simply legitimate), and disconfi rming what is invalid (e.g., it is not literally true that
“I am bad” just because I have that thought), the aim is to help shape up the patient’s ability to discriminate valid from invalid behavior.
Much like an inspector examining a conveyor belt for items that have problems before they are boxed and shipped to customers, the therapist helps the patient learn to identify experiences and behavior as valid or invalid. Of course, there are times when a behavior is both valid from one perspective (i.e., it makes sense why a thought occurred) and invalid from another perspective (i.e., the thought may not be literally true). Th is process leads to many instances of therapist validation of patient in-session behavior that the patient typically experiences as invalid. By training the patient to become more facile at recognizing and distinguishing between aff ective states, for example, the therapist is promoting acceptance of aff ective experiences as they are experienced. Importantly, the therapist also actively helps patients learn to validate the reasons why it may make sense that they have invalidated themselves cognitively (e.g., “I will never have a good relationship”), without validating the content or literal and permanent truth of the invalidating thoughts.
In addition to explicit training of validation as a skill to be learned directly, the therapist uses self-validation as a way to model to the patient. Th erapists model valida- tion by explicitly identifying how, for themselves, there are types of antecedents that commonly give rise to certain kinds of internal experiences. Similarly, therapists model how to accept oneself by validating one’s own thoughts, emotions, and actions as mak- ing sense, being eff ective, and so on. Th is is done in a manner that is sometimes playful, sometimes matter-of-fact, but always genuine and with the patient’s need to develop this skill clearly being targeted.
Experiential Exercises as a Means to Build Acceptance
Th erapists in DBT frequently use experiential exercises with their patients as a way to promote acceptance. Th ere are no specifi c experiential exercises, other than those de- scribed below as mindfulness practice, that are required in DBT. Instead, the therapist has a wide range of possible exercises that he or she may choose to use as needed during session. Th is organic use of experiential exercises allows the therapist and patient to tran- sition during sessions, sometimes back and forth within the same session, from problem- solving, chain analyses, or explicit change-focused skill training to experiential practices intended to promote acceptance, cognitive defusion, or, most broadly, insight.
Experiential exercises can be used to promote acceptance of thoughts as only thoughts and not things that have to be literally true. Patients can learn not to “buy thoughts as literally true” through experientially practicing to observe the content of thoughts changing as the context for thinking changes. Such exercises can help clients learn to accept thoughts that seem true now to be experienced simply as thoughts, neither to be held as literally true nor refused as untrue. Another use of experiential exercises might be to learn that urges to behave do not always require
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acting on the urge. Learning not to respond to urges can be an important skill that helps promote acceptance of the urge as simply an internal experience, and not a com- mand from a homunculus dictating a required action need necessarily occur. Again, there is no specifi c single exercise that is required. Th erapists can choose to use an experiential exercise that they judge will work well with any given patient in any given moment. Moreover, experiential exercises are not conceptualized as better or worse than explicit behavioral skills training. Rather, when promoting acceptance, experiential exercises can be the yin to didactic or explicit skill training’s yang.
Mindfulness Skills
Mindfulness refers to being aware of one’s experiences in a nonjudgmental, receptive manner and participating in activity based on that nonjudgmental awareness. Kabat-Zinn (2003), for example, described mindfulness as “the awareness that emerges through pay- ing attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience, moment-by-moment” (p. 145). In an attempt to operationalize mindful- ness for a research context, Bishop et al. (2004) proposed that mindfulness includes two components: self-regulation of attention and orientation to experience. Self-regulation of attention involves nonelaborative observation and awareness of events, thoughts, sensa- tions, feelings, action urges, and so on, from moment to moment. It entails the abilities to sustain attention on an intended focus and to switch attention at will to a new inten- ded focus. For example, one may practice sustaining attention to one’s breath. When the attention wanders from the breath, the practitioner learns to notice what he or she is focusing on and then move attention back to the breath. Th e second dimension of mindfulness—orientation to experience—concerns the attitude held towards present- moment experience, specifi cally an attitude of openness and curiosity toward whatever experience arises in each moment, without imposing judgments on or reacting habitually to the experience. We all are mindful to varying degrees across situations and occasions, and there appear to be relatively stable individual diff erences in average levels of mind- fulness that are signifi cantly related to a variety of indices of well-being (e.g., Brown &
Ryan, 2003). Mindful awareness often occurs without any particular intentional training or practice, and there may be a variety of methods for increasing mindfulness. However, many spiritual traditions and, more recently, some physical and mental health interven- tions, propose that meditation practices can increase the ability to be mindful. Th ere is evidence that experienced meditators on average score higher on measures of mindfulness (e.g., Baer et al., 2008; Brown & Ryan, 2003, Lykins & Baer, 2009), and that participa- tion in a mindfulness-based intervention leads to increased self-reported mindfulness (e.g., Carmody & Baer, 2008, Shapiro, Oman, Th oresen, Plante, & Flinders, 2008).
Teaching and encouraging regular practices based on mindfulness meditation is the primary content and focus of interventions such as mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1982) and mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002). In DBT, mindfulness is viewed as critical for therapists’
in-session awareness and participation, and as the core set of skills to be learned by pa- tients, but these elements are parts of a whole that includes use of many other therapist behaviors and development of many other patient skills. Mindfulness skills not only are taught as a free-standing skills module, but also are included in each of the other three skills modules, in which the relevance of mindfulness for daily life (sometimes referred to as informal mindfulness practice, in contrast to formal practice such as sitting medita- tion or body scan) becomes clear. Nonjudgmental awareness, acceptance, and nonavoid- ance of emotions, thoughts, and action urges are benefi cial for emotion regulation. Th e ability to focus mindfully on a chosen object or activity can facilitate the eff ective use of distraction to tolerate distress and avoid engaging in maladaptive escape behaviors;
awareness of goals in interpersonal interactions and the ability to not lose sight of them in the context of strong emotions are important skills for interpersonal eff ectiveness.
Mindfulness skills are taught in DBT because of their potential for clinically sig- nifi cant benefi ts that can include, among others, being less “scattered” and distractible, particularly at times of strong emotion; being more aware of and able to let go of rumi- nation; being more aware of action urges before acting on them; and being able to ex- perience life more fully and richly. Like other skills, mindfulness can be developed with intentional, deliberate practice. One common practice is to sit comfortably with eyes closed, focusing the mind on the inhalations and exhalations of the breath, and noticing the thoughts, images, sensations, and action urges that enter one’s awareness, allowing them to come and go freely without judging, holding onto, or trying to suppress them.
Other objects of focus may also be used, such as external objects, a particular idea or class of thoughts, or activities such as walking or eating. Some practices may result in physical and mental relaxation, which may allow one’s “wise mind” to be more accessible. How- ever, relaxation is not a primary goal of mindfulness practice. In fact, awareness during mindfulness practice may at times increase awareness of unpleasant experiences. Th ese experiences are not to be avoided, nor are pleasant experiences to be directly sought in mindfulness practice. Among other things, this aff ords an opportunity to observe that sensations, thoughts, emotions, action urges, and so on, are not permanent, but come and go like the waves of an ocean, while the observing self remains present.
In DBT, in the Mindfulness Skills module, mindfulness is taught as a set of “what”
skills (what to do) and a set of “how” skills (how to do it). Th e “what” skills are observ- ing one’s sense experiences, describing what one observes (e.g., “I am aware of an urge to move”), and participating, i.e., interacting with the world. Practice in observing and describing are helpful steps toward participating mindfully. Th e “how” skills are one- mindfully, focusing on one thing at a time with full awareness, nonjudgmentally, without labeling experiences or behaviors as good or bad, and eff ectively, behaving in ways that are consistent with one’s important goals and values, rather than getting caught up in goals such as proving a point. Some of the practical issues involved in teaching mindful- ness skills in DBT groups are discussed in Robins (2002).
Mindfulness skills also feature among the skills taught in each of the other three modules. In the Distress Tolerance Skills module, for example, skills for getting through
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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.