Although these priorities are presented in order of Importance however DBT practitioners believe they are all interconnected. If a person does not stay alive, they will not have the chance to receive help. If they don’t stay in therapy, they won’t get the help they need to change their quality of life. DBT aims to convince people to stay alive, stay in therapy and build a life worth living. As the person makes a commitment to life and to stopping self-destructive behaviors, DBT provides them with support in learning how to create and keep a life that is sustaining.

Some assumptions about DBT:     (from the TARA website www.tara4bpd.org)
• People with BPD are doing the best they can.
• People with BPD want to improve.
• People with BPD need to do better, to work harder, and be motivated to change.
• The lives of suicidal BPD individuals are unbearable.
• People with BPD must learn new Behaviors. for all aspects of their lives.
• People cannot fail in DBT.
• Therapists treating people with BPD need support
• Families coping with people with BPD need support.
• Stress related dissociative symptoms such as paranoia; feeling as though
  they are losing touch with reality; feeling victimized; unable to accept responsibility.
• BPD is extremely painful to the patients, to those who live with them and to
  society. People with BPD experience emotions intensely and are very vulnerable.
  They are among the most intensive and extensive utilizers of mental health services.

Top

 
Dialectical Behavioral Therapy (DBT): Is it Enough? by Tami Green

We recently featured an article which provided an extensive list of DBT inpatient facilities. Our reporter, Kara Kelly, spent considerable time researching these places and the result is a valuable resource for you. Readers since then have also suggested a few other DBT centers and hospitals, and we’ve added them to the bottom of Kara's article for you.

I also received a lot of feedback on that article from folks who have benefited by non-DBT treatment options and it occurred to me that I’ve given most of my airtime to only one recovery alternative.

Up front, to set the record straight, DBT is not the best treatment option for Borderline Personality Disorder. It is one of many, and arguably not the best for some. However, it is possibly the most widely-available option in the United States at this time, one I used, and I have also seen it transform many lives in my on-line classes.

With DBT alone, I would not have a life worth living, because, while the skills reduced my symptoms enough to be able to move on to the next stage, it did not assist me in developing a strong sense of self nor a game plan for getting my relationships, body and career on track. I used life coaching to help me get in touch with who I was and what I wanted in life. The result of coaching, and also some non-DBT therapy, is that people and circumstances now don’t knock me off course—I know me, and that remains constant.

So what exactly is DBT and where might it fall short?

DBT is a compilation of practical, yet brilliant, skills to be practiced each week, with one building upon the other. The most important of the skills is mindfulness, which is the ability to focus entirely on the present, while pushing all distractions more

Top

Dialectical Behavior Therapy Skills Part 1:       Mindfulness

      The "how" skills, which are methods by which clients can accomplish the goals of the "what" skills, consist of three components: the nonjudgmental skill, focusing on one thing in the moment, and being effective.  The nonjudgmental skill teaches us to dampen our natural tendency to apply evaluative labels to our experiences.  The rationale for this is that, quite often, our labels are based on distorted automatic thoughts, are vague, and leave us without any guidance as to how to resolve the situation.  In this sense, the skill is quite similar to cognitive restructuring, which we described in detail in a prior article.  Instead of thinking "I'm stupid," a student is trained to think "I received a failing grade on this test, and I am frustrated by that, so I need to meet with my teacher and change my approach in order to reach the final grade that I need."  In teaching clients to focus on one thing in the moment, the second "how" skill, DBT again emphasizes the importance of breaking ruminative cycles that are certain to increase the longevity and severity of our negative emotions.  In the third "how" skill, being effective, clients are taught to shift their focus away from how they wish things were, instead choosing to engage in behaviors that are the most likely to help them accomplish their goals.  The rationale behind this skill, much like several of the others, is to help the client prioritize proactive solutions to problems and to diminish the tendency to lose control of their thoughts and spiral into rumination.

    Okay, having explained the mindfulness skills as described in the Skills Training Manual for Treating Borderline Personality Disorder, I suspect that this topic still remains a bit more theoretical than most readers anticipated given the topics we have covered thus far on PBB.  That being said, let's try and consider what I described above in the context of every day life.  All of us can relate to times when we have been upset and become lost in our own thoughts.  Invariably, even when such thought spirals feel productive at the time, we eventually realize that we were exerting very little control over what we were thinking about at the moment.  Mindfulness teaches how to attain that control.  The best way for anyone to fully understand the meaning of mindfulness is through practice.  As such, I want to conclude this article by explaining a few quick mindfulness exercises.  Ideally, I would love for this to result in at least two types of responses.  First, responses from readers regarding their varying levels of success with the exercises - what went well, what did not.  Second, responses from readers regarding other mindfulness exercises worth trying.  Not everyone responds to each exercise the same way.  The key is finding something that works for you that you can apply in just about any situation when you start feeling upset.  Learning to do so will help you prevent overly powerful emotional spirals before they reach their peak.

1. Focus on breath:  In this exercise, often the first one taught in a group, your aim is to focus only on your breath. Feel the air as it passes down to your lungs.  Notice everything about the physical sensations associated with the passage of air with each breath.  Each time you complete a cycle of inhale/exhale, count it.  Start with one, count up to ten, and then reverse back down to one.  Here's the trick though, any time you have a thought other than a description of your breath and the number of breaths you have taken, start over again.  That includes thoughts like "this is hard," "I'm focusing on my breath right now," and "mindfulness is crazy."  Remember, we're being nonjudgmental here, so do not be critical of yourself.  Simply notice that a thought crept in and move your attention back to your breath.  It is extremely difficult if not impossible to accomplish a one to ten and back to one progression of counting, so the goal isn't really to finish, but rather to give you a neutral stimulus to focus on rather than your own emotionally charged thoughts.  After a few minutes of doing this (maybe even less), you'll likely feel less emotional and be in a better position to address whatever was making you upset.  There is nothing magical about your breath, but focusing on your breath instead of ruminating is a sure fire way to attain wise mind and thus put yourself in a position to make healthy behavioral choices.

2. Focus amidst distractions:  We often need to use mindfulness skills when the world around us is chaotic.  As such, this skill teaches you to chose a thought amidst stimuli competing for your attention.  Choose a song to play.  Before you start the song, decide on where you will focus your attention, but choose something other than the song.  In other words, I might choose to focus on an image in my head of the beach on Sanibel or on a box of tissues on the table in front of me.  As the song plays, maintain your focus on the thought you chose.  Observe and describe it, using only facts and withholding judgment.  Each time your thoughts wander, pull them back to your original thought rather than allowing the song to dictate your focus.

3. Mindfully attend to a pet:  If you have a pet, they will love this one.  Spend the next five minutes petting your animal.  Notice what its fur feels like, the pace at which it is breathing, the color of its eyes, or anything else about the pet that you notice.  Do not allow your mind to wander back to memories with your pet.  Keep your focus entirely on the sensations present in that moment.
   
   In all likelihood, as you attempt these skills, you'll find that it is exceptionally difficult to maintain complete control over your attention.  You'll notice things that you previously did not attend to, like the clicking of a clock, the sound of a fan, or the temperature of the surface on which your hand is resting. Now imagine how hard it would be to do this if you were upset. Taking it one step further, imagine how difficult it is for somebody who has difficulties regulating their emotions in general.  These skills require patience and practice, so do not expect to notice changes overnight, but trust that mindfulness can offer impressive reductions in stress and an increased tendency to fully enjoy your surroundings.
   
   Top
   
    

   Dialectical Behavior Therapy Skills Part 2:       Interpersonal Effectiveness

    by Michael D. Anestis, M.S.

       Yesterday, I began a discussion of DBT by providing an introduction to mindfulness, the core skills and first module of the treatment.  Today, I will shift my focus to the second module, interpersonal effectiveness.  Before doing so, however, a brief description of what goes on in a skills training group seems worthwhile.  Group sessions last two hours and typically include two co-leaders.  During the first hour, the group members take turns briefly explaining a time when they successfully implemented a DBT skill in the prior week as well as a time when they were less successful in utilizing a DBT skill.  Importantly, this is not treated as brief individual therapy sessions for each group member - that type of interaction is meant for the individual therapy component of DBT.  Instead, this is a teaching tool, an opportunity for clients to practice speaking about emotional events in an objective, fact-based manner and for group members to problem solve better ways for implementing certain skills into their lives.  Group members organize their information during the week on "diary cards," which list all of the DBT skills and provide space for the group member to indicate how often the skill was used and to list important notes.  The second hour of the group session is devoted to teaching new skills. 
    

    When a skills training group first forms, they begin with the first module of treatment, mindfulness.  After completing this module, the group transitions into interpersonal effectiveness.  Upon completion of the interpersonal effectiveness module, the group reviews mindfulness skills before moving onto module three, emotion regulation.  Mindfulness is then reviewed again prior to beginning the fourth module, distress tolerance.  Generally speaking, a skills training group will complete two full cycles in a calendar year.  Clients are told to expect to remain in treatment for two years, quite long for an empirically supported treatment.
   
       Borderline personality disorder (BPD), the disorder for which DBT was originally designed to treat, is characterized by stormy interpersonal relationships.  Many studies have examined this point empirically and found evidence supportive of this diagnostic criteria.  For example, Russell, Moskowitz, Zuroff, Sookman, and Paris (2007) found that individuals with BPD were more submissive and quarrelsome in interpersonal relationships than were individuals who did not meet criteria for a mental illness.  Additionally, Hill and colleagues (2008) found that, among DSM disorders (both Axis I and Axis II), BPD was the only disorder that specifically predicted dysfunctional romantic relationships and that individuals with BPD reported similar dysfunction in peer and work relationships.  Selby, Braithwaite, Joiner, and Fincham (2008) found that perceived emotional invalidation - the tendency to have one's emotional responses criticized and/or trivialized - partially explained the relationship between BPD and romantic relationship dysfunction.  So, given all of this evidence, the need for the development of more effective interpersonal skills appears quite clear.
   
        The skills that comprise the interpersonal effectiveness module are quite varied.  One key point that the group members are taught is that, in any interpersonal interaction, there are a variety of priorities that must be managed and how those priorities are attended to will, in large part, dictate the degree to which an individual feels like she effectively managed the encounter.  Specifically, Linehan points toward three types of effectiveness that must be considered in an interpersonal interaction:

   1. Objectives effectiveness

   2. Relationship effectiveness

   3. Self-respect effectiveness 

       Objectives effectiveness refers to prioritizing the accomplishment of clear, objective goals (e.g., obtaining a raise).  Relationship effectiveness refers to the prioritizing of maintaining a conflict-free relationship (e.g., ensuring your boss still likes you).  Self-respect effectiveness refers to prioritizing acting within your own principles so as to ensure that you feel comfortable with how you approached the situation (e.g., standing up for yourself, even if it costs you the raise and leaves your boss angry).  In any situation, all three priorities need to be considered and, to some degree, rank-ordered.  Whichever priority is of greater importance to the individual in that particular situation needs to be the primary focus, as regardless of the outcome of the situation, if that priority is addressed effectively, the individual is likely to feel reasonably satisfied with his role in the interaction.
   
       One of the reasons this skill is particularly effective is that it forces individuals to consider their desired outcomes prior to taking action.  Individuals with any of the disorders DBT has been shown to treat effectively (BPD, bulimia, and binge eating disorder) are typically characterized by a tendency to act impulsively when upset.  As such, they often act without thinking about consequences due to an overpowering urge to reduce distress.  As a result, conflicts become more likely and relationships become strained (or, alternatively, relationships are destructively fostered through undue submissions when the individual does not consider how being passive will impact his self-respect).
   
       Identifying priorities is certainly a healthy tendency, but realizing this is important is not sufficient.  Additionally, clients must learn how to go about enacting this interpersonal approach in their own lives.  The interpersonal effectiveness module addresses this in a variety of ways, but I will focus on one particular set of skills - "DEAR MAN."  DEAR MAN is an acronym comprised of particular methods for successfully navigating a potentially difficult interpersonal interaction.  The components of DEAR MAN are as follows:

   Describe
   Express
   Assert
   Reinforce

   (stay) Mindful
   Appear confident
   Negotiate

       To explain this skill, I will use a hypothetical example of Sarah, who approaches her roommate, Jessica about Jessica's refusal to wash her own dishes.  The first skill, describe asks Sarah to explain the situation to Jessica in concrete terms, without inserting her own interpretations or feelings (e.g., "Jessica, lately, I've noticed that you are piling your dishes in the sink rather than washing them."). 
   
       Express asks Sarah to explain how this situation makes her feel.  Notice, Sarah is asked to separate her feelings from the objective facts.  Additionally, Sarah is asked to explain how she feels rather than assuming that Jessica will just know on her own (e.g., "This is frustrating to me because a clean house keeps my stress levels down."). 
   
       The assert skill asks Sarah to clearly state her desired outcome (e.g., "What I would really like would be for us both to clean our dishes after we eat so they don't pile up and food does not have time to harden and become difficult to remove.").  In this skill, it is important to be mindful of your tone of voice and to remain calm and composed.
    Reinforce asks Sarah to explain why her goals will be beneficial (e.g., "If do this, I will feel significantly less stressed at night and will be much less likely to snap at you and be irritable.").  In doing this, Sarah provides motivation for Jessica to consider her proposal. 

   The stay mindful skill reminds Sarah to keep her focus on her goal.  Oftentimes, in potentially uncomfortable interactions, the other individual will either try to shift the focus of the conversation by bringing up other topics (e.g., "Well, you haven't been getting me your share of the rent on time, so I don't think you're in a position to criticize me.") or intimidate the initiator of the conversation by raising their voice, making threats, or calling names.  If Sarah takes the bait, either fighting back by calling names or yelling or discussing the new topic, her goal becomes lost and unlikely to be accomplished.  As such, she needs to not engage with Jessica when she tries such tactics.  Instead, she is instructed to ignore inflammatory comments and to act like a "broken record" by consistently reiterating her point.  In group, Sarah will learn to do this tactfully, taking care not to appear hostile in her response (e.g., "It sounds like there are some things you'd like for me to do differently too, but we're discussing the dishes right now.  Why don't we resolve this first and then we can figure out a plan for the rent check.").
   
   Top
   
       The appear confident skill essentially preaches the mantra of "fake it until you make it."  The appearance of confidence can have a significant impact upon the way a person is seen and how he or she is responded to during a conversation.  If Sarah is looking at the ground and stumbling over her words, Jessica will be less likely to take her seriously.  If, on the other hand, Sarah maintains eye contact and appears composed, Jessica will be more likely to consider her points and respond with respect.
   
       The final DEAR MAN skill, negotiate, teaches Sarah to give in order to get.  In other words, DEAR MAN is a method for increasing the likelihood that a fair outcome will be attained in an interpersonal interaction.  It is not a tool for making unsightly demands or ignoring the needs of others.  As such, by using the negotiate skill, Sarah will acknowledge Jessica's perspective and work with her towards a resolution, perhaps even asking Jessica what she thinks would be a good solution.
   
       As you have likely noticed at this point, the interpersonal effectiveness module is heavily reliant upon the idea that interpersonal situations are more successful when an individual plans ahead and proactively considers the potential utility of each course of action.  There are several more skills in this module as well as more detailed descriptions of the skills we covered in this article and we encourage you to read further as well as to comment here on DBT interpersonal effectiveness skills.  In part three of this series, we will cover emotion regulation skills.

   Dialectical Behavior Therapy Skills Part 3:    Emotion Regulation

   by Michael D. Anestis, M.S.

       The third DBT module, emotion regulation, is geared towards teaching individuals skills to better understand and adjust their affective states.  By the time a client reaches this component of DBT, she has received extensive training in mindfulness and interpersonal interactions.  The disorders typically treated through DBT, however, are characterized by unstable, overwhelming emotions, so clients are generally eager to develop these skills.
   
       The emotion regulation module generally begins with a discussion of the cycle that often characterizes emotional experiences.  A prompting event triggers automatic thoughts, which lead to an emotional experience, which in turn prompt a response.  The aftereffects of that response then start the cycle anew.  As an example, if Amanda gets stood up for a date, she might experience an automatic thought along the lines of "I am fat and undesirable."  This thought will lead to highly aversive, intense feelings of shame and sadness.  After brooding and wallowing in this upsetting series of thoughts and emotions, Amanda may then attempt to change her mood through a behavior like binge eating.  Although this behavior does offer immediate reductions in negative affect (Smyth et al., 2007), it is typically followed by additional intense negative feelings.  These feelings may then lead Amanda to withdraw socially, calling in sick for work the next day and sitting at home by herself ruminating and likely engaging in additional, similar cycles of emotion.
   
       DBT aims to prevent these cycles by educating clients about emotions and teaching them skills for more effective regulation.  The discussion of the nature of these cycles is thus followed up with a basic discussion of identifying and labeling emotions.  Alexithymia, defined as difficulty identifying, describing, and expressing emotions and somatic sensations (Sifneos, 1973), is common in borderline personality disorder (Barenbaum, 1996) and can result in a variety of maladaptive behaviors (Oyefeso, Brown, Chiang, & Clancy, 2008; Thorberg, Young, Sullivan, & Lyvers, 2009) due to a resulting lack of skills with respect to effectively managing emotion.  To address this, the emotion regulation module first teaches clients to effectively recognize and label emotions.  Referring to your mood by saying "I feel bad" or "I'm in a mood" is discouraged, with more precise descriptions such as "I am feeling frustrated" encouraged instead.  The purpose for this semantic shift is to prevent clients from viewing their emotions as vague, uncontrollable forces and to teach them to differentiate between different emotional states so as not to relate each negative emotion to all over negative things that have ever happened to them in the past.
   
   Top
   
       Building off this point, the skills training co-leaders then discuss the difference between primary and secondary emotions.  Primary emotions - our initial emotional response to stimuli - are a universal experience.  Secondary emotions - emotional responses about emotional responses - however, are uniquely human and almost universally destructive.  In other words, it's one thing to feel sadness, but it's significantly worse to feel shame about your sadness . This secondary emotion serves no practical function, as there is no evidence that shame about sadness reduces the likelihood of experiencing sadness again in the same situation.  Instead, the individual simply doubles the number of aversive affective experiences and increases negative automatic thoughts, thus heightening vulnerability to destructive behaviors.  Clients are taught to label both their primary and secondary emotions and to work to accept and experience their primary emotion without judging themselves for having it in the first place. 
   
       Before moving on to specific skills for regulating emotions, the co-leaders spend time discussing one more pivotal, basic concept: why individuals have emotions in the first place.  The evolutionary purpose of emotions is thus explained.  Emotions serve as alert systems, telling us that something in our immediate environment is positive or problematic.  We thus encode information about our environment in a salient, efficient manner that can be easily accessed the next time a similar environment is encountered.  Additionally, emotions are used to communicate.  Importantly, this communication occurs not only through verbal expression, but also through body language and facial expressions.  This is particularly true for babies, who respond to smiles and looks of fright from adults even before developing linguistic abilities.  Clients are thus taught that feeling an emotion is never "wrong."  It simply is.  You feel what you feel.  The question is what you will do about it and how you will express it.  Clients are taught to be mindful not only of what they say, but also how they say it and how they present themselves in the process.
   
       At this point, the co-leaders begin teaching specific methods for effective regulation of emotions.  The first suggestion is to reduce vulnerability.  Individuals are vulnerable to negative emotions in a variety of circumstances, including when they are hungry, sick, tired, and in pain.  As such, clients are told to prioritize a consistent and healthy pattern of sleep, diet, and exercise.  This is where the "preventive skills" come in, using an acronym P.L.E.A.S.E. PL stands for treating “PhysicaL Illness.” Make sure that your children are up to date on all their vaccinations and teach your children to wash their hands often. If your child shows symptoms of illness talk to your doctor as soon as possible and keep them home from school. E stands for balanced “Eating.” Try to get your children to eat as many fruits, vegetables and healthy grains as possible. This will give them the mental and physical energy to be productive throughout the day and less likely to cause behavioral disruptions. Take advantage of the schools reduced lunches and introduce your children to the farmers market for the wide variety of fresh fruits and vegetables the season brings. A is for “Avoiding mood altering drugs.” Watch the amount of caffeine your children are consuming and limit the amount of sugars that they eat. S is for balanced “Sleep.” Help your children get into a regular bedtime routine. This is a perfect time to start a family ritual such as bedtime stories and reading together. Finally, E is for “Exercise.” There are many ways to keep your child active throughout the school year. Take advantage of the many after school programs in our area. Other community organizations and centers give children an opportunity to meet others and learn social skills. Be active with your children and model good exercise habits. Limit TV and video game time for your children and be creative with spending more family time together perhaps playing a game instead. The more balanced these skills are the better prepared your family will be for every day.
   
   Top
   
    The second specific skill is to "build positive experiences", both short and long term.  Although at times we may find ourselves motivated to regulate negative emotions by simply doing whatever we can to immediately reduce them (Whiteside & Lynam, 2001), the best remedy for negative emotions is actually positive emotions.  It thus follows theoretically that, by increasing the amount of time that an individual feels good, you will decrease the amount of time spent feeling bad.  This may seem intuitively obvious, however, it is not the instinctual human response when we become stuck in a pattern of chronic negative affect.  As such, clients are encouraged to plan daily, short term positive experiences.  They do not need to be overly indulgent, expensive, or time-consuming, but they need to be positive, healthy activities.  This can mean going for a 10 minute walk each day, reading a chapter of a novel, calling a friend each night, or reading a silly magazine.  Long term positive experiences involve the identification of precise life changes clients would like to make, as well as incremental steps along the way that the client can make in an effort to eventually accomplish this goal.  By incorporating both daily and long term positive experiences into an individual's life, the focus can be shifted away from all the imperfections that inevitably fill any life.  During this section, clients are also taught that building mastery is a powerful emotion regulation tool.  Feeling productive and effective can serve to dramatically increase positive emotions and healthy behaviors.
   
       The second specific skill taught is mindfulness to emotions, both positive and negative.  Simply increasing positive experiences will not be particularly effective if we do not actually give those experiences our attention.  When a client schedules a half hour daily to read a fun book, she is told to think only about that experience while she does it.  If she spends that time not really paying attention to the book, thinking instead about things she has yet to do or things she wishes went differently, she will experience an increase in negative emotions and miss out entirely on the potential positive experience.  As such, the clients practice bringing their attention back to the positive activity and selecting new positive activities if they are unable to succeed with their initial choice.  Additionally, if clients attempt to avoid negative emotions, they are unlikely to become adept at managing them.  Instead, they are told to notice and accept the waves of negative emotions as they arrive, but to view them as temporary states with no power to harm.  Negative emotions are natural occurrences - accepting that they happen, whether or not we feel they "should" be there, will actually decrease the intensity and duration of the experience while teaching us not to be so overwhelmed by their presence.
   
       The third specific skill taught is acting opposite to emotion.  As we discussed in our article on rumination, when we are upset, we often feel compelled to wallow in those feelings.  At times, we even believe this is a productive course of action.  This, of course, is not actually true.  Opposite to emotion thus encourage clients to respond to sadness with behaviors they would engage in while happy.  It encourages clients to approach when afraid and to act civil when angry.  The point isn't to deny emotions - remember, clients are encouraged to be mindful to both positive and negative affect - but rather to ensure that nothing is done that will unnecessary prolong or increase the severity of negative emotions.
    

   Top
   
    Dialectical Behavior Therapy Skills Part 4:    Distress Tolerance

    by Michael D. Anestis, M.S.

       In my final article on the modules of DBT, I will cover a topic we have discussed earlier on PBB: distress tolerance.  Distress tolerance is a measure of the degree to which an individual evaluates the experience of negative emotions as unbearable  and is also defined by some as the ability to persist in goal-directed behavior when distressed   In other words, if I have low distress tolerance, it will take less stress for me to reach a point at which I am overwhelmed by what I am feeling.  Individuals with borderline personality disorder (BPD), the disorder for which DBT was originally designed, are characterized by low levels of distress tolerance, which is believed to contribute to maladaptive behavioral outcomes such as non-suicidal self-injury, and binge eating and purging.  Because of its potentially vital role in facilitating many of the problematic outcomes in BPD, distress tolerance is the focus of a substantial amount of attention in DBT skills training.
   
       Presented as the final module, distress tolerance training is often met with a certain degree of reservation by clients, as it is the least validating of all the skill sets.  The distress tolerance module, at its core, tells clients that there are times when they simply will not be able to stop feeling bad and that they are going to have to learn to weather the storm.  This is a frustrating idea for anyone, but that is especially true for individuals who experience chronically shifting, powerful emotions and who struggle to regulate those feelings without resorting to problematic behaviors.  Nonetheless, the overall message of the distress tolerance module is a positive one: this too shall pass.  Underlying this message is a simple fact, that emotions are temporary experiences powerless to actually cause us real harm, no matter how powerful they seem.
   
       Distress tolerance skills are thus centered on methods for individuals to manage difficult emotional states without using dangerous behaviors.  There are four general categories of distress tolerance skills: distraction, self-soothing, improving the moment, and focusing on the pros and cons.  The first several of these categories are addressed through an acronym, ACCEPTS:

   Activities

   • Distract with simple, healthy, pleasurable activities like taking a walk, watching a movie, gardening, or playing a sport

   Contributions

   • Help others when feeling distressed

   Comparisons

   • Compare your situation to that of those less fortunate and attempt to feel thankful not to be worse off

   • Compare yourself to how you were doing prior to treatment and focus on progress

   • Dangerous when overwhelmed by negative emotions, as cognitive distortions (e.g., dichotomous thinking, discounting positives) may skew perceptions of progress

   Opposite Emotions

   • Engage in activities that are opposite to current negative emotion (e.g., listening to happy music when sad)

   Pushing away

   • Take a "planned vacation" by focusing your mind on something pleasant that is unrelated to the current distressing situation

   • This is different than problematic dissociation.  In this instance, the individual is exerting control over his thoughts as he disengages from the immediate environment and focusing only on positive imagery and memories

   Thoughts

   • Distract with neutral thoughts like counting the number of tiles in the room, reading the titles of all the books on your bookshelf, etc...

   Sensations

   • Distract with physical sensations

   • Some individuals hold ice cubes or take warm showers and focus on the resulting physical sensations
     
     Top

   
       The ACCEPTS skills, thus, help clients to focus their attention away from aversive thoughts and feelings and to engage in either pleasurable or neutral activities until their emotional state returns to a calmer, baseline level.  Some of the skills are more proactive than others and different clients will respond differently to different skills, so practicing between sessions and experimenting with different methods for implementing the skills is pivotal. 
   
       Additional skills for improving the moment are provided after the co-leaders discuss the ACCEPTS skills and the group members spend time practicing them between sessions.  These additional skills include using positive mental imagery (e.g., imagine your favorite place and focus your energy on observing and describing every detail you can as precisely as possible), creating meaning (e.g., "make lemonade out of lemons"), praying, relaxing (e.g., progressive muscle relaxation), and doing one thing in the moment (e.g., mindfully engage in one distracting activity, allowing all other thoughts and sensations to pass through your mind as though they are on a conveyor belt).  Some of these skills overlap with other distress tolerance skills, but providing multiple angles for explaining similar concepts can increase the likelihood that all group members find a way to relate to the topic.
   
       Focusing on the pros and cons of a situation, another general category of distress tolerance skills, is also fairly straight forward, although it asks clients to go a step further than standard pro/con lists.  If an individual is considering self-injury, for instance, she would be asked to make a list of the pros and cons of engaging in this behavior, as well as the pros and cons of not engaging in the behavior.  Four columns are created, and the client is encouraged to be thorough and fair in all four columns.  There will obviously be overlap between several of the columns, but the point of the exercise is simply to slow down the behavioral response of the client and encourage her to consider all the possible repercussions of her decisions.  I have found that clients readily engage in this activity and find it incredibly helpful.  Remember, while some individuals naturally engage in this type of thoughtful analysis before making decisions, for others, a lifetime of impulsive, emotionally driven responses has made such approaches seem foreign and difficult.
   
       The final distress tolerance skill is the one that I believe may be the most important of all: radical acceptance.  Radical acceptance asks individuals to accept what they cannot change and let go of fighting what is true.  At first, clients often think this means lowering their standards, endorsing things against their beliefs, or declaring a bad outcome a good one.  This could not be further from the truth, however.  Radical acceptance simply states that screaming about your current situation is more likely to exhaust you than it is to effect the desired change.  Rather than engaging in fruitless exercises likely to only increase and prolong negative moods, acknowledge that what is happening is, in fact, happening, and begin to consider the best possible outcome given your current set of circumstances.  For instance, if a client in an inpatient ward fixates on how badly he does not want to be there, how miserable his situation is, and how nothing is the way it should be, he will likely increase his depressive symptoms while doing little to change his unfortunate set of circumstances.  If, however, he accepts that he is there and will be for the foreseeable future and looks to find ways to make that situation livable as he works toward changing it, his experience is likely to improve.  He'll still be in a place he does not want to be, but he'll be more likely to enjoy what positives are there and to find a workable solution to his problem than he would be if he simply focused on his negative emotions and his desire to be elsewhere.  In this scenario, the client does not lie to himself or candy coat what is an objectively aversive experience but rather acknowledges his reality and works within the confines of that situation to find the best possible outcome.
   
       Distress tolerance skills are imperative, not only for individuals with mental illnesses addressed by DBT (i.e., BPD, bulimia, binge eating disorder), but for anyone.  Individuals with these particular disorders simply tend to need more training in these skills.  By teaching individuals how to keep their balance amidst emotions and situations they are powerless to change at that moment, DBT skills trainers can reduce the sense of panic and helplessness that such individuals have grown accustomed to feeling when upset and replace it with an understanding that even the most powerful storm passes and, though it may leave damage in its wake, there is utility in avoiding strategies that would only make it worse.

   More on Distress Tolerance    
   by Christy Matta, MA from "Dialectical Behavior Therapy: Radical Acceptance"
    

   For many, reality is hard to accept. Unexpected and overwhelming events like lost jobs, physical illness and financial problems can make us want to give up or refuse to acknowledge the realities of our circumstances.

   In Dialectical Behavior Therapy, the ability to accept life, the reality of circumstances in which we find ourselves and the painful events that each of us must endure is taught as a skill.

   These skills can be difficult to teach and learn because the ability to respond to the world as it is, is an underlying attitude towards life. These skills, taught in the Distress Tolerance Module of the skills training group, include strategies to get both our bodies and our minds into more accepting attitudes.  Below are a few exercises on acceptance:

   Body Awareness

   To cultivate a more accepting state of mind, increase awareness of your body. Start by simply bringing your awareness to the position of your body. This can be done any time and any place. Whether you are walking, standing or sitting, notice your position. Become aware of the purpose of your position. For example, are you folding your arms across your chest in a defensive stance or are you tapping your foot in anxiety. If you notice that your mind has drifted, bring your attention back to your breath. It can be helpful to practice breathing exercises, such as counting each breath or saying “in” with each inhale and “out” with each exhale.

   Turn Your Mind

   Acceptance requires a choice. You have to turn your mind towards accepting reality, rather than rejecting and judging reality. You must commit to accepting the current situation and reality over and over. Each time your mind tells you it’s unfair or shouldn’t be as it is, you must turn your mind towards acceptance.

   Be Willing

   When the world seems unfair and you’re feeling stuck, depressed or frantic, it’s natural to want to give up, try to fix what can’t be fixed, or simply refuse to tolerate the situation. Instead of trying to impose your will on reality, focus on doing what works. Do just what is needed in each situation. Your job is to simply do your best, whatever the world throws at you.

   Accepting reality can become a habit. If done regularly, it can reduce stress and anxiety and improve your ability to identify and solve the problems in your life.   What helps you accept life as it is?

   References

   Linehan, M.M. Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press, 1993.
   
   Top