This feature by Donald Nathanson, LCSW-R is Part 1 of 2 in a series about experiential learning in DBT Skills training. In this first part, Donald begins his story and connects it with knowledge and experience as well as the experience of describing.
It was around 2 a.m. on a Saturday, and I woke up covered in blood. I was on the floor of my bathroom in my apartment, and I was not certain how long I had been there. I determined it must have been quite some given how much of the deep crimson had already begun to dry in a pool on the tile floor and on my forehead. After a few more minutes, I stood up to look in the mirror and saw I had a deep laceration above my left eyebrow, creeping and slanting to the edge of the uppermost left part of my forehead. How ugly. That was my first, most visceral thought, and I immediately began to feel frightened. I had fainted plenty of times after waking at night before due to low blood pressure and sort of knew the drill. I had even had something similar happen to my elbow in the past. But not my face. The fear came due to my realization as soon as I first saw myself: This is probably going to scar, huh?
From that moment in the mirror, throughout the next two months, I was caught in a maelstrom of judgment hell. I did not know at the time, however, that it would be the experience I needed to become a more effective DBT practitioner and trainer.
Knowledge and Experience
For the initial years of my career as a DBT therapist and skills trainer, I have the opinion now that I was not an effective teacher. At the time I would most likely have disagreed with that assertion and most likely would have told my future self that I was really good. After all, I knew (to my mind) almost everything about each skill.
I had, of course, read Marsha Linehan’s Cognitive-Behavioral Treatment of Borderline Personality Disorder, taking scrupulous notes in the margins and highlighting almost every single sentence. For my first DBT job interview, I had made flash cards of every skill, every acronym, every action urge, in order to drill them into my brain. I read not only the full Wikipedia pages for Dialectic and Marsha M. Linehan, but also the one on Hegelianism. When I was on a consult team, I relished the chance to debate the finer points of the concept and philosophy of different skills. Could a Wise Mind exercise be used as a mindfulness practice? Are there four ways to solve a problem or five? I am not so sure, but back then I was certain. My own quest was for complete and comprehensive knowledge of every DBT skill and each psychological and philosophical concept that those entailed, and that was often how I taught the skills to clients.
There is certainly utility in having full knowledge of skills, including the acronyms, psychoeducational information, supporting research, and so on. To compliment the knowledge, however, we also need to be able to guide. Guide others in how to experience the skill in a tangible, experiential way. These are two pillars by which skills are best learned, and eventually become part of our behavioral repertoire: knowledge and experience. One can be extremely knowledgeable about the concepts and not too skillful, as I myself was. It is more difficult though to be experienced in the use of skills and still not skillful. Can you really understand radical acceptance without having radically accepted something?
I consider now that a previous fault of mine as a skills trainer was putting too much emphasis on knowledge over guided experience. As DBT practitioners, we have a tendency to get absorbed by the academic minutiae of a skill at the cost of the practical translation and application of skills use for both ourselves and our clients. For this blog post, I hope to describe some of my own account with experiential learning – in this case with the mindfulness “What” skill of Describe – and to give some suggestions on how we may best guide our clients to experience what we are so passionate about conveying.
The Experience of Describing
When I arrived at the ER in the dead morning hours of that Saturday, I was initially hesitant to get out of my car to walk in. I was embarrassed, and I did not want anyone to see me. Could I maybe just let this heal by itself? The blood still cascading from my face seemed to be a fact I could not ignore. Upon entry, I was immediately put to the front of the line and granted access to triage. They are all scared of me, I look grotesque. It did not help that the ER doctor who stitched me up (for a total of 12 sutures) exclaimed upon seeing me, “Whoa! That scar is going to be like Frankenstein!” It felt like an unseen, unknowable weight was always hanging over me. My emotion minded brain told me that I looked appallingly hideous, and I could not help but assume, judge, and assert that everyone else was thinking the same.
I was well into my career as a DBT therapist and had to go to work the next Monday. I decided that I could go in only if I took many precautions. Assuredly, I would avoid looking into another mirror unless absolutely necessary. At work, I could take a detour around the hallways to get to my office so as to avoid the window that was a bit more reflective. I would try to walk the halls at less trafficked times. At clinic staff meetings in the past it had been mentioned more than once that when people keep the doors of their offices open it lends to a happier workplace. Well, I thought, whoever said that didn’t have to work next to Frankenstein. I chose to keep the door closed.
Inevitably though, I would see myself, or I would run into someone. When this happened, I was pilloried by self-judgments, like mortar fire in my brain, one after the other. On some nights I would dare to look into the same bathroom mirror. One time in particular I remember gazing at the scar pulsating on my forehead, like a long, crimson, pestilent worm. I would stare, and feel myself get at the same time smaller and heavier, my face flushing with heat.
There was a problem though with my plan that was one part avoidance and one part judgement. I still had to see clients, and many of the clients that I did see were pre-adolescent children, as my specialty was doing DBT for children, after all. Surely as kids we are all excited in some way about the idea of monsters; as a child I had loved Halloween as much as anyone. But having my therapist be a monster? That was a bit much. My solution was simple: I would wear an adhesive bandage across the entirety of my forehead at all times. It continued this way for weeks. The kids were very curious what was underneath my bandage, and what was wrong, and would ask me when I was going to take it off. I would equivocate and change the subject, most likely to talking about how their skills use was going, or try to move on to do another mindfulness practice.
Eventually, I knew this would have to change. I was a therapist, after all, and one that prided himself on knowing a lot about skills at that. I knew this was not being skillful! As I was lying down to sleep one night, the throbbing of my scar acted as the corpse underneath the floorboards in Poe’s The Tell-Tale Heart, telling me “You’re not using your skills, are you?” “You sure seem to be judging a lot.” “What would you tell a client to do?” I decided that next Monday, I would go in sans bandage.
I went in early enough so that I would be close to the first one there. Best not to see anyone. It worked out anyway, as I had an early client that morning: a 6 year old boy whose mother was bringing him in for a session before school. As I sat in my office waiting for them to arrive, I felt terrible dread, imagining what my face must look like. How could I do this to the poor kid? After some minutes, they came to my office door. The wave of my fear and embarrassment was at its peak. I felt my heart pacing faster, and the heat again build up in my face. I looked at the boy, and then at his mother, almost apologetically.
“Oh! Your bandage is off! Your scar-” my client said.
“Yes, I know, it’s ugly,” I interjected.
“No, it’s not. It’s red.”
Almost immediately, the heat from my face began to subside. My heart began to slow. I felt a lightness that I had not felt since before I had fainted. “Yeah, you’re right!” I said, “It’s totally red!” It wasn’t a worm, it was a scar. It wasn’t horrific, monstrous, anything like that. My client could see what I could not: the facts. My excitement and relief in that moment was partly because I realized this, but even more so that the child helped me to realize that he just modeled a skill which I knew about and he knew about. For the first time since I had learned and taught the skill of Describe, I had experienced it in a profound way in my own life, and I immediately wanted to share this with the family so they could benefit as well. I finally knew what I was teaching, as I had the knowledge of the experience of it and its benefit. With the boy co-leading the exercise, we all took pictures of our faces with phones and took turns saying factual descriptions about them. Like many skills, it was easiest for the six year old.
Read here for part 2 of this piece, in which Donald shares how to guide toward experience.
Donald Nathanson, LCSW-R, maintains a private clinical practice in Westchester County, NY. He primarily provides Dialectical Behavior Therapy (DBT) and Cognitive Behavioral Therapy to children, adolescents, and young adults. Previously, Mr. Nathanson was clinical faculty at Weill Cornell Medicine and New York-Presbyterian Hospital, where he was the the co-director of the Adolescent DBT Program and clinical director for the Youth DBT Program. Read his full bio here.