Wednesday, June 17, 2015

Empathic Curiosity and Dialectical Behavior Therapy

The skills offered by dialectical behavior therapy — mindfulness especially — support the development of empathic curiosity, fostering healthier relationships.

In my latest article for, I discuss how DBT can help you communicate better, understand yourself and others, and develop meaningful relationships with people you care about:

Empathic Curiosity: How DBT Builds Better Relationships

Thursday, May 28, 2015

DBT: Not Just for Borderline Personality

Perhaps best known for its effectiveness in treating borderline personality, dialectical behavior therapy can help address a range of mental health issues.

In a recent DBT Topic Expert article at, I describe how DBT helps with depression, bipolar disorder, anxiety, and difficulties managing emotions.

Self Awareness and Insight Through Dialectical Behavior Therapy: The Chain Analysis

Dialectical behavioral therapy offers an insightful tool, called a behavioral chain analysis, that examines in excruciating detail how emotions influence distressing experiences.  The DBT chain analysis is a process of curious inquiry. Curiosity strengthens empathy, helping us better understand and validate our experiences and those of others.

I describe the behavioral chain analysis in my latest Topic Expert article at, where I describe how this DBT technique can be your key to improved self-awareness and insight into your actions.

Tuesday, March 10, 2015

How PTSD Is Perpetuated by Avoidance

Traumatic events, large and small, affect many of us at some time.  Many people recover in a short period of time, but sometimes we are affected with conditions such as post-traumatic stress disorder (PTSD).  We all naturally have resilience that helps us to not only survive but to thrive and grow after bad things happen.  Yet, when something happens that does not make sense given our past experiences, it can be difficult to think about and integrate into our understanding of our lives.

Avoidance is a common reaction after experiencing trauma.  Of course we don’t want to think about a distressing event or feel upsetting emotions.  These emotions can be painful, and it makes sense to not want to experience pain.  However, the process of attempting to avoid traumatic reminders can cause anxiety symptoms that get in the way of living the lives we want.

Post-Traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder is a mental health condition created by exposure to a highly distressing event.  This exposure can be a direct experience of the traumatic event, or it can come from witnessing something terrible happen to another person.  It can also come from learning that something has happened to a family member, close friend, or loved one.

PTSD can be triggered by a specific event, such as combat or sexual assault, or by ongoing exposure such as that experienced by police officers and other first responders.  The symptoms of PTSD are clustered in categories of re-experiencing, avoidance, negative thought and mood changes, and increased arousal (hypervigilance).  I focus here on avoidance because of its role in perpetuating the cycle of PTSD symptoms.

How avoidance creates PTSD

Avoidance refers to a set of PTSD symptoms that have to do with efforts to prevent contact with thoughts, feelings, people, places, and activities that are associated with the traumatic event.  It also includes emotional numbing and the loss of interest in activities that the person used to enjoy.

Emotional numbing can be especially difficult.  People sometimes describe feeling “like a robot” or “on auto-pilot,” with feelings pushed out of awareness.  This is sometimes called “emotional anesthesia.”

In the short term, emotional avoidance may seem to work.  It gives us temporary relief.  Unfortunately, however, avoided emotions do not go away.  They are still there in our subconscious, fighting to get out.  And they grow stronger.  Unfortunately, attempts to avoid may also go stronger, leading to unhealthy coping attempts such as drug and alcohol use.

Avoidance also makes it difficult to come forward and seek help.

How do we learn to avoid?

Sometimes we receive messages from home, such as “Don’t dwell on it” or “Just let it go.”  You may have been taught that emotions are bad or destructive, or that thinking about something only makes it worse.  You may be worried that if you feel intense emotions, they will destroy or overwhelm you.  The truth is, emotions only last for a second -- until we re-trigger them with a thought or behavior.  If we let the emotion pass by like a wave in the ocean, it will pass through us and leave us open to experiencing a different emotion.

Is all avoidance bad?

There’s a fine line between distraction and avoidance. Distraction is often an effective coping strategy that helps people rebuild their lives and continue doing things they need to do after a traumatic event.  Distraction is an active coping process, which happens through adding positive events to your life -- doing things that bring about positive emotional experiencing.

Avoidance takes a lot of effort, especially when strong emotions are involved.  Rather than adding positive emotional experiences, you are focused on pushing away negative ones.  This is the type of avoidance that gets in the way.

Emotions exist for a reason!

Emotions do a lot for us.  They motivate us and help us get organized to act when we need to do something.  Through facial expressions, tone, and body language, we share important information with people around us about how we’re doing and what we need.  This helps us to get our needs met.  Emotions also help us know when something is wrong -- they function as a signal or alarm.  This intuition is important, even though it is not the same as factual information.  While we cannot treat our emotions as facts, we can use our emotions to know when to check the facts.

How can you accept difficult feelings and stop avoiding?

The most important thing is to reduce attempts to escape and avoid.

One skill that is helpful comes from Dialectical Behavior Therapy and is called Opposite Action.  This is a skill for changing emotions that you want to change.  In this case, the emotion is likely to be fear.  When fear is justified by the situation, of course, you will want to follow that feeling.  When the fear is not justified by the present situation, however, the way to diminish the feeling of fear is to approach rather than avoid.

Eventually we get used to things that are bothersome but not actually dangerous. This is the key to overcoming PTSD, and it does take time.  If you find that avoidance and other PTSD symptoms are getting in the way of living the life you want, it would be a good idea to get in touch with a therapist.  There are treatments that work -- people can and do get better.

Monday, February 16, 2015

Therapy FAQ: How Long Should I Be in Therapy?

People often want to know how long therapy will last, or how long is the ideal time to stay in therapy.  It’s often a very difficult question to answer.

Psychotherapy has traditionally been a long-term treatment, with people going to an analyst multiple times a week for years.  Now, with the involvement of managed care and other reimbursement programs, as well as the desire to make therapy affordable to many people, there is increasingly a focus on short term treatment.

Short term treatment is often helpful for resolving symptoms of anxiety and depression.  Therapy methods such as cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) have proven effective at resolving symptoms in a relatively short period of time.  

That said, people often benefit from long term, insight oriented therapies as well.  Some people will seek out therapy when they have something specific to work on, and others will decide to stay in therapy for months or years.  Some will work on specific, measurable, time-oriented goals, and others will seek a more open-ended treatment.  Discussing your goals at the beginning of therapy can begin a conversation about treatment planning, including how you will know your goals have been achieved and how long you and the therapist expect that to take.

The decision to terminate psychotherapy is a significant one, which should be discussed with your therapist to assess the risks and benefits of continuing vs. stopping therapy.  This is especially important if the decision is impacted by external factors such as cost or insurance coverage.  Termination need not be abrupt, either. It may help to taper off sessions, coming every other week and then monthly for a period of time.

Ultimately, how long to continue being in therapy is a topic for discussion between you and your therapist.  Whatever you decide, you can benefit from the length of treatment that feels right for you and fits into your life.

Monday, February 2, 2015

Book Review: Creatures of a Day by Irvin Yalom

Creatures of a Day by Irvin Yalom
I was lucky enough to receive an advance reader copy of Irvin Yalom's latest book Creatures of a Day: And Other Tales of Psychotherapy.  It's due out on February 24 but available now for pre-order.

Yalom, a prominent San Francisco psychiatrist and writer, offers a collection of ten stories from his experiences providing therapy to a diverse group of patients.  The stories focus on questions of mortality and how we find meaning in our lives as we age.

Therapists, and those who have benefited from therapy, will likely enjoy this opportunity to get closer to Yalom and his work.

As a therapist, it is a pleasure to watch the doctor as he navigates some of the most challenging existential questions that affect us all.  Yalom is humble and direct, yet clearly a master psychotherapist.

While the theme is mortality, the stories are not dark but rather are full of peaceful acceptance.  He is not afraid to touch on his own process of aging and facing the inevitability of his own future death as this process comes out in his sessions with patients.

Yalom offers profound depth in the clinical encounters he relates and writes in a style that is accessible to therapists and non-therapists alike.  He creates an intimacy with the reader while exploring the serious topic of life and its limits.

I am reminded of Garcia Marquez's One Hundred Years of Solitude in which the only way to achieve immortality and live on, as Melquíades discovers, is through writing.  Though he is but a creature of a day, Yalom is known and will be remembered for years to come by the many people he has touched through his therapy and writing.

Wednesday, January 21, 2015

Managing Pain Anxiety: A Vicious Cycle

At one time or another, everyone experiences some sort of physical pain.  Living with pain is an extremely challenging experience as it impacts all areas of our lives.  Often one of the most difficult aspects of living with pain is the anxiety that comes with it.  When people experience pain together with anxiety, the pain can be especially intense and difficult to alleviate.

This anxiety is often rooted in the fear of one’s condition worsening.  Not wanting to experience more pain or become further disabled is, of course, understandable and a valid concern.  Unfortunately, this fear can sometimes have the opposite of its intended effect.  When we make decisions based on fear, we hold ourselves back from saying yes to positive events and opportunities in our lives.

Rather than immediately acting on this fear, it is often helpful to shift your focus to listening to your body.  This is not as easy as it may sound.  Listening to your body is more than stopping an activity when it does not feel good.  Listening to your body requires a level of awareness that is only possible if you set the intention to focus on physical sensations, emotions, and thoughts.  

Attention to your physical sensations may bring up uncomfortable emotions.  Often we disconnect from that which hurts us as it is easier to distract ourselves than to tolerate pain.  On the other hand, pain has a way of making us at times more aware and more sensitive.  Fear has a way of leading  to hypervigilance.  People with chronic pain sometimes describe being constantly alert or on guard, aware of the many triggers that can make pain worse.

Pain is strongly influenced by how the brain processes its signals.  Our beliefs about these pain signals matter as they lead to emotional responses.  We may respond to pain with fear or terror.  We may see pain as a nuisance.  We also have the option to view pain more simply as communication.  Pain reminds us to be careful about irritants that are making us feel worse.  It also reminds us to make sure to seek out healing measures that make us feel better.

Anxiety and pain often coexist in a vicious cycle.  Anxiety can cause pain and pain can cause anxiety.  People living with pain often develop anxiety symptoms because of the added stress that pain adds to their lives.  Sometimes the pain gets better but the anxiety still lasts, especially if only the pain is treated.  Attention to both is key as you work toward healing.
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