DBT skills for reducing vulnerability during COVID-19
It’s a scary time right now. COVID-19 is spreading across the planet, claiming tens of thousands of lives, as the rest of the world experiences varying levels of lockdown. The future is uncertain, there’s no end in sight, and every individual’s daily routine has been greatly impacted. Anecdotally, I’m hearing a lot of fear, anxiety, and frustration from friends and family, particularly from those friends with mental illness or other health problems. It seems everyone’s vulnerability levels are very high right now, and rightly so.
I have some experience feeling highly vulnerable, and seeking to treat these feelings, and it wasn’t until I came across dialectical behavioural therapy (DBT) that I finally found some concrete methods to find relief. Regular readers might recall that DBT was developed by Marsha M. Linehan in the late 1980s as a modified form of cognitive behavioural therapy (CBT) to treat borderline personality disorder (BPD—had enough of the acronyms yet? Welcome to my life). BPD is a personality disorder characterized by a history of unstable relationships, fear of abandonment, distorted sense of self, and extreme or intense emotional reactions. In describing that emotional sensitivity, Linehan says, “people with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.”
While BPD only affects a small per cent of the adult population, the emotional vulnerability people with BPD are used to experiencing is now likely being felt on a mass scale, even by people with no history of mental illness. As is such, I thought it would be helpful to share some specific DBT skills around regulating emotional vulnerability. Just a reminder: I’m not a therapist, clinician, or doctor, and I’m sharing these skills with a belief they’ll be a great starting point for reflection, mindfulness, and finding peace during these chaotic times. People with mental illness should practice these skills with the guidance of mental health professionals.
Checking the Facts and Emotional Regulation
The first DBT skill that may prove helpful right now is checking the facts. Checking the facts entails determining whether your emotional reaction fits the facts of a situation. By identifying any beliefs or assumptions you’re layering onto an event, you can help change your emotional response. In Linehan’s book, DBT Skills Training Handouts and Worksheets, which I’ll refer to heavily in this post, she outlines how to check the facts in the following steps:
Determine what emotion you want to change. Is it fear? Anxiety? Anger?
Describe the event prompting your emotion. Is it learning about new lockdown measures? Talking to an at-risk family member? Describe the facts you observe through your senses, while challenging any judgments, absolutes, or black-and-white thinking you may find yourself engaging in.
Note your interpretations, thoughts, and assumptions about the prompting event. Are there other possible interpretations you’re not seeing? Try to find all sides of a situation and seek out any interpretations or assumptions to see if they fit the facts.
Ask yourself if you’re assuming a threat. I think it’s fair to say, in a lot of cases, people are feeling very threatened right now. Label that threat. Is it a fear of dying? The loss of a loved one? What’s the probability that the threat will actually occur? List as many other possible outcomes as you can.
This next step can be scary so please don’t engage with it unless you feel safe and ready: imagine the worst occurring, then imagine actually coping well with catastrophe. Envision yourself problem-solving or accepting the worst.
Finally, reflect on your initial emotion and ask yourself if its intensity fits the facts. By addressing any judgements or absolutes around the prompting event, you might find the intensity of your emotion is at odds with the facts of the situation.
Once you’ve determined if your emotions fit the facts you can engage in the following exercise: if your emotions do fit the facts, ask yourself if acting on those emotions will be effective. If you come to the conclusion that acting on your emotions won’t be effective, you can try opposite action. Exactly what it sounds like, opposite action consists of doing the opposite of your action urges. Every emotion has an action and an opposite action. For example, fear’s action urge is to run away or avoid. Its opposite action would be to approach. Another opposite action for fear would be to do things that give yourself as sense of control and mastery. All-the-way opposite actions for fear include staying engaged in the present moment, taking in information slowly while noticing you’re safe, changing your posture and tone of voice, or changing your body chemistry through paced breathing. You can use this same approach if you find your emotions don’t fit the facts and acting on them wouldn’t be effective.
If you find your emotions fit the facts and acting on them would be effective you can proceed to problem-solve your unwanted emotions. To solve your problem you must identify what needs to happen for you to feel okay (and keep it realistic and within your grasp). Brainstorm lots of solutions without being critical (consider asking for suggestions from people you trust if you’re having a tough time). Next, choose a solution that’s likely to work and put the solution into action. Did it work? If it didn’t, go back to your list of solutions and try another.
If you find your emotions don’t fit the facts but you still feel acting on the emotion will be effective, be sure to proceed mindfully, accept the consequences of your actions gracefully, and reconsider engaging in opposite action.
Radical Acceptance
Of all the DBT skills, radical acceptance is my least favourite to practice, but that’s just because it’s the hardest. Radical acceptance is useful when you can’t prevent painful events and emotions from arising. To radically accept something means to accept the events and emotions you’re experiencing totally, within your mind, heart, and body. To practice the skill, you must be willing to accept reality as it is (even if you don’t like the facts), that there are limitations on the future for everyone, and that life is worth living even during the most painful of times.
Why is it important to accept the reality of the circumstances we’re now collectively facing? Because rejecting what’s going on won’t change anything, and changing your reality means first accepting it. When we reject reality, our pain transforms into suffering and while accepting that the world is a scary place right now might lead to sadness, a deep calm will usually follow. As Linehan notes in her workbook, “the path out of hell is through misery. By refusing to accept the misery that is part of climbing out of hell, you fall back into hell.”
Just to be clear: radical acceptance doesn’t mean you approve of the painful events and emotions you’re experiencing, or are against changing them, it’s about letting go of the bitterness that comes with fighting reality. There are factors that can interfere with being able to successfully practice this skill including not having the skills for acceptance, the belief that if you accept a painful event you’re making light of the facts, or being too inundated by emotions.
To practice radical acceptance, move through the following steps:
Start by determining if you are questioning or fighting reality with thoughts like “it shouldn’t be this way.”
Tell yourself that as unpleasant as reality might be right now, it can’t be changed.
There are causes for reality. It can be helpful to acknowledge the history that led up to this moment by considering how people’s lives have been affected by a series of factors. If you can notice how history led up to this moment, and reality had to occur just this way, you’re on the path to radically accepting your circumstances.
Try to accept reality with your entire being—your mind, your body, and your spirit. Linehan suggests using techniques like relaxation, mindfulness of breath, prayer, or imagery while thinking about what feels unacceptable.
Practice another DBT skill: opposite action. List what your behaviour might look like if you did accept the facts and then engage with those behaviours as if you’d already accepted the facts.
Try coping ahead: imagine believing what you don’t want to accept. Rehearse in your mind what you would do if you accepted the facts (more on this below).
Tend to any bodily sensations that arise as you think about what you need to accept.
Allow in feelings of disappointment, sadness, frustration, fear, or grief.
Acknowledge that even amidst intense pain, life is worth living.
If you’re still having trouble accepting the facts, do a pros and cons list of accepting versus denying the facts.
ABC PLEASE
As a result of COVID-19, many of us are having to completely rebuild our routines from scratch, and some of us may be feeling exceptionally emotionally vulnerable as a result. A great DBT skill to practice if you’re struggling to adapt and thrive in our new circumstances is ABC PLEASE.
The first area this skill revolves around is accumulating positive emotions, both in the short and long-term. Short-term, we can all build positive experiences by increasing the number of pleasant events we participate in each day (pleasant events can be as simple as watching a movie, laying in a sun puddle, or reflecting on past positive experiences) and engaging with our positive experiences fully and mindfully. Try to avoid worries surrounding when the positive event might end, whether you deserve a positive experience, or how much more you feel you should be doing. Long-term, we can avoid avoiding and continue building the life we want by identifying the values that are important to us, selecting one value we can currently work on, identifying a few goals related to this value, and choosing a goal to work on. By identifying and taking one action step toward our values, we can begin accumulating long-term positive emotions.
The “B” in ABC PLEASE stands for building mastery. By engaging in activities that give you a sense of accomplishment you can combat helplessness and hopelessness. For example, one way I build mastery each day is by setting aside half an hour each morning to study French, Spanish, and Ukrainian. By setting a difficult but achievable goal, I can easily feel like I’ve accomplished something worthwhile every day. These days, my daily goals include a lot more than just studying languages, which you can build to over time. I also take time to reward myself and reflect on my achievements, no matter how minuscule they may seem. As the quarantine stretches on, I feel as though we’re all going to benefit from incorporating ways to build mastery into our routines.
The next step to reducing emotional vulnerability is coping ahead. Coping ahead involves rehearsing a plan to cope with emotional situations ahead of time. This starts with identifying a situation that’s likely to prompt an emotional response or problem behaviour. For example, these days, you might find grocery shopping strikes a sense of panic into you that you’ve never experienced before. Focus on exactly what is causing the panic around grocery shopping while checking the facts. Determine what difficult emotions and actions might arise and decide on some coping skills you may want to use during your next grocery shop. Now, imagine grocery shopping while using those skills. Rehearse coping effectively, both with problems that might come up while shopping, and your most feared catastrophe. Engage in relaxation practices after you’ve rehearsed.
Of course, a big part of emotional regulation involves taking care of your mind and body. In DBT, this is called the PLEASE skill (it’s not the most perfect acronym). PLEASE involves treating physical illness and taking care of your body, eating a balanced diet, avoiding mood-altering substances (or using them in moderation), getting a good night’s sleep, and exercising regularly.
Hopefully these skills will provide a jumping-off point to mindfully engage with emotions you’re experiencing during COVID-19. Stay safe and healthy, and take care of yourself.
Mad History
This issue: Plague masks
Imagine being sick and having a doctor show up dressed like a cross between the grim reaper and a predatory bird. If you were sick during the 16th century, that’s what you could expect.
For this edition’s Mad History, I’ve decided to shift focus to plague masks (given everything that’s going on). Often thought to have been embraced during the Black Death, these snazzy duds weren’t actually invented until about three centuries later. Charles de Lorme, chief physician to Louis XIII, is credited with the design, which was meant to protect the wearer from “bad air”—thought to be a cause of illness at the time. A full description of the outfit appeared in the Encyclopedia of Infectious Diseases: Modern Methodologies:
The nose [is] half a foot long, shaped like a beak, filled with perfume with only two holes, one on each side near the nostrils, but that can suffice to breathe and carry along with the air one breathes the impression of the [herbs] enclosed further along in the beak. Under the coat we wear boots made in Moroccan leather (goat leather) from the front of the breeches in smooth skin that are attached to said boots, and a short sleeved blouse in smooth skin, the bottom of which is tucked into the breeches. The hat and gloves are also made of the same skin … with spectacles over the eyes.
The outfit was topped off with a cane (details on usage vary from a tool to instruct others to a rod for fending off the ill). Needless to say, these outfits didn’t really make a difference in preventing the spread of illness, instead serving as a grim harbinger of impending death.
Recommended Reading
DBT Skills Training Handouts and Worksheets, Second Edition
By: Marsha M. Linehan
I was first introduced to this workbook through a DBT skills course at the Centre for Mental Health and Addiction. Linehan’s workbook is a distillation of her therapy into accessible handouts and worksheets that help people better engage with DBT. A must-read for any people currently practicing DBT, but also a great resource for those looking to build their mindfulness, interpersonal, emotional regulation, or distress tolerance skills.
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