Behavioral Psych Studio

Author: Staci Jacobs

Considering Culture in providing DBT for Latinx Populations in the United States

When it comes to providing therapy, including Dialectical Behavioral Therapy (DBT), there is no one-size-fits-all approach. Every individual is unique, and their experiences, values, and beliefs are shaped by their culture. Culture shapes how we understand and experience mental health, and traditional therapy approaches may not always fully address the unique needs of diverse individuals.

So today we’re talking about a topic that’s both important and perplexing – the call for consideration of culturally responsive DBT for Latinx adolescents.

Why is this Important?

In 2021, the United States Surgeon General released a report describing an emerging mental health crisis among adolescents that worsened in the wake of the COVID-19 pandemic. This report identified several racial/ethnic minority groups, more likely to experience suicidality in the aftermath of the pandemic. Among these at-risk populations, Latinx adolescents have been found to be considerably vulnerable, with one in ten Latinx adolescents attempting suicide compared to one in fourteen non-Latinx white peers. Prior studies have indicated that Latinx adolescents face additional risk factors unique to this population, such as acculturative stress (i.e., psychological impact of adaptation to a new culture) and the adverse effects of familism (i.e., higher emphasis on family than the individual) when interacting with contrasting cultural norms exposed to living in the US (i.e., individualism) increases the risk for cultural discord, family conflict, and ultimately suicidality.

You might be thinking, “Isn’t DBT an evidence-based practice that has been found to effectively address this problem?” And you would be absolutely correct.

While strides have been made in the development of “best practices” for suicide prevention and treatment interventions, historically minoritized and marginalized groups continue to be under-represented and understudied in suicide intervention research and contribute to mental health inequities that are very much alive today in the United States. More research is needed to establish the efficacy of these interventions or determine the need for potential adaptations that can fit the needs of Latinx adolescents.

Why Adapt DBT?

Well, despite initiatives to implement evidence-based practices in routine settings for children and adolescents, inequities persist in the quality of mental health care among racial/ethnic minorities, including Latinx adolescents. Historically, Latinx communities have underutilized specialty mental health services compared to non-Latinx whites. Barriers to accessing mental health services include lack of health insurance, ethno-racial discrimination, limited awareness, and lack of knowledge of available resources, economic constraints, stigma, reliance on informal supports, and alternative cultural views of the problem incompatible with formal mental healthcare use. Furthermore, when Latinx individuals seek treatment, they are less likely to receive a “minimum effective dose” due to a combination of lower-quality care that fails to follow evidence-based treatment guidelines and higher premature termination.

Culturally tailored interventions are urgently needed that respond to the needs, values, and experiences of Latinx adolescents and their parents.

What are Potential Cultural Adaptations to DBT for Latinx Populations?

A paper published by Germán and colleagues (2015), discussed how we might potentially tailor DBT to Latinx families by expanding the existing adolescent dialectical dilemmas and proposing two new dialectical dilemmas:

Old school vs. New school and Overprotecting vs. Underprotecting

Old School vs. New School refers to the tension between traditional cultural values (i.e., “old school”) and more modern values and norms (i.e., “new school”). Latinx adolescents may experience conflict between their parents’ traditional values and the more mainstream values they encounter outside of the home. The goal of treatment is to help the adolescent navigate this tension and find a balance between honoring their cultural heritage while also integrating into the larger society.

Overprotecting vs Underprotecting refers to the tension between being overly protective (i.e., “smothering”) and not protective enough (i.e., “neglectful”) suggesting that Latinx adolescents may experience this tension from their parents, who may either be overly involved in their lives or not involved enough. The goal of treatment is to help the adolescent develop healthy boundaries and assertiveness skills to communicate their needs effectively with their parents.

However, despite these recommendations, as we previously discussed, there remains a lack of research exploring DBT and any potential adaptions among this population.

So, as we wait for research to catch up to practice, here are a few things to keep in mind when implementing DBT with Latinx clients:

· Recognize the Importance of Family

For many Latinx individuals, family (or “familia”) is a highly prioritized value. The importance of placing the needs of the family above those of the individual may clash with the societal priority placed on expressing one’s individuality as a sign of maturity. In DBT, it’s important to involve family members in the therapy process whenever possible. Encouraging clients to share what they’ve learned in therapy with their family can help build a support system and reinforce healthy behaviors outside of therapy.

· Understand that Latinx Cultural Norms May Value Emotional Expression Differently

In many traditional Latinx families the emphasis on intergenerational harmony – avoidance of interpersonal conflicts, consistent expression of positive emotions, respect for elders – may conflict with typical non-Latinx White family norms (e.g., early expression of independent views, and informal communication style). Latinx culture can have traditional gender roles that can influence how individuals express and manage their emotions. Men are often encouraged to be stoic and not show vulnerability, while women are expected to be emotional and nurturing. Failure in meeting parental expectations (e.g., adhering to traditional gendered roles) can increase family discord and may be difficult to resolve. DBT involves teaching clients’ specific skills to manage their emotions and relationships.

However, the effectiveness of these skills may vary depending on the client’s cultural background. For example, skills like emphasizing assertiveness or distress tolerance may not be as effective in cultures where deference to authority or emotional restraint are highly valued. Therapists should be aware of these differences and be willing to adapt their approach to meet the client’s needs.

· Acknowledge the Impact of Religion

Religion plays an important role in many Latinx individuals’ lives. It’s important for therapists to be aware of the role religion plays in their client’s life and to incorporate spiritual practices if appropriate. Mindfulness is a key component of DBT, but cultural norms may affect how mindfulness is practiced. For example, some cultures may have specific practices or rituals around mindfulness that differ from the standard DBT approach. Therapists should be aware of these differences and be willing to adapt their approach to meet the client’s needs.

· Be Aware of Power Dynamics

Power dynamics can also impact the effectiveness of therapy. For example, clients from marginalized communities may have experienced trauma or discrimination that makes it difficult to trust authority figures. Therapists need to be aware of these power dynamics and work to create a safe and supportive environment that promotes trust and respect. Language can be a major barrier for Latinx individuals seeking therapy. Many may feel more comfortable speaking Spanish or have difficulty expressing themselves in English. It’s important for DBT therapists to provide bilingual services or work with an interpreter to ensure that clients can fully participate in therapy.

Culturally responsive DBT for Latinx individuals is an important and exciting yet underdeveloped area in mental health intervention research. Acknowledging the impact of culture, integrating cultural values, addressing cultural stigma, and promoting social justice are just some aspects DBT therapists can incorporate into their practice in order create a more effective and engaging therapy experience for their Latinx clients.

By advocating for greater representation in research, addressing systemic barriers to access, and promoting culturally responsive therapy, we can work towards greater mental health equity not just for Latinx adolescents but for all!

Works Cited:

1. Cabassa, L. J., Zayas, L. H., & Hansen, M. C. (2006). Latino Adults’ Access to Mental Health Care: a Review of Epidemiological Studies. Administration and Policy in Mental Health, 33(3), 316–330. https://doi.org/10.1007/s10488-006-0040-8

2. Lu, W., Todhunter-Reid, A., Mitsdarffer, M. L., Muñoz-Laboy, M., Yoon, A. S., & Xu, L. (2021). Barriers and Facilitators for Mental Health Service Use Among Racial/Ethnic Minority Adolescents: A Systematic Review of Literature. Frontiers in Public Health, 9, 184. https://doi.org/10.3389/fpubh.2021.641605

3. Germán, M., Smith, H. L., Rivera-Morales, C., González, G., Haliczer, L. A., Haaz, C., & Miller, A. L. (2015). Dialectical Behavior Therapy for Suicidal Latina Adolescents: Supplemental Dialectical Corollaries and Treatment Targets. American Journal of Psychotherapy, 69(2), 179–197. https://doi.org/10.1176/appi.psychotherapy.2015.69.2.179

4. US General Surgeon. Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory [Internet]. US Department of Health and Human Services; Available from: https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf

5. Youth Risk Behavior Surveillance — United States, 2019. 2020;69(1):88.

May 3, 2023
Self Compassion
Recently, in an off-handed, quasi-self deprecating way, a dear friend remarked to me, “If I were to speak to others the way I speak to myself, I don’t think I’d have that many friends.” I was struck by the statement, as my assumptions about this individual ran wholly counter to her internal experience.

“What do you mean?” I asked. (As we know in Dialectical Behavior Therapy, it’s ever-important to check the facts, lest our interpretations and assumptions run wild.)

“Oh, I just…I’m pretty cruel to myself. Just a lot of me judging me for being me.” She continued with specifics, and I was dumbfounded. All this time, my dear friend, the ‘Queen of Pep Talks’ as we call her, was evaluating herself — and not positively. At the very least, not in a fact-based light.

And you know what happened? Essentially right after I registered that I was experiencing surprise? I had a rapid fire series of thoughts, noticing this one in particular: ‘Even with my training and experiences in social work, I totally assumed that she was inured to this type of evaluation and labeling. Wow.’ I judged myself.

Well, well, well.

Upon further reflection, as well as additional use of my Mindfulness WHAT and HOW Skills, I came to a conclusion that I hadn’t yet named for myself: Perhaps I am also my harshest critic. Perhaps many of us are. (And yes, I’m going to be transparent in naming that I subsequently judged myself for coming to this conclusion, as I had the thought: ‘Duh, Avery.’)

Knowing how much we lose by judging our perceived flaws or missteps, how much pain this can bring about, and how both of these things can prompt maladaptive behavioral responses, what’s to be done? How do we tackle the seemingly automatic judgments and self-criticisms that many of us have towards ourselves? A potential answer resides in the work of Dr. Kristin Neff, a pioneer in the field of self-compassion.

Self-compassion is a Buddhist psychological construct that acts as a healing balm, a salve, in the face of self-criticism and judgment. It is something that can be practiced, flexed like a muscle, and it is best summed up — funnily enough — by treating yourself like you might treat a loved one. It is made up of three components:

Mindfulness or bringing a balanced awareness to the present moment (consider your mindfulness skills!)

Self-kindness or offering ourselves warm, gentle acceptance and comfort (consider your self-validation skills!)

Common humanity or recognizing that pain and challenges are part of the shared human experience (consider radical acceptance!)

A blogpost is not sufficient to encapsulate all the tenets of what self-compassion is, what it is not, and how to practice it. AND, to begin seeding that habit of self-compassion, a new behavior to learn and nurture, I am sharing two self-compassion exercises to get you started. These are inspired by, although slightly modified from, Dr. Neff’s work.

Exercise 1: Loving Kindness Meditation

In a space that feels safe and comfortable for you, position yourself in a mindful, wide awake position. Remember: No past. No future. Just the present moment. Let your mind run away. Catch it — and return.

Take several deep breaths in, and repeat the following phrases, or modifications that you prefer, to yourself:

May I be happy

May I be healthy

May I be at ease

May I give and receive warmth

Notice any thoughts, emotions, physical sensations, judgments that come up for you. Stay with this, or direct your loving kindness to others.

Exercise 2: Supportive Touch

Offering yourself a form of supportive touch is shown to release oxytocin, enhancing security and calming distress. Try any of the below motions, after taking several deep breaths, and notice what comes up for you:

One hand on your cheek

Cradling your face in your hands

Gently stroking your arms

Crossing your arms and giving a gentle squeeze

Gently rubbing your chest, or using circular movements

Hand on your abdomen

One hand on your abdomen and one over heart

Cupping one hand in the other in your lap

As a note, there is a clear and marked overlap between the foundational components of DBT and self-compassion. This infusion may be fruitful, and I highly recommend exploring Dr. Neff’s website, here, alongside the following texts:

For Children

Listening with My Heart (Gabi Garcia)It’s Ok: Being Kind to Yourself When Things Feel Hard (Wendy O’Leary)

For Teens

The Self-Compassion Workbook for Teens (Karen Bluth)

For Adults

Self-Compassion: The Proven Power of Being Kind to Yourself (Kristin Neff)

Radical Acceptance: Embracing Your Life with the Heart of Buddha (Tara Brach)
April 3, 2023
Cut That Cord! A Parent’s Guide to Using Opposite Action
Here we are again. You’re staring at a sink filled with food-crusted plates, overflowing cups, and more silverware than you can count. How many times have you said, “Clean up after yourself!”? How many conversations have you had about the importance of taking accountability, being responsible, doing your part? You can feel the pressure in your chest, the lump rising in your throat. You’re going to yell. You’re going to finally be heard! You’re going to…be met with sighs and protests and rolled eyes, and find yourself back here in twenty minutes, elbow-deep in dish soap and fighting back tears of guilt and a feeling of total hopelessness.

Sound familiar? Parenting is hard. Parenting when you yourself are feeling frustrated and frazzled is something of a Herculean task. Sometimes, our emotions simply get the best of us. It happens to everyone. Fortunately, in DBT we have a skill that is designed to override the automatic behaviors that piggy-back on hot-tempered emotions and help us regain control over how we respond to the situation at hand. It’s called Opposite Action.

Opposite Action involves purposely doing the opposite of what your emotion tells you to do. When we feel an intense emotion, our natural instinct is often to act on it. It’s what psychologists call engaging in mood-dependent behavior. You feel something—Boom!—you do something. Of course, this can lead to unhelpful responses like yelling, threatening, criticizing, grounding, or other forms of punishment that have the potential to not only damage the parent-child relationship, but to produce lasting and harmful psychological effects on youth.

The good news is there is a way to cut the cord between our feelings and behaviors. By using Opposite Action, we can intentionally choose to respond in a way that is opposite to our emotional urge, which can help us to regulate our own emotions and improve our relationships with our children.

So how do you do it? Follow these steps:

Notice your emotions and urges: Remember, you’ve got to name it to tame it. Tune into your body to help you identify what emotion you’re experiencing. Are you feeling angry, ashamed, and/or disappointed? What is your emotion telling you to do? Notice the strength of the urges.

Check the Facts: Oftentimes, our interpretations of an event can ramp up our emotional intensity. Our kid leaves dishes in the sink and our brain says, “They’re so inconsiderate! I’ve raised an entitled brat.” Such thoughts only serve to escalate our perfectly natural emotion of mild irritation and transform it into seething resentment. Taking a moment to catch those thoughts and rephrase them into more accurate descriptions (e.g., “He left his dishes in the sink”) and come up with more charitable interpretations of the events (e.g., “He’s had two big tests this week and is stressed out. Sometimes I leave things out when I have a lot on my plate”) can help keep our emotions in check.

Consider the consequences: Often we call this practice consulting your Wise Mind. Ask yourself, “Is acting on this emotion going to be effective in the situation?” Meaning, is following your emotional urges going to bring you closer to your long-term goal? For many parents, their long-term goal is to have a healthy relationship with their children and to share their values with them. Although it might seem like yelling, criticizing, or punishing is the only way to get through to your child, it’s important to note that the context of our words will be more salient than the content. Basically, your kid isn’t going to understand your message if their brain is focused on how you delivered it.They’re not going to empathize about dirty dishes and correct the behavior if they are being yelled at by you.

So even if in the moment your mind is telling you to just lay into them, think about the long-term consequences of acting on your urges. Will it improve the situation, or will it make things worse? Will it damage your relationship with your loved one? If so, move onto the next step.

Figure out the opposite action: Instead of yelling, criticizing, etc., choose an opposite action that is more likely to improve the situation and your relationship with your child. Oftentimes when we are angry, our emotion tells us to pounce. We get all fired up and tense and are ready to attack. Opposite action would have us adopt a different posture.

Unclench those hands (bonus points if you turn them up into a willing hands pose), release that jaw, breathe slowly into your belly.

Instead of leaning into your child, take a step back. It’s perfectly okay to take a moment to collect yourself. Call a time-out and take a break from the situation. You can always revisit it when your emotional temperature has lowered.

Soften your tone of voice and channel your most empathic self. See things through their eyes. Imagine what it’s like to be them for a moment (especially if you wish they demonstrated empathy for you). Modeling is a powerful form of teaching new behavior.

Practice opposite action: Act on the opposite action, even if it feels uncomfortable or unnatural at first. With practice (a lot of practice), it will become easier to cut the cord between your emotions and actions, putting you in the driver’s seat of your behavior. Like parenting, rehearsing opposite action is a challenging and rewarding process. If at first you don’t succeed? Resist the urge to beat yourself up and instead meet yourself with some compassion (AKA: Try using Opposite Action on yourself!). Remember that you are learning a new skill and acknowledge the effort you’re making.

To learn more about Opposite Action and further applications of this skill, check out Episode 12 of our DBT podcast House on Fire.
March 2, 2023
Addressing Body Image Concerns Using Mirror Exposure

Who hasn’t experienced some form of self-criticism about their body image? We are all too familiar with examining ourselves in the mirror and zeroing in on whatever it is that we do not like. It’s a process so many of us unconsciously engage in…but what effect does it really have on us? Negative body image is associated with lower self-esteem, anxiety, depression, eating disorders, and body dysmorphic disorder. Concerns about our appearance can have a profound effect on social functioning and intimate relationships. People may avoid wearing certain clothes, being seen or touched, or going to places based on concerns about how they look. While everyone can relate to experiencing dissatisfaction with their appearance, few of us are aware that how we examine ourselves in the mirror plays a drastic role in what we see, think, and feel.

In today’s blogpost, we are going to talk about one specific intervention for addressing body image concerns: The mirror exposure. Please note that addressing negative body image is challenging and can call for a number of different interventions including but not limited to, examining underlying beliefs about what our bodies should look like as well as the degree to which we base our self-worth on how we look. If you have an individual therapist, I recommend bringing up your body image concerns in that supportive space. If you are looking to learn more on your own, I recommend a book like: The Body Image Workbook. Okay, now back to mirror exposures…

Let’s start by debunking a myth:

Is what you see in the mirror completely accurate?…. Not quite!

Have you ever looked like yourself in one mirror and totally different in another? The lighting, type of mirror, and glass quality all affect how your image is reflected. Beyond that, consider the size of your image in a full-length mirror. Does the image in the mirror reflect your true height and width? You can experiment with this by having someone mark the top of your head and your feet in the mirror and measure it. The short answer is no.

Am I advocating for no mirrors? Of course, not. They have their value, but taking the reflection you see in the mirror as capital “T” truth and then criticizing yourself can contribute to a variety of mental health concerns.

So, what IS body image?

When we think about body image most of us will think about…well…our bodies. However, it’s a bit more complex than that. Our body image is made up of perceptions, cognitions, feelings, and behaviors. Perceptions are what we become aware of by way of our senses (e.g. the sensation of my waistband pressing on my abdomen or the way I see myself in the mirror). Cognitions are thoughts, beliefs, and interpretations about our bodies (e.g. “I’m fat”). Feelings are the emotions we feel about our body which can be amplified by negative cognitions (e.g. disgust, shame, embarrassment, and/or guilt). Finally, behaviors are actions we take (e.g. restricting food/food groups, checking your stomach in the mirror repeatedly, and/or avoiding looking at yourself in the mirror). Each of these components impacts one another and can happen in any order.

How can behaviors reinforce the cycle?

If someone assumes they look “fat” and “disgusting,” they may avoid looking in the mirror. This avoidance strengthens those beliefs by leaving them unchecked. Now, let’s say you do the opposite…you check repeatedly whether you look fat and disgusting. Well…what you discover depends on the way you assess yourself. “Flaws,” that would otherwise go unnoticed, become prominent, when you seek them out. Furthermore, scrutinizing yourself in the mirror magnifies perceived defects. Consider the study that showed how people with spider phobias perceived spiders to be larger than they actually are in reality. This is because when looking at the spiders through the lens of fear, they focused on unpleasant characteristics and ignored things in the environment that provided a reference to size. Similarly, when people study themselves in the mirror, they fixate on perceived flaws, which, in turn, magnifies them. If you are looking for a flaw, you will find it. In other words, how you examine yourself in the mirror influences what you see.

Enter stage left…the mirror exposure:

Mirror exposures, sometimes called perceptual retraining, is an intervention that works to break the cycle of negative body image. We are looking to confront anxiety, disgust, shame, guilt…any uncomfortable feelings having to do with our body. We are also practicing looking at our bodies as a whole rather than focusing on the parts of our body we dislike.

How do we do this?

1. This practice is really tricky. If you are doing this on your own (versus with a therapist), it can help to record yourself so that you can play it back afterwards and give yourself feedback.

2. Stand in front of a full-length mirror and practice systematically describing your body using neutral, objective language. Go from head to toe or toe to head.

a. Examples of neutral descriptions include: Describe colors you see, shapes you see, textures, measurements using neutral, and objective terms (e.g. my forehead is about three fingers tall). Think about any description you might use to help someone build a model of your body.

b. Examples of non-neutral descriptions: Fat, ugly, gross…need I go on?

c. If you are unsure, ask yourself, does that description feel neutral to you?

3. Pacing: Spend a similar amount of time on each area.

a. Notice if you have urges to avoid certain areas on your body. If the urge is there, practice approaching and slowing down using the neutral descriptions.

b. Conversely, if you have the urge to spend extra time on a particular section of your body part (e.g. checking), practice pacing yourself in the same way you do for a part of your body you don’t check.

4. When you are finished, listen to the recording of yourself doing this practice and determine whether there were areas of difficulty.

5. If you avoided, checked, or used non-neutral language go back over these areas and practice confronting, pacing, and using neutral language.

6. Practice this daily. You can vary the exposure using different types of clothing.

Why is this helpful?

In case it’s not already clear, mirror exposures target the self-perpetuating cycle of negative body image by…

● Disrupting hyperfocus on perceived flaws by viewing your body more globally.

● Breaking the cycle of avoidance via confronting/exposing (avoidance reinforces negative thoughts/feelings).

● Teaching you to tolerate and accept (versus fight) difficult thoughts and emotions. If we stop fighting these things, over time they will die down. Keep in mind, however, this takes time! Measure your success by the fact that you are doing the mirror exposure practice versus by the presence of negative thoughts and feelings.

To conclude:

Body dissatisfaction takes place when a person has persistent negative thoughts and feelings about their body which, in turn, shapes behaviors such as the way you look (or don’t look) at yourself in a mirror. While this is an internal process it is heavily influenced by external factors – think messages in our culture, media, and

immediate environment that tell us what the ideal body “should” look like. Mirror exposure is one practice that can help you move towards a more positive body image. What IS a positive body image? Accepting, appreciating, and respecting your body. This does not mean you are never dissatisfied with aspects of your appearance, but it does mean that you practice acceptance with all of its limitations. Positive body image is a protective factor against developing eating disorders and is also associated with higher self-esteem, self-acceptance, and more adaptive living. While changing your relationship to your body is challenging, it is worthwhile if it can leave you feeling more flexible and free to live the life you want.

February 1, 2023
The Adolescent Brain

Brains are like race cars: Powerful, innovative, dynamic, tough, and function like well-oiled machines. Sometimes, however, steering a race car can be hard to maintain control of. Brains are not that different.

Our brains have their own accelerator as well as a brake like any car. The brain’s “brake” is called the prefrontal cortex. The prefrontal cortex is largely responsible for higher and more complex brain functions such as reasoning, planning, understanding, and processing language and problem-solving. This part of our brain becomes crucial in decision-making and regulating social behaviors.

Development of the prefrontal cortex takes time. On average, the process takes 25 years. Research using MRIs shows that the brain experiences a surge of growth right before puberty (1), after which the brain spends about a decade or so rewiring itself (1). During adolescence, the rewiring of the brain specifically strengthens the prefrontal cortex, which allows for improved problem-solving and enhanced ability to process complex information. During this time, it is an opportunity for adolescents to develop interests, passions, and healthy habits that they will then bring into adulthood.

Until this process is complete, the brain’s “brake,” the prefrontal cortex, is not fully programmed, which leaves the “accelerator” unchecked for some time. In this case, the “accelerator” is the amygdala, the brain’s fear center, which is much more reactive in its danger-driven responses without the prefrontal cortex to help process and plan how to proceed (2). As a result, for many adolescents, there is more risk taking, meaning more potential for danger, since they do not yet have their “brake” in place. Over time as the prefrontal cortex develops and the structural connection to the amygdala strengthens, individuals are less likely to engage in high risk behaviors (3). Instead, they are more likely to think through what might happen, and avoid acting in ways that might be more dangerous. Additionally, with the prefrontal cortex online, there is more of a drive towards “safe” behaviors as well as becoming healthy social and emotional adults.

There are some actions we can take to promote development in this region. One such action is mindfulness, which can activate the frontmost part of the brain and strengthen the connections in the prefrontal cortex (4). Mindfulness practices can be a first step towards improving our attentional control, emotional processing, and emotion regulation that the prefrontal cortex is responsible for.

Understanding prefrontal cortex development and how to shape it, during or after adolescent years, can help you get into the driver’s seat to steer toward your life worth living.

[1] Arain, M., Haque, M., Johal, L., Mathur, P., Nel, W., Rais, A., Sandhu, R., & Sharma,

S. (2013, April 3). Maturation of the adolescent brain. Neuropsychiatric disease and treatment.

Retrieved January 19, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3621648/

[2] Baxter, M. G., & Croxson, P. L. (2012, December 14). Facing the role of the amygdala in

emotional information processing | PNAS. Facing the role of the amygdala in emotional

information processing. Retrieved January 19, 2023, from

https://www.pnas.org/doi/10.1073/pnas.1219167110

[3] Jung, W. H., Lee, S., Lerman, C., & Kable, J. W. (2019, April 18). Amygdala functional and

structural connectivity predicts individual risk tolerance. Neuron. Retrieved January 19, 2023,

from https://pubmed.ncbi.nlm.nih.gov/29628186/

[4] Kang, D.H., Jo, H.J., Jung W.H., Kim S.H., Jung Y.H., Choi C.H., Lee U.S., An S.C., Jang

J.H., Kwon J.S. (2013, January 8). The effect of meditation on brain structure: Cortical thickness

mapping and diffusion tensor imaging. Social cognitive and affective neuroscience. Retrieved

January 19, 2023, from https://pubmed.ncbi.nlm.nih.gov/22569185/

.

January 26, 2023
Start SMART this New Year

The New Year is accompanied by a fairly familiar tradition: Setting New Year’s resolutions and then great difficulty actually reaching those resolutions. It is something that, at one point or another, most of us are guilty of experiencing. We pinpoint behaviors to increase or decrease, make our best effort to change, and then struggle to make that change happen (at least consistently). Not only do we “fail” to achieve but also, we may feel guilt, shame and/or defeat for not getting there.

The problem isn’t so much that we are incapable of change (as a therapist, let me please say this is certainly not the case, otherwise I’d be out of a job). Instead, it has much more to do with how we set our New Year’s resolutions (and oftentimes our larger goals in general).

One way to cut down on this self-defeating tradition is by trying to use SMART goals, an acronym guide to creating achievable aspirations.

SMART stands for:

–Specific: Be clear and nuanced about what your goal is. Using vague language is only going to make it hard to see what you’re trying to achieve and difficult to assess the progress you make towards your goal.

–Measurable: Give yourself a way to measure what you’re doing, so you have a defined way of understanding whether you’re reaching your goal or making progress towards it.

–Attainable: Be realistic. Give yourself a goal you know you can actually reach. This doesn’t mean it has to be too easy or simple, just that your goal is something you feel you can really achieve.

–Relevant: Is this goal applicable to your life? Setting benchmarks that don’t have much to do with how you currently live or want to live won’t help you to be motivated to work on what you set for yourself.

–Time-sensitive: Give yourself a deadline. Allowing projects to go on ad infinitum will make it easy for you to make excuses when you have days you don’t want to put in the work (and you will have days like that, as we all do).

To put this into perspective, I’ll offer a common goal that many of us set for ourselves in the New Year: To exercise more. It’s one such goal that, I’ll admit, I have aspired for before and will be trying to achieve again in 2023. The issue with setting a goal of “working out more” is that I will have no real way of knowing whether or not I am doing this. Technically, if I go from never working out to working out once a week, then I have achieved this goal! Yet does that mean I’ll feel pride in this achievement? Not necessarily.

Instead, following the SMART guideline, I can set my goal like this:

–Specific: Instead of just saying “exercise more,” I can say that I want to go to the gym, following a workout routine in which I do cardio as well as weight training for certain muscle groups. I can get even more specific (Which muscle groups? Do I follow a certain routine? etc), yet for the sake of this article I’ll start there.

–Measurable: I will go to the gym three times a week for 45-minutes. I can even set the measurable goals of 10-minutes of cardio each workout if I want to. Knowing the weekly benchmark helps me know if I’m really hitting my goal and also gives me a guideline for my weekly schedule to consider when to fit in these workouts.

–Attainable: Currently, I go to the gym around once a week. Increasing to three times, while a challenge, seems achievable to me. Knowing my schedule, I can fit in two more days of workouts, while also not setting the bar so high that I will exhaust myself.

–Relevant: I’m fortunate that I have a gym room in my apartment building, so going to the gym is certainly relevant to my current life and I am definitely conscious of my health. Also, for folks who know DBT, I always want to maintain my PLEASE skills, as a good amount of exercise helps us to feel better and reduce our emotional vulnerabilities.

–Time-sensitive: By the end of January, I want to be going to the gym three times a week. This way, I give myself a deadline to work up to this goal, building necessary tolerance and motivation, and also giving myself an opportunity to reevaluate my aspiration if I’m not meeting it.

By following this acronym, we can give ourselves a roadmap to creating achievable resolutions for ourselves. Being SMART means taking the time to consider how we want to set goals and allowing ourselves the opportunity to effect positive change in our lives.

January 2, 2023
The Mindful Brain

The practice of mindfulness can transform us from a rote state to an intentional state. Like a caterpillar morphing into a beautiful butterfly, mindfulness can help transform you into a happier and healthier version of yourself. Yet, what is mindfulness doing in the brain to get us to this point of metamorphosis?

In Dialectical Behavior Therapy, mindfulness practice starts off every group and in fact is the first module taught in DBT. The core mindfulness skills are critical in helping us reduce reactivity, increase happiness, reduce suffering, and are essential tools for building a life worth living.

Many of us think of meditation when we think of the word mindfulness. We often use these words interchangeably, and while they are related, they are not the same. Meditation is a practice that uses mindfulness techniques to focus the mind for a specific period of time with the intention of limiting the impact of distracting and wandering thoughts. The DBT Core Mindfulness skills help us develop intentional awareness of the here and now without judgment of the present moment. If you have ever been in the “flow” while completing a task or engaging in an activity, you have experienced being mindful.

Engaging in a mindfulness practice can result in many desired “side effects.” It can decrease suffering, increase happiness, increase self-awareness, and help to regulate what we feel and what we do. Researchers have found that people who participated in mindfulness-based interventions experienced changes to brain structures fundamental to emotion regulation. These structures include the amygdala, the insula, and the prefrontal cortex (1). Here’s what happens for each of them when mindfulness begins to take root:

Amygdala:

As mentioned in the last blog post, individuals who participate in DBT experience DECREASED activation of the brain’s fear center, the amygdala, partly due to the impact of mindfulness. Additionally, those individuals have much less intense reactions to distressing emotions when they occur (2).

Prefrontal cortex (PFC):

Mindfulness INCREASES activation in the prefrontal and insular cortex (1). The PFC is our brain’s control center for planning, decision-making, problem-solving, emotion regulation (!), and other higher brain functions. Another role of the PFC is to step in with the amygdala, preventing it from turning up distressing emotions when they occur (3).

Insula or Insular cortex:

The insula’s primary involvement in our brain is to process the emotions that are unique to the human experience. One of the main jobs of the insula is to experience and perceive the state of our bodies at any one time (4). This is important for mindfulness practice, as an essential component of it is being able to notice our thoughts, feelings, and bodily sensations.

If mindfulness sounds like a daunting practice to undertake, know that you are not alone. It takes time and practice for these brain regions to come online and stay online. With practice over time, we become able to build up the mindfulness “muscles” in our brains, much like how weight training and flexing strengthen our muscle tone. If this sounds like something you would be interested in, why not start your practice today?

[1] Wheeler, M. S., Arnkoff, D. B., & Glass, C. R. (2017). The neuroscience of mindfulness: How mindfulness alters the brain and facilitates emotion regulation. Mindfulness, 8(6), 1471–1487. https://doi.org/10.1007/s12671-017-0742-x

[2] Iskric A, Barkley-Levenson E. Neural Changes in Borderline Personality Disorder After Dialectical Behavior Therapy-A Review. Front Psychiatry. 2021 Dec 17;12:772081. doi: 10.3389/fpsyt.2021.772081. PMID: 34975574; PMCID: PMC8718753.

[3] Dixon ML, Thiruchselvam R, Todd R, Christoff K. Emotion and the prefrontal cortex: An integrative review. Psychol Bull. 2017 Oct;143(10):1033-1081. doi: 10.1037/bul0000096. Epub 2017 Jun 15. PMID: 28616997.

[4] Haase L, Thom NJ, Shukla A, Davenport PW, Simmons AN, Stanley EA, Paulus MP, Johnson DC. Mindfulness-based training attenuates insula response to an aversive interoceptive challenge. Soc Cogn Affect Neurosci. 2016 Jan;11(1):182-90. doi: 10.1093/scan/nsu042. Epub 2014 Apr 8. PMID: 24714209; PMCID: PMC4692309.

December 8, 2022
Thinking Dialectically about Recovering from Addiction

Whether you struggle with substance abuse or know someone who does, addiction impacts all of us. It’s easy to judge, to assume, or to have strong opinions about what you think someone should do to get better and survive. It likely comes from a place of love or fear, but if there is anything I know about recovery from substance abuse, it’s that recovery comes down to the interplay between the individual’s willingness AND having the right skills. DBT offers us the duality of understanding a person AND the context of their environment: Someone can want sobriety and the environment might not be conducive OR the environment might be designed for sobriety and the person just isn’t ready. For someone to recover from substance abuse effectively, both need to occur simultaneously.

Luckily, there are skills for that–skills that target both the individual’s behavior and their environment in service of their recovery.

DBT categorizes these skills as “when the crisis is addiction” (Distress Tolerance Handouts 16-21), and guess what? Marsha hit us with yet another acronym: DCBA.

D: dialectical abstinence

C: clear mind, community reinforcement

B: burning bridges and building new ones

A: alternate rebellion, adaptive denial

Here is the crash course on skills for when the crisis is addiction that can help either you or a loved one understand the mechanisms that make recovery from substance abuse possible.

D: Dialectical Abstinence

Dialectical abstinence suggests that making a commitment to sobriety AND coping ahead for a potential slip or relapse is what increases the possibility of remaining sober. The commitment influences behavior change which makes recovery possible. You may start to attend 12-step meetings, share with your family and friends, or seek professional help, instead of just contemplating sobriety without making the necessary changes. Additionally, coping ahead for potential slips helps you devise a plan to get back on track with sobriety as soon as possible.

C: Clear Mind + Community Reinforcement

Next, there is clear mind which is the synthesis between addict mind and clean mind. Addict mind is characterized by impulsive behaviors and being willing to do anything to get your desired substance whereas clean mind is naive to possible triggers or environments and convinces you that you’re immune to temptations to use or drink. The synthesis, which is clear mind, allows for you to enjoy your success of staying sober while also acknowledging that thoughts about using may still pop into your head or be cued by the environment, which requires being cautious and coping ahead.

Community reinforcement emphasizes the need to surround yourself with people, places, and things that reinforce your recovery. Surround yourself with people who support this change that you’re making in your life. Find a community going through a similar change. Engage in sober activities that feel enjoyable to you. Avoid places and people you used to use with. Throw away your paraphernalia.

B: Burning Bridges and Building New Ones

Burning bridges and building new ones is exactly what it sounds like. Unfortunately, part of sobriety is giving something up. Sometimes this includes people who you need to take space from, jobs you may need to quit, or places you can no longer go to. Most importantly, do whatever you have to do to create a barrier between you and your drug of choice; whether that’s deleting dealers numbers or avoiding streets with liquor stores or bars you used to frequent.

Building new bridges requires creating different brain associations in your mind when you’re experiencing a craving. Build different images or smells to think about whenever you want a drink or your drug of choice: Smell and eat some chocolate, think about being on your favorite beach, or light a strong candle. This over time will reduce the intensity of your cravings, and it will make it much easier to ride them out without acting on them.

A: Alternate Rebellion and Adaptive Denial

Alternate rebellion is a skill for managing urges to be rebellious. We all have them, and sometimes we need a thrill to feel alive or to cope with intense emotions. Luckily, there are ways we can rebel without using or drinking. For example, try getting a piercing, dying your hair, buying a flight to a foreign country, or going on a date with someone who isn’t your type.

Lastly, adaptive denial is an intentional practice of giving logic a break and denying that you want the drink or drug. You actively convince yourself that you want something different. For example, when your friends are enjoying wine and you are experiencing a craving you might say to yourself, “That looks gross, I’d rather have some delicious dessert.”

If you’re reading this and contemplating whether sobriety could enhance your life or you’re suffering from addictive behavior, these skills are a start AND you may still need professional help. We’re here to help you become ready and shape your environment for success!

November 30, 2022
Science & Society: The DBT Brain

In the previous blog post on The Neuroplastic Brain, we began to explore how our environment can influence our brain’s development through neuroplasticity. Have you ever considered how this plays out in your life? Well, if you are currently or previously engaged in Dialectical Behavior Therapy (DBT), or know someone who has, you might be interested to learn that there has been some fascinating research on the impact that DBT can have on our brain and the billions of connections within.

Although psychology emerged centuries ago, we are continually learning more about what happens in the brain when we engage in psychotherapy (1). We now know through this research that psychotherapy CAN transform our brain’s neurobiology.

The developer of DBT, Marsha Linehan, states in her Biosocial Theory that invalidating environments can lead to the development of pervasive emotional dysregulation for those of us who are more biologically and emotionally vulnerable. Environments that are limited in their ability to meet our needs can include people in our daily lives such as our caregivers as well as larger systems such as schools, office spaces, communities, and society. The transaction between the invalidating environment and our biological, emotional vulnerability is a recipe for diagnoses such as Borderline Personality Disorder (BPD) to develop, where the central challenge is to regulate emotions in healthy ways.

DBT has become widely known as the gold-standard treatment for individuals with BPD. Thus far, several studies have looked at individuals with a BPD diagnosis both before and then after completing DBT. The research suggests that DBT has the ability to change our brains. This is where neuroplasticity comes in! Our brains are physically able to change as a result of therapeutic learning via the remapping of connections between neurons—the building blocks of our brains. Specifically, these studies found that the brain’s fear center, the amygdala, had much less intense reactions to negative emotions in those who completed DBT(2). This is important, as research has also found that in individuals with BPD and similar conditions, the amygdala is in fact overactive in comparison with individuals who do not have BPD.

While these physical changes are not necessarily noticeable unless under a microscope or on a brain scan, it can still be validating to know that while our brains get built during our developmental years, they can be rebuilt through psychotherapy. And you will also be able to experience these changes as you develop your toolbox of DBT skills! What we have observed in this research is testament to the fantastic work that clients and clinicians put into therapy, showing us all that hard work pays off to truly build from the brain up, your Life Worth Living.

[1] Airenti G. The Place of Development in the History of Psychology and Cognitive Science. Front Psychol. 2019 Apr 24;10:895. doi: 10.3389/fpsyg.2019.00895. PMID: 31068874; PMCID: PMC6491641.

[2] 1 Iskric A, Barkley-Levenson E. Neural Changes in Borderline Personality Disorder After Dialectical Behavior Therapy-A Review. Front Psychiatry. 2021 Dec 17;12:772081. doi: 10.3389/fpsyt.2021.772081. PMID: 34975574; PMCID: PMC8718753.

November 23, 2022
Trick or Truth? How to Change Unwanted Emotions by Checking The Facts
Picture this: You’re alone in your home and hear a loud sound coming from the next room. Immediately you think, an intruder is in the house. Panic sets in and your heart starts racing. You’re terrified, of course, because you’re in danger. . .or are you?

Research shows that often it’s our interpretation of an event, rather than the event itself, that leads to unpleasant emotions and potentially ineffective responses. Take the above example: If you thought an intruder was in your home, perhaps you’d barricade yourself in your room and listen for hours until you felt sure it was safe to come out. Maybe you’d try shimmying down your fire escape to get to safety. Maybe you’d freeze in your tracks, paralyzed with fear. But let’s step back for a moment and think about what are some other possible reasons a person would hear a sound coming from the room next door when they thought they were home alone?

Maybe the heat turned on and the radiator is the culprit.

Maybe a pet knocked over something.

Maybe a family member came home early from school or work.

If you came up with any of those reasons or other benign possibilities, then you probably realized that scaling the firescape or building a barricade might not have been the most helpful move. Altering your interpretations and assumptions about a situation can help you change your emotional reactions to it and even respond more effectively to it. But how do you go about shifting those beliefs? In DBT, we use a skill called Check the facts.

Checking the facts helps us figure out whether our emotions, their intensity, and/or duration, are actually working for or against us in a given situation. It encourages us to ask ourselves, Am I responding to what’s directly in front of me right now, or to my own thoughts about it?

So how does one check the facts? Follow these six steps:

Step 1: Ask yourself, What is the emotion I want to change?
- I always say, “You gotta name it to tame it!” Labeling emotions is a powerful first step in being able to manage them. Take a moment to observe your thoughts, physical sensations, and urges. You can also rate the intensity of the emotion on a scale from 1-10 or 1-100. Rating your emotions before and after trying a skill can help you evaluate if it was an effective intervention.
Step 2: Ask yourself, What event sparked this emotion?
- Here you want to be sure to only describe the facts that you directly observed. Use your five senses to help you. What did you see? What did you hear? Oftentimes our descriptions of events are infused with assumptions, judgmental language, and extreme interpretations, which can spark intense unpleasant emotional reactions. Sticking to the facts of a situation can help us balance our emotions.
- Take a look at the two statements below and consider which one evokes a stronger or more unpleasant emotion:
Step 3: Ask, How am I interpreting this event? What assumptions am I making?
- In the texting example, the first statement contains a few different assumptions and interpretations of the facts. First, the narrator assumes they aren’t receiving a text back because the other person “hates” them and thinks they’re an “idiot.”
- Once you’ve labeled the judgments, assumptions, and extremes in thinking, come up with some other possible innocuous interpretations. Oftentimes, we have a negativity bias that keeps us from viewing all sides of a situation, so considering benign alternatives can help balance things out. Here are some examples:
Step 4: Ask yourself, Am I assuming a threat?
- Oftentimes unpleasant emotions are the byproduct of thinking that some type of feared outcome is on the horizon. You get a D on a test and figure you’ll fail the course. You wave to a friend who doesn’t wave back and assume he’s angry with you. You get passed over for a job opportunity and conclude that you’ll never rise up the ranks.
- Once you’ve labeled the threat you can ask yourself, How likely is it to occur? What are the chances that this horrible thing I’m imagining actually comes to fruition? Usually, once we step back and start asking critical questions, we see that the undesirable outcome isn’t as likely as we’d originally thought.
- Going back to the texting example, it’s possible that the narrator has concluded that not receiving a text back means the texter is angry with them for something they did, or maybe even that the relationship is over. It’s now up to the narrator to consider what are the odds of those threats coming true.
Step 5: Imagine yourself coping with the catastrophe
- Sometimes the threat really does happen, but spiraling out rarely helps the situation and frequently exacerbates it. Instead, DBT encourages folks to consider what coping with the situation would look like. So how would you deal with failing the course or losing a job? How would you handle it? What would your next move be?
- It can be helpful to actually visualize yourself coping well with the situation. Picture yourself handling it effectively, and jot down the steps you would take to do so.
- If the narrator in our example was broken up with, perhaps they’d start off by talking to a friend about how disappointed they are that the relationship is over. Maybe they’d spend some time doing fun activities they enjoy to bring some positive experiences back into the picture. Having an action plan and envisioning things going well can help lower the intensity or reduce the duration of an unpleasant emotion.
Step 6: Reflect on your emotions now
- Now that you’ve gone through the above steps, you can ask yourself, Does my emotion fit the actual facts of the situation? Remember, a lot of times our emotions are set off not by the events themselves, but by how we think about them.
- That said, there are totally times when your emotions will fit the facts. Every emotion, including fear, anger, sadness, jealousy, and more, has its place and makes sense in certain situations. Even if you find that your emotion was justified given the facts, I’d encourage you to check your emotional temperature. Is it as high as it was in step one? Sometimes walking through the above steps is enough to help modulate the intensity of an emotion or curb its extent.
Stay tuned for more ways to get unstuck from emotions in our next blog post!
November 1, 2022