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 psychology field 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.