Tanuja Gandhi, MD: Welcome back to Mind Cast, Healthy Mind Healthy Child, a podcast from the mental health experts at Bradley Hospital. Today we will be joined by our guest, Dr. Andrea Gold, a psychologist at Bradley Hospital's Pediatric Anxiety Research Center. Dr. Gold specializes in DBT Therapy and Exposure Therapy. 

Together we'll explore what it means to stay grounded when emotions run high and discover practical tools you can use anytime, anywhere. Dr. Gold thank you for joining us. 

Andrea Gold, PhD: Please call me Andrea, and thank you so much for having me. I am really excited to talk about mindfulness from the DBT perspective. Every week in my role as a psychologist at Bradley, I encounter teens and families where teens may say I hate mindfulness, or what is it?

And so today what I really want to do is, talk to you about practical tools that can help all of us, especially with big emotions. And when we are dealing with stressors, with stressors in this world that are making emotions run high.

Greg Fritz, MD: I just want to say welcome and it's good to have you here. It seems like in the world, these days, everything seems chaotic and mindfulness is especially important. And so I think we ought to begin by really clearly defining what mindfulness is and how you see that.

Andrea Gold, PhD: Absolutely. So I'm going to talk today with my experience, teaching and practicing mindfulness from how we do it in DBT.

And to start, I want to define what DBT is. So DBT stands for Dialectical Behavior Therapy. It's a treatment model that was originally developed by a woman named Marsha Linehan, for people with high levels of emotion dysregulation who struggled with suicidal and self-harming behaviors. Since it was first developed, and supported by research evidence, it's been applied and generalized across conditions. 

But I want to point out how it's different from other therapies that you probably talk about in this podcast. It's different from treatment models like CBT or cognitive behavioral therapy that tend to be change focused. And the idea is that when Marsha Linehan was trying to develop a behavioral treatment for people with suicidal and self-harm behaviors, she found that efforts to change thoughts, which is part of the CBT, that cognitive behavior therapy led people to feel invalidated. 

On the other side, trying the opposite approach of validating or accepting people without change had the opposite effect of what she intended. Because when people were suffering so much that they felt like they were in hell, that they were being bowled over by their emotions, they were like, why are you just accepting what I'm thinking?

Why aren't you helping me to change? And so her solution was to balance the two, acceptance and change together. That's where the D in DBT comes from. It's dialectics, a worldview or a philosophy. The balance is opposite things that can be true at the same time. I think a lot of families deal with all or none, black and white thoughts and behavior.

I think there can be lots of conflict intentions, and so dialectics is the worldview or philosophy of DBT, and it's actually been a worldview and philosophy that I have practiced since I first learned it as a grad student in 2007. And mindfulness, is a major way that we practice the acceptance side of DBT and one that I find helpful as a human being with my own quick and strong emotions, and also as the parent of two little kids.

Greg Fritz, MD: So specifically, if you had to do it in one or two sentences, what is mindfulness?  

Andrea Gold, PhD: I'm going to quote Jon Kabat-Zinn. His definition of mindfulness I think makes sense. It's accessible and it's one sentence. He defines it as mindfulness is paying attention on purpose,

in the present moment, nonjudgmentally. And in DBT, we take this that can feel abstract or vague and break it down into specific skills that can be accessed anytime, any place. So instead of us being controlled by our minds or our emotions running the show, that takes us away from our values or how we want to live our lives; we are controlling our attention when we can get hijacked by our emotions and helping us make mindful choices rather than being controlled by our minds.

Tanuja Gandhi, MD: Why is it so important though, to achieve a state of mindfulness? 

Andrea Gold, PhD: Well, I think it helps to use some of our skills and how we talk about it in DBT to answer that question.

So in DBT, Marsha Linehan kind of helps us identify three different states of mind that we're all in. So the three of us sitting here right now are moving back and forth between different states of mind. Two of them are opposites. Do you guys remember what I called it? When two opposite things are true at the same time?

Tanuja Gandhi, MD: Dialectics.

Andrea Gold, PhD: Dialectics, yeah. So one state of mind is emotion mind. We're all in emotion minds at different points in our lives. The goal is to be able to notice when we're there and get unstuck from it when it causes problems. So emotion mind is all emotions. No reason. Another state of mind, reasonable mind is all thinking, all reason, no emotions.

A lot of the families I work with may come into treatment saying my emotions are bad. I want to get rid of emotions. But one thing I love about DBT is we honor that there's wisdom in our emotions, and when they fit the facts of the situation, they can be helpful. The problem is when we're stuck in emotion mind, and we're missing out what's actually happening, we can get stuck.

We can act in ways that cause harm or take us away from our values. So that's where our third state of mind comes in. In DBT, we call it Wise Mind and mindfulness skills are our path to access our wise mind. Wise Mind is a state of being that balances the valid parts of emotion mind and the valid parts of reasonable mind and holds them together at once.

So instead of either emotion or reason, it's both and. That's the dialectic. Wise mind is a place that is both intuitive. It's like when we have that gut feeling, that wisdom, that's helpful. And it's also based on experience. What we learn from doing, there's another dialectic, right? Intuitive and based on experience. 

Wise mind also is based on our self-respect, our goals that balance short-term and long-term needs. A lot of times where people get stuck with emotions is we just listen to what we want now or avoid what feels bad now, but it gets in the way of thinking about a future or long-term goals. So we're balancing the two of those.

And like I said, our values. So why is this important? When we're in emotion mind, often we experience our emotions as facts that aren't helpful. So an example actually I can share with you is before walking into this room to record with you guys, I had some anxiety, nervousness about doing it. The urge that comes with that emotion for me is to avoid.

Or sometimes with anxiety it can have us over prepare, control, fix, or make perfect. Those extremes aren't helpful and take me away from my values, like having this conversation, sharing these skills is a values-based action that I want to do. And so in this case, being able to use mindfulness and notice checking in the facts, I can make a choice that honors these things instead of just doing whatever my emotions say. 

On the flip side, when we were first scheduled to do this podcast about a month ago, I still had those urges to avoid. And turns out I was coming down with the flu, so it was the first day. I wasn't sure if I'd be contagious. I wasn't sure if I was up for it. And I used a skill that we talk about in DBT to get to mindfulness.

It's called the stop skill. Basically the letters S-T-O-P. Spell it out. It's stop, freeze. Don't move a muscle. For me, this is really important. If I feel like I'm in a threat state, fight or flight, I want to avoid or feel like I need an answer. I need certainty right now. That's a sign that I need to slow down. When I'm going fast, that's a sign I need to slow down.

And I realized, huh, this might be anxiety. This might be avoidance. Or this may actually be an effective thing to cancel, to postpone. And so what I did is I got to wise mind and realized, okay, let me approach, instead of avoid, let me do the prep I need to do, I needed to do a little bit of prep and then check in and see where I am.

That day, about a month ago, I took my temperature and sure enough, my fever started. Turns out I got the flu. I was tested for the flu and it was an effective, wise mind choice to cancel. That was avoiding in a way that was effective, right? Versus today. It was just emotion mind, not wise mind, and it was a thing to approach.

So I've kind of been able to learn overlearn, practice these skills to make effective choices in the moment, but if I didn't slow down, I might act in ways that take me away from my values.  

Tanuja Gandhi, MD: So depending on your emotional state, you may or may not be able to access the skills needed to stay regulated. That's what I'm hearing.

Andrea Gold, PhD: Yes.

Tanuja Gandhi, MD: Could you provide a brief overview of the three what and the three how mindfulness skills in DBT and why these skills are, essentially foundational to mindfulness practice.

Andrea Gold, PhD: You got it. So I'll reference the stop skill.

Tanuja Gandhi, MD: Yeah.

Andrea Gold, PhD: Stop. Take a step back. Proceed mindfully, right? But what does that mean to proceed mindfully? So I think with mindfulness we want to notice what's happening. When we're not being mindful, we can often miss information that's actually there or add on information that isn't. So the way that, that DBT breaks down mindfulness is what we call our what skills and our how skills.

So it literally tells us what we're doing and how we do it. It's important to learn these not in a state of crisis and to practice them and overlearn them so that we can use them at any time, any place. And I'll often use the metaphor of families, Hey, if you're learning to surf for the first time, are you going to do that in huge waves in Hawaii or during a hurricane?

No. Where do you learn to surf for the first time? I think most people actually say, you do it on the sand, not even in the water. So that's the approach we use in DBT. So the, there's three what skills and three how skills. What we're doing is observing, describing or participating. Each one builds off the other.

So the first one, observe is just noticing with our five senses what's happening outside of us, noticing what's inside of us, without adding anything to it. The second, what skill describe is adding on a layer. So it's noticing with our senses and then describing what we notice. Again, we're not adding anything on, but just describing what we can observe. 

From there, we move on to participating. Participating is kind of being in the moment. Being in the experience. And so a metaphor that I like to describe, the three what skills is they're similar to, like if you're driving a car, your different gears, you're moving back and forth between the what skills.

Ideally, we want to spend more and more time in participate, but sometimes the way to proceed mindfully is to slow down and just notice. So we spend a lot of time practicing those. If we think I'm not a sports fan. Are you guys sports fans?

Tanuja Gandhi, MD: Mm-hmm.

Greg Fritz, MD: Sure.

Andrea Gold, PhD: You are. So you might help me if I butcher the metaphors at all. Although this one should be straightforward. If you're thinking about watching a baseball game. Observing is what we're doing as people, spectators. You're just noticing you're taking it in. The people who, talk about the game, the announcers. Right. What do they do? They're just describing what they could observe. I'm assuming they're not adding on evaluations or interpretations, but helping describe it so people can imagine it. And then the players, the baseball players are the ones participating. They're kind of one with the experience.

So the first two, observe and describe are kind of that taking a step back, being able to notice, whereas participate is getting up close and personal with the experience. So those are our three what skills. Observe, describe, participate. The how skills, we're doing all three at once. And these are in that definition, that one sentence definition I gave you, quoting Jon Kabat-Zinn. 

We are doing things one mindfully. So right now I am here talking with both of you. This is the one thing in the universe I'm doing. My mind is probably going to wander as I'm talking. I imagine, Tanuja has your mind wandered at all while we're talking?

Tanuja Gandhi, MD: I think I should say no, but yes.

Andrea Gold, PhD: Of course it has. You're human. And we'll talk about our brains, like puppy dogs, right? I'll let the teens I work with think of their different animals and I've gotten some very creative animals. But inevitably, our minds are going to do that. They're going to go to different places, especially when emotions are high.

When mindfully is bringing us back to just this moment, which is the only moment that exists. Often we're suffering things that happen in the past or worrying about things in the future that haven't happened yet and may or may not happen. So mindfulness is like when you're training your puppy gently, kindly bringing it back.

That's one mindfully. The goal of one mindfully isn't to only be my one mindfully all the time, but again, it's the noticing and bringing your mind back. The second how skill after one mindfully, and actually these aren't in any order, but just the order I'm going now one mindfully, we have another skill called effectively, and Greg, you're going to help me with this, with the sports thing.

But somebody described effectively to me as like calling an audible in football. So effectively is doing what works in the situation you're in, not what's right or how it should be, or how you want it to be, but really taking that what skill of observing what's happening and doing what's effective, doing what works based on the reality, based on your goals.

Greg Fritz, MD: How do you know what's effective though?  

Andrea Gold, PhD: Mindfulness helps, and I think it's from experience, so paying attention again to what's happening, not those worries or past things. And I think DBT is a treatment that has a ton of skills, so you can pick kind of between the different ones. But with parents especially, we'll often suggest, ask yourself, do I want to be effective or do I want to be right?

Greg Fritz, MD: Right, right.

Andrea Gold, PhD: Right. When I teach this, I'll talk about if you're driving, there's the right of way, and ideally the person on the right side should go. But what happens if you're driving and somebody cuts you off and keeps going? The right thing would be, you go, but then you're going to get in a car crash, you're going to get hurt. It's not effective, versus figuring out what's effective. But to do that, you've gotta be kind of eyes awake. And that's, the thing with mindfulness. We practice it in DBT with eyes open because that's how we're living our lives, taking in information as it's happening. So effectively is doing what works, for our sports fans out here, an audible is if you have a play and then change it up based on

Greg Fritz, MD: Sure. The, the defensive, alignment or something like that, right?

Andrea Gold, PhD: Yeah. And it's this balance, it's a dialectic of planning things, but being ready to be flexible if it's not working. So that's effectiveness. And then the third, how skill is non-judgmentally.

So we're noticing judgments. What are judgments? I think when there is an evaluation, assumptions, interpretations, filling in the blanks, it's the opposite of describing what we can observe. And judgments are helpful because they're quick. Sometimes when we know what we mean, if, Maryanne who set up this podcast sent me information was super helpful. I said, Hey, Maryanne, good job. That's a judgment saying, good, but she knows what I mean. In other situations, when we do these quick shorthands of judgments, we lose information, that can lead to bigger emotions, higher emotions, higher arousal can make it harder to think, talk, problem solve, and can lead to more judgments.

And so with non-judgmentally, the first step is noticing the judgments. And then letting go of them. It could be as simple as letting go of them and then describing or ways to practice the non-judgmentally skill that we talk about in DBT are to keeping it simple, just observing what we could describe.

Sometimes reframing in terms of preferences. So there's a difference between, I hate this, I can't stand it. It's awful. Versus oof, I'm sad, my coffee shop was closed on my way in this morning. I would've preferred to get the, the coffee I like There's a difference there. And this can be really helpful with emotion dysregulation and communication too.

Another way we can practice nonjudgmentally is just kind of spelling out the consequences rather than getting to that evaluation. So we teach and practice ways to do this and they go together. We're practicing each of our what skills with our how skills of one mindfully, effectively, and nonjudgmentally. 

Greg Fritz, MD: So mindfulness can be challenging for kids and teenagers to embrace, I think, right?

Andrea Gold, PhD: Yeah.

Greg Fritz, MD: So what are some tips for introducing these skills in a way that feels relevant to the kids?

Andrea Gold, PhD: I like doing it experientially, doing practices.

Greg Fritz, MD: Uhhuh.  

Andrea Gold, PhD: So I think taking opportunities to describe how to practice it mindfully, do a practice, whether it's in a therapy session or, with families. I've had teenagers practice this with their friends too. I think car drives can be a good time to do it with parents and, teens as well. And then to process it afterwards. So, something we'll do is I just like a simple word game because it illustrates a lot of our what and how skills. So there's a word game where it's called last letter, first letter. So I say a word. Let's say I say cat. Tanuja would, her letter would start the first letter of your word would be the last letter of mine. So if I say cat, your word would start with t. So let's say, what would your T word be?

Tanuja Gandhi, MD: Tea.

Andrea Gold, PhD: T-E-A. And then Greg would say a word that starts with a. The reason I like this as a game is you can see how your mind is often jumping ahead, especially kids I work with, with anxiety disorders and OCD.

And you actually can't jump ahead in this game because what you say depends on what happens. So that's one example of a game that we'll have kids and parents play. Another way to break down the skills is actually using a peacock feather. If you can get your hands on one of those, and with the peacock feather, you can kind of go back and forth between just observing it, noticing it with the different senses.

Describing it. And then for participating, we'll often practice balancing a peacock feather on the tip of your finger. It's a really cool way to do it. It grabs your attention. You kind of have to be one mindful to do it, and it can bring up a lot of judgements. And with DBT, I forgot to say this before.

But with judgments, we want to actually get unstuck from and let go of both positive and negative judgments. Positive judgments can be, wow, I'm so awesome at this. Or Greg's so good at this. The problem with judgments is that they're fragile, so anything good can be judged bad and it takes away of describing and, and kind of getting more information.

And so this is something, we'll, we'll have families practice together and then reflect on it. And it's also a way to kind of figure out what's effective in doing this practice. I think practicing nonjudgmentally can be really hard to, again, we don't want to dive in the deep end. We don't want to learn to surf with tsunami weather, or, right in the middle of a hurricane.

And instead, one way to do it can be, especially with parents and teens, to have them look at each other and describe each other's shoes. That could be a way to practice just describing what you observe and it shows you how challenging it is and how quickly our brains can go to judgments. But you're doing it in a way that isn't as emotionally laden as topics like curfew or things like that.  

Tanuja Gandhi, MD: It's such great information for our listeners. I know you've described some exercises that parents and children can do together, especially the one while they're driving. Could you, give us some ideas and simple ways parents can weave mindfulness in their daily routine? Like you've already mentioned some. Are there other ways that they could incorporate it in their daily routine and strengthen relationships at home?

Andrea Gold, PhD: There's so many answers to this. What I'm going to start with, Greg challenged me to define mindfulness in one or two sentences. I'm going to do a suggestion in one word, ready, curiosity, and being curious.

Tanuja Gandhi, MD: Mm-hmm.

Andrea Gold, PhD: I want to validate that being a parent is really, really hard. Period. Like there's no question about it, especially when there's chaos in the world and when we're dealing with teens and emotion dysregulation, anxiety disorders, depression, things like that. 

For parents to notice when you're feeling angry, when you're feeling frustrated, and to replace that anger and frustration with curiosity. It's really hard to be angry when you're being curious, and it can help slowing down. Judgments can be really toxic and corrosive to relationships, can get in the way of information.

And I think there can be fear, especially in the cases of families who are struggling with suicide, self-harm behaviors. That can bring up a state of threat. And so to notice judgments, to notice anger, frustration as a sign that judgments are there, and to take a step back to use your own stop skill as a parent, and to be curious.

To notice what may be leading to this, what might be that person's experience. And I also think for parents, the more that you can learn these skills yourselves and model them, one, I think they're going to be helpful for you. I have benefited from them. I've been building my mindfulness muscles for years. I'm still building them. But as the most important people in your child's life, you're really showing them, hey, I buy this. Hey, I believe in it.

Tanuja Gandhi, MD: Mm-hmm.

Andrea Gold, PhD: And if you don't believe in it or doesn't work, that skepticism, that's something to talk about openly and being authentic. I think that goes a long way with kids. So, I think those are just some ways to practice this and bring it into your family.  

Greg Fritz, MD: Well, thanks so much. This has been fantastic. We could probably go on for another couple hours here. I sense that there's examples and exercises that would be a lot of fun and very interesting if we had more time to do, to sort of drive these principles home. But we really appreciate your being with us today. I think I've learned a lot just in this last 20 minutes or so.

Tanuja Gandhi, MD: Thank you so much Andrea, I echo the same sentiments. I've learned a lot about mindfulness and also realized how mindful I was or wasn't during our podcast recording today. But it's really helpful to think about these principles and how far along we are or we need to be and how it might benefit us in the long run.

So thank you again for joining us today.  

Andrea Gold, PhD: Oh, it's been my pleasure. And just noticing when you're not being mindful is being mindful. Right. That first step. Noticing.

Greg Fritz, MD: Yeah. Right.

Tanuja Gandhi, MD: And to our listeners, thank you for joining us. Please check out our podcast library at bradleyhospital.org/podcast. I hope you enjoyed our podcast today, and we look forward to your feedback.