Category Archives: Individual Therapy

PTSD Veteran

PTSD and Veterans

Veterans risk their physical safety, and that is only the beginning. Many veterans exposed to combat suffer with behavioral health issues as a result of their service. The suffering can be intense. Posttraumatic Stress Disorder (PTSD) may impact as many as 20% of Iraqi war veterans. While it may not seem possible, there is help. PTSD is one of the most intense and debilitating issues one can have, but there is very effective treatment that works very quickly and the results last.
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Anger Expression Styles

Anger Expression Styles

So there are a number of different anger theorists who have talked about different kinds of anger styles. But the one I’ll mention breaks anger styles into three forms of expression. So there is “anger out”; and “anger out” typically looks like the kinds of behavior we see with someone that we consider to have a temper. So they become very angry and then they are going to be doing things like yelling, they may be using profanity, they may smash cell phones or pound their fist on a desk, or something along those lines, destroy property.
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What is anger

What is anger?

What is anger?

Anger is a negative feeling and when it comes in frequencies and intensities and durations that are in the normal range, it can be quite healthy. Unfortunately, when it becomes really intense or really frequent and it is paired with behaviors that are problematic that are aggressive or uncooperative, it can cause big problems and people can run into anger management issues.
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Anger Management and Aggression

Cold Anger

Anger and Aggression in the Harsh Winter

Anger management is important year round. I haven’t seen evidence that there has been more aggression or anger outbursts this year because of a harsh winter. But there are good reasons to suspect that could be the case as our nerves become frayed.

Hot temperatures are frequently thought of as putting us at risk for violence. But there is a great deal of scientific evidence that any environmental factor that makes us uncomfortable can lead to aggression. Certainly bitter cold temperatures can do just that.

Anger is often thought to precede aggression, and many times it does. But most of us do not realize that other emotions put us at risk for aggression too. There is ample scientific evidence that any negative emotion, e.g., anxiety, guilt, loneliness, etc. make the likelihood of aggression more likely. So a difficult winter that may lead to less social contact or make us more nervous because of driving conditions could certainly put us at risk for becoming aggressive.

Another predictor of aggression is frustration. In the social science literature frustration occurs when a goal is being blocked or a desired outcome is prevented from occurring. Big snowfalls can lead to just that. People are stuck in their homes or can’t get their cars out their driveways and are prevented from completing all kinds of goals. And it is easy to see how those situations can also lead to more and more negative emotions, putting us at greater risk of becoming aggressive.

Rational Emotive Behavior Therapy

REBT-Rational Emotive Behavior Therapy

Rational-Emotive Behavior Therapy (REBT) was developed by Albert Ellis. Dr. Ellis  who was originally trained in psychoanalysis. After completing his doctoral work he began treating patients in New York City. He became frustrated by the limited progress his psychotherapy patients were making in psychoanalysis.

He then decided to turn to one of his earliest interests, philosophy. He went back and read Stoic philosophy as well as eastern philosophy. He based a new system of psychotherapy on much of this work. The hypothesis that made the most sense to him was that our emotional pain is not the product exclusively of the situation, but also our thinking about the situation, ourselves, life, and the future.

From this view of human emotion, he developed the ABC model, which is used by many Cognitive Behavior Therapists (CBT) today. In REBT, “A” stands for activating events. These are the situations, real or imagined, that trigger, or activate, our beliefs. “Bs” are these beliefs, which can be rational (or helpful) or irrational (unhelpful). Over the years the kinds and number of irrational beliefs he identified changed. The most refined version of REBT beliefs includes four core irrational beliefs and four alternative rational beliefs.

Irrational Beliefs

Demandingness (DEM)
Low frustration Tolerance (LFT)
Awfulizing (AWF)
Global Evaluations (Self-downing; SD)

Rational Beliefs

Preferences
High Frustration Tolerance (HFT)
Badness rating
Unconditional Self-acceptance (USA) or Unconditional Other/Life Acceptance

REBT posits that the combination of activating events (As) and beliefs (Bs) produce consequences or the “Cs.” The situation (A) is interpreted and evaluated (B), which results in an emotional consequence (C). For example, if a student receives a failing grade on her exam (A), and she believes this proves it, “I’m a failure (B).” She might then feel depressed  (or depressed and anxious) (C). That particular consequence is an emotional consequence (Ce). When feeling that way, certain behaviors become more likely than others. When we are depressed, staying in bed may become more likely than going to the gym. These are behavioral consequences (Cb).

REBT therapists target behavior change largely by identifying the events, irrational beliefs, and then emotions that precede the behavior they want to change. The most common intervention is to dispute (D) the irrational beliefs, i.e., asking challenging questions to reduce the strength of the irrational belief. Then once the client no longer believes the irrational beliefs as strongly, an alternative rational belief can be selected to rehearse (E; effective new philosophy).

In this case, an REBT therapist may help the client, through disputation, to recognize that even though she may have failed one exam, it does not logically follow that she becomes a failure. It may take a great deal of effort on the part of the therapist and even more on the part of the client to get there. The hope is, she will eventually let go of the belief that she is a failure, and can rehearse and practice behaviors to support the rational alternative. The rational alternative to the global evaluation/self-downing (“I”m a failure”) belief would be unconditional self-acceptance (USA). If she can accept herself unconditionally, regardless of what grades she receives, she can be more emotionally stable. Without the thinking that “I’m a failure” could be looming, the client can become less anxious she will become depressed again. Now if she fails at something, she can practice unconditional self-acceptance, and tell herself, “even though I fail at things, I do not become a failure– I do not become what I do.” This new attitude can inoculate her against self-defeating thoughts that “dog” her. And this new accepting attitude can reduce or prevent feelings of depression or anxiety that she may become depressed again. Without the anxiety she may be able to concentrate more when studying, hopefully decreasing the possibility of failing future exams.

REBT therefore aims to change beliefs in order to reduce not only future negative emotions, thereby making adaptive behaviors, e.g., effective studying, more likely, but also intends to reduce failures. Since intense negative emotions often lead to poor judgement, impulsive actions, or unhealthy coping, e.g., procrastination, drinking, overeating, etc… REBT aims to improve behaviors and life circumstances over time, by first changing thinking and feelings. So while it is a cognitive model of psychotherapy, it by no means ignores improving behaviors and life circumstances. REBT simply believes the closest target to emotion is cognition, and changing that link alters for the better the entire chain reaction, resulting in better behaviors and eventually improved life circumstances.

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[fontawesome icon=”fa-file-text-o” circle=”no” size=”medium” iconcolor=”#000000″ ] REBT Self-help Form – CBT Worksheet

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REBT References

A synopsis of rational-emotive behavior therapy (REBT); Fundamental and applied research. David, Daniel; Szentagotai, Aurora; Eva, Kallay; Macavei, Bianca
Journal of Rational-Emotive & Cognitive-Behavior Therapy, Vol 23(3), 2005, 175-221.

REBT and ACT

https://api.soundcloud.com/tracks/169254431

REBT (Rational Emotive Behavior Therapy) Interview can be heard on the link above.

Rational Emotive Behavior Therapy (REBT) and Acceptance and Commitment Therapy (ACT) are compared in terms of how psychotherapy would be conducted.  Cognitive Behavior Therapy (CBT) and Behavior Therapy are similar, but are based on different theoretical models.  REBT is rooted in a cognitive (CBT) theoretical model, while ACT advocates emphasize models of learning without reliance on cognitive restructuring.

Acceptance and Commitment Therapy (ACT) and Rational Emotive Behavior Therapy (REBT) Transcript

J. Ryan Fuller: Ok, I am Ryan Fuller and I am very pleased to be with Dr. Windy Dryden, the author of well over a 180, soon 200, books on Rational-Emotive Behavior Therapy and many other topics on counseling and psychotherapy. He is currently a professor at Goldsmith College and has a successful private practice and I am pleased to have you in the office tonight.

Windy Dryden: I am pleased to be here.

J. Ryan Fuller: So, we’ll probably cover a variety of topics, but I wanted, in particular, to make sure that we touch on a couple of elements. One, the future of Rational-Emotive Behavior Therapy and perhaps even some reflection on historical changes in the, sort of, evolution of the therapy over time. Also, maybe some comparison between REBT and ACT, which has currently received a lot of scientific attention and clinical attention. So if you would, first, maybe start with the historical and kind of move through in a temporal fashion and obviously through the development of REBT Albert Ellis even changed the name at different times and might have emphasized different things. I was wondering what particular kind of changes that you saw as, sort of, the most important or idiosyncratic that, sort of, differentiate REBT from other therapies.

Windy Dryden: From when were you thinking? J. Ryan Fuller: Really, the beginning, in the mid-50’s when he started off with a much larger number of irrational beliefs and then changing over time, incorporating more of an emphasis on behavior and things like that. Windy Dryden: I think that, the kind of, the major distinctive feature, if you like I think, stayed fairly constant, although I think the way that this particular concept has been put forward and, sort of, modified a little, is the emphasis on a concept known as beliefs. Now, in beliefs, which I think is a very distinctive feature, now, the way I tend to look at it is like this: human beings have a built-in mechanism to either prefer certain things to happen and for other things not to happen. It is, that is a built-in mechanism, which no amount of modification is going to change. Now, when people keep their desires flexible, they end up with an idea that I want something to happen but it doesn’t have to do so vs. they are transforming their want into something, which is rigid, I want something to happen and therefore it does have to do so. It is, I think, one of the defining features and distinctive features of REBT that Albert Ellis really emphasized. In his list, his original list, of irrational beliefs in which, I think, he kind of emphasized more the concept of rigidity, absolutism, and the like later on. In fact, if you look at his original list of irrational beliefs, well, I think he called them irrational ideas in those days, some of them wouldn’t pass muster as irrational beliefs now, more like, sort of, distorted influences. So I think that that particular concept is fairly distinctive and defining to the rational-emotive approach to cognitive-behavioral therapy. And I think one of the things that Ellis had been very good at over the years is that he is showing how his therapy is relevant to the changes of the zeitgeist, in terms of for example, the late 60’s he showed how his ideas could be applied to rational, ….. rather, and he developed rational ideas to how it could be applied to marriage and family counseling. He showed how it could be applied to pastoral counseling and so he’s been very good at showing the application of his ideas. In terms of the development of those ideas, I think that the real, sort of, emphasis towards the end of his days, really, was to show how people could really develop constructivistic ideas, so he really, kind of, tied down his theory out of constructivism. And he had no doubt, if he was alive today, I think he probably did just before he died, show how rationality and the rest of the behavioral approach could be applied to the concept of acceptance. In fact, I think that he and Hank Robb wrote a contribution to Steven Hayes’ edited book on acceptance and change in the 1980’s, I think, or the 1990’s.

J. Ryan Fuller: But before you…let me interrupt for one moment. I definitely want you to flush out the contributions to self-acceptance but you mentioned constructivism and the contributions it can bring. Can you just maybe expand on that a little bit for those listeners who may not be familiar with the idea?

Windy Dryden: Well, the idea is really that we as human beings, we construct various ideas instead of being, sort of, that we are not passive recipients of those ideas, although, I think you can listen to clients, kind of, talk as if they were rather passive in those ideas. Now, Ellis would argue that, although we are born with a tendency, you know, towards constructivism, in his ideas there is a definite emphasis on the idea that we actively develop and construct our, kind of, rigid ideas from the basic, kind of, idea that we want certain things to happen and don’t want certain things to happen. And then we can certainly construct rational ideas, so I don’t really think that necessarily that this was absent in REBT’s, sort of, theory prior to constructivism. But I think he saw that there was a contribution to be made. And he made it and he’s actually written some ideas, some articles on constructivism. So, I think what Ellis was very good at was in terms of propagating his ideas and showing how they could be applied to whatever was hot in terms of the day.

J. Ryan Fuller: So he was rather flexible at least in taking maybe strong beliefs he had about his theory but really, sort of, making them pertinent to what the zeitgeist of the time was.

Windy Dryden: Oh yes, absolutely.

J. Ryan Fuller: Probably made him quite adaptive and successful in the therapy office but maybe also in the larger psychotherapeutic community.

Windy Dryden: Yes, and he would write articles on the application of REBT in terms of whoever was actually kind of popular in the day.

J. Ryan Fuller: Ok. Um, if we could… I cut you off and kind of sidetracked you when you were speaking about acceptance and how he’d contributed with Hank Robb, I think, to an edited book by Steven Hayes in the 80’s.

Windy Dryden: Right. I think that certainly the thinking within the REBT community has moved on and certainly I think that the acceptance is not only applied to oneself and when it’s done that, it’s based on a certain view of human beings, which are factual. The fact, which I don’t think anybody could really deny, is (1), that we as human beings are fallible, and you can’t really dispute that. (2), that we are too complicated, too complex to be given a single rating that completely defines us. Can’t argue with that. (3), that we are in flux and we constantly change. You can’t deny that.

J. Ryan Fuller: You can’t deny that, is that what you said? Windy Dryden: You can’t deny that. I mean, I, you know, in somebody who is, you know, sort of, just kind of artificially alive is probably going to change in some, losing a few, kind of, you know, aspects of skin, their cells are changing. You know, we are constantly in flux. Finally, the idea that we are unique. Even if, you know, you were cloned, your clone would be different from you because even if you carried your clone around with you on your left hand-side, your clone would still see the world from a slightly different angle than you. That would have some sort of impact on your clothes. And so that’s a completely interesting idea to Ryan Fuller. So those, now, that idea that we can accept ourselves as that, is a difficult idea for quite a lot of clients to … ,really to, what is the easy word, accept and kind of digest. Because we, in a sense, it’s basically saying, “do not give yourself a rating to completely and utterly account for you”. Certainly rate aspects of yourself, evaluate what happens to you, but don’t, kind of, jump to an evaluation, a total evaluation of yourself. Do not do that towards others, and do not do that in terms of the world or life conditions in general. Now, I see that these are concepts like self-actualization, that nobody is going to be able to do that perfectly but it is just something to strive towards. And it’s mainly, kind of, a strive towards because not only is that a factual statement and probably a logical conclusion based on experiences, but also that it will have a particular impact on our psychological, emotional health. So, acceptance can be applied as an attitude, as a stance, as a position. J. Ryan Fuller: In a way, it’s a process, you’re saying, without end.

Windy Dryden: Without end. J. Ryan Fuller: So it’s not achieved… Windy Dryden: No, it’s not achieved once and for all. In a sense you can never say you’ve cleaned your teeth once and for all and now you are perfectly clean and do not have to be cleaned. They involve some maintenance.

J. Ryan Fuller: Right. You don’t achieve hygiene, rather, it’s something you do on a regular basis. Windy Dryden: That’s right. You can’t achieve it once and for all. You can achieve a certain level of hygiene, but you have to maintain it. And I think that that is the same as what is the concept of acceptance, if you like, as a philosophy towards the self, other people and the world. Now, what I am particularly interested in is the kind of relationship between ACT, Acceptance and Commitment Therapy, which is, kind of, you know, stems from a radical behavioral view. I think, to kind of cut to the chase here, its view is, you know, there is no real value to be gained in challenging and examining cognitions. J. Ryan Fuller: The content, to change the frequency necessarily or the duration…

Windy Dryden: That’s right. Don’t change the content. So you acknowledge that this particular thought is happening, then you actually commit yourself to whatever it is that is important to you. J. Ryan Fuller: I am going to engage in some kind of behavior to some degree independent of the content of the thought or thoughts that I might be experiencing and hopefully that behavior is in line with what is important to me, that I value. Windy Dryden: Exactly. Now I think that that is a good approach under certain conditions within the Rational Emotive Behavior Therapy process. And I particularly think that this is a good way of approaching things according to the following idea. If we go back to the ABCs of REBT where A stands for, let’s say, adversity (I think this is what we call it these days), an activating event, some negative event, some adversity. B stands for the belief system. And C, the consequences of holding this belief system of the adversity. Now, there are three main consequences, which are interrelated. The emotion consequence, we experience a feeling, when we have a tendency to fail or when we encounter an adversity and we hold either a rational or an irrational belief of that adversity. We also experience a behavioral consequence, or a tendency to act in a certain way. I am using act in the behavioral sense, not ACT as in Acceptance and Commitment Therapy sense. So when we hold again either a rational or irrational belief of an adversity, we behave in a certain way or we tend to behave in a certain way, which we can suppress. That’s one of the beauty of things of human beings, we can, actually, convert out urges to act to actions or, kind of, not act on them or we can suppress them. J. Ryan Fuller: Can you just flush that last piece out? We can convert our urges to actions, meaning I can behave while I am experiencing the urge and then the urge dissipates? When you say conversion….

Windy Dryden: No, I can act on the urge. If I have the urge to punch you in the face, which I don’t because we’re good friends, but that’s idea – we can either choose to act on the urge and actually punch you in the face, or I can choose not to act on that urge.

J. Ryan Fuller: So an urge, if we take a behavioral standpoint, is a stimulus, right? So there is this discriminative stimulus and I might with free will, or depending on our philosophical take, behave in one or another way.

Windy Dryden: Yeah. But the beliefs about the adversity will actually pull me in a certain behavioral way. One of the things that I’ve tried to do is to bring this… Before I go there let me finish the, kind of, final piece of the jigsaw. The final piece of the jigsaw is that when we experience a belief, either rational or irrational, about the adversity, that affects how we subsequently think.

J. Ryan Fuller: So the thoughts that might follow after the A and the B and temporarily there is a consequence that’s that thought, and maybe it’s more metaphorical in terms of the order but there are thoughts that come about the consequence.

Windy Dryden: Yes, and these thoughts, because they have been processed by our beliefs, they are kind of like you often call it “under the influence” of a certain belief. Let’s suppose that you, under the influence of an irrational belief, tend to think irrationally about a certain adversity. And that, you subsequent thinking will tend to be highly distorted, skewed to the negative.

J. Ryan Fuller: So there is selective abstraction taking place, we’re sort of filtering and priming.

Windy Dryden: That’s right. And I see that’s the REBT view, which Albert Ellis and I wrote to make that point in our book the Practice of Rational Emotive Behavior Therapy in the late 1980’s as a matter of fact. I couldn’t see it at that time, he saw it, the importance of what we were saying. And that is, you know, the cognitive distortions that Aaron Beck and David Burns talked about in the beginning, are really, a lot of them are cognitive consequences of irrational beliefs. So it actually kind of helps therapists to some degree with some clients who can use this framework, this somewhat complex framework to understand how their mind works.

J. Ryan Fuller: If we could, maybe, it might help some of us to understand if we, in fact, plugged in some content in an A, a B, an emotional consequence, a behavioral consequence, and then the thoughts, the cognitive consequences.

Windy Dryden: A common example, for example, is somebody who has public speaking anxiety and they become anxious about a certain threat. And the threat might be that “my mind might go blank”. It is a common fear that people have when they are in public speaking or, you know, about to speak. Now, that would be regarded as the A, that they would predict that their mind is going to go blank. Then they would evaluate that or bring their beliefs to that and their beliefs are either “my mind must not go blank”, “it would be terrible if my mind went blank”, or “look, I really don’t want my mind to go blank but if it does, I am not immune from it and I don’t have to be immune, and it would be pretty uncomfortable but it would not be the end of the world”. So if you have an irrational belief and you think that your mind will go blank, and that sort of threat becomes active, therefore your beliefs become active, you will then tend to think various things like, “If my mind goes blank, everybody will notice, I will develop a bad reputation, it will affect my job, I might lose my job, and I might not get another one”. Ok? You can see how that is much more distorted in character than the prior inference “my mind might go blank”, which is a possibility but the person who actually probably sees it as a high probability. Now, the REBT therapist would, kind of, do it differently than a cognitive therapist. Initially, you would say, “well, let’s assume it does”, so you can gain access to their beliefs, and do work on their beliefs.

J. Ryan Fuller: So rather than challenging the inference, for example, an REBT therapist might emphasize, “let’s assume the worst case scenario”…

Windy Dryden: “Let’s assume your mind is going to go blank, what can you do, you know, to minimize that, etc. etc.” We would tend not to do that initially.

J. Ryan Fuller: Let me just make sure we make that clear. So, and by doing that with the A, by sort of saying, “let’s imagine my mind does go blank”, the emphasis is going to be placed on the B, the belief about that possibility.

Windy Dryden: If you have…it’s theory consistency…if you have an idea in your theory, a main concept, that people’s emotional, behavioral, cognitive response to adversity is mediated largely by these beliefs, and your disturbance is mediated by irrational beliefs, it’s important to get at those beliefs.

J. Ryan Fuller: So the focus is going to be placed on the belief, not necessarily trying to convince someone that their expectations might be unrealistic to reduce the probability, the likelihood that I think some activating event is going to occur even when the probability I might be using might be overinflated. And by targeting the B, there is going to be a greater…we’re going to be able to generalize it across different activating events and therefore a more elegant solution is Ellis’.

Windy Dryden: Yes, although, you know, that will come later because people like to generalize in it too quickly, before they actually kind of worked through, you know, whatever is that they are disturbing themselves about but a particular situation. Now, if you take these consequences, that we are talking about, you know, these very very negative consequences, and this is the bit I want to emphasize in terms of how REBT can use the ACT idea, when you helped somebody to challenge their ideas, their beliefs rather, irrational beliefs about their mind going blank, particularly when they are approaching the situation, then there it’s a bit like going to the gym. You know, you don’t expect to go to the gym, have a workout, and be thoroughly fit. You go to the gym to, kind of, put in investment, if you like, toward your physical fitness. So, when you encourage the client to challenge their irrational beliefs, it’s the same thing. You don’t hopefully as the therapist think that therefore they are going to believe that and all these consequences are going to change. So, I see what happens is, I think that when a client is rehearsing a rational belief, which still needs to be acquired more, and they are in a situation, which, you know, that they find threatening, they are still going to have these distorted cognitive consequences at sea. They are still going to…part of them, part of their mind is still going think, “you know, even though I am practicing saying to myself, it’s not terrible to have my mind go blank, I am still having these thoughts, you know, that if other people notice, it will ruin my career”. Now, if you help people understand the status of these thoughts, that they are, in a sense understandable, somewhat habitual, because you have been practicing that way; thoughts which are still the, kind of, still stem from irrational beliefs which they have been rehearsing for the rest of eternity, they are still going to be somewhat activated. You can learn to not engage with those thoughts, you can learn, in a sense, to accept them. You can learn, because they are these consequences of these irrational beliefs, you can learn to accept them and this is where the bit that I say it’s important that you don’t suppress them, that you don’t distract yourself from them, nor do you engage with them.

J. Ryan Fuller: Meaning, to try to dispute a cognitive distortion that at this point is in the consequence column.

Windy Dryden: You may, kind of, want to challenge it once, but don’t expect it to, kind of, disappear. It’s still going to be active.

J. Ryan Fuller: So if I continue to dispute with it, in your term engage with it, that, in fact, might be dysfunctional to pursue.

Windy Dryden: Right, it’s like an itch. You know, one of the things is, if you tried to ignore it, you are not going to be able to. If you scratch the itch, you are going to make it worse. So, it’s like an itch. You, kind of, recognize the itch is there, and you kind of say, “ok, the itch is there, I know what this itch means, and I know what I need to do. I am tempted to, kind of, get rid of it, tempted to scratch it but I know what it is, so I am going to get on with whatever is I would be getting on if this itch wasn’t there. So I think that dealing with cognitive consequences, after perhaps an initial challenge, of both the irrational belief and the cognitive consequence itself, it would be a mistake to try to re-engage with it, because you re-engage with it, you are more likely to, kind of, re-activate the irrational belief. So, you accept in and in doing that you’ve actually moved forward.

J. Ryan Fuller: If I can, let me just, kind of, repeat that back to you to make sure I have a grasp of this. So, the concept is, from a primarily REBT standpoint, we have this activating event – “perhaps my mind will be going blank”, this expectancy, we’re not going to challenge that, rather we are going to see the belief that follows that, which may be something like a demand, like, “my mind shouldn’t go blank” with some derivative like, “and it would be awful it that were to occur”. The emotional consequence might be anxiety, my behavior may be procrastination and preparing or avoidance altogether…

Windy Dryden: Or over-preparing.

J. Ryan Fuller: Right. And the cognitive consequence might be some kind of cognitive distortion about, “and then I would lose my job and wouldn’t be able to have friends and colleagues, etc. etc.” So, that’s the way it’s laid out and then what you suggested, which is a bit of a change to some degree from the way REBT has been practiced by many people, is with that cognitive consequence I will dispute it once, but after that, regardless of what happens to my conviction about that one particular thought being true, I will then instead not distract myself, not engage it further, but rather accept it. As if it’s a secondary disturbance, that it becomes another…

Windy Dryden: Yeah. Now, I think there is a difference in that, because in a sense what I am trying to do actually with my clients and most of my trainees, is to help them, in a way, not take an accepting attitude towards ‘awfuls’. It’s learning which thoughts to engage with when and which thoughts not to engage with.

J. Ryan Fuller: So from my standpoint that’s, kind of, always the crucial aspect here, which is the serenity prayer, to have the wisdom to know what can be changed and what can’t and to discriminate. And so there may be some beliefs or thoughts with a level of conviction that is always going to show up in some form. The irrational belief, even if there is a high degree of conviction about a rational alternative, has never been erased or terminally suppressed; but rather it may not be the dominant response anymore.

Windy Dryden: Right. Exactly. So, what I am trying to do is, kind of, really, show that yes, I still want people to challenge their beliefs. I think you can overchallenge beliefs and I think people who are particularly obsessive-compulsive in mind overchallenge beliefs, and I think the risk there is you actually increase people’s tendency to ruminate. They ought to think that because they still have this belief, and some of the consequences that are going to happen if it’s still activated, they haven’t challenged it enough, that they have to smash it to smitherings, it has no effect on them whatsoever. And I think that people who do that actually keep their beliefs alive because they feel like they are helping them to…

J. Ryan Fuller: Reactivating them?

Windy Dryden: For example, I saw a client once and she had seen a cognitive therapist. And I did explain that I may be approaching things a little differently and that was fine by her. And she said, “Would you like to see the work that I have done with my cognitive therapist?” I said, “Yeah, that’s always good to see”. And then she turns up in my office with about, you know, two feet of self-help forms, daily records of dysfunctional thought forms. She didn’t like application but it was based on that idea that I have got to get rid of these thoughts and these beliefs.

J. Ryan Fuller: So, the conviction needs to come down or there needs to be a more general response, or perhaps even that my behavior improves…

Windy Dryden: Right. Because, you know, I think that we would all, you know, kind of, however important we are in terms of seeing the impact of cognition is that without behavioral change, as I put in many years ago, we have cognition without ignition. It’s the ignition of the behavior, which really makes the change process, you know, go hand in hand. So, the idea is that you, kind of, help people to act in ways consistent with their rational beliefs, but while kind of accepting the existence of these cognitive consequences in their mind until they go, until they fade away. And if you…

J. Ryan Fuller: And even if they don’t fade away…

Windy Dryden: And if they don’t fade away, you still, kind of, you know…

J. Ryan Fuller: I mean, I think that’s something that (1) bridges the gap between REBT and ACT, but to me it seems more the matter of, sort of, style or clinical judgment, and I think people can practice REBT and really determine which irrational beliefs are worthwhile to dispute, regardless of whether you think cognitive restructuring is taking place or not, the notion is, if it isn’t tied to a behavioral target, there may not be any reason in the first place to go after it.

Windy Dryden: That’s right. So, that’s really how I have attempted to, sort of, marry some of the continuity developments in terms of ACT with REBT.

J. Ryan Fuller: Well, that sounds quite similar. And if I can just, you know, we sort of recapped before, putting it in the REBT framework, in the ABC with the cognitive consequence coming. And then you could see how that, to some degree, is a form of secondary disturbance from an REBT perspective, where the consequence of the first chain becomes the activating event of the second. And I mean, what you described, to some degree, is the acceptance of this consequence. That, of course, sounds very very similar to the ACT concept of defusion, where we, sort of, one would allow the thought to be there. And as someone from the Zen school might examine it with openness and maybe a curiosity about judgment and evaluation and not continue to re-engage it, nor try to suppress or distract from it.

Windy Dryden: Right.

J. Ryan Fuller: Is there an upside to challenging that first time? You sort of mentioned engaging it one time.

Windy Dryden: Yes, because in a sense, we still want people to, sort of, see that, for example, like, ok, how do I know that this is going to…, you know, what the chances are that this is going to affect, you know, my whole career. You even might actually help them to see, you know, the label the kind of cognitive distortion as some of the cognitive therapists do. This is clearly what they might call catastrophizing, I don’t know, or …I don’t know. What is that particular cognitive distortion, where you kind of…?

J. Ryan Fuller: Magnifying?

Windy Dryden: Magnifying, right. So might say, “I am clearly magnifying, the chances are that I won’t do it.” Now, of course, people who have irrational beliefs about uncertainty, this is not going to be good enough, because they will say, “Not good enough. I have got to make this sure” and back they go, you see. So, with those people in particular you might just want to say, “You know, just bear in mind, though, what you’re trying to do”. This is what I say, “Let my help you see how your mind works from a rational-emotive behavior therapy point of view”. It is still, I think, worthwhile encouraging people to actually get in that practice, that once a day or once in a while practice because you’re trying to nurture a skill. And the skill is helping people to see that, you know, this is a highly distorted conclusion.

J. Ryan Fuller: I don’t have to take this piece of data as true, I can first check it out. That doesn’t necessarily mean it’s going to go away…

Windy Dryden: Right. What I want to avoid is people getting caught up with that so that they actually re-engage with the irrational belief that underpins it.

J. Ryan Fuller: So, I am assuming by doing that, from your standpoint, (1) they might be re-activating and, sort of, deepening the groove in the irrational belief, and (2) they are spending time and energy engaging with this thought as opposed to engaging in, sort of, a behavior that’s helping them.

Windy Dryden: Yeah. I think that, really, one of the things that has affected my thinking is all the research done on different types of rumination, depressive rumination, angry rumination, anxious rumination, worry. So, in a sense, the real danger is, you know, like in the Steven Hayes book, ‘Get Out of Your Head and Into Your Life’.

J. Ryan Fuller: Get Out of Your Mind and Into Your Life. Windy Dryden: Yeah, I like that idea. But there are times, of course, in your life when you want to get into your mind, so…

J. Ryan Fuller: The mind, obviously, is going to have benefits in planning and things but there may be times when it is …

Windy Dryden: Yeah, so what I am trying to do is to create an REBT based on the old idea of golden pole, which is under which conditions, which techniques are effective with which kind of patients. You know, under which conditions do you encourage people to challenge their beliefs and under which conditions do you, kind of, let them defuse from their beliefs, if you like, or accept them. And to what extent, you know, do you encourage them to, kind of, act behaviorally along the line. So, it’s, in a way, I am trying to, kind of, draw upon different developments in the, kind of, so-called ‘third wave’ approaches to cognitive psychotherapy. But, still very much maintain and preserve Albert Ellis’ basic message. I don’t think anything I said today, you know, contradicts that. It may make it a little bit more sophisticated but it doesn’t go against Albert’s basic message. And you know, strange as it may seem, I am probably more Albert Ellis in that than Albert Ellis, in my focus on really if we take, kind of, the rational belief alternative to a demand or a must and it’s so important that the client gets clear that it’s not only desire that they have but it’s important to negate that must. So, “I want to do well at this task but I don’t have to do so”. It’s the ‘but I don’t have to do so’, which really is, I think, what I emphasize. I think I have emphasized it more than Ellis in his right. If you look at his new book with his wife, Debbie Joffe Ellis, which I think is a good book, but he is not, or they are not, when they, kind of, go over their ‘musts’ or their alternatives to the ‘musts’, they are not good at actually specifying, spelling out the…

J. Ryan Fuller: The negation of the demand.

Windy Dryden: The negation of the demand. You see, so, in a way, I just want to make the point, I am still very much a core REBT-er in my theorizing and recognizing that, you know, the importance of the ‘musts’. But it is… ,I think you need to be a bit more sophisticated at times.

J. Ryan Fuller: At least it seems like discriminating the inflexible, keeping in mind what the overall goal of the process is.

Windy Dryden: Yes, exactly. In other words, we don’t want to create the idea that …

J. Ryan Fuller: That I must get rid of every single ‘must’. Windy Dryden: Totally, that’s an irrational belief in and of itself.

J. Ryan Fuller: Ok, well I have to say that, (1) we touched on a number of things that I’d like to possibly pick up with you in another conversation regarding some other differences, I think, between ACT and REBT having to do with, sort of, the mechanisms involved and how these changes take place, but I don’t think we have time now. But just to recap, it sounds like as though you are saying, there are quite a few similarities. And when I heard you earlier speaking about how this is a process, that sounded very much along the lines of what Steven Hayes and other ACT authors have talked about in terms of values, that sort of, something that provides direction that is important to me but something that doesn’t have, sort of, a fixed endpoint. And along that process there are going to be behaviors or goals that we are moving towards. And that some of the differences may be about the emphasis on the, sort of, sophisticated switch your are making in terms of the cognitive consequence being something that perhaps we can acknowledge and accept without trying to get rid of it. But that there are these, sort of, overlapping congruent pieces between the two theories.

Windy Dryden: Exactly, yeah. J. Ryan Fuller: Well, thank you very much, Windy Dryden. We appreciate you coming in and sharing your ideas. I wanted to just follow up with one quick mention. I think you had mentioned that there was a new book you have coming out and I didn’t know if you were actually able to mention this shift and how you’re tackling the cognitive consequence or if it’s that something we can look forward to in a future book.

Windy Dryden: Well, I’ve got, I mean, I always have a book coming out, that’s my addiction, you know. But I think that one place that people can actually get a hold of these particular ideas, in terms of how I have talked about them in practice, is I’ve got coming out in September two linked books. One is called ‘Dealing with Emotional Problems’ in what I call Rational-Emotive Cognitive Therapy, a clients’ guide and there’s a linked practitioners’ guide. And I certainly show how you can actually, kind of, deal with that particularly in certain emotional disorders. J. Ryan Fuller: So, clinicians can learn and clients alike how possible to deal with the cognitive consequences a little differently.

Windy Dryden: Yes, with just a little bit of how I have done this. I have written a clients’ guide and in the practitioners’ guide the clients’ guide is reproduced but in a different typeface, a heavier typeface. I show clinicians how you can apply these with clients and then, kind of, the main obstacles that can crop up at different junctures. So, that’s a sort of, kind of, fairly, like if you look at ‘Mind over Mood’, which is a very very popular and well-written and well-received book, and there is a clinicians’ guide. They approach it very differently. What I am trying to do here is, kind of, the practitioners’ is on the same page as the client but they’ve got some extra, sort of, guidelines to help them to deal with that. And one of the guidelines is how you can deal with these cognitive consequences in different emotional disorders so that the client doesn’t get re-activated, caught up in them.

J. Ryan Fuller: Great. Well, I think listeners will really benefit from getting that kind of guidance because I think as you have mentioned one of the things that really distinguishes how effective a therapy session can be, is sort of the art and sophistication of when and how to intervene with what tool with any particular client. And I think it’s something that many books can’t quite communicate.

Windy Dryden: And also, I think, the more that we can, if you like, help people to understand how their mind works, as I like to call it, what’s now called mentalization, partly, as well as how other people’s minds work, that they can actually learn to become their own therapist. And themselves know when to, kind of, challenge which thought and when not to challenge thoughts.

J. Ryan Fuller: So helping them become their own sophisticated therapist so they can be independent and autonomous.

Windy Dryden: Yes.

J. Ryan Fuller: Great. Thank you very much for coming in.

Windy Dryden: My pleasure.

 

anger management

Video to Control Anger with Deep Breathing

Anger Management – How to Control Anger with Deep Breathing

I am Dr. Ryan Fuller and I am going to talk to you a little bit about how to control anger with deep breathing. So anger is an emotion that has high levels of arousal associated with it. In fact, anger is one of two emotions that really go along with the fight or flight stress response. So in the case of a crisis or a danger, our sympathetic nervous system, that is part of our autonomic nervous system, goes into motion increasing respiration, increasing heart rate, driving up blood pressure, releasing glucose into the limbs so there is energy. All these things are really about speeding things up, so that the organism, or the human in this case, is prepared for fighting or fleeing. Now, with that said, when we’re really angry or when we’re aroused in those ways, one good way to modulate or change the anger experiences, is, in fact, to change the physiology. There are different ways to go about that, so in using relaxation techniques, one form is progressive muscle relaxation. And that doesn’t have to do with breathing techniques. But we’re going to talk today about breathing, as a form of relaxation, which makes sense in the case of anger management, because as I just said, anger has high levels of arousal in terms of physiological activation. And the research in anger management techniques has shown that relaxation skills alone are highly effective in helping people to manage their anger. So one of the skills that I like using with breathwork is very simple and easy to remember and there is scientific research to show that it really does a good job of helping to temp down the sympathetic nervous system activity. And so it’s really slowing respiration and it’s looking at a 4-7-8 ratio. What that means is we’re going to have clients inhale for 4 counts, hold for 7, and then exhale for a count of 8. Now, what’s important to know is 1, anytime you’re trying a technique like this, you do want to make sure you have spoken to your physician and to make sure there is no contraindications based on any health risk factors you have, or asthma, or heart condition. But typically, what I find is after my clients have spoken to the physician, most physicians are highly encouraging of this kind of relaxation activity. The other important thing to keep in mind is, it’s the ratio that matters the most. We don’t want people to think they have to count for 4 seconds, 7 seconds, and 8 seconds where they get a very long count and they end up passing out or straining themselves. You really want to just find the amount of time that works for you but to try to keep the ratio close to 4, 7, and 8. The main thing is that the exhale becomes much longer than the inhale. So, I will give a quick demonstration. It’s not perfectly necessary that you have to inhale through your nose and exhale through your mouth, but that’s generally the way I teach it. So the client is going to inhale to the count of about 4, hold for the count of about 7, and then exhale from the mouth to the count of about 8. So it looks like this, inhale, hold, and then exhale. And sometimes I have them exhale from a pursed lips. So even though it is a very simple, easy-to-use breathing exercise, if you do that a number of times, say you do 5-10 rounds, you’ll likely experience a relaxation response. And oftentimes, especially if I have clients who are somewhat skeptical, I’ll ask them to take their pulse beforehand especially if they are kind of worked up, to practice the response, and then take their pulse again. Again, you want to speak to your healthcare provider, your physician or otherwise, and you don’t want to do it if you are driving or something like that. But if you practice it first with a professional, and then on your own, it is something that might help you reduce intense physiological arousal, especially if it’s an anger response.

Robin Williams

Robin Williams’ Full Life

Robin Williams

I am not sure anyone would have predicted how many thoughts and feelings of so many people would be dedicated to the loss of Robin Williams. Personally, I found myself thinking about it during a morning jog, and the rest of that day. I wondered what clients of mine and everyone else would think about someone probably considered by most of us as incredibly successful, loved, rich, fortunate, and funny taking his own life. How would we make sense of it? Would there be judgment? Would people sympathize or empathize? Would people not at all be able to connect to someone seemingly having so much of what some of us long for and still suffering enough to choose to end his life? Or would this passing not have much of an impact?

It turns out my clients and, it seems Americans in general, have been spending considerable time reflecting on the passing. I was astounded how much his passing affected the national consciousness. I was also touched by the gentleness expressed in so many posts online about how his work had brought enjoyment and how much sympathy fans had for him and his family.

Initially as I ran that morning, I imagined writing about suicide and how difficult it is for many if us to truly imagine suffering so great we would do almost anything to make it stop. Hoping that with greater understanding more people could bring support to those in need and perhaps create policies and fund research to aid treatment efficacy. Originally I thought I would list some of the predictors of suicide, explain how the primary psychological mechanism was responsible, and discuss which treatments could be preventative, and how there are still people we can’t reach. I planned on explaining that many people who could be helped aren’t and there is still a group of people who receive treatment for which it isn’t effective and that these are the reasons we need more research and more open dialogues about this too common tragic end.

But as I listened to people talk about Robin Williams and as I read about him, about all of the other days of his life- not his last one, about all of his other behaviors; all of his other choices seemed so incredibly important.

While I can never know what his experiences were, it seems likely from much of what he shared publicly, even mentioning details in his stand-up acts, that he battled addiction. I don’t claim to know what or even if he had other diagnoses, but I imagine that there was considerable emotional and psychological pain that often accompany addiction issues.

But with that internal pain, there were still so many days, performances, and interactions. What became clear as I remembered movies of his I had seen, and discovered as I talked to people, was that in part so many people were so moved by someone they didn’t know because of the sheer magnitude of his contribution to our memories- he was prolific. His performances were not only Oscar worthy- but they were frequent – he gave tons of performances for children, adults- for everyone. There is no doubt there had to be many days he didn’t feel like it. Yet he gave.

I have found myself many times quoting his Scottish golf bit from one of his performances. In fact, in between finishing that last sentence and this one, I went and watched it again- his performances are that enjoyable. And who won’t laugh while watching Mrs. Doubtfire or laugh and fight back tears watching Good Morning Vietnam? So many days he gave performances- and probably carried emotional pain and psychological conflict with him, even on some of those days. We all benefitted from those choices, our lives have been richer because of those choices- hopefully his life was richer from choosing to work and persist too.

Psychological Pain and Values

Maybe his suffering was far greater than many of ours- we can never know. What I do believe is that as humans, we all carry the capacity to suffer intense psychological pain, and if you can’t imagine that, please consider yourself fortunate. I also believe his great body of work is a testament to what one can do, acting even while carrying pain, instead of waiting for all pain to cease- valuing what is most important, persisting, and persevering. He gave performances that moved us, entertained us, and will continue to do so for generations to come.

His wife, Susan Schneider, said “As he is remembered, it is our hope the focus will not be on Robin’s death, but on the countless moments of joy and laughter he gave to millions.” While it may seem impossible not to think of his death, if anyone can make us forget about pain and loss, Robin Williams may be the guy. I’ve said many times that I believe humor to be a potent therapeutic tool. In fact, it seems laughter in therapy sessions is typically a very good prognostic indicator from my standpoint. He gave us laughter and joy- what gifts. Those gifts could be enough to make us appreciate him- but as I read there was more. Outside of professional life, and apparently many times outside of the public eye, he gave in other ways.

Click here For more information about Depression.

I heard an amazing anecdote that may give those of us who didn’t know him an idea of what he found important. Jessica Cole, a young girl, diagnosed with brain cancer, had been granted her dying wish, to meet her hero, Robin Williams. Unfortunately, she became too weak and was not going to be able handle the long flight. After hearing that, Robin Williams paid for his own chartered flight to go to her. Other stories have surfaced as well- all indicating other ways he connected to people outside of acting and stand up comedy.

He will surely be missed by his family and friends. He will also be missed by the rest of us whose lives were enriched by his work- choosing on so many days to give his best. Perhaps we can also benefit by recognizing and emulating the behaviors in his life that were dedicated to values like compassion, connection, and generosity.

At times we may hope with the next achievement or insight we will discover the life without the dark shadow, the sky without storm clouds, the emotional life free of bad feelings- but are any of us ever free of that? Perhaps that too is why this particular loss, the death of a man that brought us such joy and laughter doesn’t make sense to us. How could he have elicited so much joy and appeared so energetic and ebullient- while at times suffering underneath to such an extent? I hope we can all open up to the possibility that meaningful work and satisfying lives may not be free from emotional pain. Robin Williams most certainly had emotional pain in his life and struggled, and for so many years continued to work, connecting us to him, and to each other. We can all learn from choices like that.

As always Kahlil Gibran gives a perspective that may elucidate some of these issues.

On Joy and Sorrow

By Kahlil Gibran

Your joy is your sorrow unmasked.
And the selfsame well from which your laughter rises was oftentimes filled with your tears.
And how else can it be?
The deeper that sorrow carves into your being, the more joy you can contain.
Is not the cup that holds your wine the very cup that was burned in the potter’s oven?
And is not the lute that soothes your spirit, the very wood that was hollowed with knives?
When you are joyous, look deep into your heart and you shall find it is only that which has given you sorrow that is giving you joy.
When you are sorrowful look again in your heart, and you shall see that in truth you are weeping for that which has been your delight.

Some of you say, “Joy is greater than sorrow,” and others say, “Nay, sorrow is the greater.”
But I say unto you, they are inseparable.
Together they come, and when one sits, alone with you at your board, remember that the other is asleep upon your bed.

Verily you are suspended like scales between your sorrow and your joy.
Only when you are empty are you at standstill and balanced.
When the treasure-keeper lifts you to weigh his gold and his silver, needs must your joy or your sorrow rise or fall.

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Dialectical Behavior Therapy – DBT

What is Dialectical Behavior Therapy (DBT)

Dialectical Behavior Therapy (DBT) is an integration of Cognitive Behavior Therapy (CBT), a Western science based psychotherapy, and a Zen Buddhist approach to mindfulness, an Eastern philosophical and mediation practice.  Together these approaches help DBT clients achieve their behavioral goals by learning how to accept and change both feelings and thoughts, and by learning how to control their attention to these internal experiences.

DBT Development

Dialectical Behavior Therapy (DBT) was developed by Dr. Marsha Linehan. She had been using traditional Cognitive Behavior Therapy (CBT) and Behavior Therapy (BT) with chronically depressed women with high levels of suicidal ideation, suicide attempts, and self-injurious behaviors, e.g., cutting.  Unfortunately, while these psychological treatments had been shown to be very effective for many depressed patients, these women were not responsive, and some in fact, became worse during the CBT treatment.

In an attempt to understand how CBT therapy was making these clients worse, she and her colleagues began conducting behavioral analyses of the sessions.  What they discovered was that these patients and therapists were reinforcing and punishing behaviors in the exact opposite direction of the therapeutic goals.  When these patients directed high levels of anger toward the therapist in response to an intervention, the therapists would frequently avoid that intervention and shift to something else.  Rather than helping the client learn to tolerate, understand, assertively communicate, or decrease her anger response, she learned that expressing anger aggressively would allow her to escape from an uncomfortable exchange with the therapist.  Likewise the therapist learned to avoid that topic.  Of course neither may have been aware in session of what was being reinforced, but nonetheless the pattern was being strengthened, leading to more anger and avoidance, and less growth.

Cognitive Behavior Therapy (CBT)

Cognitive Behavior Therapy (CBT) at the time was also ill suited for this population for a few other reasons.  Most CBT therapies, e.g., Cognitive Therapy of Aaron Beck, Rational Emotive Behavior Therapy (REBT) of Albert Ellis, posit that one of the most significant causes of our emotions is our beliefs or interpretations about a situation, ourselves, other people, or the world.  For example, it is not only that someone stepped on my foot as I waited in line at the DMV that leads to my anger, but also that I thought to myself and believed strongly that, “He must be a selfish guy to not look where he is going and should know better given that he is an adult.”   Together the trigger (having my foot stepped on) and my belief about the action and the guy who did it lead to my incredibly strong feeling of anger.  Standard Cognitive Behavior Therapy (CBT) suggests the best way to change that anger is to take responsibility for identifying one’s beliefs and then challenging the accuracy and logic of those interpretations and rehearsing something more rational.  While this technique had been shown to work for many depressed and anxious patients previously, these chronically depressed, suicidal, self-injuring women often experienced this as invalidation.  In fact, challenging their beliefs, may have made them “feel” as though their feelings about the situation were being challenged and therefore that the CBT Therapist didn’t believe the patients’ anger experience was valid.  This often led to an increase in anger or other negative emotions, like shame or guilt for feeling angry, when they shouldn’t have because it wasn’t a valid emotional response.  While the CBT Therapist was attempting to decrease the negative emotional experience, instead through invalidation the CBT technique of disputation of irrational beliefs were making these patients symptoms worse.

Standard CBT sessions are typically held once per week for approximately 45 minutes, and include setting an agenda at the beginning of the session.  Dr. Linehan, and others who have since treated patients like this, discovered that both the high number of crises presented in session and the intensity with which they were often present make it anywhere from challenging to impossible to follow and complete the therapy agenda.  These patients simply appear to present in ways and to be experiencing crises in a way that make one individual 45 minute session suboptimal as an effective treatment.

Borderline Personality Disorder (BPD)

Although Dr. Linehan was unaware at the time, the symptoms presented by these women seem to fit quite well under the diagnosis of Borderline Personality Disorder (BPD).  BPD involves at least five of nine possible symptoms.  This, of course, means that many different presentations are possible as some clients will present with very different symptoms.

BPD Symptoms include:

  • extreme fears and other feelings about abandonment
  • intense and often volatile interpersonal relationships with lovers, parents, siblings, friends, and co-workers
  • unstable and poor self-concept, impulsive and risky behaviors that could include unsafe sex, overspending, overeating
  • frequent suicidal ideation and/or urges to self-injure
  • intense and often rapidly shifting emotional states
  • chronic feelings of emptiness
  • anger management problems, often involving intense emotional experiences and self-defeating ways of expressing the anger
  • dissociative symptoms

When she began this work, no effective treatment for Borderline Personality Disorder (BPD) existed.  Therefore, her work to first conduct a thorough assessment of why standard Cognitive Behavior Therapy (CBT) was making these women suffering from BPD worse, was the beginning of the development of Dialectical Behavior Therapy (DBT).

Dialectical Behavior Therapy (DBT)

Dr. Linehan had some experience with Christian contemplative prayer and also Zen Buddhism.  And she had already been well trained as a behaviorist, i.e., the scientific and clinical approach to psychotherapy based on learning principles such as classical and operant conditioning.  The challenges to treating women with BPD were numerous and complex.  They were experiencing high levels of emotional suffering, had few healthy and stable interpersonal relationships, had difficulty inhibiting impulsive urges that were self-defeating, and were not benefitting from standard CBT Therapy.

Therefore Linehan’s new approach had to provide tools for CBT Therapists that did not invalidate the emotional suffering of clients, provided enough time and a format that could facilitate addressing a multitude of crises, provide BPD patients with tools to better communicate in interpersonal conflicts and to initiate, nurture, and maintain relationships.  And that was just for the BPD patients.  What she and her colleagues also learned during this time is that the CBT Therapists who were treating this group were also experiencing high levels of stress.  Therapy sessions with BPD patients are incredibly intense, often involve high levels of anger, high potential for suicide, and so many presenting problems- there is never a sense of completion.  These therapists were at risk for burnout.

A new CBT Therapy for BPD would need to include high levels of validation to BPD patients, a way to provide patients with a lot of tools while not triggering emotional upset, and more support for both BPD patients and the CBT Therapists providing treatment.  Dialectical Behavior Therapy (DBT) has developed to address these issues.

Dialectical Behavior Therapy (DBT) Comprehensive Program

Dialectical Behavior Therapy as a comprehensive treatment involves four components.  There is weekly individual therapy, weekly DBT Skills Group, coaching calls between the BPD client and individual CBT Therapist, and weekly Consultation Group for DBT Therapists.  Together these components allow greater support for everyone involved in the therapeutic process and a number of scientific studies have demonstrated that comprehensive DBT results in fewer days of hospitalization, self-injuries, and suicides.  It also requires a 12-month commitment from the BPD patient.  Shorter treatment is believed to be less effective.

A DBT patient therefore would see her individual therapist to learn how to better handle the current problems in her life.  And also, once enough fluency with her new DBT Skills are present, more significant symptoms, like those of Post-traumatic Stress Disorder (PTSD) may be treated with exposure therapy in individual therapy sessions.  Problems that came up during the week are often understood by conducting a chain analysis, which is a DBT term for doing a behavioral analysis of the event. The DBT client with her therapist identifies all of the links in the chain of the episode from beginning to end.  This helps both of them understand what likely predicts future episodes and how to best intervene.  For example, after conducting a number of chain analyses on anger episodes with her co-workers, it may become clear that a common pattern is a link in the chain that involves going to bed late and not getting enough sleep.  Problem solving skills are then implemented to efficiently test new ways of handling the situation moving forward while practicing self-compassion.

DBT Skills Group are conducted weekly.  These are typically led by a therapist other than the individual DBT therapist.  While this is part of the comprehensive DBT program, it is largely seen as psychoeducational.  Four modules of skills are taught to clients in a warm, supportive, and efficient manner.  DBT Group Leaders provide structure so that the content can be discussed without unnecessarily triggering and emotionally dysregulating group members.  For instance, DBT Group members are prohibited from discussing self-injury in ways that would trigger another member.  The DBT Group is begun with a mindfulness exercise, which is one of the four content modules that is taught during the 12-month program.  Similarly to CBT individual therapy homework is checked at the beginning of sessions and assigned at the end of sessions.  The four modules that are taught during DBT Group are Core Mindfulness, Interpersonal Effectiveness, Distress Tolerance, and Emotion Regulation.

DBT Coaching Calls are another component that typically sets it apart from other Cognitive Behavioral Therapies (CBT).  Many CBT Therapists are concerned that coaching calls between sessions can lead to dependency and prevent CBT clients from developing self-efficacy skills by practicing their newly developed skills in between sessions.  However DBT believes that properly conducted DBT Coaching Calls facilitate the generalization of skills learned in session into the real world for BPD patients who may otherwise fall back on older more reliable ways of managing interpersonal conflicts and emotional suffering, strategies like self-injury or substance use.
Targets for coaching calls can include:

  • Decreasing suicidal and self-injury behaviors
  • Increasing the generalization of DBT skills into the real world setting
  • Decreasing conflict or “feelings” of distance from the individual therapist

DBT Coaching Calls need to be conducted properly though, or like standard CBT Therapy they can in fact exacerbate the symptoms of a BPD client and lead to burnout for the individual therapist.

DBT Consultation Teams meet weekly as well.  During these meetings DBT Therapists who provide both individual DBT Therapy sessions and DBT Skills Group meet to improve their own DBT Skills as therapists and group leaders. DBT Team Members share information about DBT patients and do so in a non-judgmental manner.  They work to utilize dialectical philosophy, e.g., acknowledging that there is no absolute truth.  And as such, accepting that and moving forward through synthesis can best support all of the members of the team.  This support allows the DBT Therapists to prevent themselves from burnout, hone their skills, receive technical guidance from other team members who may have a different perspective on a problem that has yet to be successfully addressed by a particular DBT Therapist.

BPD clients clearly face very serious challenges given the number of ways they suffer.  It is also clear though that comprehensive DBT, is just that comprehensive.  It provides very specific content, format, and clear parameters for how each is to be conducted.  It also provides DBT Therapists with the training and support necessary to effectively treat these courageous people diagnosed with BPD who through this process can dramatically reduce their suffering and create lives worth living.

Ben-Porath, D.D., Koons, C.R. Telephone coaching in dialectical behavior therapy: A decision-tree model for managing inter-session contact with clients. Cognitive and Behavioral Practice, Volume 12, Issue 4, Autumn 2005, Pages 448–460.

Sleep and Health

Sleep patterns matter- don’t they?  Early to bed, early to rise, makes a man (or woman) healthy, wealthy, and wise. Health, financial security, and wisdom are probably pretty valuable for most of us. There may even be scientific evidence that sleep can help in the pursuit of these values. But the recipe of going to bed early and waking up early could be a recipe for disaster for those who are just naturally late risers- and there may not be a need.

Unless we are college students studying or partying excessively, most of us sleep daily. Sleep is as common as a behavior gets for humans. We all do it frequently and we spend lots of time doing it relative to other behaviors. Can you think of another single behavior you spend more time doing? Despite all of our experience with it, many of us may not be good at it and may have many questions about it.

Questions about Sleep

Is it better for me to wake up early and go to bed early?

Is sleep the best way to relax?

Is reading a good way to cure insomnia?

Is it better to sleep a lot?

Sleep Patterns

We are going to look at the answer to this first question, “Does the early bird really get the worm, leaving the night owl to starve?” Early birds and night owls refer to two different extreme sleep patterns- those who prefer to wake up early and those who like to sleep in, these extreme patterns are called chronotypes. Most of the colloquial sayings indicate that a chronotype of sleeping late probably leads to poor outcomes across the board. But research on chronotypes demonstrates something quite different.

Productivity and Sleep

Research indicates that when early birds and night owls are directed to follow their own natural cycles, night owls may outperform early birds on tasks after a significant amount of time has passed from their wake time. For example, a night owl who wakes at 12:00 pm may perform better on tasks requiring sustained attention at 11:00 pm than an early bird who woke at 6:00 am trying to complete the same task at 5:00 pm. Even though they have both been awake for 11 hours, it seems early birds have a tougher time as the hours pass. Of course early risers likely can get a lot of worms before the night owl even wakes up- so technically the early bird does likely get the first worm. But for those of us who are early risers we may want to take heed and plan accordingly- scheduling tasks that require sustained attention earlier and recognizing efficiency and attention may decrease in late evening. Other research has indicated that rotating shifts, which is often the most challenging shift and has the poorest health outcomes seems to be better tolerated by early birds or those said to have “morningness”, i.e., those who are more alert early, compared to the other extreme of eveningness. Research indicates that sleep quality was much worse for those with eveningness (the night owls) than the early birds.
Scheduling shifts or personal schedules according to our chronotype could really improve our output and increase our accuracy, avoiding errors due to decreases in sustained attention, and ensuring that the quality of our sleep is protected.

So it may be a good idea to know if you are naturally an early bird or night owl, not forced into that schedule by work demands. And if you are one of the two, you should schedule your tasks accordingly, and perhaps even change jobs or advocate with your employer for the shifts best suited for your biological clock.

Sleep References

Chung, M.H.; Chang, F.M.; Yang, C.C.; Kuo, T.B., Hsu, N. (January 2009). Sleep quality and morningness-eveningness of shift nurses. Journal of Clinical Nursing, 18 (2): 279–284.

Gibertini, M., Graham, C., Cook, M.R. (1999). Self-report of circadian type reflects the phase of the melatonin rhythm. Biological Psychology, 50 (1): 19–33.

Schmidt C, Collette F, Leclercq Y, Sterpenich V, Vandewalle G, Berthomier P, Berthomier C, Philipps C, Tinguely G, Darsaud A, Gais S, Schabus M, Desseilles M, Dang-Vu T, Salmon E, Balteau E, Degueldre C, Luxen A, Maquet P, Cajochen C, Peigneux P. (2009).  Homeostatic sleep pressure and responses to sustained attention in the suprachiasmatic area. Science, 324 (5926):516-9.
Sleep Chronotype Additional Reading
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Philip Seymour Hoffman

No Hope for Drug Addiction in America

Tragic Death

Phillip Seymour Hoffman was in so many ways exceptional.

And, like the character he played in Death of a Salesman, Willie Lowman, he was a man struggling with his own personal demons that led him to a tragic end.  While it may give some of us a sense of safety to believe this is a problem for celebrities or those struggling in the projects- the data indicate that while it is a problem in Hollywood and the projects- it is also a problem in each of our neighborhoods.

And from my standpoint the tragic nature of Phillip Seymour Hoffman’s death doesn’t have to do with the many accolades he rightly deserved.  Rather it is tragic because he was one of us, and like all of us- trying his best, and at times failing.  It seems even more tragic to me, perhaps because tragedies like this seem so preventable, if only we could better understand and address addiction, if only we could agree on the goal and effectively use our resources efficiently in pursuit of the goal, instead of waste them in gridlock in service of politics.  And in Mr. Hoffman’s case, here was someone with resources, someone who had been on the wagon for decades, had courageously publicly acknowledged addiction, had been in drug treatment, and still met a tragic end.

Drug Statistics

Drug addiction is a common problem in the United States.  I have seen estimates that approximately 9% of Americans have a substance abuse problem.  Drug and alcohol abuse contribute to 100,000 American deaths each year.  The Robert Wood Johnson Foundation in 2001 identified drug abuse as our number one health problem.  While obesity and related diseases are certainly an incredible problem now, our drug issues haven’t improved much since 2001.  The economic costs are well over $400 billion each year.  While there are a staggering number of people using drugs, the vast majority never seek treatment.  Some estimates indicate that approximately 6% of alcoholics, 16% of drug users, and 22% of those abusing drugs and alcohol seek treatment- most never get professional drug treatment.  What are the reasons for such small numbers of those struggling with addiction to utilize services?  I am sure the answer lies both with the individual and with how services are provided.  Can any society be satisfied with utilization rates that low, when the problem is so costly in terms of lives and financial costs?  This is a serious and widespread problem in our country that is costing us talent, dollars, and loved ones.  Do we as Americans, who put people on the moon, really believe we can’t leverage the same ambition, passion, intellect, and national determination to improve our current system and the behaviors of our citizens?  Do our attitudes about personal and societal responsibility for drug abuse support our moral goals or create barriers to progress?

Philip Seymour Hoffman

I was somewhat surprised by the discourse in the media, even the main stream media regarding Mr. Hoffman- I probably shouldn’t have been.  I read and heard so many comments along the lines of,  “How could Philip Seymour Hoffman do this to his children and partner?”  I believe that question is a good one.   How we answer that question is crucial in developing a more effective response to our drug problem.  Yes, how could one unless there was a level of pain so loud it could drown out the rational, responsible voices.  Or, “He must have been a selfish sociopath, without feelings for his own children. “ Unfortunately, the intention with which I inferred that kind of question may have often times been asked, was more along the lines of other comments that said things like he was prioritizing recreation over responsibility.  It was not a question in need of an accurate answer based on evidence, e.g., “Did he typically display affection and careful attention to the needs of his children, or was he more likely aloof and cold in response to their needs?”  The conclusion was reached before the question was asked.  Or perhaps, fortunately for the person asking, he/she could not imagine a scenario by which a father could make those kinds of choices- and it was a sincere search for understanding of what to all of us seems a terrible decision and outcome that must have involved awful psychological pain.

Professionally and personally I have come across a few people where a particular choice to use may have been about recreation on a particular day or night over a specific responsibility.  But, in my experience, that is rarely the case of anyone who is really struggling with a heroin addiction.  Rather the person addicted, is significantly suffering physical, emotional, and psychological pain and chooses to use drugs to temporarily escape, only to face the same or worse conditions again.  They aren’t turning up the volume on a stereo to make the party more fun, even if it wakes up their young children.  Rather the most ingrained way they have to escape suffering in the moment (turning down the volume on the pain), also happens to put them and their loved ones at risk for greater suffering over the long run.  Certainly the better choice in the long-term is to endure the pain (hopefully with support and coping skills) and to refrain from using, but I do not envy their situation.

I believe each adult is responsible for his or her choices.  By that I mean, he/she will have to face the consequences that follow each choice and therefore he/she is the biggest stakeholder.  I also believe that physiological and environmental experiences and consequences influence our decisions.  Politely passing on a second helping of food is much more difficult if you are starving (physiology).  And yet, one might say, “No thank you,” if he/she expects to be beaten (environment) by a parent for rudely asking for more.   This is an extreme example, but so is heroin use.  Emotional pain and the physiological withdrawal symptoms can be excruciating and the potential consequences of use are incredibly hazardous.  As a society, we have choices to make about environmental consequences.  We must believe our current traditional justice system has an impact on people’s choice to use drugs, otherwise why have it?  Therefore it behooves us if we are spending money to support it, to consider if it is the most effective environment (consequence) for the financial cost.

As a scientist, specifically a behaviorist, providing a jail sentence or any harsh penalty following heroin use could be acceptable to me given my goal to prevent further use, if it is effective.  In fact, I may even consider something incredibly extreme, e.g., public canings, once all other non-corporal interventions were exhausted.  The acceptability of the consequence should largely be based on its effectiveness.  The effectiveness of a jail sentence, corporal punishment, mandatory drug treatment, or any other consequence is what matters most. The punishment should be determined by its effectiveness at reducing the behavior from occurring again.  I see the moral choice for our community as the selection of the consequence that is most successful at helping the individual from choosing what is in his/her long-term best interest the next time (and society’s).  Selecting an intense, severe, aversive punishment can make sense if it is the mildest effective consequence at our disposal.  This is where I believe science can help in the process of following our moral compass.

Public Policy: Morality versus Science

Our beliefs about choice, addiction, and our moral beliefs about drugs likely influence what we think public policy and the legal system should be in the case of drug use.  Is free will – completely free?  Does someone in the throes of addiction have the same kind of choice, or should that matter even be considered in terms of the legal consequences?

My heading Morality vs. Science is often the starting point for an unproductive discussion.  It also seems to be a common theme when it comes to drug policy in this country.  I believe whenever possible morality should be used to inform our thinking as we establish goals, and the scientific method should be used as a tool to determine the best processes to achieve those morally, value informed goals.  Our laws and their enforcement can flow directly from that process.  Polarized sound bites may be effective political rhetoric.  But they lead to an unwillingness to consider and test new possibilities in service of reaching the best possible outcome.  They breed contempt, indifference, and stagnant ineffective systems.

When it comes to drug use, it is unlikely there will be a convergence of everyone’s moral beliefs.  There are those who prioritize freedom for adults to have ultimate liberty regarding personal behaviors that do not directly affect others and believe the individual should face the consequences without governmental intervention, no matter how dire.  There are those who believe that each person has a moral obligation to treat his/her body as a sacred temple, and the rest of the community has an obligation to prevent an individual from doing anything harmful to him/herself.  Without question, drug use is a complex and charged issue.  Regardless of our philosophical viewpoints and the complexities of the issue, can we accept the status quo as a viable option?  Despite the distance between the opposing factions, don’t we have a moral obligation to be engaged- to discuss, open our minds and our hearts, negotiate, compromise, and continually test and evaluate the process and the outcomes?

There is research on our traditional system, Drug Courts, and other alternative systems, e.g., Portugal’s approach.  Sometimes I like to get a sense of my own values, morals, preferences, biases, and emotions on a topic before immersing myself in the data.  I believe that without some level of self-awareness, I may prematurely judge the information I am reviewing or even select or ignore materials based on those biases, unless I am fully aware of what I think and feel in advance.  Below are a few questions I have been asking myself- for a long time, but more frequently recently in response to the many news stories on Philip Seymour Hoffman.

If you are interested in getting a sense of what your attitudes about drug use and what possible changes to our system you may or may not consider- you could take a look at one or two of the questions below.  In order to gain insight about your answers, it may be valuable to ask yourself what values, assumptions, and inferences were important in your reasoning to respond to the question.

If you have any constructive responses or comments and are willing to share here or with your friends and family, I would be interested to see if we can have a more constructive and open dialogue on drug addiction for once. It may be unclear where we go from here, but simply accepting where we are seems unworkable, given what I know of most Americans’ values, goals, and beliefs. Let’s see if our morality and science can let us hope and experiment in order to improve our world.

  1. Should all victimless crimes be legalized, e.g., gambling, prostitution, illicit drug use?
  2. Should any current victimless behaviors such as consuming excessive calories, consuming high amounts of sugar if one is diabetic, smoking cigarettes, drinking alcohol, etc. be made illegal?
  3. If I believe any of these behaviors should be illegal, what criteria should be used to establish the appropriate consequences for a violation of the law?
  4. Are there any reasons a criminal penalty should be considered for a victimless crime?
  5. While keeping in mind the actions I believe should be illegal, the penalties for those acts, and the expected effectiveness of those penalties, what role should society have in treating or providing for someone who a) is engaging in those illegal acts, e.g., illicit drug use, overeating while it is negatively affecting his/her health, gambling, etc., and is asking for help or b) is in need of medical intervention to save his/her life when he/she does not have any resources to cover the costs?
  6. What are the pros/cons the Good Samaritan Laws?
  7. If jail sentences or corporal punishment were scientifically proven to be the most effective treatment for victimless crimes, would I support either?
  8. If decriminalizing victimless crimes, drug courts, simply providing treatment, or some other alternative to incarceration, were shown to be the most cost-effective approach, would I support any or all of them?