Behavioral Psych Studio

Category: blog

  • Owning Your Attachment Style

    Owning Your Attachment Style

    Turns out I am anxiously attached…so now what?!

    Thank you, readers, for patiently waiting! Now that we have learned about what the heck Attachment Style is, we can apply some DBT tools that can help assist us in owning our attachment in a way that maintains our self-respect, our relationships, and our needs!

    Imagine…you have been on three dates with someone you met on the apps. It has been going super well…or so you thought. That is, until they left you on read for two days and now you are spinning…

    What did I do wrong?

    Not again… I am destined to be alone.

    Why does this always happen to me?

    I knew it was too good to be true.

    I simply can’t tolerate it until I figure out what they are thinking!

    Before you say or do something you might regret, let’s slow it all down and lean on our DBT skills with the steps laid out below:

    Step 1: Check SUDS

    Check your emotional temperature. SUDS stands for our Subjective Unit of Distress Scale. Think about asking yourself where you fall on a scale of 0-10, where 0 symbolizes pure serenity and 10 symbolizes the most distressed you can imagine feeling. If you are lower than a 6 AND you trust that you will not act in emotion mind, (hot headed, urgent, impulsive) then skip to step 3. Otherwise, continue to step 2.

    SUDS are a 9.

    Step 2: Tolerate distress

    Take a beat. Before saying or doing the thing that will likely damage the relationship or your self-respect and most likely not get you any closer to your objective, try the STOP skill or one of your other DBT crisis survival skills: Distract with ACCEPTS, TIP, Pros/Cons, or Self-soothe. Set a timer for 20-minutes as you one-mindfully use your Distress Tolerance skills and allow your emotional temperature to reduce to a comfortable number. You may not feel “good,” but we are aiming for “slightly better.”

    I put my phone down, take a 10-minute cold shower (TIP) to calm my nervous system, I set a timer for 20-minutes and one-mindfully watch an episode of Never Have I Ever (Distract) until I feel my emotional temperature simmer down.

    Step 3: Mindfulness of internal experience

    Now that your SUDS are tolerable and things feel a little less dire, try to label your emotions, body sensations, urges, and thoughts. Become a curious observer of your internal world.

    My SUDS are a 4. I am feeling fear. I have a tightness in my chest and jitteriness in my limbs but it is not as bad as before. I have urges to reach out and I also have urges to ruminate about the unknown. My thoughts are telling me “this is over” and “I will never find love.” I am noticing that my anxious attachment is activated right now because I am feeling afraid of abandonment in the presence of disconnection and uncertainty.

    Step 4: Identify your goals

    Identify what your goals are (more specifically, your long-term goals). Sometimes your goals might compete with one another, and we must choose to prioritize one or two over the other at any given point in time. What is your self-respect goal, your objective/need goal, and your relationship goal?

    Because I do not know this dating prospect well, my relationship goal is to continue seeing this person and continue to be in their good graces. I don’t want to blow it before giving it a real chance! My self-respect goal is to correspond with this person and also to regulate my emotions in a way that I can feel proud of. My objective/need is to connect with this person. I recognize that relieving my anxiety in the moment is a short-term objective whereas upholding my self-respect is a long-term objective.

    Step 5: Act in Wise Mind

    The penultimate step is to act from a place of wise mind. Wise mind could tell you something very different depending on who you are and what the context it. Your wise mind is your intuition and your inner knowing. We’ve all got one. It is a state of mind that guides you towards the life you want to be living.

    Wise Mind tells me that for now, I want to prioritize my self-respect and my long-term objectives, which means tending to my emotional experience, without projecting my fears onto this person. While it would feel good in the moment to try to connect and double or even triple text (think protest behavior), I know it will compromise my long-term objectives. Wise mind tells me that it would be advantageous to soothe myself and validate my fears, focusing on connecting with well-established and safe relationships in my life. I may decide to voice my needs for more frequent communication in the future AND my wise mind tells me that it does not feel appropriate to the relationship right now. I will choose to accept the uncertainty in this moment.

    Step 6: DEARMAN

    If the context calls for it, you may lean on your effective communication strategies, such as DEARMAN, to accurately and effectively communicate your needs to someone else. Your aim is to accurately communicate your feelings and your needs in a way that is clear and fair, both to you, and the other person.

    Instead of communicating to the person I have been on three dates with, I called my friend and let her know how painful it is to feel attachment wounds early on in dating. She was able to validate my experience and I was able to feel connected to my friend.

    For more information on this topic, you can tune into our back-to-back episodes on our podcast, House on Fire.

    References:

    Mundin, Dr. Joann, and Katarina Schultz. DBT Self Help, 8 June 2023, dbtselfhelp.com/.

     

  • Attachment Styles

    Attachment Styles

     

    Do any of the following thoughts ring true for you when dating or in relationship?

    I feel smothered.

    She is way too needy.

    They always leave.

    He doesn’t respect my space.

    I feel comfortable being close to my partner.

    I feel anxious when I am away from my partner.

    These beliefs in relationship held by you and/or your partner are best explained by attachment theory. I will be referring to Amir Levine, M.D. and Rachel S.F. Heller, M.A.’s book, Attached, which in my opinion is the holy grail of attachment style books.

    What is Attachment Style?

    Attachment theory, originally ideated by John Bowlby in the 1930s and further developed by Mary Ainsworth’s, Strange Situation experiment in the 1970s theorizes that as infants we develop styles of attachment to our caregivers, which often informs how we attach to our loved ones as adults. Bowlby proposed that we have a biological need to depend on others for our own safety and protection. We remain safe by maintaining connection with our caregiver, who is responsible for providing nourishment and security as early as our development in the womb. This attachment mechanism is impacted by our bond, or lack thereof, with our primary caregiver. Genetically, we are programmed to maintain connection; however, if we do not have a predictable or secure environment, then maintaining connection to our caregiver or trusting that our caregiver will be dependable, may be less adaptive and interfere with developing a secure attachment mechanism. If I know that when I cry and scream, my mother will sometimes be able to soothe me and sometimes neglect me, then I may develop an insecure attachment, unsure of how to get my needs met. Across the life span, attachment style is based on our view of intimacy, how we deal with conflict, attitude towards sex, ability to assert our needs and communicate our feelings, as well as our expectations from our partners and relationships. Ainsworth discovered that there are three main attachment styles described below: Anxious, Avoidant, and Secure. Less common (in about 8-9% of the population) is a fourth attachment style; Disorganized (or fearful).

    Anxious Attachment:

    Making up about 20% of the population, anxiously attached individuals are often preoccupied with maintaining connection in their relationships and fear perceived or real threats to abandonment. Someone with an anxious attachment often desires a lot of closeness in relationship, expresses insecurities, fears rejection, and often negatively interprets their partner’s actions. They often have a sensitive attachment mechanism. In an attempt to reestablish connection with their partner, they might engage in “activating behaviors” also known as “protest behaviors.” These behaviors might look like tantrums or crying spouts as a child and as an adult they can look like acting out, picking a fight, withdrawing, threatening to leave, or trying to provoke jealousy. While their need for connection is valid, these behaviors can often push others away, reinforcing their fear that others cannot meet their needs for emotional safety and further emphasizing that they are destined to be alone.

    Avoidant Attachment:

    Making up about 25% of the population, avoidantly attached individuals value their independence, are emotionally self-sufficient, and fear closeness in relationships as a threat to their emotional safety. These individuals, like anxiously attached individuals, also have an insecure attachment mechanism; however, it manifests differently. While avoidants also learn that they cannot depend on others, instead of activating or “getting louder” to get their needs met, they often prefer to withdraw and engage in “deactivating behaviors.” These behaviors include using distancing strategies (emotionally or physically) when their partner gets “too close,” thinking that they cannot trust their partner, difficulty committing to a relationship, shutting down, avoiding difficult conversations, and sometimes belittling or criticizing their partner. While their need for emotional safety is valid and while maintaining emotionally self-sufficiency has most likely been adaptive as a child, these behaviors create distance and thus conflict in relationships, which further reinforces their ingrained belief that they are better off alone.

    Secure Attachment:

    Making up about 50% of the population, securely attached individuals are comfortable with closeness, accurately express their needs and feelings, are dependable, are flexible in their thinking, are comfortable with commitment, are trusting of others, are consistent in their behavior, and do not often feel threatened by boundaries and healthy distance. Secure individuals still have needs, as we all do, they are just better able to identify them, communicate them, and tolerate them when they are not met. Secure individuals also take partial responsibility for their partner’s well-being.

    The commonly held beliefs, “You shouldn’t need to rely on anyone” and “Depending on others is unhealthy” are myths. There is a healthy amount of dependence on others that is essential for our survival and happiness from the womb all the way to the grave. The trick is to identify your attachment style and subsequently learn tools to replace ineffective, activating or deactivating strategies, with effective strategies. While our attachment style is fairly consistent across the life span, it is malleable and possible to move from an insecure attachment to an “earned secure” attachment. Stay tuned for skills in the next blog post for how to own your attachment style, improve your relationships, and even earn a secure attachment!

    References

    Levine, A., & Heller, R. (2011). Attached: The new science of adult attachment and how it can help you find–and keep–love. TarcherPerigee.

    Mcleod, S. (2023, June 4). Attachment theory: Bowlby and Ainsworth’s theory explained. Simply Psychology. https://www.simplypsychology.org/attachment.html

     

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

    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.

     

     

  • Cut That Cord! A Parent’s Guide to Using Opposite Action

    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.

  • Addressing Body Image Concerns Using Mirror Exposure

    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.

  • The Adolescent Brain

    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/

     

     

     

    .

  • Start SMART this New Year

    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.  

  • The Mindful Brain

    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.

  • Thinking Dialectically about Recovering from Addiction

    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!

     

  • Science & Society: The DBT Brain

    Science & Society: The DBT Brain

    Science & Society: The Neuroplastic 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.