Clients who have completed the mindfulness training module in dialectical behavior therapy (DBT) then move on to the second core skills module, interpersonal effectiveness. These skills are extremely important because the way we communicate with others has a significant impact on the quality of our relationships and on the outcome of our interactions. In order to communicate more effectively, DBT clients are taught skills that help them approach conversations in a more thoughtful and deliberate manner rather than acting and reacting impulsively due to stress or intense emotions. Two key components of interpersonal effectiveness are the ability to ask for things and to say no to requests, when appropriate.

In the Skills Training Manual for Treating Borderline Personality Disorder, DBT founder Marsha Linehan identifies three types of effectiveness that must be addressed in interpersonal exchanges:

1. Objective effectiveness
2. Relationship effectiveness
3. Self-respect effectiveness

For any given situation, these three factors must be considered and prioritized. The individual is likely to be more satisfied with the interaction and outcome if his or her highest priority has been addressed.

The term objective effectiveness refers to the goal or purpose of the interaction, which often is a tangible outcome. For instance, a woman might want her husband to call her when he will be working late. Relationship effectiveness represents the goal of a conflict-free relationship. In this example, the wife might rank emotional closeness and harmony as her highest priority. Alternately, self-respect effectiveness might be the top priority if this woman feels that his failure to call is disrespectful to her.

Dialectical behavior therapy utilizes acronyms to help clients remember the skills that are tied to each type of effectiveness. For objective effectiveness, the acronym is DEAR MAN, and the skills are as follows:

D – Describe: Describe the situation in concrete terms and without judgment.

E – Express: Express feelings, conveying to the other party how the situation makes you feel.

A – Assert: Assert your wishes, i.e. clearly state what you do or do not want.

R – Reinforce: Reinforce why the desired outcome is desirable, and reward people who respond positively to the request.

M – Mindful: Be mindful and present in the moment, focused on the current goal.

A – Appear: Appear confident, adopting a confident posture and tone, and maintain eye contact.

N – Negotiate: Be willing to negotiate and give in order to get, with the understanding that both parties have valid needs and feelings

Moving on to relationship effectiveness, the DBT acronym is GIVE:

G – Gentle: Approach the other party in a gentle and nonthreatening manner, avoiding attacks and judgmental statements.

 I – Interested: Act interested by listening to the other person and not interrupting.

V – Validate: Validate and acknowledge the other person’s wishes, feelings, and opinions.

E – Easy: Assume an easy manner by smiling and using a light-hearted, humorous tone.

Finally, the DBT acronym for self-respect effectiveness is FAST:

F – Fair: Be fair to yourself and to the other party, to avoid resentment on both sides.

A – Apologize: Apologize less, taking responsibility only when appropriate.

S – Stick: Stick to your values and don’t compromise your integrity to gain an outcome.

T – Truthful: Be truthful and avoid exaggerating or acting helpless to manipulate others.

The interpersonal skills taught in DBT can increase the likelihood of positive outcomes, regardless of how the client prioritizes objective, relationship, and self-respect effectiveness for that particular interaction. When used effectively, the DEAR MAN-GIVE-FAST skills help the individual convey his or her needs and wishes clearly, without the other party having to “read their mind.” It enables the person to ask for what he or she wants respectfully and with integrity, while considering the other person’s feelings and preserving the relationship.

Many people associate a sandbox with children’s play. However, there is a special type of expressive therapy in which a tray of sand is used to create and explore imaginary worlds. This modality, called sand tray therapy, can be appropriate for people of any age. Many adult clients enjoy sand tray therapy as a way to bypass the logical and intellectual parts of themselves in order to access a deeper, creative aspect.

Sand tray therapy has been in use since the 1940s. It emerged in the form of Jungian sandplay, a type of psychoanalytic expressive therapy in which clients were asked to “create a world” in the sand. In current times, sand tray therapy has evolved to be used by therapists from a variety of backgrounds, including humanistic or transpersonal.

How It Works
The sand tray that is used in therapy with adults and adolescents is a rectangular, wooden tray, several inches deep and painted blue on the inside. Typically, the tray is placed on a wheeled table that is about regular table height. The tray is filled about two-thirds full with clean, white sand.

In the same room, there is an open shelf containing a broad variety of small toys or figurines. These usually include human figures of different types, as well as animals, plants, buildings, vehicles, and other types of things that are commonly seen in everyday experience. Any of these figurines can be placed within the sand tray to create a small, imaginary world. In addition, the sand in the tray can be shifted to make an evocative landscape. Sand can be piled up to show a hill or mountain, or it can be scraped away from the bottom of the tray to show the blue interior in order to represent water.

How It Helps
Sand tray therapy can be used with adults when success with verbal therapies is stifled, or when a therapeutic modality that allows more access to innate creativity is desired. An excellent use for the sand tray can be with grief or trauma, when words are difficult to utter or fully process. When clients touch the sand, it can be very soothing to the psyche, offering a healing beyond what we can visibly understand.

“When the beginnings of self-destruction enter the heart, it seems no bigger than a grain of sand.” —John Cheever

There are several components of sand tray therapy that make it effective for many people, including:

• The design of the sand tray environment is a safe, contained world that is fully controlled by the client, and can be manipulated or changed by adding, subtracting, or moving figurines within the scene.
• It does not require any artistic skill to have a satisfying sand tray experience—only selecting and placing objects.
• Physically moving representational objects within the sand tray container has a beneficial effect on the body, especially in people who have undergone traumatic experiences—more so than simply talking about memories or ideas.

What to Expect
In a session using sand tray therapy, the therapist will typically begin by encouraging the client to explore the sensory experience of the sand tray itself. Many clients may spend a few minutes just experiencing the cool, smooth sand on their fingers.

The client can leave the sand smooth and flat or create a landscape by shifting the sand in the tray. Then the therapist will explain how to choose figurines in order to create a world or scene in the sand tray. The therapist will instruct the client to choose several figurines that elicit a strong reaction, either positive or negative, and reassure the client that it’s OK not to “know” what each figure represents. Then the client will decide where to place each object in the sand landscape. The scene may be static, or it may evolve over the course of the session. The therapist will encourage the client to observe what has happened in the world of the sand tray and discuss the meaning that the client sees in this experience. A photograph of the scene may be taken in order to keep a record of the session.

My Experience
Having sand trays in therapy rooms can provoke a client’s curiosity. I recall a non-sand tray client in the sand tray room stroking the sand as he was talking to me. I called his attention to this and he remarked, “It’s soothing.” Just having the sand tray nearby to touch supported his ability to relax in the room. Another example is when I was working with a couple. After a turbulent session with his wife, the man took the opportunity before he left the therapy room to put a shark head down in the sand—a visual and nonverbal communication about his feelings.

As I allow each and every client to have his or her own experience, I find the benefits of sand tray therapy useful. It allows clients to have experiences they may not if they were to use only language.

Reference:

The Columbia World of Quotations (1996), Columbia University Press. Retrieved April 11, 2013, from http://quotes.dictionary.com/search/sand_?page=3

“The greatest hazard of all, losing one’s self, can occur very quietly in the world, as if it were nothing at all. No other loss can occur so quietly; any other loss—an arm, a leg, five dollars, a wife, etc.—is sure to be noticed.” ―Søren Kierkegaard

So often, people come to therapy seeking to “find themselves,” typically after a tragedy has occurred or some major shift has taken place in life and they realize they have somehow “lost” themselves along the way. But there is another way of losing oneself that is more insidious, more subtle, and can be even more damaging. This is what I call self-erosion.

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Self-erosion occurs over a period of time and happens so quietly that the person doesn’t even realize it’s happening. Self-erosion happens when we are so busy doing other things—such as working, going to school, raising kids, and being in incompatible relationships—that we slowly lose touch with who we are. Our lives become so much about what we do, how we contribute, and what we offer the world that we lose touch with who we are. The tragedy of the self-erosion experience is that when we finally come face to face with the reality that we have no idea who we are anymore, we have no idea where to start.

You might be experiencing self-erosion if you have noticed any of the following:

• You don’t know what you like to do for fun.
• You can’t remember the last time you had a really good laugh.
• Your identity is tied to what you do (“I’m Jane’s mom,” “I’m a therapist,” “I’m a CEO,” and so on).
• You rarely take time for yourself.

If you are experiencing any of these, it is likely that you have lost touch with yourself. You may be very content with your life in many ways, but in some ways you find yourself longing for more. Whatever that “more” consists of is very personal and different for everyone, but the important thing is that you get back in touch with it.

Start with allowing yourself to do something you’ve always liked but don’t do often, whether that is taking a long, luxurious bath or going for a walk. It may be hiding away in a coffee shop and reading a book you have wanted to read but haven’t made time for. Maybe it will be going to Baskin-Robbins and trying every flavor until you find just the right one for you. Spend some time reflecting on all the things you used to do and greatly enjoyed, even when you were a child. You may find some keys to things that bring back the spark to your eyes, the joy to your living, and the passion in your existence.

The path to finding yourself does not have to begin at the crossroads of crisis; you can decide to own your life anytime you choose. I hope you choose today—this moment—to begin.

“Art washes away from the soul the dust of everyday life.” —Pablo Picasso

I am privileged to work with new moms in my private practice. It is tremendously gratifying to help women and their families move through what can be one of the most challenging life transitions—that of parenthood. In my work with mothers, I see many women who experience perinatal mood/anxiety issues (PMADs), perinatal loss (miscarriage), fertility challenges, and traumatic birth situations (see prior articles on these subjects on my GoodTherapy.org profile page). Most often, interventions with moms are a combination of evidence-based cognitive behavioral work and interpersonal approach to assist the client in full recovery.  I have also found great benefit in the use of expressive arts to assist this population in healing.

Expressive arts therapies are defined as the use of creative arts (art, dance, music, writing, drama) as a form of psychotherapy. The process of art making is emphasized versus the final product. In my practice, I employ the use of visual arts and crafts as a powerful intervention with clients of all ages. Although I am not an art therapist, I believe the use of art intervention is incredibly meaningful and assists in recovery from PMADs.

The American Art Therapy Association defines art therapy as a practice as “the therapeutic use of art making, within a professional relationship, by people who experience illness, trauma, or challenges in living, and by people who seek personal development.” Art therapy itself is considered a specific subspecialty in the field of psychology/counseling and requires an intensive registration and education process. With either expressive arts intervention or art therapy, the client does not need to have prior art training and need not feel pressured to produce a masterpiece. Again, the focus of the intervention is the process, not necessarily the product outcome.

I was initially exposed to the power of art to heal trauma in the drawings of child survivors of domestic violence in a San Diego shelter when I first began my career in clinical social work 20 years ago. In graduate school, I worked with a registered art therapist in a hospice setting, counseling children and families who experienced the loss of a loved one due to terminal illness. Art intervention was the primary modality in individual, group, and family work.

Moving forward through my career, most every setting I have been employed in involved the use of art as an intervention and source of healing. School and clinic-based settings provided ample opportunity to continue to bring art and creativity to the therapy process for children and adults managing depression, anxiety, trauma recovery, loss, life transitions, divorce, social skills issues, and medical traumas.

Art intervention is incredibly helpful for trauma survivors and those recovering from life challenges (including for clients feeling a sense of PTSD from perinatal depression). Art allows the right brain to be balanced and integrated with the rational, logical left brain. The bilateral movement of the hand moving across the page (mimicking the back-and-forth motion of EMDR) in turn assists in releasing trauma and integrating the experience in the brain.

Typically I will invite my client to participate in an art intervention at a point in her healing process in which she is beginning to feel the first glimpses of recovery. Sleep is beginning to be restored, mood is lifting, and anxiety is starting containment. Prior to art intervention, I will have helped to stabilize any crisis, link my client with other helping professionals and extended support networks (psychiatrists, lactation consultants, doulas, support groups, family support), and work with her to attain a level of recovery in which her focus and concentration are improving, along with her mood health. She may begin an exercise regimen; she may have hired a doula (caregiver) or enlisted the assistance of her extended family with baby care. She is beginning to feel biochemical relief, perhaps with the assistance of an SSRI, improving her nutrition with omega-3 fish oils, and she is sleeping for at least five consecutive hours (a full sleep cycle which restores serotonin).

Art interventions which I find particularly helpful for new moms contending with PMADs (which can also be adapted to other populations) can be created in individual or group modalities. Significant others of new moms may also participate in a couple/family session. The following are suggestions for use with new moms recovering from PMADs:

• Treasure Map; A Compass to Guide Me

Materials needed: colored pencils/markers, large poster paper.

Have client draw images of symbols which represent the wishes she hopes to manifest (for example, “good health/vitality” may be a sunshine image); encourage client to add powerful affirmation to the page (“I am reclaiming the best of my health and vitality”) and label each image. Invite client to post “treasure map” in a prominent location in her house to be reminded of the goals she is setting for herself in active manifestation.

Purpose: a visual guide to affirm client’s goals and provide reassurance.

• Magazine Photo Collage; A Lantern to Light the Way

Materials needed: magazines with a variety of images, large butcher/poster paper.

Have client select images from magazines which represent her new identity transformation as a mother, or use theme in intervention above to guide client in goal attainment for self-care and balance as a new mom. Discuss images and invite client to verbalize how the images are important and meaningful to her.

Purpose: validation and support with role transition to new motherhood.

• Masks; Outside/Inside Worlds

Materials needed: preformed paper/cardboard face masks (available in craft supply stores), feathers, colored markers, beads, yarn.

Ask client to create one mask which demonstrates how she presents to the “outside world.” The second mask will reflect how she feels “inside” as a new mom. Discuss how masks are similar and different and why. What is the purpose of each emotional mask?

Purpose: identifying how feelings inside often do not match what we show to the outside world.

• Sculpy Figurines; Talismans of Strength and Courage

Materials needed: sculpy clay, paint, paintbrushes.

Invite client to create image out of sculpy clay (that which can be baked and hardened at a later time, then painted). The image can be a symbol of new motherhood, an image of mother/baby, or an object representing courage and healing (perhaps a bead for a charm bracelet or necklace). Once completed, client gets to keep the object in a special place as a reminder of her strength and courage in her healing process.

Purpose: a transitional object/symbol of the work the client is doing in psychotherapy and a tangible representation of her inner strength and courage.

• Journals; Drawing Out My Feelings

Materials needed: art journal, colored pencils/markers/paint/paintbrushes.

Many clients prefer to draw feelings in lieu of writing about feelings. Invite client to create image of her birth experience using vibrant color of her choice, and to narrate her story of the experience. This exercise is especially helpful in working with survivors of birth trauma. It is also helpful to add second exercise of an image in which client creates a symbol on paper representing healing and recovery.

Purpose: Recording emotions (written or drawn/painted) allows a container for the client to “place” her feelings so she is less overwhelmed. She is able to “master” any traumas by telling her story and her experience.

• Beaded Jewelry (Bracelet, Necklace); Embrace Motherhood Beads

Materials needed: array of bead supplies (beads, bracelet/necklace wires, etc.).

Invite client to create jewelry representing her new identity as a mother, her connection with her child.

Purpose: affirmation of new role and connection/attachment to new baby.

• New Mom Memory Box/Book; The New Me

Materials needed: shoebox, construction paper, markers/pens/paints, any supply to decorate a box or album.

Assist client with decorating a special box to hold keepsakes (photos, poems, cards, etc.) as she becomes a new mother. A scrapbook can be a similar project. Discuss her identity transformation and the joys/positives of this new life role.

Purpose: recording the most transformational journey a woman can ever go through and celebrating it.

• Mandala Drawing; Drawing the Soul

Materials needed: paper, pastels, paints, pencils/pens.

Mandalas are circular images from ancient cultures and religions which represent the power of one’s healing process (see Mandala book). Invite client to create a mandala with the materials of her choice.

Purpose: for client to enjoy process (versus product) of art making and generating an image which represents healing and recovery; practicing self-care through creativity flow.

• Dream Catcher; Rest for the Weary

Materials needed: paper plate, yarn, beads, feather, single-hole punch, scotch tape.

Assist client in constructing a native American dreamcatcher, which can symbolically protect her from nightmares and scary, intrusive thoughts at night. Discuss the dreamcatcher as symbol of nighttime inner peace and tranquility.

Purpose: Most moms with PMADs have horrible sleep initially and need comfort at night. This craft is a great visual to calm the nerves and assuage the soul. Add some lavender- and vanilla-scented oil to the dreamcatcher, and invite client to place above her bed.

• Worry Dolls; A Place to Leave My Worry

Materials needed: clothespin, yarn, tongue depressors, colored pens, fabric scraps.

Invite client to create a Guatemalan worry doll which can hold her worries before she goes to sleep at night or when she begins her day (see The Kid’s Multicultural Art Book).

Purpose: Women with PMADs are anxious. They need a “container” in which to place their worries and fears; worry doll may represent transitional object of the therapist in between sessions.

“The aim of art is not to represent the outward appearance of things, but their inner significance.” —Aristotle, 384-322 B.C.

The following are books and websites which have been, and continue to be, a source of inspiration and enlightenment:

1. Allen, Pat (1995). Art Is a Way of Knowing, Shambala.
2. England, Pam (1998). Birthing from Within: The Extraordinary Guide to Childbirth Preparation,Partera Press.
3. Fincher, Susanne (2009). The Mandala Workbook: A Creative Guide for Self-Exploration, Balance, and Well-Being.
4. Malchiodi, Cathy (2006). The Art Therapy Sourcebook, McGraw-Hill.
5. Malchiodi, Cathy (2006). The Soul’s Palette: Drawing on Art’s Transformative Power,Shambala.
6. McNiff, Shaun (1992). Art as Medicine,Shambala.
7. Terzian, Alexandria (1993). The Kid’s Multicultural Art Book: Art and Craft Experiences from Around the World,Williamson Publishing Company.
8. Arttherapy.org:  American Art Therapy Association.
9. Atwb.org : Art Therapy Without Borders: Promoting international art therapy initiatives in mental health, health care, and education worldwide.

The third module of dialectical behavior therapy (DBT) is emotion regulation, which teaches clients how to manage negative and overwhelming emotions while increasing their positive experiences. This module encompasses three goals:

1. Understand one’s emotions
2. Reduce emotional vulnerability
3. Decrease emotional suffering

An important aspect of emotion regulation is understanding that negative emotions are not bad, or something that must be avoided. They are a normal part of life, but there are ways to acknowledge and then let go of these feelings so that one is not controlled by them.

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Often, clients with extreme emotional sensitivity go through cycles that begin with an event that triggers automatic negative thoughts. These thoughts then prompt an extreme or adverse emotional response, which may subsequently lead to destructive behavioral choices. The detrimental behavior is then followed by more negative emotions, such as shame and self-loathing.

Understanding and Labeling Emotions
The first skill in emotion regulation involves recognizing and naming emotions. Clients are taught to use descriptive labels such as “frustrated” or “anxious,” rather than general terms like “feeling bad,” because vaguely defined feelings are much more difficult to manage.

Another important distinction is that of primary and secondary emotions. A primary emotion is the initial reaction to an event, or to triggers in one’s environment, while a secondary emotion is a reaction to one’s thoughts, i.e., feeling depressed about having gotten angry. Secondary emotions are often destructive, making an individual more vulnerable to unhealthy behaviors. Therefore, in addition to naming both primary and secondary emotions, it is important for clients to learn to accept their primary emotion without judging themselves for experiencing it.

In DBT skills sessions, group leaders also discuss myths about emotions, such as the misconception that there are “right” and “wrong” ways to feel in certain situations. An additional topic is the purpose that emotions serve—which is to alert us that something in our environment is either beneficial or problematic. These emotional responses are stored in memory, and we are then more prepared when encountering similar situations in the future. Additionally, our emotions communicate messages to others through our words, facial expressions, and body language.

Reducing Emotional Vulnerability
The acronym for the first skill set in reducing emotional vulnerability is PLEASE MASTER:

PL – represents taking care of our physical health and treating pain and/or illness.

E – is for eating a balanced diet and avoiding excess sugar, fat, and caffeine.

A – stands for avoiding alcohol and drugs, which only exacerbate emotional instability.

S – represents getting regular and adequate sleep.

E – is for getting regular exercise.

MASTER – refers to doing daily activities that build confidence and competency.

The second skill designed to reduce emotional vulnerability is the building of positive experiences in order to balance life’s negative incidents and feelings. To accomplish this, clients are encouraged to plan one or more daily experiences that they can look forward to and enjoy. This might be participating in a hobby or sport, reading a book, spending time with a friend, or anything that brings the individual contentment. It is important to engage in these activities mindfully, centering attention on what one is currently doing. If an individual has difficulty focusing on the activity, he or she is advised to try something different. The client is also encouraged to identify long-term goals that will bring increased positive experiences into his or her life, such as learning a new skill or making a job change.

Decreasing Emotional Suffering
The last component of this module, decreasing emotional suffering, is comprised of two skills:

1. Letting go
2. Taking opposite action

Letting go refers to being aware of the current emotion through mindfulness, naming it, and then letting it go—rather than avoiding, dwelling on, or fighting it. This might involve taking a breath and visualizing the thought or feeling floating away, or picturing the emotion as a wave that comes and goes.

Taking opposite action means to engage in behaviors that would be typical when one is experiencing the emotion that is in direct contrast to the current feeling. For example, if a client is sad, he or she might try being active, standing straight, and speaking confidently—as the person would if he or she was happy. When an individual is experiencing anger, the person behaves as if he or she were calm by speaking in a soft voice and doing something nice for someone. This skill is not aimed at denying the current emotion; the individual should still name the emotion and let it go. However, acting opposite will likely lessen the length and severity of the negative feelings.

Some of the emotion-regulation skills may sound a bit vague to those unfamiliar with dialectical behavior therapy. In group sessions, DBT leaders cover these skills with clients in more detail, incorporating role playing so that the clients can transfer the new skills to situations in their own lives. Ultimately, these skills empower people to manage their emotions, rather than being managed by them.

One of the aspects of existential psychotherapy that I most value is the idea of personal responsibility. On one hand, we humans are free to live our lives the way we choose (within reason), while on the other, we are responsible for the choices we make. Freedom and responsibility go hand in hand, whether we like it or not.

Often, clients who enter psychotherapy have complaints about their lives, including their marriages, children, work environments, and many other interpersonal situations. Just as often, the clients are steadily looking outward at other people they deem responsible for the trouble. It is the spouse who is selfish, the children who just won’t listen, the unreasonable boss and the inconsiderate friends who drove the person to seek therapy. It is less often that a client comes in with a strong sense of personal responsibility and willingness to change in the beginning stages of therapy.

That is one of the challenges therapists face: how to help the client assume responsibility for his or her life without shaming or blaming. Without the clients taking on personal responsibility, no change can ever really happen because, as we all know, we can change and improve only ourselves. When faced with this challenge, I like to ask my client, “In all of the bad relationships, failed communications, and frustrating encounters in your life, what is the one common denominator?” That question allows the client to begin focusing on his or her role in whatever situation he or she is facing. Even if his or her role is as little as 1% of the issue, that 1% is where we start working. That 1% is where the change begins, and generally, the acceptance of responsibility of that small amount is what leads the client to being able to recognize other ways of being that may cause problems in his or her life.

The ability to take responsibility for one’s life is one of the greatest gifts we can offer ourselves and our clients. Although the weight of responsibility may seem heavy at times, it carries within in the seeds of freedom. When a person assumes responsibility for himself or herself, the person becomes empowered to be the person he or she chooses to be. Holocaust survivor and psychiatrist Viktor Frankl reminded us that the “last of the great human freedoms is to choose how to behave in any given circumstance.” Indeed, we have complete authorship over our attitudes, interactions, and responses.

Philosopher Jean-Paul Sartre states that to be responsible is to be the “uncontested author of an event or thing” and means that each individual, alone, is responsible for the creation of his or her life, including “self, destiny, life predicaments, feelings, and if such be the case, one’s own suffering” (Yalom, 1980). Becoming the author of one’s own life may start with something as simple as taking ownership for the 1% that is you, but will likely lead to a much deeper sense of ownership and freedom in one’s entire life. Therapy, done well, will assist participants in grasping a greater sense of self by way of freedom and responsibility.

At first glance, the injunction to bless and release sounds just beautiful, and so evolved. On reflection, it is missing a crucial component: learning from the experience before you let it go. Jumping right to bless and release without first opening to the lesson is like putting a Band-Aid on a broken leg. You may think you did something helpful, but it’s a superficial solution.

If it were that easy to just bless and release, people would forgive far more readily, and generally move through relationship roadblocks and inner conflicts with ease. As you know, nothing could be further from the truth.

If you take stock of a situation, ask yourself what you could glean from it, and then consciously open your heart, you will be more able to truly bless the people involved and let it go. The psychic lightness you experience as a result comes from true detachment.

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In Buddhism, the concept of detachment is often misunderstood. It does not mean detaching your love and caring from someone; rather, it is detachment from outcome. This requires an understanding of your expectations, even when they are not readily accessible. It’s just another good reason to take time to meditate, as it allows previously buried thoughts and feelings to emerge from your unconscious to your conscious mind.

Once you are aware of your expectations, i.e., your attachment to certain outcomes, you can work to release them. The first step in letting go is acknowledging the hold they have on you. Is there a pattern of thinking, judging, reacting, or expecting that has dogged you in the past? If so, please resist the temptation to blame yourself. Trust that you were doing the best you could, and refuse to enter the cycle of self-criticism, as it will only impede your progress.

Accepting other people’s different ways of being and behaving is a wonderful goal. Like all major cognitive and heart-opening shifts, it does not happen overnight. A good way to start is by being aware of your thought patterns, behaviors, and physical responses to certain people and situations. If you sense a tightness in your chest or abdomen, ask yourself what you might be thinking about someone’s behavior. Are you judging it? Are you being critical of his or her way of handling something? Are you comparing how you would do things differently? Breathe into whatever tightness you feel. Give yourself a cosmic permission slip to have those initial reactions without resorting to self-condemnation. Then ask yourself: “How would I rather think and feel about this person?”Imagine reacting that way. Use all five senses to really feel the difference. Now, notice any changes in your body.

If you like how you think and feel after that exercise, you may be ready to bless. Following the teaching of the Buddha on metta, or loving-kindness meditation, bless yourself first. To Western minds, this may appear selfish, but it sets the stage for opening your heart to others. Once you feel that positive intention toward yourself, you can bless the other person. A classic invocation is: “May you be peaceful, may you be happy, may you be free from suffering.”

If that felt good, let it all go. This is easier said than done, as humans can’t erase memories at will; however, you can let go of any residual negative feelings, such as anger, resentment, or jealousy, especially if you feel yourself joyfully moving forward.

Letting go is powerful psychological medicine when it is done with a truly forgiving heart. Be patient with yourself as you traverse this new territory, and practice self-forgiveness as it paves the way to being more loving and understanding of others.

Hypnosis has long been fodder for television shows and stand-up acts, and most people are familiar with hypnotists who claim to be able to make anyone do anything while under hypnosis. But hypnosis is no longer just a sideshow performance, and an increasing number of people are turning to hypnosis to quit smoking, get over depression and anxiety, lose weight, and forget about phobias.

Hypnosis is still controversial within mental health, partially because it’s often part of a comedy act and not real treatment and partially because some hypnotherapists have induced false memories under regression-based hypnotherapy.

What Is It?
Hypnosis isn’t a magic trick. It’s an altered state of consciousness that hypnotists induce via the power of suggestion. Hypnotists may use relaxation techniques, key words, guided imagery, or some combination of these to help clients slowly relax. Then, while under hypnosis, hypnotists make suggestions about changes in behavior.

The idea behind hypnosis is that, even when the conscious mind wants to do something, the unconscious mind might not fully accept this change. Hypnotists claim that, under the right conditions, they can subtly alter the effects the unconscious mind has on the conscious mind and help bring about behavioral changes. Some hypnotists use hypnosis to help gradually alter a client’s perceptions. A person struggling with pain, for example, might undergo hypnosis to help him or her see the pain as pressure. An increasing number of women are even using hypnosis to help cope with the pain of childbirth.

Does It Work?
You can’t be hypnotized to do something that is outside of your moral compass or that you don’t really want to do. People who try to quit gambling or spending through hypnosis will likely not see results if they’re quitting only because of family pressure. Hypnosis can’t change the way you think; it simply makes it easier to follow through with behavioral changes. Hypnosis can also bring about a state of relaxation, and some hypnotherapists teach their clients how to self-hypnotize under stressful conditions. For people with anxiety issues, severe stress, or depression, this can help ease the symptoms.

But hypnosis is not a panacea, and is most effective when it’s used in conjunction with therapy and lifestyle changes. Particularly for long-term, chronic problems, it may take several hypnosis sessions to see results. Some people don’t see any results at all; because hypnosis thrives on suggestibility, if you’re not particularly suggestible it probably won’t work.

Choosing a Hypnotist
If you’re thinking about trying hypnotherapy, get a recommendation from your therapist. The American Society of Clinical Hypnosis also maintains a directory of qualified hypnotists with a clinical background. Make sure you know how long your hypnotist has been practicing and what methods he or she uses. The messages you hear under hypnosis should not come as a surprise, and your hypnotist should discuss the specific tools he or she is going to use before hypnotizing you.

Regression-based hypnosis, which is used to recover repressed memories, can be dangerous. Because people are more suggestible under hypnosis, the hypnotist can inadvertently fabricate memories that didn’t actually occur. Particularly if these memories are traumatic, this can lead to additional mental health issues. People with a history of psychosis should not undergo hypnosis without first taking to their doctors, because hypnosis increases their risk of a psychotic episode.

References:

1. About the society. (n.d.). American Society of Clinical Hypnosis. Retrieved from http://www.asch.net/
2. Beattie-Moss, M. (n.d.). Does hypnosis work? Research Penn State. Retrieved from http://www.rps.psu.edu/probing/hypnosis.html
3. Mental health and hypnosis. (n.d.). WebMD. Retrieved from http://www.webmd.com/anxiety-panic/guide/mental-health-hypnotherapy
4. Portenoy, R. (2008, August 18). How does hypnosis work, can anyone be hypnotized, and when is it used? ABC News. Retrieved from http://abcnews.go.com/Health/TreatingPain/story?id=4047906

As discussed in the overview of dialectical behavior therapy (DBT), the first of the four primary DBT modules is core mindfulness. Derived largely from Eastern zen philosophies and Western contemplative practices, mindfulness forms the foundation for the other three DBT modules of interpersonal effectiveness, distress tolerance, and emotion regulation.

Mindfulness is the practice of observing one’s emotions and environment, describing feelings and experiences, and fully participating in the moment. By learning and incorporating mindfulness skills, clients become more aware of their feelings, thoughts, impulses, and behaviors. This awareness empowers the individual to better regulate his or her emotions and choose more appropriate actions.

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Three States of Mind
A central concept of core mindfulness in DBT is that there are three states of mind: the logical mind, the emotional mind, and the wise mind. In Cognitive-Behavioral Treatment of Borderline Personality Disorder, DBT founder Dr. Marsha Linehan explains that mindfulness helps achieve the wise mind state, which is a balance between the logical (or “cool”) state of mind and the emotional (or “hot”) state of mind. In the wise mind, the individual considers things rationally while factoring in his or her feelings. This enables the person to acknowledge intense emotions in a nonjudgmental manner while making healthier behavioral choices.

“What” and “How” Mindfulness Skills
In DBT, the practice of core mindfulness is taught through “what” skills and “how” skills, i.e., what can we do to become mindful and how should we do it? The three “what” skills are observing, describing, and participating. The observing skill refers to observing the current environment and events, as well as the client’s own sensations, thoughts, and feelings—without describing or judging him or her. This process helps prevent impulsive reactions and the triggering of negative emotions and internal dialogues.

The second step is to describe what has been observed and experienced, being careful to express facts rather than interpretations. For example, the client might say, “I am feeling frustrated with the complexity of this project,” rather than, “I am too stupid to complete this project.”

The third “what” skill is participation, wherein the individual is fully engaged in the present moment. The focus is on the discussion one is engaged in, or the event he or she is attending, rather than allowing the mind to wander about past incidents or future possibilities—which generally increases feelings of agitation.

In practicing the “what” skills, it is critical to employ the “how” skills, which explain how to perform the “what” skills: nonjudgmentally, one-mindfully, and effectively. The nonjudgmental skill helps neutralize the common tendency to label experiences and feelings as “good” or “bad.” In applying this skill, the individual describes the key facts of the experience rather than his or her feelings and judgments about it.

The second “how” skill, one-mindfulness, refers to focusing 100% attention on the present situation rather than multitasking—in other words, participating mindfully as opposed to mindlessly. This skill is helpful in breaking the habit of dwelling on negative thought patterns, which tends to prolong and aggravate distressing emotions.

Finally, the effectiveness skill enhances the capability to select behaviors that are consistent with achieving goals rather than deliberating on what is fair or unfair, and how things “should be.” The idea is to take productive and goal-oriented actions instead of being caught up in a cycle of negative thinking and behaviors.

Mindfulness can be a challenging skill for some people to develop. Many of us have become accustomed to focusing on something that has already happened or may occur in the future, rather than what is happening right in front of us. With training and practice, however, core mindfulness enables clients to become more flexible in their thinking and avoid being controlled by their emotions. It can help reduce the tendency to react negatively based on internal triggers, allowing clients to be fully present in the moment and engage in more productive behaviors.

Humans have been making music ever since they realized that tapping two sticks together could create an engaging beat. Music can foster feelings of joy, unleash our creativity, and is often a key feature of our most enjoyable social gatherings. Ever versatile, music can set the tone for romance or relaxation, and can impel us to move our bodies, whether for exercise or self-expression.

In the mid-twentieth century, music therapy emerged as a discipline, and the development of modern technologies has since shed new light on how music can change the structure and function of the brain, improve mood, and help us recover after a stroke.

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Music and the Brain

One thing we have learned is that music is processed by a number of different areas of the brain, including ones involved in spoken language. Learning to play music changes the structure of our brains in a way that is somewhat analogous to how physical exercise tones our muscles and makes us stronger and more dexterous. A number of studies with healthy and clinical samples have shown temporary cognitive benefits associated with listening to pleasant music, including improved information processing speed, reasoning, attention and memory, and creativity.

In some studies, verbal material that was presented in a musical context was learned and recalled better than spoken verbal material. Music therapy has also helped people who have had strokes to improve their gait, mood, speech, social interactions, and to reduce visual neglect.

Music Therapy and Visual Processing

Visual neglect is the inability to recognize objects in part of the visual field due to lesions in the visual cortex. Specifically, a lesion in one hemisphere produces neglect in the opposite visual field (so a stroke in the left visual cortex would result in one being unable recognize objects in the right visual field, and vice versa). In one study of stroke patients experiencing visual neglect, listening to pleasant music resulted in both better mood and a statistically significant improvement in their ability to describe the color and shape of geometric objects presented via computer. No such effects were observed when patients sat in silence or when they were presented with music that they did not like.

Further examination with functional magnetic resonance imaging (fMRI) confirmed that listening to pleasant music activated a number of different brain areas, including those involved in visual processing.

Memory, Attention, and Mood

The same team conducted another study, this time with 60 patients who had recently suffered a stroke. Participants were randomly assigned to one of three groups: a music group, an audio book group, or a control group receiving neither intervention. All groups otherwise received standard medical treatments. Those in the two audio groups were allowed to select either the music or audio books of their choice and were asked to listen for an hour daily for two months, and then more on their own after the intervention period ended.

Listening to music was associated with greater recovery of verbal memory and focused attention in the music group versus the other two. Furthermore, the music group participants had significantly less depression and confusion than those in the control group. This benefit was seen within the first three months of listening.

The act of listening to music has been associated with a number of benefits, including on mood, cognition, and physical functioning in healthy people and in clinical samples, such as those who have suffered a stroke.

Those in the music group reported that listening helped them relax, increased their motor activity, and improved their moods. In both the music and audio book groups, participants said the experiences provided positive stimulation. Preliminary imaging results suggest that listening to music following a stroke may result in observable changes to the structure and function of the brain that enhance recovery.

The researchers speculate that the short-term cognitive benefits of music therapy post-stroke may be related to effects on the brain’s reward system and effects on the neurotransmitter dopamine, but the long-term effect is more likely due to improvements in mood somehow impacting improvements in verbal memory and attention. Music may also mitigate the negative effects of stress on the brain and body, and impact other neurotransmitters that play a role in recovery.

The act of listening to music has been associated with a number of benefits, including on mood, cognition, and physical functioning in healthy people and in clinical samples, such as those who have suffered a stroke. Although we are still learning about how and why music helps, it is worth making time for music to move your body, engage your mind, and soothe your soul.

References:

1. American Music Therapy Association: http://www.musictherapy.org
2. Thaut, M., & McIntosh, G. (2010). How Music Helps to Heal the Injured Brain. Therapeutic Use Crescendos Thanks to Advances in Brain Science. Cerebrum. http://dana.org/news/cerebrum/detail.aspx?id=26122
3. Sarkamo, T., & Soto, D.  (2012). Music listening after stroke: Beneficial effects and potential neural mechanisms. Ann. N.Y. Acad. Sci., 1252, 266–281.

In recent years, support of psychodynamic psychotherapy for the treatment of schizophrenia spectrum and other forms of psychosis has diminished. This is not entirely a result of lack of validity or efficacy, but rather an investigative shift from traditional methods of therapy to more novel approaches. However, according to a recent study led by Bent Rosenbaum of the Department of Psychology at the University of Copenhagen in Denmark, psychodynamic therapy is still one of the most effective forms of treatment.

Rosenbaum compared treatment as usual (TaU) to TaU with supportive psychodynamic psychotherapy (SPP) in a sample of 269 adults admitted for psychosis. The participants were measured for global functioning and symptom severity before, during, and after the two-year treatment period. Rosenbaum found that the SPP group improved far more than the TaU group with respect to all levels of functioning and symptoms of psychosis. Over the course of two years of treatment, there were significant gains on social functioning and significant decreases on maladaptive symptoms for the participants in the SPP group.

These findings demonstrate that psychodynamic therapy and the core elements associated with that approach can still adequately serve the needs of many individuals with schizophrenia and other psychotic issues. Rosenbaum believes that when working with psychotic clients, clinicians should focus on the fundamental aspects of psychodynamic therapy. This includes overcoming obstacles to emotional processing, mental functioning relating to sense of self, and the development and maintenance of relational bonds. Cognitive development and attention to the present should also be incorporated to ensure maximum benefits for clients who struggle with these issues.

Rosenbaum hopes that this research will bring clinicians back to SPP and approaches of that kind. “It furthers recovery when it is used as a supplement to medical and social treatment modalities.” He added, “SPP should thus be taken into account as a modality in future research and treatment.” Doing so will open avenues of treatment for clients with varying levels of mental illness.

Reference:
Rosenbaum, Bent, Susanne Harder, Per Knudsen, Anne Koster, Anne Lindhardt, Matilde Lajer, Kristian Valbak, and Gerda Winther. Supportive psychodynamic psychotherapy versus treatment as usual for first-episode psychosis: Two-year outcome. Psychiatry: Interpersonal & Biological Processes 75.4 (2012): 331-41. Print

Dialectical behavior therapy (DBT) distress tolerance skills address the tendency of some individuals to experience negative emotions as overwhelming and unbearable. People with a low tolerance for distress can become overwhelmed at relatively mild levels of stress, and may react with negative behaviors. Many traditional treatment approaches focus on avoiding painful situations, but in the distress tolerance module of DBT, clients learn that there will be times when pain is unavoidable and the best course is to learn to accept and tolerate distress.

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A key ingredient of distress tolerance is the concept of radical acceptance. This refers to experiencing the situation and accepting the reality of it when it is something the person cannot change. By practicing radical acceptance without being judgmental or trying to fight reality, the client will be less vulnerable to intense and prolonged negative feelings. Within the distress tolerance module, there are four skill categories:

1. Distracting
2. Self-soothing
3. Improving the moment
4. Focusing on pros and cons

These skills are aimed at helping individuals cope with crisis and experience distress without avoiding it or making it worse.

Skill No. 1: Distracting
The first skill, distracting, helps clients change their focus from upsetting thoughts and emotions to more enjoyable or neutral activities. This skill is taught with the acronym ACCEPTS:

A – is for activities and distracting oneself with healthy, enjoyable pursuits such as hobbies, exercise, and visiting with friends.

C – is for contributing and doing things to help others, through volunteering or just a thoughtful gesture.

C – is for comparing oneself to those less fortunate, finding reasons to be grateful.

E – is for emotion; identifying the current negative emotion and acting in an opposite manner, such as dancing or singing when one is feeling sad.

P – is for pushing away, by mentally leaving the current situation and focusing on something pleasant and unconnected to the present circumstances.

T – is for thoughts; diverting one’s attention from the negative feelings with unrelated and neural thoughts, such as counting items or doing a puzzle.

S – is for sensations, and distracting oneself with physical sensations using multiple senses, like holding an ice cube, drinking a hot beverage, or enjoying a warm foot soak.

Skill No. 2: Self-Soothing
The second skill in distress tolerance is self-soothing; clients can use the five senses to nurture themselves in a variety of ways:

1. Vision: Look at beautiful things such as flowers, art, a landscape, or an artistic performance.
2. Hearing: Listen to music, lively or soft, or enjoy the sounds of nature such as birds chirping and waves crashing. Savor the voice of a relative or friend.
3. Smell: Use a favorite lotion or perfume, light a scented candle, notice the scents of nature, or bake an aromatic recipe.
4. Taste: Enjoy a hearty meal or indulge in decadent dessert. Experiment with a new flavor or texture, and focus on the food’s flavors.
5. Touch: Pet an animal or give someone a hug. Have a massage, rub on lotion, or snuggle up in a soft blanket.

Skill No. 3: Improving the Moment
In the third distress tolerance skill, the goal is to use positive mental imagery to improve one’s current situation. The acronym for this skill is IMPROVE:

I – is for imagery, such as visualizing a relaxing scene or a successful interaction. Imagine negative feelings melting away.

M – is for creating meaning or purpose from a difficult situation or from pain, i.e., finding the silver lining.

P – is for prayer—to God or a higher power—for strength and to be open in the moment.

R – is for relaxation, by breathing deeply and progressively relaxing the large muscle groups. Listen to music, watch a funny television show, drink warm milk, or enjoy a neck or foot massage.

O – is for one thing in the moment, meaning the individual strives to remain mindful and focus on a neutral activity in the present moment.

V – is for vacation, as in taking a mental break from a challenging situation by imagining or doing something pleasant. This could also be taking a day trip, or ignoring calls and emails for a few hours.

E – is for encouragement, by talking to oneself in a positive and supportive manner to help cope with a stressful situation.

Skill No. 4: Focusing on Pros and Cons
In focusing on pros and cons, the individual is asked to list the pros and cons of tolerating the distress and of not tolerating the stress (i.e., coping through self-destructive behaviors). It can be helpful to remember the past consequences of not tolerating distress, and to imagine how it will feel to successfully tolerate the current distress and avoid negative behaviors. Through evaluating the short-term and long-term pros and cons, clients can understand the benefits of tolerating pain and distress, and thereby reduce impulsive reactions.

The distress tolerance skills are valuable tools in helping individuals maintain balance in the face of crises, teaching them to accept the distress and cope with it in healthier ways. By practicing the skills of distracting, self-soothing, improving the moment, and focusing on pros and cons, clients can weather stressful circumstances and decrease painful feelings and destructive impulses.