DBT: Interpersonal Effectiveness Diagram

Interpersonal Effectiveness is the most broadly applicable skill in the Dialectical Behavior Therapy (DBT) set. I've coached CEO's in these skills to effectively manage (maybe corall) board members, and lead inpatient group therapy for individuals with chronic interpersonal instability. These skills undoubtedly effect my communication both socially and in the therapy office.

As a visual thinker, I tend to put constructs or concepts into mental images. This frequently helps my clients as well - it helps with understanding the concepts, but also recollection. There is something concrete about visuals that helps recollection even in times of distress. It is a common cognitive behavioral approach to diagram conceptualizations of our clients in a flowchart manner (starting with a trigger, ending in a problem behavior or symptom, which in turn increases the likelihood of the trigger recurring).

The continuum

There is a continuum in the degree to which to think about our own needs (self-focus) versus the needs of others (relationship needs). My experience has been that most people can quickly identify where they sit on this continuum.

Do you keep yourself quiet and small, not speak up about your opinions, tell yourself you are easy-going, but sometimes eventually become resentful that everyone else gets their way?

Do you feel as though you need to quickly, loudly and assertively (or even aggressively) push for your needs and opinions? Do you fear you won't get heard, your way or your needs met if you don't, or that it is just the normal way of communicating, and if others' care, they can also be as assertive?

Rate yourself on a scale of -5 (almost totally focused on relationship/others' needs) to +5 (highly assertive, focused on your own needs), 0 being a balance of the two. Neither is better or worse, just part of who we are personally and interpersonally. However, there can be benefits and drawbacks that we will continue to explore.

Self-Respect

Linehan indicates that when our prioritization in a given situation - self-needs vs relationship needs - is off, it comes at the cost of self-respect. When we have made a balanced decision about self vs relationship need priorities, and handled the interpersonal situation appropriately, our self-respect increases. This is both an indicator, telling us we made the right decision and behavior, as well as a therapeutic outcome: increase self-respect has vast (and obvious) therapeutic implications.

Consider the chronic people-pleaser who does not speak up for their needs. Their behavior communicates iteratively (back to themselves) that they aren't important enough to speak up, or important enough to other people that they will tolerate them if they have an opinion. This clearly hurts our core beliefs and probably reinforces existing ones - a self-fulfilling prophecy.

Conversely, think about times you've gotten more angry than sits well with you. It maybe feels like it went against your values or is not the character you identify with. You feel regretful. This costs self-respect. We can be assertive without sacrificing our values and self-respect. This is a common misconception: that assertiveness is the same as aggressiveness. A surprising frequency of client's tell me they don't actually know what assertiveness is, despite familiarity with the word.

Fight vs. Flight

A component not highlighted in the original DBT skills training ties fight or flight response into this concept. A major barrier to practicing effectiveness and being assertive is anxiety. It blinds us, muddies our mind, and leads us back to our habitual, symptomatic way of coping and being in the world. The person who rated themselves a -5 typically has a flight response to the anxiety of an interpersonal situation in which they must either speak up for themselves or submit - they flight from perceived conflict rather than asserting and thereby risking conflict.

In Shakespeare's To Be Or Not To Be soliloquy, Hamlet contemplates whether to fight and consequently face potential dire conflict or submit.

People who tend toward a flight response often don't recognize the underlying (unconscious) anxiety. They may experience, and are often labeled as, aggressive. We see this phenomenon most starkly in psychopathy - a significant portion of the literature goes so far as to say they do not have anxiety, but a subset of which I tend to agree indicates that the anxiety is exiled and isolated from conscious experience because that would be a threat and vulnerability. However, whether psychopathic or otherwise, the experience labeled as aggression comes with the same physiological expression as what is more commonly recognized as anxiety: rapid heart rate, possibly cold clammy hands, and rapid and shallow breathing, to name a few.

We need to a) come to recognize the anxiety and what our early warnings signs are, and b) self-sooth in order to utilize interpersonal effectiveness skills. Self-soothing often includes deep breathing, progressive muscle relaxation, guided imagery or grounding, and mindfulness. Once achieved, we can move onto the DEAR MAN or GIVE FAST skills.