NJ-ACT - Shireen Rizvi

Dr. Shireen Rizvi Addresses NJ-ACT on DBT

By Lynn Mollick

On Sunday January 24, 78 NJ-ACT members met to hear Dr. Shireen Rizvi teach two DBT skills: distress tolerance and emotion regulation. Dr. Rizvi began by describing DBT’s central dialectic: “I accept you totally as you are, and you need to change.” In DBT, patients are assumed to be doing the best they can, but at the same time they, are expected to develop more motivation and to work harder at change.

True DBT consists of 4 component modules: Emotion regulation and interpersonal effectiveness focus on change, while mindfulness and distress tolerance focus on acceptance. Marsha Linehan’s Skills Training Manual for Treating Borderline Personality Disorder (Guilford, 1993) precisely describes how to implement these four DBT components and provides reproducible hand-outs and work sheets.

DBT views self-destructive behavior (e.g. cutting, bingeing, tantruming, drug and alcohol abuse) as ways of avoiding painful emotions. But these behaviors create more problems than they solve. So instead of employing self-destructive behavior, DBT teaches emotion regulation skills to diminish painful emotions, and distress tolerance skills to help patients tolerate those emotions they cannot regulate.

Distress Tolerance

At the workshop, Dr. Rizvi asked us to hold our arms straight out, parallel to the floor, beyond the point when they began to ache. She then asked us to describe the distress tolerance skills we used during this exercise. Here are six DBT distress tolerance skills:

1. Distract, summarized by the acronym ACCEPTS:

Activities – Do something different.

Contribute – Do something for others.

Compare – Compare yourself to others who are worse off, or to yourself as you once were.

Emotions – Elicit an emotion that opposes your negative mood. Watch a scary movie, listen to music, sing.

Push away the distressing thought. Tell yourself “I’ll think about it later.”

Thoughts – Think about something that competes with the negative mood, e.g. count, do a difficult puzzle.

Sensations – Elicit different sensations, e.g. hold ice in your hand or do jumping jacks.

2. Self-soothe the five senses. If patients can’t think of pleasurable activities for vision, hearing, smell, taste, and touch, there’s a list to assist them on page 167 of the Skills Training Manual.

3. Improve the moment. Replace negatives with positives. (Improving the moment overlaps with distraction.)

Imagery – Imagine pleasant and relaxing scenes and experiences.

Meaning – What’s good in a bad experience? Find meaning in adversity.

Prayer – It need not be religious, but it should be positive, like the Serenity Prayer.

Relaxation – any kind.

One thing at a time – Stay in the present with total awareness.

Vacation – Take a break from the pressure, even for an hour or two.

Encouragement – Be your own cheerleader. Encourage yourself. “I’m doing the best I can.” “This won’t last forever.”

4. Do a pro’s & con’s chart. This reduces impulsivity, even if the solution reached isn’t ideal.

5. Mindfulness. The Skills Training Manual (pages 170-175) describes three general mindfulness techniques for accepting reality: observing the breath, half smiling, and reality awareness.

6. Radical acceptance means acknowledging difficulties instead of struggling against them. It means adopting an attitude of “willingness,” and choosing to be effective and doing what is required in every specific situation. Radical acceptance means abandoning “willfulness,” it means making necessary changes while giving up trying to fix everything. Radical Acceptance is an ongoing decision-making process that eventually leads to meaningful change.

Emotion Regulation

Distress Tolerance is an acceptance skill while Emotion Regulation is a change skill. Emotion Regulation Training has 3 goals:

1. Understand emotional experience. Patients learn to label their emotions, identify the events that prompt them, and understand the interpretations they make of them. (Skills Training Manual pages 139-152.) DBT debunks common myths about emotion – e.g. “there’s a right way to feel in every situation,” “showing feelings is weakness,” or “negative feelings like anger are bad.” DBT also explains that emotions can be helpful by informing and motivating action.

2. Reduce emotional vulnerability. Reduce vulnerability to negative emotions by avoiding hunger, fatigue, and irritability. Treat any physical illness and avoid mood-altering drugs.

Increasing positive emotions also reduces emotional vulnerability. Do something every day that is enjoyable and/or creates feelings of competence and mastery. Work toward goals, attend to relationships, and “avoid avoiding.”

Be mindful of positive experiences. Refocus when the mind wanders from positive experience. Distract yourself from worry about when good things will end, when more will be expected, or the thought that you don’t deserve anything good.

3. Decrease emotional suffering. Let go of painful emotions with mindfulness. Ride out painful experiences as though they are waves that crest and then recede. Remember that painful experiences only last a few minutes.

Finally, change negative emotions into positive emotions by “acting opposite.” All emotions have an urge to action associated with them. For example, fear is associated with an urge to run and anger is associated with an urge to be aggressive. Recognize the emotion and the associated urge. Then do the opposite. Face fear and say or do nothing when you’re angry. Opposite action leads eventually to more pleasant emotions and less destructive action.

Marsha Linehan developed DBT for patients with borderline personality disorder because they experience intense emotional reactions to a wide range of stimuli and their emotions return to baseline very slowly. Recent evidence suggests that DBT is also helpful for Binge Eating Disorder and PTSD, two other problems with emotional dysregulation at their core.