I became aware during college that I was drawn to remoteness amidst gatherings of people, and self-imposed deprivation amidst plenty. So it was not as unusual as it may sound that for nearly a week during one Thanksgiving break I confined myself alone to the depths of the university’s catacomb-like biological laboratories, where almost the only living things were in crates, cages, jars, bowls, and Petri dishes. As if camping, I arrived with food, drink, a sleeping bag, my guitar, my diary, and a book to read if I needed a break from my singular focus, a research project for a biology class. Though I hardly knew it at the time, the motivations to spend my first ever Thanksgiving alone were as much personal as academic. I was studying interdependency, connection, and communication within a biological system, while personally, I was on retreat from other humans, communicating with no one.

I wanted to answer a question. How can all of the two billion separate heart muscle cells of the human heart, each one having the inherent capacity to “beat” at its own pace, beat together, like members of a synchronized swim team swimming together, unerringly, from birth to death? Each cell has its own complex inner world, with its own complete set of DNA and multiple magnificent molecular machines contained within a sophisticated semi-permeable membrane, allowing just the right things to pass through from outside to inside and from inside to outside. How could so many separate cellular beings beat as one, propelling blood throughout the body, sustaining life? How did each one know when to beat? If they didn’t beat together it would be fatal.

A specialized collection of cells at the top of the right atrium, known as the sinus node (SN) or the sino-atrial node (SAN), functions like the coxswain of a crew boat in a race, setting the pace for all muscle cells to beat as one. Delicately reflecting the range of bodily needs coming to it from sympathetic and parasympathetic nervous systems, from hormones and other chemical influences, these nodal cells have the capacity to initiate an “action potential” forty to one hundred times per minute, which spreads like an electrical impulse coursing along electrical wires, across specialized conducting channels in the wall of the atrial chambers. Within a fraction of a second, that action potential arrives at a second specialized cell collection, the atrial-ventricular (AV) node, which serves as a “relay station” sending the impulse along similar conducting channels in the walls of the ventricles. Such is the “electrical” conducting system in the heart.

The mechanism for sending an action impulse from cell to cell along a pathway is not dissimilar from the way action potentials pass from one neuron to the next, and is therefore not that puzzling. An action potential results from an asymmetrical distribution of positive and negative ions (small molecules with either positive or negative charges) across a cell membrane, which creates a very small but measurable electromagnetic charge. In a process known as depolarization, the membrane of that cell suddenly allows ions to pass through. The ions rush in directions, through the membrane, that equalizes the charge between inside and outside the cell. The changes external to the cell membrane immediately impacts the membrane of the next cell, leading to depolarization of that one. Very rapidly, a wave of depolarization takes place from cell to cell along the specialized conducting channels.

Much more puzzling, at least back in 1969 when I was doing the project, was that the impulses not only traveled down these channels, but also spread like a wave across the entire heart muscle. While the vast majority of heart muscle cells were not adjacent to the specialized conducting channels, still they would beat in synch with all other cells, at the pace set by the sinus node. When the membrane of a cell depolarized, the flow of ions would change the internal milieu of the cell, causing the cell to “contract” through changes in the micro-tubular skeleton of the cell. But how could each cell know when to beat? How did the message get communicated across the heart so quickly, allowing so many to act as one? Could I find structures within the cell membranes that would facilitate such a wave? That was my question.

For those six days the only human I saw was a security officer who walked the halls once in the morning and once at night. He was aware of me, and we never spoke. I was alone with some live frog embryos that had been left for me by my professor. My strategic plan, while I knew it would be technically challenging, was clear to me. What I did not expect was the sense of foreboding that gripped me at different times of day and night. I felt as if something bad were about to happen. I tried to ward off the unnamed demons by talking out loud, singing to myself, taking brief walks down the hallways, soothing myself: “Charlie, don’t worry, there is nothing weird going on here, it’s just your imagination.” I couldn’t eliminate the sense that it was spooky to spend days and nights without human contact amidst long dark corridors, watched over by collections of dead and live biological specimens. I began to dissect the frogs that were left for me. When I separated the hearts from the brains, the hearts continued to beat. When I severed connections to the rest of the body, still the beats continued. The hearts had lives of their own, living in life-sustaining soups in Petri dishes, pumping away even though divorced from anything to pump.

With a scalpel, next I cut each heart into small pieces of heart tissue, each piece still beating but not necessarily at the same pace as other pieces. Then I cut each piece into smaller pieces. Still they kept beating, the way that members of an orchestra separated from the whole might reassemble themselves to play in quartets and trios. As I cut the pieces smaller and smaller, inevitably a point would come when the beating would stop; the heart cells would stop. At some moment, impossible to determine exactly when, the music would end, life would stop, as a result of my cutting. My technical challenge was to cut the hearts into clusters of cells that were as small as possible but still beating. When I was spooked, I felt eerily as if I were playing God with frog embryo hearts, that it was wrong to do so, and that there would be consequences.

This went on for about three days, perhaps longer, I can’t tell. Every step forward followed dozens of missteps in a process of trial and error. My patience and tolerance were seriously tested. After innumerable trials, I was able to predict at what point in cutting the tissue into smaller and smaller pieces, the cells would stop beating. I learned to stop cutting just this side of the life-and-death line, and then count the number of cells remaining in the cluster, using a microscope. Finally I isolated several tissue clusters with fewer than 25 cells each, maintaining their beats. I was glad to have arrived at the end of the technical challenge by then, since my irrational mind had again fallen prey to dark and eerie forces. For instance, a few times, after cutting and cutting, I pictured pieces of tissue, clusters of dead cells, all emerging from the carnage, joining together, zombie cell clusters attacking me from all sides. I deliberately interrupted the troubling images, shining the light of reality on them. But I couldn’t deny that paranoia had crept in. It troubled me to think that if the dead cell clusters smothered me to death, no one would ever know what happened.

I bathed the tiniest still-beating clusters in liquid nitrogen, freezing them instantaneously, stopping all cellular activity while preserving cellular structure and membrane integrity to the degree possible. Finally I had several frozen clusters. In the next step, known as freeze fracturing, which would have to wait until school was back in session, I would gently but firmly strike the frozen clusters with a small tool called a microtome, causing the frozen clusters to fracture. Done correctly, the fractures would occur along predictable plane, between cell membranes, so that on one side I would find the outer surfaces of some cell membranes, and on the other side the outer surfaces of cell membranes that had been adjacent to the first ones. As I ended my most bizarre Thanksgiving ever, I emerged from the long dark hallways back into the light, clutching my precious frozen tissue samples. I was glad to leave the dark dream-like world in which tiny heart cells were superior beings capable of extraordinary capacities, that I was a Godzilla playing with their lives, and that in the interest of scientific technique I was destroying their communities.

As school resumed, I took my treasure to the medical school, where with the help of a professor and a technician, I freeze fractured the clusters into smaller clusters. As hoped, the samples fractured along the planes of the cell membranes. We could view the outer surfaces of the membranes under the extraordinary power of the electron microscope, which appeared like the surface of the moon, with bumps and valleys, clumps and tiny structures. We could look at the cell membranes of two adjacent cells, which had been juxtaposed, and we could see where the configurations on one cell membrane matched up with corresponding ones on another membrane. It was amazing, and we recognized that the among the structures on the membranes were a multitude of well-defined tiny holes, large enough to allow small molecules to pass through but small enough to block larger molecules or organelles from leaving or entering the cell. These holes turned out to be gap junctions discovered in research in that era, well constructed channels that linked the inside of one cell to the inside of another, the perfect candidates for structures that could allow small ions (e.g., potassium, calcium, and sodium) to pass through with almost no resistance, depolarizing the cell membranes, which could cause the cell to contract.

Suddenly a new concept took hold in my mind. If the wave of depolarization could happen within the same second across the entire heart, opening up all gap junctions of all heart muscle cell membranes almost simultaneously, allowing the flow of ions all nearly at the same time, all driven by the beat of the sinus node, it was imaginable to have two billion cells act in synch. In fact, the two billion independent cells, by opening the windows between them throughout the heart all at the same time, would functionally convert two billion small independent chambers into one big cooperative one. The contractile potential of all two billion could be activated at (nearly) the same time.

It’s been almost fifty years. The memory of those days remains vivid: the excitement of the investigation; the challenge of isolating a “living” cluster of cells; the thrill of succeeding; and the paranoid halo that came and went. But the most lasting legacy of this project for me is my respect, even love, for the miraculous lives of cells. A cell membrane surrounds, protects, and supports the complex inner world of the cell: a world with dozens of complex structures perfectly adapted to carry out dozens upon dozens of activities; hundreds, perhaps thousands, of different types of molecules, always moving, always transforming, and playing their parts in the intricate cellular world; and processes of energy production, genetic transcription, protein construction, waste removal, nutrient ingestion, and more. To think that something so small could be so complex and so beautifully organized for the ultimate purpose, the heartbeat that sustains us, is incredible. And that cell, each of those cells, lives in a huge neighborhood of cells, crowding each other like apartments in a giant apartment building.
Molecules flow between and among the cells through a variety of specially constructed openings, through both active and passive transport in both directions.

The life of a cell carries lessons. 1) This is a living entity that has a clearly defined purpose, which justifies the multitude of operations going on inside and around it. It all makes sense, far more so than often seems to be the case with our lives. The suggestion, as I see it, is that regardless of the nature of my current purpose, I am functioning at my best when I am attuned to processes around and beyond me, finding my purposes there. 2) The cell is so busy, and conducts it all with such amazing balance. What is taken in must be balanced with what is put out. What is consumed by the constant activity of the cell has to be replaced by nutrients and oxygen. The cell lives with rhythms balancing activity and rest, energy output with recovery and replenishment, attending to the inner life while maintaining awareness and responsiveness to the outer world. 3) As I see it, the cell is a model of willingness to do just what is needed, humility in playing a small part in a large world, and model of sustainability in constantly recycling just the right amounts and types of matter and energy to stay alive and fresh. If I am adrift or preoccupied, I can sometimes think about the life of a cell, which moves me toward purpose, willingness, humility, balance, rhythm, flow, and the kind of sustainability that comes from maintaining my inner self and the world around me with which I am interdependent.

Perhaps the deepest lesson I take from the life of a cell is the capacity to be both independent and interdependent. The cell, as a distinct entity boundaried by a cell membrane, is made up entirely of elements that come from outside itself. Even the central “identity” of the cell, as stored in the DNA in the nucleus, is the same DNA double helix to be found in all other cells. In this respect, the cell has no uniqueness, no true separateness, any more than one wave in the ocean is separate from all other waves. The cell is entirely a recycling operation, carrying out its assigned purpose. Similarly, the concept that there is a boundary around the cell turns out to be an illusion. There is a semi-permeable membrane, made up of elements that are constantly turning over, and that allow things to move in and out so that the heart cells, the two billion of them, can act as one. In one sense there are two billion cells; in another sense, there is one. When I personally allow myself to see that I am made up entirely of circulating stuff from the rest of the universe and that there is no unique Charlie Swenson substance inside, that I represent a constant recycling operation, and that there is no true boundary around me–I am in constant exchange with the world around me to a degree far beyond my usual notions, I try to relax into this level of truth. I feel more relaxed, more joined with what is around me, and energized. It automatically creates in me a greater sense of synchrony and responsibility with and for the rest of the world. I can never accomplish this to the degree that a cell can do it without even trying, but I still find it helpful to have a hero to look up to.

In 1980, when I visited China with a group of twenty-five other Americans, before the modernization of that country, I remember waking up early in my hotel in Beijing. Looking out the window, at about 6:15 a.m., I saw hundreds of people gathered in a large open space. They were practicing the ancient art of Tai Chi, and they were silently moving in complete synchrony with one another. Hundreds became thousands as individuals and families from every generation arrived, joining in the same movements and with the same rhythm. Each person was like a heart muscle cell, separate and complicated. Without missing a beat and without hesitation they synchronized with each other, creating something much larger and more powerful than any one of them. At 7:00 a.m., a horn sounded in the city, and within seconds they all were on their way, most on bicycles, others on foot.

It can be reassuring to realize that each of us is breathing in, breathing out; opening up, closing down; eating, fasting; sleeping, then being awake; acting in harmony, acting in conflict; joining, then separating; and that this rhythm is what life is. And that to the degree that we can synchronize our rhythms, and the opening and closing of our personal “gap junctions,” we can join with each other to do amazing things that we cannot do alone.

His Holiness the Dalai Lama gave a public lecture in our little town, Northampton, Massachusetts. When he invited questions from the audience, he was asked if he had any advice for raising children.

“Raise children? Me? I’m afraid I have no experience.”

He laughed his sweet Dalai Lama laugh at the thought of being considered an expert on raising children, reminding the audience of his celibacy vows.

“Maybe I will go away from here and have children and raise them so that I can answer your question.”

He went on after a pause:

“But I do know something about raising children, because I was a child and I was raised by my parents. And I learned that the most important thing is to love the child no matter what. The child needs to feel loved.”

We might expand on this to say that everyone needs love.

But what do we do if the love in our family, or in the families with which we work as therapists, has for all practical purposes been extinguished, replaced by acrimony, disengagement, mutual disrespect and invalidation? Given how important it is, how do we access or catalyze love among them? We can think of it as the glue that holds things together through thick and thin. Without it things deteriorate, things fly apart, things can become quite ugly. I once worked with a single father and his two sons, ages 13 and 15. During the previous year, the mother had died at the end of a prolonged illness. The father wanted to have family therapy to address the level of tension and conflict among the three of them. Both boys had essentially retreated since their mother died, staying in their rooms, playing videogames, using social media to stay in touch with friends, decisively objecting to any efforts the father made to engage with them or to bring them together with each other. The only way the father got them to family therapy was through blackmail—he threatened to stop giving the rides to their friends’ houses if they refused, not a great way to begin but from his point of view, the only way.

In sessions the boys were silent to the extreme, resisting my efforts to converse with them, attacking the father if he tried to get them to talk. The only words they uttered at the start were in response to something the father said, in which case they would attack his credibility and intentions.

“He acts that way here, but if you saw him at home all you would see is that he yells at us, and goes out to meet girl friends. He doesn’t care about us!”

If one of the boys were to paint himself in a positive light the other one would accuse him of being a liar, or worse than that a goody-goody. Mutual invalidation was the default position, and invalidation flew in every direction including at me. If I validated any one of them, one or both of the others would invalidate my validation. It was bleak.

I met individually with each of them to establish some rapport and to get some history. The picture that emerged was of a family in which there was a good deal of love, affection, activity, laughter, and mutual engagement, all of which died as the mother became terribly sick, until her death. She had been the connector in the center between the three males, and now the connection was gone. The father was searching for a way to rekindle the connections and the love among them. His failures in doing were burning him out, which showed in his frustration toward the boys.

Within my family of origin I had three brothers and a sister. I had personal experiences with the male-male connection, and a lot of pained feeling about it. And my wife and I had two sons and no daughters. In our family, disconnection between the boys, and between the boys and myself, often caused me distress. So the distance, the hurt, and the disappointment among the males in this family in therapy, obscured by acrimony and accusations, was painful to see. Any effort to define and solve a problem was immediately shot down. Any hint of validation, in any direction, was immediately shot down. What was left was tension, heartache, and paralysis. To say that I felt ineffective would be the understatement of the century. In my heart of hearts I was hoping they would quit, as the sessions evoked such hopelessness, helplessness, and eventually irritation in me. In my individual meeting with each of them, I found them to be courteous, interesting, willing to reflect life past, present, and future, and able to accept validation and support. But it all vanished in the group context. It was clear to me that there was hunger for normal exchanges, desires to be understood, but not manifest in the family sessions. Still I could find no way to break through in the sessions by addressing these matters. I couldn’t bring them out.

I shifted my focus away from them, disclosing some of my own pain and disappointment. I explained that when I was 12 years old, and one of my best friends was killed in a freak accident, electrocuted in the presence of his father, I withdrew from life, became bitter, and questioned the point of living. The boys asked detailed questions about him and what happened. It would not have worked if they perceived my personal story as a gimmick to get them to open up. As I recalled the story, I was definitely, emotionally, into it. When I said how much I had missed my friend, day after day, the 13 year old said that he missed his mother every day. The others were silent, as if he had touched a dangerous live wire. Little by little the boys and their father alternated between small but potent doses of talking about her death, and then focusing on conflicts in the house such as curfew, chores, and the use of cell phones after bedtime. Movement was slow but obvious. I wish I could say the outcome was positive. Maybe it was helpful in the long run, but sadly, the therapy ground to halt when the 15 year old suddenly refused to attend any more sessions, and the father insisted that we not continue without his older son. I haven’t heard from them again.

Love in a family takes direct forms: physical and verbal expressions of affection, tuning in to the other’s distress, jumping in to help when help is needed, protecting one another and so on. And it takes indirect forms when things are difficult: biting your tongue when you are dying to scream at someone, taking distance when closeness breeds judgment and contempt, maintaining the mundane details of family life when relationships are fragile, basically holding things together when they are coming apart. Love manifests as concern, more as compassion than passion. Love starts with understanding where the other family member is coming from, and acting accordingly. It is hardest, of course, when other family members are behaving in ways that repel us, alienate or hurt us, and drive us away. Most broadly, love is the life force that motivates us to hang in there, to move toward one another, to work things out, ultimately creating safety and bonds of concern.

When things are coming apart, as was the case with the father and two sons I was treating, so many ordinary strategies don’t work. Identifying a problem, defining it, taking hold of it, and solving it, seems impossible. The trust and willingness isn’t there. Simply listening, reflecting, expressing sympathy and understanding, resonating with distress, seem to go nowhere, and may trigger a downward spiral of invalidation and judgment. As therapists (or as friends to another family), sometimes the best we can do is a holding action, maintaining the status quo for the time being, using trial and error, specifically refraining from doing those things that make things worse. It’s like having arrived deep within a maze, having run into several dead ends, not knowing which way to turn. It is at this point that the DBT therapist turns to the principles and strategies of the dialectical paradigm, the paradigm specializing in patterns of opposition, polarization, isolation and stuckness. It is at this same point, in working with families, that family therapists find ways to contain the conflicts without inflaming them, engage in maneuvers to disrupt the painful family homeostasis without knowing what the outcome will be. The therapist might have people switch places in the room, might use paradox or counterparadox, and might at times come up with off-the-wall interventions. Carl Whitaker, when stuck, used to “fall asleep” in the middle of a session, “wake up with a dream,” share the dream, and move the session in an entirely different direction. It is no accident that DBT’s dialectical paradigm functions in a way similar to these disruptive and creative family therapy strategies, since Linehan admired and studied the work of family therapists when she was working out her ideas about dialectics. Using these ideas with families is different than using them with individuals. We have to center our thinking on the group as a whole rather than as a bunch of disengaged individuals.

More than two decades ago, while attending a course at the Ackerman Family Institute in New York, several of us had the privilege of watching an amazingly skilled family therapist, Olga Silverstein, treat a family from New York’s Orthodox Jewish community. The identified patient was a 15 year-old boy, previously a spirited, ambitious and accomplished student, who had stopped attending school for no obvious reason. He refused to do schoolwork, and at home he was distant and irritated. The parents, having tried every way they could think of to get him to attend school, seemed worn out, defeated by their son’s stubbornness. They brought the son, and his sister, in hopes that Olga could solve the problem and get their son back on track.

From the beginning, she barely even looked at or acknowledged the boy, who looked downward throughout the sessions, or at his rather shy 13 year-old sister. She just spoke with the parents. The tension in the room was high, although Olga’s demeanor was relaxed and open, a stark contrast to their icy stances. As if taking part in a casual conversation, she sympathized with the challenges of parenthood and learned about the parents’ work lives. The father acted as the authority in the family, sitting bolt upright, head up, his arms folded in front of his chest. His wife deferred to him, and he seemed baffled and amazed that he could not get his son back to school, as if his son’s willfulness was a threat to his authority. The mother expressed her worries about her son, but also about her husband since he seemed so distant and angry. Olga wandered her way into an appreciation of each parent, and perhaps of greatest importance, gradually kindled rapport with the father. It seemed that mutual respect grew between them, and even humor at times.

The father’s frustration with the process spilled into the fourth session. Nothing was changing at home, sessions seemed non-productive, the boy was missing school and living mostly in his room. The father insisted that Olga give them advice immediately about how to break the logjam. She caught him by surprise, all of them really, when she responded,

“don’t worry, we’ll get to that, but for now I think we should see what we can do about your depression.”

This was a shock to all of them; they were not accustomed to having someone challenge the father, or even comment on his behavior. The son looked up for the first time, seeming genuinely interested and concerned. The wife looked frightened, anticipating her husband’s response. He seemed insulted:

“what makes you think I’m depressed?”

Olga:

“It’s rather obvious. You never smile, you seem grumpy and irritable, you seem distant and withdrawn from everyone including your wife, and you are filled with pessimism about your highly accomplished son who is taking a little break. You just don’t seem at all happy.”

The father dismissed her comments, saying that to talk about him would be a waste of time.

“I’m fine!”

The session ended on this note.

As the next session began, the mother couldn’t wait to speak. She explained that her husband, for the first time in their marriage, had moved out of the bedroom and into a vacant room in the attic. He was not speaking to her or anyone else. Meanwhile, their son, in a complete reversal, without a word of explanation, had returned to school, was back to doing his homework, and seemed more engaged in his life than he had been in a long time. Olga spoke with the boy, asking him about his studies. His responses were normal and upbeat. She spoke with the shy 13 year-old about her interests. The father sat still, looking down at the floor, emanating tension and disappoval. Olga announced, mid-session, that the kids were no longer needed. She sent them to the waiting room.

Then she inquired into the father’s mood in more detail, and noted that his move to the attic confirmed her impression that he was unhappy with his wife. As his wife quietly wept, he admitted that his love for her had waned many years earlier, maybe beginning around the time the children were born. His wife, as he put it, had abandoned her job as a wife in order to be a mother. He knew that the children needed her, but still he felt he should have come first. He was giving voice to a grudge he had kept to himself since the kids were born. He wondered aloud whether they had had children too soon, indeed whether they should have had children at all. Olga asked them about their relationship with each other before the children were born. The tone became sweeter; it was clear that they both had enjoyed the brief time they had together prior to children. In remembering some of the good times, they seemed more joined. Olga recommended a series of couples sessions to recapture and resume the connection they had in the beginning.

Olga navigated the tensions and the oppositions dialectically—not taking sides but finding wisdom on all sides, letting the process unfold without knowing where it would go, finding balance and freedom by moving in unexpected directions, and keeping things moving even when they seemed to be stuck. It seemed that the locked door between the two parents was unlocked, and for the first time since sessions began they seemed and acted like a couple. There was some kidding and the father smiled now and then.

Per the Dalai Lama, love is at the center; everyone needs it. Per the case examples, love can be extinguished or buried in response to accumulated hurts and disappointment, almost impossible to access. By working with principles and interventions of the dialectical paradigm of DBT to create disequilibrium and movement, new configurations and new elements come into view that open new possibilities. Once the system shifts, the therapist can work with principles and interventions from the more “ordinary” paradigms of acceptance, including mindfulness and validation, and of change, including problem solving. Family members whose lives have been inexplicably interrupted can, if they can get “unhooked” from some paralyzing dynamics, move on with more freedom. Ultimately the family can function as a safe, trustworthy platform for each member, so that he or she can thrive at chosen life goals.

Was I out of my mind? Standing at the porch, having already rung the doorbell, I was having serious second thoughts. Maybe this wasn’t such a good idea. In short, I was scared! I had just walked nearly half a mile through the neighborhood to find the house, and I was the only white person I saw. I passed two different groups of black teenagers standing around, staring at me as I walked by. Of course they stared at me; I was totally out of place, I was one of a kind. What was I doing in their neighborhood? Still, I was terrified. I might have been more likely to run if I wasn’t such a slow runner; plus no one had done one thing that posed even the slightest threat. Never have I felt so stiff, so uncool, so vulnerable. Further confusing me, I didn’t want to think that my fear reflected racial stereotyping, but it undoubtedly did. I looked straight ahead, walked with determination, on automatic pilot.

It was the fall of 1970; I was 21 years old. I had taken a leave of absence after my junior year of college, not wanting to stick around and accumulate loans when I didn’t know what to do with my education. I would have left earlier, but being in school gave me a deferment from the military when we were fighting Viet Nam, a war with which I adamantly disagreed. The very first draft lottery for the war determined the order in which young men would be called into the selective service, based on birth dates drawn from a glass bowl. Mine, May 13, was priority number 315 out of 366, which realistically meant that I would never be drafted. I put in for a leave of absence to begin at the end of the school year in May, 1970.

After three months of hiking and camping alone in the mountains of New Hampshire, Vermont, New York, and Canada, I returned to Boston to find work. I was interested in biology, health care, and community organizing. They all came together in a minimum wage job at a health care clinic in Dorchester, where the medical director was a politically progressive obstetrician who had given up a lucrative private practice to dedicate himself to providing good care to those without resources. high quality health care for those who could not afford it. He hired me to convert the medical records over to a new system. I wanted to find a room to rent in the area, since I didn’t have a car, and I wanted to be more familiar with the community. I pu t an ad on the bulletin board in a nearby grocery store.

One day later Beulah Williams called me at work. She had a Southern accent, sounded like she might be black, and came across as a warm person. She invited me to come over after work because she may have a room to rent. Hence it was that I found myself standing on the porch, having walked half a mile, having rung the doorbell, and fighting the urge to run away. Mrs. Williams opened the door and welcomed me in, offered me a cup of tea, and next thing I knew I was sitting opposite her at the kitchen table. She explained that the house had three floors, and that the kids, all eight of them, refused to go up to the third floor because they thought there were ghosts up there. I could live up there. John and Beulah Williams had moved to the house from Columbia, South Carolina, where they had spent their lives. They had 7 children of their own, from age 2 to 25, one 4 year-old nephew, and almost no money. They lived on John’s salary, during the times he was working and not in jail, and welfare. Beulah was proud of the house, which she kept fastidiously, with the help of the plastic coverings on all furniture.

As I learned later, Beulah had already decided, based on our phone call that she would offer the room to rent. She had complete confidence in her ability to assess on first sight (or sound) whether someone was trustworthy. She had the warmest, broadest smile, and she put me at ease as she told me about the family. She didn’t seem to need to know very much about me. After a few minutes she offered me the room on the third floor, subject to approval by her husband when he came home from work. She mentioned him in such a way that I became nervous about meeting him. He would be home soon.

While I finish making dinner, why don’t you go upstairs and find the kids. They are hanging out on the second floor, listening to music or something.

Suddenly my anxiety skyrocketed as I anticipated walking in on a bunch of kids that didn’t expect me. I wouldn’t know what to say. I wouldn’t know how to relate. They would be suspicious of me. But Mrs. Williams left no room for hesitation. She whisked me up the stairs, and yelled at the kids, who didn’t hear her because their music was loud.

At the top of the stairs was a room, not that big, in which there were about six young people ranging from ages 4 to 17. They were dancing to the Jackson Five, their earliest music. They were totally into it, singing along with Michael and the others. Just as I feared, suddenly there I was, standing alongside them awkwardly as they continued to sing and dance. I was a tall, awkward, white hippy with a beard and long hair, with a bearing that essentially said,I don’t dance!Ugh! What was I doing there? Finally I sat on a couch with a plastic cover, getting out of their way, until the song was done. Happily, I was ignored. But as the song ended, Ray turned off the music and stood in front of me. Although he was only 12 years old, he stood tall and spoke with the authority of a man.

What are you doing here? Did my mom bring you here?

I answered that I was working at the health care center and was looking for a room to rent. Ray (with astonishment and disapproval):

mom said you could live here?

She seemed okay with it, but I’m supposed to meet with your father next.

Good luck with that!

Two of the teenage girls went,

mmmhmm,

nodding in agreement with Don. I had no idea what else to say. I was out of my element, and the father was growing in size every minute. The music went on again, and the dancing resumed. The 8 year-old boy, Jeremy, who would become my closest buddy in the household over time, sat down next to me, silently conveying approval.

John arrived home from work a few minutes later. Beulah called upstairs for me. I arrived at the bottom of the stairs and John was seated at the kitchen table. He was dirty and sweaty, looked tired, and was rubbing his forehead. In his t-shirt, jeans, and work boots, carrying his black metal lunch pail, he came across as impatient, maybe irritated to have to see me. Beulah brought him a glass of water, she sat next to him, and motioned for me to sit down next to her husband. She explained the situation. She seemed to be in charge, but she acted respectfully, even deferentially toward her husband as she quietly lobbied for him to approve of the plan to rent a room to me. After barely any exchange, Joe spoke with deliberateness.

I am a black man,

he said.

Life is not easy for black people. We have worked hard to get this house. You can move in to the third floor, but let me say this. There is one bathroom for all of us, and things don’t always go smoothly. If it works out, beautiful, you can stay here. If it does not work out, we will ask you to leave immediately and you will have to go. For now, I am tired, I want to get a beer, sit in front of the TV, and relax.

He got up and left, leaving a quietly jubilant Beulah and an ambivalent tenant.

The following seven months were jam packed with memorable experiences. But for now I just want to zero in on one incident, probably about two months into living with the Williams. Beulah worried about intruders and thieves; she took nothing for granted. She saved up $300.00 to buy a Great Dane and named her Missy. Missy was to be a watchdog as well as a companion. She was a beautiful, young, well-behaved Great Dane. Beulah treasured her. One day, when I was up in my room and everyone else was on the second floor, she looked out her bedroom window and saw an unfamiliar car parked next to the house. Within the next minute, a white man in his sixties, dressed in a drab suit, arrived at the car with a Great Dane and put it in the back seat. Clearly, the dog was Missy, the man was the person who sold her the dog, and he was stealing Beulah’s treasure.

Beulah was on the phone in seconds, calling a neighbor who lived two blocks down the street, in the direction where the man drove with the dog. She called out to me and her kids, and within seconds we were all following her down the street, following the car. Minutes later we arrived at a gathering of people surrounding the car with the man and Missy. Beulah’s neighbor had quickly assembled a posse of about two dozen people to stand in front of the car. The man looked frightened. Beulah walked calmly up to the driver’s window and motioned for the man to open it. He was white as a sheet and followed her directions. She spoke to him without a hint of threat in her voice:

Why don’t you turn around and come back to the house?

The neighbors gave him room to turn his car around, and he drove back to the Williams’ house.

We walked back and met him at the house. Mrs. Williams asked him to please bring Missy into the kitchen, where we gathered. Beulah sent the kids upstairs and asked me to stay with her. She invited the culprit to sit at the kitchen table. Speaking calmly, warmly, and respectfully, she offered him a cup of coffee. I could detect no trace of anger in her. Head looking down at the table, he turned down the offer of coffee, acting as if he didn’t deserve it.  She insisted. She gave him a cup of coffee and a slice of sweet potato pie. Her generosity made him uncomfortable. I’m sure he was anticipating at least a tongue-lashing if not an arrest. She sat down at the table opposite him, and what she said next has never left my memory.

Sir, I know you have to be very unhappy in your life. You knew what I paid for the dog, you knew that we don’t have much, and no happy person would have stolen that dog back. I’m sorry about your unhappiness, I really am, and I know you are sorry for what you did. I can see it in your eyes. That’s why I invited you in. You need something. At least I can give you coffee and pie, something good to eat. I can’t let you have the dog; she means everything to me.

The man started weeping, and apologized again.

If I had been in Beulah’s shoes and if I had spoken to him like this, it would have been a way to punish him, to enhance his guilt, under the guise of kindness. But it wasn’t like that with Beulah. It was pure. She had acted decisively, gotten her dog back, and didn’t seem to feel the need to punish him. She saw him as a good human on a bad path. To me it was breathtaking at the time, and still is, that Beulah could act so decisively, so instantaneously, so effectively, in one minute, and then pivot to pure forgiveness and compassion the next. For those of us who have spent years working to understand wise mind, mindfulness, radical acceptance, and effective action, I knew that this was the real deal.

The first two paragraphs provide a very brief summary of the principles of Change and Acceptance, which I covered in more detail in the last two blogs. So if you prefer, you can jump past them and go right to the principles of the Dialectical Paradigm. Think of any difficult spot in which you find yourself. There may be something you need to say to a friend, but it is difficult or painful to say it. You may be noticing worrisome physical symptoms, you have avoided seeing a doctor due to fear, and things seem to be getting worse. You might be in a job that you hate: your boss or supervisor has a negative attitude about you, you have been unfairly accused of being lazy, the atmosphere at work is demoralizing,and you have put little energy into making the situation better or finding another job. You might be the parent of a teenager engaged in using drugs, he or she denies that there is any problem, and you are convinced that there is. Life brings us one problem to solve after another, some of course much worse than others. We apply principles of the Change Paradigm.

In doing so, we: 1) determine a specific, clear, compelling objective; 2) generate enough force, motivation, commitment, or energy for initiating the pursuit of the objective; 3) ensure sufficient perseverance to get the job done; 4) intelligently assess obstacles, come up with a plan to solve those obstacles, adjusting as you go; and 5) ensure that you have the skills or techniques you need to carry out the tasks at hand. When you apply these five principles to a stubborn problem you will run into brick walls and unforeseen adversaries. You tire, get frustrated or demoralized, lose your way, and feel like giving up. Sometimes when you keep on pushing, you aggravate the situation. At such a point you can pivot to the Acceptance Paradigm to shift perspective, to get relief, and to find your way forward. You may blend the two paradigms, or alternate between them. By engaging the principles of Acceptance, you: 1) allow yourself to wake up to the realities of the present moment, and you fully inhabit that reality; 2) in which you maintain awareness that the present moment is the only moment, one in an ever-changing stream in which everything, no matter how solid it seems, is impermanent; 3) you see, as if from outside yourself, your attachment to certain beliefs, preferences, desires, and expectations, things that are actually not within your control, and you work to let go of those attachments; 4) looking deeply, you see that everything mutually influences everything else, that everything is made up of everything else, that boundaries are conventional beliefs but that looking deeply there are no such things, and there is no such thing as a unique self; and 5) you recognize that everything that is happening at this moment is exactly as it should be, given all moments that have come before. And you relax into the present moment and embrace reality whether you like it or not.

For most problems in daily life, moving through Change and Acceptance principles will give you all you need to find solutions and move on. But the more stubborn problems in life may require dipping into the principles of the Dialectical Paradigm. This is what you need to deal with opposition and life’s dead ends, to adapt to new and unforeseen circumstances, and to improvise when standard things are not working. Dialectical principles arise as part of dialectical philosophy, focusing on how truth evolves and how things change. We can compare it to improvising in jazz, or while dancing.

Dialectical Principles

1. Opposition
2. Synthesis
3. Systemic Thinking
4. Transactional Processes
5. Flux

The first dialectical principle is that of opposition. We recognize that reality consists of opposing forces. X elicits (–X). While we may not see it at first, the presence of tension, conflict, chaos, and confusion often manifest, and obscure, the presence of two opposing positions or forces. We try to see the opposing sides with clear eyes, try to locate the wisdom or validity on each side. We hesitate to choose which side is correct, and don’t simply accept that they can coexist. We see that the opposing sides create a tension that can evolve into a synthesis of the two sides (next principle). Polarization is not the exception, it is the rule. If we can deeply accept that opposition is to be expected, we can relax into it and maintain clarity, openness, flexibility, and creativity. For instance, when we are stuck in our relationship with our teenager, battling over some limit or rule, and the tension rises, we try to remember that conflict is to be expected, and to try to see the wisdom of both sides.

The second dialectical principle is that of synthesis. Once we have encountered opposition and characterized both sides, we allow the situation to move toward synthesis, which is a new position that brings together the wisdom of both sides. Truth comes into being through the synthesis of both sides, again and again. Faced with polarization, we stay with it and ask ourselves, how can we find the “middle path” that includes both sides? In a mundane example, we are just getting a new puppy in our family and there are strong opposing opinions about what to name the dog. Everyone has a preference and no one likes anyone else’s preference. My wife will have the final say as she was the driving force to get the new puppy, but she wants to handle it dialectically, to the degree possible finding a name that everyone can embrace. We need to brainstorm, adapt, create, listen to each other, and see if we can find our way to the “truth.” The process of synthesis is inclusive, mutually validating, and can be invigorating and innovative.

The third dialectical principle is that of systemic thinking. Essentially, every element (a person, a behavior, an idea, a thing, etc.) is one element within a larger system, a context. An individual is one element within a larger systems–the family, the neighborhood, the society–and the individual contains elements such as organs, tissues, cells, and molecules, all of which are related to each other, to the individual as a whole, to the family, and so on. Any change in any one element will bring about changes in all other interrelated system elements. Changes in a community will change the biochemistry of each individual within it. Changes in one organ (heart, liver, kidney) will change all other organs, the person as a whole, the family, and the community. Thinking systemically about any one element, any conflict, or any behavior, opens up an incredible field of interdependencies, which widens the possibilities for assessment and for intervening to deal with things. Family therapists think systemically when they intervene with one family member in a way that changes others. Thinking systemically opens options, loosens up a rigid process, enhances the process of brainstorming, and can help to arrive at a synthesis between opposing positions.

The fourth dialectical principle focuses our attention on transactional processes. We realize that the identity of any one person is determined, in part, by the nature of transactions with another person or group of people. I.e., For instance, one’s identity does not “stand alone, “ but is determined transactionally. For instance, if I am with you, and you clearly value me, I am likely to feel enhanced. Your input becomes part of my identity. If you criticize or dismiss me, I am more likely to feel ashamed or doubtful about myself, which becomes, for the time being, part of who I am. If you are treated as credible and likeable out in the world but as limited and annoying at home, your identity is, in part, a product of the two different transactions. Once we recognize the nature and potency of transactions for each of us, we may recognize a range of ways to use the transaction to change the other person. Many of DBT’s dialectical strategies work because the transaction is so influential. If I can’t change myself, or change the situation in which I am stuck, perhaps I can change some other transaction, which will then influence me and ultimately change the situation. In future blog posts we will explore ways to do this.

The fifth dialectical principle involves the understanding of flux,. While impermanence (principle of the Acceptance Paradigm) emphasizes the transient nature of everything, flux emphasizes the presence of constant change, of perpetual movement. Every system, every person, every cell of every person, every molecule of every cell, every atom in every molecule, and every subparticle within every atom, is moving all the time. Looking deeply, while something may appear to be stuck, in fact we can realize that every part of every thing is moving at every second. “Stuckness” is an idea, not a reality. This is important, because the perception of stuckness can generate a pervasive feeling of hopelessness. It can be helpful to realize that if you try to change things, things will change, and if you do nothing to change things, things will change. Things cannot not change. A good therapist, aware that movement is constant even when not apparent, engages the patient with tempered optimism, and will intervene to generate or support speed, movement, and flow. And in our personal lives, the recognition of the principle of flux should encourage us to assume change is happening, to generate hope for the future, to counter our delusions that things are stuck, and to engage in movement.

In the prior two blog posts and this one, we have now covered all three paradigms, each bringing 5 principles. It’s a potent vocabulary of possibilities. Beyond that, each principle “flows” into life skills which will become part of this blog over time. Now we are in a position in future posts to apply this vocabulary to difficult situations that result in adversity. To state it simply, we are now ready to consider how to cope with hell, to keep moving if we are in hell, and to find a way out.

1. Presence
2. Impermanence
3. Non-attachment
4. Inter-being
5. Perfect-as-is

One Sunday in October, years ago, I was driving my family to visit a wonderful Halloween maze created every year by a farmer in his field. I don’t recall what I was thinking about, but I was preoccupied with something related to my work, trying to figure something out. In our terminology, I was operating within the change paradigm, busily trying to solve something. At the same time I recognized that my wife and our two sons were engaged with each other, laughing and having a good time. I was torn between my silent preoccupations and my wish to just be there, having a good time, with them. I was, you might say, not present. I wanted to shift gears, to leave my work behind and to join the fun. It was not easy. Intention alone was not enough. Then I decided to focus my attention entirely on my breath—my in breath, my out breath, and the associated sensations. I was able to do that, and to just let go of the preoccupations. Within about a minute, I was laughing with my wife and kids.

When we operate from the change paradigm we are driving toward a destination, a change of some kind. It’s all about “getting from here to there.” We focus on a target, we summon the force we need, we monitor our progress and persevere in the face of obstacles, we assess the obstacles and approach them strategically, and we push like hell. As Churchill said, “never, never, never give up.” In stark contrast, when we operate from the acceptance paradigm, there is no destination. We arrive—we wake up, so to speak—in this very moment, just noticing things as they are. While Change focuses on doing, Acceptance focuses on being. When we push for change, our focus narrows, as our minds selectively attend to destinations and obstacles. When we wake up to this moment with acceptance, our focus expands, and we recognize the factual elements in us and around us—sensations, movement, perceptions, thoughts as they float through, details of the world around us. We don’t “enter” the present moment, stepping into it; we wake up to it, as it is already there.

Paradigms of Change and Acceptance are radically different from each other, opposites in some respects. As such, they make wonderful partners for coping with life, each being the counterpoint of the other. Let’s say we are pushing for some kind of change. We inevitably encounter an obstacle, which may seem insurmountable in that moment. We might push harder. Still no success. We then have the option to step back from the push. We can pivot from change to acceptance. We can allow our minds to expand into this very moment, unburdened by the attachment to a destination. In that “new space,” we experience things differently. We see things differently. We take a breath, we “look around.” We increase our patience. We might then notice, from the spacious place of acceptance, what has been blocking our way. If so, we can elect to pivot back into the change paradigm, armed with wider awareness and a new strategy as we continue our journey. We are probably most effective when we pursue change with 100% of our being, and then when we pivot to acceptance, we wake up to the moment with 100% of our being, rather than to find a compromise, a mid-point, between the two. In the next blog, I will discuss the Dialectical Paradigm, where we will discuss the value of finding the optimal synthesis between acceptance and change. Now let’s break down the acceptance paradigm into five more specific ingredients, each of which brings a slightly different flavor.

Presence

I keep mentioning being present. The first acceptance principle is presence, by which I refer to the effort to bring attention, again and again, to the present moment, without judgment. We bring our minds back, again and again, to this moment, in which we are aware of perceptions, sensations, bodily reactions, actions, emotions, thoughts, and what is going on around us. In the practice of DBT, this serves not only to ground the therapist in the reality of the moment, but also tends to communicate to the patient, whether the words are spoken or not, “my dear patient, I am present, I am here for you right now.” For anyone to arrive into the present moment in the middle of difficult times, anytime in life, is to create space and freedom when we are feeling confined and pressured. We find the eye in the middle of the hurricane.

Impermanence

The second acceptance principle is impermanence, which refers to our acute awareness that this present and unique moment is the only moment, never to be repeated, in an endless flow of unique moments. To be aware of impermanence is to deepen our participation in the present moment. If we bring this awareness into our interactions with others, the perspective can come through, influencing the whole encounter, and can generate a similar perspective in the other(s). We recognize the impermanency of everything in the universe, and we correspondingly appreciate the preciousness of now. If we bring the same perspective to a distressing situation which has given rise to the belief that it will never change, we know that it will indeed change, that it is in fact changing at that moment, and it can bring hope and temper impatience. I’m not sure why I keep thinking of things that were said by Winston Churchill, but when London was gong through hell during World War II, he said: “when you are going through hell, just keep going.” He communicated an essential faith that things are changing, in spite of all appearances.

Non-attachment

The third acceptance principle, which is part and parcel of being in the present moment, is non-attachment, which refers to the practice of letting go of our attachments: not attachments to people, but attachments to our beliefs, our desires, our perceptions and expectations. We tend to cling to what we think “should” be true, usually things that bring us pleasure: that we should stay young, that we should stay healthy, that we should not lose those people close to us, that nothing should stand in our way, that we should be appreciated, be happy, be successful, and have the partners and families of our dreams. We suffer when we are attached in these ways, since life will inevitably disappoint us, sometimes harshly. With non-attachment, we relinquish our insistence that life take any particular preferred course. I find it to be a paradox within the practice of DBT that even though it is an outcome-oriented treatment, validated ultimately by accomplishing its goals, it is best practiced when the therapist repeatedly returns to the present moment, letting go of desired outcomes. To be too attached to the outcomes for which we strive can lead to the therapists’ disappointment, emotional dysregulation, and burnout. Similarly, in life in general, by letting go of attachments, along with resting our attention in the here and now, we cultivate freshness, resiliency, freedom, humor, and curiosity. There is no contradiction between non-attachment and the pursuit of a better life or world.

Inter-being

The fourth acceptance principle is inter-being. This refers to several interrelated core insights: 1) that from a certain perspective there is no such thing as boundaries, 2) that there is no such thing as self, 3) that any entity is made up entirely of other entities (which is known as emptiness in Buddhist thinking), and 4) that the degree of interdependency among all phenomena is deep and constant. The awareness and practice of inter-being promotes the dissolution of boundaries between patient and therapist, promotes the sense that “we are in it together,” and increases the therapist’s genuineness and reciprocity. Awareness of non-self helps the therapist to realize that his behaviors are influenced by context and contingencies as much as the patient’s behaviors. He is able to see reality more objectively and to consider the mutual influences between him, the patient, and the context. The linked concepts of inter-being are valuable to anyone, to realize that in our families, in our social milieus, in our places of work, and so on, we are wise to see that we are all embedded in an exquisitely interconnected web of relationships, information, and energy, constantly influenced by each other, and less unique and separate than we usually think.

Perfect-as-is

The fifth and final acceptance principle is perfect-as-is, by which we refer to the understanding that everything emerges from causes and conditions, and that everything is therefore exactly as it should be whether we like it or not. Flowing from the awareness of this reality is the whole set of validation strategies in the practice of DBT. It promotes radical acceptance of reality, reduces the suffering that results from denying reality, and helps the therapist (or anyone else!) to maintain his or her balance and freshness.
So if you find yourself engaged in a frustrating effort to change reality, if you experience yourself as preoccupied with your attachments to things as they ought to be, and your patience and resilience are wearing thin, you might shift over to this entirely other frame of reference: acceptance. You can then wake up to the realities of the present moment, letting go of attachments to the past or future, recognize that each moment is unique and fleeting, that things are changing whether you see it or not, that everything is deeply interdependent on everything else, that we are all in it together and that we influence those around us all the time, and that in fact, whether you like it or not, things are exactly as they should be, given everything that came before. And hopefully, in that rich package of acceptance-based principles, you will find yourself refreshed, more resilient, more alive, more compassionate, and ultimately more effective.

Yesterday I was getting dressed in the locker room at the YMCA after swimming. I overheard a conversation taking place between two guys who obviously knew each other. One was upset with his son-in-law.

He’s been complaining, on and on and on, about the fact that the school next to their house has put up a new playground right next to them, and of course there’s a lot of noise, you know, kids playing and yelling. But he doesn’t do anything about it. He’s just pissed off about the school doing that. He just complains. So I say, ‘what do you expect, it’s a school? When you moved next to a school, didn’t you think this might happen?’

The other guy echoed the first guy’s attitude.

Yeah, that’s what schools do. They have children, and lots of noise. Why doesn’t your son-in-law talk to the school, see if anything can be done? Maybe they can put a wall up or some hedges or bushes or something?

Then the first guy, with exasperation, continued:

Yeah, I’ve told him things like that. But it seems like he’s more interested in complaining than in doing anything about it. So I just told him, ‘suck it up,’ ‘accept it,’ ‘let it go,’ ‘live with it.’ ‘It is as it is.’ Sometimes you can’t do anything about it.

I just sat there listening to this wonderful and rather typical episode of “locker room therapy.” One guy shares a problem of daily life with another guy, who typically agrees and validates it. The first guy gets to vent, receives a hearing, and maybe they do a little problem solving together. The wisdom of locker room conversations. They usually don’t go very deep (though sometimes they really do!), but they represent one way to get some help with emotion regulation in daily life. And they are guided by the same principles that guide the DBT therapist. It goes on all the time; in locker rooms, barber shops, at the dump where you take your trash, at a diner in the morning, at a bar at night. A lot of men get help this way.

In this conversation, the father-in-law laid out the problem faced by the angry, complaining son-in-law. The other guy immediately went after solutions to the problem, suggesting that the son-in-law could push the school for a solution, perhaps put up a barrier to block the sound. It wasn’t a bad direction to consider, but as it goes with locker room therapy, it was dropped in the next statement. The father-in-law quickly pivoted toward the Acceptance Paradigm, going down the road of “suck it up,’ ‘let it go,’ and ‘live with it.’ Of course that can be incredibly helpful, not easy to do, worthy of consideration, but naturally it too was dropped in the next comment. They weren’t really trying to come up with solutions for the son-in-law. The more immediate function of the conversation was to connect interpersonally within the locker room space, and for the one guy to express his frustration and receive some validation from the other guy. Time limits these therapeutic conversations as both guys needed to get to work. But had they taken the third direction laid out within DBT, the Dialectical Paradigm, they might have noted that 1) the son-in-law’s frustration and anger were understandable, that 2) the school’s construction of a playground was understandable, that 3) there was an understandable collision between the two, and 4) perhaps a creative synthesis could be found that includes both agendas, includes acceptance and change, and that involves ongoing movement toward a resolution.

What if the two guys wanted to seriously come up with a solution for the son-in-law, using Change, Acceptance, and/or Dialectics; i.e., whatever it would take? That’s where it comes in handy to know the five principles, or guidelines, of each. Today I will lay out the five principles of the Change Paradigm. In my next blog I’ll do the same with the the Acceptance Paradigm, and following that, the Dialectical Paradigm. In future blogs after these, we will consider one dead end situation of life after another, bringing with us the three paradigms and fifteen principles.

Change Principles (derived from Cognitive-Behavioral Therapy)

1. Direction
2. Force
3. Perseverance
4. Intelligence
5. Technique

Direction

Sometimes we get lucky, and a problem is solved for us, almost without effort. But most stubborn problems need to become the focus of our deliberate attention. We decide to change things. To do so, it helps to start out by stating the problem, and envisioning a positive outcome. Maybe the problem is intolerable conflict in the family; the positive outcome would be a family atmosphere that is safe and trusting, with greater harmony, where each person can thrive. We start at point “A” and we try to envision our destination, point “B.” We “lock in” on the destination, the way a guided missile locks on to the target.

We spell out the obstacles on the way to the destination. Those are the problems to be solved. Each one requires attention and focus in its own right. In short, there are usually multiple objectives, or targets, on the way to the ultimate destination, and we take them on, one at a time, in some sensible order of priority. We can’t just convert our conflict-ridden family to harmony, we have to tackle one piece at a time, perhaps starting with creating more harmony and trust between the two parents (if there are two), or with the oldest child, and then move on to building some agreement between everyone. Much as we “lock on” to the ultimate destination, we need to “lock on” to each objective as we go, until we solve it. Some problems with problem solving can be traced to the lack of a specified destination to aim for, a vague definition of the objectives along the way, or the failure to devote 100% focus to each objective.

The nature of the destination, and the objectives, matters. These aims should be compelling, should be defined with as much specificity as possible. “We want a happier family” is nice, but breaking it down to specified objectives is a better way to solve it. “I want my husband to respect me” is a good place to start. To specify just what it means, behaviorally, for him to respect his wife, is more productive in solving the problem. And we want the destination and the objectives to be collaborative, among those involved, including any individual who is trying to help. It is most powerful if everyone involved “owns” the efforts. And finally, the destination and the objectives need to be realistic. Maybe I want to be able to jump higher. If my maximal effort to date has been to clear four feet, and I set my goal to be seven feet, all the problem solving in the world is likely to fall short. On the other hand, we want to reach for the stars (those stars that might conceivably be within reach).

Force

Having determined a direction, we cannot bring about change in a stubborn situation without requisite force. The failure to solve a problem often results from a failure to generate sufficient initial force toward solving it. We typically need 100% devotion and determination to get to the destination, and so solve each obstacle along the way. Even 90% might be insufficient. How to generate that force varies from person to person and from situation to situation. Within the practice of DBT, when trying to generate sufficient force, or commitment, from the client, we turn to several factors that are relevant to any problem solving. First, the person has to see that the specified change is in his/her best interest, or even necessary to one’s well being. Second, making a public declaration of one’s intent to change, made to a person or people who matter to the individual, can help. Third, being attached to someone who cares about the change can matter, which may require strengthening that attachment. Fourth, understanding the “rules’ of life—why this particular change will lead to more desirable outcomes and the failure to change will lead to negative outcomes—can help to generate force.
Within DBT there are several formal “commitment strategies” used by the therapist to strengthen the client’s commitment. These can be adapted to help any of us strengthen our commitments. We can weigh the pros and cons of making a change. We can recognize each step in the right direction, even mini-steps, and find ways to reinforce ourselves for those steps (e.g., stars on a calendar). We can try to make a huge leap, going beyond what anyone thinks we can do, or we can decide to take baby steps, succeeding at each one and getting some momentum. We can keep reminding ourselves of our original commitment to a destination or objective, or we can remember other things in our lives that have required a lot or force and that we have successfully accomplished. And finally, we can challenge ourselves by playing the devil’s advocate: e.g., “c’mon, Charlie, you know you can’t do that, don’t even try,” which if done with the right balance might increase motivation.
Obviously, the point is that, no matter how you do it, you generate force, devotion, determination, passion, commitment. You go for 100%, not 90%. You decide to “do it” rather than settling for “I’ll give it a try.’” Failing to attend deliberately to the magnitude of force or commitment can be just as damning to the effort to solve stubborn problems as it is to have a poorly defined direction.

Perseverance

Establishing one’s direction, and generating sufficient force at the outset, has to be followed, in most cases, by momentum, endurance, and often “blood, sweat, and tears” shed over time. Without attending to this, we may have a great start which then dissolves as the battle continues. We get distracted, or frustrated, impatient or demoralized. Perseverance can’t be taken for granted; we have to build it, and often to resurrect it. We need to build in whatever structure and support is needed to enhance perseverance. We may benefit from some kind of system of ongoing accountability where we keep track of our progress, review it, and make adjustments. Having a person who plays the role of helping us stay on target, an “accountability partner,” can help. We should assume from the start that we will drift, we will fade from our initial efforts if they don’t produce quick success, and have a plan to address it. Within DBT’s treatment program, this is accomplished by: 1) having regularly scheduled weekly meeting with a therapist who serves as an “accountability partner,” 2) filling out a “diary card” every night on which we record our target-related behaviors of that day, and 3) sharing that diary card with the therapist every week to begin the session. In our lives, we need equivalent supports and mechanisms to keep us on track and maintain our momentum. We might need to keep a diary, to keep track of our efforts on a calendar, and to establish an “accountability partner” of some kind. Like a marathon runner or someone trying to keep up an exercise regimen, we need periodic recognition, reinforcement, and cheerleading from someone outside ourselves. We know the term “self starter.” We need as much focus on being a “self-continuer.”

Intelligence

Direction, force, and perseverance are necessary but not sufficient to solve stubborn problems. Brute determination and force are typically not enough. Obstacles arise every time we try to change a stubborn behavioral pattern of our own, of someone else, of a system. We can count on it. Actions elicit opposite reactions. Things get complicated. We have to proceed strategically, with intelligence. Specifically, this means we need a system to assess the obstacles, a way to convert the assessment into a formulation, and have the kind of formulation that leads to interventions. Within the practice of DBT, we repeatedly engage the patient in a process of behavioral chain analysis as an assessment tool, from which we develop a behavioral case conceptualization, and from this we derive a treatment plan.

There isn’t one formula for this, but we do need some way to step back, to consider the obstacles, to evaluate our failures, and to come up with intelligent ways to proceed. It will most likely be a trial-and-error process, in which we try this, try that, modify this or that, and eventually figure out what works. If we don’t have a “road map,” where we can map out where we are going, what gets in the way, and where we can see the other ways to get where we want to go, we are stuck. Without it, we are shooting in the dark, relying on sheer force, luck, and prayer. We might get lucky, but usually not. The parent concerned about her drug-using teenager will have a destination, may have objectives along the way, is driven with maximal force and perseverance by the attachment and the pain, but after multiple appeals, demands, inspirational talks, and limit-setting doesn’t work, the parent needs a road map of possibilities. He or she has to bring together knowledge of that child, an informed understanding of the process of addiction, and perhaps an understanding of the family system and of the child’s peer culture. So often, the failure to achieve one’s destination can be traced to the paralyzing experience of running out of ideas, running out of a bigger way to think about the problem, and thereby running out of alternative pathways.

Technique

The individual that engages with intelligence arrives at hypotheses, solutions, and interventions to implement the solutions. But this then requires the fifth change principle: Technique. We have to have the know-how, have the skills within our repertoire to carry out the indicated plans. In treatment, this means that the therapist has to master the treatment strategies and intimately understand the skills. In “real life” it is the same: we need to have the capabilities to carry out what is needed, and the more we understand what is required and how to do them, the better. There are strategies and skills associated with problem solving—with changing interpersonal situations and changing our emotional responses—and we might need them. We might need the skills associated with acceptance—how to “let go,” to be in the present moment, and to embrace what is rather than always pushing for what could be. Some of us self-sufficient types might need to learn to ask for help rather than to go it alone. I am reminded of a very capable woman whose beloved son decided to transition to being female. After the initial shock and pain, she began to study, and to attend courses, about the transgender process and community, and she took on the task of learning to relate to her daughter in ways that would facilitate their ongoing relationship. Perfectly defined direction, maximally engaged force, extraordinary perseverance, and applied intelligence, will fall short in the face of a stubborn predicament if the needed technique isn’t brought to bear. We usually need all five principles in action.

In the next blog we will take up the Acceptance Paradigm, which is extraordinarily helpful in augmenting and balancing the Change Paradigm, especially when problem-solving alone is insufficient to solve the problem.

Marsha Linehan developed DBT to help suicidal individuals get out of emotional hell and to help them build lives worth living. As it turns out, the therapeutic action of the treatment seems to depend on helping the patient gain the capacity to regulate emotions more effectively, relying heavily on learning and applying skills. But think about it. We all suffer, at least at times, from emotional dysregulation. We all encounter rough patches, stress-induced dysregulation. When I lost my best friend to her eleven-year battle with cancer, I suffered and grieved. I needed skills. The parents whose teenage child, or adult child, struggles with substance abuse, suffers, as does the kid. They all need skills. The individual dealing with chronic pain and disability, or a dementing condition, needs skills, as does the person who is caring for him or her. Life deals us some painful cards, some agonizing dilemmas, again and again. Companies encounter periods of decline, or chaos, or conflict, in which nearly every employee suffers. Leaders of companies and other organizations are challenged again and again to adjust to stressful environmental conditions or difficulties with employees. The point is obvious: everyone gets dysregulated from time to time, every organization goes through its own versions of hell, and everyone needs skills. Of course we have a lot of the skills already, and you can find them in all kinds of guides and manuals for living. But I haven’t found a better set of principles, each of which brings very specific and concrete “tools,” than what exists within DBT. And it is reassuring that these arise as part of an evidence-based treatment program designed to get people out of emotional and behavioral hell.

This is what I want to explore in this blog. In today’s blog post and in the next two, I will lay out the three paradigms and the fifteen principles of DBT, as these are the basic building blocks from which I will draw in all future entries, which will take the form of a series “case studies.” Once we begin to look at examples of getting ourselves out of hell—loss, injury, illness, unrelenting conflict, relationship stalemates, “family hell,” organizational dysfunction, etc.—we will see how DBT’s paradigms and principles give rise to specific tools–strategies and skills—that give us so many more options than what we thought. In addition to exploring this principle- and skill-based way of coping with life’s hells, I think there is another application. The individual who is not in hell but is reaching for the stars, trying to take his or her “game,” whatever it may be, to the highest level, I believe that the same paradigms, the same principles, and the same skills, apply. I hope to look at the athlete or performer looking to maximize his or her potential, the student or worker trying to maximize his or her performance, and the family looking to establish the most trusting and nurturant atmosphere for all family members. DBT provides a program for effective and compassionate living. But I get way ahead of where I am; let me tell you about the paradigms today, and move on to the principles in the next two entries.
I will be as clear as I can be in laying out the paradigms and principles, but if you want to read about them in more detail and with case examples, as applied to the practice of psychotherapy, you can check out my book, DBT Principles in Action: Acceptance, Change, and Dialectics (Guilford Press, 2016). When we search to get out of hell or to reach the sky, we can be overwhelmed with the number of suggestions, the number of solutions, everywhere we turn. If you are raising an infant who is having trouble of some kind, you will find no lack of advice from experts, books, magazines, friends, family members, and sometimes even strangers on the street. Even within the DBT treatment manuals, the therapist has access to more than 85 strategies and more than 100 skills, as well as several protocols. How to proceed? What to do? Who wants to be entertaining almost 200 options at a moment of distress and uncertainty. But here is the good news: from another perspective, the individual drawing from DBT makes a choice between three directions, and having made one of those choices other options open up. What are those choices? We either choose 1) to change the problem confronting us, 2) to accept the predicament we encounter and the feelings that go with it, or 3) by locating the opposing positions at the center of our dilemma, find the wisdom on both sides, and move toward a synthesis of those two “wisdoms,” maintaining movement instead of grinding to a depressing halt.

I had a friend who was very important to me even though we did not see each other frequently. Circumstances arose in which one of my children needed a certain kind of help with which this friend could assist. I contacted him, asked him if he would help, and he graciously and willingly did so. I was grateful. Two months later a similar need arose, regarding the same child, and I asked him again for his help. He helped again. I thanked him again. But after that, he never returned any emails or calls from me, most of which were simply friendly gestures on my part. Long story short: an important bond between us seems to have snapped, but no matter what I did I couldn’t get him to respond. I became quite upset about it, with urgent feelings about getting it fixed as soon as I could. I felt his absence and his non-response as a big loss. And on top of that, I felt that I had asked too much of him, that it was not reciprocal in that he had asked for nothing from me. I felt guilty. Looking back on it, I realize that my distress may have been out of proportion with an objective assessment of the level of trouble from which it rose. But, nevertheless, it was awful for me, and it preoccupied me.

When I thought about what to do, I asked which of the three directions to take. 1) Should I push for a solution, pursuing him yet again, trying to get more creative or even a bit intrusive? Maybe I should reach out to mutual friends, or his family members. 2) Should I accept the predicament, at least for the time being, accept his non-response, accept my level of distress and preoccupation, while suspending any problem solving activities? As the Beatles said, maybe I should just “let it be.” 3) Or should I take a thoughtful look at the situation, trying to locate the nature of the opposition at the center of it, find the opposing sides, and find the wisdom on both sides before moving forward? I found it incredibly helpful to lay out my initial choices in this way. I realized that I didn’t really have to choose only one direction, but still it clarified matters for me. Sometimes when you find yourself in some version of hell small or large, it is so helpful just to have a way to stepping back and breaking down your choices. Intuitively, I concluded that I should leave him alone for the time being, accept his non-response without knowing for sure what it meant. If I could simply step back into myself, acknowledging the impasse, accepting that I could remain in the dark, that I could wait, that things could change and probably would, and let it settle, I would arrive at a “wiser” place in myself. There was nothing that I had to do.

From this path of “acceptance,” I moved easily into considering what might have gone wrong between us, what could be the opposition between us. I then remembered that this friend had fairly recently felt neglected by me when I came to the town where he lived to visit someone else. He heard about my visit and I heard through someone else that he was feeling hurt. I figured that he might now resent that episode, after which I twice asked him for help. I was able to imagine that his non-response may have been a way to protect himself against another slight or a feeling of being exploited. It may also have served as a silent way to communicate to me that he felt unhappy with me. As for my side, perhaps I had inadvertently exploited our friendship, and I knew that I wanted contact with him to express my gratitude and to reassure myself that things were all right between us. His response, or non-response, probably made complete sense, my inadvertent “exploitation” of him was understandable, my desire to re-connect made sense, and we were momentarily at odds. Thinking of it that way led me to a possible synthesis: to simply send him a thank you gift for the help he gave to my son, delivered without warning and without any expectation of hearing back from him in the near future. It “felt right” as a solution. I sent him a box of fruits, cheeses, and snacks with a thank you note. About a month later he wrote me an email thanking me for the gift and wondering if I’d like to get together.

These three directions are associated with the three paradigms, the three philosophies, providing the bases of DBT as a treatment. They are pivotal in translating this evidence-based treatment approach, developed to help a certain suffering patient population, to a guide for all of us in coping with our own hells and maximizing our own potentials. The first is the Change Paradigm, based on Cognitive-Behavioral Therapy approaches, and represented in DBT in problem-solving strategies. The second is the Acceptance Paradigm, based in Mindfulness principles and practices, and represented in DBT in the form of mindfulness practices and validation strategies. The third is the Dialectical Paradigm, based in Dialectical Philosophy and represented in DBT in the form of dialectical strategies. In the next blog entry I will spell out these three paradigms, and the five principles of each, more clearly.

For years my wife contributed money to a nearby animal shelter. In the annual drawing, her name was chosen from those of other contributors, amounting to her first ever win in a contest like that. And the prize was immense: two nights for two people at the Plaza Hotel in New York City, two tickets to her choice of a Broadway play, and two dinners, with a bottle of champagne, on one of the ferries that goes around the island of Manhattan.

A home run! And she chose to take me as the other person, Thank God!

When we got to the Plaza, and while I was checking in and she was parking the car, I was fourth in line and had some time to observe. A well-dressed man swaggering in with an air of great importance bypassed the entire line, went to the front, and demanded to see the supervisor or manager. The hotel employee quickly summoned the manager, who arrived in seconds, and the very important man insisted on checking in right away. I could feel the resentment of the employee in spite of her tact, as she had to interrupt her work with other customers to submit to this man’s request.

This came during a time that I was teaching the DBT module on Interpersonal Skills in a group at the hospital, and I watched the scene through that lens. I could not dispute the fact that the highly important man was effective at achieving his primary objective, to get his room as fast as possible, even if he was personally offensive. I stood there and considered what kind of approach I would use to achieve an objective when I got to the front of the line. Guessing that guests of the Plaza coming from animal shelter raffles would not be among the higher priorities, I decided to ask for an elite, upscale room. I reviewed the “DEAR MAN” skills for achieving my objective, and in particular considered how I might reinforce her (the “R” in “DEAR MAN”).

I scoped out the woman who would be checking us in. She was a lovely young person, seeming very sweet, working very hard to be officious and proper for these well-heeled patrons. My intuition told me that she lived modestly, that she was not elitist, and that she was likely to be the kind of individual who would be kind to strangers and animals. I decided to appeal to the non-elite person within her, using a compliment and a story to forge a connection. When I arrived at the front, I began by complimenting her for handling such a variety of customers including one who was rather demanding. She smiled and seemed to accept the compliment.

I then said, “I am checking in for me and my wife. She won two nights at the Plaza when her name was picked out of a hat among those who had donated money to our animal shelter. She’s never won anything before, and we are so excited to get to come here. We have never stayed in a fancy place like this before. She’s off parking the car, looking for a reasonably priced parking lot.” (I admit that the latter statement was a manipulative lie; there is no such thing near the Plaza.) The woman listened intently. I continued. “So I want to ask you, though I realize it’s not very likely, if you can offer us one of the best rooms in the house, short of the penthouse. I know it’s probably impossible, even if you wanted to, so I am just asking if you can do whatever you can. Anything is fine.” She leaned toward me, lowered her voice, looked me in the eye, and spoke as if she were sharing a secret. She winked at me and said, “let’s get your wife a fabulous room!”

I thanked her rather calmly, hiding my excitement. The thrill of victory! We would get a fabulous room, and my “DEAR MAN” skills had paid off! They work! What a great teaching story this would be! And beyond that, a further incentive for applying DBT skills broadly to my life.

This blog will be dedicated to the notion that DBT as a treatment model, with its principles, strategies, and skills, can be “exported” from the clinical environment to the non-clinical world, to the “dead ends” within our daily lives. Having just published a professional book detailing how therapists can use DBT’s principles to help suffering patients get out of hell, here I bring the same tools to anyone who can use them. Admittedly, the example in this blog, based in the elite context of the Plaza, hardly speaks to the process of getting out of hell. But, frankly, I have found these principles and skills to help not only in getting out of hell, but also in improving daily life and even getting to the mountain top. Stay tuned for personal stories and examples from non-clinical domains such as education, sports, business, institutional settings, and family life.

Charlie
July 8, 2016