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6/7/15- Using the breath to down-regulate


So many things we take for granted. We have so many gifts, so many strengths that are so common, so "mundane" that we forget about them. The breath is probably one of the most powerful emotion-changing tools we have, but we often forget to use this basic tool. When a very intense emotion like anger or fear overwhelms us, the part of the brain that can reason and use logic is fairly over-run. It's like being caught under a wave and getting swirled around so fast and so powerfully you don't know which end is up (if this has actually ever happened to you, you know exactly how this feels, and how panic-inducing it can be). Slowing and regulating our breath tells the brain to slow down (i.e "down-regulate"), it sends an "un-panic" signal. Once the un-panic signal is received, the brain in turn begins to send back neurotransmitters to calm down. This is an example of both the opposite action skill and mindfulness. There are lots of variations on how to slow the breath- paced breathing where the exhale is about 2 counts longer than the inhale is a prime example (note- this kind of breathing also helps runner's cramp). But even just taking a moment to really acknowledge the act of breathing and focus on the breath acts as a down-regulator. Here is a video of some kids doing this to help them manage anger.


5/13/14Understanding Secondary Emotions


In DBT our work is often focused on really increasing our understanding of emotions generally and our own emotions specifically. This work takes time and it's why we spend more time in the "emotion regulation" module than probably any other (noting that we circle back to mindfulness more frequently- but emotion regulation is the longest module). So, for example, in my own deepening of understanding regarding emotion, I identified that "attacking" may be a behavior associated with anger in many cases (and sometimes I experience the "fight" urge as well), but for me specifically, I've noticed that another action urge for anger is to withdraw, to shut-down. I have also noticed how I feel anger in my body, the tenseness in my shoulders, a hollowness in my stomach, heat rising in my cheeks. These are all part of the physiologic experiences of emotion.

Secondary emotions are the emotions that spin off from the primary emotion. So I might feel an initial emotion of anger and then have a spin-off reaction of shame *in reaction* to that anger. These kinds of "spin-offs" often make us more dysregulated than we would be if were able to feel and process the original emotion.

Linehan (CBT for BPD, 1993) references Greenberg and Safran (1987) in writing:


"[secondary emotions]...are reactions to primary cognitive appraisals and emotional responses; they are the end products of chains of feelings and thoughts. Dysfunctional and maladaptive emotions, according to Greenberg and Safran, are usually secondary emotions that block the experience and expression of primary emotions." (p. 227).


Thus the more we work on being able to identify, experience (i.e "process), and find validation for our emotions, the less we tend to engage in secondary emotion spin-off.





I have been thinking about this skill a lot lately. This skill belongs to the DBT "Distress Tolerance" module and is a part of wise mind "ACCEPTS" (activities, contributing, comparisons, emotions, pushing away, thoughts, sensations). "Comparisons" represents the act of looking at other situations held next to your current [unpleasant] situation with the aim of helping to better tolerate your own problems.  When I teach this skill I always emphasize that the point of comparisons is not to invalidate or minimize your problems. You can recognize this might be happening when thoughts like this one are observed: "I'm such an awful person-other people have REAL problems and here I am crying about this stupid situation." This is certainly not the aim of comparisons.

Truthfully, I've never loved the name of this skill, perhaps because "comparing" can evoke a negative connotation.  I think the kind of comparing taught in DBT is different; this skill taps into a way of producing perspective that helps us see our problems in a different light. So while it wouldn't be very DBT of me to change the name, in my mind this is the "perspective" skill. I'll name a few different examples of ways this skill can be useful-


*Reading about how someone else makes the best of an incredible challenge.


In a recent Time article (Nov 18th, 2013), veteran Bobby Henline shares his story of being the sole survivor of an IED attack that left him severely burned, resulted in the loss of his left hand, and left him with PTSD symptoms. Bobby shares his experience of finding meaning, joy, and purpose through his recovery and its unlikely path to standup comedy. As I read his story, I noted  many skills he's using to rebuild his life: mindfulness, exposure (through his comedy, incorporating his experience of the explosion, he is relieved to find space where he doesn't have to avoid in order to cope), contributing (he uses his comedy to reach out to other burn victims), radical acceptance, and of course- comparisons (he feels lucky to have survived when the 4 other soldiers with him didn't).


*Learning about someone else’s difficult situation.


A client (who gives permission to use this anecdote) recently shared how spending time with a friend who has a dying parent helped put some of her own symptoms in perspective.


*Remembering our own difficult situations.


Because I specialize in the treatment of eating disorders, where negative body perception and physical discomfort are so common, I sometimes use feeling run-over by a wicked cold as an example. I illustrate how *in the moment* because having a nasty cold can be so uncomfortable, it can feel as though it will never pass. I have grown used to supplying myself with grounding self-talk (DBT cheerleading, cognitive challenging) like “yes, this is a drag but remember last time you had a cold- it went away after a few days- faster if we rest". Actually remembering the time from my past when I thought “UGH, this cold is dreadful” helps me in the moment; I gain perspective.


Comparisons help us gain perspective that can help us not only feel differently in the moment but also act more skillfully in addressing our current situation.



7/14/13-Body Appreciation

The ability to tune in to the aspects of our physical selves that we appreciate rather than find fault in is essential to our well-being. Sometimes when we think about what we appreciate about our bodies we may think of physical appearance or what we find attractive about ourselves. While I believe that appreciating those qualities about ourselves can be important too, what I am proposing with this skill is taking time to focus on something that your body does for you that you have gratitude for.


Example: the other day in the rain-storms of June, I was walking my dog and hit a patch of sidewalk slick with mud. I hit a slippery patch and felt my feet start to make a path for the air. Somehow my body found balance and righted itself without taking a spill on the sidewalk. For this pleasant suprise, I was profoundly grateful and took a moment to thank my body's sense of balance.


Take the time to acknowledge what your body does for you: taste buds that magnify a strawberry, an immune system that fights off a cold, an ear for music, a strong throwing arm, etc.



3/10/13-Avoiding Avoidance


I have to smile a bit to myself as I start to write about this skill as I am drawing on it as I type *this very moment*. Avoidance can take many shapes- almost every student I've ever worked with has to face the dreaded procrastination monster at some point. I am living proof that this can carry over past time served chasing a degree. So we can avoid diving into projects that seem overwhelming (hello PowerPoint presentation for the class I'm teaching next weekend, how are you?), we can avoid talking to someone about something they did that hurt us, we can avoid looking at the stack of bills, trimming the dog's nails, making the dentist appointment, etc, etc, etc.


But what tends to happen when we avoid? The very thing we are avoiding starts to take on a life of its own that is almost always an exaggerated and far scarier version than reality. When we avoid, it may temporarily decrease our sense of dread and anxiety (that's called negative reinforcement- something that's aversive gets taken away by doing something- which increases the likelihood we're going to do that something again), but it increases our long-term anxiety because the problem doesn't get solved. In preparing for this class (hey, wait a minute, am I avoiding my class prep by writing this? My wise mind says it's okay as long as I get back to class prep as soon as this is done) I was just reminded that negative reinforcement can be more powerful than positive reinforcement (when we get something that's rewarding by doing something-which increases the likelihood we're going to do that something again) because positive reinforcement involves what is known while negative reinforcement largely involves the imagined. Let me explain- I want soup- soup is rewarding to me. So I know that if I take the time to thaw some chicken, sautee some ginger & lemon grass, get that all going in a pot, etc, this is going to be rewarded with **** soup (yay!). So soup is a known entity. Fear about what will happen if I don't prepare for my class in just the right way involves the unknown- I will be paralyzed by my lack of preparation, my students will be bored, they might (gasp!!) even think I'm not brilliant at what I do, they might be so disappointed in the class they all walk out, they might mutiny!! You see how this goes?

When we really take a look, avoidance is far scarier than facing into something.


Avoiding avoidance may involve some self-talk, which is a cognitive-behavioral skill. Mine usually sounds like this:

"Wow, you are really avoiding right now. What's going on with that? You know it will feel so much better just to get going, so what needs to happen so we can do that? You need to take some time away from other things to prioritize this- let's go find the files right now and get them up on the computer so we can take a look at what we have..." etc, etc.


If a task is feeling daunting, it helps to break it down into smaller steps. For example, getting my son's birthday party organized is broken down into: today let's make the invitations and ask for help getting them sent. Tomorrow I'll inventory goody bags and see how many we need to buy.


Lastly, it really helps to reinforce ourselves for doing hard things. "Wow, you really wanted to avoid that but you didn't. Feels so much better, doesn't it? Nice work, self, remember this for next time!"


I could keep going but I've got to get back to class prep...they may still mutiny but at least I'll be prepared!


2/11/13-Dropping In.

So I'm going to be talking a lot about mindfulness. Mindfulness is a core DBT skill that is so foundational to what we teach in DBT, we engage in mindfulness practice at every group and we teach the module 3x more often than the other 3. It's that important.


A simple definition of mindfulness is being fully present and aware without judgment. This, of course, is not simple or easy much of the time. That's why we need to practice. This act of being fully present in our lives helps us with a lot. Here I'm going to focus on 2 big things: worry thoughts and rumination. Worry thoughts relate to what's yet to happen; rumination on what has occurred in the past. Both of these categories of thinking tend to get us caught in a kind of spinning- expending energy without producing much.


When I notice that I am hovering above my own life, disconnected and "spinning", the image that helps me get grounded is that of "dropping in". Having a love of snowboarding has inspired this image. Every year at some point I find myself watching one of the big snowboarding competitions- mainly the "super pipe" where boarders ride a giant "U" shaped tube competing on style, height, and diffculty of tricks. For all the fanciness of the tricks, though, my favorite moment is when each rider eases their board towards the pipe and with a magic fluidity of knees and limbs, "drops in". It looks like it feels free.


The other day my son asked me to play with him and I eagerly said "yes". As we sifted through piles of lego I noticed I wasn't really there, I was caught up in thoughts about what I hadn't gotten done that day. "Drop in" I told myself. I paid attention to the feel of the lego bricks: "what piece should go here?"; "what are you working on?"; "you can't just take my plant without trading me something for it!". When we drop in, the other stuff falls away. It doesn't mean it won't come back. That's when we drop in again. And again.