)
What is MBT?
MBT is a type of psychotherapy created to treat people with borderline personality disorder. It’s also been found to be useful for people with other types of mental illness. As the name suggests, it centres on the concept of ‘mentalisation’. I struggled to understand what exactly this is, which could be further evidence of my need for this therapy or just that I’m a bit dim. But I finally grasped that it’s unscarily straightforward. Mentalisation is simply about recognising what’s going on in our own heads and what might be going on in other people’s heads.
So what’s the big deal? Surely we’re all pretty in touch with what we’re thinking and feeling, and have got as good a chance as anyone else of guessing what others are doing? Er, no. Unfortunately those of us with BPD are unlikely to be top scorers in the Minds’ Awareness League. Not great at accurately identifying what’s happening in our own minds and even less likely to correctly work out what’s in other people’s minds. Especially if we’re feeling stressed out.
And there’s an even more fundamental problem here. When we’re feeling crap, we’re likely to shut down (or at best tone down) our ability to ‘mentalise’. Thinking becomes a real effort, and reasoned thinking about thinking nearly impossible. Certainly for me, when things are tough I often self-harm specifically to avoid thinking, as that’s too painful. Self-harming gives us something very concrete to focus on, which links with another aspect of BPD. Apparently, if we’ve got BPD we tend to find it easier to believe things that we can see rather than imagining what might have led to a particular situation. (No money under the pillow, definitely no tooth fairy.)
MBT is intended both to help us sharpen up our ability to mentalise and to be willing to use it, especially when we’re feeling intense emotions. For example, in a session the therapist might ask us to consider what the other person in a difficult situation might have been thinking, and help us move past our initial assumption, especially if it’s a really negative one.
What’s the difference between ‘mentalising’ and thinking and why can mentalising sometimes be better?
Thinking is thinking. Mentalising is thinking about thinking and feeling, our own and other people’s. Obviously it’s often best just to get on and have thoughts. About whether Borat is the funniest film ever made or a shocking and trashy piece of sexist and racist rubbish. About whether there’s something we can do as a non-punitive alternative to self-harming.
I’ve found it helpful looking at mentalising from the perspective of people with autism. Perhaps it’s because I’ve struggled to understand quite what mentalisation is about that it’s been useful to me to consider a group of people with a totally different disability to mine. People with autism live very much in the here and now. They have been described as having no ‘theory of mind’, as most are unaware of their own thinking processes and have even less recognition that other people think or have feelings. Clearly people with autism think. (An inordinate amount of the time, it seems, about Thomas the Tank Engine, at least when they’re kids.) But it’s a very automatic experience, and reflecting on their own thoughts just doesn’t arise. And the way they see the world is such that although they may notice the manifestation of others’ thoughts and feelings, for example they can see that someone is smiling or hear them shouting, they don’t connect that with the emotions that produce those observable responses. People with autism find it almost impossible to imagine themselves ‘in someone else’s shoes’.
For those of us with BPD rather than autism, mentalising is an acquirable skill, and one which can give us valuable extra perspective on a situation. For example, if I’m planning to take an overdose, just thinking about it tends to take me along a route which lets me confirm this is the ‘right’ thing to do. But if I have to mentalise, I have to look at my thinking. It’s hard for me to do this without concluding that I’m not thinking straight. That my thoughts and feelings about the overdose are caused by feeling seriously crap and that I should at least try to hold off any decision til I’m feeling more settled.
And if I then move on to thinking about others’ thoughts and feelings, it takes me to the painful place of knowing how traumatised my friends are if they find out that I’ve taken an overdose. Let alone the impact on them if the next overdose turns out to be fatal.
None of this mentalising necessarily stops me from taking self-damaging action but it at least gives my self-protective side a decent shot at introducing some logic to the situation.
What’s it like having MBT?
You might expect that a therapy with mentalisation at its heart would involve the therapist endlessly asking “And what was in your mind? And what was in their mind?” But, luckily, this hasn’t happened. It’s all much more nuanced than that. Similarly, although the approach is very non-directive, when I ask for advice or need help in practical problem-solving with something I’m wrestling with, my psychiatrist will often respond in a ‘normal’ way and help me out.
I had cognitive behavioural therapy with a psychologist before I ended up being sectioned. At that stage, I was taken on by a personality disorder unit as an outpatient and have had MBT weekly with a psychiatrist for about 18 months. Both types of therapy feel very similar, despite the psychologist and psychiatrist being very different types of people. Both approaches have felt supportive, non-judgmental and focused on what I’m thinking. I’ve been able to see issues, especially painful ones, from a different perspective and to understand what might be fuelling the tough stuff. Both have made me feel like I’m setting the agenda about what we talk about and that I can say anything, however embarrassing or ridiculous I feel it is. And I know that the self-protective part of me, which tries to resist my self-destructive tendencies, gets crucial reinforcement.
The most noticeable difference in style is that my psychiatrist has very ‘high boundaries’, so I know almost nothing about him and his life, other than what I can pick up from clues around his office. (He either rides a motorbike or is excessively worried about getting a head injury when driving his car.)
Perhaps the most tangible difference I experience is that I’ve only once self-harmed after a session with the psychiatrist whereas I used to do so regularly after my previous sessions. This really puzzled me til I read a couple of books about MBT. These made me realise that while the MBT sessions feel quite normal and ‘spontaneous’, they’re carefully designed to be at a level of intensity, or intrusiveness, that I can comfortably cope with. (This relates back to the business about us closing off if things become too painful.) This doesn’t mean that I’m never moved outside my comfort zone – most sessions we cover things which make me cry. But somehow, overall I don’t end up feeling completely jangled or bursting with feelings I don’t know how to or don’t want to deal with.
Does it work?
Well, I’ve been able to survive 4 years of pretty consistent suicidal feelings and still be around to write this. And studies have shown that it certainly works for a lot of, but not all, patients. One very reassuring thing is that it’s been designed as a result of careful research into both the causes of BPD and the impact of MBT. I don’t really understand all the stuff about how BPD develops, but it goes something like this.
If mothers have problems connecting well with their babies, they respond differently to other mothers. One thing that the research shows is that when the babies are really upset, these mothers don’t calm the babies in a way that helps the babies to ‘understand’ or learn what’s their own distress and what’s the mother’s. It’s a bit like the baby’s distress is magnified and bounced back at the little thing rather than being soothed and dissolved by the mother. As well as emotional mishaps like this, it’s been found that many people who develop BPD often have early experiences of abuse or neglect by parents. These things lead to many of us being unable to soothe ourselves in ways that are conventional, or not self-destructive, again reinforcing our tendencies to self-harm.
Another central proposition of MBT is that when we’re babies and our mothers aren’t able to comfort us in an effective way, we sort of bung onto our mother the parts of ourselves we can’t cope with. This results later on in life with us coping particularly badly with the loss of someone close to us, partly because we might have ‘assigned over’ to them the painful parts of ourselves. This contributes in a rather complicated way to our tendencies to self-harm and be suicidal, apparently to feel re-connected to the outsourced part of ourselves.
The quality of ‘attachment’ in our earliest years continues to affect how we feel and think right through our lives, and if they’ve got off to a bad start we’ll have difficulties with other close relationships. Including potentially the one with our therapist.
The MBT therapist, then, will be very aware of this and will be careful that we don’t just slot back into a pattern of feeling overwhelmed by intensely painful feelings which make us close off thinking, especially about our own and the therapist’s thoughts. Feeling understood by someone we trust (the therapist), is a sound place to be able to move into a calmer, safer way of coping with difficult stuff.
More information about MBT
If you want to know and understand more about MBT… unfortunately there isn’t much information out there. And what there is has been written for therapists rather than patients. The most accessible of this limited literature is Mentalization Based Therapy for Borderline Personality Disorder by Bateman and Fonagy. I’ve only been able to find one thing on the Internet, a press release from the Royal College of Psychiatrists which provides a clear but brief explanation of MBT and its effectiveness: http://www.rcpsych.ac.uk/pressparliament/pressreleasearchive/pr748.aspx
There’s much more written about the obscurely titled Dialectical Behaviour Therapy. So it’s time for those of us getting MBT to start writing as well as reading about it.
2. Dialectical Behavioural Therapy
To prevent me spending too much of my life watching Curb Your Enthusiasm, my MBT is supplemented by DBT, courtesy of my astoundingly wonderful 'crisis therapist' Patrick Doyle. (Patrick's website is http://personfirstsolutions.synthasite.com/). It's a whole other story about having an out-of-hours' crisis therapist, so for now - well, nothing at all about that and here's what the incomparable Wikipedia has to say about DBT:
Dialectical behavior therapy (DBT) is a therapeutic methodology developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat persons with borderline personality disorder (BPD).[1][2] DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of mindful awareness, distress tolerance, and acceptance largely derived from Buddhist meditative practice. DBT is the first therapy that has been experimentally demonstrated to be effective for treating BPD. Research indicates that DBT is also effective in treating patients who represent varied symptoms and behaviors associated with spectrum mood disorders, including self-injury.[3]
Linehan created DBT in response to her observation of therapist burnout after repudiating patients’ motivation to cooperate in successful treatment. Her first core insight was to recognize that the chronically suicidal patients she studied had been raised in profoundly invalidating environments and required a climate of unconditional acceptance (not Carl Rogers’ humanistically "positive" version, but Thich Nhat Hanh’s metaphysically neutral one) in which to develop a successful therapeutic alliance. Her second insight concerned the need for a commensurate commitment from patients to (be willing to) change—subject to their skillfulness in the present moment--based on 'radical acceptance' of their dire level of emotional dysfunction.
Linehan united commitment to the core conditions of acceptance and change through the Hegelian principle of dialectical progress, in which thesis + antithesis → synthesis, and proceeded to assemble a modular array of skills for emotional self-regulation, drawn from Western (e.g., CBT and an interpersonal variant, “assertiveness training”) and Eastern (e.g., Buddhist mindfulness meditation) psychological traditions. Arguably her signal contribution was to elide the adversarial paradigm implicit in the hierarchical modernist therapeutic alliance, using the deconstructive spirit of Hegel and the Buddha to substitute a postmodern alliance based on intersubjectivetough love.
All DBT involves two components:
- An individual component in which the therapist and patient discuss issues that come up during the week, recorded on diary cards, and follow a treatment target hierarchy. Self-injurious and suicidal behaviors take first priority, followed by therapy interfering behaviors. Then there are quality of life issues and finally working towards improving one's life generally. During the individual therapy, the therapist and patient work towards improving skill use. Often, a skills group is discussed and obstacles to acting skillfully are addressed.
- The group, which ordinarily meets once weekly for two to two-and-a-half hours, learns to use specific skills that are broken down into four modules: core mindfulness skills, interpersonal effectiveness skills, emotion regulation skills, and distress tolerance skills.
Mindfulness
Mindfulness is one of the core concepts behind all elements of DBT. Mindfulness is the capacity to pay attention, nonjudgmentally, to the present moment. Mindfulness is all about living in the moment, experiencing one's emotions and senses fully, yet with perspective. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional Buddhist practice, though the version taught in DBT does not involve any religious or metaphysical concepts.
Interpersonal effectiveness
Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.
Individuals with borderline personality disorder frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioral sequence when analyzing his or her own situation.
The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g., requesting that someone do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect.
Emotion regulation
Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. Dialectical behavior therapy skills for emotion regulation include:[4][5]
- Identifying and labeling emotions
- Identifying obstacles to changing emotions
- Reducing vulnerability to emotion mind
- Increasing positive emotional events
- Increasing mindfulness to current emotions
- Taking opposite action
- Applying distress tolerance techniques
Many current approaches to mental health treatment focus on changing distressing events and circumstances. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully.
Distress tolerance skills constitute a natural development from mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Although this is a nonjudgmental stance, this does not mean that it is one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.
Skills for acceptance include radical acceptance, turning the mind toward acceptance, and distinguishing between "willingness" (acting skillfully, from a realistic understanding of the present situation) and "willfulness" (trying to impose one's will regardless of reality). Participants also learn four crisis survival skills, to help deal with immediate emotional responses that may seem overwhelming: distracting oneself, self-soothing, improving the moment, and thinking of pros and cons.
Big thanks to Wikipedia for this. And even bigger thanks to Marsha Linehan for creating what was truly a 'breakthrough' therapy for people with BPD.
3. Getting the most from therapy
There's an excellent feature on how to really benefit from therapy:
Therapy 101, How To Succeed in Therapy
http://www.orangecountycounseling.com/relationships/advanced-therapy-guide.html
)
