Blog - Page 5 of 7 - Kate Gegg, AM, LCSW

June 23, 2021March 27, 2023

American Insurance Networks

American Insurance is incredibly complicated, but understanding it empowers you and can save you thousands in your physical and mental health care
I do all of my own billing, and while I’m not an insurance broker I know a lot about common pitfalls that leave people confused and on the hook with surprise costs.
This multi-part series will break down this complicated system so you can get the most out of your benefits, access the care you need, and keep you as protected as possible from unexpected costs
Starting Broad. In the insurance world providers are divided into two categories: In Network and Out of Network. All plans have “in-network” and some plans have “out of network” benefits and they are most often different. Usually it costs you less to see someone in network, BUT depending on the plan some have excellent benefits in both categories
In Network:
- The total amount a provider is paid per session is determined by the insurance company
- How much you as a client pays is determined by the insurance company
- Be on the lookout for carve outs! See post for details
Out of Network:
- The total amount the provider is paid is determined by the PROVIDER.
- If your insurance plan has out of network benefits insurance may chip in none, some, or all of the cost depending on the specifics of your plan
- Some providers are willing to send these sessions to insurance to help you save money. Some are not. Ask your provider.
Both in-work and out of network:
- When using insurance know that your insurance company collects information about you to determine whether or not they consider this a “valid” use of the medical treatment provided. To cover a mental health session they always require a diagnosis.
Yes. If you are in therapy and you or your therapist are sending claims to insurance this means you have a diagnosis. You have every right to ask what that diagnosis is, and to understand what symptoms your provider sees in you that led them to making that diagnosis.
If you want to know costs in advance of scheduling with a provider you can ask the provider if they are in or out of network, and you can contact your insurance company to verify. You can also contact your insurance company and ask what you should expect your “out of pocket” (i.e. your personal) costs should be.
When calling insurance you can provide the CPT codes (these are billing codes providers use) to get exact dollar amounts:
- Initial appointment is often: 90791
- Additional appointments are often: 90837, 90834, and 90832 for individual work or 90847 and 90846 for family / couples work

One major barrier to treatment in the United States – our incredibly complex insurance system.

Insurance networks have two categories: Providers that are in -network and providers that are out-of-network.

Some key differences:

A provider who is IN network is a provider who has signed a contract and agreed to set of rules for how to operate their practice.

How this effects you: This means the provider has agreed to accept fees at a certain rate for the treatment they provide. This usually means the provider is responsible for billing the insurance company on your behalf.

Example (with made up numbers): I say my fee for therapy is $150/hour. The insurance company says to be in our network you have to agree to be paid $100/hour. I can decide to accept that, try to bargain for a higher rate, or decide not to be in network, but once I decide I am “in the network” I have to agree to accept the rate the insurance company and I agreed to for every client I see who has that insurance.

Things that make In-network more complicated:

(1) There is a thing called “carve outs”. This is when you have a plan from one insurance company but they “carve out” a particular kind of health care to another insurance company. I.e. it says “Insurance A” on your card, but ACTUALLY your mental health benefits are through “Insurance company B”. The only way to know if this is the case with you plan is to call and ask before billing happens.

(2) Insurance companies can decide change how much they pay providers. Which means your costs can change even if your plan doesn’t.

A provider who is OUT of network has decided not to sign a contact with an insurance company. Those providers set their own fees, which means the insurance company has no say over how much you will pay per session.

Example continued: I say my fee is $150. You pay me $150. The insurance company doesn’t have any say over it.

At the end of the day, you are responsible for the cost of your healthcare, so be your own advocate, protect your finances, and call your insurance company to make sure you understand what they will cover and what they won’t.

Notes:

I’m quite serious that knowing and understanding how insurance works can save you huge amounts of money. I can’t tell you how many times claims have been processed in a manner inconsistent with how I or my clients have understood their plans to work – and understanding this system has enabled both me and them to challenge an insurance company to have payments made where they were previously denied.
If you’re going to call an insurance company to check on costs, ask for a confirmation number at the end of the call ad write down / keep that number. If there is as issue down the road they will be able to find record of your call when you supply that confirmation number – which may be the “evidence” that you need to get the company to operate in a manner consistent with what they told you at that time (and yes, I have seen this happen many times before).
In Illinois we have something called the “Illinois Dept of Insurance”. I am guessing other states have it too if you want to dig around a bit. This is a government agency that investigates fraudulent uses of insurance by both providers and by insurance companies. If you are spinning because you know something isn’t right with how payment or insurance is being handled this free service will step in on your behalf and investigate. Don’t be afraid to file a claim, I’ve filed half a dozen or so over my last 10 years in business and it works. Sometimes we all need an outside advocate. https://mc.insurance.illinois.gov/messagecenter.nsf

June 14, 2021March 27, 2023

Acceptance

Sometimes the reality we want or believe “should” exist is not the reality that’s in front of us
When we don’t want or can’t accept something we can fight it by hiding from it, pushing it away, denying it, or actively resisting it
This applies to our external reality (including facts about our family, our culture, our country, our jobs, and our lives)
It also applies to our internal reality, including thoughts / feelings we may not like or want to be there, and thoughts / feelings others tell us we “shouldn’t” have.
When we are stuck in the place of non-acceptance, we are in a no-mans-land of desperation, anxiety, resistance without traction, refusal, and misery where we are trying to control, change, and prevent something that already is.
For many of us, the fixation on the reality we wish were true is a distraction – a way to shield ourselves from the pain, shame, embarrassment, loss, or disappointment that would come if we conceded to what the reality in front of us was telling us about our lives or the situation we were in.
When we accept the reality in front of us we can still work towards changing that reality. When we accept we don’t have to approve, or condone.
With acceptance we acknowledge what IS and from that baseline we can make changes in our lives, relationships, or the world around us – rather than being caught in the in-between of what is true vs what we wish or want to be true.
Sometimes the most important thing for us to accept is that we don’t have the power or authority to make or prevent a change we are not comfortable with. When we accept that reality we can begin to refocus on items we do have control over and pursue what is meaningful to us in other ways.
If you have found yourself “cycling”, unable to stop thinking about something, or in a pattern of repetition in your life consider that you may be resisting accepting the reality of something in front of you.

A lot of the distress in our lives is driven by our struggles to acknowledge and accept a reality we do not like or approve of. A “this can’t be happening” mentality can consume us, and efforts to “make it right” or “not let it happen” can preoccupy us. We can just refuse to put up with it as though digging our heels in and not accepting something changes it from being real or true.

As Bessel Van Der Kolk writes of his training, “The greatest sources of our suffering are the lies we tell ourselves’ …be honest with ourselves about every facet of our own experience…people can’t get better without knowing what they know and feeling what they feel”. Our refusal to accept the situation at hand (which includes realities in both our internal and external worlds) creates the suffering Van Der Kolk writes about; we are miserably stuck in-between what we wish to be true and what is. This is when we can get stuck doing the same things over and over – wanting a different result, but not getting one.

We can then be given advice that may not sit right with us, which is to “accept” the situation at hand. For many of us the term accept has associations of approval tied to it, “if I accept it, that means I am saying it’s ok”. So we push aside that advice and continue on in our state of limbo where on the one side we have the reality we wish were true, and on the other side we have the reality that actually is.

If the term “accept” doesn’t sit well with you try concepts like acknowledge, recognize, or observe. When we acknowledge what is happening, we recognize the reality in front of us without condoning or approving of it. We don’t have to like it, but until we can acknowledge it for what it is we can’t start making changes that make us happier, or make our lives or our world better.

For nearly all of us, once we reach that point of acceptance or acknowledgement of what “IS”, a huge burden of distress is lifted. We can be left with loss, pain, and other difficult feelings, but feelings can be resolved, unlike the constant cycling of refusal, desperation, anxiety, and resistance that can stay with us when we are not recognizing and accepting the reality in front of us.

Notes:

Sample statements that can help move you towards radical acceptance / acknowledgement; “this is just what is happening right now”; “I don’t like it, I don’t approve of it, but it is the reality in front of me”; “I want to work to change it, because I’m not ok with it, but I accept this is what is happening and I will do what’s in my power to work towards creating a different reality”.
This post describes radical acceptance as outlined in Marsha Linehan’s‘s skills training manual on pages 176 and 102 Full citation: Linehan, M., M., (2014). DBT Training Manual. New York, NY: The Guilford Press.
The quote is from pages 27-28 of “the body keeps the score”. Full citation: Van, . K. B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma.

June 14, 2021March 27, 2023

Why Meditation

We can work towards having control over our inner world by increasing our ability to control what we pay attention to
For many of us a powerful thought, reaction, or feeling can arise and completely take us over
This is often disruptive, exhausting, and time consuming. We can feel like the thought or feeling is in control of us.
We can dramatically increase our ability to take the intensity out of our thoughts and feelings which gives us more control over our inner experience, actions, and reactions
To do this, we want work to control what we pay attention to, rather than trying to control what comes up for us.
With meditation we can strengthen our ability to select where we place our attention and energy, rather than having our thoughts or feelings decide for us
We can also learn to tolerate our thoughts and feelings without having intense reactions to them
This is NOT learning to “block” feelings, experiences, or thoughts by “tuning them out”.
This is also NOT sitting with a blank mind or a relaxation exercise.
There will be more instruction to come on how to do this, but the goal is to increase your ability to have thoughts, feelings, and take in experiences while still remaining in the driver’s seat of your life.

We can’t control what happens to us, and “what happens to us” includes our thoughts and feelings. We can develop strategies for how to manage them, but ultimately the thought or feeling that arises for us is as much out of our control as the actions of the person down the street.

One of the most powerful things we can learn to do to help us manage our mental health is to strengthen our ability to control where we place our attention, and to increase our ability to tolerate our thoughts and feelings. The more skilled we are at this, the better we are able to manage difficult internal thoughts and feelings when they arise, and the more control we can have over our actions and reactions.

Most of us do not have an intentional relationship with our internal world. We feel a strong emotion, or have a strong reaction and that takes over our attention. Our internal world can then distract us from our external world – making it difficult to focus on an activity, project, person, or event.

There will always be overwhelming moments in life. Most of us can’t learn to take all the power and intensity out of those moments, even with meditation. Sometimes, we will still be distracted by intensity in our internal world, or events that disturb us in our lives. However, we can dramatically reduce our susceptibility to the intensity of these experiences by increasing our ability to control where we place our attention.

With meditation we learn to develop a spotlight around whatever we’ve chosen to focus our attention on. Like a spotlight, the stronger our ability to control our attention, the more we can focus on what we’ve chosen to focus on, and the less energy and attention is given to what we’ve chosen not to pay attention to.

The specific skill that I’ve seen enable many of my clients (and others) is a particular kind of meditation where we are working on observing our thoughts, feelings, and sensations without reacting to them. This skill, like a muscle, requires practice. The good news is it can take as little as 30 seconds a day for you to dramatically increase your ability to control your attention.

Future post to cover HOW to do this.

Notes:

1`. Chelsea Handler’s book, life will be the death of me, covers her journey through therapy and how her use of mindfulness (and therapy) changed her life.

2. I want to be clear: meditation is not intended to numb you, or desensitize you from painful experiences in your life or events in your community. We are not sticking our heads in the sand and “ignoring”. When we control our attention the goal is not to “block things out” (that would be avoidance). There will be more posts to come on how to do this!

3. Jon Kabat-Zinn ‘s book “wherever you go there you are” is an excellent introduction into mindfulness and meditation

June 4, 2021March 27, 2023

Tolerating Trauma

Sometimes the most tragic of stories are the ones we have a hard time finding empathy for.
Instead, we can create distance from the story, person, or situation by finding ways it couldn’t happen to us, in our lives, or in our community.
Sometimes that can look like denying it could happen to or near us.
Other times we create a narrative about how the person participated in creating their painful experience
Something like: “if they had lived their lives differently, more carefully, this wouldn’t have happened to them, and so I can feel secure that this won’t happen in my life because I would be careful in ways they were not”
This is a natural response; we are trying to keep our sense of safety in the world as we know it intact.
While natural and often automatic, it is important that we own it as OUR response to OUR sense of vulnerability and OUR fears that this could happen to us.
Too often, how someone may or may not have participated in the outcome of their situation becomes the focus of the conversation with and about people who have experienced something terrible
While accountability, when due, is an important part of prevention moving forward, we can be tempted to hold someone TOO accountable for their tragedy as a way to help ourselves feel safer in our lives.
There are unfortunate consequences to this style of coping by distancing for all parties. Learn more about the impact of this in today’s post.

Have you ever found yourself hearing a story about something horrible that happened to someone, only to find yourself distracted by your internal effort to look for a reason that couldn’t happen to you or in your life?

Some version of “this wouldn’t happen to me because I live my life in a such a way where I am protected from the possibility of this horrible thing happening here, to my family, or to me”.

Examples include: “My child couldn’t drown in a pool, I would have a gate up.”

“I would never be out that late in that place”

In those moments we are doing something very natural, which is trying to keep our sense of security in our world intact after hearing a story that leaves us feeling profoundly unsafe.
As Bessel Van Der Kolk writes, “We all want to live in a world that is safe, manageable, and predictable, and victims remind us that this is not always the case”.

It is natural for us to want to feel safe in our lives, and having these protective thoughts is ok – and for many of us very automatic. It is important, however, that we recognize when we think in this way it is a response to our sense of vulnerability and our fears that our lives could be shattered in the way we are hearing about.

If we don’t recognize this is OUR protective mechanism, rather than an objective reflection on the situation, there can unfortunate consequences to you, the person sharing their struggle, and your relationship with that person.

If the focus of our response is on how safety could have been preserved if they acted differently we leave a person whose sense of safety has been shattered feeling isolated, and at times ashamed or like the outcome is entirely their fault*.

We can, in an effort to hold on to our sense of safety and order, develop blindspots about threats in our community that could impact someone more vulnerable than us, and eventually us.

Responding in this way to someone’s vulnerability when they share their story shuts off your vulnerability from you AND from them, creating disconnection.

There is no one “the right” way to respond in these situations, but be on the lookout for your own need to feel safe interfering with you ability to hear someone else’s pain or story.

Notes:

Quote is from page 196 of the Body Keeps the Score by Bessel Van Der Kolk. Full citation: van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.
*I do not mean to undermine the importance of accountability when it is due. Instead, I want us as the listener to be on the lookout for our desire to find a way that this couldn’t happen to us. Sometimes we have trouble accepting that someone may truly just be a victim and some times terrible things happen despite reasonable efforts to prevent them.
It is not your job (unless you are a therapist) to tolerate hearing all the gory details of someone’s traumatic situation. Instead be mindful of your own protective mechanisms when someone is being vulnerable with you and sharing their difficulties. It is always ok to hold a boundary around what you feel able to hear and when you feel able to hear it.

May 31, 2021March 27, 2023

Emotional Blocking

Our emotions continue to effect us even if we don’t perceive them
Even if we don’t feel or notice our feelings they can still have a major impact on how we process the world around us
Some of us believe our emotions don’t influence us, and we are ruled only by logic or reason
Some of us know we have feelings, but they slip away and escape us before we can really make sense of them
This post is for those of you who feel like your emotions are far away or hard to hold on to. There will be posts to come to help you sustainably get in touch with your inner world
To get better at noticing, feeling, and making sense of our emotions we need to learn how to turn the volume up on our feelings in a way that doesn’t overwhelm us, but has emotions stick around long enough for us to make use of them.
Emotions are complex, but they involve brain and body changes in a feedback loop. We can learn to tap into that feedback loop to help us be in better touch with our feelings
For those of us that have a hard time registering what we are feeling starting with our bodies is often the more accessible entry point.
Each feeling has combination of body sensations and brain changes that make it distinct. We can learn to pay attention to those body changes and stay present with them as a way to help us connect more to our emotional world.
Remember: if something feels like too much, return to grounding skills.

Thus far I have written a lot about feeling overwhelmed by emotion, the times when we are filled to the brim or feel like we are bursting. For many of us, however, we have the opposite relationship with our emotions, we struggle with not being able to hold on to our feelings; they slip our of reach, or just aren’t there.

At times, it’s not an intentional pushing down or away, it’s just what happens, like the feelings don’t ever really seem to bubble up. Other times it may be more intentional. Some of us have come to believe that emotions are a waste of time, or we we’ve trained ourselves “not to have them” and consider ourselves to be ruled solely by logic and reasoning.

As Daniel Seigel writes, there are consequences to this non-experience of emotions too, “When we block our awareness of our feelings, they continue to affect us anyway. Research has repeatedly shown that neural input from the internal world of the body and emotion influences our reasoning and our decision making. Even facial expressions we’re not aware of…directly affect how we feel and so how we perceive the world.”

In short, what Dr. Seigel writes is that even if we don’t notice our feelings are there, they are. Even though we aren’t conscious of them, they impact us, our decision making, and how we perceive what’s going on around us.

So, for these folks, we want to help you learn how to turn the volume up on emotions in a sustainable way. For that to happen, we need to help you tolerate the experience of your emotions, which have probably been whittled down because at one point they were too painful, or perhaps you came from an environment where they were not welcome.

We can help you increase your ability to notice your internal world by helping you work to be more connected to your body. Emotions are complex, but they involve brain and body changes in a type of feedback loop. We want to help you plug into that feedback loop by being more present with your body. That way we can help you work to notice and gradually hold on to the emotional signals within you.

There will be more on how to do this, but keep your eyes peeled for mindfulness and body based posts to come.

Notes:

The Daniel Siegel quote comes from his book, Mindsight. (page 125). Full Citation: Siegel, Daniel J., Mindsight : The New Science of Personal Transformation. New York: Bantam Books, 2010.
The theory of emotions (the part about emotions being a feedback loop that involve brain and body changes) is a brief summary of what is laid out on pages 87 – 88 and page 137 of Marsha Linehan’s DBT manual. Full Citation: Linehan, M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.
If you are eager to start working on increasing your awareness of your emotional world run yourself through the exercise of taking some core emotions (anger, sadness, fear, joy, confusion), and sit quietly. Work to pay attention to what happens in your body as you bring up a memory that includes each emotion. Each emotion has a distinct feeling experience in our bodies, and we want to become aware of how those feelings manifest in each of us. Knowing “what” they feel like and “how” it feels in our bodies, and being able to tolerate that feeling helps us become more able to identify and tolerate emotions as they come up naturally in our lives. Be sure you have mastered grounding skills before trying this, it may be overwhelming to start “turning up the volume”. If so, consider starting only with emotions that are more tolerable to feel and get to the more difficult ones once you’re comfortable there.
Wondering why on earth you’d want to feel your feelings – especially your negative ones? Read this post about how are emotions are like “traffic signals” in our inner world .

May 26, 2021March 27, 2023

How to Ground

Grounding skills are the “reset” button for our brain
Many of us avoid our feelings because they are too overwhelming for us to handle
When feelings are too much they can overload us (fill us to the brim and consume us), or numb us (leaving us with nothingness, tired, unable to focus)
When we can effectively use grounding skills we know how to bring ourselves back from those moments
Having this ability to bring ourselves back makes our emotions much less scary – because we know we can always hit “reset” if needed.
These can be done ANYTIME, including when you are around other people and they don’t ever have to know you’re doing it. They can take as little as 20-60 seconds.
For grounding skills to work it is ESSENTIAL that you 1) Engage your senses 2) Engage your whole self (which means no thinking about the thing that’s going on while doing it!) and 3) are mindful of keeping yourself and others safe
Nearly every time I introduce these to a client they roll their eyes at me and ask me if I’m kidding. I am not kidding. This really works. Try it and see for yourself.
The skill I have seen that is most effective is counting a particular classification of objects in a room (i.e. how many circular objects do you see, how many green items are in the room, how many places where you could set something down)
I consider grounding skills to be essential prerequisites for intensive psychotherapy. For us to face our painful emotions we need to have the skills (and to confidence) to come back from them.
There are thousands of grounding skills. Learn more in today’s post.

Grounding skills are essential “bail out tools” for the mind. These are the life raft, oxygen mask, parachute of the brain – essential for helping us “come back to the ground” when our internal world is more intense than we know how to handle (when we are outside our window of tolerance.

These are skills we want to keep in our back pocket at all times, and I encourage my clients to use them in low stress scenarios before relying on them in high stress scenarios so that they get used to what it feels like to “bring themselves back online”.

There are thousands of grounding skills, and you can even make them up can work as long as they meets some basic criteria: 1. Engages your senses 2. You commit yourself with ALL your attention and capacity at that moment 3. Does not have the potential to cause harm to you or others 4. is done at a time when your safety is not threatened. If your physical safety is threatened you need to get to a safe place first. Grounding can help you find emotional safety.

Despite being simple (almost laughably simple) these exercises are often powerful IF we follow the criteria listed above. I find the biggest pitfall is not following criteria 2 – it is essential that we not multi-task and think about something else, we have to bring our brain back to exercise again and again if it veers away. It will be natural for it to veer away, just keep coming back to the task. I also find it helps to keep it simple – if counting works for you (it’s my favorite), rely on counting, and keep counting different types of things in the space around you until the intensity has dissipated.

Grounding exercises work because they engage a different part of our brain AWAY from our emotional center (which is overloaded prior to grounding). These exercises also force us to come back to the present, which is often not as threatening as our internal world.
Examples of other grounding exercises in the comments, you can also search the internet for lists of these.

Notes:

Grounding Exercise: Visual. Counting a particular classification of objects in a room: How many circular objects do you see, how many green items are in the room, how many metallic items, how many places where you could set something down, how many soft items, how many hard items. The list goes on and on. This one is excellent for doing discreetly.
Grounding Exercise: Touch based: While in place, scan through your body and notice every part of your body that is touching something other than air. Notice how it all feels on your skin. Notice the pressure of where your weight is, the feeling of fabric on your skin etc. Experiment with pressing into what you are touching. Count how many different items your body is in contact with. This one is excellent for doing discreetly. This grounding skill might be challenging for someone struggling with body image concerns.
Grounding exercise: Touch, smell, sight, sound. Shower with fragrant (and different than usual) scented cleansing products. Notice the temperature difference between the water and your body. Showers can be very powerful, but this is obviously not one you can do in place.
Grounding exercise: Smell. Put on a lotion or perfume. Smell it and see if you can pick out the different scents in it. How many can you identify. This can be done discreetly, but does require keeping something scented with you which might be a barrier for some.
Grounding Exercise: Taste and touch If you have a liquid with you put it in your mouth and hold it before swallowing (be mindful of not doing something that causes pain – aka – make sure it’s not too hot!). Notice the temperature change. Notice any tastes. See if you can classify them.
Grounding exercise: Hold an ice cube. This one is awesome because it is very hard to think about anything else while you are holding an ice cube. What I don’t like about it is that it a) requires you have access to ice b) requires you move from where you are – which you may not feel motivated to do in the throes of emotion and c) leaves you wet which can be annoying and something that deters you from doing it. I like to think about this one as one to try when you’ve tried some internal ones as those aren’t working as well as you’d like
Grounding exercise: If you search the internet you’ll find this one: identify 5 things you see, 4 things you feel, 3 things you hear, 2 things you smell and 1 thing you taste. This is great because it really engages all your sense and is very powerful at bringing you back because of how much focus it requires of your brain. What I don’t like about it is that it might be hard to remember in the moment, and it might be frustrating if you can’t smell or hear anything at the moment.
All of this sound totally ridiculous? Check out why we need Distress Tolerance skills.
See more about how to gradually incorporate a skill in my post on How Change Happens.
Are you finding you need to ground often? I’d encourage you to consider one on one therapy to help.

May 26, 2021March 27, 2023

Controlling our Attention

We can’t control what happens to us. What happens to us includes events, but it also includes our thoughts and our feelings
Many of us experience inner anguish because we have trouble accepting that what we think and feel is not actually within our control.
We feel what we feel, we think what we think and the best way to insulate ourselves from tough times is work to build coping skills that help us live in harmony with our inability to have the inner world we believe (or have been told) we “should” have.
We can use meditation and mindfulness based skills to help us detach from the intensity of our thoughts and feelings. While we can’t control what happens, these skills help us increase our control over what we pay attention to.
We can use emotion regulation skills that help us to “turn down the dial” on emotions when they are intense, but not at their most powerful.
When emotions are their most intense we can use distress tolerance skills to help us get through a situation without responding to them in a way that will create a problem for us further down the road.
This account will help you learn skills in all three of these categories, and work to help you build awareness of when it makes sense to use which kind of skill.
These skills help us manage pain when it arises in a way that won’t create further suffering for us, and will help protect our relationships and get us through with as little suffering as possible.
No one manages their thoughts and feelings ideally 100% of the time. That is not possible. We are all human. The goal is to help you have the skills so that you know what to do, aren’t so lost in those moments, and can get through them with as little suffering as possible.

One of the things we therapists know, and we work to help our clients accept, is that coping is about learning and accepting what we can and can’t control. We can’t completely control what happens to us, our thoughts and our feelings.

Many of us have luck for sometime pushing thoughts and feelings down or away. We also can organize our lives in such a way that we can have some control over what happens in it, though that’s more often possible when we have more resources. Regardless, at best we only have some control, and we don’t have the level of control many of us wish we did.

I want to be clear: pushing feelings or thoughts down or away isn’t bad. It’s a skill. A skill that works some of the time. However, if we only rely on that particular skill for coping with our internal world we are not equipped for very difficult times, or for when a tidal wave of thoughts or feelings comes in. Further, we lose our ability to learn from our feelings if we rely too heavily on pushing them away.

So, we all need to have a broad array of coping skills. Think of them like tools in a tool belt, different skills for different scenarios.

Instead of trying to control what happens to us, our thoughts, or our feeling we can work to increase our ability to control what we pay attention to and to detach from the intensity of what we may be feeling or thinking. This can be done through meditation and mindfulness based work.

Sometimes we need to learn how to lower intense feelings, that’s called emotion regulation. We use emotion regulation skills when we feel emotions on a level where they “need some wrangling” (i.e. they aren’t dissipating on their own), but not when they are at their most powerful.

When our feelings are really intense, and emotion regulation skills don’t work we can learn to ride them out, let them peter off, distract, or soothe ourselves through distress tolerance skills. With these skills we are working on introducing new and different focal points to divert our attention for a period of time. We are not solving or changing, we are getting through and in doing so helping our brains “reset” so we can tackle the issue when our feelings are not as intense.

Notes:

This post outlines three of the fours modules in Dialectical Behavior Therapy’s skill’s training program. For more information Full Citation: Linehan, M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.
Pushing thoughts and feelings down or away, as mentioned in the post, is a distress tolerance skill. It is a powerful tool to use when our emotions are too overwhelming for us to face, or when the scenario we are in requires we move forward rather than address our experience. For more on why we need distress tolerance skills see the argument for distress tolerance. As with ANY distress tolerance skill we want to return to the topic at hand once we are available to face it (i.e. the scenario allows it, and our internal world feels more balanced).
We use emotion regulation skills when we are still in our window of tolerance, but nearing the edges of it, or perhaps just outside of it. For information on what our window of tolerance is and what it feels like to be outside of it, see “window of tolerance”.
Another reason it is difficult to control our thoughts and feelings is outlined in the post “your brain as an association machine“.
Post covering how we can learn from our emotions is called “emotions as traffic signals” .
Unsure if your emotion is dissipating on its own, or if you need to intervene to help? See Emotions are brief.
One thing that feels important to acknowledge: While these skills can help us manage pain they are not the be all end all and it’s not as though these replace the need for therapy or support from others at times. These skills do not turn us into a one person “cope with anything and everything” machine. These skills help us manage pain when it arises in a way that won’t create further suffering for us, and will help protect our relationships and get us through with as little suffering as possible.

May 18, 2021March 27, 2023

The Argument for Distress Tolerance

Often times when we feel intense negative emotion our drive will be to pull towards, so we can do something / say something / solve something to “release” the emotion
Blood actually starts flowing differently in our brains when we are in high distress – it flows away from the parts of our brain that are best at problem solving, and thinking through consequences, pros, cons, priorities, and values.
This means despite that intense desire to lean it, in those moments we actually want to lean away.
Part of coping well is knowing where that line is in ourselves, when we need to step away rather than step towards. Sometimes we can’t problem solve right away, we just have to get through.
When we are feeling our negative feelings very intensely (like an 8 or a 9 out of 10) we need a different set of strategies. In those times we need to work on distracting, calming, soothing, and diverting attention
Distress tolerance skills teach us to try and shift our attention away instead of trying to manage the problem at hand
For these skills to work we *really* need to shift our attention completely and allow ourselves to be completely engaged in something else. This helps the brain “reset”. Sometimes this means we have to shift our attention again and again until our brains cooperate.
Learn more about why we need distress tolerance skills in today’s post. Specific skills to follow another day.

One of the big gripes I hear about distress tolerance skills – skills and techniques that help you get through the moment (like focusing on your breathing, going for a walk, watching a show) – is that we’re not problem solving. These types of skills don’t actually make the situation better or address the problem at hand. They just divert your attention from whatever the problem is.

All of that is true. Those types of coping mechanisms don’t make the situation better or solve the issue at hand.

That is not their purpose.

Distress tolerance skills help YOU feel better so YOU can (eventually) effectively tackle the situation at hand. They help YOU come back “online” so that you can problem solve, think clearly about solutions, consequences, pros, cons, priorities, and values. They help YOU be in the mindset to tackle a concern with all of your facilities – which we have less access to when we are in a panic, or when we are overwhelmed with emotion.

Think about it. Have you ever quickly addressed what felt like a pressing issue at the time only to reflect later (in a less intense state of mind) to realize you could’ve handled it better? When our emotions are running high (and I mean we’re feeling them at an 8 or a 9 on a scale of 1-10) our brains don’t work the same as they do when we are calmer.*

Often, when we feel strong emotions we feel them with urgency and we believe we need to act NOW. But usually that desire to act NOW is more about making the feeling “go away” than it is a response to any true urgency from the situation at hand.

When we use distress tolerance skills we are not trying to change how we feel or the situation we are in. Instead, we are changing where we focus our attention. This gives us a break from a very intense situation so we can return to it later with our full attention and our facilities intact.

The key with distress tolerance skills is to let things settle and then return to the problem or situation at hand when the external circumstances permit and when your internal state of mind is more balanced. If we don’t return to the problem at hand we’re engaging in avoidance, and that creates a whole host of other issues in our life.

Notes:

* Blood flows differently in our brains when we are experiencing intense negative emotion. This is our brain’s way of trying to protect us when we experience a signal of “alarm” from our emotions, so that our bodies can be ready to handle what our emotions are telling us is a major issue. Your frontal lobe (a section of your brain just behind your forehead) has many functions, but one of them is to help you process the signals from your emotional world and weave those with logical decision making and discerning judgment. As Bessel Van Der Kolk describes in his book, “The Body Keeps the Score”, our frontal lobes have less blood flowing to them when we are in intense emotional states, “As long as you are not too upset, your frontal lobes can restore your balance…Neuroimaging Studies of human beings in highly emotional states reveal that intense fear, sadness, and anger, all increase the activation of subcortical brain regions involved in emotions and significantly reduce the activity in various areas in the frontal lobe” (Pages 62-63) (The Subcortical regions of the brain he refers to are the areas of the brain under the frontal lobe). Full citation for the book: Van, . K. B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma.

Unsure how to identify if your brain may not be “online”? See post dated May 11th called The Window of Tolerance. This post covers what it can feel like when we’re in a place where we want to consider using distress tolerance skills.
Sometimes it can take practice, trial, and error to come to recognize when we’re “not really here”. It will get easier with time.
Much of what I pull from in this post regarding classification of “what” a distress tolerance skill is comes from Marsha Linehan’s Skills Training Manual for Treating Borderline Personality Disorder. Full Citation: Linehan, M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.

May 18, 2021March 27, 2023

The Brain as an “Association Machine”

Think of your brain like one giant association machine
It is constantly looking to learn, make connections from prior experiences, keep you safe, and make sure your needs are met
The majority of associations and connections are made when we are kids, when most development happens
Those associations are our brain trying to make sense of the world in a way that protects us, our relationships, and gets our emotional, physical, and relational needs met.
Sometimes the associations from one phase of life serve us very well in that phase, but then don’t serve us as universally well in others.
If you are stuck and unsure what to do, or if you (or someone in your life) is having reactions that don’t quite make sense consider that your brain may be trying to solve a new problem in the “old” way
We can learn new ways, build new associations, and make genuine changes, but first we have to come to recognize what is hard wired in us from the environments we developed in
It is easier to do that if we can have compassion for our past selves, and accept that what we are doing may have made sense before, but may not (as universally) make sense now
See examples in comments for illustrations which show how our patterns can both serve us and hold us back
The good news is we are working on EXPANDING patterns, not abandoning parts of ourselves. What worked in the past may work again so we can ADD new tools and ways of being.

Think of your brain like a giant association machine that at all times is working on learning and making connections. It’s developing a sense of cause and effect, right and wrong, should and shouldn’t – rules for living and operating; the dos and don’ts of life so you can learn from your mistakes and optimize your successes. Your brain makes the most connections in childhood when most development happens, but throughout adulthood your brain still actively works to keep you safe and protected.

If you grew up in an ideal environment (and there’s really actually no such thing) your brain would have all the ideal associations. Instead, each of us starts to make connections based on our own personal experiences, our family norms, and lessons from what we see and experience in our culture and community.

These patterns – regardless of how effective they are in a diversity of situations – get hard wired in and become second nature. They are our automatic go-to solutions and ways of thinking about things, responding to ourselves, and responding to others.

Some of those associations serve us forever, and in a diversity of scenarios (like knowing smiling is a signal of friendliness). Some of those associations served us at one point in our life and in one environment (like with the folks that raised us) but then maybe don’t quite make so much sense in other environments (examples in comments).

So, when we have reactions that don’t quite make sense to us, it’s likely your brain is associating the current situation with one from the past. Your brain is trying to apply the old rules to a new situation, and sometimes it doesn’t work out in our favor.

We can learn be more discerning and less automatic with these associations through building insight into what our automatic patterns are, and challenging that automated way of being through the use of mindful and intentional responses, choices, and actions. We can also learn to add in responses that may have been “off limits” in our early environment by observing what works for others that we may not feel is accessible for us (yet). And of course – therapy can help too.

Notes:

Season 1 of the HBO show WestWorld explores this concept through its use of humans and robots. The show explores how humans, like robots, can build such strong associations and patterns that they lose their ability to think critically and respond to individual moments and situations.
Wondering how this applies to you? Ask yourself what feel like your hard and fast rules for how you handle: your feelings, your friendships, saying yes to something, saying no to something, making plans, handling conflict. Bring as much curiosity as you can to what feels “normal” to you and the environment you came from – and then – think about if you’ve seen other examples of how those same scenarios are handled by others. What’s a “rule” or “norm” for you, may not be as universal as you may believe.
I talk about themes related to this in my post from April 15th, “for every action there is an equal and opposite reaction”.
Examples of relational and emotional health related associations made in childhood that may have protected us as children but may not serve us as well as adults are numbered below.
Example 1: Imagine you grew up in a home where you were a pretty emotional kid, and your parents were less emotional people. Or maybe they were emotional, but often preoccupied and not very plugged into you. Once they knew you were upset they would be very comforting and supportive, but it was hard for them to see early (or even mid – cues) that you were in distress and needed support. To get the help you might learn you needed to have BIG reactions. Yelling, crying, screaming – expressing emotions at a high level. We can understand then the association your brain would build – if i need emotional help, I have to be LOUD for the people around me to plug into me. So as an adult you might have BIG reactions, and yes – people would know how you felt, but, it might also be hard for others to tolerate such big reactions. While your sensitive and emotional nature might be very appreciated by others (because empathy may come very naturally to you) your way of handling your big feelings might not work in an environment where people are more plugged into you.
Example 2: Imagine you grew up in a home where you had a parent that needed a lost of positivity from you. Whenever you shared your frustrations or sadness they would find a positive spin to it. If you pushed on expressing your sadness, anger, jealousy etc they would tell you you had a bad attitude and you learned that if you brought your negative emotions to the relationship the parent would push you away. You would probably learn to push away your negative emotions too, and keep things light and positive around yourself and others (because what you’ve learned is these negative emotions just cause issues). In many scenarios in your life having that optimistic attitude would probably serve you – you’d always find a way to see the upside of things. People would probably really like your positive energy and spirit. But, not all situations in life HAVE a positive spin, and part of getting through life is being able to get through the rough times – some of which there just won’t be an upside to. So, some people may think of you as a bit of a “pollyanna’ and people may not talk to you about the REALLY hard stuff, because it could feel dismissive to have you try and find the positive when they are really hurting or struggling with something. Also, you may be more vulnerable to experiencing depression at some point in your life because your most heavily relied upon coping mechanism is to “find the positive’. This is a GREAT coping mechanism, and one we want you to keep, AND we’d want you to learn more ways to manage negative feelings beyond trying to “find the positive”. This would help you build resilience and likely help you connect better and more meaningfully with others in your life.
Example 3: Imagine you lived in a home where your parent became very angry with you when you made a mistake. Maybe you were punished, or shamed, or told you should know better. The parent never acknowledged they might have over-reacted, and so what you learned was that your relationships suffer (and you feel overwhelming feelings you can’t really handle) when you make mistakes. You might become an adult who is very high functioning and proficient (because you rarely make mistakes), but you might carry with you a lot of anxiety about making mistakes for fear of it hurting relationships, or for fear of how it makes you feel. You also might become an adult who hides their mistakes from those around them (for fear that finding out about the mistake would harm the relationship, or bring up those feelings). You might have a hard time with vulnerability. People “catching” you in mistakes might make you defensive (because your brain will go to all kinds of extremes to do what it thinks will protect you from having a problem in your relationship or from feeling those feelings that feel way too big to manage). As you can imagine, though, this might actually CREATE problems in your relationship because a) you have a hard time admitting when you’re wrong and taking accountability and b) you might be spending a lot of time preoccupied with not making mistakes instead of focusing on the big picture. You will also become more avoidant of your feelings which may leave you more vulnerable to anxiety and or depression.
Example 4: Imagine you grew up in a home where your parent would shut down if you challenged them, regardless of whether you were right or wrong. You’d probably learn that it’s best not to be direct with people, regardless of the circumstances. Being more indirect would serve you with your parents, and perhaps in other relationships too. People might see you as non-abrasive and approachable. However, if we don’t EVER feel it’s acceptable to be direct then there are situations where it will be called for (like with someone who may not have strong intuitive skills, or who may need things really laid out for them to “get it”). Because that “directness” feels inaccessible, we’ll be stuck in those moments in part because indirectness feels so essential to us.
Interested in trying to build up that capacity for mindfulness? See this post, “Foundations of Meditation“.
What I discuss in this post is backed by neuroscience. David Wallin’s Attachment in Psychotherapy explains how the work of Daniel Siegel and others shows the associational nature of brain development: “Siegel explains that what registers in the mind and body as ‘experience’ corresponds at the neural level to patterns in the firing or activation of brain cells. These pattern of neuronal firing establish synaptic connections in the brain that determine the nature of its structure and functioning…the architecture of the brain is associational” – Page 69: Wallin, D. J. (2007). Attachment in Psychotherapy. Guilford Press.

May 18, 2021March 27, 2023

Emotions Are Brief

Often, when we feel difficult feelings for extended periods time it’s because we don’t know how to release them
Our emotions are brief – often times only seconds to minutes
Many of us, however, get stuck in emotional states for far longer periods of time.
This happens because we re-expose ourselves to what sets off our feelings either with our thoughts, our memories, or the moment we are in
As a result, the emotional signal from our brain re-fires again and again stringing together one long experience of feeling an emotion
When this happens it can be time consuming, exhausting, and overwhelming.
We can get wiped out from these experiences of having such lengthy emotional states.
We can start to feel like our feelings are too much, too hard, too disruptive, and we can start to cope by just cutting them off or pushing them away
Or some of us lose hours of our time stuck in feeling states with little ability to truly be present in our lives at those times
We want to feel our emotions long enough to process through them and learn from them. But then we want to be able to move on from them and get on with our lives

Marsha’s Linehan’s research backed treatment, Dialectal Behavior Therapy (DBT) teaches: “Emotions come and go. They are like waves in the sea. Most emotions last from several seconds to minutes”.

When I share this with my clients I hear a lot of “Not mine. Mine last for hours”.
For many of us this is true, we can feel sad, scared, lonely, angry, upset – you name it – for extended periods of time, far beyond a few minutes.

So what’s happening?

DBT addresses this too, “Emotions are also self-perpetuating. Once an emotion starts, it keeps restarting itself”.

This means that when feelings go on and on it’s actually the same brief emotional signal being fired in the brain repeatedly (until something stops the signal). It all connects to feel like one big long feeling, but it’s not. It’s a bunch of very brief emotional signals from our brain strung together.

So why does the signal keep re-firing?

Often it’s because of how we RESPOND to the experience of having the emotion.

Sometimes our thoughts trigger the re-firing: “I can’t believe I did it again”, “I hate it when he does this, “I’m going to put her in her place and tell her…”.

Sometimes our memories trigger the re-firing, like when we play the scene over and over in our heads.

Sometimes the conversation or event that’s triggering the feeling goes on and on (like when you’re sad throughout an entire funeral or angry throughout an entire fight).

Why does this matter?

The crux of being able to cope productively with negative feelings is being able to interrupt that firing process at the appropriate time. When our emotions stick around for extended periods of time it’s because something (internally or externally) repeatedly sets off the emotion. Emotions themselves don’t necessarily HAVE to last so long, and we can learn how to interrupt the re-firing process with coping skills and with processing through the feelings.

There will be more on that to come (look out for distress tolerance and emotion regulation skills) so we can increase our ability to keep emotions with us long enough to make use of them, and then release them (rather than re-start them) once that process is done.

Notes:
1. The DBT quote comes from page 87 of Marsha Linehan’s Skills Training Manual for Treating Borderline Personality Disorder. Full Citation: Linehan, M., M., (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York, NY: The Guilford Press.
2. We can feel more than one feeling at once, and we can have multiple feeling signals firing from the brain around the same topic.
3. Some people struggle to hold on to feelings rather than feel like they stick around too long. There will be another post on the impact of that relationship with your emotional world.
4. See post called Emotions as Traffic Signals for more about why it’s important to be able to feel our whole range of emotions, positive and negative.