How group therapy works: Behavioral activation, personal relationships, groups, intimacy, connection, and growth.
Newer behavior therapies are looking at how people can change their behavior despite how they feel. The difficulty with focusing on behavior change is that most clinicians think that by focusing on behavior, private experiences such as thoughts and emotions are ignored.
The truth is, most people exhibit certain behaviors when they are feeling a certain way. For example, an anxious person might become overly chatty, focus on “safe” topics, avoid talking about anything personal, or present as very “intellectual”. Someone who is afraid of being disliked or judged might acquiesce easily, become a people pleaser, and become excessively compliant. Someone who is afraid of being excluded might become critical and judgmental in order to avoid the vulnerability of feeling more ostracized. Someone who has a hard time with intimate relationships might inhibit self-disclosure, refrain from sharing personal information, or lie to avoid the risk of discovery. Someone who has a lot of self-hatred might be dismissive of compliments, avoid positive feedback, or avoid rewarding activities.
The benefit of looking at how you behave when you feel a certain way increases opportunities for therapeutic interventions. All of the examples listed in the above paragraphs are behaviors that matter in personal relationships- and will likely show up in group settings. Being able to identify what you do when you feel a certain way is one of the steps to understanding what alternatives are available. Knowing where and how you get stuck is the first step to experimenting with how you can get yourself unstuck.
Here are some examples:
If you are anxious and tend to be chatty or intellectual, try experimenting with the following: Tolerate pregnant pauses, awkward silences, and situations in which there doesn’t seem to be anything to say.
If you have a tendency to be a people pleaser, try asserting yourself in minimally threatening situations. Ask for one thing and then change your mind at the deli counter or a restaurant. Experiment with introducing small things that may be somewhat different from the norms of your social circle.
If you tend to have prickly relationships and often feel threatened, try softening your facial expression, making gentle eye contact, focusing on what you have in common with others, and refraining from criticism.
If you struggling with intimacy, connection, feeling visible, or being “known”; or you have extreme social anxiety, you may want to consider small ways that you make yourself a bit more visible or known. If being the center of attention is too much, find ways in which you can start to voice your thoughts, feelings, and opinions in less riskier situations.
If you have a lot of self-hatred, practice being receptive to the positive things. Make eye contact when receiving positive feedback, allow yourself to feel the warm fuzzies, and treat yourself with kindness on purpose by doing things that are personally rewarding and enjoyable.
Part of identifying how services can be helpful is being able to observe and describe one’s own behaviors. This includes being sensitive to the impact it has on other people the consequence of how it makes you feel- as well as the ways in which current behavior simply doesn’t work. Being able to figure out what specific alternative behaviors you can do when you have the urge to do what you’ve always done is one of the keys in successful treatment. Increasing meaningful relationships and creating a fulfilling life takes work, feedback, sharing, and challenges. Changing one’s behavior often puts people in touch with emotional discomfort. What is the benefit? The benefit is that if one acts and behaves in a way that signifies being “better”, one will be less controlled by emotions and thoughts- especially thoughts and emotions that don’t “go away”! Taking risks is scary, but the cost of not making these changes is sometimes worse.
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.
People tell me all the time that they don’t deserve to feel the way they feel. When they start to feel sad/distressed/upset, they immediately think of all the positive things they have in their lives, convince themselves that they have no reason be upset, and spend a considerable amount of time in their heads trying to argue away the existence of their emotions. The problem with this kind of response is that it doesn’t make emotions disappear in the long run.
If you are one of these people who has “no reason” to feel the way you feel, here are a couple of things you can try:
1) Make a list of all the stressors going on in your life. Brainstorm every little thing, even if it seems small. Little things (like an annoying smell) can actually create a lot more stress than actually realize. Doing this exercise can help you actually identify the extent of your stressors. Some people find it quite validating.
2) Identify if there have been recent changes, losses, or shifts in relationships or life situations that have been hard on you. Sometimes these things seem subtle; such as no longer being able to have lunch with a friend who is suddenly preoccupied with something else in his/her life. This person may have a good reason to stop meeting with you, but the interactions and what they meant to you are suddenly no longer available. This naturally may elicit sadness.
3) Consider if your environment tends to diminish, dismiss, or ignore your requests to be heard, get your point across, or communicate what you feel. Sometimes people end up in pretty harsh environments and then blame themselves when others ignore or dismiss them.
4) Even if you can’t figure out why, try focusing instead on the what. What you feel is experienced in your body. A tightness in the chest, a pit at the bottom or your stomach, or a sense of restlessness and agitation are all feelings. When you focus on the what, try to make space for the experience of your feelings to simply exist, without you trying to change them. Your feelings are probably trying to tell you something! This is the opposite of what you do when you can’t figure out why (i.e., ruminate endlessly, suppress feelings, and try to talk yourself out of experiencing what is felt). Give yourself the opportunity to simply allow feelings to be-without a wordy, logistical, or rational explanation.
The problem with figuring out if anger is “good” or “bad”; “healthy” or “unhealthy” doesn’t allow any opportunity to figure out what anger does, how it works, and why it makes sense.
Think of your living room couch. Is it a “good” couch or a “bad” couch? Wouldn’t it sort of depend on a bunch of different things- such as comfort, style, how old the couch is, how many people can fit on the couch, or if the couch actually suits you? Usually if a couch has a use, serves a purpose, or does what it is supposed to it is considered valuable. While it is possible that you are sick of your living room couch- perhaps you think it is time to get a new one- your couch may be necessary to hang on to for now. On the flip side, you may be very happy with your living room couch. This could make it more likeable and increase your tendency to say, “It is a good couch.”
Emotions- like anger- are like couches. Instead of thinking about anger as being “good” or “bad”, it is more important to consider the following:
How is anger serving a purpose, fulfilling a function, or doing something useful? Anger can function to communicate, get someone to back off or change behavior, or change a situation for the better. Think of it like a red flag, a signal, or a message.
Is the way in which the expression of anger is effective? In other words, is the way you communicate your anger working for you? What a person can make use of their anger by being aware of it (experiencing, tolerating, and understanding what it does for them) it increases the opportunity for effective expression (ie, another person heard, understood, and responded accordingly). On the other side, ranting or attacking often hurts relationships and doesn’t always send a clear message about expectations or desired change.
What are the relationship consequences for how the anger is being expressed? Relationships at some point might undergo rifts, misunderstandings, and irritation. The ability for people to tolerate these things in relationships sometimes help people grow, initiate important discussions, and bring about change or intimacy. On the other hand, anger that is overly intense can damage relationships, hurt other people, or add insult to injury.
First of all, I’m going to say that focusing on the why this behavior occurs is probably not the most effective approach to addressing adolescent self-harm. I’ll give you some reasons why teenagers self-harm in a minute, but the one fallacy that people often have is that if they could explain why behavior occurs, then they would actually have the tools to fix or change it. More specifically, teenagers who may not understand the behavior themselves can often be put in an awkward situation in which they are forced to explain the unexplainable. If they don’t understand why the behavior is occurring in the first place, they may end up giving inaccurate reasons simply to appease their environment.
Self-harm behaviors likely have something to do with emotional pain. Possibilities include ways to control feelings, ways to control oneself or one’s behavior, ways to increase intensity of feeling (ie, the need to feel “real” or the need to feel “something”), or ways to decrease intensity of feeling (“If I didn’t cut I wouldn’t have been able to tolerate the situation”). Understanding how emotions work and what they do for people may is critical in understanding the role of self-harm behavior. For instance, feelings are functional in that they give useful information about what matters to us, communicate to ourselves and others, and help us become organized and prepare for action. Without feelings we just wouldn’t care.
In adolescence, self-harm behaviors may play a role in identity, communication, and intimacy. Self-harm may be kept very private or it may be made public. It may be an attempt at controlling one’s environment or letting someone else know that the person doing the self-harm cannot be controlled. The function of the behaviors may communicate to oneself (I know I matter, I know what I have to say is important, I can’t stand by and let nothing happen, I am not pleased by the situation, This is my way of making a statement), or to others (Back off, This is too much, I can control your reactions, I know you will be upset and freak out, There is nothing you can do about this, You can’t claim to know me, You think you know everything and you don’t).
Treatments for self-injury are not as simple as publicizing behavior (ie, making sure that others know about it), invading privacy by doing body checks, or just stopping doing it. If there was no benefit to doing it, no one would do it! That’s just simply how it works. Knowing the benefit can help someone to organize an effective solution. Teenagers who can obtain help in identifying, accurately labeling, understanding, and communicating their feelings effectively will have more options for what they can do when the urges to self harm show up. Increasing options, understanding the short and long term consequences of this behavior, and providing alternatives for how to tolerate intense, painful, and negative emotions is certainly one way to start.
It’s important to remember that teenagers also have their own feelings about this behavior. Some are opposed to changing it, some don’t want anyone to know about it, some want everyone to know about it, and some feel really hopeless that they can’t stop doing it. Most have some degree of mixed feelings. Assuming and communicating that a teenager simply doesn’t want to change is probably not going to help solve the situation. While it might be a likely, blaming a teenager for doing it usually only serves to communicate a parent’s frustration.
Similarly so, parents have their own feelings about it and may feel disgusted, hopeless, overwhelmed, inadequate, or guilty. How parents communicate and address painful emotion will also impact the situation; and thinking through the effectiveness and intensity of one’s own responses may be part of the work involved in addressing teen behavior.
I think it is important to consider that the problem of self-harm behavior has solutions. Sometimes providers, teachers, parents, and community react with an abject horror that stirs the pot, gets everyone all worked up, and in some cases emphasizes the solution (self-harm) and not the problem itself. Emotional problem solving is really just that- emotional problem solving. If a person can figure out how to problem solve (ie, address, tolerate, understand, deal with, validate, survive) painful emotions, then their way of solving problems (ie, self-harm) may decrease. Finding effective solutions means having an adequate way to assess and address these behaviors with a skilled professional who understands the role that these behaviors serve.
One of the reasons mindfulness is used is to get yourself calm. If you are a person with a lot of anxiety, your anxiety might get in your way of handling problems, thinking clearly, or addressing something with your full attention.
Mindfulness is one way to lower emotional arousal, center yourself, and help you get back on track. When emotional arousal returns to baseline, accessing the problem solving part of your brain becomes easier.
1) Inhale to the count of one, exhale to the count of two. Keep going until you get to the bottom of six. Start over. Do this for about three minutes. If you get lost or distracted simply start over. The point is to have something to focus your attention on; which helps cut the distractions of your mind.
2) Trace your hand. Inhale on the way to the tips of your fingers, exhale on the way to the crevice. This can be done with pen/ pencil on paper or with the finger of the opposite hand. This is a tactile way to “trace” your breath and focus your mind. Keep your attention on your breath.
3) Pause for three minutes and focus your attention entirely on sound. Try to tune in to every possible nuance of sound. See what you can hear that you typically don’t pay attention to. If your mind drifts, bring it gently back to the experience of hearing.
Individual outpatient therapy with adolescents can sometimes be limited in that
1) It can fall into Question and Answer sessions-losing the spontaneity and flow of a helpful interaction
2) Adolescents have shorter attention spans, and keeping them focused on painful topics on purpose can be, well, painful!
3) Sharing personal information with an adult you don’t know, but were paired up with because your parents are making you, doesn’t always have the desired results.
4) Adolescents aren’t necessarily going to do things differently because an adult is telling them to.
Group therapy has several advantages in that
1) Its members will be able to tell your daughter if they like it, how it is helpful, and what it has done for them.
2) It is private (no one knows each other outside of the groups) and participation can be minimal (it doesn’t have to be about you all the time).
3) Group members can help each other think things through, make decisions, look at consequences, generate feedback, and put words on experiences in way that an adult provider may not be able to.
4) Talking about peer situations leads to identifying oneself in peer situations- thus what matters is sometimes brought up by someone other than yourself- or an adult, who may not have a clue.
(Hey! I’m not in high school anymore!)
Did you miss the teleseminar in February on
How to Be Around People in Extreme Emotional Distress?
If so, make sure you sign up for my mailing list so you can be alerted to upcoming classes for April, May, and June of 2014.
Online classes cost about the same as an insurance co-pay, are packed with information, and present opportunities to listen live and ask questions.
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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.
Two different concepts that often come up for handling emotions might at first appear contradictory:
1) In order to handle emotions effectively, a person has to be able to step back and notice what they feel (observe).
2) In order to survive strong emotions, a person needs to fully experience the nuances and physiological discomfort that arises when emotion is present (enter into the experience).
Can you see how both of these concepts make sense?
Being able to step back and observe emotions is effective because it increases options and awareness for how to respond to emotional material. Without the ability to “stand by”, a person might immediately act on their emotion. When a person always acts on their emotions, he/ she might regret it later. For instance, if you become really angry at someone you care about, you might lash out. The ability to “step back” and observe what you are feeling can help you organize a thoughtful response in which you maintain integrity, speak clearly, and feel better about yourself later. Sometimes refraining from taking immediate action is very effective.
On the other had, a willingness to experience strong emotions when they arise is a critical element to being human and being alive. Emotions give us very important information that we can’t always ignore. When we experience emotions fully, we are in touch with what matters. When we suppress, hide, ignore, or push away strong feelings they may become worse or “blow up” on us down the road.
In some ways, a person can both experience and observe emotion. A willingness to get in touch with what hurts and to hold off on any immediate reactions can increases options for the best response.