Effective, Creative and Mindful Work with Challenging Clients
By Karin Shola von Daler, MFT and Lori Schwanbeck, MFT

Working creatively and effectively with clients who present with extreme emotional dysregulation often seems daunting, if not impossible. These are individuals who struggle with challenging diagnoses such as Borderline Personality Disorder (BPD), PTSD, eating and mood disorders. We have found that it is possible to work with the Expressive Arts (EXA) to effect change while also staying inspired and avoiding burnout. Combining the successful treatment model of DBT with somatic awareness and EXA, clinicians can learn how to successfully teach mindfulness to help highly reactive clients find emotional balance. Drawing on the latest neurological research, we use hands-on, relational ways of engaging both the sensory and rational parts of the brain to balance the emotional systems. This paper will outline some of the theoretical and clinical considerations on which we have based our workshops and trainings for both clinicians and clients.

As many clinicians have experienced, some EXA, creative and somatic therapy modalities are not directive enough to contain and focus highly emotionally dysregulated clients and effect constructive changes in their lives. For example, following the client's lead into their imagination or into free movement can often result in emotional flooding and re-experiencing of trauma. At these times, client and therapist can both feel overwhelmed and at a loss. Even when this unstructured creative expression evokes emotional catharsis, often there is no learning of new behaviors or skills, which could be used in the client's life where emotional triggers threaten to destabilize any therapeutic growth.

On the other end of the continuum, the more structured therapies, such as Cognitive Behavioral Therapy, favor the cognitive to the exclusion of the sensory and somatic where resources, connection, and aliveness can be experienced for both therapist and client.

Combining these elements, we have created a treatment approach that allows clients to experience change in their mind, body, and relationships, and more creatively meet the challenges of their life.

Dialectical Behavior Therapy
Our work is strongly influenced by Dialectical Behavior Therapy, or DBT. Developed by Marcia Linehan, it is a treatment model proven highly effective with clients suffering from BPD, addictions, eating and mood disorders. It is a directive, skills based approach that teaches clients life skills in emotional regulation, distress tolerance, and interpersonal effectiveness. The foundation of these skills is an active relationship with mindfulness, or the ability to intentionally observe without getting caught in or identified with one's experience.

DBT assumes that there are important life skills that must be taught and consciously practiced in order to find balance in emotions and relationships. Some people learn these skills naturally in their development and others do not. DBT aims to actively build them for those without the internal or relational resources to do so on their own.

Brain Functioning and Behavioral/Emotional Change
Recent advances in brain research shows that the wiring of the brain actually changes with each experience, thought, and emotion that we have. This concept called neuroplasticity, is a promising key in understanding how experience shapes our reality.

By intentionally creating adaptive responses to stressful thoughts and emotions, we are rewiring the brain. For example, when feeling flooded with anger, a client is instructed to choose something self-soothing such as working with clay rather than binge eating. In doing so, the client is engaging the somato-sensory part of the brain, which creates somatic associations between the feeling of anger and an adaptive response of tactile engagement with the clay. This association can act as a somatic marker, or anchor, for skillful behavior. The next step is to actively reinforce these new responses through validation and repetition. This weakens the default mode of overeating when faced with the stimulus of anger and builds the new response of tactile engagement and self-soothing.

Clinical Model
Our clinical treatment model is based on this theory of learning and neuroplasticity. We have found that there are three phases that seem to repeat themselves in successful intervention with our population:

1. Distraction, moving away from the problem focus. The initial focus in building new responses to adverse stimuli is to redirect attention away from the client's habitual patterns of behavior and thought.

2. Creating a new experience Once attention is shifted away from the problem, a new experience is needed for the mind and body with which to engage.

3. Application of the new skill in the client's life. When clients learn that they have the ability to refocus attention, and hence experience emotional regulation, reinforcement is needed. New experience of emotionally adaptive responses must be practiced over and over to become as compelling and easy to choose as the older, less adaptive ones.

These stages are a natural outgrowth of DBT treatment. However, the addition of the embodied, direct sensory experience of the arts, allows us to teach them to our clients more effectively. Further, the more sensory associations we have with an experience, the deeper the learning will be. Also, at a theoretical level there seems to be a natural fit between DBT theory and an arts based EXA approach (Knill, Barba, Fuchs, 1995). In the following we will briefly illustrate this combination and fit.

Key DBT Concepts And Their Expressive Arts Correlates
Mindfulness - The depth is on the surface.
Mindfulness supports the development of a witnessing capacity that is usually lacking in our population. In expressive arts terms, staying with the phenomena of the art or movement piece ("art piece" in the following) brings about a similar experience. When we stay with their concrete manifestation of line, color, tone, movement, the arts naturally let us experience this witnessing directly through our senses.

Distraction - Decentering
The DBT skill of distraction is the intentional shifting of attention away from a distressing inner or outer experience. In EXA terms, we are helping the client to "de-center" (Knill, Barba, Fuchs, 1995). Instead of focusing on the problem represented in the client's art piece, attention is intentionally directed toward another aspect. In DBT terms, this process develops a cognitive-behavioral skill; in EXA terms the imaginative skills are being nourished. This is the goal of our first stage: Distraction, moving away from the problem focus.

Building Positive Experiences - Range of Play
The DBT skill of building positive experience is an active pursuit of enjoyable activities, in order to deliberately increase positive emotions. This parallels the expressive arts strategy of expanding the "range of play" by offering a broader aesthetic repertoire, and is one aspect of our second stage: Creating a new experience.

Skills application - Rehearsal and Performance
The third and final stage of our approach is the Application of the new skill in the client's life. In DBT this is implemented via weekly skills training and structured daily reflection and practice. In EXA terms, the art created in session is a tangible, sensory manifestation of the learning that took place. Thinking or viewing the art piece outside of session reactivates the felt sense and beliefs associated with creating it.

Dialectics and creative conflict
A dialectical perspective takes the stance that reality is not static or balanced but "comprised of internal opposing forces (Linehan, 1993)." This is a vital cognitive skill that challenges all-or-nothing thinking. Similarly, creative imagination expressed in concrete arts enables us better to hold the tension and conflict inherent in our lives (Levine, 1995).

Creating a life worth living
The overall goal of DBT skills training is creating a life worth living. In this, too, we see a fit with Expressive and Creative arts models, which emphasize resources and creativity in contrast to therapeutic models that operate from a pathology/cure paradigm. Bringing these two perspectives together in our model we say that the ultimate act of creation is creating a life worth living. Our goal is to support clients by increasing their life-skill palate.

Let us summarize the premise of our work: Through mindful engagement of the senses in the arts we create new, more adaptive ways to respond to emotional overwhelm. When these new responses are repeatedly reinforced over time, they bring about neurological change, making the new responses increasingly easy to choose over less adaptive ones. Simply put, because our brains rewire based on our experience, intentional creation of positive experiences changes the brain in positive ways. In addition, the more these experiences are associated with a variety of senses, the more sensory triggers are available to evoke this positive, or emotionally regulated, state of consciousness.

Our workshops show how to apply this work in practice. We teach the skills experientially for both individual and group clinical application. Our goal is to have workshop participants come away re-inspired about their work with challenging clients and have skillful, experiential interventions to use immediately.

REFERENCES
Knill, P.; Barba, H.; Fuchs, M. (1995). Minstrels of Soul. Ontario, CAN: Palmerston Press
Levine, E. (1995). Tending the Fire. Studies in Art, Therapy and Creativity. Ontario, CAN: Palmerston Press
Linehan, M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York, NY. The Guilford Press