a crisis include distraction, self-soothing activities, and reminding oneself of the pros and cons of tolerating distress versus not tolerating it. All of these skills require the per- son to maintain focused awareness and to experience reality without judgment. In addi- tion, mindfulness of daily activities, such as walking or doing dishes, is taught as a tool for increasing acceptance of life, and skills group participants learn to observe willfulness when it arises and to turn their mind toward acceptance of reality and willingness to act eff ectively. In the Emotion Regulation Skills module, one strategy taught for regulating emotions is simply to be mindful of the current emotion, observing it come and go, without fi ghting it, but also without holding onto, or amplifying it. Th is can decrease its duration or intensity, because unless “fueled” by thoughts or other behaviors, emo- tional responses are naturally short-lived. Furthermore, it provides another opportunity to observe that diffi cult emotions can be tolerated and do not have to be avoided, nor does the individual need to judge him or herself for an emotion, thereby setting off a cascade of secondary emotions about the emotion. In the Interpersonal Skills module, mindfulness features as one of the component skills for making assertive requests and refusals, as summarized by the acronym DEAR MAN: Describe the situation, Express how you feel about it, Assert what you want, and Reinforce the other person, doing all this Mindfully, while Appearing confi dent, and with willingness to Negotiate.
the therapist when those goals are not yet achieved or when the patient seems to be less committed to, or works less diligently toward, those goals than the therapist. Th is does not mean that frustration, worry, sadness, and other possibly diffi cult experiences do not arise, only that it may be possible to allow them to be present without internal struggle and attempts to avoid them, and without one’s mind being hijacked by internal verbal elaboration on the experience. Diffi culty in dealing with diffi cult emotions that arise as a therapist, particularly in working with “diffi cult-to-treat” patients, may contribute to- ward a therapist becoming burned out with a given patient or with conducting therapy in general. Although we are not aware of any relevant empirical data, cultivation of a sense of acceptance, in general and particularly within the context of one’s work as a clinician, may help reduce the risk of burnout.
Case Illustration
In this prototypical case example, the patient, Kate, is a 33-year-old single woman with BPD, social anxiety, recurrent symptoms of major depression, chronic pain, and a his- tory of sexual victimization. Kate has been in DBT for fi ve months, and during this time she has learned to use mindfulness skills to increase awareness of present cognitions, sensations, subjective feeling states, and action urges.
Th erapist (T): So, before we get started, let’s do what we have done before to help begin our session in a skillful way. Let’s do a mindfulness practice.
Patient (P): I don’t want to do a mindfulness practice. I am so mad right now. I can’t even stand it! (Patient puts head down and sighs loudly.) You are not going to believe what my mother said to me today! I could just scream.
T: Your mind may be telling you that you can’t stand being mad right now, and that you might scream, and those thoughts may seem true. But here’s the thing: you can stand it, without screaming, because you have been really mad before, in this room, and you have tolerated feeling mad without making things worse. Let me ask you a question: In your Wise Mind, what do you think will be the most eff ec- tive thing we can do right now—a brief mindfulness practice, or you telling me about how mad you are at your mom?
P: I want to tell you what she said. It was horrible . . . . Awful.
T: I would like to hear about it. Th e question is this: will me hearing about it right now help you more than us doing a mindfulness practice?
P: Okay, I get it. Let’s do mindfulness fi rst.
T: What kind of brief practice helps you the most when you are mad, to keep you from doing things that you might later regret?
P: I liked the loving kindness practice we did last time. I don’t know why, but it actually helped me calm down.
T: Do you want to be less mad right now?
P: Yes!
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T: Okay, then let’s do this practice. Begin by settling into your chair, breathing in and out deeply to get centered. Now . . .
(Th erapist directs a standard loving kindness practice.) T: Okay, now, are you feeling less mad?
P: Yes. I am still mad at her, but that practice, I don’t know what it is, but it really helps.
T: Good. Notice that you are tolerating feeling mad, and using skills to bring your anger down. Good work so far! Okay. So it has been over three months since you thought about hurting yourself, and all of a sudden this week you cut yourself.
Let’s talk some about what happened.
P: Okay. (Patient puts head down and looks away.)
T: But before we do, can I just check in with you about your current emotions? What emotions are you feeling, if any, right now?
P: Um, I don’t know. I . . . I’m sorry; it’s just that I . . . I am so mad at my mom right now.
I know that’s not what you want to talk about, but you just wouldn’t believe what she said to me this morning. We were getting into the car to come here, and that bitch had the nerve—I’m sorry to swear, I know that I do that too much—but you won’t believe what she said. We’re getting into the car, and that’s my car you know;
she doesn’t have the right to be bossin’ me around in my car, and she starts in on me . . . starts calling me lazy, an idiot, you name it . . .
T: Not exactly her fi nest moment as a mom.
P: You’re damn right! And listen to this . . .
T (interrupts gently): I will, but fi rst let me ask you a question. Are you feeling any other emotions besides anger?
P: No, I’m just pissed.
T: And I see why. I’d hate to be called those things too. I wonder though, if you stop and be mindful of your emotions, now, in this present moment, what other emotions are you experiencing?
P: I don’t know. Th e only thing I feel is anger.
T: Th ere is no question that you are feeling anger. Th e question is whether there is any- thing else you are feeling, not instead of, but in addition to anger? You cut yourself this week for the fi rst time in a while. And I am wondering if you are feeling any emotions related to talking about hurting yourself ?
P: I don’t want to talk about what happened.
T: Okay, good job noticing that. Try and notice if there is an emotion you are feeling related to not wanting to talk about hurting yourself.
P: Guilt? Shame?
T: Which one?
P: Well, I feel guilty for what I did, because I cut myself on purpose, knowing my mom would see it.
T: Okay. So, now that you are aware that you are feeling guilt right now, what skill could you use to help change your guilt? Or would you rather work on accepting and tolerating the guilt using more mindfulness skills?
P: No, I don’t think I want to do another mindfulness exercise. But I can tell you that I feel really guilty, and mad, about what happened.
T: Your anger is related to your urge to scream about your mom. Can you be mindful of any urges you are having right now, coming from feeling guilty?
P: Yes. Like I said, I don’t want to talk about what happened.
T: So, as you stop and notice your urges, the urge is to avoid talking about cutting yourself ?
P: I guess.
T: Okay. Would it be skillful for you to act with the guilty urge or to act opposite to it by talking about what happened?
P: I guess we should talk about what happened.
T: Okay.