Two things make DBT unique. The first is the dynamic balance between acceptance of oneself and one’s situation in life, on the one hand, and embracing change toward a better life, on the other. (That is what “dialectics” means—the balance of opposites and the coming to a synthesis.)
The solution I arrived at was to find a way to balance both acceptance and change, a dynamic dance between the two: back and forth, back and forth, back and forth. This balance between pursuing change strategies and pursuing acceptance strategies is a basis of DBT, and unique to DBT. This emphasis on acceptance as a counterbalance to change flows directly from the integration of Eastern (Zen) practice, as I experienced it, and Western psychological practice
The goal of any behavior therapy is to help individuals change behaviors, in particular behavior patterns that significantly disrupt their lives at home and in the workplace, and to replace those with more effective behavioral alternatives. Dialectical Behavior Therapy is a type of behavior therapy—but, as I just explained, it is very different from traditional behavior therapy.
Learning skills is central to the effectiveness of DBT: skills that help a client find a way to transform a truly miserable life into one that is worth living and in which the client is effective in her life. I have been privileged enough to witness this transformation many, many times.
But these same skills are extraordinarily important to each and every one of us in our daily lives. And, as such, you could call them life skills. They help us navigate relationships we have with loved ones, friends, colleagues at work, and the world in general, and they help us manage our emotions and overcome fears. They are important in how well we manage in the practical realm, such as doing a job well.
My stance toward each client is this: “You know what you need in your life, but you don’t know how to get what you need. Your problem is you might have good motives, but you don’t have good skills. I will teach you good skills.”
The fourth is the story of the enormous power of love in my life, of how love affairs both put me on top of the world and later caused one of the deepest sorrows of my life. The power of accepting the kindness and love of so many people who were always ready to pull me up. And, in turn, the power of loving others, which pulled me up from falling in its own way.
“apparent competence.” I’ll elaborate on this below, but in short, it is when an individual appears to be in control of her life while inside she is in complete emotional turmoil and pain.
“It is not enough to be compassionate. You must act.” Compassion without action is like going into that small white room that is a person’s individual hell, feeling a person’s pain, feeling a desire to get a person out of hell—but never finding the door to get the person out.
I needed skills. Skills to regulate my own emotions and behavior, skills to tolerate the pain I was living with, and the skills to effectively ask for and get what I needed.
The way I describe the situation is that Mother saw me as a tulip and desperately wanted to make me into a rose. She thought I’d be happier as a rose. But I did not have what it took to be a rose, not then and not now. This tulip/rose conflict eventually became part of the way I talk to my clients in DBT.
This is what I tell them:
If you’re a tulip, don’t try to be a rose. Go find a tulip garden.
All of my clients are tulips, and they’re trying to be roses. It doesn’t work. They drive themselves crazy trying. I recognize that some people don’t have the skills to plant the garden they need. But everybody can learn how to garden.
This constant disapproval, this constant pressure to be someone else—this is an example of a concept I came up with as I developed DBT: an invalidating environment and, in the extreme, a traumatic invalidating environment.
Traumatic invalidation may occur only once, as when a mother refuses to believe that her daughter is telling the truth when she reports sexual abuse, or when a witness falsely testifies that a person committed a crime he did not commit. It can be an accumulation of pervasive misreading of emotions by others, such as when someone insists incorrectly that a person is angry, jealous, afraid, or lying or insists that the person has internal motives he or she doesn’t have. Trauma is most likely when these actions make the individual feel like an outsider.
Imposing this rule on myself, to prevent destructive behavior and stay in a place that was at least tolerable, is an example of what I later termed “building a life experienced as worth living.” This is the overall goal of DBT. Even if you can’t create an ideal life for yourself, you have sufficient control to live a life that has enough positive elements to it that it is indeed worth living.
This dynamic became something of a pattern in my life: people telling me what I couldn’t do, and me thinking, “You just wait and see. I’ll show you.”
And eventually it became a good message for me, and also for my clients and their families: Believe, whether you believe or not. I tell them that it may be difficult to believe, but believe you must. You can do it.
I developed a strategy for managing my money so that I wouldn’t run out. I had to close a door in my mind, to tell myself a fiction about how much money I had, and to believe what I said to myself.
This sleight of mind, convincing yourself that something is true when in fact it is not, turned out to be a very helpful skill. It ultimately became an important DBT skill, particularly for people with addictions, a skill I named adaptive denial. Like many ideas in DBT, it is based on acceptance: accepting things as they are. In a later chapter I will tell you in detail how I used adaptive denial to help me stop smoking.
If you talk when you pray, it is a dialogue with someone separate from you. But if you don’t talk, there is nothing separate from you. You are as one with God. If you keep it up, there is every chance that you will ultimately experience that oneness. It is hard to articulate what I mean, just as with love it is hard to articulate what we really, deeply mean. In this case, it means I am in the middle of God.
Although Ted was fully and freely giving me what I needed, which was unconditional love and support, I was unable to say “Thank you.” I could say it later, but not as I was wrestling with such despair and loneliness. So, if you also are helping someone who is in hell, holding them physically and emotionally, don’t interpret their absence of thanks as a sign that you are not giving them what they desperately need. You very probably are. That’s the first lesson.
you are with someone who is in hell, keep loving them, because in the end it will be transformative. They are like someone walking in a mist. They don’t see the mist, and you may not see it, either. They don’t see that they are getting wet. But if they have a pail for water, you put it out in the mist. Each moment of love adds to the mist, adds to the water in the pail. By itself, each moment of love may not be enough. But ultimately the pail fills and the person who has been in hell will be able to drink that water of love and be transformed. I know. I have been there. I have drunk from that pail.
I love the organization’s motto: “Flowers before bread.” People need the special pleasures in life, in addition to the necessities. “Love, dignity and beauty in life are as essential to life as physical needs,” they assert. If I learned anything from my mother, I learned the value of beauty, and that the effort to bring beauty into any setting is worth the work it entails.
Gradually, my personal experience expanded to become a more universal understanding that God is in everyone and everything, loves everyone and everything. It was a recognition of a universal unity, a great oneness, and, as Sister Thérèse said, a universal goodness. Everywhere.
A behaviorist outlook is based on social learning theory, which is what its name implies: that much of an individual’s behavior is learned, through observing and mimicking others, rather than being driven by elusive inner forces or as mechanical responses to punishments or rewards.
One of the research projects was on assertiveness. I had a model that understood suicide as a cry for help—that suicidal people can’t get the help they need. Learning assertiveness is learning to be effective in the world, to be able to get what you need through effective behavior, while at the same time maintaining good relationships and maintaining your self-respect. If I could teach suicidal individuals how to be assertive, how to be effective, they would then be able to get the help they need
Assertiveness became one of a suite of DBT skills that enable people to be effective in their interactions with others. These skills equip individuals with the ability to achieve their goals while at the same time not alienating the other person or losing their self-respect. Assertiveness skills are change skills. (You will see later that DBT skills fall into one of two major categories: acceptance skills and change skills.)
Assertiveness skills are also the social skills you need to make new friends, maintain existing friendships, and recognize when a relationship is toxic and act on that. These skills come naturally to us, some more so than others. It is part of being the social creatures we are. But, no matter how good we are, practice always makes for greater effectiveness, and being effective in our relationships is the goal of interpersonal effectiveness skills.
Being assertive, for instance, helps you make clear to others what your immediate goals are. It is about being effective, doing what works. For instance, with a boss you might say, “I would like a raise. Can you give it to me?” Or with a spouse: “We simply do not have the money for the vacation we planned this year.” It is about being unambiguous in what you say and in your relationships with others.
DEAR MAN stands for “describe, express, assert, reinforce, (stay) mindful, appear confident, negotiate.”
Describe the Situation:
Begin by briefly describing the situation you are reacting to. This ensures that the other person is oriented to the events that led to the request.
Express Clearly:
Express clearly how you feel or what you believe about the situation. Don’t expect the other person to read your mind or know how you feel.
Assert Wishes:
Don’t beat around the bush, never really asking or saying no. Be clear, concise, and assertive. Bite the bullet and ask or say no.
Reinforce:
Explain to the other person that they, too, will benefit if they agree with what you are asking or saying. At a minimum, express appreciation after anyone does something related to what you are asking or saying.
(Stay) Mindful:
Be persistent in what it is you are asking for, saying, or expressing your opinion about. Do not be distracted or diverted into discussions about other topics. Keep going down the same path, in a mellow tone of voice.
Appear Confident:
Use a confident tone of voice, and display a confident physical manner and posture, with appropriate eye contact. No stammering, whispering, staring at the floor, retreating, saying you’re not sure, or the like. It is perfectly normal to be nervous or scared in a difficult situation; however, acting nervous or scared will interfere with effectiveness.
Negotiate:
Be willing to give to get. Offer and ask for alternatives.
Change your behavior and you will change your emotions. (Fear is an emotion.) When the facts say that what you are afraid of is not actually dangerous, the trick is to do just the opposite of your fear. Parents walk their child into the room; we get up our courage and assert ourselves with a person who is likely to respond well; you get back on the horse that is unlikely to throw you again. Sit in the room with the corpse to absorb the information that dead people don’t spontaneously rise up and your fear will go down.
Repeat opposite action as often as you can, over and over, every chance you get. Some of the time, opposite action works immediately. But most of the time you have to practice a lot before the emotion you are trying to control (fear, for example) abates.
I developed a line that encapsulates this new worldview:
You can’t think yourself into new ways of acting; you can only act yourself into new ways of thinking.
Persistence has pretty much defined me throughout my life: I doggedly pursue my goals, never giving up. Fulfilling my vow to God is an overarching theme, of course. With Gene, I couldn’t take no for an answer. It’s something I try to inculcate in my clients: Never give up. It doesn’t matter how many times you fall; what’s important is that you always get up and try again
Behavior therapy is the behaviorist’s tool to help people extinguish unwanted behaviors and ignite wanted behaviors. Behavior therapy may be thought of as a technology of behavioral change, in which assessment and treatment are soundly based on evidence collected in scientific observation. The focus of the treatment is to help clients replace negative behaviors, such as anger and aggression toward others, with positive behaviors, including acceptance and the understanding that there is no good or bad. It is about letting go of the negative in your life and embracing the positive.
But to approach problems more from a religious or spiritual perspective by learning to tolerate distress can be just as effective, and more readily achieved. This is my approach. An important distinguishing factor of DBT is its emphasis on learning how to tolerate and accept distress.
Why take this path? Two reasons. First, pain and distress are part of life; they cannot be entirely avoided or removed. A person who cannot accept this will find herself in more pain and more suffering in the long run. Second, in the larger context of life and how you might want to improve yourself, learning how to tolerate and accept distress is part of that general change toward self-improvement.
The intense exercise skill is simply engaging in an aerobic activity of your choice—running around the block or jumping on a trampoline, pedaling an exercise bike, using a StairMaster, anything that gets your heart rate up to around 70 percent of the maximum for your age—for about twenty minutes. Research shows that doing this increases positive emotions. You feel better about yourself and your circumstances, and you are better able to do whatever is necessary to start fixing your challenging circumstances.
