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Dialectical Behaviour Therapy (DBT) and the Buddhist Philosophy

DBT deals with intense and labile emotions. There is a connection between mindfulness and emotion regulation. Mindfulness facilitates adaptive emotion regulation.

Dialectical Behaviour Therapy (DBT) and the Buddhist Philosophy

Posted on March 20th, 2017
Ruwan M Jayatunge M.D.

Dialectical behavior therapy (DBT) is a modified form of cognitive behavioral therapy (CBT) that was developed in late 1970s by Marsha M. Linehan a psychology researcher at the University of Washington (Linehan, 1993). DBT is an empirically supported treatment for suicidal individuals (Linehan et al., 2015). It can be adapted to treat borderline personality disorder patients with comorbid substance-abuse disorder (Koerner & Linehan, 2000) and depressed elderly clients with personality disorders (Lynch et al., 2003). DBT addresses deficits in emotion regulation, distress tolerance and interpersonal relationship.

The patients with borderline personality disorder have faulty schemas and splitting in the patient’s relations to others. They have frantic efforts to avoid real or imagined abandonment. Often they have pattern of unstable and intense interpersonal relationships, impulsivity, emotional instability and recurrent suicidal behavior. In addition they are impacted by chronic feelings of emptiness. Borderline personality disorder is treated with psychotherapy and medication. Dialectical Behavior Therapy and Buddhist Psychotherapy are effective in treating borderline personality disorder.

The basis for DBT is stemming from the mindfulness practice of the Buddhist teachings and the philosophy of dialectics. Mindfulness according to the Buddhism is bare attention a sort of non-judgmental, non-discursive attending to the moment-to-moment flow of consciousness (Sharf, 2015). Mindfulness meditation has three overarching purposes: knowing the mind; training the mind; and freeing the mind (Fronsdal, 2006). As described by Palmer (2002) developing the capacity for being mindful and living in the moment allows a greater potential for feeling appropriately in charge of the self.

DBT combines mindful awareness largely derived from Buddhist meditative practice. Kirmayer (2015) concluded that Mindfulness meditation and other techniques drawn from Buddhism have increasingly been integrated into forms of psycho-therapeutic intervention. Since the 1990s, mindfulness meditation has been applied to multiple mental and physical health conditions, and has received much attention in psychological research (Tang & Posner, 2013). Mindfulness has been described as a practice of learning to focus attention on moment-by moment experience with an attitude of curiosity, openness, and acceptance (Marchand, 2012) Schmidt (2004) states that mindfulness is strongly related to compassion, and it is compassion that serves as a source for all healing intentionality. Both mindfulness and self-compassion involve promoting an attitude of curiosity and non-judgment towards one’s experiences (Raab, 2014). The core mindfulness skills (focus, compassion, curiosity, inner calm, balance, and awareness) lead to serenity.

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What’s so great about mindfulness?

Mindfulness

Mindfulness

It has been integrated into many different treatments since the mid 90s for chronic pain, depression and, perhaps most famously, borderline personality disorder via DBT (Dialectical Behaviour Therapy).

What’s so great about mindfulness?
Kyle MacDonald
5:00 PM Thursday Mar 3, 20167 comments

I’ve been told I should meditate for my anxiety, but it’s too hard. Any tips?Anxious, Napier

Mindfulness is very trendy at the moment, and it’s not often you can say that about a psychological treatment. But it isn’t all incense, throw cushions and sitting cross-legged with your eyes shut.

So what is mindfulness and why is it so popular?

Mindfulness comes from Buddhist traditions and is a series of meditation techniques that help with mental focus, concentration and emotions by way of improving our ability to more actively control our attention.

It has been integrated into many different treatments since the mid 90s for chronic pain, depression and, perhaps most famously, borderline personality disorder via DBT (Dialectical Behaviour Therapy).

With practice we can all improve our ability to not let our mind “run away” with emotions, painful thoughts or difficult memories.

It’s particularly effective for anxiety and protecting against relapse in depression.

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Being Mindful of Emotion to Validate Self and Others

Kelly Koerner, PhD – Dialectical Behavior Therapy: The State of the Art and Science – April 2-3 Seattle, WA


Ambiguity is the greatest threat

In 2009, I attended the International Society for the Study of Personality Disorders (ISSPD) in New York. Dr. Glen Gabbard, MD, a psychiatrist and clinician that treats people with Borderline Personality Disorder (#BPD). About halfway through his presentation, Dr. Gabbard said: “Ambiguity is the greatest threat.” He was speaking in the context of a clinician treating someone with BPD. Many studies have show that people with BPD react to neutral facial expressions as if the person is angry. People with BPD interpret neutral faces as angry. I once saw a woman with BPD view a picture of a neutral face and she said, “He’s angry with me.” Dr. Gabbard was suggesting to the clinicians treating people with BPD to NOT be neutral, to not use the “blank slate” approach.

The main problem with BPD is that these people are exquisitely emotionally sensitive. Their emotional tolerance is set very, very low.  Dr. Gabbard had a slide in his presentation that read: “Neuroimaging data of adult BPD patients suggest that amygdalar hypersensitivity and emotional dysregulation may be related to specific dyfunctions in the prefrotal cortex and the ACC.” This suggests that emotional (from the amygdala) hypersensitivity (the person is on an emotional hair-trigger) and emotional dysregulation could be due to an inability to integrate information (which is what the prefrontal cortex does) and is personalized (through the ACC).  Basically, the emotional anaphylactic reaction of someone with BPD could be a brain dysfunction. The ambiguity of what could happen is overwhelming.

The other day, I had a coaching session with a husband who has a wife with BPD. He just couldn’t understand why his wife thought that he was “angry with her all the time.” He told me he remained calm during her emotional dysregulation and that she interpreted his reactions as angry. Neutrality in the face of strong emotional reactions will be interpreted as disapproval. The person with BPD will be unable to communicate his/her emotional pain and think “I’m falling apart here and he’s so calm! He doesn’t understand me!” This client’s wife was interpreting his neutral reactions as angry ones. Add the fact that people with BPD have trouble regulating their own emotions such that they typically attach to another person who they expect to regulate the emotions for them. In other words, the internal emotional regulator is externalized and embodied in another person, usually the “attachment person” (like a parent, partner or friend). When the external regulator reacts in a way that is misaligned with their internal state (i.e. is calm when they are not), the person with BPD will feel as if they’ve lost control of a part of themselves. This causes more intense emotional dysregulation. From When Hope is Not Enough:

As a buyer on eBay, you don’t give neutral feedback to a seller when everything about the sale is perfect. You give neutral feedback when something is wrong. A person with BPD will interpret a neutral face as “something wrong.”

When Hope is Not Enough ebook (Kindle Locations 459-461).

Ambiguity about the future and what may come can cause ruminating. Unpredictability of the attachment person can cause fear and that fear often morphs to anger. People with BPD live in with a cloud hanging over their future… they are always waiting for and dreading the other shoe dropping.

So, what are you to do as a supporter, family member or partner of someone with BPD? In When Hope is Not Enough, I suggest this:

Most people believe that remaining calm in the face of strong emotions expressed by their BP loved one is the best and most effective course of action, but in reality, it is not. A study of BPD patients using functional MRI technology “found that the level of amygdala activation to the Fearful, and Neutral faces in BPD patients is significantly correlated with diagnostic measures of emotional lability.”28 What does that mean to you? Well, although clothed in scientific language, what that means is that a person with BPD is more likely to view a “neutral” (or calm) face as a threat and become fearful. If you go “calm” on her, in the face of her emotional dysregulation, she will see you as a threat and, if she sees you as a threat, she will do one of two things: fight or flee. Additionally, the tenor and tone of your voice matters in this area.

The purpose of someone coming to you in an emotionally dysregulated (or close to one) state is to communicate the emotions that she feels. She may have difficulty expressing these emotions and may use other means for expressing them such as blame, sobbing, cutting, raging or other behaviors that are difficult for you to deal with. The underlying point however is one of communication – she is trying to tell you something, but she doesn’t have the language for it. Therefore, if you respond to an emotional communication in either an invalidating fashion (using one of the many, many invalidating phrases above) or in a way that doesn’t match the emotional distress, the BP will feel unable to communicate. She will think “I’m going off the deep end here and you are so calm! You don’t understand anything! You’ll never understand me!”, and not trust you. The tenor of your voice is more effective if you express your emotional identification with emotion in your voice as well, but with slightly less emotion than the BP is feeling. In other words, express distress in the identification, but less emotion than if you are actually in distress yourself.

When Hope is Not Enough ebook (Kindle Locations 1264-1277).

How mentalization skills can help children at risk

Mentalization lets kids consider situations from many points of view

Thinking About Thinking May Help At-Risk Children
Mentalization lets kids consider situations from many points of view
Published on May 18, 2013 by Kristi Pikiewicz, PhD in Meaningful You

Imagine that you have arrived at a museum to view an Ancient Grecian statue. Your experience, including your thoughts, emotions, and physiological reactions, would be dictated by two factors: the nature and quality of the artwork itself, and the space within which it is presented. The statue may be beautiful or frightening, sturdy or fragile, well-preserved or in a state of disrepair. These are immutable properties that cannot be easily changed, but your reaction to the piece will also be informed by how it is presented. The size and layout of the gallery determines whether or not you may move around the statue to see it from all angles, appraise it from afar or up close, or even gain enough distance to see multiple statues at once and compare them.

This metaphor may tell us something important about the social and emotional development of children. Each child carries models of relationships unconsciously — templates about how people will treat and react to him or her — borne out of early experiences with caregivers in infancy. These models are like the statue: old and difficult to change. The gallery represents the internal space in which those models exist: that is, the child’s ability to think about and reflect on the mental states of the self and others. Attachment theorists such as Mary Main and Peter Fonagy have long proposed that the development of such a reflective capacity, also known as mentalization, ought to be protective for children whose early models are problematic. (Children may develop troublesome models for a variety of reasons, stemming from parental, environmental, and genetic sources.) A child with high mentalization would have the space to consider his models from all sides, compare and contrast them, and choose how near or far to “stand” from them. On the other hand, without the ability to mentalize a child may feel trapped with distorted or fractured models, repeatedly entering into new relationships with expectations of painfulness and chaos.
Continue reading How mentalization skills can help children at risk

Story about resentments from Zen

I really like the book Zen Shorts, which is a children’s book about Zen and Zen stories. There are 3 stories in the book and this is my favorite, which is about resentments and hanging on to negative feelings:

Two traveling monks reached a town where there was a young woman waiting to step out of her sedan chair. The rains had made deep puddles and she couldn’t step across without spoiling her silken robes. She stood there, looking very cross and impatient. She was scolding her attendants. They had nowhere to place the packages they held for her, so they couldn’t help her across the puddle.

The younger monk noticed the woman, said nothing, and walked by. The older monk quickly picked her up and put her on his back, transported her across the water, and put her down on the other side. She didn’t thank the older monk, she just shoved him out of the way and departed.

As they continued on their way, the young monk was brooding and preoccupied. After several hours, unable to hold his silence, he spoke out. “That woman back there was very selfish and rude, but you picked her up on your back and carried her! Then she didn’t even thank you!”

“I set the woman down hours ago,” the older monk replied. “Why are you still carrying her?”

Zen Shorts (Caldecott Honor Book)


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