Question 1

What key DBT skills would you recommend that clinicians who haven't had formal, foundational DBT training learn and use with patients and their families affected by cancer? Is it enough to just have knowledge of the skills? Thank you

Elizabeth Cohn Stuntz · Accepted Answer

We have adapted DBT skills for patients and their families affected by cancer.
 
Clinicians do not need formal, foundational DBT training to use these skills. Ronda Reitz, Ph.D. (a DBT clinician, trainer, and consultant) and I offer an abbreviated cancer-specific training, emphasizing three core DBT principles, validation, mindfulness and dialectics.

Validation is valuable as cancer patients can doubt themselves and question their coping. We help people understand that there's a large spectrum of natural coping styles, from very emotional to very restrained – not one right or wrong way to cope.   We present wise mind to help patients respect and honor their own natural responses to stress and uncertainty. Self-talk is taught to help people be kinder, less critical of their own understandable reactions. Interpersonal effectiveness skills help people communicate when they feel their emotions, thoughts and/or actions are misunderstood by their loved ones, colleagues and/or medical providers. People are shown how they can effectively ask others to respect their input and give it sufficient importance.

Dialectical thinking, the view that two things that seem to be opposite can both hold important truths, helps patients and their loved ones see that it's actually possible to think, feel, or act in more than just one way. People may come to recognize that life, their feelings and actions are more complex than simply one way OR the other. They find it helpful to understand that it's possible to BOTH feel:
- frightened AND have hope, 
- unhappy about cancer AND still happy about other parts of their life
- helpless about what's out of their control AND recognize that there are things that can be changed

People may also come to understand that they are coping the best way they know how right now AND that it's possible to learn ways to be even more effective.

Mindfulness skills can be helpful in both making effective decisions and regulating emotions. With mindfulness skills people are less likely to overlook valuable information necessary for effective decisions. When people focus on the present moment, they are less likely to spend time on unproductive thoughts about what happened in the past or worries about what might happen in the future. They may also be less likely to overlook the joy that exists right now.   Mindfulness has been shown to help cancer patients decrease anxiety and stress, minimize rumination and difficulties with sleep and fatigue, as well as increase focus and concentration. Physical health benefits include improved pain tolerance and immune functioning, with some studies reporting anti-inflammatory benefits.

Question 2

How would you introduce Wise Mind and dialectics to someone who has just received a cancer diagnosis, in a way that is directly relevant to their situation?

Elizabeth Cohn Stuntz · Accepted Answer

We introduce dialectics with the idea that balance is the key to effective coping.

Using the metaphor of the constant ebb and flow of a seesaw, we teach that we are all always balancing the constant, inevitable changes of life and our reactions to these changes. We illustrate the point by saying that when dark clouds cast a shadow on the sun, we may not be pleased. Perhaps our mood matches the darkness and we seem to forget the sun even exists. Yet, when the sun inevitably reappears, our hope may come up as well. We present the idea that while we don't always have control over changes in life that can throw us off balance, we can take some control by deciding how to respond. Effective coping is about recognizing what's happened (mindfully paying attention) and then choosing to balance reactions that are not in our interest.

We present wise mind as a balanced understanding that takes a fuller view of the whole situation. We refer to it as taking a helicopter view that includes and synthesizes both extremes of dialectic perspectives. Wise mind balances internal (emotions and quality of life concerns) with external considerations (facts and other outside input) to come to a sense of what's in one's best interest at this moment. We encourage people to keep in mind that no one actually stays in the balanced center of a seesaw all the time. None of us is in wise mind all the time, yet with practice our balance improves.

Question 3

Can you talk about your experiences of working with clients with cancer on radical acceptance? I'm curious about communicating this without being invalidating.

Elizabeth Cohn Stuntz · Accepted Answer

The myths that acceptance means passively giving in or agreeing to cancer can get in the way of using the term radical acceptance.  We validate the understandable wish for patients and their loved ones to turn away from upsetting realities and fight cancer.  We also highlight a distinction between fighting cancer, doing everything possible to promote health, and fighting by not accepting truths about their cancer and its impact. We stress the importance of facing problems so they can be effectively addressed.  People need to face the distressing facts about cancer, to fight for their health and change its impact on their lives. We use a version of Randy Pausch’s quote saying, “You can’t change the cards you’re dealt, but if you face what’s in your hand you can choose how to play them.”

DBT Skills for Coping with Cancer

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