Clinical Handbook of Mindfulness (72 page)

behavior, and teach her other more skillful means of regulating her affect.

Mindfulness skills were conceptualized as essential throughout the treat-

ment for Mia. Main areas of emphasis included (1) helping her use “Wise

Mind” to make more effective decisions about her life that were based on

her values, rather than on avoidance of immediate negative affect, and (2)

increasing her ability to observe her private experiences without judgment,

self-invalidation, or avoidance, so that she could (a) tolerate negative affect

more skillfully, and (b) more mindfully choose an effective response (thereby

decreasing impulsive, destructive behavior).

The focus on mindfulness was primarily achieved by emphasizing the

seven mindfulness skills in individual therapy. This was not done in a for-

mal protocol, but in response to the problems and issues Mia brought up

each week in treatment. Practicing the skills in the treatment session was

a priority, as the skills were novel and difficult for Mia. Simply describing

them and assigning them for homework would have set her up for failure.

Examples of how the skills were incorporated into the treatment session are

given below.

Wise Mind

Mia, like the majority of clients with BPD, immediately identified herself

as someone who “
lives in emotion mind
” and had difficulty acting mind-

fully based on her values/internal wisdom. The following is an example of

how wise mind was used in a conversation about giving up self-injury as an

option.

T: OK, so what did you cut yourself with?

C: A razor blade. . .

T: but I thought you got rid of all of them last week. . .did you go out and

buy one?

C: No. . .I had to keep one, just in case. I kept one saved. It’s a special one to

me. I guess I’m really not ready to do this. I won’t give this up. All I can

say is that cutting works for now and to be honest I really don’t think

I want to give it up. It made sense when we were talking about it last

week but now I know this is just not for me
.

Chapter 13 Mindfulness and Borderline Personality Disorder

253

T: So you’ve been thinking about this a lot
.

C: yes. . .

T: Ok. So did you go over Wise Mind in group last night?

C: Yes. . .

T: So here is what I want to do, is go over this decision of whether or not to

give up cutting but use Wise Mind, really practice that skill here. Here’s

why; when we were talking about it last week, you had all the reasons

to stop cutting, you had the logic, what state of mind would you call

that?

C: Reason mind
.

T: Right, yes, because you’re using reason. Now it strikes me that when you

got home and threw out all those razor blades except one, I am betting

that you made that decision from emotion mind. Do you know what I

mean?

C: Yeah, I agree. I should do it but it feels like I can’t. That’s like the story

of my life
.

T: Well, right, for many people that is true, we can think about something

logically before we’re tempted with something but when we’re upset we

think with our emotions. Using the Wise Mind skill is trying to use mind-

ful awareness to get out of that trap, to really go inside yourself and

access your own wisdom, and that has both logic and emotion. So I

want to actually practice that right now and just see what your wise

mind says about this decision with cutting. Because even if my Wise

Mind wants you to do this and you agree when you’re with me, ulti-

mately it’s true that you have to know in your own Wise Mind. So, what

practice did you find the most helpful in group in terms of finding wise

mind?

C: I liked the one where we pretended we were a flake of rock, floating to

the bottom of a lake and the bottom was wise mind
.

T: Ok, so lets do that now. Just notice your breath and then imagine the

rock. . .when you get to the bottom, I want you to see if you can just

notice what your Wise Mind says about letting go of that last razor.

Don’t force anything. Just notice what comes
.

Following this exercise, Mia said that she felt that her wise mind was telling

her that she needed to close the door on cutting and that it was the right

thing to do, but that her fear of “going crazy” without the outlet of cutting

was holding her back from fully committing to abstinence. This realization

facilitated a discussion about ways to tolerate intense emotion, and also a

plan to agree to give up cutting for three months with the understanding

that her fear was valid, and that if help from the therapist and the DBT

skills did not work, she could always go back to cutting later.

Observe and Describe

Observing and describing were used to help Mia begin to experience

moments of intense negative affect, and to mindfully chose her responses

instead of reacting impulsively. Emphasis was placed on observing the

“wave” of emotions and allowing them to peak and decrease without engag-

ing in avoidance behaviors. During sessions, the therapist frequently asked

254

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

Mia to observe and describe her emotions and tolerate them for increasingly

lengthy periods of time (30 seconds, 2 minutes, etc.) without engaging in

efforts to avoid. Instead of “becoming” her emotion, Mia learned to step

back and observe the thoughts, physiological sensations, and urges she was

having. She also began asking “can I tolerate this moment?” or “can I tolerate

this for the next 5 minutes?” She would then use the describe skills to either

describe to herself what was happening
(“I notice the thought that I can’t

stand this. . .there are tears in my eyes and I feel the urge to run out of

the room. . .my chest is tight. . .I feel hot. . .”)
. The difficulty of this task for

Mia (and many clients with BPD) cannot be overstated. However, practicing

these mindfulness skills in this manner was extremely useful and she began

to recognize that her emotions “
may hurt but won’t kill me. . .and they do

go down on their own even if I don’t do anything to stop them
.”

Other Mindfulness Skills

The other mindfulness skills were also incorporated into the treatment often;

space precludes detailed transcripts of each. Working on decreasing self-

judgments, which were frequent for Mia and tended to increase her emo-

tional vulnerability, was a frequent topic in treatment. In therapy, the follow-

ing types of interactions occurred numerous times:

C: I’m just so STUPID! Why do I do these things. . .

T: Could you please tell me what you mean and lose the judgment?

C: I can’t believe I. . .did something. . .so stupid. . .

T: So stupid doesn’t tell me anything. . .what is the thought? Use the

describe skill. . .

C: I’m so mad at myself that I avoided class
.

T: Wonderful! So you noticed anger at yourself for avoiding. So that was

great, now I know what’s happening and you and I can work on solving

this problem. . .

The key to interactions such as this one is a light, nonjudgmental (even

gently teasing or irreverent) tone, and coaching where needed. Mia worked

on observing judgments, and mindfully choosing to either reframe them,

noticing them and letting them go, or building empathy.

Mia incorporated the participate skills in several ways. First, she would use

this skill often to throw herself into whatever skillful behavior she chose as an

alternative to cutting; for instance, she would often go walking and mindfully

observe her feet touching the ground, all physical sensations, and so forth.

She was often prompted by the therapist to practice the participate skill

during sessions, as well, especially when she was tempted to avoid difficult

content. Finally, she began participating in routine household tasks, such as

washing dishes and doing laundry. Mia also used the “one-mindful” skill in

similar ways, to help her engage fully in skillful alternates to self-injury. She

also used this skill to help herself “slow down” in highly emotional moments,

and it appeared to both her and the therapist that this was extremely useful

in decreasing impulsive behavior.

Over the course of treatment, Mia showed remarkable improvement. By

the end of treatment, she had stopped all self-injurious behavior, was much

Chapter 13 Mindfulness and Borderline Personality Disorder

255

less judgmental of herself, and was steadily attending classes and doing well.

She eventually ended the relationship with her boyfriend in a highly skillful

manner, and moved into a house with female roommates. It appeared to

both the therapist and Mia that the mindfulness skills had been of paramount

importance to her. The most striking example was her use of the observe

and describe skills; once Mia learned that she could tolerate emotional

pain and that it would not last forever
without her doing anything about

it
, avoidance behaviors such as self-injury decreased dramatically. It also

appeared that the practice of these skills, along with participating and

wise mind, resulted in her increased sense of self. The practice of the

nonjudgmental and effective skills was also very helpful to her in increasing

her behavioral control.

Specific Mindfulness Exercises

What follows are some specific mindfulness exercises that we use in our

practice of therapy with BPD clients. This list should be considered illus-

trative rather than exhaustive. As one practices DBT, one quickly realizes

that there is no limit to the possibilities for mindfulness practice! Remember-

ing that the
how
skills are incorporated into the practice of wise mind and

the what skills, we did not include specific exercises for them. Rather, the

DBT therapist is mindful of a client’s judgment, engagement in more than

one thing at a time, use of “should statements” throughout the practice, and

the presence of willfulness (as opposed to effective willingness to engage

in the process). There are also many written sources available for mindful-

ness practice ideas. The DBT skills are heavily influenced by the writings of

Thich Nhat Hanh and many of his published books contain valuable practice

exercises. Another source for exercises is Jon Kabat-Zinn’s
Full Catastrophe

Living
(1990) and
Whereever you go, There you are
(1994). Furthermore,

the Linehan skills manual (1993b), recent publications of a book on adap-

tations of DBT in clinical settings
(Dimeff & Koerner, 2007),
and a book on DBT for adolescents
(Miller, Rathus, & Linehan, 2007)
contain additional DBT

practice exercises.

Wise Mind

• Clients are asked to use imagery and imagine that they are a flake of rock

drifting to the bottom of a deep and clear lake. The therapist guides the

imagery by instructing with some statements as: “Imagine that you are a

little flake of rock skipping across a lake, out into the water. As this flake of

rock, you begin to go down in the water, floating in circles, deeper in the

clear, cool water containing you. Slowly, you circle further down and then

you reach the bottom. As you rest there at the bottom, you experience

being centered and at peace.”

• Ask clients to follow the feeling and cadence of their breath with a sim-

ple practice or whatever practice has already been learned. After a few

moments, ask clients if they can experience or connect with a wise, cen-

tered place within them.

256

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

Observe

• The therapist can say a word like “elephant” and ask clients to just notice

that word going through their mind. Clients are instructed not to push it

away or to hold on to it, but rather to just watch the word come and go.

• The therapist can bring in something small to eat like a raisin, piece of

fruit, mint, or small chocolate. Clients are asked to observe the sensa-

tions of eating, such as taste, texture, smell, and the physical sensation

of swallowing.

• The therapist can play music that is quite dissonant, or might be experi-

enced as unpleasant by many. Clients are instructed to observe the sound,

and also observe any thoughts, emotions or sensations that arise.

Describe

• Pictures of people making emotional expressions (e.g., anger, fear, joy) can

be brought in and clients asked to describe what they see. Often clients

will say “she’s really angry” or “he’s scared” and the therapist can point

out that anger and fear are not directly observable and therefore cannot be

described. Rather, “lips turned down,” “brow furrowed,” “squinted eyes,”