Dialectical Behavior Therapy, Part 2

Working in a DBT program requires strict adherence to the treatment model, which is why all clinicians are members of the consultation team. The idea is that nobody should have to work with this challenging population without peer supervision and support. I won’t get into the dialectical framework here, except to say that there are strategies that facilitate balance – the synthesis between opposites. Hegel wrote about how the dialectic between thesis and antithesis leads to synthesis. Similarly, wise mind is a synthesis of reasonable mind and emotion mind. A good DBT therapist has to think dialectically, and DBT is a highly strategic therapy.

My education in the model introduced me to the concept of parasuicidal behaviors: non-lethal self-destructive behaviors that are the result of the same impulses that lead to suicide attempts. These behaviors include the abuse of alcohol and/or illegal drugs, abuse of prescription drugs, self-mutilation, and other self-destructive acts. People who perceive themselves as living in Hell often have a profound ambivalence around the issue of living v. dying. If you define your life as “the problem,” then suicide can seem to be “the solution.” Many preventable suicides occur as a mood-specific behavior (i.e. nobody attempts suicide in a happy mood), because of such irrational formulations.

Being a therapist isn’t a one-way street. If I’ve helped some people to improve their lives, my own life has been enriched by working with quietly heroic people who have striven mightily to change themselves. This is true of people across the diagnostic spectrum; but I felt privileged to work in a DBT program, and to watch emotionally unbalanced people learn balance, and learn to build lives worth living. It’s some of the most difficult work I’ve ever done, intellectually, and some of the most rewarding. People diagnosed with BPD used to be regarded as untreatable by many in the mental health field. DBT is an empirically validated cognitive-behavioral therapy. That means there’s scientific evidence that it works.

Marsha Linehan has courageously revealed that DBT came from her own journey out of Hell. She started her career studying highly suicidal people, and coming up with survival tactics and strategies for emotionally volatile people who are trying to finds reasons to go on living. Another feature of BPD – or having “borderline traits” – is being extremely judgmental, both of self and others. That’s why an important component of DBT mindfulness training is learning to notice details in your here-and-now experience without making judgments. People with the BPD diagnosis tend to frequently attribute their emotions and behaviors to external things (relationships, circumstances), and the DBT program teaches skills that help clients to own their own choices, and learn to make better ones.

With DBT clients at high risk of suicide, the primary goal of treatment is to keep her alive until the benefits of the program start to rick in, and suicide risk diminishes. Sly humor is sometimes appropriate in individual therapy sessions, and I remember saying to a client, with a straight face, “One thing that’s clear from the research is that this therapy can’t work if you’re dead.” Suicide prevention is where some of the treatment agreement contingencies come in. With what I knew about mental health clients with the BPD diagnosis early in my career, I never could have imagined that someday I’d give one my home phone number in case of emergencies. But I did, and never regretted having done so.

People with the BPD diagnosis often have long histories of suicide attempts, and for putting crisis line workers in a difficult position, threatening suicide unless _____ happens. As a DBT therapist, I was available at home to my individual therapy clients on evenings and weekends – but I got to set my own boundaries. Mine were not before nine in the morning and not after nine in the evening, and my clients never once abused their contact privilege. DBT clients know that the processing of details (therapy on the phone) wouldn’t be tolerated, that the call would only last five-to-ten minutes, and that the focus would be on skills: What skills have you already tried? What skill has worked for you in this kind of situation before? What skill do you plan to try next? Just knowing that their therapist was available to them in times of crisis, if only for a brief consultation, was helpful in itself. They understood that if they attempted any “suicide blackmail” games, their therapist would call 911.

One built-in contingency was that the client could call her therapist at home only if she hadn’t already engaged in parasuicidal or suicidal behavior prior to calling. Once she had cut herself or taken an overdose, she lost her privilege of calling for help. This was a highly effective contingency. Another contingency had to do with the weekly individual therapy session. Most DBT clients value their limited time with their individual therapist, and often have specific issues they want to talk about in session. But individual therapy sessions generally begin with a review of the week’s diary cards. For the client to get to select the topic of discussion was contingent on not having engaged in suicidal or parasuicidal behaviors during the prior week. Any self-destructive incident would be the automatic focus of the therapy hour. In that instance the client knew that her therapist would engage with her in a detailed “behavior chain analysis” of thoughts, feelings and actions that led up to the self-harm. These therapeutic contingencies help clients to resist impulses to harm themselves. Impulse control is a learnable skill set for most people. It saves lives.

Dialectical Behavior Therapy, Part 1

For two years I worked in a Dialectical Behavior Therapy (DBT) program at Columbia Area Mental Health Center. The program director was Dr. Sherri Manning, trained by Dr. Marsha Linehan, who had devised DBT for people (mostly women) diagnosed with Borderline Personality Disorder (BPD). People with that diagnosis are notoriously difficult to treat, and DBT provided the first effective, empirically validated therapy for that disorder.  Working in a DBT program requires the study of Dr. Linehan’s groundbreaking textbook, Cognitive-behavioral Treatment of Borderline Personality Disorder and the accompanying Skills Training Manual for  Treating Borderline Personality Disorder.  Every clinician in a DBT program is a member of the “consultation team,” which supports the team members in their challenging work.

Borderline Personality Disorder is characterized by extreme emotional dysregulation, or imbalance. Personality disorders are  diagnosed on Axis II of the DSM (the “Bible” of psychodiagnosis), apart from Axis I diagnoses like depression, anxiety disorders and schizophrenia. According to Dr. Linehan, all people with BPD have an underlying Axis I pathology, but have also experienced trauma that has shaped their behavior in persistent, dysfunctional ways. People with the disorder are often suicidal, and frequently engage in self-destructive behavior, including drug abuse and/or self-mutilation. They go to extremes in over-valuing and then rejecting significant others – sometimes in the same day. Dr. Linehan describes them as living in Hell and not knowing there’s a way out.

In order to be accepted in a DBT program, the client has to sign a year-long treatment agreement, to be renewed at year’s end if the client wants to stay in the program. She agrees to keep a daily diary card, charting moods, thoughts, and behaviors; and agrees to keep individual and group therapy appointments. Participation in the program is contingent on living up to the terms of the treatment agreement, and the client also agrees to other specified contingencies, which I’ll write about later. In the DBT program I worked in, patients were seen once a week for individual therapy and twice a week for skills training group sessions. Although individual therapy plays an important role in DBT, the skills training groups are at its heart. There’s no processing of issues in these sessions, but rather the presentation of skills by the group leaders, and coaching in their use.

One of the skills taught to DBT therapists is radical validation. Whereas I might equivocate if someone said I’d yelled at them, under normal circumstances (i.e. “I didn’t yell, I raised my voice because I felt frustrated.”), if a client in the program accused me of yelling at her, I’d validate her perception and immediately apologize for yelling. People with the BPD diagnosis are frequently blamed for things they can’t control. Many have never heard validating messages like, “You didn’t choose to be like this. If you knew better ways of  dealing with your pain, you’d use them. I believe in you and your ability to create a better life for yourself.”

Four modules are taught in DBT skills training groups: Core Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. Group leaders are trained in specific techniques to facilitate skill acquisition, strengthening and generalization. There are a lot of handouts and homework assignments. The groups reinforce what the clients are learning by keeping their daily diary cards. DBT is a cognitive-behavioral therapy in that it helps clients to learn the connections between emotions, thoughts and behaviors, and to apply that knowledge. A primary goal of the therapy is to help the clients achieve balance in their lives.

Marsha Linehan studied meditation with a Buddhist roshi (master) and a contemplative Catholic priest, and mindfulness is at the core of DBT skills training. Group members are taught that there are three primary states of mind: reasonable mind, emotion mind, and wise mind -the last of which is an integration of the first two. That they have a wise mind is a revelation to most clients. Being in the state of wise mind adds intuitive knowing to emotional experiencing and logical analysis. It’s explained as, “learning to be in control of your mind, instead of letting your mind control you.” One of the skills taught in the Core Mindfulness module is how to be mindful without judging.

The Interpersonal Effectiveness module helps clients to learn how to ask for things they want and how to say “no.”  It teaches them to prioritize and self-validate in setting relationship boundaries. It teaches “what” and “how’ skills for getting reasonable things you want and not caving-in to pressure to do things you don’t want to do. The Emotion Regulation module helps clients to learn the role of emotions, positive and negative, and to deal with them in a balanced manner. It teaches them how to build positive experiences and avoid negative experiences, and to feel a sense of agency in their reactions to emotions. The Distress Tolerance module teaches such skills as distraction, self-soothing, and improving the moment. It includes thinking skills and physical techniques for tolerating stress without responding in extreme, self-destructive ways. It teaches the concept of “radical acceptance” of things that can’t be changed.

After finishing the Distress Tolerance module, the group starts on Core Mindfulness again; so group members get multiple exposures to all four modules. I personally think that the skills taught in DBT groups can also help people with other diagnoses. I’ll continue to write about DBT in my next post.


Working with juvenile sex offenders

I’m a compassionate person by nature, and felt a calling – like a calling to the priesthood or some other religious vocation – to be a psychotherapist. But the limits of my compassion have been tested from time to time throughout my career. I’ve encountered people who did very bad things, not because they were “sick” or mentally ill, but simply because they were evil. When I’ve heard someone utter the cliché that there’s some good in everyone, I’ve been tempted to say “You haven’t met everyone.” I’ve met some violent felons who got off on hurting others, felt no pangs of conscience, and only regretted having been caught. They fantasized about doing more of what earned them hard time in prison, without getting caught.

My first exposure to antisocial juveniles was when I worked at correctional institution for older teenagers serving time for crimes against people (not just  property). During my time in juvenile corrections I co-led sex offender treatment groups. One belief I had confirmed is that, whether you call it rape or molestation, it’s more about power-and-control than about uncontrolled sexual drives. I’ve led or co-led many different kinds of treatment groups over the years, but only once was it what I’d call hard-ass treatment. I was trained to be a treatment team member of the Sex Offender Treatment Program (SOTP) and was mentored in the sex offender group treatment model by my two co-leaders, two tough, competent female social workers. You have to be both tough and savvy to work with this treatment population, and I especially admire women who have what it takes to do this kind of work.

By the time they’re caught, tried and sentenced, most juvenile sex offenders have already gotten away with a progression of sexual assaults, usually on younger children. The more they’ve gotten away with, the bolder they’ve become. They fantasize about what they’ve done and what they want to do next. With fixated sex offenders, the connection between the thrill of having power-and-control over a person, and sexual gratification, becomes something neurologically akin to addiction. They want more, and their obsessive thoughts feed their sexual compulsions.

There’s a limit to the range of defense mechanisms that sex offenders predictably resort to in an attempt to distance themselves from their sexual violations, and I’ve heard them all. The first is outright denial: “I didn’t do it!” Faced with proof that he did, the next step is minimalization: “It was the only time I ever did anything like that. I never even thought about it before. It’s really not a big deal anyway.” The last defense mechanism to be employed is rationalization: “She led me on./It’s her fault./ I only did what he wanted me to do.”

The goal of sex offender treatment groups was to break through the bullshit barrier and get sex offenders to own up to what they’d done, to understand the harm they’d done, and to acknowledge that they were at risk of re-offending. In this regard it’s similar to the recovery model for substance abusers, in that you can’t recover from a compulsive behavior pattern without first acknowledging the nature of the problem. The next step involves coming up with a risk reduction plan. All we could hope to do in the SOTP was to reduce the risk of recidivism for as many sex offenders as we could reach.

I believe that some sex offenders can be rehabilitated, and that it’s worth the effort and expense to provide treatment opportunities in correctional facilities for those who are sincerely motivated to change. Some fixated sex offenders don’t want to change their ways, and can’t be helped by any treatment that I’m aware of.  That’s why we have life sentences without the possibility of parole.

The sex offenders I worked with weren’t internally motivated to attend group, and the SOTP groups weren’t mandatory. But most eligible boys eventually applied (there was a waiting list), once they learned that if they got honest about their crimes and made progress in the program, they might earn a positive parole recommendation to the Parole Board. The groups were “open,” meaning that new members joined ongoing groups with boys who’d been in the group for months and understood the group process.

This process was characterized by confrontations by both group leaders and peers, and every boy spent time in the “hot seat” – the focus of group attention. Every “old-timer” in the group had already been called out by professionals and peers on his denials, minimizations and rationalizations, and could see through the defenses of his peers. While in the hot seat every group member eventually heard something like this: “Most everyone in this room can see through your bullshit, and we’re waiting for you to get real about what you did, and what you need to do if you’re not going to do it again.”

The only way for a group member to avoid hard-ass confrontation was  to get honest and disclose in detail the circumstances (thoughts, situations, actions) of every sexual violation that led up to the crime for which he was serving time. In time, most of the boys came to understand that full disclosure was just the first step, and understood the phrase “reducing the risk of recidivism.” The boys knew that the Parole Board would be asking the SOTP team members about their relative risk to re-offend. SOTP recommendations might make the difference in the board’s decisions, and sometimes that meant the difference between parole at age eighteen, or transfer to adult corrections to serve the remainder of their sentence.

Working with sex offenders and antisocial criminals was some of the most difficult work I’ve ever done, emotionally, because of my compassion for their victims. (I’ve worked with many more victims of violence and abuse than perpetrators.) I believe that in some instances compassion can be learned. But I’ve encountered people who understood the concept and might be able to mimic it, but have never felt it, or only in a very limited way. I remember asking a boy who had admitted to torturing cats if he’d ever tortured a dog. He look at me like I was stupid and said, “Of course not! I like dogs.” As if that explained everything.


What the hippies got right

I didn’t attend Woodstock – I was in ROTC summer camp at Fort Bragg – and never made a pilgrimage to Haight-Ashbury, but there was a time in my life when I considered myself a citizen of the Woodstock Nation. Recently, looking over my faded and dog-eared copy of one of the Whole Earth Catalog editions that came out in the sixties and early seventies, I reflected on what the hippies got right.

Each Whole Earth cover displayed that first iconic image of Earth seen from space and bore the subtitle “access  to tools.” The series was like a Sears & Roebuck catalog (ask your grandparents) of resources for alternative lifestyles, with all you needed to know about guides to living off the land, healthy lifestyles, sustainable energy, spiritual development, affordable shelter – including geodesic domes – and anything else you might need to drop out and start a farming commune. In retrospect I see the Whole Earth Catalog as the Bible of the hippie ethos. I had never heard about ecology or the benefits of meditation until I read the catalogs, and editor Stewart Brand became one of my primary culture heroes. Steve Jobs described the catalogs as a predecessor of the World Wide Web.

I came to hippiedom long after the funeral for the movement had been held in San Francisco, and five years after Woodstock. I’d been a Citadel cadet during the Summer of Love and an Army officer until 1974. But in grad school I grew my first beard, let my hair grow out to shoulder length, and rebelled (culturally, at least) against The Establishment for a few years. But once I had my degree and was starting my career I decided, like so many of the idealistic flower children of my generation, to drop the costume and the self-indulgences of the movement and “join the System to change it from within.”

Hippies were essentially a media invention to explain a very real generational rebellion. I expect  that when most people who never identified with the movement think about it, they think about long hair , tie dyed clothes, drugs and free love. But those were only the outer trappings. Some of the hippest folks I knew in the day dressed conventionally, and didn’t do drugs or sleep around. True hipness is a state of mind, not a conformity to unconventional dress and habits. Most hippies believed that marijuana should be legalized, long before the mainstream became tolerant of its use and recognized its medicinal benefits. Free love never went mainstream, but I think the hippies’ tolerance for sexualities other than heterosexuality was influential in the gradual mainstream acceptance of LGBTQ persons. And hippies were part of the core of early feminists.

When I look at certain positive trends in the 21st century, I see their origins in the hippie counterculture. The notion that we should question authority and conformity has proliferated in my lifetime. Unconventional hairstyles are no longer “freak flags” that brand the wearer a presumed pot-smoking anarchist; they’re simply preferences in style. The hippies challenged the idea that being “normal” (conventional) was a virtue. I think that the “Rainbow Tribe” view of mankind – tolerance for people who don’t necessarily look like you or act like the majority acts – has endured and spread within our culture.

The whole Green Movement, everything from organic farming, recycling and composting, to renewable energy got its initial momentum from the Whole Earth crowd. The hippies promoted the notion of the Earth as our mother – or alternately as Spaceship Earth, on whose life support system we all ultimately depend. “You are what you eat” was a hippie mantra. Hippies were ridiculed as granola eaters and “health food nuts,” but now we have public service campaigns about healthy diets, and detailed nutritional information is printed on the packaging of most processed foods, to help us make better choices. Granola, yogurt and tofu have gone mainstream, and vegetarians/vegans are no longer regarded as weirdos.

Hippie resources like the Whole Earth Catalog introduced many of my generation to yoga and other forms of meditation. What we called living in the here-and-now is now widely known as mindfulness. Such practices have been scientifically validated as activities that promote wellness, and have become mainstays of behavioral medicine. Now yoga and meditation have gone mainstream.

The hippie ethos was a rejection of the unquestioning conventionality of the post-war era and an embrace of new possibilities. Some of its seeds have taken root in the wider culture and flowered, helping to cultivate more tolerant, free-thinking, health-minded, and environmentally conscious Americans.


Mental illness and stigma

I’ve worked as a case manager and therapist with people who have chronic mental illnesses for over thirty years, and have learned a lot from them about the varieties of human experience. I’ve learned not to be quick to judge. I’ve observed over the years that many folks tend to stereotype mentally ill people, not realizing that each of them is as unique a human being as they themselves are. Some mentally ill people are of below-average intelligence, most have normal intelligence, and others are brilliant. Some are insightful about their need for treatment, others are in deep denial. Some are kind and some are mean-spirited. Some are potentially dangerous to others, most are not. In my experience mentally ill people are more likely to be of danger to themselves  than to others.

The cumulative effect of this widespread stereotyping is stigma – society-wide prejudice and discrimination. I’ve seen it in persons and in policies. I think this stigma is one of the reasons for the deterioration of the mental health system, as described in my last post. We now have federal legislation that supposedly establishes parity of treatment for mental illness with physical illness, but I haven’t seen that result in any significant improvement in mental health treatment. Addiction to opioids has become a public health epidemic, but some people have no compassion for addicts, due to stigma. They thinks addicts are bad, or morally weak, individuals who don’t deserve help.

Writers who should know better -notably book reviewers and film critics – still don’t seem to know the difference between schizophrenia and “split personality” (now known as dissociative identity disorder). Schizophrenia is characterized  by a disorganization or distortion of thought processes, not by the development of separate identities. I think that fear is at the root of the stigma attached to mental illness. At some level all of us fear losing control, because we know that if we were to lose control of our minds, anything could happen to us. So we tend to avoid looking at mental illness too closely. It’s too disturbing.

Another basis for the widespread fear and resulting stigma comes from media depictions of “insanity.” From Alfred Hitchcock’s classic horror film to the books and films about Hannibal Lector, the term psycho – a prefix that has come to be used both as a noun and an adjective – has taken on an aura of threat. Many people don’t know the difference between psychosis (being out of touch with consensus reality) and psychopathy, also know as sociopathy.  A sociopath commits antisocial acts and has no sense of conscience about the harm done. When psychopathic people do horrible things, many people think of them as “crazy” or “sick,” rather than simply evil. While psychosis is recognized as a medical condition, psychopathy doesn’t appear to be one.

One of the forms stigma takes is the attitude, “I want mentally ill people to get the treatment they need, but not in my neighborhood.” The acronym NIMBY is well known in the mental health community: Not In My Back Yard. I remember some years ago reading a letter to the editor in a local newspaper from a man warning readers to beware of allowing people in their neighborhoods to become “mentor families.” Mentor families are families who are willing to take in a mentally ill boarder – someone they’ve already gotten to know and trust. The letter writer apparently didn’t like the idea of having mentally ill neighbors, or wanted to know who they might be and where they lived. I wrote a reply in which I told the silly man that if he lived in a neighborhood of any size, he already has mentally ill neighbors. And that’s no reason to be scared. Mental illness isn’t  a rare thing, and most mentally ill people aren’t a threat to anyone.

Speaking to the House Education and Labor Committee in 2007 about her 35 years of mental health advocacy, Rosalynn Carter observed, “When I began, no one understood the brain or how to treat mental illness. Today everything has changed – except stigma, of course, which holds back progress in the field.” Progress in the field is exactly what we need. We need to systematically address stigma as a part of the problem, and restore community services that not only prevent more expensive episodes of inpatient treatment, but improve the quality of life for people with mental illnesses.

The Slow Death of a Dream

Whatever his personal shortcomings, President John F. Kennedy was undeniably a visionary. He envisioned and enabled a robust NASA space program, he established the Peace Corps, and he laid the foundation for a nationwide community mental health care system. NASA has sent astronauts to the moon and the Peace Corps is still making friends for the U.S. all over the world, but the dream of a national program of affordable, local preventive mental health services has been dying a slow death. Now we have a bare bones system inadequate to meeting the needs of the neediest, let alone providing preventive services to individuals and families in crisis.

The Community Mental Health Care Act of 1963 authorized federal funding for the establishment of local mental health centers all over the country, with the long-term goal of de-institutionalization. The plan was to enable states to empty-out their expensive centralized state hospitals/asylums for the custodial and medical care of chronically mentally ill persons, and to shift to less-expensive local outpatient care.  Little did I know when I began my career as a mental health professional in 1976 that I was joining the fledgling system near its zenith, and that I’d witness a steady decline in public sector service provision throughout the rest of my career.

The dream of an adequate nationwide community mental health care system died of legislative neglect, all over the country. Seeing a windfall for state general funds, most state legislatures pulled a bait-and-switch operation. They accepted federal funds for as long as they were available, but didn’t follow-through on the intent of the law with state matching funds. They saved a lot of money by closing their centralized mental institutions, but didn’t allocate nearly enough of the savings to establish adequate local care alternatives. Good outpatient care prevents costly inpatient treatment.

Most of my first ten years of clinical practice were in rural Alabama and South Carolina, at satellite offices of regional mental health centers. At that time individuals and families could get counseling for a very reasonable sliding scale fee, based on income. With such services available, suicides are prevented, marriages are saved, dysfunctional families become more functional, and individuals learn skills that enable them to function at a higher level. I’ve seen all those things happen. It’s been a privilege to be there as a counselor for people who can’t afford services from private sector providers, and I mourn the loss of that level of service provision in communities.

These days most community mental health centers are understaffed, and clinicians spend much or most of their time providing basic case management services to overwhelming caseloads. That’s why jails and prisons have become major mental health service providers, why hospital emergency departments are frequently overwhelmed by patients needing emergency mental health care, why so many mentally ill people are homeless, and why dangerous people increasingly fall through the widening cracks in the system.

Because of the legislative gutting of the mental health system, patient care is down to the bare bones. Outpatient counseling and other preventive services are hard to find. We desperately need more community resources. Effective outpatient services not only prevent hospitalizations, they save lives. Every dollar cut from preventive services ends up being spent elsewhere – in hospital emergency departments, jails, prisons, and homeless shelters. Our lawmakers seem to have forgotten the wisdom that an once of prevention is worth a pound of cure.

Looking back, I have my criticisms of the system I used to be a part of, but many of them are due to the diminished funding over the years. Community mental health has done a lot of good for a lot of people, and I saw lives change because affordable counseling was available to individuals and families. But the community mental health system didn’t offer alternatives to the dominant medical model. As resources dwindled, patient care for persons with chronic mental illnesses mostly consisted of case management services, occasional and short “psychiatric medical assessments” (PMAs), and the prescription of psychiatric medications – many of which have serious side effects. Sedating people with drugs is cheaper – at least in the short term – than providing support services that might reduce reliance on chemicals that only treat symptoms.

I’m not hopeful that the mental health system will be repaired anytime soon. Although I’m retired from clinical practice, I remain an active advocate for the rights of mentally ill persons. We need to modify the mental health system by taking a more holistic approach and providing alternatives to PMAs as the sole basis of treatment for people with chronic mental illnesses. I think that psych meds can be an important component of treatment. But I think there’s an over-reliance on their use, because of the influence of Big Pharma on the system and because of the lack of holistic support services available to people who suffer from mental illnesses.

If you want to know more about what’s wrong with the mental health system, I recommend Pete Earley’s still-timely 2006 book, Crazy – A Father’s Search Through America’s Mental Health Madness. In alternating chapters he tells the story of his own heartbreaking difficulties trying to get help for his bipolar son in a broken system, and details what he learned as a journalist at the Miami-Dade County Jail about how we got to this sad state of affairs. If you want to join others in advocating for the rights of mentally ill folks, check out NAMI, the National Alliance for the Mentally Ill.

Programming your brain

The human brain is wired to be adaptive. We humans are “the magic animal” because we can imagine things that don’t exist and create them, and see things not only as they are, but as they could be. Our limitations as individuals are often determined by our limited thinking. As a therapist I sometimes had the privilege of working with people whose goal in therapy was personal growth, and of seeing them grow. Two fundamental questions for such clients are, “How do you want to change?” and “What do you see as hindering you from making that change?” Insight may play a role in the process of choosing to change your behavior, but it often requires learning and practicing new skills. One of the psycho-educational groups I used to teach was “Skills for Growth.”

One apt metaphor for growth psychology is upgrading your mental programming. A good therapist can help people to identify outdated or defective programs in their operating system, and to upgrade them with new “software.” There’s growing evidence of the brain’s neuroplasticity, which is to say that behavioral changes can actually “re-wire” synaptic connections in the brain, making it easier to maintain the new behavior.

We all inherit beliefs from our social environments as we grow up, whether those beliefs shape our behavior in a functional or dysfunctional manner. Clusters of beliefs about this or that aspect of life are known as schemas, and they guide our behavior for better or worse. For instance, Fred grew up in a family where his father dominated his mother, sometimes yelling at her and slapping her around. His father taught him that the husband “wears the pants in the family” and that sometimes husbands have to hit their wives, to remind them who’s boss. This is Fred’s schema – mental model – for marriage until he falls in love with Susie, who believes (like her parents) that husbands and wives should be equal partners in marriage. So Fred goes to pre-marital counseling with Susie, at her insistence, and realizes that she’ll never be a submissive wife like his mother. He comes to realize that his  “marriage programming” is outdated and needs an upgrade, if he wants to marry Susie. So he listens and learns, upgrading his schema regarding marriage.

Similarly, Angela may decide that she needs to replace her stress relief schema and stop relying on alcohol and other drugs to chill out. And Paul may decide that he doesn’t like being programmed for dependency, and install new programming for increased autonomy and initiative-taking. Upgrading your programming doesn’t necessarily require the help of a therapist, if you’re a self-starter. Once you become aware that there are upgrades for obsolete or ineffective programs, you can re-program on your own. New possibilities become visible when we change our thinking and examine our attitudes.

We can use mnemonic devices – memory aids – to change bad habits, setting rules and keeping score to systematically reinforce desired behavior changes. As an example, I decided to establish a zero-tolerance policy regarding my occasional failure to turn off stove burners or the oven after cooking. I chose as my mnemonic device turning on the stove light whenever I’m cooking. Ideally, I don’t leave the kitchen to eat until I’ve turned off the light, and I don’t turn the light off until I’ve made sure that all the burners and the oven are turned off. This works most of the time. The consequence for leaving a burner or the oven on after I’ve finished cooking is that I record it on a calendar that hangs near the stove. I don’t like having to record failures, so in the language of behavior modification this is a mildly aversive consequence. But it’s enough to shape my behavior in the desired direction, and I have an accurate record of my rate of behavior change. It’s been over six months since my last transgression, and I intend to keep on with my protocol until I’ve “extinguished the target behavior” entirely, and go for a whole year without a slip. By then I will have created a new reflex behavior and, perhaps, a new synaptic connection in my brain.

Behavior modification is all about targeted and systematic behavior change, but you don’t have to be in therapy to use the principles to re-shape your behavior. You can set goals and create your own plan. Announcing your goal to friends and loved ones, and establishing meaningful consequences for not making measurable progress toward your goals, can help. Consequences can include positive reinforcers (rewards, tangible or intangible), negative reinforcers (withholding positive reinforcers), and/or aversive consequences, like marking your calendar every time you fail to achieve your target behavior, or having to admit to your friends that you didn’t meet your goal.

Mental rehearsal is part of programming ourselves – positively or negatively – for the achievement of goals. We rehearse for upcoming events in our minds, sometimes encountering anticipatory anxiety. Sometimes we reflexively rehearse for failure, ruminating about everything that could go wrong in our upcoming performance, whether on the stage, in the bedroom, or in the conference room. Sometimes we give up and stop trying because we convince ourselves that we can’t succeed. Rule number one in rehearsing for success is not to ruminate on failure scenarios, or to focus on your doubts and insecurities. Rule number two is to actively rehearse for success, behaviorally and attitudinally. If it’s a public performance of some kind, practice, practice, practice until you’ve got it down to a reflex. And then harness the power of your imagination to rehearse for success. If it’s a public speaking engagement you’re nervous about, perform it in front of a mirror repeatedly and imagine the enthusiastic applause you’ll get – or even a standing ovation!

Teaching psycho-educational groups, I used to cite a psychological experiment I’d heard about in which two groups of ten people with average basketball free throw skills were to have ten free throws for record, to see whether Team A or Team B would score more baskets. Team A got to have ten practice throws before throwing for record. Team B was told to relax and visualize ten perfect throws in front of a cheering crowd. Obviously, Team B scored higher. While the members of Team A sunk some baskets and missed others while practicing, the members of Team B had a mental set of 100% success. I can’t give you a reference to this particular experiment in motivational psychology, but I can tell you that visualization of optimal performance and success is an important element in sports psychology. Visualizing positive outcomes – rehearsing for success – can help anyone to perform at their best, if they’re well-prepared.

If we discover that one of our mental programs/schemas is obsolete and limits our potentials, we can upgrade to an improved program that allows for new possibilities. Our past is not our potential.