The pros and cons skill is one of my favorites from DBT because of its practicality and versatility. When clients are struggling with a decision -- anything from whether to leave a job to end a relationship to drink alcohol -- I enthusiastically screen-share my virtual whiteboard and create a four-square grid for us to fill in. The benefit of this format is that it's comprehensive -- you see gaps and add details that you may not consider if simply freestyling out loud. It is also incredibly validating, because we see in black and white how complex many decisions are, how there are significant consequences in every direction rather than one clear, "right" answer. (No wonder we're struggling.) Despite the complexity, having things spelled out has a tendency to nudge us forward. We glimpse that ultimately, we're going to pick a square and live with the consequences, because even "not" choosing is a choice -- it's choosing inaction/"no"... which has consequences.
The example above is a relic from pre-pandemic in-office days that explores a client's habit of isolating when depressed ("TB" means target behavior in DBT-speak). As you would expect, enumerating the pros of not isolating can be motivating. Less intuitive is that listing out the cons of not isolating can be validating rather than shaming -- we see and appreciate how hard it can be to make that choice when in the thick of things. Identifying specific cons further allows us to brainstorm what can help reduce the feared consequences, such as emotion regulation and distress tolerance skills. We also note which elements are short-term (S here) and which are long-term (L) to get a better sense of how to weight the decision and make a plan to cope. Lastly, clients can screen-shot the finished pros and cons matrix for continued reflection outside of session.
Which dilemma in your life could use a fancy pros and cons?
DEARMAN from DBT is an outline for how to ask for something or say no to a request. The basic structure can be used for a variety of potentially emotionally-charged conversations, from eliciting an apology for a partner's empathic rupture to confronting a roommate’s messiness, proposing defining relationship status or saying no to a parental guilt-trip. The example here is for asking for more money at work. While working in inpatient treatment early in my career, I procured a meaningful raise using this very skill.
The DEAR part is what you’re saying:
D - describe. Start off on a neutral foot / avoid triggering your listener’s defensiveness with just the facts of the situation, with no more and no less detail than needed. “It’s been almost a year since my last performance review, and since that time, I’ve exceeded the goals I set and taken on a new challenge of developing the curriculum for and leading the ACT group.”
E - express. Venture into subjectivity and humanness now — what are your thoughts and feelings about the situation? “I love what I do here, and am proud of the clarity, precision, and compassion I bring to my work with clients.”
A - assert. Ask for what you want (or say no) unambiguously. “I’d like a 10% raise.”
R - reinforce. How is it either neutral or positive for your listener to give you what you want? Why should they feel good about your request? “That will bring my salary to a level that is commensurate with my performance and years of experience, which will give me the peace of mind I need to keep investing at a very high level here every day.”
The MAN part is how you’re saying it:
M - mindfully. While you can’t always wait for ideal circumstances, strongly consider the timing of your request, the format (face-to-face, text, etc.), your body language. Also stay mindful of the main thrust of your request, and “broken-record” if necessary to redirect from distractions (like when a partner “kitchen-sinks,” or throws in many unrelated concerns).
A - appear confident. Don’t have to be all guns blazing, but no apologizing for asking either. Deep breath, eyes up, simply and straightforwardly.
N - negotiate. When appropriate (i.e., as long as it’s not a serious safety or self-respect issue), consider in advance what compromises you may be willing to make. For example, less money but more paid vacation, or not ten days your parents’ for Christmas (dear god) but four.
Above all, be specific and concise. Good luck and reach out with questions! Long live Marsha Linehan, PhD (developer of DBT).
Dialectical Behavior Therapy is a mouthful. So we say DBT. But what does it mean?
Marsha Linehan, a genius badass academic/clinician based out of the University of Washington, pioneered DBT in the 1990s as a treatment for chronically suicidal people with borderline personality disorder. Since then, DBT has earned evidence-based status as treatment for a host of other concerns. Although the full DBT protocol is necessary for achieving results with severe mental illness, literally anyone in the world could benefit from learning a bit about the basic principles, which involve fundamental knowledge on regulating emotions, tolerating distress, strengthening relationships, and that often-alluded to, rarely understood concept: mindfulness.
For a tiny taste of DBT, voilà The Five Options for solving any problem:
1. Change it
2. Change how you feel about it
3. Accept it
4. Stay miserable
5. Make things worse
Let's apply this template to a problem we will define as "loneliness." As mammals, we reflexively prefer pleasure to pain, amirite, and want to reduce negative emotions as much as possible. So our preferred choice is usually #1, to change loneliness. So we might make plans with a friend, or if we're single, try a dating app, or if we're feeling lonely while in a relationship, address an empathic rupture that may have occurred.
Sometimes the change option isn't available, either in the moment, longer term, or indefinitely (such as when the problem is "mortality"). In that case, the next best option is #2, change how we feel about it. What are some ways to do this? Remember that loneliness is often a temporary, normative part of life! Your operating system is working as designed if you sometimes feel lonely. Loneliness doesn't make us less than, it makes us just like others... Remember also that past early childhood, there are very few make-or-break moments where we fundamentally rely on others to survive. We all need people AND this is not an emergency. Another option would be to recognize loneliness as a reminder to contribute to someone else in our lives -- for example, text that friend whose mom died a while back, or chat up the elderly neighbor who has been dying to regale someone about the aphids on his roses in exhaustive detail. Also, do all the basic biological stuff like remember to eat, balance sleep, take meds, moderate drinking, etc. to reduce the intensity of loneliness, especially for highly sensitive folks.
If you've tried #2 and the feeling isn't changing, your best bet is to practice acceptance. This doesn't mean passivity, this doesn't mean we won't still pull for change over time, it just means that in the moment, the pain is what it is. This allows us to humanely self-validate, to have "clean" pain that is dignified and manageable, vs. #4, suffering that feels shitty, dirty, and intolerable. Often what keeps us in #4 are beliefs like "I can't stand this," "It will always be this way," or "This isn't fair" that undermine our coping skills, as well as behaviors like social media compare-and-despair. We pull a #5 when we are using no skills, and that's when we see things like drinking a bottle of wine at home alone, eating an entire pizza (I see you. my gluten-sensitive compatriots), and texting the emotionally unavailable and sexually selfish ex we just dumped. That's two steps back.
I have had clients post the official DBT handout version of this on their fridge until reflecting on this hierarchy becomes second nature. What can I do to make things better right now? What am I doing that is making things worse? This skill draws on the central dialectic (synthesis of opposites) at the heart of DBT, the balance of acceptance and change. And of course it's good, clean fun to dream about (and not act on) how one could make things worse, too.
Rebecca Robinson, LMFT provides expert online, evidence-based therapy to deep-thinking/deep-feeling adults in California and Pennsylvania.