Music Alright, welcome back to the Psychiatry and Psychotherapy podcast. Before we start this podcast, I just wanted to give a brief announcement. This is the second year we will be running Psychotherapy cohorts. I had a wonderful group of therapists, psychiatrists,

and our spectators. announcement. This is the second year we will be running psychotherapy cohorts. I had a wonderful group of therapists, psychiatrists, nurse practitioners from around the world. In our last one, we will be going into a deep dive on psychodynamic psychotherapy, reflective function, transference, counter-transference. We will be in the process of utilizing these things in a highly applicable like how do we actually do this in therapy? That's the goal of this type of cohort. And also this type of cohort is just a great time to get to know each other, different professionals. It is weekly two hours. It's a commitment of reading some material every time. If you're interested in this, we have a link in the show notes. It will be on the podcast website, psychiatrypodcast.com on the top bar. If you're getting this later, then the application process allows. We already have some spots filled. You can apply and ask to be put on the waiting list for next year. My wonderful assistant Jonathan is calling each person to make sure that they get these emails once you submit the application. And we will be building a wait list for future groups. I also have some different colleagues who will be co-leading or not co-leading, but we're all leading the same material, but they will be leading their own groups. These are people that I trust that have been through the process before. So if you're interested, please apply. All right. Welcome back to the podcast. I am joined with Alissa Jarrett. She has written a book called Emotion, Savvy Parenting, Shame-Free Guide to Navigating Emotional Storms and Deepening Connection. She has a background in dialectal behavioral therapy and specifically behavioral approaches to anxiety. Why don't you give us a little bit about your background and how you got into this? Yeah, sure. Thank you so much for having me first of all. So I'm a licensed clinical psychologist and I really, as you said, primarily specialize in exposure-based treatments for anxiety-related disorders, but I also really enjoy working with others to help them better navigate their own emotions. And then I especially as a mom of two kids, I especially enjoy working with parents to help them do the same. And so that's kind of a little bit about what I do. And then also like led to me writing this book that I wrote. Okay, so yeah let's let's talk a little bit about your your background here. So you've been seeing patients for how many years? Oh my my, um, I graduated in 2016 started my postdoc then. And then I was kind of on my own beginning in 2018. Okay. And what was your postdoc in? Uh, well, I was working at the Center for the Treatment, Inside of, sorry, Center for the Treatment and Study of Anxiety at the University of Pennsylvania. So really they are doing a lot of exposure therapy for the, you know, for OCD, social anxiety, specific phobias, PTSD, all anxiety related disorders. Great, great. And then when did you get the DBT background? When did that come? I was really lucky. I went to the University of Washington to get my doctorate and that's

commercial in a hand is. I actually was a part of her two-year DBT practicum. First, we

took a good number of courses with her and then I was part of her treatment team. Really, every single week getting to have meetings with her as part of that, we would watch videos of her and other DBT therapists doing DBT and then also provide both DBT on an individual basis as well as kind of two groups. So I led and co led a DBT group there as well. Great, great. Yeah. I haven't done too much on DBT during this podcast, so it's good to get some exposure in that. And then it seems like we're applying this, a lot of your expertise to the parenting role and to the emotions that come up with the parent. Yeah, exactly. And so, yeah, tell me about just the accept, regulate, tolerate framework, art. Yeah. So this is something that I include in the book. And then I talk about all the time, even in my private practice, my website has this framework on there too, because I think this is just kind of so key to being able to live skillfully with whatever emotions show up. So maybe first, I'll just say that, right, as humans, we're kind of wired to want to avoid emotional pain, right?

Whether or not, and I should say pain of any kind, right? So if our hands in the fire, we want to pull that hand out. And if we're feeling anxious, we're angry, we're sad, we want to not have to feel that so strongly. And that's so understandable, so normal, so natural. natural. The thing though is with emotional pain oftentimes our attempts to avoid it can kind of

prolong and exacerbate our suffering. And so I could go through many examples of that. But really art is designed, this framework that I came up with is rooted in both the exposure-based treatments I provide as well as DBT skills. And it's about helping people accept, regularly, and tolerate their emotions and not just their emotions, but other things in the environment as well. So for instance, with accept, we can accept not only our own emotions, but also others' emotions, our thoughts, our physical sensations, our surroundings, including again what other people are feeling, our thinking, saying, maybe even what they're doing, not always, maybe we can't accept it, but to be clear here acceptance really doesn't mean liking or approving of something. It just means kind of noticing what's actually happening and just noticing the facts, nothing more. So we really can accept just about, you know, most things I would say we can work toward accepting. That's accept. And then regulating is all about how can we kind of like understand what we're feeling, understand or emotion so that we can in understanding them and accepting them and understanding them, use that information to help us be less vulnerable to experiencing painful emotions in the first place. And to help us begin to meet you, change those emotions when they arise and aren't serving us all that well. And then the final set of skills, or the final letter in that framework is T-Tolerate, which is for when we are experiencing strong unwanted emotions, and there's maybe a situation we can't change. This is just how things are and it kind of, you know, it stinks. It's not enjoyable. It's hard. How can we tolerate that situation at that moment? Those emotions we may be feeling without doing something that we might lead her regret. That might make the situation worse. Okay. That's the framework. That's the framework. And then maybe I could go through some difficult situations and see kind of what we're doing. So like let's say you have a parent, a new parent who's at home with the toddler all day feeling deeply alone despite not being alone. And this deep loneliness is there. So maybe there's some frustration with this feeling of loneliness like, gosh, I thought I would enjoy this more than I am. So what do you do with that? Well, first I think you got to accept that you're feeling alone because we can't change a given emotion or circumstance unless we're aware of it. Right? So first it's an acceptance and one tool, one skill we can use to help us be more accepting is mindfulness, which is simply the act of paying attention to the present moment on purpose without judgment as experienced through any one of the five

senses. And we can be mindful of just that emotion. Like, oh, yeah, right. That feeling of being alone, just noticing that it's there, not that it's a bad thing, not that it shouldn't be there. Just that is there. Right. And that can cue us in to say, okay, this isn't emotion. It's an a month, doesn't feel good to feel lonely or alone. And it might not be serving her all that well, maybe it's the feeling of being isolated and alone is making it hard to show up as she wants to with or he wants to do that person wants to with her kid, right? And so then it could be thinking about, well, okay, that might be a situation where where we can regulate, right? We can go in and possibly change that emotion.

That's possible to do that. I mean, that'd be easy, but maybe this person could problem solve, right? So that's an emotion regulation skill. There are a number of different emotion regulation skills. One of them is problem solving. Okay, what might help them to feel a little less alone? Right? be possible to join some play groups where the toddler can play, they can connect with other parents, that sort of thing. Maybe it's just inviting friends over. Maybe it's hard to get out of the house with a toddler sometimes. Could they invite somebody over to their house to just hang out, spend time? If none of that is even an option, would it be possible to connect with people over, you know, over the phone, over FaceTime, zoom, that sort of thing? So that's, you know, that's just one option, problem solving at that level. What I will just say to, that might be helpful to note is that our emotions, it turns out, are much more complex than many of us realize. And so part of the reason it's so helpful to understand that piece, that complexity is because then that offers so many different avenues for intervention. Right. So on the regulate side, there are those, all those skills we can use to regulate emotions and other regulating skills that we can use would be to maybe like change the vulnerability factors. Maybe there are things that are making this person feel especially vulnerable to being lonely, right? Maybe they're also maybe because they're so busy as a parent of a toddler, not having time to do things that help to kind of help them feel good. So maybe they could get back if they're not getting enough sleep. If they're not having chance to exercise or to nourish their body, right? Like they could do those things, which I realize might not sound like rocket science, but it can go a long way to kind of enabling us to be less and more normal maybe to that loneliness, for instance. Okay, so what if they feel like so much guilt and shame that they're feeling lonely at all? Like I shouldn't feel lonely, I should, you know, like, so what do you, I mean, I imagine they could feel guilt and shame for anger, if they feel frustrated, if they feel like, so what do we do? What's your approach for the guilt and the shame and just the self-loathing maybe even that I should be this? I didn't imagine it this way. I didn't imagine I would ever feel anger towards my child. Oh my gosh, well this could be actually like a whole podcast just in and of itself. I think I will say that those feelings, all the unwanted emotions that exist under the sun are all really normal and natural for parents to feel at times. And I hear it so often in parents saying, you know, like, no good, mom or dad should feel this way. And what I would say is we all do it right. We're human. We're wired to have those emotions. And so of course, we're going to find yourself feeling angry sometimes, resentful sometimes, only sometimes as a parent. And what's tricky is when we kind of judge ourselves for that. We, you know, say we shouldn't be feeling that way. That's when we can turn that like the pain that comes with feeling anger, you know, isolation, like lonely, sad. That turns that pain into suffering. Because then it's not just, then we don't just have the pain of like, or the discomfort of feeling angry. Now we've got like the shame and the got the shame and the judgment that I'm layering on top of that. And that can just make our experience so much more overwhelming and hard to navigate. And what I will say is we rarely do our best when we're feeling badly about ourselves. So when we get caught up, when we start beating ourselves up, we think we're doing that to maybe that to maybe make ourselves like do better, but it actually can make it harder to do better because we're kind of feeling so down on ourselves. It's harder than show up as our best selves. And so the more parents can use the mindfulness skills there, really practice noticing not that that's a bad thing that you're feeling that way or that you're having thoughts about your kid like, oh my gosh, I can't believe, you know, like who is this kid or, you know, there's such a jerk. We all have those kinds of thoughts from time to time about our kids. And so not giving yourself such a hard time for that, but instead just noticing, oh, I'm having that thought. Or this is what I'm feeling that can actually go a long way, but it's certainly easier said and done. And I guess maybe I'll add in too, right? When we're feeling a really strong emotion, trying to bring in mindfulness, if we haven't established a mindfulness practice, can be really challenging because mindfulness is this skill that we really do have to build, build up to. It's like strengthening that muscle for being able to tune into the present.

And so it's like trying to ride a bike

for the first time on a downhill, right?

It's almost gonna be impossible.

That's your first time to ever ride a bike.

You need to first practice on the flat surfaces,

same with mindfulness.

So ideally, people would be first practicing,

you know, when drinking their first sip of coffee

in the morning, when doing the dishes, when going for a walk, like at times where steaks are low, emotions are not super high and heated before trying to use it in these more challenging moments, when a strong emotion is on board. What do you think is the easiest beginning approaches to mindfulness? Like you said coffee, like you imagine, just sipping the coffee slowly and just enjoying that first sip. That's a great one. I love it. Right. I try to do that every morning and it doesn't mean I drink my whole cup mindfully, but maybe it's just that very first set. Right. So we can practice martial linihan talks about it as like Pac-Man size bites, I believe she says, right? You know, in the game Pac-Man where each time you like get a little kind of dot, the Pac-Man gets a little stronger. And same thing like each time we tune in just even if it's for half a second to the present moment, our muscles for being able to do so get a little stronger. And so yeah, whether it's that, I think it really depends. Some people are finding it easier to tune into the external world first. Because for many of us, we are kind of taught to want to avoid our own emotions, especially those uncomfortable ones. And so we're kind of used to more looking outward. And that can be an easier place to start, but it could be, you know, the leaves rustling in the trees. It could be tuning into the beats in a piece of music or just noticing this is more kind of turning inward but it might be just noticing like what does it feel like to have your hand on a table, like on the flat table and I realize all this might seem kind of boring and mundane but it actually like, like, we, it kind of really can open our eyes to things that we never even noticed before. When we tune into these brief little moments, and again, can be a tool that we can use in general to sharpen our focus, help us better appreciate moments when, you know, those kind of positive moments and help us better tolerate those, those tougher moments as well. So my understanding is that in DBT groups, they don't do walking mindfulness. And I've heard Marshall and I had tried to do it, but then everyone hated the idea of walking around in a circle, but I actually found that really enjoyable to like just walk and feel the bottom of my feet. I do that just kind of a grounding thing between clients sometimes to kind of recenter myself. Yeah. Any thoughts on walking mindfulness and just feeling the very bottom of your feet? Yeah, I think it's a fabulous way to practice mindfulness or to go walk and maybe you choose to instead focus on the external as you're walking. What other people around you in the park are doing? We're just, you know, again, like the leaves, like I said, rustling in the trees. I will just know in DBT groups, that walking mindfulness exercise is actually one sometimes we'll use to help with non-judgmentalness. Right? So in DBT, mindfulness is broken down into a number of different kind of skills that you use. The what skills in the house skills and one of the house skills is nonjudgmentally. And it can be really hard to, if you're walking around in a circle with like, you know, following other people who are walking slower than you want to be walking, you can start to have a lot of judgments about that. And so it can be a way to practice just that walk, noticing those judgments when they show up, because we're going to have judgments come up from time to time. We're going to have distracting thoughts come up from time to time when we're practicing mindfulness. It's all about noticing those and then gently bringing ourselves back to whatever it is we're choosing to be mindful of. So that's an exercise where it's like a great practice of being able to like notice the judgments and then come back.

And so same thing will have people look at their hands because most of us have like imperfections on our hands that we don't love. So you can just be mindful of that. Notice the judgments when they come up, but then shift your attention back to like kind of just noticing or describing what you see on your hand non-judgmentally. Same thing with you could write the alphabet with just your left hand. I'm assuming people here are all right handed. That's clearly not the case. But write with your non-dominant hand. It's going to look really messy and you're probably going to have judgments about how it looks, but getting back to doing it and really throwing yourself into it without judging those letters that you're writing. That's good. So it's kind of, it's like a behavioral experiment of reducing self-judgment, right? So that when you get to harder things like your anger or our anger, we all have anger. We can have less judgment about it, realizing

that the judgment and maybe makes it worse, right? Because then we maybe don't see it for what it is or we make less of it or create defenses around it. Is that is that is that essentially like progressively De-sensitizing someone to the experience of internal judgment Yeah, and I don't even know what I'd say De-sensitizing because like we're gonna have those internal negative judgments and sometimes they're gonna be hard to sit with Right sometimes that we're gonna have thoughts about ourselves that aren't gonna be pleasant But I ideally were helping people notice that when that shows up and know that like, oh, I don't have to stew on those thoughts on that negative judgment. I can notice that. Notice that I'm having those thoughts and then choose to shift my attention back onto the present moment. Choose to do something that's going to be more effective in the present moment. And know that like, I just, you know, this is a little separate from mindfulness,

but just, you know, just we're all of your listeners to know, right? Like, again, we are all human. We're all going to feel like you said emotions like anger. And so the more we can just give ourselves some self-compassion, I think, whether we're parents or not, like life is hard and interacting with other people or like just you know the the challenges of our day to day and bring up really difficult emotions like anger and so the more we can just note that that like just about anyone would probably or many people would be struggling in this situation right or in other situations even if somebody might not find this very situation hard there are other people out there struggling in other situations too and feeling this kind of emotion and just giving yourself that compassion to like allow yourself to feel that way again without that judgment can be really freeing and can again kind of like lessen the intensity of those emotions. Okay. Okay. So some of the other skills that I found helpful that I've learned from DBT is like holding ice. And this morning I went into my sauna, went into the cold plunge. And I find the cold plunge to be a whole lot better than holding ice. But I'm curious like what your thoughts are in terms of where you integrate that into this sort of approach. Obviously, it's like a more gripping or like walking mindfulness or breathing mindfulness, which I think learning those things is good as well, but there's something about temperature, which really kind of just pulls you back into your body in a powerful way. Yeah, yeah. So I think ice in general, I think of it as a skill that we can use to help increase distress tolerance. So if you think about those, the different skills I talked about, the regulating skills are all about how can we kind of prevent unwanted emotions from firing in the first place, and start to change them when they do arise and aren't serving us all that. Distressed, tolerant skills are really like when an emotion is there. How can we sit with that emotion again without making the situation worse, without doing something we're going to regret? And that's where the ice comes in, at least in DBT, and where I talk about it in my book. So the first kind of way it may come in, the example you're giving is more, And maybe you're not using it as this. Maybe you're actually using that cold blunge in a more

mindful way where you're just noticing the physical sensations in your body when you choose to do a cold plunge, which is great, fabulous. And yes, it's certainly you're going to really notice those physical sensations. It's going to be easier to tune into them when you're feeling probably such, if I had to guess there are probably some, you know,

pretty drastic shifts that occur in your body that can help you really tune into those. Other times though, ice, like holding, you know, ice cubes in your hand, can be an example of distracting yourself, right? Just to get not as like a long-term solution to a given situation, but sometimes when we're so heated, we're so aroused, our brains are kind of offline. The prefrontal cortex, like we can't engage that because it's been hijacked in that moment by the more primitive parts of our brain. And so in those moments, we can use something to maybe help just take the edge off of that emotion a little bit so that we might be able to use more effortful strategies after the fact. And so the ice is a way we can kind of like distract a little bit from the you know from what we may be feeling in the moments you could hold ice in your hand for instance even like just drinking cold glass of water could be an example that you might do there. My favorite one of all though is actually a skill that is designed to elicit what's called the die reflex. And it's the, what tends to happen to us when we are submerged in very cold water. We may be familiar with this, right? Yeah. So our heart rates kind of slow down, stop pumping blood to our extremities in order to conserve energy and heat our core rate. And so we can elicit that die reflex, especially when like we're really, really aroused by, say, taking like a cold ice pack or a bowl filling it with cold water, maybe adding a few ice cubes. And then we can either put that ice pack kind of above on our cheekbones and our temples can leave it there for about 30 seconds. Or we can dunk our into that bowl of water which can get a little messy. But doing it for 30 seconds, and I should say for those listening that this is a skill that if you have a heart condition or some other medical condition that might affect your heart, you want to talk with your doctor before doing this. But for those who don't, these can drastically reduce heart rates by about 50% or more I've seen it within 30 seconds, right? I do it every day. Yeah, right in the cold blood, yeah.

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