I had the privilege of interviewing Dr. Peggilee Wupperman, a researcher and clinician who is associate professor at John Jay College/City University of New York, assistant clinical professor at Yale School of Medicine, and a senior psychologist at the American Institute for Cognitive Therapy. Before acquiring her current faculty positions, Dr. Wupperman completed a predoctoral internship and post-doctoral fellowship at Yale University School of Medicine, as well as a DBT postdoctoral fellowship at the University of Washington.
Dr. Wupperman is invested in improving the understanding – and ultimately treatment of — behavioral dysregulation (often known as “impulsive” or “addictive” behavior). Her research focuses on: evaluation and dissemination of a psychotherapy called Mindfulness and Modification Therapy to target behavioral dysregulation; Her research also explores the constructs underlying dysregulation; and 3) investigation of the effects of mindfulness and emotion-regulation skills on mental health and well-being.
She recently completed her third grant-funded clinical trial of MMT, which can be customized to target specific dysregulated behaviors. MMT has shown promising results in treating alcohol abuse, drug use, physical aggression, verbal aggression, binge eating, trichotillomania, and a variety of other dysregulated behaviors. In our interview she discusses mindfulness, dysregulated behavior and the therapy she created to target behavioral dysregulation, Mindfulness & Modification Therapy.
You can listen to the interview below. Just hit the play button.
Welcome Dr. Wupperman. So what is Mindfulness & Modification Therapy and can you tell me more about the people you work with?
Mindfulness and Modification Therapy is a therapy for dysregulated behaviors. Basically what people would call impulsive behaviors or addictive behaviors — we call them dysregulated because sometimes someone can decide in the morning something can go wrong and they can decided I can’t wait ’till I get home at seven o’clock tonight and binge eat or I can’t wait until I get home tonight and get wasted. So you can’t really say impulsive but sometimes dysregulated behavior can include things like anger issues where people will get mad and yell at people or say things that they would regret later or that can be used against them or hit or throw things and you can’t really call anger an addictive behavior… so that’s why we call it a dysregulated behavior.
As far as the people who have done the MMT program, we have done one clinical trial for women — court referred — for women with aggression and alcohol use disorders. They have all engaged in at least one act of physical aggression and they all had alcohol abuse and I can’t remember exactly but 60 to 70 percent also had drug use. We recently finished a trial at St. Luke’s Roosevelt hospital which is now a part of Mt. Sinai, of women who were self-referred for anger issues… so anger that got in the way of their relationships, of their daily functioning, who also had alcohol problems. Some of them — about 75% met criteria for an alcohol use disorder but some had previous previous alcohol abuse disorders and maybe just recent problematic drinking. Then about 70% also met a drug use diagnosis.
But these women varied from… we had someone who was veritably homeless and just living in various places with other people that she could find to live with, and then we had people who owned apartments. We actually had more than one who owned apartments on the Upper East Side that I could definitely not afford. So this huge range even within that one style of socio-economic status and backgrounds and everything else.
We also finished a clinical trial for binge eating disorders. These were John Jay College student; they were women. It was small, just a series of case studies. And so, these women happen to be pretty high achieving, they all had A’s or A-B averages, but just struggled with over-eating, just binge eating. Then I’ve done case studies with Trichotillomania which is hair pulling, eyelash pulling, and also with men with substance use disorders.
So that’s a very long answer to your question in that, there really isn’t a typical client. The part of it that’s typical is that there’s some sort of behavior, whether it be binge eating or substance use or anger or pulling hair or a lot of times also have avoidance like sleeping all day when they feel bad or wanting to do things but getting scared and canceling or you know, hibernating. But there’s some sort of behavior or behaviors that get in the way of them living the kind of life they want; feeling like the kind of person they want to be, living a life that feels valuable to them. And so that is the unifying factor of all the people we’ve seen in MMT is that there’s behavior that’s getting in the way of who they want to be and the life that they want. But other than that, there’s just a huge range of differences.
Why did you feel that mindfulness was such a large component in improving people’s lives?
I think mindfulness can definitely be used to help improve people’s lives and part of it was because I read. I had read mindfulness based cognitive therapy. The first time I discovered the dialectical behavior therapy book I was in grad school and it is not an exaggeration to say that it changed my life in that I went into a DBT internship and post-doc and dialectical behavior therapy has mindfulness. It just fit with what being able to experience and tolerate and accept emotions and thoughts just fit with things that I believed, with things that I read, with the research and then as more research coming out showing its effects… so I had this background of reading things that showed the improvement of mindfulness, but of course, what really helped pushed me over the edge was working with clients.
Sometimes these clients would have an urge to do something and literally thought it was impossible not to act on it. Or they get disappointed about something or feel really sad one day or feel really anxious and know that engaging in whatever behavior it is — binge eating, getting wasted, cutting — would actually make them feel worse in the long run but at that moment they just felt like they couldn’t not do it. And so it made sense to me that mindfulness, like purposely experiencing the moment, gaining the ability to experience the moment might help; it made sense to me that people who have trouble with mindfulness — because there are people who are lower in their ability to engage mindfully in day to day life even in neutral situations —it makes sense that people who have trouble experiencing and tolerating emotions and sensations and thoughts in day to day life in neutral situations are going to have extreme trouble tolerating them when they’re distressing or upsetting. So possibly, if we can work to get people to actually learn how to experience and tolerate internal experiences and you know, situations that are neutral, maybe we can then little by little work to help them tolerate the more distressing situations.
A lot of times people come to us, and I’m talking about low socio-economic status and also very high, outwardly successful people, and they feel like they’ve almost lost who they are and what’s really important to them in life. What they value. They’ve gotten so caught up in doing what others think. Or trying to hide the things about them that they feel are bad. And so it also made sense that mindfulness… it’s really hard to give up a behavior that actually helps decrease pain if you don’t have things that you’re working toward, if you don’t have things in your life that you value. And so it made sense to me that mindfulness would help on both levels. Both help people tolerate the distress that one feels when one gives up a coping behavior that really helps — even though it hurts in the long run — while also feeling like they’re more clear of what would make their life feel more valuable. They’re more clear of how to feel like their life is more fulfilling. And to be able to actually do that. And to me both components are very important.
So how does that work in Mindfulness and Modification Therapy? How does one person start with having no background in mindfulness. What was the program like for clients?
That’s a great question, how someone with no background in mindfulness enters the program and actually gets started in mindfulness. So we work really hard to actually make it accessible. In our first session, we find out what’s important to the client. We find out what the client’s life would look like if it felt more fulfilling, if they felt more like the kind of person they wanted to be. Sometimes they don’t know and so we get to start working on that. But we work to get clients to start being clearer about their values and letting us know what they are, because that a big component — is to help them live a more valued life.
We work to help them see how these behaviors get in the way of it and then we explain in depth how mindfulness practice can help. So that they have a clear understanding. It’s not just saying, “hey go do this and it’ll help.” And then we give mindfulness.
So our first mindfulness exercise, we call it the Color Body Scan. We take the body scan that many other people have used. John Kabat Zinn started it. But we’ve actually found, or I’ve found that with some of the clients we worked with… So the body scan is being aware of different sensations in different parts of your body. Usually it starts with the toes and spreads to your whole foot, and then the lower legs… So we found that of our clients had trouble doing that, at least some of them had trouble focusing on that. And so we played around with a few things and found that if you imagine that part of your body turns a color, and you get to choose your own color, and then you’re aware of the physical sensations and any emotions or anything else.
So it’s practice being aware, experiencing and tolerating the current moment and physical sensations tend to be somewhat neutral. And the color actually makes it more helpful. So we give our clients guided audios to be aware of different parts of their body and imagine their parts turn a color when it’s awareness so that… and that seems to help. It’s still hard to get clients to do. So what tends to happen is we assign that practice, we give that guided audio, which to me makes a huge difference and then if they come in the next week and they haven’t engaged in the practice, you know like any good therapy, we work to figure out what got in the way, and then work to actually find ways to get them to increase the practice.
We’ve always worked to be very nonjudgmental about it. What tends to happens is… and then we give other practices. We have a thing called the “Best B” that clients do and it’s not guided. It takes about two minutes. They get to do it on their own time, when they choose. So they can do it on the subway, or they can do it at lunch, or they can go sit in their car, or you know, sitting at the table in the morning. It’s an acronym: B is focus on your breath; E is be aware of your emotions; S is your physical sensations; T is your thoughts; and then B is focus again on your breath and allow your mind to go to the fact that you are moving closer toward your values and what those values look like. So it’s a very short thing. You know just very brief check in. So what tends to happen is that for the first few weeks, it takes a lot of work — nonjudgmental and accepting work — but a lot of work to get clients to start doing these regularly. And then over time we give them different audios. What tend to happens is, usually around week — well it depends, we’ll not even say a week — but sometime within the first few weeks, clients will actually start noticing some sort of change. And then it gets easier. Yeah. It get’s easier. And then we give different audios and have more of a variety, it also gets easier but yeah, a lot of times in fact we’ve had clients that actually say to us later in treatment, you know the first couple of weeks, I understood what you said, but it didn’t really sink in and I was sort of doing the stuff because you know, you were nice to me, or I felt a connection, or I thought you know, I don’t have anything to lose and I have to do something or whatever… But then over time I started noticing a difference.
Since we’re on the subject of mindfulness, there’s a lot of confusion. Like you definitely helped me understand what mindfulness is better, but what are some of the myths that people have about mindfulness?
Oh my goodness, myths about mindfulness — that would be a twelve hour show in and of itself. There are a lot of them. Some of the top ones… a lot of people think mindfulness and relaxation training are the same thing. In fact I’ve even known therapists who say, “We’re going to do a mindfulness practice,” and then they’ve done, “okay now try to relax.” Mindfulness means being able to be aware and attentive and accepting of the experience that’s going on in the moment. People often find mindfulness practices to be relaxing but it doesn’t mean that mindfulness has to be relaxing. And if you’re experiencing one thing and you tell yourself, “I shouldn’t be feeling tense, I should relax. Right now I’m going to try to relax.” That’s actually the opposite of mindfulness. That’s actually not accepting an experience of what you’re feeling.
So mindfulness is the ability to experience what you’re experiencing. So that if you’re anxious, the ability to experience the anxiety. Mindfulness is the ability to be aware, attentive and accepting of what you are experiencing. Accepting doesn’t necessarily mean that you like it or you want it to stay or that you’re not going to do anything at some point to change it, but at this moment, if I’m feeling anxious — to accept the fact that I’m feeling anxious at this moment. Or if I’m feeling sad, to accept the fact that I’m feeling sad. Now I might call someone then, that I tend to feel a little happier around, but while I’m feeling sad, to accept that fact. And if I call someone and I feel 50% happier, but I want to feel 80% happier, to accept the fact that I’m feeling sadder than I’d like. As opposed to telling myself, “Oh what’s wrong with you, why are you always a gloomy person, like you should be happy, you have nothing to feel sad about..” So when people do mindfulness practice, sometimes, a lot of times people will feel it to be relaxing. The body scan I told you about, sometimes people tend to feel that as relaxing. But we’ll sometimes have clients that come in that say, “Well, it worked for me for a while but it’s not working for me anymore.” And I’ll say, “Well, what do you mean?” And they’ll say, “Well, I used to get relaxed and in a calm state, and now I actually get agitated.” And so we’ll say, “So were you aware about the fact that you were agitated? And did you keep doing the exercise?” “Well yeah.” Okay, then it worked! You were actually mindful of the fact that you were agitated and, especially with clients who are dysregulated, they’re so used to, when an emotion feels too uncomfortable, to have the feeling and need to stop that emotion. Whether it’s with a dysregulated behavior or with something else. And so by actually engaging in mindfulness when you don’t feel relaxed and happy and calm, you’re actually giving yourself practice. Your sort of building you muscles we’ll say. And actually being able to experience these emotions, without feeling the need to do something that will hurt yourself in the long run.
So yes, the fact that mindfulness is relaxing or has to be relaxing that’s a myth. The fact that if someone’s mindful they’re never going to be upset about anything. That they’re sort of going to walk around like a zen zombie. You know just sort of in a soft voice and never feeling strongly about anything.
I one time worked in a facility where we had clients where they ran out of Kleenex and toilet paper. And I went to the facilities and said, “We are seeing clients that come here after a full day’s work. You have got to find a way to get us toilet paper and/or Kleenex. We cannot be out of both at the same time!” And the guy, he knew that I did a mindfulness therapy said, “That’s okay, that’s okay, now just be mindful, don’t get upset about it.” And mindfulness doesn’t mean never getting upset. Sometimes getting upset is helpful to help get things done; to help stand for people or yourself. It means when you are upset, the ability to actually experience the emotion and then have a choice in how to react. So when you’re upset to be able to decide, “okay do I want to express the fact that I’m upset with someone else? or at this point in time do I feel like it wouldn’t be worth my while; do I feel like it would be better not to.” That if you choose to express the uspetness or irritation or anger, how do I want to do it? Do I want to do it calmly and explain, “We need more toilet paper…” or do I want to scream and throw things.
So basically what we tell our clients is that a lot of time people come to us feeling like they’re controlled by their emotions or urges. If I have an urge or emotion, I sort of either have to act on the urge or act on the emotion or turn off the emotion. And so mindfulness means no longer being controlled by urges or emotions. You still feel the emotions, you might still feel the urges, but having a choice of whether to act on them. So it doesn’t necessarily mean being calm and not really caring about anything, which would be incredibly boring, but it means being able to experience it without feeling the need to automatically turn it off. And then to have the choice with how you want to act on it as opposed to it controlling you. So that’s a very long answer to myth number two.
Another myth is that mindfulness means you can totally focus attention. So doing a mindfulness practice means you’ll be totally able to focus your attention the whole time. We also have clients that will come in and say, I’ve sort of did it at first, but I’m not doing it well anymore. And we’ll ask them why and they’ll say, my attention kept wandering. As long as you keep bringing your attention back, it’s working every bit as good as the times where — so again to use the body scan as an example, if you’re aware of your foot and your ankle, and your lower leg, but then miss you knee and your thigh and your lower trunk and then come back to your upper trunk, but then you noticed, “Oh wow, my mind’s been wandering a lot.” And so you bring it back to your trunk and then it goes to your arm and then it wanders eight or nine times but then you bring it back to your arm — it’s working every bit as good. As long as once you notice your mind wandering, whether it’s a little while or a long while, you then bring it back. It’s working every bit as well as a time where you’re pretty much aware the whole time with only minor distractions. It’s like they both work different muscles. So the easier times, you’re getting certain things out of it; the harder times, you’re almost gaining practice again, for when you’re in more difficult stages in life. Sometimes dysregulated behavior, sometimes people will say, you know, it’s not even like I really made the decision to go take that drink or to go eat that cake, or to go cut or yell at that person. I know I was really upset and the next thing I knew I was picking up that bottle, or I was picking up that knife. So when you’re doing mindfulness and your mind is wandering all over, but you’re still bringing it back, it’s actually building your muscles. It’s actually helping increase your ability to be mindful and aware at those times when you’re mind does feel like it’s pulled in different directions. At times when you feel like you’re not aware of urges until they get high. So the more upset, the more distracted times. You’re getting practice for those sort of times, being able to — even when your mind is pulled away — to be able to bring it back and be aware of “Oh wait. I’ve got this urge that’s climbing really high and this really distressed emotion and I probably need to do something before it feels like it goes over the top.”
For some final thoughts, what would you like them to take away, for those people that are listening to this audio?
So you asked me what I hope people leave with. It really depends on their reason for listening to this. For people with dysregulated behavior, if you have times, which you probably do, where you feel like “my emotions aren’t that valuable; my thoughts aren’t that valuable,” or more likely, “I could be more valuable if I didn’t have this stupid emotion or if I didn’t have these stupid thoughts… if there were these things about me that were totally different” — know that those feelings are so incredibly common. You know, the “there’s something wrong with me” feeling; “there’s something bad about me that other people won’t even get because they don’t have the same badness, those same deficits.” Those feelings are so incredibly common even thought people don’t talk about them much because people feel like hiding them. But they’re very common. And it does not mean that you cannot be helped.
If you’ve tried various therapies, if you tried willpower on your own, if you know that engaging in whatever behavior is your behavior, if you know that it’s going to make you feel bad after, if you know it might hurt other people because it might cause you to cancel plans, or it might cause you to do things you’d regret, and you told yourself you’re not going to do that, I’m not that kind of person… but then you end up at some point in high stress — high distress — engaging in that behavior anyway — it doesn’t mean that you’re lazy, it doesn’t mean that you don’t care about others, or that you’re selfish, or all of those very critical and negative things that you’ve been taught to believe. It means that feelings and urges probably feel intolerable to you and you’ve never learned how to actually process and cope with them. There are things out there that can help you. There are various sort of therapies — I don’t Mindfulness & Modification is the end-all-be-all.
But find a therapist. And if you feel like you and your therapist don’t connect, if you’ve given it a while, if you feel judged by your therapist, if you feel like your therapist talks down to you, give it a while and I really suggest you bring it up to the therapist. Because maybe your therapist doesn’t feel that way at all, but if over time you just can’t connect, do your best to find someone else. Because different treatments work for different people, different personalities connect, and, you know, I personally think that mindfulness can be helpful. So if you can find a therapist that can incorporate mindfulness, that’s wonderful.
But I think the biggest take home is, a lot of people with dysregulation feel like there’s something just so horribly wrong with them, that a lot of times they don’t even feel like they don’t even deserve to be helped. Because they must be weak or bad or lazy or whatever to actually do these things that hurt themselves and others. And that really isn’t the case. And for almost everyone I’ve seen regardless of what behavior there is.. You know I hear various stories and I know various things about them and I think, I can’t say I wouldn’t be doing exactly the same thing if I were in their shoes. And I can’t necessarily even say I’d be functioning as well as they do. So for people with dysregulated behavior that would be my take home point.