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How to Use Dialectical Behavior Therapy Skills in a Pandemic: A Day in the Life of a Psychologist.

Dialectical Behavior Therapy (DBT) is a an evidence based treatment that focuses on teaching skills to help regulate intense emotions, develop relationship effectiveness, and create a life worth living. In this post, Dr. Rebecca Berger, a clinical psychologist at MindWell NYC provides a first person perspective about what it is like to use DBT skills on a day in quarantine during the COVID19 pandemic.

8am:  The alarm clock rings and the first thing I think to myself is “not again”. Waking up these days is hard. There are long stretches of time where my mind runs wild and I feel anxious and sometimes even fearful. I close my eyes again and hope that the second alarm takes ages to arrive. Fifteen minutes later it rings again and I know it’s time to use opposite action. Opposite action is an emotion regulation skill intended to help change strong or painful emotions. Opposite action means engaging in the opposite of what our emotion is telling us to do, if it makes sense to do so. In other words, it’s doing the opposite of what we want to do in that moment. We use opposite action when we know that it is more effective not to give in to the emotion urge. For example, if I tried to use opposite action when waiting to cross a busy street that would just be foolish. In that case it fits the facts to follow my urge to wait. However, in the case of wanting to stay in bed all day to avoid the reality of quarantine, it makes sense for me to act opposite and face the day. So, I get up, get in the shower, and get ready to tackle the day.

12pm:  Lunch time. I notice that I am hungry and extremely thirsty. Have I been drinking enough water? One of the challenges of the pandemic and quarantine is how tired I have been. It seems that no matter how many hours of sleep I get I am sluggish and sleepy. I notice racing thoughts- “I must have the virus!” “Am I getting sick?”  No, Becca, you are okay, I think to myself. There is no evidence that I am sick other than feeling tired. I might be having the thought that I am getting sick but that does not make that thought a fact. Our thoughts are POWERFUL and we often believe that they are an absolute truth, when in reality, they are simply content our brain creates to help make sense of our world. I notice that I am having this thought and label it as such, which is a core part of mindfulnessobserving and then simply describing that experience without judgment- “I am having the thought that….” Once I am able to check the facts (also an emotion regulation skill) I notice an almost immediate decrease in my distress and I can go back to focusing on what my body needs- food and water. An unfortunate circumstance of bodies under stress is that they produce more cortisol, which is the human stress hormone. This has a variety of unpleasant effects, including an increase in fatigue. I have fallen into the trap of drinking more and more caffeine to deal with this which only amplifies the physical symptoms of anxiety such as a racing heart, increased sweat production, and racing thoughts.  I decide to put down the third cup of coffee and fill up my water bottle. DBT emphasizes the brain-body connection using the “PLEASE” skills. This is an acronym that stands for treating physical illness, eating multiple times per day in a healthful and intuitive way, avoiding mood altering substances (including caffeine!), getting a minimum of 7 hours of sleep per night, and exercising at least a few times per week (that one I admittedly am still working on….).  As I sip on my newly filled water bottle and eat my lunch I notice the urge to check the news for the 100th time. I allow myself to check only objective news sources including the CDC website and the Johns Hopkins COVID data website. Ensuring objective information is another way I am employing the checking the facts skill.

1pm: I notice a surge of guilt. I am having the thought that I don’t want to go back to work and have anymore telemedicine sessions today. Staring at screen all day takes a toll. I care deeply about my clients and supporting them and I also simultaneously want a break and some time to myself.  Then I remember that two opposite truths can exist at the same time and neither one is wrong or right. In this moment I am grateful to DBT for reminding me of dialectics– the concept that we can make space for more than one truth.  When I am able to remember and practice this I am able to more fully engage in what I am doing, which in this case, is more therapy sessions. This is the participate skill of mindfulness. Allowing ourselves to be fully present with whatever it is we are doing in the moment. This skill is always important and I would argue it is even more important during this pandemic uncertainty. The only option we have is to be fully engaged in the present moment as it is currently (and really always) all we have. 

7pm: “YES ANOTHER WORK DAY DONE!” I excitedly think to myself. I go into the kitchen and open up the fridge and look at my bottle of rosé that seems to be asking me to drink it. On another night I might decide that a glass of wine is exactly what I’d like to relax. Drinking alcohol in moderation is sometimes okay. Sometimes, it’s not. I recognize that today my anxiety has been high and that adding alcohol to the mix is likely to feel good in the moment and to make me feel more anxious or tearful when the buzz wears off. So I choose to be willing to do what works and attend to my “PLEASE” skills tonight instead. A cup of tea will do. I sigh- it is not as exciting or desirable- and it just is more wise- minded. We are all torn between making decisions based in emotion and decisions based in reason. Both have their dangers. DBT emphasizes the importance of making decisions from our wise mind. Wise mind accounts for both our emotions and our logic and chooses the best middle path.  Tonight my middle path is a cup of tea with the agreement to myself that if I feel less anxious tomorrow I can have that wine. Will I always choose this wisely? Nope. I am human, after all.  I choose a cup of mint tea because I find the smell soothing. I add some fuzzy socks to the mix, pull a blanket over my lap, and snuggle into the couch with my dog. Finding small and creative ways to self–soothe using our 5 senses is an important way to tolerate distress.  On days when emotions feel overwhelming or too painful to bear, skills such as self-soothing and distracting (Bravo TV anyone?! ) can be particularly helpful in making it through the wave of emotion without engaging in behaviors that may feel good in the moment and actually make the distress worse over time. Often we are engaging in some of these skills without even realizing it. Labeling behaviors as skillful and effective helps increase pride and a sense of mastery over our experiences. Most of us have unknowingly already found some creative ways to tolerate our distress during quarantine (I am looking at you with the sourdough starter!) and that, in and of itself, is a skill.

9pm: I notice I am feeling the most content I have all day. I feel happy and am mindful to notice it. Observing positive emotion and practicing gratitude for it helps to bolster well-being. Therapy is not all about simply decreasing what is not working. It is also about increasing what is working! I know that what works to help me accumulate positive emotion is engaging in pleasant events– another DBT skill! My secret recipe for increasing positive emotion includes Real Housewives themed Zoom trivia, FaceTime-ing with my family, asking for hugs from my partner, and painting my nails at least twice a week during quarantine. Tonight I engaged in two of these activities, which has helped prompt this increased sense of contentment, and for that I am thankful.

11:30pm: I am laying in bed staring up at the ceiling and watching the ceiling fan spin. Where is that peace I just felt an hour ago?? Now as I try to fall asleep I notice my heart rate quickening and I am restless under my blanket. Difficulty falling asleep is extremely common for anxiety sufferers and the pandemic has only amplified this for me. I decide it is time to use a few more distress tolerance skills. First, I practice paced breathing; Paced breathing is intentional deep breathing. I inhale slowly and deeply (about 4-5 seconds) all the way into my stomach and then exhale even more slowly (about 6-8 seconds).  After a few cycles of this I notice my heart rate begins to slow and I feel less tension in my body. Paced breathing works because it helps to regulate our parasympathetic nervous system, which is responsible for rest and relaxation, among other things- plus, it can be practiced ANYWHERE.  After I notice myself begin to relax I remind myself of the concept of radical acceptance– one of the most challenging DBT skills, as well as my personal favorite.  To be human means to experience pain, and none of us are immune to that. We do not have control over the pain we inevitably feel throughout our lives. What we do have control over is whether or not we choose to ride those waves, or to fight them. Imagine it this way; you are swimming in the ocean and a wave catches you. You panic and start fighting the current. The rule of thumb is not to do this, as the current will win and you will tire yourself out leading to more danger. When this happens we are supposed to let the current take us, and then bring us back to shore. We expend less energy and are more likely to survive this way. The same thing goes with our painful emotions. We can’t stop them and yet we can accept and therefore survive them. During the COVID19 pandemic I have felt many things including fear, sadness, and anger. To practice radical acceptance during this uncertain time means to allow my myriad of feelings to exist, to accept only what has happened thus far and NOT what could happen (why try accept the future when it has not happened yet? That’s a whole lot of non-facts), and to practice compassion with others and myself. This notion is difficult and yet I find it soothing. With this in mind I settle more comfortably into bed and begin to fall asleep with the knowledge that I have what it takes to do this again tomorrow.

For more information on DBT and Dr. Rebecca Berger please visit www.mindwellnyc.com where you can learn more about this evidenced–based treatment as well as the practice at which Dr. Berger works. MindWell NYC is located in Manhattan, NY where Dr. Berger is the clinical director.

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