Originally published in NCPS, June 2009
A lot of anxiety, depression, and even psychotic symptoms relate to how patients see themselves, how they judge themselves. Usually a core problem is black or white thinking, that one is either good or bad, normal or not normal, worthy or unworthy. This belief system that comes from childhood has a deep hold.
Distorted beliefs can come from minor traumas of childhood to more pathogenic traumas such as molestation or neglect. We have dual goals in treatment. Fixing the disorder, means treating the negative psychology, while enhancing the patient’s strengths, effectiveness, fulfillment, and wellness involves treating the positive psychology of the patient.
Doctors and most therapists are trained to deal with the negative psychology, far fewer work with the positive. There are many benefits from focusing on the positive psychology equally if not more so than the focus on negative. This includes motivating patients to change their lifestyle in long-term ways that reduce the likelihood of recurrence of psychiatric symptoms, improve physical health and effectiveness.
Take the example of self-worth on the negative side and self-care on the positive side. These are tied at the hip. Probably the most common resistance or obstacle to self-care is self-worth. Many of us have spent hours trying to help patients feel better about themselves, a.k.a. improving self worth or self-esteem. Goals include patients taking better care of themselves, including setting boundaries, relaxing and having intimacy and a greater sense of purpose. We are taught to help them improve their lives from the inside out, starting with why they feel and think the way they do, to changing those thoughts and feelings, then often behaviors, outlook, relationships and everything else will improve. DBT, as a behavioral therapy takes an opposite perspective. Patients learn that when they change their behaviors, they can change their emotions, when they see that they can change their emotions they build up confidence and self-worth. We see when they focus on their wellness activities and priorities, self worth becomes less and less of an issue.
An all-too-common mistake made by patients as well as therapists is to wait for the thinking to change before the behaviors change. Only some tweaking of thinking is required in order to change the behaviors which in turn can lead to changes in personality, as evidenced by DBT research. Many of the techniques used in DBT are beneficial in approaching anxiety disorders, PTSD, depression, and other disorders were emotion dysregulation is a factor.
When patients come to see us, we can explain to them the model of negative and positive psychology. We can connect for them perhaps a triangle, on one corner the current problem, situation and symptoms. A second corner, how they see themselves– self-worth, self image, their beliefs. In the third corner, emotion regulation, problem solving, priorities and boundaries, “self-care”. We can help them gently, and with less and less shame, to see their distorted thinking, and to fairly quickly see how it is distorted and yet deeply believed. I tell them, similar to the way David Burns, M.D. explains, “There’s bad news and good news– the bad news is that black-and-white thinking is deep and may never change, you grew up with it and around it, like a nail hammered into a young tree, tree grows up around it and there’s always a defect there. The good news is that you can learn to work around it”. Thus begins the concept of changing behaviors despite what you think. We give them other reasons to change their behavior, to do homework, practice mindfulness, try applying the skills. These motivations include having more energy and ability to do more and help others. We can say that in general, the better people take care of themselves, set boundaries, practice mindfulness and/or relaxation exercises, do nurturing things, the less medication they’ll need. (I tell them that doesn’t necessarily mean they’ll be able to do well without medications). People can rationally see this, and with reinforcement and follow-up the emotion regulation, problem-solving, sometimes interpersonal skills they learn, the homework assignments, mindfulness and other wellness practices can be applied to their specific symptoms and situations.