Embracing Reality: Mindfulness, Acceptance and Affect Regulation; Integrating Relational Psychoanalysis and Dialectical Behavior Therapy

ABSTRACT

In this essay, I introduce the reader to possibilities for integrating Dialectical Behavior Therapy (DBT) and Relational analytic treatment, when working with patients who present with frequent intense affect storms and chronic self-injury. I offer a brief summary of DBT and explore my integrative work with Barry, a man tormented by early trauma, unrelenting affect instability and a long history of self-injury. I describe the integration into our analytically oriented work of Buddhist ideas related to acceptance, and specific Mindfulness exercises designed to help him calm his mind and body and distract himself from self-injury. I also present a rationale and concrete procedures for the introduction into Relational work of Behavioral structures and techniques designed to help a patient alter behaviors outside of the consulting room. I explore conceptual and clinical overlaps of the two models, including the shared model of mind. I also consider basic differences between these two ways of working and the complementary roles played by these differences in an integrative treatment. Additionally, I explore the complexity of the therapist’s internal process when working integratively.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

¹ Dissociation, in a Relational context, refers to vertical splits, more or less permeable, between parts of the self, as well as to a rigid separation of affect and cognition.

² There are early and notable exceptions to this characterization: e.g., (Wachtel, 1977).

³ Behavior is understood in DBT to include observable behavior, thoughts and affects – essentially anything a person does or experiences internally is considered a behavior.

⁴ Crucial to using mindfulness with this group of patients is to begin with exercises that focus on external and sensory experiences and take a patient out of her own mind – a place often populated with horrific memories and disorganized, sometimes psychotic thinking. Over the course of a long treatment, the focus of mindfulness can gradually move inward, toward observing and tolerating internal experiences.

⁵ An important caveat for clinicians interested in integration: it is in my opinion essential to thoroughly learn and work independently with each treatment before working toward integration.

⁶ A task that can distract the mind away from thoughts and urges of self-harm, and can calm agitation, in part by providing non-harmful discomfort.

Additional information

Notes on contributors

Lisa S. Lyons

Lisa S. Lyons, Ph.D., psychologist and psychoanalyst, is faculty at the NYU Post-Doctoral program in psychoanalysis and psychotherapy, the Stephen Mitchell Relational Study Center, where she is co-director of the brief seminar series, and the National Institute for the Psychotherapies Four Year Psychoanalytic Program and Program in Integrative Psychotherapy. Dr. Lyons was also intensively trained in Dialectical Behavior Therapy by Dr. Marsha Linehan and was founder and for six years Director of the adult DBT program at Montefiore Medical Center. She has written and published on many topics, including the Integration of Relational Psychoanalysis and Dialectical Behavior Therapy, the Inter-Generational Transmission of Trauma, Dreams and Reverie, Mindfulness, and Political Repression. She has a private practice in New York City and Teaneck, New Jersey.