Medicine

Mindfulness and DBT

At the heart of Dialectical Behavior Therapy (DBT) is a concept called mindfulness. It is the classic dialectical concept, both simple and complex, easy and difficult. Many DBT practitioners bring Eastern philosophies and practices to the teaching and practice of mindfulness but I want to talk more about my understanding of it and how I apply it in my own life.

We go through life with various levels of awareness of the world around us. A neurosurgeon needs to be intensely focused on his brain surgery and little else. A child, playing in an open field, is aware of the sun, the sky, the breeze, the plants and flowers, playmates and pets. Very differing levels of awareness.

Many of us, mentally ill or not, spend a great deal of our time far more intensely focused than we need to be. In particular, for those of us who have a mental illness, that focus is often on negative emotions and undesirable behaviors, and we shut out the rest of the world around us.

Mindfulness is living, being, in the present. It’s easy to stop ruminating or anticipating for a few seconds and accept that which is now. Then, most of us go back to the thought processes and behaviors we were doing before we were “interrupted”.

That interruption is why DBT uses mindfulness. Being in the present moment rips us away from a past we cannot change no matter how much we ruminate. It takes us to the present where our emotions can be observed and named without being acted upon. It opens the world around us to our souls, where we can feel the warmth of sunlight or the smell of roses as part of our reality and not an intrusion.

I think most of us would agree that the guy who is so focused on his phone that he walks into the street and is hit by a car could use a whole lot of mindfulness. But, how many of us notice the trigger that results in our anger? It was there, I guarantee. Increasing our mindfulness means that we may be able to observe that trigger and not react with anger.

It is not a “time out” but a “time in”. By becoming more mindful, we became more accepting of reality, of ourselves, and of the existence around us. We become an actual observer of life, and able to make choices about our participation. It’s tough to take action if you don’t know what’s going on.

Mindfulness tells me that everything does not suck. Mindfulness tells me that there is more to life than reliving the past over and over. Mindfulness allows me to observe myself and my surroundings without making a judgement. It is what it is. I can observe and that allows me choices to participate.

Life is not depression and anxiety. It contains those emotions but it is not filled with them. I have a choice how I react to those emotions and that is one big step in healing from my mental illness. And I want to heal.

Finding the Lethargy Spot


One of the most persistent symptoms in my mental illness is the need to sleep for most of the day. The medical community and the mental health community have differing terms for this symptom. My therapist would say I am suffering from lethargy. My physician might call it obtundation. Whatever you may call it, sleeping all the time prevents me from getting a lot of tasks done, getting necessary exercise, and contributes to the continuation of my illness. I have slept about 14 hours today.

Lethargy is found in history, both in literature and in reports from the era. More than one person is reported to have “taken to their bed” and stayed there for years or decades. In The Natural History of Pliny, Volume 5, in the first century AD, notes the condition. A History of Epidemics in Britain notes lethargy having caused fatalities in the 1360s.

Severe fatigue can be a symptom in many mental illnesses. Among them are:

  • Major (or Clinical) Depression
  • Bipolar disorder
  • Generalized anxiety disorder

I readily admit that I use fatigue as an excuse at times to escape the stresses of my life. I have for decades.

There are three types of fatigue or lethargy that I experience that appear to be less driven by a conscious decision.

In a very stressful life experience, it is not unusual for me to become overwhelmed by lethargy. It arrives like a tidal wave.

If I am unusually physically active, or accomplish a greater number of tasks than I usually do in a day, it is not unusual for me to be extremely fatigued the following day (or even days). This is often accompanied by muscle aches and/or joint pain.

I also have, rarely, what I call “I’m going to fall down” moments. Fatigue hits rapidly and so strongly that I have to go directly to bed or risk collapsing.

Now for the “rule outs”. Medical conditions and substance abuse can also cause similar fatigue symptoms. I do not drink or take any non-prescribed medications. My thyroid and other blood tests are normal.

My prescribed medications may contribute to my lethargy. Many of them have fatigue or drowsiness as a side effect. Other than serving to trigger my anxiety when I read the side effects, I cannot tell if they are causing a portion of my symptoms.

Dialectical Behavior Therapy encourages the use of a skill called “opposite action” to fight lethargy. The Mindfulness Muse describes the symptom thus:

The experience of lethargy is often accompanied by a lack of mental, physical, and emotional energy. There may be urges to avoid doing much of anything. Lethargy may be accompanied by the sense that just about anything would take a colossal amount of effort. There is often a strong desire to sit and do nothing at all.

As the Muse notes, lethargy produces lethargy. There is no progress or movement.

The opposite action for lethargy is to throw yourself into activity. It does not have to be a major task. A list of several, small but doable, activities can be accomplished and produce an emotional reaction opposite to the lethargy. This is often described as a “just do it” or “push through” moment, because you will have to push yourself to achieve the goal of an opposite emotional experience.

The title of this piece is a play on words. I do want to tell you that life is not all lethargy, that it is a limited experience, and can be overcome. The use of the DBT skill “opposite action”, even once, can bring you a sense of accomplishment that negates some of the lethargy that you are feeling. Lethargy leaves the control of your life to chance while opposite action places control of your life in your own hands.

Take an Emotional Inventory

One of the most interesting techniques that DBT teaches is that of an emotional inventory. As #ActuallyAutistic, I have never processed emotions well, and have had little experience in recognizing those I am experiencing. It I cannot name it, I, correspondingly, have difficulty in enjoying it or coping with it.

Lately I have been trying to do an emotional inventory every night before sleep. The major issue is that I still lack names for many of the nuanced emotions. I have to work on that.

Doing an inventory allows me to look back and find the moments during the day when I experienced enjoyable emotions. When you experience major depression, it is easy to overlook the very real fact that some of your moments each day contain satisfaction, happiness, joy, love, peace. By picking them out and accepting that I experienced them, the negatives become less compelling.

As Aspergers, I also recognize that other cultures, other languages, will be different. That fills me with curiosity, and a certain wonder. Are there more ways to describe the various types of love than English provides? It’s like painting a picture with a hundred different shades of paint rather than just ten.

The wheel at the beginning of this post illustrates one perception of the relationships between various emotions. In Urdu or Han, it would likely be different. Even in English, we might disagree on where an emotion is placed or feel that one has been left out.

Another thing that this wheel illustrates is the connection between basic emotions and those with a nuance. Anger and frustration, for example. For me, anger is often the mask that frustration wears.

So, what I am suggesting is that you take some time each day to be mindful of the emotions that you have experienced that day. Take time to name them and accept that you experienced them. The past is gone and cannot be changed. Don’t ruminate about the incidents involved, just point at the emotion and name it.

And, most of all, find those pleasant emotions that you felt and overlooked. Savor the day’s good.