Currently, many people are asking how DBT skills can help as healthcare providers face the challenges of the COVID-19 pandemic. This makes a great deal of sense in the current crisis as DBT is well-known for Crisis Survival strategies. Yet, DBT is much more than surviving crises, and using DBT skills well means using a number of skills to act most effectively for one’s goals based on what is required in any given moment. The following is an excerpt of a discussion between Tony DuBose, PsyD, Chief Training Executive at Behavioral Tech Institute, and Esequias Caetano, a psychologist in Patos de Minas, Brazil. This post suggests balancing among several DBT skills.
Please keep in mind that these are examples of only a very few of the many DBT skills that are available. Since this is the first time in most of our lifetimes that we are faced with a pandemic of this scale, no one has conducted rigorous research on the best way to use DBT skills in this situation. These suggestions are provided with that in mind. These skills are not the only way to respond skillfully, and if they don’t work for you, it doesn’t mean there aren’t other skills that might be more helpful.
Moving between Mindfulness of Current Thoughts and Emotions, Effectively Doing what is Needed, and One-thing-in-the-Moment
ESEQUIAS: Around the world, we are facing a major challenge: COVID-19. Many healthcare professionals, such as physicians, nurses, and psychotherapists, are at the forefront of this work. From an emotional and psychological point of view, what are they expected to experience?
TONY: It is important to understand and accept that anxiety and fear are normal and expected experiences in situations like this. It is typical to have thoughts and fears about the impact of the pandemic on ourselves and our loved ones. Fighting these experiences intensifies them, so the most helpful thing we can do is to practice mindfulness of the emotional experience and allow ourselves to notice what is happening to us without pushing the emotion or thoughts away or holding onto them.
While it is important to practice mindfulness of our thoughts and emotions, there is a time and place for everything. If we are required to take focused action in a particular moment it may be necessary to effectively focus our attention on the task at hand and distract from the current personal experience. This requires a sharp focus on doing what is needed in the moment.
If a health-care provider is consumed by personal concerns while working with patients, the care of that patient will likely suffer. However, if we fail to notice our experiences when that important task is complete, we may find ourselves overwhelmed, more anxious, or depressed over time. Hence the need to return to mindfulness of current thoughts and emotions.
We are becoming increasingly aware of how important emotions are in our survival. They don’t just go away when we ignore them, and it can be particularly problematic if we suppress them (see Linehan, 2015, Skills Training Manual, Chapter 9).
Here is an example:
I notice that I’m feeling quite anxious about how my work has changed, and how there are increasing demands upon me. In the course of my work as a mental health provider, I notice that my patients are saying they feel more loneliness and fear, and I know that some of them are thinking more about suicide. On top of all of this, I fear for the health of my elderly parents, and start thinking about what will happen in the future should I lose people close to me. I’m also worried about what is happening to me financially. If I begin ruminating about these things, I can get caught in what seems to be an endless cycle of thoughts that keep looping back around.
In the discomfort of this I may tell myself I shouldn’t feel or think this way, or on the other hand, I might become overwhelmed and just obsess. The trick to dealing with this situation is to be mindful of the emotions and the thoughts that arise. This involves just observing the emotions and thoughts come and go with a curious eye. It means taking no action about them; neither suppressing them nor holding on to them. It means just accepting them without judgment and letting them be.
If in the next moment I have a patient who calls in crisis, I move from noticing my thoughts and emotions and shift the focus of my attention to what is required for effective action with the patient; focusing only on the one-thing-in-the-moment that is needed to help the patient. When the interaction with the patient comes to a close, I then check in with myself. I again observe what I am experiencing; simply bringing a curious eye toward noticing what’s happening.
The movement through this cycle of skills may happen countless times over the course of a day. It takes a lot of work, and we get better at it with practice over time. The key to all of this is a skill that we call radical acceptance. It is accepting the moment exactly as it is without rejecting reality and engaging in futile attempts to exert control over it.
Radical acceptance also means heeding calls to action. While it’s important to notice thoughts and emotions without controlling them, it is very important when we see an opportunity to help that we move into an action. Truly skillful behavior means knowing when things cannot be changed and taking action when they can.
Mindfulness and distress tolerance (Paced Breathing)
ESEQUIAS: Many psychotherapists are attending to medical and nursing professionals and need to help them cope with their work routine in caring for patients infected with COVID-19. What things should these therapists focus on? What is the best way to help doctors and nurses on the front lines?
TONY: If you are in a moment that requires intense focus, and you find that you are close to being overwhelmed and breaking down, notice your breath. It can be a very powerful experience to redirect your attention to your breath, noticing the air entering your lungs and leaving your mouth.
We know from psychophysiological research that exhaling longer than inhaling can kick in the parasympathetic nervous system and have a calming effect. The great news about this skill is that it doesn’t require any tools or props, just your breath, your attention, and a bit of counting. While the numbers may differ for different persons, you can begin by breathing in for 4 seconds and breathing out for 6 seconds. Practice it for a while until you find the right numbers that work for you. Even in the most intense and extremely difficult moments, find a way to have a moment of peace and calm.
Also, when there is an opportunity to rest, do so. This again requires being in only in this one moment, with no regrets or grieving about the past or fretting about the future. While it is important to grieve what is lost, and to effectively plan for the future, it is equally important that we have moments of just being in the moment and letting these things go.
Balancing Validation and Problem-Solving
ESEQUIAS: The relatives of these professionals also experience a variety of difficult emotions, such as fear, sadness and loneliness. When we are serving them, what things should we focus on?
TONY: I think we must first acknowledge that we are in a situation that is beyond the control of any one person, and that emotions such as fear, sadness, and loneliness make all the sense in the world given what we are facing.
It is important that we validate the experiences of our loved ones. Now is a time when it is particularly important that we listen to each other in a way that leaves others with an experience of us really understanding and caring about what is going on with them. Beyond listening, it is important that we do things for each other when needed, as it is important to remember that actions speak louder than words. If we see that someone has a problem that we can help them solve, go beyond words and functionally validate them by problem-solving. However, be careful not to force problem-solving on others when we aren’t being invited to do so.
Walking the Middle Path, Checking the Facts and Mindfully Participating in life
ESEQUIAS: There are still many people who consider COVID-19 to be just a cold and, consequently, adopt risky behaviors for infection. This leads them to expose other people to risk, too. How can we manage, in the clinic, the denial of the complexity of the problem?
TONY: In DBT we have a skill called “Check the Facts”. We assume that happiness in life, and the best actions we can take are based on seeing reality as it really is. The problem is that as people, we often have very different notions about reality. I think it is important to consult the most reliable sources of information, and to realize that what I observe in my immediate vicinity may not be representative of what is happening in the next town.
Since we place so much emphasis on walking the middle path in DBT, I think it is important to aspire to taking the pandemic very seriously (based on scientific data) while not becoming immobilized by the weight of it. My own experience of this is that I have been in my home since the end of February, except to go to the grocery store. I’m working more hours than usual. I’m very aware that there are others I know who have been personally affected by illness and death. At the same time, I’m currently healthy, the sun is shining, I’m cooking and gardening, and my neighbors are being very kind to each other (from a distance).
Each day is an exercise in remembering the dangers that are present while also being in the moment and fully participating in what can be enjoyed in life, given the restrictions we are currently facing. I also realize that others may see this from a very different perspective. If I want to act skillfully, I remember that dialectics teaches us the find the kernel of truth in the perspective of others.
Radical Acceptance, Mindfulness of Emotions, and Interpersonal Effectiveness
ESEQUIAS: It is very likely that many health professionals will lose patients because of the coronavirus, and certainly, many people will also lose family members to the disease. What things should we psychotherapists focus on to help both health professionals and family members to experience these losses more effectively?
TONY: We know that loss and sadness (and a range of other emotions) are inevitable in this situation. We can refuse to accept the situation and make ourselves even more miserable. On the other hand, we can accept the situation, with all of its pain, and find what ways we can to get through it and connect with others.
We know that grief is also an important process in human survival. Our sadness indicates to others that we need comfort and support. It is important to be mindful of the sadness that we experience, and to communicate what we need to each other. This may require interpersonal skills to reach out to others and let them know what it is that we need. It may also require us to notice what others need and extend an offer of help.
Grief that goes unattended can become quite complicated over time. Should that happen there are treatments that had been developed to help with that. For more information check out the Center for Complicated Grief at Columbia University.
Reducing vulnerability to emotion mind
ESEQUIAS: Psychotherapists who will assist doctors, nurses and their families will also be exposed to a high degree of stress. What strategies can they use for self-care and to manage their own stress in the face of the situation?
TONY: Everything we do is made more difficult, or easier, based on the level of vulnerability that we experience in any given moment. To decrease vulnerability amid a crisis such as this it is very important that we engage in the DBT skills of ABC PLEASE. This is an acronym for steps that can be taken to reduce our vulnerability for falling into emotion dysregulation and despair.
- Accumulate positives. While many of us are facing greater demands, be sure to find time for enjoyment. This might even be something that becomes a part of your life for the long-haul. Maybe now is the time to pick up a new hobby that can be done at home.
- Build mastery in some area so if brings a sense of accomplishment. Take something on that will really push you to do your best.
- Anticipate things that will be difficult and practice coping ahead. This involves imagining acting skillfully in the worst-case scenario.
- It is important that we take care of ourselves physically. Don’t ignore indications of physical illness. Treat it as quickly as possible.
- Get adequate exercise. Particularly if you are bound to your home, find creative ways to do this. It could be climbing stairs, doing yoga, or walking in your neighborhood (if allowed). Many people are holding exercise sessions via video-conference.
- Avoid excessive or improper use of medications, drugs, or alcohol. I’m sure any of us can recall of examples of when this might not have been the best idea.
- Make sure to get adequate sleep. While it’s very tempting to work extended hours to get through this or spend a great deal of time reading or watching the news until late in the evening, be careful of these temptations. Sleep deprivation has both short- and long-term serious side effects. Ask yourself, “Is it really necessary that I be losing sleep to do this?”
- Be sure to eat well.
Thank you to Esequias and Tony for sharing this interview. Exchanges like these are proof that we are all members of a broader global community and we are working with each other in respectuful collaboration to find ways to address our needs and those of our clients in a way that aligns with our values. We hope that some of the thoughts shared in this post help you find skillful means to take care of yourselves and your clients as well.
Tony DuBose, PsyD is the Chief Training Executive & Director of CE/CME for Behavioral Tech Institute the company founded by Marsha Linehan, Ph.D., ABPP, for the dissemination of evidence-based treatments. He is a Founding Member and serves on the Advisory Board of the Evidence Based Treatment Centers of Seattle, PLLC. Read his full biography here.
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