How to use DBT skills to manage the pain of grief

There are some self-help strategies in DBT (dialectical behavior therapy) that I used to manage my grief. Now I want to be clear that while I used these skills, I didn’t know at the time that they were actual DBT skills but looking back, I can now identify how I used them in my grief process. I’m going to tell you what those are, and how I used them to help myself through the devastating loss of my son, Charles, to suicide. 

DBT was developed by Dr. Marsha M. Linehan, an American psychologist. This methodology can apply to situations beyond grief but at any point when you want to change how you feel.  It won’t “fix” the pain but it will prevent you from needlessly wallowing in your pain for extended periods of time. 

In short, it lessens your suffering. Are you with me so far? Because who wants to suffer more?

DBT includes four modules—Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. Instead of an exhaustive DBT lesson, we’re just going to focus on a few that you can use right away. There is an explanation of the skill and an example applied in grief so you can see how it might be used.  

When we grieve, we tend to live in the past (What if I had done this or that…?)

Or in the future (When will I move forward again?)

DBT asks us to focus on the present: to accept things as they are without judgment

DBT Skills

Mindfulness

This is a foundation for DBT. In grief, we tend to ruminate on the past—“What did I do wrong?” “Why did I decide that that surgery was good for my child?” “What if I hadn’t been driving on that highway at that time? Maybe my husband would still be alive.” Then we also hover over a future that has yet to happen, wondering how we rebuild our lives and our sense of self when what we have imagined it to be has exploded in our faces. It leaves us lost and feeling broken, not able to see ahead of us.

Mindfulness is about staying in the present. It’s about telling yourself to focus on that moment. It’s about acknowledging any “what ifs” and “coulda woulda shouldas” and then bringing your mind back to the present, and what’s happening right now.

Example: Next time you find yourself thinking “I can’t possibly survive this loss,” remind yourself: “Yeah, this hurts like mad. And I’m doing all I can right now to cope and survive.” Because it’s just going to take a while to accept the loss and learn to live without your loved one.

Another Example: “I could have saved him from suicide.” I’d take a deep breath and I say to myself, “I know it’s a preventable death which really hurts. And I have to recognize I can’t control the actions of another human being. I can only control my actions and reactions. We had a loving family. We went to the beach together, we baked cakes and had birthday parties and bonfires. I don’t need to put a magnifying glass on the 5% I did imperfectly but instead on the 95% of parenting I did do well. And this might take some time.” You might dwell in the “what ifs’ and “coulda woulda shouldas” for a while. It’s a process so be patient with yourself.

Emotion Regulation-Wave skill

Riding the wave is about allowing your emotions to be with you without acting ineffectively. In short, when you are emotionally overwrought we can make some really uninformed and detrimental decisions that we can regret later. The wave skill is about moving with your emotions instead of fighting them much like a surfer who rides the waves.  In times of distress, you can experience emotional tsunamis. Coping with powerful emotions in a harmful or ineffective way can make the situation worse. This skill is all about riding it out instead of overcompensating with harmful behavior.

Going with the flow. riding the wave involves observing and coping with the experience without trying to change it. The more frequent tendency is to escape and/or attempt to fix an uncomfortable state of being, so riding the wave, sitting with the discomfort may seem unnatural. But no emotion is permanent. They are always changing and the worst of it lasts some 60-90 seconds.

Although these emotions can be met with intense fear and can seem counterintuitive, accepting painful emotions can lessen your suffering. Do you want to prolong it? Or do you want to move through it and heal?

Example: You might think that drinking a bottle of wine might help you manage your pain of loss but instead it can bring on more problems, making your situation far worse. You might get in the car and drive because your judgment is poor enough in grief and even worse when you’ve had too much to drink, therefore putting others in danger. Even worse, you could become dependent or addicted.

Months after losing Charles, I had a conversation with a dad who told me it would never get better. It had been seven years since he’d lost his son. He then revealed he drank heavily every day since that death to deal with the pain. In other words, he numbed it, leaving him in that raw state of grief so many years later. At first, I thought I was doomed to never enjoy life again.

It was only after having lunch with my friend Roz that I recognized how she had moved forward through creating a foundation and giving back. Although she’d lost her son seven years prior, she had learned to live with the death and enjoy life again without forgetting or minimizing her son’s legacy. She didn’t rely on temporary in-the-moment, feel-good strategies like overeating or drinking too much. And she proceeded to tell me about her upcoming planned vacation.

The goal is to focus on healthy coping strategies and accepting and sitting with difficult emotions.

Distress Tolerance – Radical Acceptance

Radical acceptance is exactly what it says it is. It is a way to thoroughly, and without reservation, invest and engage in the process of embracing reality, however harsh. Those feelings of loss feel like they will kill you but they won’t.

Within the context of grieving, radical acceptance invites us to dive into the center of our mourning without judging ourselves or circling the wagons. Have you been trying to avoid your pain? What is one step you can take toward that pain, knowing that these are the building blocks to emotional healing?

The really intense moments of pain last 60-90 seconds and while it feels intolerable and like you won’t survive, no feeling is permanent. And you will survive because billions (if not trillions) of others before you have.  So if you allow your emotions to happen, you can sit with them until they dissipate, and then when the pain lifts, you can distract yourself with some other activity.

Pushing them away has the effect of stalling your process and leaving you in the rawness of pain for a lot longer than you need to be.

Example: Shortly after we had arrived home after the police officers had delivered the news they’d found our son dead, my husband and I collapsed on the floor. I didn’t think it was possible to live through pain this intense. While I was telling myself there was no way I could survive the pain, something in my head pinged and said, “You will survive. As bad as it is right now, and I know it’s brutal, it will never be as bad as getting the news. That part is over and it will never hurt that much again.” I also dreaded waking up the next day but forced myself back into the present because I needed to call my family and I would just repeat “You will survive. I don’t know how but I will.”

Emotional Regulation- Check the Facts

We assume a lot. So, it helps to go back and check the facts particularly if we are in an emotional or irrational state of mind. Right after the memorial service, I was sure none of my friends were calling me because I had lost a child and had been permanently branded as “no fun at all, forever, for the rest of my life.” In my head, I had cooked up all kinds of scenarios that they, my friends, were avoiding me until one day I challenged my ridiculous “oh woes me” illusions by thinking about the facts. And then I asked myself, “Do you really think they are not calling because they are avoiding you are don’t like you all of a sudden after 20 years?”

When I thought about it, I realized how ridiculous it was to think that. How would I feel if one of my friends lost a child to suicide? Could it be that they are not sure what I wanted?  Might they have been fearful of walking into my tragedy? Didn’t they have busy lives, family, and probably weren’t aware of my day-to-day agony or even know what to do? Were they even aware that I needed to hear from them and wanted to go out some? How could I help them understand what I wanted?

Smoke signals weren’t going to work. Not saying anything and brooding wasn’t going to work. Sitting around demonizing the world wasn’t going to do anything but make me bitter. So I decided to have a party—to have them all over. It was a signal that I wanted their company and didn’t want to isolate.

I provided the space and they all came– brought the food and wine since I was incapable of all that. We had fun sitting on my deck at night. Later I would share with one of them what I needed so they could share with the group. Sure, there are people who will never reach out. That’s their loss! But most want to do something, they are just not sure what to do because each of us wants something different and they cannot read minds. So we need to communicate that to at least one person in the friend group.

Emotional Regulation – Opposite Action

This helps when what you need to do isn’t what you want to do. Because sometimes grief gets in the way of the life we have to live or want to be living. So when is the worst time for you? For many, it’s first thing in the morning. (The nighttime isn’t great either.)

Opposite action won’t “fix” the pain but it will prevent you from needlessly wallowing in your pain for extended periods of time. In short, it lessens your suffering.

Example: In the days and months following the loss of my son Charles to suicide, facing the morning sun’s assault on my consciousness reminded me that child was dead. Sleep was a break from this reality and where I could live in dreams where he was alive and even hugging me. The mornings were brutal but I set my intention to get up and go running every morning which was the opposite action of what I wanted to do. I really wanted to crawl back in bed and hibernate. Thinking ahead to all those steps was overwhelming so I broke it down into small, doable steps.

Step one, I’d tell myself, “Just lift your head, turn around and put your feet on the floor. That’s all you have to do.” Next, I’d focus on, going to the bathroom and then brushing my teeth. I didn’t set some big, bodacious goals but rather small, doable micro-steps because my mind couldn’t grasp a whole set of steps but it could do one.

Low and behold I would find myself outside eventually and I would say, “I don’t have to run, but since I’m out here, I might as well try.” By the end of my run, despite crying for at least the first mile of a three-mile run, I did feel better by the end. So I didn’t deny my feelings or try to push them away. I felt the feelings and I just ran with them. The cold and the exercise helped me lessen the amount of time I spent suffering.

I used opposite action when I wanted to blow off going to suicide loss support group. Instead, I made myself go and never regretted it. I used it again when a friend asked me to go out to lunch. I did cry at the table when I arrived because it was my first holiday after the loss and the emotions overwhelmed me when I saw her. I freaked the waiter out with my tears but so what? The world did not explode or stop spinning because I balled for thirty seconds in a restaurant. My friend didn’t post a photo on social media but instead gave me a much-needed hug. And then we laughed at the fact that the waiter was totally freaked and that my grand entrance was met with a desperate search for Kleenex.

Not what I had envisioned but I was a grieving mother and I decided not to admonish myself for what is a perfectly natural response. I also appreciated my friend because asking me to go somewhere which was brave of her to do and I know she was pushing through her own fear to do it.

All emotions trigger some kind of action. And some emotions spur actions that might not be beneficial to you and your goals.  You can use the opposite action because you fear failure, rejection, suffer guilt or because you feel lethargic.

I remember Tammy Ozolins told me that as a young adult, she had to get on the phone and find help for her bipolar disorder in the midst of a depressive episode. It was the last thing she wanted to do but by doing so she saved herself. 

Our opposite actions can lead us to feel better and even discover successes we have not even imagined.

Distress Tolerance – TIPP Skills

TIPP=Temperature, Intense Exercise, Paced Breathing, Paired Muscle Relaxation. TIPP skills are survival skills and are used to bring yourself into a state of stability from a crisis mode. They won’t eradicate the source of the pain but offer strategies of healthy coping in a moment of extreme pain.

Temperature

When we are sad or upset, our bodies heat up. To counter that effect, you can hold an ice cube to your wrist, splash your face with cold water, or run/walk outside in the cold (that’s what I did). Changing your body temperature helps reset your brain both physically and emotionally. In fact, a strategy for those who are suicidal is to dunk your face in ice water for 30 seconds.

Intense Exercise

Exercise intensely enough to match your current emotion. You don’t need to be a world-record runner. Walk fast, sprint to the end of the street, jump rope, run the stairs or do whatever would be considered intense for you until you’ve worn yourself out. Investing that energy and rechanneling it into intense exercise increases your oxygen flow, helps decrease stress levels and what’s more, it’s impossible to stay dangerously upset when you’re exhausted. It gives you an outlet for extreme emotions.

Paced Breathing

Breathing, which Karla Helbert LPC covers really well in this post, Breathing strategies to quiet anxiety or manage grief, has a profound impact on reducing emotional pain. I won’t go into it in detail here because Karla has covered it so well in the linked article.

Paired Muscle Relaxation

I call this Rigid to Ragdoll. You tighten, tighten, tighten a muscle, then relax it, and allow it to rest. A more relaxed muscle requires less oxygen, so your breathing and heart rate slow. Try this technique by focusing on a group of muscles, such as the muscles in your back and arms. Tighten the muscles as much as you can for five seconds. Then let go. Rigid to Ragdoll.

Example: Specifically, I used running in the very cold weather to manage my pain. And this is covered in the example under opposite action. I used the breathing for all the skills described here to find stability and allow my “thinking brain” to re-attach.

Interpersonal Effectiveness – A Change Skill

This skill focuses on getting what you want while also nurturing relationships and maintaining your self-respect. We’ll focus on the most popular: DEAR MAN.

DEAR MAN is an exercise that helps people express their needs to others. It involves:

Describing the Situation

Expressing Feelings

Asserting Wishes

Reinforcing

(Staying) Mindful

Appearing Confident

So here is one way this might be applied in a grief situation where well-meaning relatives want to push you back into the light before you are ready.

Example:

Scenario: Your sister has told family members that you insert commentary about your deceased child every chance you get despite the fact it’s been six years since her death. This makes her uncomfortable which has infuriated you and made you feel hurt. What’s more, she’s expressed concern that you are still visiting your child’s grave which to her, indicates you are not “moving on” from the loss in a way she thinks you should.

Here’s how you can use DBT skills and “I feel” phrases to address this because it’s hurtful and you want to be able to tell your sister in a thoughtful and respectful way that preserves your relationship but allows you to be heard instead of frustrated and angry. You can also write this in a letter. It helps to be able to let it sit overnight so that you remove dagger phrases that might otherwise strain your relationship.

Describing the Situation – “Whenever I bring up my sweet Denise who died, you cut me off and change the subject. What’s more, you have expressed discomfort with the fact that I visit my child’s grave even though she died many years ago.”

Express Feelings – “This loss was extremely painful and it has evolved over time to where I can enjoy life but there are times I will feel sad and want to talk about my deceased child–to remember her and know you do, too. When you cut me off in conversation when I speak of her, it makes me feel like I should erase her from my family tree and forget her. As if you’d rather she was forgotten. And I don’t feel you understand that talking about her and visiting her grave helps me cope with this loss in a healthy and productive way. I don’t think it was your intention to grief shame me but that’s how it feels. Wouldn’t you want me to be able to live with the grief in a way that helps me cope? I have to ask if your daughter died, would you want no one to ever utter her name because she died?”

Assert Wishes – “I would appreciate it if you didn’t make comments that make me feel invalidated but instead supported my need to talk about my daughter, even engaging in conversation about things you remember about Denise. Because she loved you so much and you both had such a special relationship. Those stories are soothing to me and it reinforces that she is remembered by my family as the special person she was.”

Reinforce – “If you could, just ask me how it feels to me so you can understand things from my perspective since you’ve not had this happen to you. And I am grateful for that and would never ever want it to. So I invite you to just ask me and let’s have open conversation. Don’t worry that you are reminding me of her. I think of her every day since her death. All I need is a few minutes and not an exhaustive conversation about her.”

Remain in the present and be prepared to stand your ground but also open to negotiation. Your sister might not be in a place to manage this well so give her some grace for making an effort even if it’s clumsy and imperfect. Because she doesn’t know how it feels to you and it’s likely to take some time before she can understand what to do and say and fully accept that something is not “wrong” with you because it’s not. If you find that after a year after your loss you are completely unable to find joy in anything, you might need to look for a therapist for complicated grief.

So how might you any of these strategies to help yourself through a tough time?

Forgiving myself