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One of the things I have noticed about Dialectical Behavior Therapy Family Skills versus Mentalization Based Skills is that they operate at a different link on the behavioral chain. In “When Hope is Not Enough” I have a section called “the BPD Dynamic.” What this dynamic outlines is a behavioral chain. That chain goes like this:
Event -> Interpretation -> Emotional/Physical Feelings -> Action Impulses -> Expression and Behavior
DBT-FST seems to me to operate at the Action Impulses to Expression and Behavior link, while validating the Emotional/Physical Feelings link. Don’t get me wrong, the DBT-FST skills are extremely powerful in communicating with someone with BPD. Yet, the change that is requested is at the end of the chain. I have heard that Marsha Linehan is quoted as saying something like, “Just because you feel like a crazy person, doesn’t mean you have to behave like one.” The point here is that DBT is a behavioral therapy and by modifying behavior, that works backwards toward regulating emotion and tolerating distress. In other words, DBT trains you to behave differently based on your feelings. When you gradually learn that your new behavior is more effective than the previous behavior, you break the conditioned chain between Action Impulses and Expression and Behavior. That is the essence of the DBT skill “Opposite Action.” An interesting side note is that by practicing Opposite Action (that is, doing the exact opposite of what your feelings implore you to do – such as engaging when you feel sad, rather than hiding under the covers all day), you actually feel better, because the action does work backward. Dr. Paul Ekman found that configuring one’s face to mimic a certain feeling actually causes that feeling to be experienced. That is the theory behind DBT’s “Half Smile” skill. Ultimately though, by working at that link in the chain, the person still feels the emotion, yet he or she just behaves differently than the emotion originally informed him/her to behave.
MBT on the other hand takes on the on the problem at the Interpretation link. By asking questions and being open to alternative interpretations, the person with BPD is more likely to have a broader view of other people’s behavior and the events in life. DBT never asks about the intent or motivation of the other person and just takes the interpretation as a given in a person with BPD. If a person with BPD says something happens and that something means X, then in DBT it means X. There is very little questioning of the validity of the interpretation X. In MBT, however, the interpretation X can be questioned and alternative interpretations (such as Y or Z) can be examined. The nice thing about this is that when the person with BPD is faced with a similar situation, he/she is less likely to jump to conclusion X and might consider Y or Z.
An example of the differences in the two approaches is as follows:
My daughter comes home from school after being teased by a boy on the playground. My daughter ends up throwing a thermos at the boy’s head.
With DBT, I would validate her anger and ask her how she could behave more effectively the next time this teasing occurs. So next time she will behave more effectively and not throw the thermos.
With MBT, I would validate her feelings and begin to probe with curious and straight-forward questions as to the intent of the boy. Perhaps he actually likes my daughter and that is why he is teasing. Perhaps he is showing off to his friends. If this approach is taken, my daughter is more likely to consider the boy’s motivation for the teasing. If she understands the motivation, she can actually never get angry and risk throwing the thermos.
All of that being said, I believe these skills have to be learned as a “ladder” to effectiveness. You can’t start at point E without going through points A-D. DBT-FST provide the foundation for more advanced skills, like those in MBT.
 Unfortunately, the concept of cheerleading is something that I mention in WHINE, but I left out as a tool for a Non-BP/BPD relationship. I mention it when talking about what NOT to do in when a person with BPD is emotionally dysregulated (or experiencing an EDM – emotional dysregulation moment). I am planning on providing a “supplement” to WHINE on this website when I finish working on it. I left out a few things that can be effective in a relationship with someone with Borderline Personality Disorder, and these things have come up in the ATSTP Email Support Group. So, I’ve decided to address one of these, cheerleading, now.
Not all interactions are appropriate for cheerleading; in fact, many interactions are not. If you tell someone “you can do it” when they deeply believe that they can’t, this could lead to a mistrust of your opinion of them. In the case of dealing with an emotional person, typically, “positive mental attitude” statements are unhelpful and invalidating. Saying there’s “no need to be sad/scared/angry” for example just serves to invalidate the emotion that the other person is already feeling.
Many people think that effective cheerleading statements involve saying that one person is “proud of” the other, “believes in” the other or “loves” the other. The problem with each of these is that 1) those statements are about how YOU feel and 2) Those statements don’t necessarily foster effective behavior.
At www.dbtselfhelp.com (which is a wonderful resource that I highly recommend) the worksheet on cheerleading states that there are three types of effective cheerleading statements. Mainly, that site is for self-cheerleading, so I will try to adapt these to relationship cheerleading. The types are:
Three types of cheerleading statements:
1. Statements that provide the courage to act effectively
2. Statements that help in preparing for the situation, getting ready to be effective, to focus on what works
3. Statements that counteract myths about interpersonal behavior.
In WHINE, I suggest a tool that can help with #1, which is the tool to “Be Brave.” While a person’s inclination may be to avoid an uncomfortable situation or to behave in a conditioned or ineffective manner (because of lack of courage or self-assurance about the situation), being brave in the face of uncomfortable situations reinforces itself and serves to support type #1.
Some examples of #1 might be:
“You can do hard things.” (which is my favorite and can apply to both #1 and #2)
“Remember the time you did [whatever]. That was so brave of you in that situation.”
“I’m impressed with your courage in the face of that.”
“Yeah, that is really hard. At the same time you have faced something like that before…”
If you combine “Be Brave” with “You can do hard things,” you go a long way to being more effective, because these two concepts help counteract the idea that you are “walking on eggshells” around someone else and that your feeling that avoidance of an emotional situation is the best route to take. I believe taking on an emotional situation head-on is more effective than letting it fester – both for you and for the person with BPD.
In type #2, the focus should be on effective behavior for a future task. #2 is quite important and, in some ways, is the most difficult type to effectively navigate. Because of conditioned ineffective behavior and the sway of negative emotions, a person might be tempted to repeat ineffective behavior, based on the emotions that they are feeling. A work (or school) situation is a good example of this dynamic. If someone is having a problem with their boss, they might, in anger, have the urge to quit the job or lash out at the boss (or the customers). Work situations can be especially frustrating for a highly emotional person. Work that they consider menial or “beneath them,” overbearing bosses, long periods of downtime in which a person can ruminate or become paranoid that others don’t like them, all contribute to frustration at work.
Some examples of #2 might be:
“You have every right to be angry. Still, the last time he said that sort of thing, you reacted positively. I think that worked out pretty well.”
“Bosses can be a real pain. I know when my boss gets on me; I try to do [something effective]. I’ve seen you do that in the past, so you know you’re capable.”
“You had a similar situation when [whatever] happened and you handled that well.”
In type #3, you are debunking deeply-held beliefs about interpersonal behavior. This technique can be tricky, because a person who is overcome with emotion might not be able to see the other side of the coin. In this type, you are basically reiterating that a person has the rights to their feelings and emotions and helps counteract the idea that other people might not like them just because of an emotional situation.
Some examples of #3 are:
“It’s hard when your co-workers are angry at you. I know I don’t like that either. Yet sometimes it’s about their anger more than your behavior.”
“I think you have the right to state your feelings about the situation.”
“You have every right to ask for what you want, even if you think that will annoy them.”
“I think there’s a lot of validity in how you feel, certainly as much as how they feel.”
“Sometimes I think you have to stand up for your rights. I’m impressed when you have done that in the past.”
“Sometimes people get annoyed when you don’t do exactly what they want. However, you have rights and feelings too.”
I have discovered some resources on the web that may help those with BPD (and those nons who are in a relationship with someone with BPD). These resources are:
Mass General Hospital Mood Charting (thanks to Tides…)
DBT Skills Help:
Emotional Regulation Skills… from dbtselfhelp.com … from Borderline Personality From the Inside Out
Mindfulness Skills… from dbtselfhelp.com
Distress Tolerance Skills… from dbtselfhelp.com
Interpersonal Effectiveness Skills… from dbtselfhelp.com
DBT Family Skills Training… from middle-path.org
You can gain access to more DBT resources, to other pertinent files, and to advice from me and other group members by joining the ATSTP (Anything to Stop the Pain) Google Email List.
PUVAS is an acronym that comes from “Stop Walking on Eggshells” it means:
Pay attention
Understand fully
Validate emotions
Assert yourself
Shift responsibility where it belongs
Paying attention to what is being helps us avoid making assumptions.
Understanding what someone is trying to communicate may require seeking clarification so we don’t make assumptions.
Validating the emotional statements of the other person will pave the way for further smooth communications.
Asserting yourself is a form of setting boundaries and is a very important piece of the healthy communication process.
 When Hope is Not EnoughGet the Non-BP book that has helped hundreds! Basically, it is similiar to a combination of DEAR MAN and the GIVE skills from DBT. DEAR MAN is extremely helpful for have a conversation with someone who is emotional and to prevent from engaging your emotions yourself. DEAR MAN is:
DEAR (what to do):
Describe – describe the situation WITHOUT being judgmental. Just say what happened without making value judgments of the meaning of what happened or the intentions of the other person.
Express – express how you feel about it with an emotional word (such as sad, glad, mad or scared). Do not judge with this statement either.
Assert – assert what you’d like to happen in the future in this situation – what will not trigger the emotion you expressed.
Reinforce – reinforce means to back up the other person’s statement that moves toward what you wish. If the person says, “I’m sorry. I will try and not do that in the future.” You say, “I would really appreciate that. I don’t like feeling [whatever]. That would make me much happier.”
MAN (how to do it):
Mindfully – this is the “pay attention” part. You should be totally in the conversation and listen to the responses. However, you should ignore statements that are not addressing the issue at hand. You can also repeat your points agina until the other person fully understands what you are saying.
Appear Confident – even if you don’t feel confident discussing the point, you should appear confident. This prevents the other person from attacking or playing on your vulnerabilities.
Negiotiate – in cases where a “middle ground” makes sense, being willing to negiotiate is helpful because no one comes out the total “winner” or “loser”.
The GIVE skills are this:
Be Gentle – don’t attack.
Act Interested – listen carefully to what the other person says and the needs expressed.
Validate – use emotionally validation skills to “soften the blow”.
Easy Manner – use an easy manner and do not dominate the conversation.
An article on DBT skills and validation:
There are few things people want more in life than to be told that they are right about what they are thinking, feeling and doing. Upon being told this, people usually calm down and feel better, which makes communicating with them much easier. Validation basically involves communicating that we understand, appreciate or approve of something in another person, such as their beliefs, emotions or actions. Though we may be able to validate everything someone feels or does (especially if these are destructive) we can learn to find something in the person’s feelings or behaviors that we can understand and agree with.
http://www.dbtsf.com/helping-someone.htm
An article on DBT training for family members of borderlines:
Individual DBT has addressed the problems of the individual’s emotional vulnerability (high sensitivity, high reactivity, slow return to baseline) component by intervening directly with the individual patient. Although interventions with family members are briefly noted in the original treatment manual, standard DBT does not directly attempt to affect the second component of the etiological model for BPD and related disorders, namely, that of the invalidating environment. There are several levels of adapting DBT that are possible. First, one could simply apply DBT essentially intact to new populations (for example, to battering men; Fruzzetti, Rubio, & Thorp, 1998). Or, one could use the existing treatment to augment outcomes with borderline clients (like teaching the original DBT skills to family members or partners of borderline clients; Fruzzetti, Hoffman, & Linehan, in press). Finally, one could also develop new interventions (skill modules and/or treatment strategies), consistent with the transactional model, to intervene specifically at the level of the environment (say, a family or a residential center; Fruzzetti et al., in press). All three of these approaches have been initiated and are presently being evaluated.
http://www.middle-path.org/DBT/Article_Archive/dbtfst.html
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