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?
A few weeks ago I had the pleasure of uniting with fellow overcontrolled types at the RO DBT conference in Chicago. There the developer of the treatment, Thomas Lynch, PhD, presented a new research-backed skill in progress, the Grief Protocol.
I also had the pleasure (j/k) of test-driving this skill vis-à-vis a recent loss I've suffered, so I can personally vouch for it as a powerful tool for processing and letting go of difficult emotions. (Although I will note that the first time I sat down to do it, my gut said “Nope, not ready to let go yet,” so I waited another couple of days to try again and that felt better.)
Drawing on the principles of CBT and exposure therapy, the five main parts are as follows:
1. Identify the area in your life that may require grieving (through prompts to help clarify this).
2. Acknowledge that a loss occurred. We use the word “loss” for two reasons: First, to place the event in the past tense, helping establish psychological distance from it. Second, to avoid getting stuck on blame, judgment, or determinations of fairness of the event, which can impede moving on.
3. Identify the emotions triggered by the loss and the beliefs or expectations it violates (again, with the aid of prompts—and your therapist).
4. Practice grieving. Begin by telling the story of the loss using the third person (e.g., John had landed what he thought was his dream job, only to realize… or Kate was in her eighth week of pregnancy when…). This too helps establish a sense of healing distance from the event, which results, through repetition, in reduced pain.
5. Lastly, read a grief script template aloud, which we are encouraged to edit to taste, as desired. Here it is in full:
For today’s practice, I need to grieve the loss of my expectations that [insert unmet expectation or belief here]. It is sad to not have this expectation met.
By feeling the sadness of my loss, I open myself up for the possibility of new learning and new meaning to emerge. What is my loss trying to teach me today?
My sadness reminds me that the world is not always as I expect it or want it to be. It allows me to let go of useless anger, shame, guilt, yearning, resentment, or rumination.
Feeling sad about my unmet expectation for [unmet expectation or belief] allows me to reclaim my life and live more fully in the present.
As I end the practice today, I recognize that although it is sad to not get what I want, I am able to move on. I am committed to practicing this grieving process again, whenever thoughts or memories about my loss arise in the future. I will allow myself to feel the sadness of my loss while remaining open to any new learning that may emerge—and then I will let it go, by turning my mind back to the present moment and using an emotion regulation skill as needed. I will repeat this process—again, and again—until the memory of the past injury no longer dominates my life or triggers a strong reaction.
This loss will not defeat me.
If you think you would benefit from such a practice, feel free to reach out, or discuss with your own therapist.
Wishing you healing, learning, and growth,
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).
Radically open dialectical behavior therapy, or RO DBT for short/reasonable, is an evidence-based treatment shown to reduce emotional loneliness. Many of my clients, as well as myself and many other therapists, tend toward an overcontrolled coping style, meaning we are often more inhibited than we want or than would be effective. RO DBT is a framework and skill set for opening up. The delicious irony is that it is also highly manualized and empirically validated, so fellow nerds, take heart: letting loose in the quite specific RO DBT sense will lead to better outcomes in relationships and all of life, not awkwardness, annoyingness, or anarchy.
I frequently use this graphic (whose source I regretfully cannot recall) to explain a core tenet of RO DBT: our “social signaling,” and how it can lead to either connection or isolation:
On the left, at the top, we have the strategy that many highly sensitive people, neurodivergent folks, people with traumatic or dysfunctional childhoods, members of racial, class, sexual or other minority groups, etc. employ: we mask. It often starts in middle school, at the onset of puberty, but can emerge whenever there is a real or perceived poorness of fit between us and the environment (e.g. agreeing that Mrs. Williams was "lame" for assigning too much boring reading when in fact I thought she was awesome and The Red Badge of Courage changed my life). Although masking can sometimes be effective in the short-term, relationships built on it often fail to deepen or become truly fulfilling, and/or they fall apart because people consciously or unconsciously smell bullshit. This leads to either loneliness in the phony relationship or loneliness for having been found out and rejected.
Part of what makes us vulnerable to masking is that when our modern minds evolved, tens of thousands of years ago, we lived in bands of a dozen or so individuals, and if those people thought you were defective, you were fucked; meaning, social ostricization from a tight band relying on each other for survival in an austere landscape meant death. It still kind of feels/is like that as a young child dependent on acceptance from a family of origin, or in middle school, but once we are adults, we have many many more choices and outlets for connection. So if you are still essentially scared that cool kids will shun you for admitting you raise carnivorous plants, speak Latin (regular, not pig), really like sex (as a woman), or even that you want to make a shit-ton of money and and such an admission is a poor fit for at least one social context in your life -- good news! There's someone out there who thinks that's dope! I promise. Risking being not liked is pretty much key to being liked. And boy howdy, it's great when you can drop the mask and feel loved for who you are. As Steven Hayes, developer of acceptance and commitment therapy, put it, "When we play false to feel accepted, we feel false even when we are accepted." And when we let our freak flags fly -- i.e., when we congruently socially signal -- we find our tribe.
Rebecca Robinson, LMFT provides expert online, evidence-based therapy to deep-thinking/deep-feeling adults in California and Pennsylvania.