Intrusive thoughts are a frequent complaint. They are often quite frightening patients especially since they seem to persist in conscious awareness even when we try to drive them out. Some thoughts involve horrible images of doing harm to others, especially those that we love. At other times, we may “see” ourselves doing things that go against our moral code.

So in order to help my patients manage these thoughts and get some measure of peace of mind, I offer them the following psychoeducation:

1) They are not alone! Almost everyone from time to time experiences such frightening and bothersome thoughts (including this writer). The fact that so many of us have such experiences yet DON’T act on them means that such thoughts do not lead to action.

2) Thinking something doesn’t mean you’ll do it. Think of all of the errands and tasks that you’ve thought of doing. I know that I’ve been saying that I’ll wash our car or clean out the refrigerator for three weeks. In fact, every time I open the fridge or get in the car, I say to myself, “gee, it’s really gross in here”. Yet, with all of my thinking, the car and the refrigerator are still a mess. Tachlis conclusion:

THOUGHTS DON’T EQUAL ACTION

3) Trying to stop them makes them worse. Fighting with your thoughts is usually pretty hopeless. The more that you try, the more they seem to dig in and get even worse. And that’s when the problem just gets worse because now you’re exhausted from this hopeless fight AND you’re demoralized from having failed.

So what then is your best position? I like to think of a train that is roaring by me as I stand on the side of the tracks. As you may know, a train, especially one that is really moving, can be frighteningly loud. Trying to stop that train won’t work. Putting my fingers in my ears also won’t work. The only thing that works is to simply let the train roar on through and to stay out of the way. The same is true of frightening thoughts; let them pass and stay out of their way. Eventually they will pass; it may take a minute or an hour or a month. They will however eventually stop.

4) You are not your thoughts. You are also not your mind. Just because you have crazy, violent, weird thoughts doesn’t mean that you are crazy, violent, or weird. What are you? For starters, you are the sum total of ALL of your ACTIONS. To paraphrase Forrest Gump, Crazy, weird, and violent is as crazy, weird, violent does; not as it thinks. (If it indeed were true that we are what we think that I would have lost thousands of pounds and also punched out about a million of my fellow motorists.)

5) Keep some band-aids handy. While intrusive thoughts can be valuable helpers for self knowledge, it is best to leave exploring them for times when you are less stressed. In the meantime, it is good to have some quick tricks on hand for those times when they really bother you. Here are some of my favorite tricks:
a) Speak a mantra aloud for ten minutes. I set a timer on my watch or kitchen stove and then say something over and over and over again for those ten minutes. It can be any phrase provided that it is something that has some meaning to me. Here are some that I recall:
Thank you
Any curse word
A phrase from Tanach or pirkay avos
A number or list that I want to remember (Examples would be credit card numbers, birth dates, names of presidents, names of capitals of the 50 states).

When time is up, I give myself a big yasher koach (kudos) for doing something to bring light into the wacky darkness of my mind. It’s also refreshing to realize that I am ten minutes that much closer to actually feeling better.

b) Taking a nap even if I don’t actually fall asleep.

c) Listening to music on my MP3 player.

d) Listening to guided imagery on my MP3 or computer.

e) Lying down on the floor and looking up at the ceiling.

f) Using drugs. Not illegal drugs of course! There are many, many effective calming remedies out there that really help. Some may be purchased in a reputable health food store in the form of a homeopathic remedy. Others need a doctor’s prescription.

g) Vigorous physical activity that gets me occupied with my body instead of my head.

h) Prayer. Whether it is reciting Tehillim (Psalms) or writing a letter to God, it’s really nice to ask for help. Sometimes, I use a very simple prayer that I came across years ago while reading Reader’s Digest:
May I be free from fear
May I be free from suffering
May I be happy
May I be filled with lovingkindness

i) Read uplifting poems and inspirational literature. Here is one of my very favorites. This poem, written by Sybil Partridge, has gotten me through life since I first read it in the worst days of a crippling depression.

Just for today I will be happy. This assumes what Abraham Lincoln said is true: 'Most folks are about as happy as they make their mind up to be.'

Just for today I will try to adjust myself to what is; not try to adjust everything to my own desires. I will take my family, my business, and my luck as they come and fit myself to them.


Just for today I will take care of my body. I will exercise it, care for it, nourish it, not abuse or neglect it, so that it will be a perfect machine for my bidding.


Just for today I will try to strengthen my mind. I will learn something useful. I will not be a mental loafer. I will read something that requires effort, thought, and concentration.


Just for today I will exercise my soul in two ways: I will do someone a good turn and not get found out. I will do at least two chores I don't want to do, as William James suggests, just for exercise.


Just for today I will be agreeable. I will look as well as I can, speak diplomatically, act courteously, be liberal with praise, criticize not at all, nor find fault with anything, and not try to regulate or improve anyone.


Just for today I will try to live through this day only, not tackle my whole life problem at once. I can do things for twelve hours that would appall me if I had to keep them up for a lifetime.


Just for today I will have a program. I will write down what I expect to do every hour. I may not follow it exactly, but I will have it. It will eliminate two pests: hurrying and indecision.


Just for today I will have a quiet half hour by myself and relax. In this half hour sometimes I will think of God, so as to get a little more perspective into my life.


Just for today I will be unafraid. Particularly, I will be unafraid to be happy; to enjoy what is beautiful; to love; and to believe that those I love, love me.


These ideas have helped many people. Try them out for size and see what you get. If you’ve got some other tricks please add them!

Here is a video that celebrates curiosity and the exuberance of the human adventure. Enjoy

It was just a few weeks ago that a patient asked me point blank, “Josh, why do you get up in the morning?”

After we laughed about the hassles of peeing in bed, I sheepishly answered that the reason I get out of bed in the morning is because I’m scared of what will happen if I don’t.

Here were some of the fears that I listed:

Fear of poverty-if I stay in bed my patients will not stay with me

Fear of hating myself-if I stay in bed I’ll feel like an idiot since everyone I know gets out of bed and does something with their lives.

Fear of feeling weird-I’ve been working since I was twelve or thirteen years old. My work ethic is still potent enough to get me moving.

Later on though, as I reflected on our discussion, I realized that I was a bit too hard on myself. I actually believe that I, and for that matter humanity, get out of bed because we want to. Lying in bed is boring and boredom in humans is literally deadly. Our unquenchable curiosity carries us forward into life even as we may be deathly afraid of life and its contents. Yes, that curiosity has gotten us into loads of trouble beginning with Eve’s wondering what that pretty fruit tasted like. Yet, it is that same wondering that makes us want to be a part of our individual dramas. In fact, our curiosity is what drives us with a frenetic ferocity towards the deepest of experience: God.

In this season of destruction and comfort, I found myself reflecting on the words of Dovid HaMelech in Tehillim Chapter 138, verse 8

If I ascend to the heavens You are there; and should I recline in Hell, You would be there.

This verse speaks of the loving presence of God in any state that the Jew finds himself or herself in. Whether it is in giddy exuberance or the deepest of suicidal despairs God is there.

“Yes, but so what?” you ask. “If I am so bulloxed in my exuberance or despair what does the presence of God mean? His presence means nothing to me in such states.”

The answer lies in destruction and in the real meaning of comfort. We have all been indoctrinated into how catastrophic the destruction of the Temple was. I have no doubt that it was. Yet to dismiss the whole story as absolutely black is to fail to see the universal truth in destruction: there can be no growth without the destruction of the old. In order for the beautiful new buildings to go up, the old ones must come down. Enlightenment follows disillusionment. Joy follows sadness. Peace follows war. Day follows night. Light follows darkness.

The destruction of the Temples and all of the horrors that befell us since were unquestionably bad events. Yet they have all been part of the amazing story that is the Jewish people of today of tomorrow. Indeed, on a personal level a life without a bit of destruction is in fact a sure sign that one has failed to mature in his or her relationship with the Divine. That Dovid HaMelech could find God in those states was in fact a result of his willingness to break down the autistic cocoon of emotional experience. Both in times of heavenly joy and deep despair, Dovid swung the wrecking ball of longing to find the imminence of God.

So in this time of destruction, let us swing away at the walls of self imposed limits. On the other side of those wall, in the rubble of self, we will find all that we long for.

It's been awhile since I last posted. But that hasn't stopped me from thinking about you all and frummydbt. In fact, I've been busy at work on the first draft of my forthcoming book on borderline personality disorder. It's exciting since this book gives me a chance to set some things straight about borderline and yiddishkeit and the misrepresentation of the two. So stay tuned!

The thought that I would like to post tonight is about the pain of existence that is in fact our greatest savior. The idea actually began with a reflection on the Talmudic legend of how God went to Yishmael and Esav and offered them the Torah before He turned to the Jewish people. It struck me as odd that there is no record of those "offers". That led me to posit that perhaps God's offer to Yishmael and Esav was not so much a solicitation akin to those which I receive in the mail or by phone. Rather, the offer was couched in existential pain and confusion. It is the kind of bone-breaking-cancer-causing pain that is born of the tug of war between our desperate instinct for self preservation and the great question of why should I tolerate all of the misery of existence? The pain was an invitation: either transform the pain and longing by finding meaning in Me or try and distract yourselves from the pain by gung-ho materialism. Yishmael and Esav took the latter option because, as the Talmud tells us, they believed that their hard wired personalities could never, ever change. They failed to see the magic in the human ability to transform and to undergo metamorphosis. Perhaps, they slipped into the same self idolatry that ruined Narcissus' life and doomed him to a loveless life. Whatever it was, it the Jew's belief in the ability of human transformation through action, as reflected in Naaseh VeNishma, we will do and then we will hear, that carried the day. From that fundamental optimism the Jew was able to accept the only logical path out of misery and into bliss: the surrender to God.

A Short Intro To Dialectical Behavioral Therapy

Skills, Skills, Skills: The Only Way To Go

Writer’s Reflection
Some years ago a fascinating discovery about the brain was widely reported in the news. Research conducted in England was coming out that appeared to stand previous scientific understandings of the human mind on their head. Stroke victims paralyzed on the right side of their bodies, were regaining use of their previously useless limbs. When their brains were examined with a special kind of xray, doctors found something amazing: the damaged parts of the brain were repairing themselves! And how did this miracle come about? To bring this about, the researchers immobilized the functioning arms of the patients for twelve hours at a time. For these twelve hours patients were expected to feed themselves as well as do all the activities that they would normally do but only with their injured arm. Guess what?! Within hours these previously ‘dead’ arms were back at work! What was previously a permanent disability was no more. Such is the power of determination that it can inspire growth when none was thought possible. And when determination and the skills that you’ll learn about are put together borderline personality won’t stand a chance.


Throughout this book, borderline personality disorder has been described as a group of destructive strategies to deal with very real and highly individual agonies and confusions. Thus in order to leave the most destructive aspects of borderline behind, one must find more effective strategies for dealing with the pain and confusion in living. More than needing a personality transplant, people with borderline personality disorder need ways to cope that respect their sensitivities and celebrate their unique abilities.

And this is what skills training can offer.

This of course was not always the case. For many years well meaning therapists tried to accomplish the worthy goal of healing the person with borderline through reflective therapy. The thinking behind this effort was that a healing supportive relationship could bring about the end of the pain.

Unfortunately, this approach didn’t work. Many patients got worse. They were hospitalized for long periods. Families, mental health professionals, and the patients themselves despaired of ever stopping the cycles of rage, self mutilation, suicidal behaviors and the chaos of borderline personality disorder. In effect, the therapy was undermining patients by making no effort whatsoever at helping them find a way in the world.

In the mid eighties, psychologist Marsha Linehan, bothered by the failure of talk therapy began to reconsider the whole treatment approach. She threw out “the book” so to speak and endeavored to find a new approach that would both help understand the disorder and provide some direction for treatment. Linehan observed that people with borderline personality disorder, more than needing a therapist who passively listened to the horrible complications of their lives, really needed practical assistance in calming their inner turmoil. Due to their exquisite sensitivities they needed real help in making sense of a world that they see as mad. In essence, Dr. Linehan discovered that far from being defective or ‘crazy’, people with borderline personality disorder were deep thinkers, confused by the pain and conflict that exists in the world. While most of us are able to make an uneasy peace such inconsistencies, these people by nature are bothered to no end by them.

Linehan put together a treatment program that taught emotional management skills and offered a sound philosophy for living at peace in their world. This program came to be called dialectical behavioral therapy or DBT. Dialectics refers to a practical philosophical discipline that concretely teaches how to live with the many paradoxes of life. One such paradox includes the desire for change with acceptance of the present moment. Another paradox centers around kindness and personal rights. Without understanding how to thrive in a world of paradox, patients remain stuck in a cloud of confusion that results in impulsive and destructive thinking and action.

Dialectics teaches us that two seemingly two opposed or paradoxical ideas can coexist.

Teaching philosophy however was of course not enough to tame the chaos of borderline personality disorder. Even with a grounded understanding of how the world works, people with borderline still had great difficulties in relationships, solving their problems, and managing their feelings. In response, Dr. Linehan developed a practical curriculum that teaches the skills necessary for positive relationships, solving the real problems of life, and finding joy in life. And because many of the most destructive dimensions of borderline personality disorder become habits with a life of their own such a self mutilation and suicidal behaviors, she developed techniques for creating new alternatives to take the place of the old ones.

The success of Linehan’s program is hard to dispute. People with borderline who have undergone dialectical behavioral therapy engage in far less self mutilation and require less hospitalization than those who receive standard talk therapy. They are more likely to be working and to report satisfaction in their lives.


The skills of DBT focus on the four areas that are the most problematic for people with borderline personality disorder. Without transforming these deficits into strengths, argued Linehan, all of the best intentioned therapies will fail. These skills are designed to empower and guide as people go about the very real business of making a life for themselves.

The skill groups are:
a. Mindfulness Skills
b. Interpersonal Effectiveness Skills
c. Distress Tolerance Skills
d. Emotional Regulation Skills
As detailed in the following chapters, the mastery of these skills will restore control in each of the characteristics of borderline personality disorder.

Focus on: The Difference Between Bipolar Disorder and Borderline Personality Disorder

One of the thorniest issues when it comes to borderline personality disorder is its relationship to depression and bipolar disorder. After all eighty percent of individuals diagnosed with borderline also exhibits symptoms of bipolar disorder. Many people have heard of bipolar disorder, one of the most documented and researched psychiatric disorders. Someone suffering from bipolar disorder is prone to experience frequent, dramatic mood swings. In many ways, it would seem that bipolar disorder and borderline personality disorder are on and the same.

Nothing however could be further from the truth.

Consider these differences:
1. The violent mood swings, rage, hyperactivity, and impulsivity experienced by someone with borderline personality disorder is triggered by inner turmoil. The extreme behaviors are may in fact be strategies to deal with the pain that is felt inside. The moodiness, impulsivity, and hyperactivity of someone suffering from bipolar disorder have a mind of its own. While episodes may be sparked by outside stress, the behaviors of mania and depression have little to do with the inner world.
2. The symptoms of bipolar disorder are usually well controlled with medication. This is usually with some combination of mood stabilizer medication and anti-depressant. The manifestations of borderline personality disorder however are poorly controlled by medication. Some behavioral manifestations of borderline such as depression, impulsivity, self mutilation, and suicidality may be controlled with medication. The inner psychology of the person however remains the same.
3. Whereas dread of abandonment is a hallmark of borderline personality disorder, there is no such parallel among those diagnosed with bipolar disorder.
4. Self mutilatory behaviors are common among those with borderline personality disorder. Similar behaviors are not present among those with bipolar disorder.