What’s The Fuss About? A Super Brief History Of Behaviorism, Cognitive Behavior Therapy, And What Is Really Meant By Third Wave Behavior Therapies.

Behavior therapies have been around for a long time in helping people address problems of depression and anxiety. Here is a short article about old ways of thinking about behaviorism and what newer “third wave” therapies have to offer.

Old behavior theories are often criticized for this idea that there is no “person” on the “inside”, rather everything was a matter of stimulus and response. For instance, the presence of a stop sign (stimulus) would prompt the behavior or stopping (response), and behavior could be controlled by stimulus in the environment. Criticisms of this way of thinking included the lack of free will or choice. Behaviorism in the current way of thinking would take into account learning history, which would explain how different persons have different responses to the same situations. It also takes into consideration how the context of the situation may influence the outcome, such as snowy weather conditions or the fact that a person was busily distracted with their cell phone when coming to the intersection.

Old paradigms of thinking about behaviorism include methodological behaviorism; the gist of it being that if behavior was not observed, it did not exist and was not worthy of study. Clearly this created problems for people who want to understand emotions. Current ways of thinking of behaviorism (radical as opposed to methodological) refutes the idea that behavior has to be publicly observed in order to exist. All the “stuff” that occurs within the skin (emotions!) are alive, real, in existence, and worthy of study. The more global way of understanding behavior is that any behavior is worthy of analysis and understanding. Thus, an emotion or a highly conflictual altercation (the stuff that comes up in therapy) is clearly worthy of study.

Cognitive Behavior Therapies (CBT) often emphasized the thought process that ensues when a person reacts to a situation. People have a tendency (especially when panicked or a in a bad mood) to think the worst will happen, jump to conclusions, and make assumptions about situations and people that are not accurate. Cognitive Behavior Therapies have often emphasized the thought process/ thinking/ cognition; and often challenged persons’s perceptions of reality. This can get tricky when dealing with paranoia, post-traumatic stress, or psychotic thought processes; and can create even more problems when people are told their perceptions of reality are not, indeed, real. Focusing solely on cognitive ways to solving problems can result in trying to think one’s way out of pain and discomfort, which sort of backfires when people have problems with rumination, over-analyzing, or overthinking. That being said, CBT has been helpful to numerous people and has had a key role in reducing suffering, depression, and anxiety.

Exposure therapies are often considered under the umbrella of cognitive behavior therapies and include specific treatment for anxiety disorders. This is where a person comes into contact with a feared stimulus and behaves differently from the typical response. The goal is to increase one’s tolerance to anxiety, increase the repertoire of responding adaptively, and not let feared stimuli control one’s life. Here are some typical examples of treating anxiety through exposures: Obsessive Compulsive Disorder (people that are disgusted by dirty things are encouraged to touch dirty things such that they become less bothered by dirty things over time: watch the move Dirty Filthy Love), Social Anxiety (people are encouraged to join a small group and share more openly than they otherwise would and feel less isolated and have better social abilities), and Borderline Personality Disorder (exposures help people tolerate emotions better such as practicing breathing when angry instead of ranting angrily or picking a fight).

Behavioral Activation is a treatment for depression that includes engaging people in life situations that increase natural reinforcers. In a nutshell, the behavior of depression is often one of detachment, withdrawal, inhibition of activity, loss, flatness, tearfulness, loss of focus, and sometimes aggravation. Activating behavior may include increasing pleasurable activity, engaging in meaningful behavior, doing things to build mastery and challenge oneself, managing stress and time management, and decreasing commitments that result in being overwhelmed. These are ways of managing mood that don’t include medication. (A really great book on this is Overcoming Depression One Step At A Time, which can be found under “books I recommend.”)

The newer behavior therapies or “Third Wave” therapies are often considered an offshoot of Cognitive Behavioral Therapy. Technically, behavior is given an emphasis over cognition. This is because behaviorists consider the thought process to be only one aspect of behavior and is not given any kind of special treatment. For political purposes (and for the general lay population) this distinction can be confusing and for some, probably not necessary. However, all behavior is open to analysis and one’s thought process is not the only focus of treatment. The idea of Third Wave therapies is a return to radical behaviorism (hence the analysis of behavior), an acknowledgement of the ways behaviorism has been both hurtful/ helpful/ misunderstood, and an expansion of how behavioral ways of thinking have been making phenomenal comebacks (and changes) on intimate, psychotherapeutic relationships.

Third Wave behavior therapies are different in that they are interested in two things: 1) Context and 2) Function. Behavior (which can include anything you want to analyze for the focus of your therapy session, such as an emotion) can happen anywhere in time and space. Current conditions (ie., the context under which behavior occurs) will influence behavior. Behavior does not happen in a vacuum and is not situationally isolated. It is fluid and subject to change. Consider how “repressed” memories “show up”, and if you more or less likely to remember repressed memories if you have a warm, caring therapist who is expressing curiosity about your past. How you remember, what you remember, and what you are willing to tell this person are all influenced by the current context. If, in your learning history, people are not to be trusted; a warm caring person asking you this personal information may result in you changing the subject or talking excessively. Learning history clearly plays a part in how a person will respond to a therapist, and again shows how the overly simplistic stimulus-response models of early behaviorism fall short.

The function of behavior has to do with the purpose it serves. The same behavior of two people can have very different purposes, show up in different settings or circumstances, and have different outcomes or consequences. The behavior of vomiting after eating (such as the case of bulimia) can serve to communicate, validate, express anger, maintain privacy, prove a point, assert independence, or prevent the discomfort of feeling full. The fact that the same behavior does different things for different people and has different consequences makes it such that two people with the same diagnosis can need very different treatments. This is partly why there is so much confusion and controversy over mental health diagnoses and their varying treatments, and why any one “template” approach doesn’t work the same way for any two people.

Third Wave Behavior therapies are also coming to terms with spirituality. While past therapies focused on making unwanted emotions/ thoughts etc. dissipate, new wave therapies are getting people to look at what they want more of, what they value, and what is important to them. Instead of saying “What do you want to avoid or get rid of in your life?” they are saying “What do you want more of in your life?” or “How are you missing out on what is important because anxiety/ depression gets in the way?” There is a renewed focus on mindfulness and acceptance and a recognition that painful thoughts and emotions are part of human existence.

We’ve worked really hard to eradicate pain and that hasn’t worked, so what can be done instead? Making peace with our discomfort by not letting anxiety and our depression control our life is done through some applied principles from Bhuddism, mindfulness, and the concept of being “zen.” Spirituality clearly has helped many people cope, come up with their “why”, and rely on powers outside of their control to help them survive emotional pain. (Ie., “Let go and let God”). The shift in Third Wave Therapies is to look towards a more expansive way of thinking and also addresses a more existential concern. You don’t have be clinically depressed to benefit from examining values, enhancing your quality of life, and growing as a person. And at least one of these treatments, ACT, is being used in non-psychotherapy settings such as organizational and business consulting. (The Association for Contextual and Behavioral Sciences is the umbrella organization of the growing interest in Third Wave Behavior therapies, and offer an annual international conference to interested parties. Click here to visit their website.)

Third Wave Behavior Therapies are generally considered to be Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), Functional Analytic Psychotherapy (FAP), and various mindfulness and compassion based therapies. DBT was somewhat of an early forerunner in bringing acceptance based practices to psychotherapy, the “dialectic” being that of acceptance vs. change. This was somewhat in response to the fact that Cognitive Behavior Therapy, despite the multitude of people that it helped, was a therapy based solely in principles of what needed to be changed. DBT skills include prayer, radical acceptance, finding meaning, and value-based goal setting. DBT’s founder, Marsha Linehan, grew up Catholic and developed the treatment based on her exposure to Eastern thinking and Bhuddism; she has written multiple articles on spirituality.

ACT is complex and a bit tricky to explain, but here are two principles that ACT encompasses: 1) Flexibility, or a flexible repertoire of responses to life’s challenges. A metaphor I heard recently was like a car hitting a pot hole- a car with no “bounce” or “give” is like a person who has difficulty adapting to life’s bumps. The more shock absorption that a car has, the more likely the car can navigate the pot holes and not get “tied up” or “stuck”. 2) Impermanence, or “self-as-context”. This means that the self that is “you” will change over time but still be the same “you”, and this “you” can change perspective in time and space. This matters in the sense that people who are really and truly “stuck” sometimes experiences their situations and self-criticism as permanent. The self-as-context concept often entails compassion focused exercises that allow you to see yourself differently; with compassion, and as an observer who can take a step back form being “fused” with emotional pain and rigid thought patterns. Compassion based practices have capitalized on the approach and address concerns related to extreme self-hatred, shame, and the ubiquity of human suffering. (Compassion Based Therapy is also considered it’s own independent treatment).

FAP at its heart has based its tenets on the principles of Awareness, Courage, and Love. (Known as the ACL model). Clients are encouraged to consider how their relational problems outside of session also show up inside of session, and to bring these similarities under direct observation as they show up in the relationship with the therapist. Immediacy (ie., What are you feeling right now as you are telling me this?) can evoke the discomfort clients often feel when in intimate situations, and encourage clients to develop more meaningful and fulfilling relationships via the interaction with their therapist. FAP is highly evocative, and clients grow in the courage to address things in therapy they tend to avoid. Because lack of intimacy is associated with mortality, intimacy and connection is a value that shows up consistently across FAP. If you think about this treatment from a behavioral standpoint, the environmental context (how a therapist responds) can have a profound influence on generating change. If the relationship with the therapist had no influence on the client, there would be no such thing as psychotherapy. Thus the focus on the environment (ie, the behavior of the therapist) is consistent with a behavioral approach to treatment.

The best way that I think of behaviorism is that there is no permanent, fixed, or reification of private experience such as thoughts, emotions, or sensations. The fluidity and impermanence of how we experience “self” changes across time, contexts, and situations. Problems often ensue when our thoughts are treated as structures, things, or objects. Problems crop up when we think we “have”, possess, or own the experiences within our skin. In order to “not have” depression, something would have change. Consider the difference between “having” depression vs. “experiencing” oneself as depressed. Which do you think is more hopeful, temporary, and subject to change? Third Wave Behaviorism, or “radical” behaviorism is making its comeback.

 

 

 

What if I’m wrong?

Here are a couple of thoughts on the business of being “wrong.” First, the question itself begs a certain dichotomy to form in a relationship. It implies a one-up, one-down position. It can make one person more powerful, keep another at a distance, or in extreme circumstances serve as an opportunity to belittle or berate. What does being “wrong” imply about the relationship, the importance of keeping a relationship, or the way that people will continue to relate to each other? Is it worth it to damage or hurt a relationship to be “right”? If one person is “wrong”, then how is the relationship handled in the future? How do people move forward?

Next, being “wrong” might be rephrased as being technically inaccurate. If you are responding in a way to that does not match reality in a reasonable sort of way, you may be considered “wrong.” However, in some circumstances this begs the question of differences in opinion, perception, feelings, and agendas. A person can have a valid point of view, see things differently, or see aspects of a situation that another person is not able to see. This can prevent communities from being rigid, thinking “inside-the-box”, refusing to consider alternatives, or being racist or non-diverse in their thinking. Trying to understand the validity in where others come from can help us be more understanding, have better relationships, be more forgiving, and become less “stuck” in the right/wrong dichotomy. If you are technically “wrong”, this also might be your opportunity for self-correction, learning, or growth. Consider teasing out the differences of being “wrong” vs. being technically accurate, and if being “wrong” has anything to do with conflict around perspective, perception, intention, or emotion.

In addition, there is a certain cost to being “wrong.” Everyone at some point in their life has probably had an experience in which they thought something to be true, accurate, or reasonable but found this to not be the case. The cost to being “wrong” is often related to embarrassment, shame, humiliation, or perhaps the loss of trust or leadership. Are you able to correct your actions based on what happened? Can you tolerate the pain of your own humiliation and consider what really matters? If the inability to bear the cost of being “wrong” results in isolation, criticism, withdrawal, and becoming more adamant that you were “right”; you may want to give some thought to what it is costing you in terms of your relationships.

Here are some final questions for you to consider:

  • What are your intentions? Sometimes we are in long term work, romantic, or family relationships that must be giving careful consideration.
  • What are the intentions of the other person? (Are you sure, or are you assuming? What evidence do you have?)
  • What is the true cost of being told you are “wrong”? What do you have to gain by making sure others know you are “right”?
  • If you are “wrong,” can you tolerate your embarrassment enough to grow, learn, regroup, or reconsider how you will handle future situations?
  • Is it more important to be right than to be effective? (Consider what the relationship means to you and if your own self-respect in handling the situation is on the line).
  • Are you unforgiving of other people when they are “wrong”, thus unable to forgive yourself? Is your own criticism preventing you from moving on, getting unstuck, or responding in a way that is potentially painful but perhaps necessary?

Is everything really going to be okay?

When people tell you that everything is going to be okay, sometimes it is helpful to hear. Sometimes it is soothing, and can give you a sense of hopefulness and shared understanding. There are many ways in which other people try to soothe us, and which we find help and assurance in cases of extreme distress.

However, people sometimes use this statement in a way that is unhelpful. For instance, the statement that everything is going to be okay may be an attempt to avoid the subject, offer a platitude, or inhibit communication of distress. Sometimes it is more helpful to obtain some acknowledgment or understanding of how you really feel. Sometimes worries, fears, or concerns about the future just need to be openly expressed. In addition, it is hard to know that things are going to be okay when you don’t have a way to solve the current problem.

The statement that everything is going to be okay is a statement of expressed hope. It can be offered to the person who is going through the most severe of all crises, and even though there may be some irony to it, there is some truth to it as well. Sometimes when we feel very hopeless it is hard for us to hear the usefulness of this statement. Sometimes in the worst of moments we can find and create experiences of hope and joy- despite significant loss. Being able to find and participate in these moments help people survive.

Thinking about the ways in which this statement is both helpful and not helpful at the same time can help us to create space for different perspectives. When we can see things from different angles, we have more flexibility in addressing situations, responding to our environment, and finding help that may actually be helpful. There is always some element of truth to things turning out okay, but there are also moments when hopelessness prevails. Sometimes it is nice to consider the kindness of another person’s intentions, even if their attempts to be helpful aren’t always exactly what we need to hear in our moment of our pain.

10 Reasons why you need The Emotional Extremist’s Guide to Handling Cartoon Elephants book this holiday season

1. The Cartoon Elephant book, after being temporarily unavailable through Amazon, is now back on the market. The retail price is $26.95, but sometimes Amazon will let it go for a bit less.

2. Cartoon Elephants approach painful emotions with humor. If there is an elephant in the room in your family, this book is the starting point for approaching avoided conversations. You will recognize yourself and others in this book. There is no finger pointing or blaming.
 
3. Cartoon Elephants is something you can put on your coffee table. Because it is a graphic book with pictures and fun fonts, it is an easy read. The elephants will fit nicely next to big picture books about Africa and Asia.
 
4. The Cartoon Elephant book is being used to teach people in Dialectical Behavior Therapy skills groups about emotions. Loaded with psycho-educational material and teaching points, it cleverly accomplishes the task of making people think they are reading something fun yet giving them something valuable.
 
5. This book is not hard to read. There is no “plugging away” at chapters. If you want to bring something to someone’s attention in a way that is universally applicable, this book will do the trick. You don’t need to have painful emotions to appreciate elephants- you just need to have emotions.
 
6. If you are going to buy someone a self-help book for Christmas, this is safe bet.
Whether they believe it or not, everyone has cartoon elephants. The research proving this to be true is cited in the back of the book.
 
7. This book can be used and re-used, read and re-read. You can share it with family members, friends, or long lost relatives. It won’t go out of style. Emotions, as a rule, will be with you as long as you live.
 
8. You will get some food for thought about how and where you see yourself in relationship to your elephants. This is great for discussion groups, weekend retreats, and writing workshops.
 
9. This book is great for people of all ages. If you’re trying to get your kid to read something important, heavy, and deep, you can give them this book. It won’t take long to read and it is much more fun with illustrations.
 
10. The book will be the perfect introduction for my live series on emotions starting January 20, 2014. Of course you don’t need the book to sign up, but if you have the book you will have a better appreciation for cartoon elephants in general.

 

 

On being “right”: Demystifying the “stiff and rigid” cartoon person from The Emotional Extremist’s Guide to Handling Cartoon elephants.

StiffRigid2 copySometimes being “right” has to do with maintaining a sense of justification, power, or virtue. Sometimes being “right” has to do with feeling valued or heard, or even finding others to support your point of view. Sometimes it has to do with taking sides, feeling validated, or knowing that you have something important to add that is being left out of the equation. Sometimes being “right” has to do with not sacrificing a point of view, a perspective, or an observation.

Sometimes, when people feel emotionally threatened, they focus on the “right”-ness of where they are coming from. When threatened, attention is often narrowed and constricted to the threat- thus making it difficult to shift perspective, see things from different points of view, or understand the person who is identified as a threat. Sometimes being “right” has a certain quality, characteristic, or experience that feels guarded, shut down, or even restricted. It’s a way of being that builds walls, doesn’t let other people in, and sends a strong message. It builds a dichotomy in which one person has the upper hand, and the other person doesn’t.

Sometimes people need to be “right” to gain a sense of influence, power, or importance in a relationship or situation. Being “right” may have to do with making a statement, communicating something strongly or clearly, or not yielding to an expectation. It may have to do with mattering.

Sometimes being “right” means sacrificing a relationship, failing to get along with someone, or being seen as someone who is approachable. This can create difficulties in important and unavoidable relationships.

Sometimes being “right” isn’t so much about being non-negotiable as much as it is about trying to define values, being clear about how much you can take, knowing that you can no longer make the sacrifices you are making, or suddenly realizing the demand that someone is placing on you. Sometimes it is difficult to define the “right”-ness of your experience and keep important relationships.

Here are some ways in which you might re-consider being “right”:

  • Even if you are “right”, consider the impact that communicating being “right” has on the relationship.
  • Stop thinking about one person being “right” and the other person being “wrong.” Start thinking about it as “this is my experience” and “this is the experience of the other person.” Make space for them to be different.
  • Sometimes it makes sense to simply stop bringing it up. Refraining from pointing out your point of view can challenge you to tolerate differences, anxiety, or some other threat in order to make for better relationships. Making strong overtures in which you are constantly proving your point can exhaust any conversation.
  • If you are in the middle of one of those conversations that bring out the “I have to be right” in you, consider having the conversation while practicing loose and floppy (refer to the cartoon elephant book for more specific guidelines!).
  • Consider what you would lose if you found out conflicting information that challenges your “right”-ness. What’s the threat?

PS- Want to get a free Cartoon Elephant book? Make sure you check out the last blog post for details…

The dialectics of depression

Dialectics has to do with the concept that two seemingly inconsistent or incompatible ideas can both be true. Conflicting realities have elements of truth that can both fit together despite being conflicting. One is not more true than the other, and one is not more true at the expense of the other.

The treatment for depression generally involves behavioral activation- taking some sort of action to increase contact with pleasurable events or rewarding activities. Depressed people become easily overwhelmed, tend to avoid people and activities, and withdraw from life. This inactivity also decreases contact with naturally rewarding interactions.  The agenda of behavioral activation is to get people engaged with with people, activities, or events that generate pleasure, give meaning, and provide a sense of accomplishment. Without these things, it kind of makes sense that people get depressed. So the message is essentially: Put your energy towards getting active, engaged, and connected!

On the other hand, people who are depressed often feel a great deal of misery. Often they struggle with unreasonable guilt and low self-esteem. They may have made multiple attempts at making connections and have had bad experiences.   They may have reached out and been punished for it. They may feel so bad about themselves-and have worked so hard on changing who they are- that they got lost along the way.  They may have stopped liking themselves because they worked so hard to make things different. They may have become exhausted at the prospect of change. They may have a very strong need to be accepted as they are- without having to do something, keep changing, and keep trying.

Do you see the dialectic? 1) Changing behavior is a part of the treatment for being less depressed. Get involved! 2) Don’t try to be or become something that you are not. You are fine just the way you are!

 

A note on dialectics and relationships

Person A is described as miserly, grumpy, short, and abrupt. We’ll say that Person A doesn’t offer any extra information when asked personal questions, rarely smiles, and almost never makes eye contact.

Now, one way of responding to this situation is to simply say that Person A is kind of a jerk. You could sort of see how Person A is pretty unlikeable, and you could even kind of get yourself on a non-liking tangent.

While being on the non-liking tangent may have some benefits to you, it actually may not help you solve interacting problems with Person A. If anything, it may make interacting with Person A slightly worse- if not downright uncomfortable.

Assuming that Person A is someone you can’t avoid, and assuming that you could get more relaxed and self-confident around people that drive you a bit crazy- you’d probably have to do something besides walking around thinking that Person A is a jerk.

Thus consider alternative interpretations of Person A’s behavior. Start with the potential benefits of “miserly, grumpy, short, and abrupt.” I would have to guess that Person A is not a time waster- he probably doesn’t like to chit- chat. This in turn might mean that he is more efficient, which could be an attractive trait to some.  He probably also doesn’t have a lot of people around that bug him very much. Who knows? Perhaps he likes his privacy. Perhaps he is lonely. Perhaps he didn’t grow up with a lot of easy going personalities. Perhaps he grew up around people that were really harsh and abrupt with him.

You see how coming up with different interpretations for Person A’s behavior can change your feelings about Person A? Alternative explanations might provide understandable reasons for behaviors that may be hard to understand. And when we can be more understanding, we can be more accepting of ourselves and of others.

On dialectics: Perspective and truth with the shark and the jellyfish

In the great deep ocean, there was a shark and a jellyfish.

The jelly was made of flotsam and jetsam and floated around in an aimless manner. He was not made of substance and lived mostly at the whim of the currents and waves. He was mostly transparent and extremely shy.

The shark had big pointed teeth and yellowish eyes and would jet through the ocean, eating up the little sea creatures and fishes for dinner. He was bold and daring and liked to think he ruled the Pacific and the Atlantic, the Aegean and Indian the Mediterranean and the Baltic.

One day the shark swam up to the jellyfish and bellowed, “You brainless, spineless, heartless creature!”

The jelly was stung by the mean words of the shark, but the jelly couldn’t think of a single thing to say. In fact, the jelly had to admit, he had no heart, no spine, and no brain. The jelly wanted to sink into the depths of the ocean, never to return, believing in the mean harsh words of the shark.

At the bottom of the ocean the grenadier fish told the jelly “You are known for getting taken advantage of, agreeing with everyone, and not standing up for yourself. You need some perspective.”  And the jelly thought of all the things he had seen and heard in the depths the ocean and decided that perspective might be a better idea than blaming himself and feeling bad.

So the jelly, despite having limited control of his direction of float-ability, blobbed himself back to the non nether-regions of the ocean until he saw the shark again.  And then he said, “Perhaps it is true that I have a hard time standing up for myself. But it appears to me that you are a mean bully shark and do not have any friends.  I have lots of friends. Perhaps life would be better if the mean bully sharks of the ocean stopped trying to get their point across and the jellies of the ocean stopped being completely invisible, then reality could not only be seen more clearly but ocean life  would be more bearable.”