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Exploring Mindfulness in Dialectical Behavior Therapy (DBT) 

Dr. Melanie du Preez

1. Introduction to Mindfulness in DBT

Increased interest in DBT has been paralleled by a nascent focus on Mindfulness, constituting one of its four main treatment modules. Led by founder Marsha Linehan and her colleagues, current DBT experts have written a manual for its close followers, have crafted guidelines for teaching clients the skills tailoring it for specific issues such as reducing substance abuse and, particularly, eating disorders, and opening clinical centres offering DBT. While, to date, the empirical evidence base for using DBT for other conditions is limited, more attention has been paid to the Mindfulness module. DBT has its roots in an eclectic mix of ideas and practices from Eastern and Western philosophies, the psychosocial problems of highly suicidal women, a cognitive-behavioural orientation and the demonstrated clinical effectiveness of clients' skills. Defining Mindfulness, a cornerstone of DBT, is an important first step. Linehan described Mindfulness as having two characteristics: orientation, coping style, and conflict resolution. (Zeifman et al.2020)

In the past two decades, research on Mindfulness-based treatments has dramatically increased as interest in this topic has grown. One of the centres of this research has been the Center for Mindfulness at the University of Massachusetts Medical Center, located in Worcester. This institution has sponsored professional training workshops and conferences on Mindfulness, has run a postgraduate training program, and has developed training modules and study materials for teaching MBSR (Mindfulness-Based Stress Reduction), both its original 8-week format and an abbreviated version. Grounded in the concepts and practices of Mindfulness, MBSR and children's programs based on it have been the subjects of much research, and MBSR has been exported to Europe. (Toniolo–Barrios et al., 2020)

1.1. Definition and Importance of Mindfulness

Traditional Mindfulness is a well-practised religious-based mental discipline originally found within the context of Vipassana, Zen, and Zazen. Although usually developed within a spiritual focus, traditional Mindfulness is equally effective when secularised, concentrating objective, tranquil observation on neutral sensory events within the surrounding environment. DBT emphasises a diverse, personal, and broad individual experimental definition of Mindfulness, which expands to include personal experience without criticism and teaches the ability to observe personal experience without excessive disturbing anxiety. Mindfulness also highlights the importance of fresh, new, and impartial observation of the present and resolving personal emotional experiences. (Weber, 2021)

Mindfulness in DBT signifies a new relationship to one's personal experience. It delineates a focus coupled with an attitude respecting one's personal experience. It demands an operational state of awareness toward personal, situational pressure and tranquillity, comprehensive, objective self-observational ability.

DBT views Mindfulness as an essential skill promoting a state of mind and a comprehensive, insightful, and functional self-management capability. Mindfulness is one of the four skill sets in the functionally adaptive stage of behavioral skills acquisition. The skill of Mindfulness is centred on the intrapersonal human life-enhancing principle of balance. Through Mindfulness, humans can maintain thinking about their thoughts without over- or undervaluing their personal sensory or mental experiences. Consequently, they can comprehend more quickly and accurately how to perceive, interpret, solidify personal strength, and avoid complicated obstacles. (Schuman-Olivier et al.2020)

1.2. Integration of Mindfulness in DBT

To build a 'Wise Mind' is to attend to change and acceptance strategies effectively, and DBT further divides these problem-solving skills into a number of specific Mindfulness-related skills, each of which is taught so that the patient has direct 'hands-on' experience of how to experience a situation with greater emotional control and acceptance. DBT techniques assist with problematic responses to potentially threatening or life-threatening experiences, and these techniques allow the patient a window into their own ability to remain present. Along with this, DBT techniques need to address widespread resistance among individuals to tolerate and accept negative feelings, anxiety, or depression. The concept of an unworkable mind is linked to a failure to accept the reality that changes and fulfilment of life ambitions will not be forthcoming. Mindfulness exercises aim to gradually train the patient to tolerate the impermanence of these situations. Practising Mindfulness helps patients to develop four specific skills: observing experience without over-personalizing; describing the experience in non-judgmental terms; differentiating between emotion and the event that occurred to provoke the emotion; and employing non-judgmental thinking skills that allow for the acceptance of experience.

DBT's treatment hierarchy includes target hierarchies. The highest intention, or ultimate goal of DBT practice, is to help patients build a more mindful way of living. DBT approaches behavioral problems using a two-pronged strategy: on one hand, the behaviors themselves are directly addressed and change is sought. DBT directly teaches patients skills to alter unwanted behavior. On the other hand, the lifestyles and environmental contingencies that may contribute to avoidant or maladaptive behavior are also explored. To most effectively help an individual with a behavior problem, it is not enough to use behavior change. Training individuals in skills to be more effective in their social environment is often effective to a degree. However, an individual may still be inhibited by his or her fear of abandonment. So, if the person is avoiding a situation and is, in effect, anticipating an experience of abandonment or worthlessness, it would seem wise to lend appropriate assistance. Mindfulness skills would help. Training clients in Mindfulness skills teaches them to approach, with acceptance and calmness, that which they would prefer to avoid. That said, the topic of Mindfulness and its tasks of acceptance and letting go are not traditionally introduced early in psychotherapy. Certainly not as a direct treatment of choice for anxious distress.

In the DBT model, Mindfulness is seen as both a skill and a chain link, all within the DBT hierarchical chain of treatment goals. This is a central feature of DBT, so it deserves some explanation. Two sets of problems are of special concern, those related to controlling unwanted behavior and those associated with the quality of life. These two particular problems are allocated to DBT's behavior-changing and acceptance strategies. Yet while change strategies and acceptance strategies diverge in many areas, a problem is solved.

This section will expound upon many of the features of DBT that make it a unique example of treatment practice utilising Mindfulness meditation. This work proposes that Mindfulness is, first and foremost, a cognitive coping strategy. As a cognitive coping strategy, it is suggested that Mindfulness involves consciously shifting attention to the present moment and choosing to adopt and maintain a purposeful non-judgmental attitude.

2. Understanding Wise Mind

Wise Mind is not the result of consciously weighing emotional and logical data to achieve a compromise; neither is it a mystical gift, like the oracle at Delphi. It is not a state where only spirituality manages all the difficult decisions and concludes satisfactorily to the spirit, if not to the intellect. Nor is it an answer to all the questions. When an individual is in Wise Mind, there is no need to take a leap of faith. Wise Mind just is. Finally, Wise Mind is preceded by balanced amount of one-mind and is alternative outcome to either frame of mind. There are many such dichotomies in DBT, like dual systems, Logic Mind versus Emotion Mind. Wise Mind is not only a part of self as many of the other concepts, but also the central part of DBT approach and is the most challenging compilation of self-discovery and acceptance.

According to DBT theory, when the Logic Mind, which emphasises the "whats" and the emotional mind, which emphasises the "feeling", meet, it is called Wise Mind. It emphasises the "whats", the "whys", "feel", and intuitive knowing without engaging in judging them as bad or good. Instead of using the words of self-judgment, right or wrong, the individual experiences a feeling of peace. In other words, the wise mind is an interesting combination of both accurate thinking abilities (the left hemisphere is called the 'Logic mind') and emotional reactivity and intuition (the right hemisphere is called the 'emotional mind'). While Logic Mind makes logical, rational sense and uses logical decision skills, the emotional mind uses emotion, intuition, and creativity. However, being in Wise Mind is different from using intellect or intuition. (Hayrynen, 2022)

2.1. Definition and Significance of Wise Mind

Recognising what is reasonable and what is emotional in the moment, people then participate in this moment as effectively as possible. Their wise selves might still feel angry with someone or disappointed with something, but mindful reason guides their coping processes. Mindfulness within the DBT framework serves a further important function. Creating a safe and loving relationship with oneself develops into an ultimate goal of DBT for a person with BPD. Mindfulness helps erode and eliminate the barriers that inhibit this need. When they step into a mindful stance, emotionally reactive people build the capacity to be kind to themselves. Then, as the patient begins to develop and refine this capacity, he or she experiences wise self-love viewed from within Mindfulness.

Dialectical Behavior Therapy (DBT) describes three states of mind: reasonable, emotional, and wise. Logic Mind is guided by facts and logic, Emotion Mind is guided by feelings, and Wise Mind is guided by both facts and inner wisdom. Wise Mind is the part of each person that can be accessed and known through Mindfulness. Marshaling thoughtful self-awareness through Mindfulness holds the key to Wise Mind. Through Mindfulness, people learn to view their behavior and others' reactions to them nonjudgmentally, with compassion, and with complete attention. This stands in stark contrast to the emotion-driven reactions.

3. DBT Skills: What and How

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4. Applications and Websites for Mindfulness Practice

Applications and websites can help mental health professionals approach clients and vice versa. Indeed, created by mental health professionals, they encompass mental health and other aspects of general health. Moreover, compared to paper or audio formats, applications and websites represent an accessible and available means for most people. Finally, they can be used in different settings. For instance, apps can be used in inpatients, outpatients, and prisons.

Mindfulness has been assimilated in various countries and in many cultures. The different ways an individual can practice and learn about Mindfulness have multiplied, and knowledge and research have expanded. This work reviews the major applications and websites available, providing information about them and the possibility of accessing some of them for free. These applications and websites differ in various aspects, such as cost or the number of exercises.

4.1. Benefits of Using Technology in Mindfulness Practice

There are some advantages that may be accrued in using technology to promote Mindfulness. It is especially apt to reach this particular demographic. Normal time allocation realities are easier: People are often pressed for time and are not able to attend Mindfulness classes. The ability to complete Mindfulness exercises at one's pace, in one's room, and with no partner in attendance, which may be a plus for some clients, may be considered a positive feature. There is the possibility of using social media fitness portals and apps to reach out to more private or socially reserved people. There are websites offering Mindfulness at no cost or minimal costs, or even half-price costs. This is particularly beneficial considering societal poverty and the increasing reluctance of insurance companies to remit for services.

One of the features that may be particularly pertinent to the millennial era is the introduction of technology in Mindfulness practice.

4.2. Top Apps for Mindfulness

All the existing applications consist of more functionality, including contemplation of the desired situation and a practice that appears subtly sown. The structure of these personal training applications could not be considered complete compared to implementing a face-to-face training program. In general, they still fail to address possible doubts that undermine the confidence to perform exercises correctly. However, these applications can work as edified bicycle wheels on the basic issues of Mindfulness, aiming at the main goals so that one gets used and ultimately uses traditional practices, which work innovatively for them with a mentor.

In the current social context, where we are immersed in technology and where options for activities have greatly expanded, it is interesting to use technology to train Mindfulness since it would allow for more flexible use and would be potentially more attractive to users. This would allow more users to become familiar in the short term with those first steps of Mindfulness practice. We present and discuss the most used and effective apps; for example, BaM Personalized Mindfulness elements such as Training, Check-In, and Feedback are described. The application includes comprehensive sessions in which users can view their progress in Mindfulness and emotional states.

4.3. Recommended Websites for Mindfulness

For applications that can be used on the phone, Headspace offers mini-meditations for students, Relax Melodies allows access to nature sounds, Insight Timer can be used as a meditation tool with access to other meditators, and My3 teaches mood tracking for emotion regulation as part of dialectical behaviour therapy (DBT). These cell phone tools and websites are relatively easily accessible, easy to use and understand. Social networking apps also offer reminders.

Through general web searches or through Google Play Store or iTunes, there are an abundance of websites and apps that offer tips to practice informal Mindfulness in daily living activities. Several of these free resources explain Mindfulness so that students and teachers can learn about Mindfulness together. These resources include Mindful, Greater Good in Education, Edutopia, and Mindful Schools. These sites include videos, articles, research, programs, and tips on how to teach Mindfulness. All these sites have regular tips on Mindfulness that educators can receive. Many of these sites have free resources that come with registration but do not cost money.

 

References: 

Hayrynen, N. R. (2022). Developing the Wise Mind: Exploring the Experience of DBT. [HTML] 

Zeifman, R. J., Boritz, T., Barnhart, R., Labrish, C., & McMain, S. F. (2020). The independent roles of Mindfulness and distress tolerance in treatment outcomes in dialectical behavior therapy skills training. Personality Disorders: Theory, Research, and Treatment, 11(3), 181. [HTML] 

This post is for informational purposes only. It should not be considered therapy. This blog is only for informational and educational purposes and should not be considered therapy or any form of treatment. We are not able to respond to specific questions or comments about personal situations, appropriate diagnosis or treatment, or otherwise provide any clinical opinions. If you think you need immediate assistance, call your local doctor/psychologist or psychiatrist or the SADAG Mental Health Line on 011 234 4837. If necessary, please phone the Suicide Crisis Line on 0800 567 567 or sms 31393. 

This blog is only for informational and educational purposes and should not be considered therapy or any form of treatment. We are not able to respond to specific questions or comments about personal situations, appropriate diagnosis or treatment, or otherwise provide any clinical opinions. If you think you need immediate assistance, call your local doctor/psychologist or psychiatrist or the SADAG Mental health Line on 011 234 4837. If necessary, please phone the Suicide Crisis Line on 0800 567 567 or sms 31393.