Another fascinating insight from DBT founder Marsha Linehan

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There is not a day that goes by that I don’t think, “Thank goodness for Marsha Linehan,” the developer of Dialectical Behavior Therapy (DBT). She has taught us so many ways to increase skillful behavior.

It happened again recently while I was attending the Latin American Conference on DBT in Argentina.

After missing her international flight from Seattle due to weather, her presentation was rescheduled for 8 a.m. the following day. I value hearing Marsha speak, but I didn’t make it to the conference venue that early. When I did arrive, I learned she had taught a new skill.

My disappointment turned to anxiety when the conference coordinator asked me to sit with Marsha while he took care of some things; I wondered, “Does she knows I missed her talk?”

After a quick kiss on each cheek (we were in Argentina, after all), Marsha moved right in: “So, Lucene what did you think of my talk?”

Oh snap! Now what? What happens if you lie to the developer queen of DBT? In my mind, I ran through the pros and cons of lying and decided instead to be radically genuine: “Marsha, I missed your talk. I really needed the extra sleep. I am sorry I missed it though, because I hear you taught a new skill.”

Marsha let me off the hook: “I support sleep”, she said. “You need it to function effectively.”

Marsha then relayed the following story: After missing her connecting flight she was forced to sleep on the floor at the airport.

She told me she figured out a skill that helps you get to sleep. As someone who struggles with sleep when I travel, I was all ears.  She described the skill as a combination of mindful breathing and counting. Breathe in, count one, breath out count two, and continue until you fall asleep.

Incredulous, I complain: “Marsha, that’s not a new skill; that’s counting sheep.”

“Oh no,” she drawled, “This is different. You breathe and count mindfully and when your mind wanders, don’t go back to one; just pick up where  you left off and continue until you fall asleep.”

I still thought it sounded a lot like counting sheep.

That night, in my strange Argentine hotel room, I had trouble falling asleep. Begrudgingly, I used the strategy… and it worked. Somehow the combination of mindful breathing and not having to start back at one when I got off track was effective for me.

I shared this story with a colleague. He told me he had discovered the same method for falling asleep through yoga. He suggested that the real difference between counting sheep and Marsha’s method is the absence of self-judgment.

If you lose count and have to start over at one, it feels like a penalty, he said. Even though it’s actually a sign that you’re starting to doze off, some small corner of your brain is trying to stay more alert so you don’t have to go all the way back to one again.

The small difference of picking up wherever you think you left off is like giving yourself permission to be imperfect.

This made sense to me. Marsha’s method is fundamentally mindful, non-judgmental breathing and counting. It’s so beautifully DBT. This must be, I think, exactly what Marsha was going for. My conclusion: Marsha Linehan is a genius (but you already knew that).

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How DBT helps when the client has something difficult to tell the therapist

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Previously, I’ve written about the framework DBT provides to help therapists address therapy interfering behaviors in session with their clients.

But what if the client feels the therapist is engaging in behaviors that interfere with treatment? How do you have these conversations? DBT offers some guidelines about this as well. (Frankly, these strategies may help you have courageous conversations with ANYONE important in your life.)

1. Remember: In DBT the therapist and client are considered to have a relationship between equals. This suggests that it is reasonable – perhaps even EXPECTED – that if you have a problem with the other person, you will talk about it.

This is true in most relationships, why should the therapy relationship be different?  Find a nonjudgmental/compassionate way to understand the therapist’s behavior. Try to remember that your therapist is on your side, that she or he is human, and that we all make mistakes. In DBT we call this “phenomenological empathy.”

2. Before having the conversation, do some prep work. This is not a conversation to take lightly, and it requires some thinking-through before executing.

Clarify the issue in your mind: What exactly is the problem you want to discuss with your therapist? Make it behavioral and objective. For example:

  • You are wondering if your symptoms are improving.
  • You would like your therapist to give you more validating statements.
  • It would help for the therapist to push you harder and focus on change.
  • You want your therapist to start sessions on time.
  • Your therapist said something in the last session that has left you feeling judged and confused.

Practice your emotion regulation and distress tolerance skills to effectively manage your emotions.

3. Consider putting the issue on the DBT session agenda. If you need to have a difficult conversation with your therapist, add it to Target 2 when setting the agenda for the session. This puts it out in the open and decreases the possibility that you will run out of time (or avoid bringing it up in the first place). In session, observe and describe the behavior and why you see it as a problem. Consider using your Interpersonal effectiveness skills.

4. Ask for collaboration on what to do about it. Can we talk about how to best handle this? And Reinforce your therapist for collaboration. Thanks for hearing me out… Thanks for being willing to work on this with me…  It really means a lot to me….  (even therapists need to hear some positive words).

Remember that you can practice having this conversation in your DBT skills group or get some coaching from your skills group leader. If you are not in a DBT skills group, find one; it will change your life.

Go forth and have courageous conversations!

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Courageous conversations about Therapy Interfering Behaviors

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In Dialectical Behavior Therapy, we use the construct of Therapy Interfering Behaviors (TIBs) to discuss issues that get in the way of us providing, or the client receiving, expert DBT treatment. Identifying TIBs is one thing; addressing them is another.
How do you define a Therapy Interfering Behavior? How do you conceptualize it? How do you phrase it in conversation? When do you talk about it? Where do you start? Here are some recommendations

  1. Do some prep work. This is not a conversation to take lightly, and requires some thinking through before executing.

a. Clarify the issue in your mind: What exactly is the problem you want to discuss with your patient? Make it behavioral and objective.

b. Find a compassionate way to understand the behavior. Is this an example of trying to get one’s needs met? Has she been reinforced for this in the past? In DBT we call this phenomenological empathy. Thinking of the behavior in this way can help us to find more understanding and care.

c. Practice stating it in a non-judgmental way. Most of us have negative emotions when we feel judged.

2. Consider timing. Is this a good time to bring up this issue? It is not likely a good time if the behavior is happening in the moment and you haven’t already discussed it.

If you tend toward avoidance, you might want to do it now (no time like the present). If you are a little on the impulsive side, you might want to move more deliberately and consider if there would be a better time to have this discussion.

3. Get Confirmation. Using observe-and-describe skills, share the behavior and why you see it as problematic. This is important: Confirm that the patient understands the problem you defined. Say, “Tell me back what you are hearing me say.” Listen to make certain that the individual is hearing the message you intended to deliver. I find this step to be crucial.

4. Ask for collaboration. Don’t assume the patient wants to change the behavior you find a problem. If willing, collaboratively develop a plan to address the issue .

The notion of addressing difficult behaviors is important to all relationships, not just to therapeutic ones. I use these strategies with my loved ones as well – when a relative makes a comment about my parenting, or my son has left his wet shower towel on the bed (again!). Go forth and have courageous conversations!

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