COVID-19 Education Nonfiction

The Pandemic and DBT Skills.

If you look at my archives, you can tell when the burden of the pandemic (whether due to the pandemic itself or the consequences of it) became great: Weeks or months went by without a post. This doesn’t mean I stopped writing; I just stopped posting. Though it is true that some writing (i.e., ranting, rambling) is better kept private, my lack of posting was chiefly due to fatigue. One must think about something to write about something and, you know, I, along with everyone else, am tired and cognitively impaired.

While walking along the still waters of Lake Washington with a friend recently, we reflected on the endless opportunities to practice dialectical behavior therapy (DBT) skills throughout the pandemic. I had the good fortune to learn about and practice DBT for a full year of my psychiatry residency training; I also led the DBT skills training group. As such, I taught the skills to myself over and over again (as that, for me, is the only way I feel comfortable teaching these skills to other people). To the group I often said, “I use these skills all the time.” They may have thought I was telling a white lie, though I was not: I used them all the time and continue to use them now.

Mindfulness. In DBT, this refers to paying attention, without judgment, to what’s happening right now. (See “Right now, it’s like this.”) When we give our attention to what is happening right now, we can witness the events that are (or are not) happening, our reactions to those events, and other “things” we might be adding to the situation. (Our minds are miraculous thought-generating machines, just as our hearts are amazing pumpers of blood. That’s just what they do.) We cannot take next steps if we don’t know what’s happening right now. For example, if a friend is trying to give you directions, but you have no idea where you are, you and your friend will have a hard time finding each other.

The underlying dialectic in DBT is acceptance versus change. If you don’t accept that you don’t know where you are, you cannot change. If I insist that I’m in Los Angeles, even though I’m actually in Seattle, then I am in for a lot of suffering as I try to get to Diddy Riese Cookies by public transport. It is only when I accept that I’m in Seattle that I change and, instead, go to Hello Robin Cookies.

Yes, it’s hard to give our attention to the pandemic and the illness and deaths it has caused, American politics and the ensuing vitriol, and the suffering that both (and other events) have wrought. Acceptance doesn’t mean agreement. Without acceptance, we cannot take next steps.

Distress tolerance. The acceptance described above is a form of distress tolerance (and, in DBT parlance, is called “radical acceptance”). Distress is difficult to tolerate; who among us wants to feel distressed? Wouldn’t you rather feel serene or joyful? Sometimes we worry that the distress will overwhelm us, that the shame or anger will consume us and never go away. Distress tolerance involves mindfulness to attend to what is happening right now, accepting that right now, it’s like this, and then choosing how to cope with the current reality. (See Viktor Frankl’s comment about the space between stimulus and response.) We can’t evade distress. We can choose how we respond to it.

Last winter, one strategy I used to manage my distress was eating a lot of carbohydrates: Pizza, burgers, noodles, dumplings, and my beloved cookies. I understand why I chose that strategy (and it’s one I still fall into on occasion), but it’s not one I want to repeat this year (largely because it didn’t actually reduce my distress much). Oddly enough, the distress feels less acute and piercing this year, perhaps because it is impossible to maintain those physiological and psychological levels of stress for a prolonged period of time. It may also be that I have come to embrace that yes, we all can die at any moment and, thus, we must enjoy all the little things that are lovely while they are happening.

Interpersonal effectiveness. When we don’t feel at our best, our communication and interactions with other people can sour. Not even because we want to come across as aloof or jerky; it just takes energy and mindfulness to assert ourselves and maintain harmonious relationships. Often interpersonal effectiveness skills focus on asking for what you want, managing perceived (and sometimes real) conflict, and boundaries.

If I am alone when I learn of new Covid cases at work, it is not uncommon for me to groan and mumble words that may or may not be profane. Sharing such sentiments with colleagues, though, isn’t helpful and doesn’t increase my effectiveness. Crabbiness generally isn’t charming. Assertiveness scripts or nonviolent communication templates may seem unnatural, though, with practice and personal tailoring, help all of us get along when we’re all feeling tired and cranky.

Emotion regulation. Though internal and external voices may tell you otherwise, your emotions, regardless of what they are, are valid. You feel what you feel. There are, however, things we all can do to increase the likelihood that we will feel certain emotions. In 12-step groups, people often refer to “HALT”: Hungry, Angry, Lonely, and Tired. If we are already experiencing one of those four things, we are more likely to feel worse if another stressor comes our way. (Hence the value of eating and sleeping regularly, as well as building and sustaining community—whatever that may mean to you.) Naming emotions (with the help of mindfulness) is also a skill, as that helps us recognize that we are feeling an emotion, we are not actually the emotion. Emotions give us vital information, though sometimes we realize that there are no logical reasons that underlie how we feel. If I feel anxious because I believe I’m in the way, but I’m not actually in anyone’s way, then the task is to do the thing that will make me feel more anxious… so I eventually stop feeling anxiety due to thoughts about being in the way.

The duration of the pandemic and its consequences makes emotion regulation hard. We can try to reduce our vulnerabilities by eating, sleeping, and connecting with others as well as we can, though ongoing news of illness, death, conflict, and violence reduce our resilience. There are real problems in the systems we live in and under in the US. It is unfair and inaccurate to ask individuals to keep their chins up and “just be happy” when our current context is so abnormal. We, however, can still make choices in that space between stimulus and response.

I often quip (with decreasing levels of energy) that the pandemic is developing my character, though I’m ready to be done with personal growth. Right now, though, it is like this. We also know that everything changes. The pandemic will end (just not when we want it to), things will change (though perhaps not in the way that we anticipate), and many of us enjoy blessings right now that we take for granted (e.g., you are able to read these words! you have access to the internet! most, if not all, of you know where you will sleep tonight! you haven’t died from Covid!).

If you’d like to learn more about dialectical behavior therapy and the four skills above, this website is pretty good and covers the four core skills with plenty of examples.