Dialectics in Behavior Therapy

Dialectics in Balancing Goals

Maintaining a dialectical stance can be hard for therapists because the pull is to become locked into a concept at either end of the pole rather than directly experience how two truths stand side by side as part of a larger synthesis. This can be particularly difficult for two of DBT's main goals enhancing client emotion regulations and decreasing priority targets such as self-injury. For this reason, DBT therapists view both these goals in dialectical terms.

Dialectics of Emotion Regulation

DBT (Dialectical Behavior Therapy) proposes a dialectical goal regarding emotion regulation. Clients learn skills to change emotion and to accept emotion as it is. In the abstract, these positions seem contradictory, a mixed message about how to respond to private experience. Yet we examine our actual experience, the paradox resolves. The most difficult moments of our lives often require both downregulating (changing and mindfully experiencing (accepting) our emotional responses..

Consider a clinical example. A client, in bitter divorce proceedings, lost primary custody of her 2-year-old daughter. The husband's lawyer built a humiliating account of her repeated psychiatric hospitalizations and suicide attempts, successfully negating her more recent treatment progress. Anyone would feel anguished at losing custody, especially when one's own transgressions contributed to the decision. However, for this client, her emotions were at an unrelenting, all-consuming intensity. She was crazed with pain. Contact with her ex-husband, both in real life and imagination, was like a match to gasoline. Her pain would ignite into rage and revenge fantasies. She loathed herself, certain that his claim she was a terrible mother was true and her daughter would be better off without her. She sobbed, grief-stricken each time she imagined a future without living day to day with her daughter. She had urges to capitulate and give up visitation rather than endure the pain. She sat in shock, detached and numb for hours.

She had little time, however, to sort out these feelings to inform her next set of actions because the court required that she begin mediation to determine visitation privileges. To establish credibility and best negotiate terms for visitation the client needed to demonstrate her competence. In these emotionally challenging interactions with the court or her ex-husband, her mind was in an uproar. Yet if she displayed even a whiff of emotion dysregulation, her husband would use it against her. Her goals in the situation demanded exquisite emotion regulation.

Dialectics in our beliefs. Photo by Elena.

Based on the chain analysis, the therapist and client identified shame as the primary emotion that led to the most escaping into problematic responding. This was especially the case when the client heard or thought she was a “bad mother.” In one extended session, the client and therapist looked in an unflinching way at how this criticism was true; that is, the client listed all the ways she had failed her daughter and failed to meet her own standards. The therapist used validation to hold the client in informal exposure episodes so that she could experience shame without escaping into problematic secondary responses.

Validation also cued adaptive emotion: the reason for her hurt and shame was how desperately she loved and wanted the best for her daughter, how terribly she longed to be a good mother. The client and therapist practiced the Dialectical Behavior Therapy skill of radical acceptance, looking at the causal web that created all the conditions that led to the failings as a mother, without sugarcoating the harm the client had done. Both spontaneously and with the therapist's help, the client experienced how shame transformed into deep regret and the healthy action urge to make amends and repair the damage. She found a kernel of pride at how fiercely she was using this therapy to change to do better by her daughter.

The client also struggled with rage at her husband, Here the therapist helped the client actively downregulate anger and avoid anger cues in order to avoid physically or verbally attacking her husband or his property (which she had done many times in the past). For example, the client's friends loyally sided with her, and fueled her anger by doing things like using the husband's picture as a dartboard, plotting to ruin his reputation at work, and talking endlessly about how unfair he had been. In the lead up to the mediation meeting, the client recruited her friends to change tactics with her: they either talked about the circumstances in a completely low-key nonjudgmental manner (e.g., “divorces are really hard”, “there are things about this situation I don't like”) or they avoided the topic and focused on areas where the client was building a new life.

Balancing therapy and life. Photo by Elena.

Further, the client and therapist identified the two most anger-provoking things the husband did and practiced drills where the therapist presented the cues and the client deliberately altered her breathing to calm herself. She inhaled for a count of 3, held her breath for a count of 2, then exhaled for 5, slowly and fully, pausing for 2 counts at the end of the exhalation. In this practice, she actively imagined picking up each thought or emotion about her situation and putting it in a box, gently saying “later”. She practiced this exercise and radical acceptance of shame on her own while gazing at a picture of her husband holding their daughter. She repeatedly put the picture into an envelope and then brought it out again to gaze at the picture and practice. The client learned how to control her attention in order to make fuller contact with emotion cues. She also learned to distract from emotion cues in order to down-regulate emotion. From a dialectical perspective, both approaches are valid and the focus was to help the client discriminate when either strategy did or did not fit her goals in the moment.

Dialectically Balancing Strategies

Using strategies dialectically keeps the therapy moving through impasse.  Validation strategies are dialectically balanced with behavioral strategies such as orienting, commitment, chain analysis, and problem solving. Three other important strategy sets are used dialectically to prevent rigid polarization: stylistic strategies, case management strategies, and specific dialectical strategies. Stylistic strategies  offer a practical dialectic in how the therapist communicates, balancing being warmly reciprocal and irreverently confrontive. Case management strategies concern how the therapist helps the client to navigate his or her social environment, balancing consulting to the client with direct intervention on the client's behalf in some limited cases. Specifically, dialectical strategies directly target polarization. In each case, the aim is to create the appropriate mix of acceptance of the client's vulnerability and change that recognizes the client's strengths.

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

The last leaves. Photo by Elena.

Say It with Flowers

Say It with Flowers

By Poul Anderson

Save for a bunk, the cabin was bare. Tiny, comfortless, atremble with the energies of the ship, it surrounded Flowers like a robot womb. That was his first thought as he struggled back to consciousness.

The, through the racking stutter of a pulse run wild, he knew that hands lifted his head off the deck. He gasped for breath, Sweat drenched his coverall, chill and stinking. Feat reflexes turned the universe into horror. Through blurred vision, he looked up at the bluejacket who squatted to cradle his head.

“Flip that intercom, Pete!” the North American was saying. “Get hold of the doc. Fast!”

Flowers tried to speak, but could only rattle past the soreness in his throat.

The other guard, invisible to him, reported: “The prisoner, sir. We heard him call out and then fall. He was unconscious when we opened the door. Come to in a couple of minutes, but he's cold to touch and got a heartbeat like to bust his ribs.”

“Possibly cardiac,” said the intercom. “Carry him to sickbay. I”ll be there'”

Flowers tried to relax in the arms of the young men and bring his too rapid breathing under control. That wasn't easy. When they laid him on an examination bench, amidst goblin-eyed instruments, he must force his spine to unarch.

The medical officer was a chubby man who poked him with deft fingers while reeling off, :Chest pains?” Shortness of breath? Ever had any seizures before?” He signaled an orderly to attach electrodes.

“No. No. I ache all over, but -”

“Cardiogram normal, aside from the tachycardia,” the doctor read off the printouts.

“Encephalogram... hm-m-m, hard to tell, not epileptiform, probably just extreme agitation. Neurogram shows low-level pain activity. Take a blood sample, Collins.” He ran his palms more thoroughly over abdomen, chest and throat. “My God,” he muttered, “where did you get those tattoos?” His gaze sharpened. “Redness here, under the chin. Sore?”

“Uh-huh,” whispered Flowers.

“What happened to you?”

“I dunno. Started feeling bad. Blacked out.”

A chemical analyzer burped and extruded a strip of paper. The orderly ripped it off. “Blood pH quite high, sir,” he read. “Everything else negative.”

“Well-” The doctor rubbed his chin. “We can't do more except take an X-ray. A warcraft isn't equipped like a clinic.” He nodded at Flowers. “Don't worry. You'll transfer to the other ship in half an hour or so, and I understand she's going almost directly to Vesta. The camp there has adequate facilities. Though you look a little better already.”

“What... might this... a been?” Flowers managed to ask.

“My guess,” said the doctor, “is an allergic reaction to something you ate. That can overstimulate the vagus nerve and produce these other symptoms. You asterites never see a good many Terrestrial foods, and this navy prides itself on its menus. I'll find out what went into your dinner, including seasonings, and give you a list. Avoid those things, till the culprit has been identified, and you may have no more trouble.”

Flowers lay back while they X-rayed him. That was negative, too. The doctor said he could stay where he was, under guard, till transfer time. He stared at the overhead and concentrated on getting well.

I love you enough to tell the truth, but you must be brave enough to accept it (en anglais). Photo by Elena.

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.