Clinical Handbook of Mindfulness (71 page)

DBT Mindfulness Skills

In DBT, mindfulness is conceptualized as the experience of entering fully

into the present moment, at the level of direct and immediate experience. In

order to accomplish this, a set of seven concrete skills is taught and practiced

on a regular basis. These skills are considered “core” skills in that they are

directly relevant to effective practice of all other DBT skills and are therefore

repeated frequently in instruction. These seven skills are wise mind, observe,

describe, participate, nonjudgmentally, one-mindfully, and effectively.

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In DBT, it is assumed that all people have innate access to wisdom. This

state of wisdom, or “wise mind,” represents the synthesis of two other

abstract “states of mind”: “emotion mind” and “reasonable mind.” Emotion

mind refers to the state in which emotions are experienced as controlling

thoughts and behavior. Commonly, clients with BPD who start treatment

describe feeling like they are continually in emotion mind because they con-

stantly feel under the control of their emotions. In contrast, reasonable mind

refers to the state in which logic and reason control thoughts and behav-

ior. Whereas emotion mind is hot and impulsive, reasonable mind is cool

and calculating. Wise mind is considered to be a blend of the best parts of

these states of mind in addition to the quality of an intuitive sense of
know-

ing
something deep within. Accessing wise mind allows one to take action

with ease even though the action itself may be challenging. For instance,

wise mind may guide one to enter a burning house to save a child, an action

that is clearly difficult but is accompanied by clarity of intuitive knowing.

An assumption in DBT is that everyone is “in wise mind” some of the time;

through practice, wise mind can be experienced on a more regular basis and

more readily accessed when desired.

The other six mindfulness skills are categorized into
what
skills and
how

skills.
What
skills describe the actions that one takes when practicing mind-

fulness. These include:
observing, describing
, and
participating
. The
what

skills can only be practiced one at a time; for example, it is not possible

to observe and describe or to describe and participate in the same moment.

The how skills include
nonjudgmentally, one-mindfully
, and
effectively
. The

how skills can be practiced individually when learning and, as skill increases,

can be brought to bear simultaneously as one practices particular
what
skills.

The first what skill,
observing
, is direct perception of experiences, with-

out the addition of concepts or categories. This can be extremely unfamiliar

and difficult for many clients (and many therapists!). It is useful to think of the

five senses when practicing the observe skill because sounds, touch, taste,

sight, and smell provide constant opportunity for observation. The instruc-

tion invites clients to bring their attention to the level of direct sensation

and to
just notice
. Frequently when teaching this skill, clients report auto-

matically attending to conceptual descriptions. For instance, a client might

observe a sound of “chirp chirp” outside the window and ascribe a label to

it (e.g., “that’s a bird”). The therapist helps to identify the categorization that

has occurred and redirect the client back to the sensations of sound. Often,

categorization will be quickly followed by judgmental evaluation (e.g., “I hate

birds; this place is too noisy; I can’t practice this stupid homework thing any-

way”). Practice with the observing skill helps clients to return again and

again to direct sensation, including those judged to be unpleasant. Observa-

tions can also be applied to internal experiences, such as the sensations of a

particular emotion. By just noticing what anger feels like, for example, with-

out doing anything to change it, one can observe the physical sensations and,

over time, recognize that the emotion itself is not threatening.

Describing
involves adding a descriptive label to what is observed. When

individuals are asked to recount what they observed aloud to the thera-

pist or the group, they are being asked to describe. For instance, if the

client described above had been practicing describing, she might have been

instructed to note “thinking,” as in “I had the thought that a bird is going

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Shireen L. Rizvi, Stacy Shaw Welch, and Sona Dimidjian

‘chirp chirp”’ or “judging,” as in “the judgment ‘this is stupid’ went through

my mind.” Many clients experience thoughts as literal and objective facts.

While many thoughts that are assumed to be facts are relatively harmless

(e.g., “that sound is being made by a bird”), other thoughts assumed to be

facts can be associated with significant negative consequences. For exam-

ple, clients report that they “know” that somebody doesn’t like them based

on a facial expression or a comment that they interpret as malicious. Recog-

nizing that the
thought
“she doesn’t like me” is different than the
fact
“she

doesn’t like me” is an important step in learning new behavior. If it is just a

thought, then it is open to supporting evidence of falsification. Practicing the

skill of describing allows clients to begin to experience thoughts as mental

events that arise and pass away in the mind. Clients can practice describ-

ing using external experiences (e.g., sounds, colors) or internal experiences

(e.g., thoughts, emotions).

Participating
refers to entering fully and completely into an experience.

When participating, the separation between self and activity falls away. It is

a state of full engagement, similar to the state of flow described by other

authors (e.g.,
Csikszentmihalyi, 1991).
It is also void of self-consciousness, as self and activity are experienced in a united state. Clients can often call

to mind some activities in which they participate fully and naturally; this

varies widely, but examples include sports activity, dancing, or participating

in conversations that captivate interest. However, practicing participation in

a greater number of daily activities can be very difficult for clients with BPD,

who frequently struggle with high levels of self-consciousness. Both indi-

vidual and group therapy can be opportunities for practice of this skill and

clients are often asked to throw themselves into the activity of participating

in therapy. Participating can also be a valuable practice for clients who are

sensation seeking or likely to judge certain activities as mundane/boring.

In many ways, the first how skill, n
onjudgmentally
, is the most radical skill

taught in DBT. It involves letting go of all judgments, including both good

and bad judgments, about self and others. Often clients object to this skill

because they assume that to give up judgment means to give up preference

or approval. For instance, clients often assume that being judgmental means

that they cannot hate something very painful. It is important to clarify that

being nonjudgmental does not mean giving up strong emotional responses.

Moreover, it does not mean giving up values and preferences in the world.

A client can prefer to live in a world without prejudice against people with

mental illness, can in fact hate instances of prejudice when they occur, and

still be nonjudgmental. Being nonjudgmental involves emphasizing observ-

able facts (e.g., who, what, when, and where) and describing consequences,

as opposed to making evaluations and interpretations. Clients are asked to

practice the nonjudgmental skill by just describing, without adding on their

interpretations. They are also challenged to restructure judgmental cogni-

tions in the moment and to repeat a phrase or statement nonjudgmentally.

One-mindfully
simply means attending to one thing at a time. It is the

opposite of multi-tasking and doing one thing while thinking about another.

Clients are encouraged to think that everything can be done one-mindfully. A

well-used example is referencing Thich Nhat Hanh’s description of washing

dishes (1991). He writes “Washing the dishes is at the same time a means and

an end – that is, not only do we do the dishes in order to have clean dishes,

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we also do the dishes just to do the dishes, to live fully in each moment while

washing them” (1991, p. 27). When taught this skill, clients often respond

by saying that they get more done when they are doing many things at once

and that doing one thing at a time is inefficient. Here it is useful to cite the

research that suggests that multi-tasking is associated with more time spent

on each task (e.g,
Foerde, Knowlton, & Poldrack, 2006).
Personal anecdotes about how multi-tasking creates more problems are also useful demonstrations of the negative consequences of doing more than one thing at a time

(e.g., talking on a cell phone while driving led to a near-accident, having a

conversation with someone while thinking about something else led to an

embarrassing moment in which you didn’t know what the person just asked

you). Positive consequences of practicing one-mindfully include increased

attentional control and decreased rumination, which can often reduce emo-

tional distress.

The skill of
effectively
asks clients to practice giving up being “right” in

favor of doing “what works.” The maxim “Don’t cut off your nose to spite

your face” is appropriate here. Practicing effectively means doing just what

is needed in the moment to achieve one’s desired goals, no more and no less.

Clients with BPD often struggle with this skill due to the strong emphasis

on proving that they are “right” and that things “should” be a certain way.

Clients are taught that whether they are right or wrong is not at question,

but rather the focus is on getting what they want. DBT with clients with BPD

frequently provides a multitude of opportunities for clients to practice being

effective; interactions with family members, friends, and treatment providers

are all valuable contexts in which to practice. Being effective, thus, is high-

lighted throughout treatment and therapists frequently ask clients “what is

the effective thing to do in this situation?” as a way of guiding and structur-

ing client behavioral responses.

It is important to note that throughout DBT therapy, the therapist is mod-

eling the use of all these skills. The DBT therapist one-mindfully participates

in therapy in a nonjudgmental and effective manner. The therapist practices

with the client and shares his or her own experience of mindfulness practice.

Ideally, the therapist demonstrates that mindfulness is not easily acquired but

with practice and diligence, the use of these skills will lead to an overall

improvement in quality of life.

Case Example

As previously mentioned, mindfulness is taught to all clients in DBT skills

groups, and is considered to be the basis for many other skills. The degree to

which mindfulness is emphasized by the individual DBT therapist depends

on the client’s goals, therapy targets, and case formulation. The following

case example will illustrate how mindfulness skills are woven into the indi-

vidual therapy mode of DBT. “
Mia”1
was a 22-year-old woman who met criteria for BPD. She reported a history of suicide attempts and non-suicidal self-

injury, typically cutting, which she had engaged in between 10–30 times per

month since she was 17. Mia attended a local community college and lived

1 Names and details have been altered to protect confidentiality.

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Shireen L. Rizvi, Stacy Shaw Welch, and Sona Dimidjian

with her boyfriend, with whom she had a tumultuous relationship that often

included intense arguments followed by temporary break-ups. He would typ-

ically leave the apartment they shared for several days, sometimes getting

involved with other women, before returning and re-engaging in the rela-

tionship. Mia would typically cut herself or take non-lethal overdoses of pain

medication after fights with her boyfriend. Detailed analyses indicated that

the typical pattern was that after a conflict, she would take enough pain med-

ication to put herself to sleep, with the thought that “if it kills me, fine.” Upon

waking, she would cut herself until she felt “soothed” and would then skip

classes and spend the day alone. This pattern occurred 1–5 times per month,

and had also resulted in academic struggles and threat of suspension, despite

the fact that Mia was an extremely bright, dedicated student who did very

well academically despite this pattern and hoped to attend medical school

one day.

The initial stages of therapy focused on helping Mia stop all self-injurious