DBT and Distressed Elephants: An Expert Interview with Renee Hoekstra

An Elephant in the Room

I recently had the opportunity to speak with Renee Hoekstra, Psy.D. about her practice, finding a quiet moment and how elephants can teach us something about our emotions.  I'm happy to share with you, today, what she had to say.

Christy:  In your practice you focus on reducing suffering that accompanies misery, isolation, disconnection, alienation and loneliness.  How do you approach these problems?

Renee:  These problems can be very profound and rarely made public. What I really enjoy about some of the DBT material is that if offers qualitative information about the types of experiences people have, the reasons and causes for some of these experiences, and a way of making sense, sort of speak, of these experiences.

Clients come to my groups and have tremendous difficulty putting words on experience as well as organizing and understanding their own behaviors. It can be quite powerful to find they are not alone.

I approach the above problems in two ways. One is by offering really good content, handouts, and literature that is somewhat universal, emotionally salient, and generally on target with what clients can’t make sense of alone. The second is through the experience and feedback of group members- including opportunities for intimacy, disclosure, and connection through shared struggles.

Christy:  You’ve blogged about finding a quiet moment.  Why is that so elusive these days and what makes it important?

Renee:  Finding a quiet moment helps us to quiet the mind. When the mind is quiet, the brain is calm, and concentration and attention come easier. When the mind is being pulled in a million directions thoughts jump all over one another and tasks aren’t completed with care. Since intense emotions tend to interfere with our concentration and attention, mindfulness is a crucial element in being able to control our mood and our actions.

I remember many periods in my graduate school training in which I felt I had too much homework and couldn’t possibly get it done in time. I had to structure my time so tightly that I didn’t always get enough “down time.” People don’t always realize how living their lives in fast forward and “jumping” at the beck and call of multiple demands gets them in places they never intended to be in the first place.

I think that “practicing” mindfulness is at times elusive and difficult. I enjoy the constant challenge of teaching mindfulness to people who don’t “get” it, and repeatedly seeking a variety of ways to teach it effectively.

Christy:  What are 2 or 3 simple strategies that people might use to reduce emotional arousal?

Renee:  First, I like to remind clients that the agenda in helping clients deal with intense and painful emotions does not include getting rid of emotions. A lot of times when people say they try skills and they don’t work clients think that emotional pain goes away.

Reducing emotional arousal means exactly that- lowering the intensity of emotional experience so that it becomes more tolerable and more manageable. Once this is accomplished, the person has a lot more options in terms of exploring the emotion, getting information from the emotion, and making decisions based on this information.

One of my favorite skills is mindfulness to emotion- that includes a willingness to feel and tolerate every sensation that is arising within the skin. This may seem counter-intuitive, but the more that people can tolerate emotional intensity, the less threatening emotions become. Lots of people work really hard to not do this, and can find really creative (but ineffective) ways to escape emotional experiences.

Another one of my favorites is putting an ice pack on the face (covered by a cloth or towel). I like this skill because it works well when the rational side of the brain is working on problem solving, but the emotions don’t seem to care. It kicks in the parasympathetic nervous system so self-regulation happens rather quickly.

Christy:  You’ve created 2 books of cartoons titled The emotion-phobic user’s guide to handling cartoon elephants and The emotion-phobic user’s guide to handling the crises of cartoon elephants.  How are they intended to be helpful to people with emotional difficulties?

Renee:  Seeing emotions is a really hard thing to do. Stepping back and seeing the contents of one’s mind is quite an abstract concept. Plus emotions are tremendously complicated.

Cartoon elephants (aka emotions) are playful, but if not handled well they have the capacity to create a lot of problems. Specific suggestions to handle these gigantic, overwhelming pink pachyderms help people to get cartoon elephants to work for them instead of against them.

Christy:  How are metaphors and a visual representation (in the form of elephants) for problems managing emotions helpful?

Renee:  Did you ever have an elephant in the room? Have you ever tried inviting your elephant to show up? Have you ever tried to get in touch with your true cartoons? People are walking around with all these elephants…oh dear…and they really need my book.

Christy:  You turned your goal to get your books published into a challenge for others.  Can you describe it and why you made this challenge?

Renee:  This is entirely new endeavor that involves a variety of components I have not faced before- the self-publication process, the graphic design element, the learning of Adobe InDesign, and the editing process. The original books were done with an energy and haste about getting my ideas out- and while they contain a lot of good ideas they need to have a much better flow and organization. Editing something with artwork is bit of a challenge for me. Thus I have tended to avoid it. I kind of regret the procrastination because it would mean a lot to me to have my book in print.

I try to find ways to relate to clients who struggle with behavior change. I’ve found something that is difficult for me in a way that I haven’t really come up against before. So I like to try to think about ways in which I may not be doing what I might ask my clients to do- commit to the first step, create a deadline, and get it done. I also think it is nice to get clients to think about building mastery and gaining a sense of accomplishment, which is also a skill to reduce vulnerability to negative emotions.

About Renee Hoekstra, Psy.D.

Renee Hoekstra, Psy.D. is a Licensed clinical psychologist, in Massachusetts who specializes in DBT groups.  She has extensive training in Dialectical Behavior Therapy and is an expert in Interpersonal process groups.  Dr. Hoekstra founded the Early Career Psychologist initiatives in the greater Boston area, including EPPP licensing forums, business-of-practice building events, and social/referral networks for post-doctoral fellows and recently licensed psychologists and is the Massachusetts Psychological Association Early Career Psychologist Chair.  For more on Dr. Hoekstra, visit her web site at www.bostondbtgroups.com.

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