The Dialectics of Being Lost at Sea – Differences between Acceptance and Distraction

Marsha Linehan developed Dialectical Behaviour Therapy as a way to help treat the most suicidal patients. Having lived through this wretched place in her own life, she was deeply empathic in her quest to aid these people. These patients had been traditionally shipwrecked, as Emily Dickinson so beautifully put it  without ‘even a Report of Land’. The clinical psychologyfield had been at a loss when it came to the controversial and highly stigmatised diagnoses of borderline personality disorder that Linehan decided to target. Linehan drew upon the philosophical perspective of dialectics (balancing opposites) in order to develop this behaviour therapy. She balanced the concept of acceptance with change, when working with the emotional storms her patients were experiencing. Sometimes people needed to learn emotional regulation techniques that could contain and shift their emotional overwhelm. Other times they needed to learn ‘radical acceptance’ in order to get back to a ‘wise’ way of living. Both of the strategies that are the focus of this post – acceptance and distraction – are found in DBT.

I am a huge fan of the Acceptance and Commitment Therapy (ACT) principle of acceptance and committed actions in service of your valued direction in life. This can seem similar to distraction as an emotional regulation strategy, but there are subtle differences. As Rob Wilson puts it the difference is all about intention. Distraction is a strategy to escape painful thoughts and feelings. Acceptance and valued actions lets the thoughts and feelings be there, whilst you engage with meaningful activities and relationships.

I’m with Marsha Linehan in her view that distraction can be a useful tool at specific times. There are people that have such severe emotional regulation problems that acceptance is a step too far in the beginning. Prof Paul Gilbert once described someone he was working with, that smashed her head through a window when asked to accept her feelings because she was so distressed! For some people their emotional thermostat is too sensitive for acceptance in the beginning. This is why DBT uses skilful distraction as part of the emotional regulation and distress tolerance modules.

Distraction can be enhanced by using the skills from positive psychology concept of flow. We can ensure a task is challenging and requires skill which is balanced to our ability; we concentrate in an ‘effortless’ way and there are clear goals with immediate feedback. We can pick more complex tasks like sports, creative pursuits or complex intellectual challenges. We can also try to speed up an activity so we are just at the edge of our abilities. We can pick activities that naturally grab our attention like books, movies or music we enjoy. There is clearly a place for this and DBT demonstrates the effectiveness of this side of the dialectic.

However, distraction has its limitations. It doesn’t always work, there can be levels of emotional distress that mean we can’t get absorbed in activities. Sometimes distractions work for a period of time but when we finish the distracting activity the emotional distress can come back even stronger. We can’t always perform at the high level of intensity needed for absorbing distraction, and we might not deal with the underlying problems in our lives or relationships which are feeding or causing the distress. Acceptance and committed action is another powerful option, that with practice can be a more flexible psychological tool. It can still lead to states of flow, but it really supports us when our mental health disrupts our ability to concentrate or engage with what we are doing.

To describe this approach I like David Veale’s metaphor that this acceptance approach is like walking along a pavement next to a busy road. The difficult thoughts and emotions are like cars on the road. If we try to flag them down or stop them we are likely to experience all kinds of problems. But if we focus on the pavement we are walking on, who we are walking with and what activities we are doing, we may notice the cars on the road but we let them go past while focusing on the meaningful activities we are doing on our path. It takes time to develop this skill, but like any complex task we can build our ability with practice.

Behavioural Activation Part 3 – The Internal Saboteur

Its official – there are parts of us that are not in our own corner. In the clasp of depression this can show up as an internal voice or feeling that sabotages our efforts to make positive changes. It might be that heavy thick feeling of pain or it might be the voice telling you that ‘this isn’t working and you’ll never recover’. Many modern approaches to psychotherapy see the brain as made up of different systems or competing parts. In evolutionary psychology this model is called the modular mind. It’s even reflected in our language when we say ‘part of me wanted to do x’ or ‘I’m in two minds about y’. We even see it explored in literature like Dr Jekyll and Mr Hyde. Unfortunately, this layered network of different evolutionary stages can overreact, misfire or even turn on ourselves as the inner critic. These competing parts can have a large role in depression. So, what do we do to cope with this internal sabotage?

3. Talk to your self – I’ve mentioned the power of compassionate self-talk before on the blog. Just think of an endurance athlete and what they say to themselves in their heads to push through the pain and focus on their goals. In many ways this is a close replica of the depressed person. It is often an endurance event to get through the day. Use self-talk to both help concentration and motivation.

Emergency service drivers are taught to narrate their driving to help them concentrate when they are sleep deprived. You can do the same here: gently and kindly narrate what you are doing. Narrate each step and congratulate yourself when you achieve each step. Be the compassionate coach that Mary Welford describes.

There are studies that show that using self-talk can enhance your abilities in many areas, even finding lost items. So, use this skill to help you function when you are struggling. You can slow down the self-talk if you are struggling to concentrate, you can even talk to yourself out loud if you are in the right place for that. Its highly likely you will have the negative inner critic voice there as well, aim to have these voices running in parallel (rather than competing). Can you listen to your own positive, compassionate self-talk while the critic continues in the background? Can you focus more attention on the kind voice than the critic? It’s a skill that can be trained so it is unlikely to produce miracles right away, but give it time. You are strengthening this skill each time you try.

4. Dealing with rumination/negative thoughts – its widely acknowledged that negative ruminations feed depression. They will come up as you do BA. As in the point above try to let them be there as you focus on your kind self-talk and the actions you are taking. You might try to use the 3-minute breathing space from MBCT. Or you can label what you are feeling and remind yourself of your values (for example to be happy and health, to support and love others, to enjoy life etc).

Can you try to accept your negative thoughts and not fuel them with further rumination? Instead keep bringing your attention back to what you are doing and focusing on your goals. This is just like meditation; in the beginning of practice you need to keep returning your focus to your breath, until eventually you can stay focused on the breath while your negative thoughts float past in the background. The spotlight of attention is on what you are doing. The volume is turned up on thoughts that aid performance and the critic is turned down.

Also, choose some activities that help you break negative rumination cycles. Have an enjoyable and engaging book to hand, using the language systems of our brains can help to quieten the rumination cycles. Play fun computer games, do puzzles or sudoku, do sports, talk to people about things other than your ruminations. Even better, do activities outdoors with other people.

 

Why not give these tools a try and let me know what you think?

We will cover some tools in the next article which focus particularly on the emotional feelings that can challenge the BA process.

Behavioural Activation Part 2 – Why You Need More than Common Sense

As I wrote in part 1 BA is a common-sense approach to mental health. The problem is when you are in the depths of depression and anxiety the logical common-sense part of your brain is inhibited. You also struggle to hold on to the positive experiences in this state. In fact, at times your brain actively seems to resist them. Professor Richard Davidson elucidated this in his brilliant bookThe Emotional Life of your Brain’. Davidson describes that in comparison studies, depressed patients report the same level of positive emotion in response to pleasant stimuli. The difference is in the half life of these positive emotions. In the control group these positive emotions increased as the subjects reflected and savoured the experience, whereas, in the depressed individuals the positive emotions dropped away sharply. This was reflected in the brain region related to reward and pleasure, the nucleus accumbens. The ‘notes’ of pleasure in the brains of depressed patients were trailing off far quicker than in healthy controls. I think anyone who has experienced depression will relate to this, there are moments of happiness and pleasure, but these are often followed by even deeper lows as you lament for what slipped through your fingers. Sometimes these highs are so subtle that they even go unregistered, so the depressed person is tricked into believing there is only the darkness.

There is also the lack of motivation or the paralysis of fear to deal with. You literally can’t get yourself to think, move or act in a positive way. You might even know what will help you but your body doesn’t seem to move or your overwhelming thoughts convince you that nothing will help or you don’t deserve recovery.

Many theorists posit that depression has an evolved function. In the days of our ancestors this mood state would induce you to go back to the cave to rest and avoid danger. Or it might mean that you kept a lower status in the group so that the dominant members of the tribe would not attack you. Is it perhaps a mechanism that in smaller dose’s can be beneficial, but is not designed for our modern world? Is depression triggered by an overactive physiological response to the everyday stresses of modern life? These theories make sense to me. Perhaps we can use them to help us be kind with our harsh inner critics and cut ourselves some slack. After all, it is not our fault that we have tricky brains.

So, what can you do when you are depressed and want to utilise BA? As MBCT states ‘In depression, we have to do something before we are able to want to do it’. Over the next series of blogs, I’m going to describe 10 tools that have helped me. Needless to say, it will always be most effective to do BA under the guidance of a trained professional.

 

  1. Divide and conquer – The science of procrastination has a lot of transferable tools here (see Prof Timothy Psychl brilliant book for more details). Divide every task up into smaller and smaller chunks, until it seems possible. At the extreme end of the scale, getting out of bed and going downstairs for breakfast could be divided into multiple steps, each one being focused on in turn. Start small in terms of changes, with one or two new items added to your schedule a day (or week). Start with the simpler tasks and build up to anything more challenging.

 

  1. Put it down on paper – As discussed in the first article, BA is typically recorded hour by hour on paper. It really helps to write the plan down and focus on each hour rather than the potentially overwhelming full day or week. Generate and write down your list of pleasure and mastery activities that reflect your values and goals.

 

These first two points work in partnership. Putting our plans down on paper helps us to divide and conquer. But what happens when your thoughts and feelings resist this process? We will take a look at tools to work with our tricky minds in the next article.