Imagine — Mary and her husband, John, have the same predictable fight week after week. John cheated on Mary five years ago and she can’t let it go. When John is late getting home from work, which happens frequently, she obsesses he’s having another affair and is going to leave her. By the time he gets home, she is so worked up she accuses him of cheating and threatens suicide if he leaves. He dreads walking in the door because he knows what’s coming. By the time he pulls in the driveway, he’s just as worked up as she is. According to script, he rages while she cries and begs and throws things. He starts drinking and she goes to the bathroom to cut away the pain with a razor blade. The next morning, she apologizes and he goes about his business silent and hung over. She calls him six times over the course of the day to apologize. He refuses her calls. In between calls, she beats herself up for what happened. She can’t let go of the thought that he is going to leave and it will be her fault.
Like most relationship issues, Mary and her husband’s situation is complex. Mary has borderline personality disorder and her husband is an alcoholic. They have had the same predictable fight week after week for almost five years. They have it down to who says what when.
They both could benefit from Dialectical Behavior Therapy (DBT). Where to start? There are so many skills that could have changed the course of the scenario above.
What Skills Might Have Helped?
There are a number of skills that could have helped John and Mary avoid the seemingly inevitable fight. The fact is there’s nothing inevitable about this fight they have been having for five years.
DBT skills are organized in four categories. Distress tolerance skills are used when things happen that can’t be controlled. Distress tolerance hinges on reducing symptoms and accepting what is. Emotion regulation skills are used to change how clients handle their emotions. The goal is for clients to learn to self-regulate or stay within their window of tolerance, neither too emotionally hyper-aroused (e.g., crying, yelling, throwing things uncontrollably) nor shut down or hypo-aroused. Mindfulness skills focus on being aware of what’s happening in the moment, both internally and externally, as well as being nonjudgmental and effective. Change is not possible without awareness. Judging what’s happening in the moment (as opposed to accepting it) impedes change. Interpersonal effectiveness skills help clients transform their relationships with others.
These skills are based on two core dialectics, seemingly opposite positions that are both true. First, change hinges on accepting what is both internally and externally. Second, a client may not have caused his/her problem, but only he/she can solve it. Hence, neither John nor Mary can control the other but each can change his or her own behavior. Each one is responsible for themselves. Neither can control the outcome.
The good news is family systems theory tells us when one member of the couples’ relationship changes, the other will change as well. In other words, when old patterns of behavior don’t achieve the same goals, the other will adjust his or her behaviors to bring the relationship back into equilibrium. The response is not always immediate. In fact, the situation may worsen in the short run. But over time, positive change in one leads to positive change in the other or so much dissonance that one leaves the relationship.
Rarely is one skill sufficient. Skills must be used in combination or sequence to achieve goals. Each combination or sequence is context specific so require experimentation and practice. It helps to examine what worked and didn’t work in individual therapy, using chain analysis.
Distress Tolerance Skills
Distress tolerance skills are the first skills needed. Neither John nor Mary is tolerating the stress of the situation well. Both are out of their window of tolerance before the first word is uttered. Both would benefit from TIPP skills. The TIPP skills act to regulate body chemistry quickly when clients are so distressed they can’t think. TIPP stands for temperature, intense exercise, paced breathing and progressive muscle relaxation. Click below to see guided videos illustrating how to use each technique.
Different TIPP skills are more/less effective for different people so clients will have to experiment. For most people, changing temperature or intense exercise first will change body chemistry most quickly; however, the positive benefit won’t last long. The quick reduction in distress will jog cognitive capacity so clients can switch to paced breathing or progressive muscle relaxation.
Once they have lowered their acute distress, John and/or Mary can distract themselves with other activities, self-soothe or even improve the moment with an enjoyable activity. When they are back within their window of tolerance, they might do some self-talk to radically accept “what is” without interpretation, storytelling or judgment.
The key here is figuring out what to radically accept. If Mary radically accepts that John is cheating again that can only lead to more misery for both of them. She needs to be able to differentiate “what is” from interpretations and storytelling. The fact is Mary doesn’t know whether he is cheating or not. That is an interpretation not based on fact.
The only fact Mary can say for sure is that John is late coming home from work. The most likely explanation is that he had to work late. The only fact John knows for sure is that Mary believes he is cheating again. That’s what needs to be radically accepted. Radical acceptance is not resignation (e.g., Here he is late again or she believes I’m cheating again. I’m helpless.”) As we will see later, neither of them is helpless in this situation.
Once one or both of them is back in their window of tolerance, they can begin using emotional regulation skills.
Emotion Regulation Skills
“What’s the evidence?” or “How do I know this is true?” This DBT skill will help them differentiate between facts and interpretations and to accept “what is” without judgment. Using this skill, Mary will challenge her interpretation that John is cheating, exploring alternative explanations with curiosity rather than judgment. John could ask himself, “How do I know Mary won’t react differently this time?”
Emotion regulations also challenge them to surf the waves of emotion, noticing and accepting emotions, riding the swells and troughs; then letting the emotions disappear into the sand instead of crashing into the rocks and going back out to sea only to return again.
When the emotions John and Mary’s stories elicit make them miserable, another DBT skill they might practice is acting opposite to their thoughts and emotions, doing something that makes them happy when they feel sad or doing the thing they fear or something other than the expected. John might call Mary to let her know he will be late and why. Mary might make a special meal for John.
Coping ahead is another important emotion regulation skill. Using this skill, Mary and John will independently figure out in advance what they will do and say, including alternative ways to respond to the expected script, when John gets home from work. They may need to rehearse their words and body language so it feels more natural.
If using these skills is effective, it will lay the beginnings of building mastery. Mastery takes frequent practice but is fundamental to long-term change. The bonus is the more often they use the skills, the more automatic the skills become.
Change starts with mindfully observing what is happening both internally and externally. To change anything, either Mary or John will have to notice what is happening week after week and accept personal responsibility for changing their own behaviors in the interaction while accepting they may not get the desired outcome.
After one or both of them notices that there might be a better way to handle the situation, the next step is to mindfully describe “what is” without judgment of each other or themselves and without telling stories or ascribing motives or intent. None of these are easy to do.
Of course there are the obvious judgments “I’m worthless” or “he should …” or “why didn’t I?” Often judgments are more nuanced. They are communicated in tone or pitch of voice and body language as well as more sophisticated sarcasm and implied judgments.
Storytelling comes in many forms: jumping to conclusions (without checking the facts), making assumptions (like assuming you know what others are thinking or feeling), thinking it’s all or nothing (look for words like all or never, good or bad, right or wrong), crystal-ball gazing (thinking you can predict the future) and other ways. Ascribing motives or intent is a type of storytelling, called mindreading. It’s the distorted belief that someone can know what another person is thinking or feeling. Try as we might, we can never know for sure and if we guess we’re as likely to be wrong as right.
Mary or John will need to decide what being effective would look or feel like. Being effective assumes they have both immediate and longer-term goals. One or both of them may have the immediate goal of avoiding the same old fight. They may not know what their long-term goals are because neither can see beyond their pain. An intermediate goal might be each working on his or her individual issues in therapy so they can discern their longer-term goals. Their longer term goal might be deciding to increase emotional closeness or deciding whether to end the marriage amicably. Being effective requires John and Mary to act in ways that lead them closer to achieving their goals and to avoid actions that lead them further from their goals.
Interpersonal Effectiveness Skills
Interpersonal effectiveness skills will help John and Mary each balance three types of effectiveness: achieving the desired outcomes, attending to the relationship and maintaining integrity. To find this balance, one or both will prioritize these three objectives to decide which skills will be most effective. There is a set of skills associated with each type of effectiveness that John and/or Mary will use in combination or sequence.
DBT uses acronyms to help you remember skills tied to each type of effectiveness. Effectiveness that focuses on achieving the desired outcome uses the DEAR MAN skills:
D – Describe: Describe the situation in concrete terms and without judgment.
E – Express: Express feelings, conveying to the other party how the situation makes you feel.
A – Assert: Assert your wishes, i.e. clearly state what you do or do not want.
R – Reinforce: Reinforce why the desired outcome is desirable, and reward people who respond positively to the request.
M – Mindful: Be mindful and present in the moment, focused on the current goal.
A – Appear: Appear confident, adopting a confident posture and tone, and maintain eye contact.
N – Negotiate: Be willing to negotiate and give in order to get, with the understanding that both parties have valid needs and feelings
The DBT acronym for effectively attending to relationships is GIVE.
G – Gentle: Approach the other party in a gentle and nonthreatening manner, avoiding attacks and judgmental statements.
I – Interested: Act interested by listening to the other person and not interrupting.
V – Validate: Validate and acknowledge the other person’s wishes, feelings, and opinions.
E – Easy: Assume an easy manner by smiling and using a light-hearted, humorous tone.
The DBT acronym for effectively maintaining integrity or self-respect is FAST:
F – Fair: Be fair to yourself and to the other party, to avoid resentment on both sides.
A – Apologize: Apologize less, taking responsibility only when appropriate.
S – Stick: Stick to your values and don’t compromise your integrity to gain an outcome.
T – Truthful: Be truthful and avoid exaggerating or acting helpless to manipulate others.
These skills will help John and Mary learn when and how to set limits, state their needs, say “no,” be assertive, walk away from conflict and so on.
Where Can Couples Learn DBT Skills Together?
Dr. Alan Fruzetti has written an extraordinary book The High Conflict Couple: A DBT Guide to Finding Peace, Intimacy & Validation with a foreword by Dr. Marsha Linehan, who developed DBT as an evidence-based practice. The book is written for clinicians and clients alike.
In September 2016, St. Louis DBT will offer a skills training group for high conflict couples based on Fruzetti’s book. If you have clients who would benefit, call St Louis DBT at 314-932-7415 or email firstname.lastname@example.org to get on the list. Watch this space to learn more.
Sandra Miller, MSW, LCSW and sometimes blogger, is one of five therapists who see clients at St. Louis DBT, LLC. Learn more about St. Louis DBT.