Tag Archives: DBT

The Secondary Gains (and Losses) of Psychiatric Hospitalization

Seven years ago today, probably at roughly this time, I was being admitted to my first psychiatric hospitalization. I was in my second real appointment with my first therapist (third if you count the intake assessment), and told her that I was planning to drive several hours away the next day to purchase a gun at a gun show. Looking back on this, I don’t believe I’d have ever reached the gun show, as my driving anxiety is so bad it would probably override the most intense desire to die.

Am I sorry that I was hospitalized to prevent me from doing something that I probably would not have done anyway? That’s a very difficult question. A month prior I’d been taken to the ER by a sheriff’s deputy who was sent for a wellness check, and when I spoke with him a week later he was appalled that I was still waiting for an intake assessment. He thought I’d be on medication by then. In fact, the process required an intake assessment and at least three regular therapy appointments before a referral to a psychiatrist could even be made. Hospitalization definitely fast-tracked that process.

On the other hand, that hospitalization set a precedent. Last week my therapist and I were discussing the Dialectical Behavior Therapy (DBT) concept of secondary gains. It’s the idea that when a person behaves in a way that causes harm, there is some (possibly non-obvious) way in which that behavior benefits them. That could be someone using illegal drugs because they alleviate symptoms of untreated mental illness. That could be someone self-harming because the endorphins released by physical injury create feelings of pleasure. That could be someone acting out in class because it results in being removed from that situation, where perhaps they are being bullied or experiencing some sort of embarrassment.

While I was discharged from my final hospitalization one year, three months, and 11 days ago, the 15 or so hospitalizations in the preceding almost six years were as much an escape as anything else. Very little of the treatment that took place was beneficial. The assumption when someone is hospitalized for mental illness is that medication changes are obviously necessary, so they piled on more drugs, raised dosages, switched out meds that hadn’t even had a chance to take effect. The answer is rarely “this medication is causing problems so we’ll remove it”. Instead the answer is “we’ll give you another medication to counteract the problems this one is causing”.

I try very hard to view life experiences, pleasant or unpleasant, as a source of knowledge that I can then share with others. I try to find the humorous stories to make others laugh. However, I’d be lying if I said that I didn’t wish that first hospitalization never happened. Coming out of a hospitalization is difficult, even if it’s only for a day or two, and the more times I was hospitalized the harder I found it to not be hospitalized. Looking back, I can see many instances where I was making progress in therapy and regressed, with the secondary gain of going to a place where I could escape the demands of the outside world.

There’s no way of knowing how my treatment would have progressed if avoiding hospitalization had been the ultimate goal at that time. With my current therapist it is a significant goal, and I very much appreciate her for that. I know my life would be very different had I not followed the winding path that started with my first hospitalization. I’m not sorry about what my life is now. I do sincerely wish I’d been given a chance to reach a similar place without the experiences I had. I will admit to being selfish internally. Although I do help people whenever I can, I also wish I didn’t have those experiences to share in order to help them.

The What and the How of Mindfulness

There are six core skills in the Dialectical Behavior Therapy (DBT) Mindfulness module, separated into two groups of three. The “what” skills describe what mindfulness is and the “how” skills describe how to do it.

“What” Skills

Observe: Notice what is happening around you. Notice the environment and the people. Notice what you can experience with your five senses. Observing is not putting words on the experience, just being aware.

Describe: Now is when you put words on the experience. Tell yourself what you are observing.

Participate: Throw yourself completely into the moment. Don’t hold anything back.

The “what” skills build upon one another. You cannot describe without first observing. You cannot participate without first observing and describing.

It can be difficult to separate the three skills. My therapist gives the example of being in a room. You observe when you notice that the walls are painted. You describe when you tell yourself that the paint color is beige. You participate when you remember the paint color after leaving the room.

“How” Skills

One-Mindfully: Focus on only one task or thought. If your mind drifts, bring it back. If there is an interruption, such as a phone call, switch your attention fully to the call and then return to the original task. Do not multitask. Multitasking leads to errors, and actually takes longer than completing one task before starting the next.

Effectively: Do what works in the situation. Let go of stubbornness. I am reminded of a work situation where I needed someone’s help to complete a task. There were steps I could have taken to make progress while waiting, but I behaved ineffectively and stopped all work during my long wait for a response.

Non-Judgmentally: Let go of right and wrong. Do not label things as good or bad. If you must label, use phrasing such as healthy vs. unhealthy. If you find yourself judging, don’t judge yourself for judging. It is virtually impossible not to have some judgmental thoughts. This does not mean you have failed at being non-judgmental. Reinterpret the situation in a non-judgmental way.

DBT: A Primer

Dialectical Behavior Therapy (DBT) is a therapeutic program created by Dr. Marsha Linehan. The first edition of her skills training manual and client handouts was published in 1993, with a revised edition published in 2014. DBT is based on a blend of Cognitive Behavioral Therapy (CBT) and Buddhist principles. The program was originally designed to treat Borderline Personality Disorder (BPD), but has since been expanded for a number of mental health issues. As one of my former therapists said, “Everyone needs these skills. Some people just didn’t learn them from their parents.”

In addition to Dr. Linehan’s manuals, there are many other materials available about DBT, including workbooks, skills for children, and decks of skills cards. The one I have used most is from Moonshine Consulting. It has simplified versions of some skills, as well as a few new skills not discussed by Dr. Linehan.

DBT is made up of four modules: Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness. This is not the order they are presented in the material, but I placed them in this order because it seems like the most logical progression for building upon earlier skills. I will be elaborating on specific skills in future posts, so here I present a brief description of each module.


Mindfulness is the act of staying focused on one task in the present moment. Not multitasking, not living in the past or future. Mindfulness primarily consists of the three “what” skills and the three “how” skills.

Distress Tolerance

The purpose of Distress Tolerance is “to tolerate distress”, as I sarcastically say each time my therapist asks. Of course, I follow up with the serious answer. Distress Tolerance is a set of skills to be used to cope in difficult, painful, intense situations without making the situation worse. This module is not about fixing. It’s about damage control.

Emotion Regulation

Emotion Regulation picks up after distress has been tolerated. This module is for understanding the source and function of our emotions and learning not to let them control our actions.

Interpersonal Effectiveness

Interpersonal Effectiveness does what it says on the tin. It teaches us how to interact with others in ways that meet our needs. How to ask for help and set boundaries. How to do these things in ways that show respect for both ourselves and the other party.

That, in a tiny nutshell, is DBT. There are two main components to a DBT program: group and individual therapy. In group therapy, we learn the skills. In individual, we can have focused guidance on applying the skills and working through our trouble spots.

A feature of DBT that can bring some frustration and resistance is diary cards. Both group and individual diary cards ask the client to note which DBT skills are used throughout the week. An individual diary card also asks for information on emotions and impulses that were experienced and/or acted upon. Ideally the client would fill this in daily, but in my experience most (including me!) are going to wait until right before the appointment and frantically scribble it in to the best of their memory.