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.