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 6 – A Tool for the Future and a Promethean Act of Will

William James (1842 – 1910), the philosopher and pioneer of American psychology (teaching the first psychology course in the USA at Harvard) suffered bouts of depression throughout his life. At times they took what he described as a ‘Promethean Act of Will’ to overcome this ‘crisis of meaning’. BA is a tool that you can use for the rest of your life. At times it will be easy, for some people at times, it will require James’ Promethean Act of Will.

You may have times when you use BA more formally and write down an hour by hour daily plan. Other times you might use the principles to ensure you are giving yourself a balance of pleasant and mastery focused activities. You may completely forget about BA at times and then decide to come back to it if you notice changes in your mood.

These last two points are considerations for the future:

9. Prepare for lapses – Unfortunately for most people with anxiety or mood disorders there are likely to be lapses. When life throws new pain and losses at you, stress levels rise, or we stop looking after ourselves so well, then old brain pathways can resurface. Be ready for this and restart what worked as soon as you notice any signs of a lapse. Start planning BA and use your other tools as soon as you can. This was one of the key ideas of MBCT, the ability to detect the early warning signs of depression using mindfulness and to start to take care of ourselves early with BA.

10. Connect and get help – I have mentioned already that a number of these steps work better with friends or in groups. However, we have to watch for the tendency to ruminate out loud with another person. Can we instead put our attention on what they are saying, on their life? Can we do shared activities together rather than talk about our depression? It can be useful to talk to a professional therapist or a close friend or family member. But if it seems like we are going over the same unsolvable loops out loud, then try to switch into a problem-solving mode of what actions you are going to take, or observe and accept the thoughts whilst taking action with the other people.

Again, it’s worth noting that indigenous communities with lower levels of depression tend to spend almost every hour of the day with their friends and family. As they say in Dialectical Behavioural Therapy we need to do opposite action to what the emotion is telling us. So, try to connect with others and face to face connection is always best! Our blood pressure lowers and our heart rate variability improves when we are with friends, its how our nervous systems have evolved!

It can be really disheartening if we experience a lapse or a relapse in our symptoms. It can be important to contact our therapist right away or to connect with our support networks. Depression can resurface but if we continue to practice what worked and to open up with acceptance to these feelings and pursue meaningful activities, then we can recover again. As we develop these skills in a lapse, we actually become more confident that we know what to do next time. Each time we experience these difficult emotions and develop the ability to focus on meaningful goal-directed actions with the people we love (willingly carrying these emotions on our backs), our confidence grows. We get stronger through these promethean trials, much like a right of passage. I hope you have found this series useful and feel free to share any thoughts or questions in the comments below.

Behavioural Activation Part 5 – Lets Get Physical – Activate Through Activity

If you look at many high functioning people who have experienced depression, you often find exercise is part of their recovery. The likes of Tim Ferris, Stephen Fry and world class endurance athlete Christopher Bergland all have credited exercise to helping them maintain and improve their mental health (if you do a little more research online you’ll find the list is extensive). Exercise has been found to have comparable effects to anti-depressant medication in a number of studies. Not to mention the fact that there are all of the additional health benefits of exercise.

But what if you can’t get off the couch, out of bed or think clearly enough to exercise? We all find it difficult to exercise at times, imagine how difficult it is when you are suffering from major depression and you can barely move. I have experienced this dark place myself and it feels like an Olympian feat to simply get moving! But we do have some agency in the painful abyss of depression. We can strengthen the ability to make healthy choices whilst carrying these Atlas-like emotions on our backs. This is where scheduling physical activity in your BA schedule can be so helpful and having the support of friends and family to get you moving. Here are a few other ideas that might help:

7. Start small and build up – Walking is a really useful tool here. The key is to start with a really small and gentle amount. This might even be walking round your house for 2 minutes. Then moving onto a 5-minute brisk walk, then 10 minutes round the block and upwards. Also try integrating exercise with things, you have to do in your day – like commuting, shopping or visiting friends.

Exercising with other people is even more powerful and if you get out in nature as well then you have the coup de gras. It can be beneficial to do a mixture of relaxing and slow exercise like yoga & tai chi and also more intense aerobic exercise & weight lifting. This combination can have a really positive impact on our mental health.

8.What if it’s boring – A lot of people find exercise boring, even when they are feeling well, so (as always) be kind and self-compassionate. If exercise is boring then you might not have found the right fit. What did you use to enjoy before depression? Think back to when you were a kid (a useful tool for filling your BA schedule more generally) and what games, sports, outdoor activities did you use to enjoy and can you add them back in? Connect with other people in groups. Get an exercise buddy to help motivate you. Sometimes (as long as we have the all clear from our doctor) boredom can be a sign that we are not pushing ourselves hard enough. We might need a bit more sweat to access the pleasant rewards of exercise. Its also important to congratulate yourself in your head for achieving your goal when you finish your exercise. Many people don’t do this last step and often berate themselves and go straight into negative rumination after exercise.

Can we use exercise to train our focus and concentration, either through mindfulness of movement and breath or even by listening to music or a favourite podcast? Every time our mind drifts away we notice and come back. Sometimes people use exercise as a time to ruminate, engage in self-criticism or to worry. Can we notice and accept these thoughts and bring our minds back to the present moment? You can use encouraging self-talk to help you as we have talked about in the previous articles. Just like an endurance athlete encourages themselves internally and thinks of their goals.

Some theorists suggest that the stress of living a modern life, far from what we evolved for in the Pleistocene epoch, is one cause of the rise in depression. Indigenous cultures that report much lower levels of depression tend to get 4 hours + of exercise a day (just by going about their day and living their lives) and middle aged and older individuals are built like Olympic athletes! Can we reclaim a bit of this indigenous antidepressant lifestyle by building more exercise into our lives? Alongside exercise, a healthy diet and sleep are incredibly important ways to take care of ourselves and build into our behavioural activation. We will look at these topics in future articles.

Let me know your favourite ways to activate yourself through exercise below?

Behavioural Activation Part 4 – Actions Speak Louder Than Thoughts and Emotions

Our feelings have evolved to hijack our attention, behaviour and motivational systems. At times this can be incredibly useful, even lifesaving. But there are times when the better-safe-than-sorry ‘smoke detectors’ in our brain produce feelings that drive behaviours that don’t help us! There is a level of sadness which can be useful in helping us to pause and reflect, to feel love and compassion or to appreciate the bitter-sweet flavours of our life’s banquet. But there is a level of sadness that pushes us into a numbness or painful states of depression that induce shutdown and social isolation. The pain can be unbearable, there are even common neural correlates in the brain between depression and pain. These agonising feelings can place real barriers to behavioural activation. Often, we need to do the opposite to what our feelings are telling us. We need to get up and exercise when our beds call soporifically to our exhaustion. We need to contact and connect with our friends when every impulse in us is saying to avoid them and retreat back to the cave. We have covered a number of useful tools for working with painful emotions in part 3 of this series, but here are two more ideas to put in the mix:

5. Fake it till you make it – as Mark Freeman says ‘focus on changing actions, not thoughts and feelings’. It’s much better to do your chosen BA actions focusing on what you are doing and trying as best as you can not to monitor how you feel. Excessive self-focus is a large part of the problem. Can you aim to have far more of your focus out on the world and the people you are with? You may very well feel awful when you first start BA, but can you improve your ability to function and concentrate whilst these difficult thoughts and feelings are in the background? Can that be your aim, rather than aiming to feel better?

It is likely it has taken months and years to build to this point of your depression. It might well take some time to break the patterns that led to it, so it’s far better to focus on achieving your goals and concentrating out into the world rather than whether or not you are feeling better. Do the activities you used to enjoy, or new activities that reflect your values even if you don’t feel like it. Having experienced depression, anxiety, depersonalisation and OCD myself, I know how difficult this is, but if we progress gradually then we can get better at changing actions with the heavy thoughts and feelings in the background.

6. Parallel emotions – Another useful concept that I found in the work of a number of expert’s (Mark Freeman ,Reid Wilson, Leslie Greenberg) is the concept that you can have emotions in parallel. There is space for depression and gratitude, anxiety and savouring. In fact, Greenberg (leading researcher and expert on Emotion Focused Therapy) has found that to transform painful emotions they need to be activated alongside positive emotions. Can you learn to accept or tolerate the emotion whilst your concentration is on something enjoyable or satisfying? We really can train this skill of concentrating on gratitude, savouring and flow even when our concentration feels weakened by depression. I found flow to be particularly useful here as we just need to (i) focus (ii) have goals with clear feedback, and (iii) have a balance between our skill and the challenge (not too easy or too hard).

The key is not to battle with our painful emotions. We can use different tools to help us tolerate and then accept our pain but we need to try and develop them alongside our pain, not to battle with it. You might also find my article the acceptance spectrum useful for ideas on managing challenging emotions.