Mindfulness or Mindlessness?

Stress tolerance skills are great, but why not remove the source of stress?

Published on February 17, 2014 by David M. Allen, M.D. in A Matter of Personality

“God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference” ~ The Serenity PrayerThe latest fad in both psychotherapy and self help is “mindfulness.” Mindfulness, which is derived from Zen Buddhism and first made popular in psychotherapy by Marsha Linehan (founder of Dialectical Behavior Therapy [DBT] for borderline personality disorder [BPD]) and others, is basically a skill one can use to better tolerate and cope with emotional distress.

Gregory J. Johanson, Ph.D. discusses it thusly:

“For clinical purposes, mindfulness can be considered a distinct state of consciousness distinguished from the ordinary consciousness of everyday living. In general, a mindful state of consciousness is characterized by awareness turned inward toward present felt experience. It is passive, though alert, open, curious, and exploratory. It seeks to simply be aware of what is, as opposed to attempting to do or confirm anything.

Thus, it is an expression of non-doing, or non-efforting where one self-consciously suspends agendas, judgments, and normal-common understandings. In so doing, one can easily lose track of space and time, like a child at play who becomes totally engaged in the activity before her. In addition to the passive capacity to simply witness experience as it unfolds, a mindful state of consciousness may also manifest essential qualities such as compassion and acceptance, highlighted by Almaas, R. Schwartz and others; qualities that can be positively brought to bear on what comes into awareness.

These characteristics contrast with ordinary consciousness, appropriate for much life in the everyday world, where attention is actively directed outward, in regular space and time, normally in the service of some agenda or task, most often ruled by habitual response patterns, and where one by and large has an investment in one’s theories and actions.

Mindfulness was even featured as a cover story in a recent issue of Time Magazine, pictured above. It often incorporates another concept pioneered by Marsha Linehan, radical acceptance. Radical acceptance means completely and totally accepting the reality of your own life. You are supposed to stop fighting this reality and learn to tolerate it.

Practicing mindfulness techniques can help you to stay calm when things are going badly, without resorting to an occasional tranquilizer or a stiff drink, although in some ways it accomplishes much the same thing. So therapists like to teach this skill to help their highly reactive, chronically upset, or emotionally unstable patients to calm down and not resort to acting out, such as cutting oneself or other self-destructive or self defeating acts.

So, is there anything wrong with that? Well, not as far as it goes. Certainly remaining calm and not going off the deep end in the face of adversity is a very useful skill. Some people prefer learning coping skills to accomplish this over medication, although there is nothing wrong with temporarily taking medications to decrease your reactivity either.

But I started this post with the serenity prayer for a reason. Mindfulness is relevant to the first part of the prayer – accepting things that one cannot change. What about changing the things that need changing? Where does the wisdom to know which things can be changed and which ones cannot come from, and how does one go about changing them?

People feel emotional pain for the same reason they feel physical pain – it is a signal to the person that something in the environment is wrong and needs attention. To employ a metaphor I’ve used before: What if another person is walking next to you constantly stabbing you in the shoulder with a pen knife? If I am a doctor, I can give you an opiate so you don’t feel the pain, and you can go on with your life. But would it not be much better to get the guy with the knife to stop stabbing you?

Most of the non-psychotic people in therapy who are chronically highly reactive, upset and emotional, and who are not in the midst of an episode of a major mood disorder, are reacting to the environment. Specifically, the social environment. Even more specifically, as anyone who reads this blog should know by now, the family-of-origin social environment. Biological psychiatrists and some cognitive behavioral therapists seem to think that the whole problem is all going on inside a patient’s head and has nothing to do with what other people are doing. Baloney.

Marsha Linehan herself acknowledges this. In her Skills Manual for Treating Borderline Personality Disorder, she lists the following goals of the skills training portion of DBT treatment:

Goals of Skills Training: To learn and refine skills in hanging behavioral, emotional, and thinking patterns associated with problems in living, that is, those causing misery and distress.

Specific Goals of Skills Training:

Behaviors to decrease:

1. Interpersonal chaos
2. Labile emotions, moods
3. Impulsiveness
4. Confusion about self, cognitive dysregulation

Behaviors to Increase:

1. Interpersonal effectiveness skills
2. Emotion regulation skills
3. Distress tolerance skills
4. Core Mindfulness skills

Notice that she talks about becoming more effective in dealing with interpersonal environment before she even gets to her distress tolerance skills, numbers 2, 3, and 4.

Unfortunately, in practice, dealing with specific dysfunctional family interactions is one of the last things many of these therapists get to, if they get to them at all. Marsha Linehan believes – with little “empirical” evidence by the way – that the reactivity of patients with borderline personality disorder is both biologically innate AND caused by an “invalidating environment.” This invalidating environment is not described specifically, nor is there much written about what makes family members act that way.

The Skills Training Manual is 180 pages long, including a section with handouts that starts on page 105 and goes all the way to the end. Of the first 104 pages, only 14 are devoted to interpersonal effectiveness skills, and most of what is written there strongly implies that the interpersonal problems experienced by someone with BPD are due to their own skill deficits rather than the fact that they are dealing with people who are difficult (if not nearly impossible) or who are frankly abusive or distancing.

Blaming the victim.

In the handout section, interpersonal effectiveness skills are only addressed from pages 115-133. The rest is all about emotional regulation. Almost all of the skills described in the interpersonal skills section are basic assertiveness skills or are lists of “myths” about interpersonal effectiveness such as “I can’t stand it when someone gets upset with me.” That’s one of cognitive therapy’s “irrational beliefs.”

As such, it is conceived of as a flaw in the thinker, and once again completely discounts the importance of the social environment in which the thinker resides. Paradoxically, telling a patient with BPD that their thinking is skewed is incredibly invalidating! In the case of BPD, what the thought actually means is, “When someone gets upset with me, all hell breaks loose.” And that is NOT an irrational thought in these families.

So what happens if someone with BPD gets assertive with their families? Nothing much. Just the reactions of family members who in response start engaging in behaviors such as violence, suicides, suicide threats, increased drinking and drug use, interpersonal chaos, blaming and invalidating the assertive person, literally exiling the assertive person from the entire family or giving him or her the silent treatment for weeks, taking anger at the assertive family member out on other family members – just to name a few. Nothing too bad, really.

So back to the Serenity Prayer. Are these things one can change? YES!!! It’s not easy, or the person could figure out how to do it and would. It’s emotionally trying. It requires incredible patience and persistance and ingenuity. It usually requires the services of a therapist who knows a little about the family dynamics of BPD.

So if your therapist is telling you to just tolerate or ignore the person stabbing you in shoulder with the pen knife – and nothing more – fire your therapist and find one who can actually help you.