Dialectical Behavior Therapy

Doing Dialectical Behavior Therapy

 

Natural contingencies are the powerful natural consequences that occur within each therapeutoc interaction that are also similar to how things work in nontherapy relationships. Self-involving self-disclosure is one way the DBT therapist uses natural contingencies to benefit the client.

Interactions with the therapist or aspects of the therapy itself (e.g. Session frequency or length, payment) may evoke some of the same behaviors that trouble the client in other relationships. For example, the client takes an angry, demanding tone when he makes a request of the therapist that is an imposition of the therapists's time. Others in the client's life are turned off and withdraw from him when he does this to them; his angry tirades inhibit others from giving him feedback; he feels lonely and incapable of keeping good relationships. This is a key place to use self-involving self-disclosure to help the client see the contingency between his behavior and its effects. The therapist might say, “Your voice tone sounds quite angry and demanding as you ask me to do this for you. Were you aware of how your tone comes across? When you ask me in this way, it makes me feel less like doing it. If you asked in a way that showed you realize it may be an imposition, you'd get more of what you want from people.”

It is beneficial when the client engages in behaviors with the therapist that are similar to those that cause problems in other relationships because a well-known aspect of reinforcement is that the closer in time and place the behavior is to its consequences, the greater the effect of those consequences. The key is to be aware, from chain analysis and formulation in advance, of what you are trying to strengthen and what you do not want to reinforce. For example, in one case, others would not respond to an emotional pain of a person unless this person became dramatically upset and made extreme statements such as “I'm going to kill myself if she says that again!” The contingency in therapy should be different: you would want to tune in and respond to distress with plenty of help without in having to escalate.

Loneliness. Photo by Elena.

Therefore, warmth, care, and attention should be at a good baseline frequency so that low-level requests and expressions of difficulty regularly produce appropriate help. You would closely monitor the client's current vulnerability factors and antecedents so that when the chain to the pattern is triggered, you can quickly attend to emotional pain but block extreme statements. For example, when this person begins to tell you about an interpersonal conflict similar to those that have led to extreme statements and suicide threats, you might say “I'd really like to help you get things to go the way you want in this situation, so that you do not have to escalate but instead really get what you need.” You would stay responsive and warm to the client's appropriate expression, and become cooler when extreme statements are made, even actively blocking them. “When you threaten suicide, it makes us have to assess the risk. To me that takes a lot of time and distracts from what's most important, which is that you are upset by a real problem – could you tell be about it without the threats.

What happens close in time to the incident is more likely to affect the behavior's future probability. Treatment effects will be stronger, therefor, if client's problem behaviors and improvements occur during the session, where they are closest in time and place to the available reinforcement that the therapist can provide. Nowhere is this more visible than when the therapist and client negotiate solutions to problems in their therapy relationship by by explicitly discussing how each person's responses reinforce our fail to reinforce the other's motivation and engagement in therapy.

Some people have objections to contingency management, as if deliberately responding in a contingent way is harmful or deceitful. This objection ignores the fact that we are all responding contingently all the time with everyone anyway. If I am sharing something about myself, you are either responding in a way that makes me more likely to continue to share or less likely to continue to share; this happens whether either of is is aware of the effects or not. As therapists, we want to be as aware as we can be so that we harness our responses to the client's benefit rather than simply responding to alleviate our own discomfort. A good base rate of genuinely noncontingent positive regard is a prerequisite to effective use of contingency management. Unless the client experiences you as genuinely invested in his or her best interests, contingency management feels manipulative or coercive.

Doing Dialectical Behavior Therapy (A Practical Guide by Kelly Koerner)

Oblivion. Photo by Elena.

Cognitive Modification

Cognitive Modification

Effective behavior is sometimes inhibited by faulty beliefs and assumptions. In DBT cognitive modification is based on logical consistency or consistency with one's true or wise-mind beliefs (e.g., “Is this belief what I believe in my wisest moments?”) and on effectiveness (“Is this this belief useful to meet my goals?” This emphasis on finding what is valid is due in part to clients' sensitivity to invalidation. Focusing intervention on what is wrong with the client's interpretations, especially through Socratic questioning, is too evocative and aversive for many. Although the DBT therapist may sometimes challenge problematic beliefs with reason or through dialectical persuasion – conversations that create the experience of the contradictions inherent in the client's position. For example., in the last chapter a client described getting immediate relief from emotional pain when she burnt herself with a cigarette; she said it was no big deal. The therapist the asked the client would she burn her little niece's arm to help feel better, if the child was in great emotional pain? The client replied, “I just wouldn't do it. It's not right.” The conversation heightened the client's emotional tension and discomfort of holding a double standard. In dialectical persuasion, the therapist highlights the inconsistencies among the client's own action, beliefs, and values.

In addition, the therapist helps the client develop guidelines on when to trust and when to suspect her interpretations. For example, the skill “check the facts” distills many basic cognitive modification strategies into a self-help intervention. Further, in DBT, the therapist actively teaches the client to become better able to discern contingencies, clarifying the if-then effects of their behavior in the therapy relationship as well as in the client's other relationships. Clients learn to observe and describe their own thinking style, and implicit rules, to notice when their thinking is ineffective, and to confront and challenge problematic thoughts in order to generate a more functional or dialectical sense of truth. The client leans to increasingly rely on wise mind, an intuitive knowing that.

Yet change interventions can be experienced as highly invalidating. The therapist's attempts to help can  feel critical and can seem to confirm that the client has not tried hard enough – just as others have always said. Clients with histories of pervasive invalidation can be exquisitely sensitive. For this reason, active, disciplined, and precise validation of what is “right” or “correct” about the client's current responses in required to motivate emotion regulation and thereby create conditions for other change.

From Doing Dialectical Behavior Therapy (A Practical Guide by Kelly Koerner).

Reflections about our life... Photo by Elena.

Vox

Vox

A novel by Christina Dalcher, excerpt 

Sometimes, I trace invisible letters on my palm. While Patrick and the boys talk with their tongues outside, I talk with my fingers. I scream and whine and curse about what, in Patrick's words “used to be”.

This is how things are now: We have allotments of one hundred words a day. My books, even the old copies of Julia Child and – here's irony – the tattered red-and-white checked Better Hones and Gardens a friend decided would be a cute joke for a wedding gift, are locked in cupboards so Sonia can't get the. Which means I can't get at them either. Patrick carries the keys around like a weight, and sometimes I think it's the heaviness of this burden that makes him look older.

It's the little stuff I miss most: jars of pens and pencils tucked int the corners of every room, notepads wedged in between cookbooks, the dry-erase shopping list on the wall next to the spice cabinet. Even my old refrigerator poetry magnets, the ones Steven used to concoct ridiculous Italo-English sentences with, laughing himself to pieces. Gone, gone. Like my e-mail account.

Like everything.

Some of life's little silliness remain the same. I still drive, hit the grocery store on Tuesdays and Fridays, shop for new dresses and hand-bags, get my hair done once a month down at Iannuzi's Not that I've changed the cut – I'd need too many precious words to tell Stefano how much to take off here ad how much to leave there. My leisure reading limits itself to billboards advertising the latest energy drink, ingredients lists on ketchup bottles washing instructions on clothing tags: Do not bleach.

Riveting material, all of it.

Sundays, we take the kids to a movie and buy popcorn and soda, those little rectangular boxes of chocolates with the white nonpareils on top, the kind you find only in movie theaters, never in the shops. Sonia always laughs at the cartoons that play while the audience files in. The fils are a distraction, the only time I hear female voices unconstrained and unlimited. Actresses are allowed a special dispensation while they're on the job. Their lines, of course, are written by men.

During the first months, I did sneak a peek at a book now and again, scratch a quick note on the back of a cereal box or an egg carton, writhe a love note to Patrick in lipstick on our bathroom mirror. I had good reasons, very good ones – Don't think about them, Jean; don't think about the women you saw in the grocery store – to keep note writing inside the house. Then Sonia came in one morning, caught the lipstick message she couldn't read, and yelped, “Letters! Bad!”

I kept communication inside me from that point, only writing a few words to Patrick in the evenings after the kids were in bed, burning the paper scraps in a tin can. With Steven the way he is now, I don't even risk that.

Patrick and the boys, out on the back porch close to my window, are swapping stories about school, politics, the news, while crickets buzz in the dark around our bungalows. They make so much noise, those boys and those crickets. Deafening.

All my words ricochet in my head as I listen, emerge from my throat in a heavy, meaningless sigh. And all I can think about are Jackie's last words to me.

Think about what you need to do to stay free.

Venus. Photo by Elena.

About Perpetual Machines

About Perpetual Machines

Were it not for the first law of thermodynamics, we could build perpetual machines of the first kind, as they are called, whose driving power comes from nowhere. Were it not for the second law of thermodynamics, we could build perpetual motion machines of the second kind, which would draw their energy from anywhere. For instance, a motor at room temperature could be driven by the air molecules that happen to collide with is piston. The impossibility of this is not immediately obvious, which is why it was not established until the 19th century and is still overlooked in many science fiction stories.

Numerous people who understand the second law as a principle governing heat engines can get bewildered about the wider applications. These involve entropy, about which science fiction has also perpetrated a great deal of nonsense. Actually entropy is a measurable quantity, though you need calculus to describe it mathematically. In any thermodynamic process where an amount of heat Q is exchanged at a temperature T (which may vary throughout the volume and during the time in which things happen), the increase of entropy is equal to the integral of dQ/T.

Now “increase” can be negative, that is, represent a decrease. When something occurs thermodynamically in a system, entropy can and often does decrease somewhere. However, it increases elsewhere, and the second law states that the total gain in entropy is always positive. That is, whenever a change involving an energy transfer takes place in a system, entropy always is greater at the end of the process than it was in the beginning.

A “system” can be anything: an atom, a molecule, a machine, a living organism, a galaxy, the cosmos as a whole, anything. But we must consider the entire system, not just a selected part of it.

An increase in entropy corresponds tp, or measures an increase in disorder, or a decrease in the orderliness of the system. Therefore, whenever something changes, we find there is less order afterward than there was before.

Here is a very rough example or analogy. Think of a house whose lady has brought it to absolutely perfect arrangement and cleanliness – not a single item of furniture out of place, not a speck of dirt or dust anywhere, Then her children come home from school and her husband home from the office, and the family starts using the place. Things happen in it The immaculate condition doesn't last long, does it?

True, next morning the lady can restore her dwelling to its former orderliness. However, to do so she must expend energy, both her own and the energy of whatever appliances she uses, such as a vacuum cleaner. That energy comes from the conversion of food in her body – or fuel in an electric generator somewhere – into disorganized gasses and masses. The house may become neat again, but the environment as a whole is more chaotic than it was.

This is not an argument against good housekeeping! It is simply a reminder that everything has its price.

All biological processes require entropy increase. Illustration by Elena.

Epilogue

Epilogue

By Poul Anderson

There was no soil, only sand, rusty red and yellow. But outside the circle which had been devastated by the boat's jets, Darkington found the earth carpeted with prismatic growth, a few inches high, seemingly rooted in the ground. He broke one off for closer examination and saw tiny crystals, endlessly repeated, in some transparent siliceous material: like snowflakes and spiderwebs of glass.

It sparkled so brightly, making so many rainbows, that he couldn't well study the interior. He could barely make out at the center a dark clump pf wires, coils transistors? No, he told himself, don't be silly. He gave it to Frederika, who exclaimed at its beauty.

He himself walked across an open stretch, hoping for a view even vaguely familiar. Where the hillside dropped too sharply to support anything but the crystals – they made it one dazzle of diamonds – he saw eroded contours, the remote white sword of a waterfall, strewn boulders and a few crags like worn-out obelisks. The land rolled away into blue distances; a snowcapped mountain range guarded the eastern horizon. The sky overhead was darker than in his day, faintly greenish blue, full of clouds. He couldn't look near the fierce big sun.

Kuroki joined him. “What d'you think, Hugh?” the pilot asked.

“I hardly dare say. You?”

“Hell, I can't think with that bloody boiler factory clattering at me.” Kuroki grimaced behind his faceplate. “Turn off your sonic mike and let's talk by radio.”

Darkington agreed. Without amplification, the noise reached him through his insulated helmet as a far-off tolling. “ We can take it for granted,” he said, “that none of this is accidental. No minerals could simply crystallize our like this.

“Don't look manufactured to me, though.”

“Well, said Darkington, “you wouldn't expect them to turn out their products in anything like a human machine shop.”

“Them?”

“Whoever... whatever made this. For whatever purpose.”

Kuroki whistled. “I was afraid you'd say something like that. But we didn't see a trace of – cities, roads, anything – from orbit. I know the cloudiness made seeing pretty bad, but we couldn't have missed the signs of a civilization able to produce stuff on this scale.” 

“Why not?” If the civilization isn't remotely like anything we've ever imagined?”

Frederika approached, leaving a cartful of instruments behind. “The low and medium frequency radio spectrum is crawling,” she reported. “You never heard so many assorted hoots, buzzes, whirrs, squeals, and whines in your life.”

“We picked up an occasional bit of radio racket while in orbit,” Kuroki nodded. “Didn't think much about it, then.”

“Just noise,” Frederika said hastily. “Not varied enough to be any kind of... of communication. But I wonder what's doing it?”

“Oscillators,” Darkington said. “Incidental radiation from a variety of – oh, hell, I<ll speak plainly – machines.”

“But - “ Her hand stole toward his. Glove grasped glove. She wet her lips. “No, Hugh, this is absurd. How could any one be capable of making... what we see... and not have detected us in orbit and - and done something about us?”

Darkington shrugged. The gesture was lost in his armor/  Maybe they'r bidding their time. Maybe they aren't here at the moment. The whole planet could be an automated factory, you know. Like those ocean mineral harvesters we had in our time” - it hurt to say that - “which Sam mentioned on the way down. Somebody may come around periodically and collect the production.”

“Where do they come from?” asked Kuroki in a rough tone.

“I don't know, I tell you. Let's stop making wild guesses and start gathering data.”

Silence grew between them. The skeleton towers belled. Finally Kuroki nodded. “Yeas. What say we take a little stroll? We may come on something.”

Nobody mentioned fear. They dared not.

Silence grows. Photograph by Elena.