Thread by @Drsafariboob

Dialectical Behaviour Therapy - The Tweet Thread

an interpretation by Dr. Safari Boob

DBT is a common approach to treatment of #BPD or #BorderlinePersonalityDisorder. (#EUPD #cPTSD)

It is commonly done in groups with guidance. Please seek medical help for excessive distress.

5 modules

Dialectics - The Forest
Mindfulness - The Sea
Distress Tolerance - The Storm
Emotion Regulation - Within
Interpersonal Effectiveness - Heart/Brain/Soul

Plans aren’t actions, repetition creates foundation (ie: you need to learn the alphabet before you learn to read)

Module 1 - Dialectics - The Forest

Dialectic is a word rooted in philosophy and is defined as:
- The art of investigating or discussing the truth of opinions
- Inquiry into metaphysical contradictions and their solutions

In simpler terms this module is about learning to navigate our thoughts into the grey area as opposed to the black & white thinking (that can tend to catastrophe).

Sometimes we can’t see the forest for the trees.

The first step is becoming aware of this behaviour.

Most of our decision making, particularly if you are dysregulated, embraces this trait.

Recognise what has worked for you historically and do more of that, play to your strengths.

Your natural tendency may be to default negatively.

It’s important to learn to notice this and to slowly de-stigmatise it.

That means you stop beating yourself up for it.

Develop perspectives for problems and find the silver lining.

This is difficult, especially if you are triggered by frustration.

It is part of our pathology that we cannot process emotions easily or quickly - sometimes we are not even aware of the triggers.

Shame and guilt are emotions capable of being dysregulated (or difficult to process).

Developing compassion for other’s and their experiences is crucial to navigating relationships.

Moving forwards it might be helpful to view other’s choices that affect you negatively as un-kind or un-skillful (much like your choices might have been).

Developing flexibility is a wonderful asset for recovery.

The saying goes: those who learn to bend do not break.

Module 2 - Mindfulness - The Sea

A foundational skill of DBT is the concept Wise Mind.

We also use other concepts of:
Emotional Mind – a mind completely driven by emotional reaction
&
Logic Mind – a mind devoid of emotion basing decisions on hard, cold logic

An even balance of the two creates Wise Mind.

You can think of it like a see-saw with emotional mind on one side and logical mind on the other.

We are striving for balance between them.

Often we are aware of our ability to thrive in an highly emotional state but we might not be as aware of our swing to the polar opposite of cold logic.

This logical place is often a more dangerous place than the emotional one.

We can make impulsive life changing decisions around all sorts of things thinking we are being rational when in reality we have completely removed emotion from the equation.

Developing this concept of self observation is difficult.

You may try closing your eyes & imagining yourself a few metres above yourself, looking down at you.

From here you may be able to learn to watch yourself during everyday life and notice patterns of your own behaviour.

Sometimes loved ones can help with this, just ask them to tell you kindly, avoiding shame and guilt if possible.

Whatever it is, you’re doing the best with what you’ve got and it’s time to de-stigmatise that this inherited mess is your fault.

This work requires you to begin to de-stigmatise your experience.

There are many negative words we tell ourselves that serve to drag us down.

We need to begin shifting that language.

It starts with observation, we can’t change what we can’t see.

The voice that tries to bring us down is there for a reason.

It’s seeking validation.

It is validly seeking validation.

It deserves to be listened to, comforted and resolved.

It wants us all on the same team yet it’s in our ability to suppress our own needs that causes its existence.

In an ideal world a caregiver would be aware of this distress and would help us process and resolve it.

That means when we try to suppress it, or if we tell it to shut up and abuse it further, it will continue to try to be heard, only louder.

Because that is you you’re ignoring.

Sometimes these things are too much to confront in the moment.

That is ok.

Whilst we’re all eager to heal and get it done with, the truth is this is all a journey.

We struggle with the concept of time passing yet it does.

Healing takes as long as it takes and if or when we do it will likely lead us to our next lesson.

Ultimately mindfulness is the ability to bring our mind to the present, responsive and emotionally balanced.

That’s not always possible for us but it’s excellent to have a target.

We are not learning to suppress this "beast" but commune with it, nourish it and collaborate with it in the creation of our own (healthy) manifestations, whatever they may be.

Module 3 - Distress Tolerance - The Storm

“Don’t make waves, ride them” – an old saying

These are the tools used in response to emotional dysregulation.

We can only begin to practice skills when we are self-aware enough of our experience in the moment.

They are most effective when combined with Wise Mind.

The journey of learning to recognise and fulfill our own needs (asking for help) is confronting but this is a journey, not a destination.

I have always found perspective shifting makes tasks take a different shape.

Perhaps instead of being overwhelmed by the idea of learning, developing and trying these things shift your perspective and instead, lament that you are never going to be this unskilled again!

The things you learn in DBT won’t stick without practice, but you also aren’t going to do harm in simply learning of their existence.

I am giving you permission to start that part of your journey.

Often people will use what can be referred to as maladaptive coping mechanisms.

Maladaptive means responding to problems in a way that typically cause further problems.

These can be:
- disordered eating
- self-harm
- substance abuse
- rage or bridge-burning (projected abandonment)
- sexual promiscuity or risk-prone behaviour
- impulsivity like gambling, hunting or extreme sports

Each often leads to some form of self-harm that is tied to another tentacle of BPD.

Our work is to recognise these maladaptive responses and learn they play a role. Then we learn to find things to use in tandem.

Our adaptive coping mechanisms.

When we are adept at using new responses we can begin to unlearn maladaptive ones.

We must accept it will take time and discover de-stigmatising ways of communicating the process kindly to those we care about (exceptionally difficult when you struggle to express your needs).

Healing from BPD is like learning to ride a bike but it’s a bike of the future.

You are going to suck so bad at it that you never want to try to ride again.

You’re going to get sick of seeing others riding around too.

If it helps, most people are so unaware of these things, you’ll be ahead of the average person for the rest of your life.

If it helps more it looks like the entire psych world is waking up to how invalidating CBT can be for folk like us.

Acronyms!

It wouldn’t be DBT without acronyms.

Strap in, write them on paper and put them on your walls.

Here’s a T.I.P.P. for acute (right now) emotional dysregulation:

T

Temperature change.

Create a situation that alters your temperature quickly - hot shower, cold water on face, less or more clothing, ice cubes on sternum, etc.

I

Intense Exercise

Do 3-10 minutes of high intensity movement, pump the blood to our typically low flow to the frontal lobe.

P

Paced Breathing

Experiment with a variety of breathing exercises. If you breathe out 2 seconds longer than you breathe in you will activate your parasympathetic nervous system (rest & digest)

P

Paired Muscle Relaxation

Take any muscle, you have two, one on each side of the body. Tense as hard as possible for 5 seconds and release. Repeat to regulate easier.

The next acronym used in Emotional Dysregulation is A.C.C.E.P.T.S.

This is about recognising what is happening, accepting it and turning our minds in another direction. We are looking to derail patterned behaviour.

A

Activities

You’re going to create a list of healthy activities. That’s it. Put it somewhere you can see it. Plan to do these things regularly, discover which ones regulate you quickly. Do more of this in your life.

C

Contributing

When you help others you stop thinking about yourself. The purpose of this is to give your mind a rest from all that over-thinking you do.

There are many different ways to give to the world, find something you are passionate about (this is not going to be difficult, you have BPD and are passionate about everything).

Another list of ideas!

Where you can see it and reflect on it.

C

Comparisons

A synonym for perspective. Perspective changes everything and change is the only constant in this world.

Our minds are hard wired to tend to the negative so developing a practice of gratitude is neural pathway shifting.

Start small, write it down, be consistent. You will get better at it.

Phone alarms and organiser apps are helpful for these things.

E

Emotions

Emotions are established responses to body sensations you have learned to tolerate instead of experience. They are choices your brain makes validly in response to historical experiences. They aren’t conscious choices they are responses to input.

In this skill we recognise the emotions using wise-mind, extract it’s opposite emotion and discover or explore behaviour that manufactures that emotion.

This skill is advanced!

P

Pushing Away

This skill is about stepping away from a problem. Pausing a heated conversation, taking time to think or calm down, sleeping to reset.

What is happening is dysregulating, time to focus on something else.

T

Thoughts

This skill is about directing your thoughts to things you know are helpful. You may wish to create a list or mood board to remind you of your favourite things or ambitions and art projects you’re working on.

Focus on something helpful.

S

Sensations

Sight, Sound, Touch, Temperature, Smell, Taste, Proprioception (balance).

Recognise your favourite sensations and go to them when in distress.

The next acronym is…

I.M.P.R.O.V.E.

This one is named after the idea we are learning to use wise-mind to recognise our moments of crisis and steer us towards behaviour that build us up rather than tear us down.

I

Imagery

Eye-sight. Something to be grateful for and something to indulge in. We specifically want to use it in a calming way so engaging in any cultural visual medium, creating with imagery (drawing, painting, photography, sculpting, flower arrangement, etc).

M

Meaning

Why do you do this work? Each person has their unique reasons, often they have hit rock bottom. Finding meaning and reason can feel difficult when you feel out of meaning and reason. This is where practicing gratitude is important.

Our brain chemistry causes us to react.

Shifting this is again like the bike riding analogy.

This world has unlimited experiences for those able to shift past their trauma.

It can’t be pushed away though, only accepted & made a part of us that works with us to move forwards.

P

Prayer

References to gods make my skin crawl. People should be allowed to discover their own belief systems. I treat gratitude as prayer. There is good in the world & it is found in your perspective of gratitude. Your privilege allows you to read and understand these words.

R

Relaxation

We are our own worst enemies, weighed down by poor self worth. Recognise your need for a break. Plan it. No, sitting on your phone/social media is not relaxation.

Sometimes breathing goes well with relaxation! So does a good stretch.

O

One Thing at a Time

Close all of your tabs. One tab open at a time. This means one activity at a time. It can also refer to difficult moments, recognise time is going to keep moving. It’s our job to ride the wave, not make it. Be kind, recognise your own needs.

V

Vacation

From a quick walk to a beach destination, check in on how much down time you give to yourself. Working on your mental health is a full time job, you need to take breaks for neural connections to really come together.

This is a journey, not a destination.

E

Encouragement

Observing our self with wise-mind and slowly shifting self-stigmatising language is one of the hardest initial boulders to move.

Watch your thoughts; they become words
Watch your words; they become actions
Watch your actions; they become habits
Watch your habits; they become your character
Watch your character; it becomes your destiny

- Frank Outlaw

With a daily practice of 3-5 minutes of positive self-affirmation via writing or your voice, change will happen.

This is why using a journal is so popular in recovery. It's very effective. You can do similarly by talking positively to yourself in the mirror.

Our goal in distress tolerance is to self-soothe.

When babies are dysregulated emotionally they typically have a parent who will swaddle them close and teach them how to calm down innately.

When you have BPD this process has been disrupted or absent for some reason.

The senses are excellent ways to calm down an overstimulated nervous system.

Cold water splashed on the face, strong favourite smells, calming music (Enya is scientifically proven), there is something that will appeal to you.

Radical Acceptance

The worst of the skills, radical acceptance is our final distress tolerance skill to develop.

Because it is placed last it isn’t practiced enough so I recommend everyone begins with learning this skill from day 1.

Radical acceptance is difficult because BPD & its symptoms are so confusing before diagnosis.

Every behaviour is explainable & whilst feeling unique to the person experiencing it understanding how those with BPD think and react to life is integral for self compassion.

When logic is in place radical acceptance becomes easier and people with BPD enjoy logic.

Logic is the justification of things based on established rules.

Sometimes when things aren’t working in distress tolerance & nothing I’ve written so far is helpful you might have to ask if you are willing to change to help yourself heal?

I’ve found the thing that stops people moving past this is yet another symptom of BPD. Poor self worth.

If you’ve read this far – YOU HAVE WORTH.

That you have done this much work already to try and understand what is going on – it gives you so much value.

The thing about this world is what we are and the things we create aren’t ultimately our own to judge.

Nobody is capable of doing what you’re capable of because – they aren’t you.

You’re unique in your experience.

You do have a duty to share your gifts here and now.

We need you to make the human race even more special.

We need to help you heal first though and to do that, you have to be willing to work at it.

Reclaim your bridge-burning skill, you’ve been honing them for this moment! It’s time to focus our bridge-burning on behaviours instead of people by altering our approach to our problems.

Make another list of your challenging behaviour and what purpose it serves.

The things we do always have purpose (when we aren’t literally having the equivalent of a seizure), once you discover the purpose you can discover alternative healthier ways to meet your needs.

As is a key factor in all of BPD, nobody is perfect.

Keep your expectations of yourself in the grey area and keep building that path to a life with less distress, brick by brick.

At the core distress is dysregulating.

Often it may feel like things in the present are the root cause but we are being reminded of our past trauma and our brains are responding as though it is happening again.

Grounding our self in time and space in the present moment can bring us into a more regulated state.

The senses are all excellent avenues for bringing ourselves to the present, along with breathing.

Sometimes distress is less immediate and more linked to an event or decision that must be made.

Our brains are only capable of holding so much information at a time and we’re always moving forwards and coping in the moment.

This leads to problems around decision making, especially when our brain anatomy literally causes impulsivity.

Using a pros vs cons list can help access our Wise Mind skill to make decisions from a not too emotional and a not too logical state.

Balanced.

Module 4 - Emotion Regulation - Within

When babies are babies and are emotionally dysregulated (unable to bring their emotional state out of distress) they are regulated by having a caregiver hold them and help them to co-regulate, to match emotional regulation.

We skipped this step!

Now we have to teach ourselves how to do it and that’s really hard.

The good news is, you aren’t the first and you won’t be the last.

Let’s get in to how to start learning!

If I haven’t drummed in the point of DBT yet – it’s a practice.

That means you need to treat it like a musical instrument or a new language.

It’s only going to become easier when you practice it.

Emotions are learned responses to situations.

We are relatively simple in nature and repetition begets this behaviour.

1. We are not our emotions.
2. Our emotions are initially physical sensations in the body that our brain responds to.

3. We hold emotions hostage in our mind, endlessly interrogating them about their existence.
4. Processing emotions involves decreasing cognition around them and increasing our attention to interoception (awareness of our self and insides)

When we begin to have more control over our emotions and emotional responses we are able to begin processing what caused them to begin with.

This process can be scary, I’m sorry.

I found many parts of DBT confronting but no more than the depths of a meltdown.

The first acronym of Emotion Regulation:

P.L.E.A.S.E.D.

The PLEASED skill is about self-care and nurturing your neglected self.

P.L.

Physical iLlness

Attend to your health and pain needs.

Prioritise making and attending appointments, keep a journal solely for keeping track of each health condition – this is exceptionally useful for other healthcare providers. You can make it pretty!

E

Eating Habits

Planning & eating health-oriented food with balance (perfection is the enemy of joy). Many of us experience disorded eating which deserves it’s own attention. It’s doubtful anyone with BPD can add yet another health specialist in.

Eating disorders are often rooted in control and therefore any approaches to change should be supported with improvements in all other areas. It is very easy for us to use EDs as a form of self harm.

A

Avoid Mind Altering Substances

Become aware of maladaptive habits related to unacknowledged needs & find adaptive solutions.

We discussed what Maladaptive means, Adaptive means responding in ways that foster resolution.

Be kind to your self here.

S

Sleep

Balance in everything. Too much or little sleep will often exacerbate our symptoms. Sleeping habits are something all people with BPD can become aware of to help manage things.

Common things affecting sleep are:
- stress
- drugs & alcohol
- caffeine
- eating 3 hours before sleep
- pain
- poor sleep hygiene
- breathing problems
- temperature regulation
- old bedding/mattress
- sleep apnoea

E

Exercise

Scans show people with BPD have poor blood flow to the frontal cortex, this is the part of our brain responsible for our personality. Cardiovascular exercise will encourage blood flow to the area which combined with skill use promotes neural plasticity.

It has many other positive effects, remember balance if you’re the sort to get addicted to exercise.

Too much will cause it’s own problems in BPD, particularly around pain over time.

D

Daily Practise

How to build mastery. Developing reward behaviour for achieving goals is said to be the key to effective habit building. I also am a firm believer in understanding the transtheoretical model of behaviour to develop habits and change.

Module 5 - Interpersonal Effectiveness - Heart/Brain/Soul

This module is about developing confidence during interactions, being aware of our own values and goals, increasing our attention to relationship needs and how to express them kindly.

The skills are designed to be used in the moment and also as tools to reflect on past behaviour or plan future behaviour.

Planning ahead is one of the greatest assets DBT has to teach us.

The first acronym of this skill is D.E.A.R.M.A.N.

It is a rundown of the steps to go through when interacting with someone you wish to maintain a relationship with.

D

Describe

This is the part where you place the pieces in front of who you’re communicating with. You’re going to be looking for your ‘what’ your ‘why’ and your ‘how’ but first you need the scene. Describe it.

E

Express

Reflect on what you think or feel about this situation. Express this information kindly.

A

Assert

We do this by asking a question or request. Assertive people are confident.

R

Reward

Reward others for meeting your requests. We set standards by reinforcing behaviour of those around us, a good boundary is access is granted to you when your needs are heard and met.

M

Mindful

We have created a plan and a goal, it’s important to keep our focus on the outcome we planned on the outset.

A

Appear Confident

Confidence is an important bargaining tool. Think of your values and be confident in your portrayal of them.

N

Negotiate

This is an opportunity to remember our tendency for black & white thinking and to steer ourselves into the grey area. Relationships are give and take.

The next acronym is F.A.S.T.

It is a spin on D.E.A.R.M.A.N and potentially an easier first step to remember when not well practiced.

F

Be Fair

Be Fair to yourself and the other person – equity is a concept that comes easily to those with BPD but we are easily able to become self-oriented when in emotional distress.

A

(No) Apologies

This is about decreasing apology that is unnecessary and conversely making active efforts to support our self. This can very difficult for some of us as we are so fearful that standing up will push others away.

S

Stick To Values

Most of us may be vaguely aware of our values but for those wishing to have mastery of their emotions it is useful to develop a personal list of values. This can then be used as a reference point for future decisions.

T

Truth

Our recovery is about acknowledging the truth of everything. Acknowledgement of truth must be coupled with de-stigmatisation of symptoms. To aid this process we can move forward with the intention of acting in truthful ways.

The last acronym in Interpersonal Effectiveness is G.I.V.E.

G.I.V.E. is specifically designed for those who struggle with kind interactions and are unable to access empathy when dysregulated.

G

Gentle (altered from Genuine by my Art Therapist)

Approach all interactions in a gentle way. We each have a reference point for gentle, behave in a way that is perceiving others to be fragile and you are avoiding breaking or hurting them.

I

Interested

If we behave in a way that is interested in what the other person is saying they are likely to be engaged with what we are sharing.

V

Validation

Nuerodivergent people will encounter the double empathy problem when trying to validate others. Everybody needs to be validated for healthy relationships. You can develop learning what you need by validating others and observing the process. Reverse engineer it.

E

Easy Manner

With heightened emotions comes intensity. The more we can recognise this the more we can steer into the grey area. We experience dysregulation of uncomfortable and comfortable emotions.

Trust

Trust is an important element in people we consider support networks. Those we trust deserve to be told what we need (with balance). When trust is broken it is a difficult thing to repair yet as usual it helps us to guide our thoughts to the grey area, avoiding extremes.

Every person is different and often it’s important for us to develop trust in ourselves first.

This is done with de-stigmatisation of self talk, being kind, gentle and curious with ourselves and grounding ourselves in the present.

Boundaries

Boundaries are a broad term for an abstract concept. Every person will have their own boundaries for their own reasons.

Our job is to discover what our own ones are and make amends with the part of us that was conditioned to drop boundaries.

Often we weren’t taught how to develop boundaries and our well-being was reliant on not having them.

To begin with you will search for someone to give you an example of their boundaries but unfortunately it is something that you develop so is hard to copy others.

As you spend time developing skills & vocabulary to describe your experience you will begin to grow your understanding of what your boundaries are.

Remember: you cannot have boundaries without a sense of self to put boundaries around, start with development of your self.

Conflict Resolution Tips

‘You can be the ripest, juiciest peach in the world and there’s still going to be people that don’t like peaches’

– Dita Von Tesse

Learn to disengage from conflict.

Often our need for conflict is rooted in the need for validation or the need to establish innocence due to an inability to process shame or guilt and the trigger that causes.

Our efforts are best spent building our self.

People like us impulsively tend to give and contribute to others, but we often do it from a very unstable place.

We should work on filling our own cup abundantly and let the overfill fill other’s cups.

...and that is D.B.T.

You will succeed faster with a therapist or group work but many do not have access to these things.

You can begin this work your self.

In fact, what a fantastic way to start developing your self.

I wish you well on your journey.
❤️‍🔥Dr. Safari Boob