On Cultivating Mindfulness: And How Dialectical Behavior Therapy(DBT) Radically Incised the World, as We Know It - Laura Goorin

I had recently completed my post-doctoral fellowship at Bellevue, and I gleefully attended a baby shower for one of my most primal, tenderest friends (from literal high school, whom I ran into in the hallways of Bellevue!) She threw her arms out and screeched, “I knew I would run into you!” “Really, at Bellevue?” I joyfully shrieked back. We went on to build the most compassionate of friendships as if no time had elapsed. Eventually, at her baby shower, I was struck by meeting one of her dearest friends, who spoke so admiringly of her amplified purpose at Montefiore Hospital in the Bronx, where she worked with an early intervention-style pediatric practice with young children, which was none other than one of my utmost passions. Later, I worked up the bravery to email her my resume, with no idea what world I lived in or that I would soon join the amplified collective purpose and cultivate mindfulness myself. Little did I know I was using a skill called “Opposite Action” by working up that courage; traditionally, I tend to feel shy about networking.

Spontaneously, I received a phone call from none other than Alec Miller, who co- authored a book that I had devoured (with all of its original notes in it, bulging the surface of the biblical tome like an inundation of information had hit it like a deluge) (Dialectical Behavior Therapy with Suicidal Adolescents, Miller, Rathus and Linehan, 2005) with none other than original gangster, Marsha Linehan, who radically invented the privileged construct of Dialectical Behavior Therapy. More on how later, Alec Miller was on the phone, and I had just witnessed the utter privilege of seeing him give a decisively intellectually rigorous, informative, charismatic talk to me at Maimonides Medical Center, where I had completed my internship while building up my clinical hours. I recorded nearly every word he uttered, as if he were speaking about something spiritual, which it, in part, was for him. He literally invented a skill called “Playing Jazz,”  and he was a jazz pianist, so mostly I was recording at this moment in time. I asked a question and, at the end, thanked him for how moved I was by his words. So now he was calling me. It turned out that my ethereal friend’s friend had given him my resume. A position had opened up at Montefiore Medical Center as an attending psychologist in the Child Outpatient Psychiatric Department and Adolescent Outpatient Psychiatry Department. I could not have predicted that these drastic events would coexist. He remembered me too! I almost had a heart attack of disbelief. I went on to come in for an interview, and it went shockingly well. I eventually met with the entire staff and felt like I clinically arrived home in a dreamspace of utter compassion.

Dialectical Behavioral Therapy (DBT) was first manualized by Marsha Linehan in 1993 for severely suicidal depression and humans with borderline personality disorder. A definition of Borderline follows with a list of its primary symptom clusters. In order to qualify for a diagnosis, you must meet five out of nine of these criteria.

1. The first one is the terror of being abandoned by others.
2. Intensely and vastly unstable relationships.
3. Identity disturbance means a vastly unstable sense of self.
4. Emotional Instability makes focusing a challenge.
5. Intense or inappropriate anger.
6. Impulsive Behaviors
7. Chronic feelings of emptiness (making it challenging to motivate)
8. Paranoia or dissociation 
9. Suicidality or non-suicidal self-injury.

Linehan had been synthesizing it since the seventies and eighties, utilizing principles that became incorporated into the joyful marriage of Behavioral Therapy since 1993—majestically and mechanistically applying Buddhist principles in her brilliant marriage thereof.  How did she envision such a prescient wedding of the dharma teachings and Behavioral Therapy? In 2011, she told the New York Times that it could not have been a more idiosyncratic odyssey, as she declared with the New York Times (Carey, Benedict: June 23, 2011, “Expert on Mental Illness Reveals Her Own Fight”). It started with a patient of hers wishing to be vindicated by the method, and acknowledging that using Wise Mind in knowing that she overcame Borderline Personality Disorder herself would give her sparks of hope that could start a metaphysical kindling to a fire. I am so heartened to hear that she put her patient’s needs first in this coming out article, all while de-escalating shame and destigmatizing Borderline Personality Disorder. That’s what a Coming Out Party does for all of us with this disorder, or those like her, who are so wounded by chronic emotional dysregulation.

She shared her own heart-wrenching, descriptive history at the mere age of 17 years of being voraciously institutionalized and how it left indelible marks on her body, not to mention the psychic scars of suicidality for decades. Then came the wise-minded or intuition (Wise Mind is what we know to be true) recognition that Cognitive Therapy, and even the use of thought records, felt too change-oriented for her state of being at that particular moment in time. Then came sparks of recognition and the realization that others who shared her overwhelmed sense of being seized by psychic incisions more often than not, like her, needed more acceptance. Therein, a quandary of her own zen coach until she was able to truly vindicate and validate. Mindfulness and its having the name “Dialectical,” and the Buddhist principle that two seemingly opposing constructs can be true simultaneously, as one of the primary attributes of the title, were endemic to her search for more validation and Buddhist dharma training at its core.

She invented, herself a maverick, her own treatment to treat her haunted, failed treatments in the past. And thereby one of DBT’s most profound core principles was nascently born—I imagine, with all of its permutations. One of Dialectical Behavioral Therapy’s fundamental truths follows, whereby we are all doing the best we can. Treatment may have failed us in the past, and yet that does not mean that you have failed treatment. She utilizes disease and cancer as a metaphor and imagines that we would try not to be as judgmental of the patient as resistant if cancer treatment failed them. We would never judge someone for failing cancer treatment– we would blame the treatment for failing them and get a second and third opinion. And so it goes for severely depressed, suicidal, and borderline patients: the basic assumptions of DBT as it is adapted for teens and their families follow. DBT assumes that people are doing the best they can, and people want to improve. People need to do better, try harder, and be more motivated to change. People may not have caused all of their own problems, and they have to deal with and heal from them. The lives of emotionally distressed teenagers and their families are painful as they are currently being lived.  Teens and families must learn and practice new behaviors in all the different situations in their lives (e.g., home, school, work, neighborhood). The Dialectical truth: There is no absolute truth. Teens and their families cannot fail in DBT.

The modules of DBT follow. We begin with an introduction to mindfulness and its basic constructs of three states of mind. This also entails mindfulness meditation and practice between sessions. Let us imagine the following scenario– whereby you see your sister, Charlie, spending all of her spare time when at home from college with her boyfriend, and you feel incredibly hurt that she is not prioritizing you. You feel incised by your internal sense of your nightmare of being abandoned coming true. The world turns shades of darkness in one second. Suddenly you feel misdirected rage at your parents, out of nowhere. “Why are they being so difficult? Do they want to fight with me? Why does everyone hate me? My best friend, Sandra, also hates me!” You say to yourself while wanting to engage in some kind of release. “I am so bored!” you scream at them for no reason. You just feel tremendous amounts of emptiness profoundly, and complaints of boredom are your only release. When your father asks, “Why are you yelling at me?” You are quick to deny this. “I am not yelling!” you yell back angrily, and suddenly fighting with him is something to do, temporarily filling the empty void.

Through a mindfulness module, the radical Linehan envisioned three states of mind, with two concentric circles co-existing. One of the circles is entitled “emotional mind,” which so predominates the Borderline symptomology clusters that follow, whereby this is what “I feel to be true.” Of all of the borderline symptoms, including: i. the terror of being abandoned by others, along with iv. emotional instability, v. along with inappropriate rage out of nowhere, along with vi. impulsivity, and iv., suicidality can all co-exist in what I feel to be true needs to be mindfully contained within what I think to be true and a “rational mind” circle. “What I think to be true” engages our thinking to be true as we are rationalizing that which is overwhelming us emotionally. Rationalizing might include literally solving a  puzzle to engage our cognitive skills, and it could also be utilizing a logical reframe, such as “as a matter of fact, I don’t have much evidence that Charlie and I truly have conflict.” “Wise mind” is the space in between those two concentric circles, and inhabits “What I know to be true.” Cultivating one’s wisdom and insight may take several days after an incredibly activating fight with Charlie. However, maybe wait a day or two, or shorter- maybe 30 minutes if you are re-regulated then. Most people with these symptoms require longer to recover. Then decide what you wish to do, whether or not to utilize interpersonal effectiveness skills and speak up to Charlie. What I find so vindicating about this method is that even these tougher clusters have a place, when they have simmered down by a few notches into finding our utmost wisdom.

Through a “Distress tolerance” module, we attempt to soothe and heal and tolerate our most profound and primal state of dysregulation. This may be elicited in the above example, whereby suddenly, after fighting with your father, because it was preferable to boredom and its internal state, profound emptiness hits you like a straitjacket to all of your emotional dysregulation, and the more you try to stop it, the more you are sobbing suddenly in public. You are so mad at your dad and suddenly terrified of losing both Charlie and him in the same breath. Suddenly you think out of nowhere, “What if I were to smoke something–to make the throbbing pain stop?” You are beyond heartbroken.

Even though you are still sad at this terrifying news, suddenly you are filled with openheartedness so big it feels expansive. You are fully engaged in accepting the truth of your parents’ separation. Again, you are openheartedly accepting that which is not within your control. You sometimes have to practice these dialectical mindsets an unlimited number of times. Sometimes you have to soften your heart. Radical Acceptance is never surrendering to a bad situation; it is simply finding clarity and open-mindedness and having a radical plan.

 “Emotional regulation” involves preparing against emotional storms of dysregulation. “Cope Ahead,” for instance, entails imagining something that is precisely provoking terror and doing a positive imaginal rehearsal for it– imagine your upcoming rehearsal of an upcoming interview whereby the whole thing goes according to plan, and you exceed expectations gloriously. Interpersonal effectiveness is so necessary because of holding intensely and vastly unstable relationships as one of the core aspects of BPD. There is a distinct series of questions about what you wish to get out of the said relationships before you discover what your skill path is. 

Dialectical dilemmas are further entailed in DBT for adults– that is, two seemingly opposing constructs can coexist and explicate a fundamental dilemma between, on the one hand, Emotional Vulnerability vs. Self-Invalidation– The Dilemma: An extreme biological sensitivity to emotional stimuli (emotions rise fast and take a long time to settle) clashes with a harsh social or internal tendency to discount, judge, or punish oneself for having those emotions. The Poles involve underregulation (Biological): Feeling emotions too intensely and reacting impulsively. And Overregulation (Social/Internal): Trying to shut down, hide, or criticize the emotion as “weak” or “wrong.” The Synthesis entails accepting the emotional reaction as real and valid without judging yourself, while still working to regulate unhelpful behaviors.

A module that Alec Miller (my supervisor, who called me out of nowhere about the position at Montefiore in the Bronx) and Jill Rathus, along with the original superstar, Marsha Linehan, herself, added for suicidal teens and families  is “Walking the middle path.” Walking the Middle Path is again a Buddhist construct borrowed for working with teens with BPD. Again, the mystified marriage of Buddhist dharma with constructs of being dialectical predominates. We attempt, for instance, to always be mindful of “both” language rather than saying “I love you, but…” Instead, you would attempt to  say, “I love you, and I know you can be more effective at curfew.” The “but” unfortunately undoes the entire messaging of what came before it. Furthermore, “walking the middle path”  involves a dialectical balance of radically opposing poles of both acceptance and change. It teaches us skills on how to validate, such as being mindful of your verbal and nonverbal reactions in order to avoid invalidation (such as rolling eyes, sucking teeth, heavy sighing, walking away, or saying, “Whatever, bro!”). Teaching these new skills matters, and so does internalizing them for entire families affected by BPD.

In my opinion, Linehan radically incised the brain of borderline symptomatology and the world, as we know it. How did she do it? She started slowly and mindfully with her own failed treatments. Thereby transforming what she considered failure. And flourished with meditation and mindfulness principles. She literally turned the shame game upside down. Then developed modules that not only treat the patient’s symptoms, but also instill sparks of hope for a population that was notoriously untreatable. The incision was generalized not just to borderline patients, and also to trauma, which most of them also experienced, along with suicidal depression in teens. May you marvel with me at her precision.