Dr. B's Blog


I found this comic relevant to some of the things we teach in DBT skills group.

Sorry comic
I emphasize the importance of having your "sorry's" reflect something meaningful. Say "sorry" if you've violated a wise-mind value of yours. If you'd like to say something else like "I appreciate your help" say that rather than "I'm sorry for being such a burden". Words matter and their mindful use can affect how others view us. And, more importantly, how we view ourselves.

Can Shame Be Useful? - The New York Times

How can emotions be helpful?

1) Motivating one's action: emotions make you do stuff.
2) Communication to others: they convey important information to others without having to actually tell them directly. 
3) Communication to yourself: they tell us important information about ourselves; what is important and meaningful.


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Link between psychological stressors and stroke risk

From the American Heart Association:

Higher levels of stress, hostility and depressive symptoms are associated with significantly increased risk of stroke or transient ischemic attack (TIA) in middle-age and older adults, according to new research in the American Heart Association journal Stroke.

This research finding isn't new or news to those of us in the mental health community but whenever there's data to corroborate what is, at times, conventional wisdom, I like to take the time to post it. What was particularly telling from this study was that hostility was also found to be linked.

When I teach mindfulness, I tend to emphasize the connection I've found between judgemental thoughts and emotion, particularly anger. As we know, hostility is a type of anger, whether that be directed towards others or ourselves. As we strive to live more mindful lives, it's worth examining the connection between our judgements and our long-term emotional and physical health.

Mindfulness may help PTSD

Mindfulness meditation may help reduce PTSD:

The scientists found that the heart and breathing rates of those who had received mindfulness training returned to their normal, baseline levels faster than those who had not received the mindfulness training. Blood levels of a tell-tale neuropeptide suggested that the mindfulness-trained Marines experienced improved immune function, as well.

I chose this particular pull quote from the article because it highlights a very important effect we've found when it comes to mindfulness practice - the physiological effect of practicing meditation. As we know, emotion has many components, from cognitive to behavioral to physiological. Making an impact on any one of these 3 parts can cause a marked difference in the experience of a situation. In CBT, we target the cognitive. In behavior therapy, we target the behaviors. In DBT, we try to go after all 3, depending on what's doable.

One of the reasons I believe DBT is so effective across a wide variety of mental health conditions is the flexibility we have to target what needs to be targeted. There's a certain pragmatism in DBT that isn't really available in some other treatments. Do what works is really the best tagline for DBT that I can think of.

Mindfulness Apps

“You’re making a mindfulness app? Isn’t the phone what’s distracting?”

One of my best friends, a college roommate and a man whom I respect greatly questioned me. Somewhat unexpectedly. He is, to put it kindly, a late-adopter. Generally, when I’m rattling on about my latest new tech gadget (“You should see it! I can stream my music from my phone to my stereo!” “No, there is no optical drive.”), he does the polite nod and waits for me to finish. He tried to understand my first app, but he could only feign interest.

He’s a good friend. So I was taken aback when he had such a strong opinion so immediately. While he has an iPhone (one he had just gotten after years of using pre-paid phones with barely passable keyboards), he seemed to have already formed a strong opinion of what the smartphone could and could not do. The phone was a good tool for distraction. Getting away from things for a while. Splitting your attention. Certainly not one that could be used to enhance mindfulness.

This sentiment was recently echoed by one of my favorite comedians, Louis CK. He had an epic rant about smartphones and what they are doing to our ability to be present. If you haven’t seen it, you should have a look. I greatly respect CK as an artist and as someone who somewhat unwittingly stumbles into some of the greatest metaphors and examples that I use with my DBT groups.

But I’ve got to disagree with him here.

The tools we have at our disposal can always be used against us. I won’t get into examples of how a hammer or drill can be a problem, but let’s just say that my 6 year-old son and I know very well that something that could help build something - is essential, in fact - can also be used for less than constructive purposes. And like a hammer or drill, the smartphone is a tool and an incredibly enabling one. It’s not essential yet, but could be in the coming years.

Given that mindfulness has always struck me as an imminently practical and flexible practice, it seemed excessively rigid to try to work against the trend of smartphone-as-constant-companion. In that light, embracing new technology to help seems to be the most prudent course of action. As we can see by the proliferation of “mindfulness apps”, people use and seem to like them. Whether they are mere totems to an ideal self or genuine efforts to cultivate new and better habits, the fact remains there are a vast number of people interested in using them to help.

I’m going to put on my psychologist hat for a moment (please pardon my indecorum at wearing a hat indoors) and lay out the steps one might take to establish a new habit and what we know works to help a new habit stick. Generally speaking, we strive for consistency and regularity in practice. Initially at least, we also strive for some sort of immediate feedback about our work. We look for reinforcement from others or change in ourselves. We want the new habit to seem our own, idiosyncratic and not cookie-cutter. Bearing these qualities in mind, it seems quite natural to expect a smartphone to be able to help us in our endeavor. Setting reminders is trivial and with the help of notes about the aforementioned reminder, we can work to give ourselves a sense that the practice was custom built for us.

“Siri, remind me to practice mindfulness every day at 8 AM.” “Ok, here’s your reminder every day at 8 AM.”

But there’s still something missing. We can’t get away from the other obligations pulling at us. How long do we practice? What shall we use to focus on? How do we get reinforcement for the practice? There are a number of mindfulness apps that can help with those questions and more that we haven’t even answered. While there may be no ideal app for that, there is quite an embarrassment of riches when it comes to ones that could fill in many of the gaps.

Despite my bias since I created Rhythm, I feel that the smartphone revolution is upon us and that there are many useful tools that can help many people cultivate a new mindful practice. Since we would like more people to practice mindfulness, smartphone-as-companion seems like a worthy trend to embrace. I created Rhythm, A Mindfulness App to fill in some of the gaps seen in the current crop of apps and I hope that many people can find it useful. If not, there are a number of others that might be suitable.

As the saying goes: Embrace and extend. Mindfulness is worth the effort. You can find my app on the App Store.

Getting started with mindfulness

One of the most frequent issues I and my clients are confronted with in therapy is how to develop new habits. It's pretty clear that many of our problems can be addressed by developing new and more adaptive routines. Establishing a new habit is hard. We all know how challenging it can be to develop a new, healthy routine. You may have the desire but life gets in your way. The kids, the internet, work, willfulness. Whatever your excuse, we've all had them.

Further exacerbating the issue of developing a new habit is our tendency to split our attention. We think that getting more than one thing done at once is the best way to approach our increasingly hectic lives and the art of balancing ten things at once is the much-sought-after and never quite attained grail of productivity. The problem is that once we split our attention, we miss out on the opportunity to learn what we're doing.

While mindfulness meditation started as an Eastern spiritual practice, it doesn't have to be associated with any particular faith or tradition (in fact, nearly every culture has some sort of contemplative practice). In my work with clients, we often come back to the notion that controlling where one's mind is focused can have significant benefits to functioning and processing. The thing is, multi-tasking is a way of life even if it is extremely detrimental to our effectiveness.

And then when you finally get yourself to the gym, you can't find parking or the machines are broken or all being used. There's nothing more frustrating than that, is there? I mean you've committed to getting a workout in and then you have even more obstacles in your way. If you're like most people, you might trudge on and get that workout in, but you are probably more reluctant the next time. As these little things pile up, your goal and motivation tend to get bogged down.

While there are any number of ways to develop and cultivate a new habit, they basically boil down to a few things:

  1. Practice doing the activity
  2. Make getting into it as easy as possible
  3. Make the activity itself as enjoyable as possible
  4. Give yourself credit for doing it, even if just a little
  5. Attach it to a more frequently done activity
  6. Repeat regularly

This isn't to say that all of these steps are required; they're not even steps in the usual way we think about them. They are, however, incremental improvements to any new activity and the more of them you do, the more likely it will be that you develop a new habit.

Why We Procrastinate - Issue 9: Time - Nautilus

Why we procrastinate:

The disconnect between our present and time-shifted selves has real implications for how we make decisions. We might choose to procrastinate, and let some other version of our self deal with problems or chores. Or, as in the case of Parfit’s smoking boy, we can focus on that version of our self that derives pleasure, and ignore the one that pays the price.

DBT, and mindfulness in general, work to help people stay in the moment because leaving your present can have unforeseen consequences on your ability to make wise choices and operate effectively. The intersection of this perspective with the research presented in this article seems to be around the connectedness we feel with ourselves and others.

Of course, the way we treat our future self is not necessarily negative: Since we think of our future self as someone else, our own decision making reflects how we treat other people. Where Parfit’s smoking boy endangers the health of his future self with nary a thought, others might act differently. “The thing is, we make sacrifices for people all the time,” says Hershfield. “In relationships, in marriages.” The silver lining of our dissociation from our future self, then, is that it is another reason to practice being good to others. One of them might be you.

The important thing to remember here is that if you don't treat yourself and others with dignity and respect, it's going to be hard to see the value in this perspective.

I've always been this way

Blackness ever blackening, Jenny Diski. Mosaic:

Nobody would have said so in the 1950s, but clearly I was a child who had depressive episodes of some sort. When they took me to the doctor, he told them what they already knew: that I was moody, that I suffered from emotional growing-pains, and he cheered them up by explaining that I’d grow out of it and by prescribing a bottle of some sweet syrup that was called a ‘tonic’.

I didn’t grow out of it.

There are times when you read something and it strikes you as so real, it's worth passing along. The experience of "depression" is so singular and idiosyncratic it's hard to generalize from one person's experience, but I've heard many stories similar to this that I thought it was worth posting about.

"I've always been this way."

Again, this line has been repeated many times in my office throughout my career. It often comes with a sense of hopelessness and resignation. Despite this, we continue on in therapy. Often, progress is made in fits and starts. "Success" is defined by keeping a job or merely staying alive. There are often small glimmers of hope and real breakthroughs occur, at times. Other times, the darkness sets in again and we prepare for another tough battle just to stay alive. During these times, I shift to a harm reduction approach and work to minimize the damage done to the frail house we've been working on.

When the moment passes, as it always does, we survey the new landscape and resume our course. It's tough work, for both of us, but over time, things get a little less bleak.

At least I hope they do. All we can do is try. The misery of sitting in my office is nothing to that of sitting alone at home.

TED Talk - Shame

Brené Brown has a way with words. This is her TED Talk about shame and how to address it. Shame is a particularly challenging emotion to understand, accept and deal with effectively. While we have our own way of dealing with shame within DBT, it's nice to hear how others approach it. 

(h/t Martha Golden during one of our groups.)