DBT for Eating Disorders Program Begins November 7th at The Counseling Group

The Counseling Group's DBT program is expanding with the addition of a skills training group for eating disorders.  In addition to our two adult, one adolescent, and one multi-family DBT skills training groups, we will begin offering a DBT skills training program specifically for eating disorder recovery starting on Thursday, November 7th. The program, which is designed to last six months, includes:

(1) one individual DBT session per week with a DBT-trained clinician to track progress on target behaviors and reinforce use of skills and elimination of symptoms. During the period of the program contract, clients may continue seeing their outpatient psychotherapist but also must be engaged once-per-week with the DBT therapist in compliance with the DBT model.

(2) one group skills training session per week led by Inge Sengelmann, LCSW, SEP and Cristina Oliver, MFT on Thursdays at 6:30 – 8:00 pm.

(3) one nutrition counseling session per week with our DBT-informed registered dietitian or with the client’s existing dietitian (preferably an eating disorder specialist). These sessions may happen less frequently with the agreement of the client’s therapist and dietitian team and only if the client is stable in their symptoms.

The Counseling Group's Eating Disorder Team

We don’t admit solely on the basis of need, but assess for willingness and commitment to the model. After a thorough intake assessment prior to admission, and up to three pre-treatment sessions to establish goals and commitments, clients will engage in five months of skills training. Skills training consists of four modules (Core Mindfulness, Emotion Regulation, Interpersonal Effectiveness, and Distress Tolerance). Each module runs for 4 weeks, and are closed during those four weeks, with one transition week in between during which clients may discharge and new clients may be admitted. Clients are expected to complete all four modules, and may repeat if they feel they need to in order to attain mastery over the skills. Clients who miss four sessions of DBT during the contract period are assumed to have dropped out and need to reapply. Clients who miss two sessions of a module need to repeat that module when it is next offered. Many clients opt to take the skills a second time to master the skills and eradicate problem behaviors or work on quality of life issues.

DBT is validated as an effective treatment for binge eating disorder and bulimia. If you are interested in participating, or know someone who is, please call our office to inquire about enrollment, obtain insurance coverage verification, and schedule an intake assessment with one of our DBT therapists. To enter by November 7th, we must conduct the intake prior to October 15th, If a client is unable to enter by November 7th, the next transition date will not be until December 19th, and then again on January 30th. 

Making Lemonade out of Lemons: Dialectics and the end of Suffering

I recently completed a six-month-long training in Dialectical Behavior Therapy (DBT), a comprehensive mode of treatment developed by Marsha Linehan, Phd, ABPP for people whose intense emotions are overwhelming and lead them to use destructive behaviors (such as self-harm, suicide attempts, substance abuse, compulsive shopping or gambling, eating disorders) to regulate them. Dr. Linehan found that these suicidal and self-injuring patients struggled with traditional cognitive-behavioral therapy and because they felt invalidated by its focus of change. And yet, they also desperately wanted to change in order to stop suffering. Dr. Linehan incorporated mindfulness-based acceptance strategies into her treatment to balance out the focus on change – making it a dialectical approach.

“Dialectics” is a philosophy that sees the truth as the synthesis of a thesis and an antithesis, meaning that we must always try to see the “kernel of truth” in each conflicting position, thus eliminating the seeming contradictions that keep therapists and patients “stuck” in unsolvable conflicts. The concept of “Wise Mind” in DBT, for example, is the dialectical integration of reasonable mind and emotional mind. Emotional balance, then, is not achieved by denying, invalidating or exterminating emotional reactions, but rather by balancing them wisely with reason, taking in all points of view.

DBT focuses on teaching people skills to manage difficult emotions, deal with painful situations and improve relationships. The treatment components include individual therapy, skills training group, skills coaching between sessions to generalize the skills to real-life situations, and a team treatment approach that requires the treatment be applied to the therapists as well as the patients. Skills are taught in a class format in the following areas, or modules: Mindfulness, Emotion Regulation, Distress Tolerance and Interpersonal Effectiveness.

Patients are required to keep a diary card to monitor their urges, emotions, and practice of the skills. Therapists meet weekly as a team to enhance their effectiveness as DBT therapists.

A DBT therapist seeks to understand a behavior’s function, thus removing the judgment about the behavior’s “right-ness or wrong-ness”, and then coming up with solutions based on whether the behavior is caused by a skills deficit (remediated by skills enhancement), an inability to tolerate distress (solved by exposure), a cognitive distortion (helped by cognitive remediation) or reinforced conditioning (solved by contingency management strategies).

The functions of a good DBT program are to enhance the capabilities of the patients by teaching them skills, to improve their motivation to recover through the use of cognitive modifications and contingent reinforcement, to assure generalization to the patient’s environment through the use of after-hours coaching and homework assignments, to help structure the patient’s environment to help with recovery through contingency management, and to enhance therapist motivation and effectiveness through the use of treatment teams and consultation.

Making lemonade out of lemons is one of the “dialectical” DBT strategies that requires a DBT therapist to take something problematic in the client and turn it into an asset; for example, seeing problems that arise in therapy or in life as opportunities to practice skills, or interpreting the patient’s “resistance” to change as a strength that allows the person to persevere until changes are made. In her textbook, Cognitive-Behavioral Therapy ofBorderline Personality Disorder, Dr. Linehan explains that her rejoicing over someone’s expressed calamity forces the recipient to stop and take in new information about how this event will allow the person to practice skills. Looking back on all the many crises in my life, I see a jar full of lemonade, a lemonade that I now serve to others who are thirsty for acceptance and change.

The Counseling Group has a team of intensively trained DBT therapists ready to help those who are eager to find alternative ways to deal with their suffering and want to create “a life worth living.” I am proud to be a part of this intensively trained team. For more information about the DBT program, please visit The Counseling Group’s DBT page or call 305-857-0050.

Koshas, Gunas and the Autonomic Nervous System

As part of my ParaYoga Master® Training, I recently finished reading the book Yoga& Psychotherapy: The Evolution of Consciousness by Swami Rama, Rudolph Ballentine, MD, and Swami Ajaya, PhD*. I couldn’t help but bring in my understanding of the autonomic nervous system, through the lens of StephenPorges’ Polyvagal Theory.**

The book examines concepts of ancient yoga traditions and modern psychology, and provides insights into the methods of yoga as therapy. It makes comparisons between yoga philosophy and Western psychological theories, as well as identifies connections to neuroscience and the awakening of specific brain centers. Psychology is a science that is fairly recent. 

Only in the last couple of centuries has Western science questioned man’s “inner being,” mental processes, motivations, and potential. Yoga, on the other hand, is the oldest continuous discipline and developed a philosophy of mind and consciousness based on internal experimentation. In yoga “body” and “mind” are just part of the picture. 

According to yoga philosophy, five “sheaths” or “covers” (known as koshas) obscure the more subtle consciousness that lies within. It identifies an evolution in the development of human consciousness to universal consciousness as these sheaths are explored and embodied (or ‘enlivened’) by pure consciousness. These five levels of being each observe and control the one below. For example, the physical state is an “embodiment” of a mental state. Although body, or Annamaya, is the entry point, it is only one dimension of our being. The five sheaths covering the “Self” or truest essence include: Annamaya (food sheath); Pranamaya (energy sheath); Manomaya (mental sheath); Vijnanamaya (intuitive sheath or Buddhi); and finally Anandamaya (blissful sheath).

As a somatic psychotherapist, I enjoyed reading about the history of body psychotherapy and its relationship to yoga, which understands more than any other science that posture and body habits influence mental and emotional states, are intrinsically linked to personality, and can either help or hinder growth and evolution. In yoga, asana and mudra can be used to create desired mental (and energetic) states. It is this “tuning in” to the body that provides the first contact with the inner realms of experience generally outside the field of our awareness. Although only the first sheath, it is a critical link to accessing the other four sheaths and experiencing a true connection of body, mind and spirit.

The second sheath or Pranamaya relates to the energy body, which is controlled by the flow and alterations or rhythms of the breath. These rhythms, the authors propose, are intimately tied to the earliest and most fundamental layers of mental life. In this sense, breathing is the most efficient intermediary between mind and body. If one can learn to consistently and deliberately control breath, mental and emotional states can be shifted. Regulation of breath – union between ida and pingala, the sun and the moon channels -- leads to mastery over mental and emotional states, which in turn influences body states.

Finally, yoga provides a comprehensive understanding of mind as having various levels that interact with one another, and we must be able to observe and not get caught up in manas, or lower mind (consisting of sensory-motor impressions); chitta, or the memory bank of all our experiences; asmita or ahankara, which may be known as “ego” in the West, and which provides a sense of “I”-ness; and finally Buddhi, which is our capacity for wisdom, discrimination, and discernment. Beyond these is Atman, or the highest Self. 

Patanjali classifies thought forms, or vrittis, in two ways: as obstacles (kleshas) and in terms of function: 1) accurate perception; 2) inaccurate perception; 3) fantasy or imagination; 4) memory; and 5) sleep. Through disentanglement from the thought forms, pure consciousness can begin to emerge. As in Jungian psychology, which seeks to bring subconscious process and symbolic content to conscious awareness, a vichara process in yoga helps us to become more intimately aware of these subconscious patterns and tendencies.

Why is all this important? To see the yoga, or union, between various theories for understanding human consciousness and behavior helps me to be more helpful to those seeking to grow and expand mentally, emotionally and/or spiritually, including myself.

The understanding of the various levels of mind correlate with my understanding of neuroanatomy and the triune brain: The primordial/instinctual/primitive/reptilian brain equaling manas; the limbic system, primarily the amygdala and hippocampus, equaling chitta; the sensory-motor cortex, insula, and anterior cingulate cortex equaling asmita/ahankara; and the most evolved areas of the prefrontal cortex perhaps being the abode of Buddhi (although I believe Buddhi may be non-local).

Additionally, my understanding of Porges’ Polyvagal Theory also matches up with concepts of yoga, including the gunas (in Samkya philosophy, the fundamental operating principles of universal nature, , which are Tamas, or inertia; Rajas, or activity; Sattva, or essence). In 1995, Stephen Porges introduced a new perspective of the autonomic nervous system, identified neural circuits involved in the regulation of autonomic states, and interpreted autonomic reactivity as evolutionarily adaptive. He proposed that there are two vagal motor systems – dorsal vagal (immobility) and ventral vegal (social engagement) – and that primary emotions are related to autonomic function (therefore residing in the Annamaya, but responding to the Manomaya). He re-conceptualized the autonomic nervous system to include target organ, afferent and efferent nerve pathways, and bidirectional communication between the heart and the central nervous system (therefore one could imply a relationship to the seven energy systems in Pranamaya known as Chakras).  

Porges stated that the autonomic nervous system responds in a highly sequenced response hierarchy to environmental stimuli, based on a neural process he calls “neuroception” that evaluates risk and modulates vagal output, triggering or inhibiting defense strategies for survival. Neuroception, as a process, determines whether specific features in the environment elicit specific physiological states that would support either a dorsal vagal immobilization response (tamas, or inertia), a sympathetic fight-flight response (rajas, or action), or a ventral-vagal or social engagement response (sattva, or universal consciousness).

As a dialectical behavior therapist and somatic experiencing practitioner, I teach people to observe sensations and behavior (Annamaya, and possibly Pranamaya for those more sensitive), as well as thoughts and beliefs (Manomaya), in the hope of creating greater awareness, cohesion and regulation (Anandamaya, or bliss) through the use of “Wise Mind” (Vijnanamaya or Buddhi).

By having a clearer understanding of the inter-relationship between the sheaths, and grasping the importance of combining the right set of practices (or therapies) for each particular individual, we can maximize the desired effects: whether it is for greater emotional balance, optimal physical health, clearer mental focus, or reaching enlightenment.

*Swami Rama, Ballentine, Ajaya (1976). Yoga & Psychotherapy: The Evolution of Consciousness. Honesdale, PA: Himalayan Institute Press.

**Porges, S.W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication and Self-Regulation. New York: W.W. Norton.

A Life Worth Living: Embodying Your Dharma Code

What are you? Where do you live? Why are you here? What do you do? How do you do it? What is it for? These were questions posed by Rev. Chris Jackson at Unity on the Bay yesterday, ageless questions humans have been asking themselves for millennia, questions that have spawned the world's religions and philosophies.

For me, pondering these questions has led me on a quest for deeper meaning, and all roads lead to the same place: within. Last week I was in Northampton, Massachusetts at an intensive training in Dialectical Behavior Therapy, a third-wave behavior therapy grounded in a dialectical worldview and mindfulness practices. For several months, I have also been involved in self-reflection and yoga practices in the tradition of Rod Stryker's Para Yoga.

Whether in a professional development training or personal self-realization workshop, the roads are converging for me. This is a nice feeling, because I want to be authentic and transparent, regardless of the setting. I am aware that I am not a typical wine-drinking, Botox injecting, Ferragamo shoe-wearing, hair coloring "Miami girl." I have never injected Botox and I haven't had a drop of alcohol in almost 25 years. I will never pay $500 for a pair of shoes. I am a down-to-earth, Børn-wearing, quinoa-eating, yoga-practicing, cancer-surviving, gray-haired, (hopefully gracefully) aging woman in search for peace and enlightenment.

I was especially excited about  the DBT worldview that DBT is therapy between equals. I might know some skills that I teach  a client who is the expert in their own experience. I influence them and they influence me. They may engage in therapy-interfering behaviors, and so might I. We are engaged in a graceful dance. Does this approach mean I can bring more of my authentic self into the equation, and let people know that I also need to practice skills to suffer less? I hope so.

Working on Rod Stryker's "Four Desires" exercises, I have identified my Dharma, or life  code, as embodying the Divine, expressing Divine ideas, writing and speaking words that inspire and change lives. I am here to heal, myself and others. I do this by attempting to see things with clarity, by nurturing my connection with Spirit daily, by trusting in the abundant love of God (as I understand God), by resting in a benevolent Universe, by releasing all attachments, by having the courage to be transparent. This is a lofty task, given my judgmental, opinionated, and self-righteous nature. But I am up for it.

Can I release self-judgment and become more real? Do I have the courage to walk through fear and reveal who I truly am? I want to. It might be helpful to me, and maybe to others as well.