Dr. Andi Stone:

Welcome to the Mood and Anxiety Family and Friends virtual programming. I'm Dr. Andi Stone, I'm the Director of the Mood and Anxiety Program and I've been with ERC Insight for over 11 years. And we're really excited about being able to provide this platform virtually right now, given what is going on in the world as we speak. Thank you for joining. And I just want to start with talking about what is our philosophy? How do we approach working with patients in our program? And the two overarching goals that therapists are always keeping in mind are helping our patients build mastery and achieve wellbeing. So what do I mean by building mastery? When we build mastery in something we develop feelings of competency, of feeling more self confident, more capable in life, developing newer, more healthier coping mechanisms.

Oftentimes, think about as a baby. Babies, this is what a natural tendency for an infant to work towards mastery on almost anything that they see in their environment. They want to begin to take those steps towards mastery. And for whatever reason, we found that our patients have predominantly lost that internal drive to develop mastery, or there's some barrier that gets in the way of them feeling competent in their lives. And so this is one of our goals to help them find their sense of mastery.

Again, also, we want to help them achieve a sense of wellbeing. The goal of our program is not to leave feeling happy, I've got no problems in the world, no stressors to deal with, but rather to develop a sense of wellbeing and a sense of I can take on life. I can learn how to experience all of my emotions and be in control of my emotions rather than have my emotions being control of me, or be in control of my thought processes rather than my thought processes be in control of me. So what we try to think about is this takes effort and skill development, and this underlying assumption is what we practice makes us stronger.

We have three phases to our program. We think about it first. We need to develop awareness and recognition. So awareness, we have to be aware of what is working, what is not working. So often this awareness sounds much easier than it actually is to become aware, because once we become really aware, we also have to be able to feel the pain that needs to be felt. This idea that we can't get rid of our present moment, despite how much we try, we teach our clients and patients how to be present in their own lives, despite their reality. So we really come from this idea that knowledge is power. And I'll talk more about that later on the presentation.

The next phase is what we call effective regulation and activation. So in order to be fully present in our own lives, with our own pain, we needed to learn how to manage and regulate our emotions. So that's what effective regulation means. And all of this, we always tie in the work we're doing to our own values. So value work is what we're in throughout all phases of our program. And we want individuals to leave here feeling like they are moving in the direction of living a life in accordance with our values. Or as Marsha Linehan, who we'll talk about in a little bit would say, live a life worth living. In terms of going about the process of living a life worth living, there's a lot of work that we need to do. And there's a lot of psycho education that we need to learn in order to do that.

We're continually assessing mood and anxiety functioning. And the important part is that we also look in our program, we're also monitoring substance abuse and traumatic stress. And as we know that substance use and traumatic stress interferes with mood and anxiety, as well as just overall functioning. So what do I mean by traumatic stress? I'm going to borrow a definition of traumatic stress by Bessel van der Kolk, who's one of the leading authorities and experts in trauma work. Traumatic stress may result from overwhelming or violent physical experiences or from difficult psychological experiences. Its impact may be sudden, dramatic or gradual and result in unrelenting violations To our sense of self. Trauma has threatened an individual sense of safety and their relationships to themselves and to other individuals within their world. So we cannot not talk about trauma or at least asking our patients what they've experienced in their lives, because we have to assume that many of the individuals that come into our center have experienced some form of trauma.

The statistic is around 80% of individuals in the general population have experienced some form of trauma. So this is something that as a team, we don't want to assume that somebody's had trauma, but we want to ask the question, as well as we want to be also looking at any substance use that they might be engaging in that could be impacting their functioning.

Our patient population we treat. So in our specific adult program, we treat adults 18 and over, major depression, bipolar depression, anxiety disorders, post traumatic stress. We also treat personality disorders. There will likely be other presentations on our virtual platform that we'll go into specifics of these disorders. So I just wanted to give you an overview of the type of patients that we tend to work with. I want to give you a quick overview of our levels of care in our Mood and Anxiety Program. We have residential treatment where an individual will live within our center 24/7, and typically a patient that needs this level of care is having active thoughts of wanting to take their life or engaging in self harm or what we call non-suicidal self-injury. They really are stuck in their ability to care for their own needs, whether that be hygiene, educational needs, occupational impairments. Medication noncompliance tends to be something that we address at residential level of care. And just overall, just inability to cope and function.

When we talk about what partial hospitalization is or PHP programs, it's really the same criteria as residential. However, the factors we look at are less pervasive, they're less intense, overall less frequent. And our patients are able to maintain their safety outside of programming. And they're also able to acquire support or ask for support when they need it. Or they're working really hard and being able to do this. They generally are able to take their medications on their own without monitoring. Self-care is improved, and they're beginning to reorient back into their communities, into their families, and they continue this journey in our IOP program, or that stands for Intensive Outpatient Programming, where again, their symptoms are less intense, less frequent. If they're not already working or in school, they're beginning again to actually start working, begin taking a class or two. We're wanting our patients in IOP to, if they're not working or in school, we are looking to help them engage in volunteer work or ways to feel that they're contributing positively to society, to their communities.

Each level of care has a different schedule. A patient can enter just through our IOP level of care and maybe some times will need more support or they'll start in our residential level of care and be with us all through IOP. And so the time that a individuals with us could be, a typical stay in residential is around 30 days. A typical stay in our partial hospitalization program is around three weeks. A typical stay in our IOP program is, typical again is anywhere from about two and a half to three months, depending upon how they're functioning. And of course we're also working with insurance. So that's just a quick snapshot of how we integrate our care and how we help transition patients through the different programs that we offer.

So where do we begin? Whether we're talking about residential level of care, partial hospitalization, IOP, we need to have an anchor. We need to think about, okay, so there are typically individuals in any level of care have multiple problems and , have multiple stressors and you need an anchor. So our anchor in the Mood and Anxiety Program is our DBT program. And the woman that started DBT, as I've already mentioned is Marsha Linehan. She is a pioneer in the treatment of patients who are at high risk and have multiple problems. And there's extensive research of Marsha Linehan's work with dialectical behavior therapy. It's a set of skills and a set of modules that are essentially, again, using the word skills, I want to highlight that. It's a set of modules and skills that help individuals learn new ways of interacting in their environment, interacting with themselves, interacting with you all. We all can practice these skills. And I really encourage you to ask your loved ones, what they're learning, have them teach you the skills that they're learning. That's what we encourage them to do.

And there are different stages in DBT. And that's again how we anchor our treatment, because we always want to focus on stabilization. No matter what level of care an individual is in, we need to make sure that they can keep themselves safe, that they're not engaging in any behaviors that are threatening their sense of wellbeing. And then we move towards helping them increase their emotional experience and emotional regulation and begin to engage in overall problems in living and be able to problem solve in an effective way.

So the way that they begin to do this is through our core skill sets that we teach. But before we talk about the skill sets, I need to explain why is it called dialectical behavior therapy. So what is the D in DBT? Dialectic is a process of thought where we establish truths on both sides rather than trying to disapprove one argument, meeting in the middle. And the most fundamental dialect is the necessity of accepting patients just as they are within a context of trying to teach them to change. So this essentially reminds us as a treatment team that under individuals or patients that we work with, because we're teaching them this, even though you might feel awful and you just feel like you can't get out of bed, you can think this and still get out of bed. So that's just an example of how we bring the thought process to actual reality or bring it to life. So the dialogical.

The B in DBT. Behavior, I can't focus on that enough. Your loved ones are coming to us. They're not just passive recipients of the information that we're teaching them. We expect them to meet us in the middle and to engage in these skills, practice, these skills that we are teaching them. This takes a lot of effort and it takes time. And so I encourage all of you to just remember this, what we're teaching them takes so much effort and time and patience, yet what we also remind them is that it takes more effort just living in misery. We teach patients, there are four options for solving any problem. So one is to solve the problem, change the situation or avoid it or leave it or get out of the situation for good. Another option is to feel better about the problem. Maybe you regulate your emotional response to the problem. Third option, you could just tolerate the problem. You could just accept and tolerate both the problem and your response to the problem. Fourth, you could stay miserable and possibly make the problem worse.

There are barriers to solving problems. We don't expect our patients just to be able to solve all their problems the minute they walk in the door, and that's why recovery also takes time. Marsha Linehan shared with us seven skills training assumptions. So they are, people are doing the best they can. People want to improve. People need to do better, try harder and be more motivated to change. People may not have caused all of their problems, but they have to solve them anyway. New behavior has to be learned in all relevant content. All behaviors, actions, thoughts, and emotions are caused. Figuring out and changing the causes of behavior work better than judging and blaming. Keep these in your mind as we continue to talk about our curriculum and you'll see how we use these assumptions and we've weave them in to our work in groups and in individual therapy.

So now we're going to move to talking about the four modules in DBT, which include core mindfulness skills, distress tolerance skills, emotion regulation skills, and interpersonal effectiveness skills. I'm going to start with mindfulness. If you all were here with me, I would ask you, what do you know about mindfulness? How many of you practice mindfulness? Really we all can be practicing mindfulness every day in order to increase our awareness of what is happening within our bodies, increase the control of our mind. I'm going to talk a little bit about acceptance and commitment therapy, but this idea that we can't control the thoughts that pop into our minds, because our minds are just meant to manufacture thoughts. What we can control is how we relate to these thoughts and how much attention we pay to these thoughts.

So if a thought, for example, let's say I'm having a thought right now that I'm just a terrible presenter. Well, that's going to really interfere with my ability to do this presentation for you all. So rather I am choosing to be mindful, I'm focusing on the present situation. I'm seeing that I am being recorded talking to you all. I'm listening to my voice. And I'm just trying to experience reality as it is rather than listen to that nagging thought that I might be having. We are always using mindfulness exercise in almost every group that we practice and we are encouraging our clients and patients to practice mindfulness and practice other skills when you're not really dysregulated, because you want these skills to become automatic, so that you don't have to think about, deal with distress in the moment, if you're distress is just beyond what feels manageable, and use a skill to bring down the distress.

So speaking of distress tolerance, this essentially means accepting that we cannot change or fix, manipulate or avoid or get rid of our present moment. So how do we cope with it? Marsha Linehan helps us practice distress tolerance by practicing radical acceptance, this idea that it is what it is, whether I like it or not. There are reasons whether I know them or not. From here, how do I build a worth living? This doesn't mean that what happened to us in the past, particularly any traumatic experience, was right, or that the therapist is condoning this, but it means that we have to accept that this has happened to us so that we can figure out how to move forward in our lives. So we can break down the barriers that are impacting us and preventing us from living a life that is in accordance with our values.

This is a really hard skill to really achieve. And we probably talk about radical acceptance in some way or another throughout most of our groups. And in order to practice radical acceptance, being able to be mindful is essential. And just a side note, when we think about mindfulness and our brains and how our brains have evolved to protect us, something I learned from, I can't remember who told this to me, but I think it's a very powerful reminder of the importance of mindfulness.

Our brains are masterful storytellers. Their purpose is to generate stories. Our minds live in the past that is already over and in the future that has not happened. So we need to teach our minds to focus on the present moment and be in tune with our bodies. Our bodies tend to be the ones to tell us the facts. My heart rate is increasing right now. I'm feeling sweaty. Our minds are the ones to tell us I'm in danger. I need to get out of this moment right now. It's too hard to feel this emotion right now. So we do a lot of work with just the mind body connection and connecting mind and body exercises, and that all boils down to really being able to practice mindfulness.

So then the next two modules in DBT focus on emotional regulation. And what do I mean by that? If I were feeling really cold right now, I might go grab a jacket. That'd be a little odd to do during a presentation, I could probably withstand it, but the idea is I'm feeling really cold. I'm going to put on a jacket and if I'm feeling hot again, I'm going to take it off. And that's the same way we think about emotion regulation. First we have to be able to identify the feelings we're having. And if I were to ask you right now in this moment, how are you feeling? What your internal experience? What emotions are coming up for you? It's not so easy to do. And we practice this skill with our patients in every group. Every group starts with a check in, your name, what pronouns you use, and what internal experiences are you having right now?

And you have to keep in mind when we're talking about emotion regulation, this idea that you can have more than one emotion at any one time. You can be experiencing joy at the same time also noticing that you're feeling a little bit distracted or preoccupied. Again, we're talking about the dialectics. We can experience one or more emotion at the same time, and it's helpful for our patients that feels chronic depression, because oftentimes they're not noticing throughout the day that there are moments where maybe they engaged in a joke with someone or they laughed with someone or they were playing a game during program and they weren't just feeling depressed at that moment. So that we take every opportunity we can to teach our patients this idea to think dialectically. That broadens our internal experience.

And then the last module within DBT is interpersonal effectiveness, improving our relationships. Also letting go of relationships that are not helping us, that lead to hopelessness. And also asking for what we want and being able to say no to requests that we don't want to fulfill. So these modules are really the core of our program. And the other types of interventions we use, essentially all the other interventions that we use, which are evidence-based treatments, exposure therapy, behavioral activation, and acceptance and commitment therapy, ACT for short or radically open DBT, all share that same philosophy of mindfulness and paying attention to our present moment in order to be able to tolerate the pain that we might be experiencing or the distress that we're having and not making anything worse. And this will move us in the direction of wellbeing and mastery.

So in terms of exposure therapy, this idea of facing our fears, challenging our fears, the only way that we can do this is by leaning in. Leaning into the distress and somehow stopping the avoidant patterns and behaviors that we have learned. And we have developed, let's say behavioral habits of avoidance, which I'm going to talk about in a second, because again, that painful reality has felt too hard to experience.

A metaphor that we use to speak more to what we mean by avoidance is the Poison Ivy metaphor. So I'm just going to read it right now. Poison Ivy is a plant that produces a strong irritant, and we all avoid it when we see it. No one wants that strong blistery, itching rash. If we are unlucky and rub against it, the rash prevails and the itching begins. If we scratch it, hoping to find relief, we only find more pain and itch. Anxiety is the same way. However, we can't avoid its effect. We must expose ourselves to it without scratching.

If we didn't experience anxiety, we wouldn't be alive. There are reasons for all of our emotions. We need to be anxious if we're crossing the street, right, if a car speeding towards us. We need anxiety to make us make a quick decision to get out of the way. However, oftentimes because of our painful existence and our painful reality, we start to avoid experiencing any kind of uncomfortable feeling. And it builds upon each other until our lives become so narrowed and essentially we're not feeling much at all. That's when we start to feel detached, numb. Patients at this point really can't even identify how they're feeling. So this is often when the focus of our work is going to be on behavioral activation and for chronic depression, this idea of why we...

Going back to exposure work. So there's two ways that we go about breaking down avoidance. We break down avoidance through leaning into our fear and distress. So moving towards, for example, we may have a patient begin to work on their resume, begin to have a conversation with their parent let's say that they've been avoiding or with their spouse. We need to show them that they can tolerate the discomfort that is going to come from this experience, but that it's moving in the direction of their values. Let's say a patient has been avoiding opening up their emails from school. They're on a leave and they want to go back to school, but the only way they're, they're going to go back to school is to open up the email, but they're avoiding opening up their emails because of the pain that they're feeling. So in groups, we're going to, we're going to work with them on making steps to opening up the email, to begin that step necessary to get back into school. So that's what we do in our exposure groups.

And at times someone isn't feeling as much anxiety, but they're feeling more chronic depression. And so this is where we're going to work with them to increase positive experiences in their lives and help them, because so often with chronic depression or even situational depression that has gone on for a long time, they develop habits that make action difficult. So we're helping them increase activity very, very gradually. If we do it gradually, it's going to make it feel more manageable and they're going to make them feel that this is doable. Again, mastery. And there's increasing their chance for change. So within our track, we call it optimal engagement. We're trying to have patients engage in life optimally, whether that's through leaning into distress and facing some of his anxiety, or whether it's more of beginning to build more positive experiences into their own lives through behavioral activation to get them out of these very stuck patterns.

And I mentioned acceptance and commitment therapy. We have a group on acceptance and commitment therapy, and we also weave tenants of acceptance and commitment therapy throughout our programming. And essentially acceptance and commitment therapy focuses again on leaning into discomfort. So again, thinking about our exposure work. By increasing our openness and flexibility and really if we can do that, it decreases the power of our thoughts. So again, I really haven't had that thought that I'm bad at doing this presentation. It's really gone back in the background. Of course, I'm noticing it now as I'm talking about it, but it's fine because I'm remaining present with you all. And so we're again, in acceptance commitment therapy, we're really focusing on changing the way we relate to our thoughts and trying to not pay so much attention to the ones that aren't working for us. And practicing again acceptance and practicing the ability to have awareness of our pain and aware of our attempts to control our pain.

So again, it's that power is knowledge piece, and this begins to loosen our hold on pain. And that's when we learn that we can be in control of our own experiences rather than our mood, our anxiety level, or having to rely on a substance or a behavioral pattern that is keeping us stuck.

I'd like to end this presentation by reading a poem, normally we'd read this together. However, I'll just read it aloud, by Rumi. And this poem really illustrates all the concepts I've talked about in this presentation. And it's a nice reminder of the work that we're doing with your loved ones. And it's a reminder of the work that we can all continue to do in our own lives.

This being human is a guest house. Every morning a new arrival. A joy, a depression, a meanness, some momentary awareness comes as an unexpected visitor. Welcome and entertain them all. Even if they are a crowd of sorrows, who violently sweep your house empty of its furniture, still treat each guest honorably. He may be clearing you out for some new delight. The dark thought, the shame, the malice, meet them at the door laughing, and invite them in. Be grateful for whatever comes, because each has been sent as a guide from beyond.

Thank you.

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